Every finding on record at Olympia Convalescent Hospital

Based on interview and record review, the facility failed to protect the residents right to be free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to the resident's body imposed for purposes of discipline or staff convenience) and without a physician's order or consent for one of three sampled residents (Resident 1). On 8/2/2026 at around 10 P.M., Licensed Vocational Nurse (LVN) 1 put LVN 1's left elbow on Resident 1's right arm, placed a sock over Resident 1's right hand, tied Resident 1's right wrist with a trash bag, tied the trash bag to the Resident 1's bed siderail, and when administering enteral bolus (nutrition to give all at once)feed (to give liquid nutrition directly into a person's stomach through a feeding tube) formula and also LVN 1's left elbow on Resident 1's right arm to Resident 1. This deficient practice resulted in Resident 1 being restrained for about four hours and risk for impaired circulation, nerve/muscle injury, skin breakdown, pain/discomfort, and psychosocial distress (damage to a person's mental health, emotional state, or social well-being caused by bad social conditions, stressful environments, or poor treatment by others).Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 2/1/2024, and readmitted Resident 1, Korean speaking) on 7/30/2026 with diagnoses including cerebral infarction (loss of blood flow to a part of the brain), Hemiplegia and hemiparesis affecting left non-dominant side, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing)and hypertension (HTN - high blood pressure). A review of Resident 1's Initial History and Physical (H&P) dated 4/8/2026, indicated Resident 1 does not have the capacity to understand and make decisions due to impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The H&P indicated Resident 1 has dysphagia and on gastrointestinal tube (G-Tube -Is a medical device placed through the belly wall directly into the stomach to administer liquid food, water, and drugs to people who cannot eat or drink safely by mouth) A review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 6/22/2026, indicated Resident 1 has cognitive impairment The MDS indicated Resident 1 is dependent on staff with upper body dressing and all other activities of daily living (ADL -activities such as bathing, dressing and toileting a person performs daily) care. A review of Resident 1's Change of Condition (COC - a noticeable, important change in the health, behavior, or mental state of a person that is different from the normal baseline) dated 8/3/2026 at 7:41 A.M., indicated that . (Resident 1) was found with her right hand in a sock and her right wrist tied to the left siderail. A review of Resident 1's Care Plan dated 8/3/2026 indicated, .The (Resident 1) is at risk for impairment to skin integrity related to sock placed over her right hand and right wrist was tied to left side rail of bed.The (Resident 1) has a psychosocial well-being problem related to incident sock placed over her right hand and right wrist was tied to left side rail of bed. A review of Resident 1's Psychiatric (related to the medical study, diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) initial visit note dated 8/3/2026 at 2:49 P.M., indicated, . staff reportedly restrained her (Resident 1) right hand to the bed rail . A review of Resident 1's Order Summary Report (OSR), indicated Resident 1 to apply hand mittens (are soft, padded hand coverings used as a physical restraint to prevent patients from scratching themselves, pulling out intravenous (IV) lines, catheters, or interfering with essential medical treatments on right hand to prevent pulling of Gtube . effective 8/4/2026, however, the same OSR did not indicate to use any form of restraint on Resident 1 prior to 8/4/2026, A review of Resident 1's Interdisciplinary Team (IDT - a group of people with different types of job skills and training who work closely together to reach a single, shared goal) Conference Record dated 8/4/2026 indicated, . a sock on her (Resident 1) right hand and plastic from a plastic bag tied to her wrist and tied to the left side rail on 8/3/2026 . A review of the facility's five-day report dated 8/6/2026, indicated that, on 8/3/2026 at around 2 A.M., . patient (Resident 1) had a sock covering the right hand and a plastic tie to the left side rail . During an interview on 8/6/2026, at 1:11 P.M., with LVN 1, LVN 1 stated that on 8/2/2026 at around 10 P.M, LVN 1 went to Resident 1's room to administer enteral bolus feed formula to Resident 1. LVN 1 stated that during the bolus feeding, she placed a sock over Resident 1's right hand, tied Resident 1's right wrist with a trash bag that LVN 1 found in Resident 1's closet and then tied the trash bag to the Resident 1's bed siderail. LVN 1 stated she placed a sock over Resident 1's right hand, tied a plastic bag to her right and then to the side rail to stop Resident 1 from moving. LVN 1 stated that Resident 1's is not a bother when it comes to bolus feeds however, on some days when she (Resident 1) keeps moving the right arm. LVN 1 would normally place her (LVN 1's) left elbow on Resident 1's right arm to prevent Resident 1's arm from moving during Gtube bolus feeding. LVN 1 stated that she forgot to go back to Resident 1's room to remove the sock over her right hand, untie the trash bag on Resident 1's right wrist attached to the bed siderail so that Resident 1 will not be restrained. During an interview on 8/6/2026 at 2:07 P.M., Certified Nursing Assistant (CNA) 3 stated that she worked on 8/2/2026 from 11 P.M. to 7 A.M. CNA 3 reported that on 8/3/2026 at approximately 12 A.M., she went to check Resident 1 and found the resident positioned on her right side, covered with a blanket up to her neck, with a pillow placed under her head. CNA 3 stated that at around 1:45 A.M. or 2 A.M. on 8/3/2026, Registered Nurse Supervisor (RNS) 1 instructed her to provide care (change) for Resident 1 after RNS 1 had changed Resident 1's intravenous (IV) access. CNA 3 indicated that when she went to assist Resident 1, RNS 1 was already at the bedside and had untied the resident. CNA 3 stated that when RNS 1 uncovered Resident 1's blanket, RNS 1 observed that Resident 1 had been tied to the bed side rail. RNS 1 asked CNA 3 if she had done it; CNA 3 stated she told RNS 1 that she had not changed Resident 1. CNA 3 further stated that at approximately 3:30 A.M. on 8/3/2026, RNS 1 informed her that the incident had been reported to the Facility Administrator (FA), that she was considered one of the suspects, and that RNS 1 needed to send her home. CNA 3 reported that on the following day, 8/4/2026, she texted the Director of Staff Development (DSD), who told her that the facility had identified the staff member responsible for restraining Resident 1 and that she could return to work that night. During an interview on 8/6/2026, at 2:27 P.M., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated that he (RNS 1) worked on 8/2/2026 from 11 P.M. to 7 A.M. RNS 1 stated that on 8/3/2026 at around 2 A.M., RNS 1 went to Resident 1's room., to disconnect (Resident 1's) IV ertapenem (medication to treat infection/s), right foot with pressure relieving boots, (Resident 1) was lying on the left side. As I was removing her boot, . I saw her right arm and hand on the left siderail across her chest area, right hand was covered in a sock, and the wrist had a plastic bag tied to her wrist to left side rail, I was like what is happening here, I immediately told the CNA (did not name the CNA) to take a scissor, I was upset, I felt very sympathetic for her, upset, I got the scissor cut it, from the siderail first and then I carefully, cut the plastic from the wrist area, when I assessed her skin, her circulation, assessed for bruising, swelling, she was still sleeping during this whole matter, did not appear to be in distress, I asked (CNA 3 and CNA 4) and why the resident was like this, I asked the charge nurse to help take the vitals, she was safe no distress or anything, I removed the iv access which was on the right foot, I reported it to the Facility Administrator (FA), California Department of Public Health (CDPH), Ombudsman(an independent referee or problem-solver who investigates complaints from regular people against a company, school, or government agency)and I kept trying the Los Angeles Police Department (LAPD) . RNS 1 stated that, placing an elbow/body weight on a resident's body part is not ok, It is considered physical restraint and causing more damage. If the resident is refusing treatment you cannot force them, for me personally get someone to translate in Korean (Resident 1's primary language), contact the family and the doctor for further guidance and assistance, family usually help a lot. During an interview on 8/6/2026, at 3:10 P.M with FA , the FA stated that FA received a phone call from RNS 1 on 8/3/2026 at around 2 A.M., and RNS 1 reported that Resident 1 was found to have a sock over the right hand, with a plastic tied to the right wrist and tied to the bed side rail. FA stated that FA told RNS 1 to report the incident with Resident 1 to all the agencies that the facility is required to report to. FA stated FA called LVN 1 who openly admitted it (restraining Resident 1). I told LVN 1 that I was calling about the incident that happened, she said it was me (LVN 1), I totally forgot to remove it (Restraining) when I left . FA stated LVN 1 said that Resident 1 was trying to remove the Gtube, scratch herself, I told her there was a process to doing that, did you call the Medical doctor (MD) for any other interventions, I am sorry I won't do it again. During an interview on 8/6/2026, at 4:04 P.M., with the Interim Director of Nursing (IDON), the IDON stated that placing an elbow/body weight on the resident to prevent them from moving is considered a physical restraint including applying a sock over the hand and a plastic bag tied to the wrist and then to the siderail. The IDON stated that applying physical restraints can injure the resident's skin, nerves, and functionality loss of the body part involver, cause deep tissue injury and may potentially lead to hospitalization. The IDON stated that resident having been placed in that position can be traumatic to the resident, impacting the psychosocial well-being of the residents leading to sadness, crying, it is traumatic. The IDON stated that LVN 1 should not have applied the sock and plastic bag then tied to the side rail on the resident, there is a process for that, LVN 1 should have notified the physician for possible alternate interventions, an order obtained and authorization prior to placing the physical restraint. A review of the facility's policy and procedures (P&P) titled Restraints with a last review date of 5/1/2026, indicated, the following: PurposeTo safely utilize restraints to treat a medical symptom when the least restrictive measures have already been used and are ineffective.I. The Facility honors the resident's right to be free from restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. The Facility will ensure that restraints will not be imposed for purposes of discipline or convenience.II. Medical symptoms will be evaluated to determine if underlying causes may be eliminated.Ill. If underlying causes of medical symptoms cannot be eliminated, alternative measures must be tried before a restraint is used.IV. If alternative measures are unsuccessful, the least restrictive form of a restraint will be used.V. Unless otherwise specified by the Attending Physician's order, alternative methods of behavioral control must be attempted and documented in the resident's medical record before a physical restraint is used.VI. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to:Treat the medical symptom;Protect the resident's safety; andHelp the resident attain the highest level of his/her physical or psychological well-being.VII. The Facility will not use restraints on a prn or as necessary basis.VIII. Every attempt will be made to avoid a decline in the resident's physical functioning.IX. Except in emergency situations, a physical restraint shall be used only after the Interdisciplinary Team (IDT) has performed an assessment, attempted to determine and alleviate precipitating factors, determined the need for restraint and identified the least restrictive device.A. Emergency use of restraints is permitted if their use is immediately necessary to prevent the resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment, and no other less-restrictive interventions are feasible.8. The Attending Physician must be notified of emergency use and the reason for the order during the application of the restraint or immediately after the restraint has been applied.C. Orders for emergency restraints may be received by telephone.D. The emergency use of restraints must not extend beyond the immediate episode.X. Treatment restraintsA. Treatment restraints will be applied:i. Pursuant to an Attending Physician's orderii. Under the supervision of a Licensed NurseB. Informed consent will be obtained from the resident or responsible party if a restraint will be used during a treatment or diagnostic procedures.i. If the resident has decision-making capacity and does not provide informedconsent after the risks and benefits have been explained, the resident's choice will be honored.C. Treatment restraints shall be applied for no longer than the time required to complete the treatment.Definitions Physical Restraint is 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 normal access to one's body. This may include bed rails, beds against walls, restrictive clothing, etc.

Based on observation, interview, and record review, the facility failed to ensure the food preparation equipment in the kitchen was clean when one of one ice machines (Ice Machine 1) had yellowish-brown debris on the interior of the ice storage compartment according to the facility's policy and procedures (P&P) titled, Cleaning Schedule, last reviewed 1/1/2026 and the Food and Drug Administration's (FDA) Food Code, dated 2022. This failure had the potential to cause foodborne illness in 120 out of 121 residents who receive and consume food prepared from the facility kitchen. Findings: During a concurrent observation and interview on 7/27/2026 at 7:50 AM with the Dietary Services Supervisor (DSS) in the kitchen, the interior of Ice Machine 1 was inspected. The surveyor (writer) used a white sheet of paper towel to wipe the interior of the compartment where the ice is stored after being formed. The sheet of paper towel was observed to have scattered wet, yellowish-brown debris. The DSS stated the yellowish-brown debris should not be present inside the ice storage compartment of Ice Machine 1. The DSS stated Ice Machine 1 must be cleaned and may need to be cleaned more frequently than once a month. The DSS further stated the yellowish-brown debris could contaminate the ice that the residents consume, which could then cause the residents to get sick. During an interview on 7/30/2026 at 9:16 AM with the Infection Preventionist Nurse (IPN), the IPN stated all kitchen equipment should be clean, including the ice machine. The ice machine must be clean because there is a high risk for the ice machine to spread diseases through water. The IPN further stated the kitchen ice machine must be clean to prevent the spread of diseases to the residents who consume the ice produced. During an interview on 7/30/2026 at 2:39 PM with the DSS, the DSS stated after the yellowish-brown debris was found inside the ice storage compartment of Ice Machine 1 on 7/27/2026, kitchen staff immediately cleaned Ice Machine 1 that same day. The DSS stated per facility policy, the ice interior of the ice machine is to be washed once a month. The DSS further stated that DSS believes the facility's policy is wrong and Ice Machine 1 should be cleaned more frequently than once a month. The DSS stated moving forward DSS will ensure the kitchen staff clean the interior of Ice Machine 1 daily to prevent the build-up of further brown debris in the ice storage compartment. During a review of the Ice Machine Cleaning Schedule for 2026, Ice Machine 1 was cleaned on the following dates: 1/13/2026, 2/17/2026, 3/17/2026, 4/27/2026, 5/11/2026, 6/29/2026, and 7/27/2026. During a review of the facility's policy and procedures (P&P) titled, Ice Machine - Operation and Cleaning, last reviewed 1/1/2026, the P&P indicated the inside of the ice machine must be washed on no less than a monthly basis. During a review of the P&P titled, Cleaning Schedule, last reviewed 1/1/2026, the P&P indicated the dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the DSS. During a review of the Food and Drug Administration's (FDA) Food Code, dated 2022, the FDA's Food Code indicated, equipment food contact surfaces shall be clean to sight and touch. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation, interview, and record review, the facility failed to ensure two of two staffs (Housekeeping Supervisor - [HKS] and the Environmental Supervisor - [EVS]) understood the correct water temperatures and drying temperatures when washing and drying linen for residents in the facility according to the facility's policy and procedures (P&P) titled, Laundry - Sorting, Washing & Drying, last reviewed 1/1/2026, California Code of Regulations Title 22 Section 71629 - Laundry Service (CCR), undated, and the manufacturer's guidelines titled, Washer-Extractor Pocket Hardmount, dated December 2005. The facility has three linen Washing Machines (1, 2, and 3) and four linen Dryer Machines (1, 2, 3, and 4).This failure increased the potential for the spread of infections and diseases among the 121 residents residing in the facility. Findings: During a tour observation of the facility's laundry room on 7/28/2026 at 12:54 PM with the Housekeeping Supervisor (HKS), the interior of the laundry room was observed to have four linen dryer machines and three linen washing machines. The facility's Hot Water Temperature Log for July 2026 and the Dryer Machine Temperature Log for July 2026 were posted along the wall inside the laundry room. During an interview on 7/28/2026 at 12:56 PM with the HKS, the HKS stated the facility has four tumble dryer machines and three washing machines in the laundry room. The HKS stated all the facility's laundry is done within the laundry room. The HKS stated first the soiled laundry is sorted in the dirty linen room. Then each load is placed in the linen washing machine to be washed. After the laundry is washed, it is immediately placed in the tumble dryer to be dried. After the laundry is dried, it is placed in the folding station to be folded. During a concurrent interview and record review on 7/28/2026 at 12:58 PM with the HKS, the facility's Hot Water Temperature Log for July 2026 was reviewed. The Hot Water Temperature Log indicated that from July 1, 2026 to July 28, 2026, the hot water temperatures for linen Washing Machines 1, 2, and 3 ranged from 130 degrees Fahrenheit (F-unit for measuring temperature) to 157 degrees F. HKS stated the laundry staff check the water temperature of each washing machine through the machine's sensor and write down the highest recorded temperature on the log daily. The HKS stated the hot water temperature for each washing machine should be within the range of 140 degrees F to 160 degrees F. The HKS further stated it is important to monitor the temperatures of the washing machines to ensure the water temperature is hot enough to kill bacteria (microorganisms that can spread disease) on the clothing and linens being washed. The HKS stated residents can get sick from the bacteria on the clothing and linens if the bacteria are not killed with hot water. During a review of the facility's Hot Water Temperature Log for June 2026, the Hot Water Temperature Log indicated that from June 1, 2026 to June 30, 2026, the hot water temperatures for linen Washing Machines 1, 2, and 3 ranged from 140 degrees F to 143 degrees F. During a review of the facility's Hot Water Temperature Log for May 2026, the Hot Water Temperature Log indicated that from May 1, 2026 to May 31, 2026, the hot water temperatures for linen Washing Machines 1, 2, and 3 ranged from 140 degrees F to 143 degrees F. During a concurrent interview and record review on 7/28/2026 at 1:00 PM with the HKS, the facility's linen Dryer Machine Temperature Log for July 2026 was reviewed. The linen Dryer Machine Temperature Log indicated that from July 1, 2026 to July 28, 2026, the temperatures for Dryer Machines 1, 2, 3, and 4 ranged from 150 degrees F to 180 degrees F. The HKS stated the goal temperature range for the dryer machines should be within 160 degrees F to 180 degrees F. During a review of the facility's linen Dryer Machine Temperature Log for June 2026, the linen Dryer Machine Temperature Log indicated that from June 1, 2026 to June 30, 2026, the temperatures for linen Dryer Machines 1, 2, 3, and 4 ranged from 155 degrees F to 175 degrees F. During a review of the facility's linen Dryer Machine Temperature Log for May 2026, the linen Dryer Machine Temperature Log indicated that from May 1, 2026 to May 31, 2026, the temperatures for linen Dryer Machines 1, 2, 3, and 4 ranged from 145 degrees F to 175 degrees F. During a concurrent observation and interview on 7/29/2026 at 2:23 PM with the HKS in the laundry room, a load of soiled linens was placed inside Washing Machine 3. The HKS started the washing cycle on Washing Machine 3 and monitored the water temperature inside through Washing Machine 3's temperature sensor. For the first minute of Washing Machine 3's wash cycle, the HKS was observed monitoring the washing machine water temperature until the water temperature reached a maximum temperature of 147 degrees F. HKS stated HKS monitors the water temperature for the first minute of the wash cycle because that is when the water reaches the highest temperature before the temperature starts lowering. The HKS stated a load of residents' clothing takes 30 minutes to wash, while a load of soiled linens takes 45 minutes to wash. During a concurrent interview and record review on 7/29/2026 at 2:38 PM with the Environmental Supervisor (EVS), the EVS stated that the hot water for the linen washing machine should be at 140 degrees F to 160 degrees F. The EVS reviewed the facility's policy and procedures (P&P) titled, Laundry - Sorting, Washing & Drying, last reviewed 1/1/2026, and confirmed that the P&P indicated that sheets, pillowcases, diapers, towels, and draw sheets must be washed with the hottest available water, along with the correct setting on the machine and that residents' clothing must be washed using established procedures while ensuring that all facility infection control procedures are followed. The EVS further stated that the facility's P&P does not specify what hot water temperatures the linens and clothing must be washed in. The EVS further stated the facility follows Title 22 of the California Code of Regulations guidelines for washing machine hot water temperatures. The EVS then left to look for additional information regarding the hot water temperature parameters for washing linen. During a concurrent interview and record review on 7/29/2026 at 2:40 PM with the EVS, California Code of Regulations Title 22 Section 71629 - Laundry Service (CCR), undated, was reviewed. The EVS stated that the CCR indicated, All linens shall be washed using an effective soap or detergent and thoroughly rinsed to remove soap or detergent and soil. Linens shall be exposed to water at a minimum temperature of 160 degrees F for at least 24 minutes during the washing process, or a lower temperature of 140 degrees F for 24 minutes may be utilized if the linens are subsequently passed through a flatwork ironer at 110-115 feet per minute at a temperature of 300 degrees F or a tumbler dryer at a temperature of 180 degrees F. The EVS stated this is the temperature requirement that the facility follows because the facility's P&P does not explicitly define the hot water temperature requirement of the washing machines. During an interview on 7/30/2026 at 9:00 AM with the Infection Preventionist Nurse (IPN), the IPN stated all laundry is washed and dried within the facility's laundry room. The IPN stated some residents in the facility prefer to have their personal clothing laundered by their family members, but all facility linens such as bedding are laundered in the facility's laundry room. The IPN further stated, It is important to wash laundry at the appropriate temperature to kill germs and prevent the spread of diseases to the residents. During an interview on 7/30/2026 at 11:08 AM with the Director of Nursing (DON), the DON stated, Clothing and linens need to be washed at the appropriate temperature because the purpose of the hot water is to kill the germs on the clothing and linen. The germs need to be killed to make sure they don't spread illness and disease to the residents. During a review of the washing machine manufacturer's guidelines titled, Washer-Extractor Pocket Hardmount, dated December 2005, the manufacturer's guidelines indicated the washing machines are capable supplying water at a temperature range of 80-200 degrees Fahrenheit.

Based on observation, interviews and record review, the facility failed to protect 19 of 19 residents' (Residents 7, 9, 13, 23, 26, 27, 33, 39, 45, 53, 55, 57, 60, 65, 82, 101, 106, 107 & 129) rights to privacy and confidentiality of records according to the facility's policies and procedures (P&P) titled Resident Rights with a review date of 1/01/2025 and titled Education Requirements-medical Records Manual-HIPAA (the Health Insurance Portability and Accountability Act of 1996 - a federal privacy rule which establishes national standards to protect individuals' medical records and other individually identifiable health information) with a review date of 1/01/2026, evidenced by when Licensed Vocational Nurse (LVN) 8 left the 9 aforementioned residents' medical records hidden under a laptop computer in the facility's hallway. This deficient practice of violating the residents' rights to privacy and confidentiality of records had the potential to result in unauthorized access to Residents 7, 9, 13, 23, 26, 27, 33, 39, 45, 53, 55, 57, 60, 65, 82, 101, 106, 107 and 129 personal information not limited to diagnoses, treatment and medication, and also placing the residents at increased risk for psychological harm and financial harm. Findings: 1.During a review of Resident 7's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Type 2 diabetes mellitus (T2DM - a disorder characterized by difficulty in blood sugar control and poor wound healing); hemiplegia and hemiparesis ([paralysis that affects one side of the body] and hemiparesis [weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing]) following cerebral infarction (damage to the tissues in the brain due to loss of oxygen to the area) affecting left non-dominant side; dysphagia following cerebral infarction (difficulty swallowing); aphasia following cerebral infarction (a language disorder that occurs when a stroke damages brain areas responsible for language processing); unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems); neuromuscular dysfunction of the bladder (a condition where the nerves and muscles controlling bladder function don't work properly due to damage to the brain, spinal cord, or nerves); and encephalopathy (brain dysfunction that can appear as confusion, memory loss, personality changes and/or coma in the most severe form). During a review of Resident 7's history and physical (H&P - a physician's complete patient examination) dated 4/18/2026 indicated, Resident 7 does not have the capacity to understand make medical decisions due to impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool) dated 6/22/2026, indicated, Resident 7 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 7 did not use any mobility devices (helps a person walk or move from place to place when one has a disability or injury) to get around. 2. During a review of Resident 9's admission record, the record indicated Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements); T2DM; reduced mobility (ability to move freely, purposefully, and independently); dysphagia; unspecified dementia; and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow and oxygen to the brain, damaging brain tissue). During a review of Resident 9's H&P dated, the H&P indicated, Resident 9 does not have the capacity to understand and make medical decisions due to unspecified dementia. During a review of Resident 9's MDS dated [DATE], indicated, Resident 9 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 9 did not use any mobility devices to get around. 3. During a review of Resident 13's admission record, the record indicated Resident 13 was admitted to the facility on [DATE] with the following diagnoses: T2DM; chronic fatigue (a serious, long-term illness that causes extreme exhaustion lasting six months or more); polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body); major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest); anxiety disorder (a condition of excessive worry about daily issues and situations); unspecified psychosis (not enough information to make a diagnosis of a specific psychotic disorder); insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early, resulting in poor sleep quality and potentially affecting daytime functioning); and dysphagia. During a review of Resident 13's H&P dated 5/06/2026, the H&P indicated, Resident 13 had the capacity to understand and make medical decisions. During a review of Resident 13's MDS dated [DATE], the MDS indicated, Resident 13 had severely impaired cognition. The MDS also indicated Resident 13 used a wheelchair for mobility/to get around. 4. During a review of Resident 23's admission record, the record indicated Resident 23 was admitted to the facility on [DATE] and readmitted on [DATE] and again on 7/18/2026 with the following diagnoses: unspecified displaced fracture of the second cervical vertebra (a broken bone high up in the neck where the broken pieces have shifted out of their normal alignment); pulmonary hypertension, unspecified (dangerously high blood pressure in the blood vessels connecting the heart to the lungs); hyperlipidemia (high cholesterol or having too much fat in your blood); atrial fibrillation (a-fib - an irregular and often very rapid heart rhythm); heart failure (when heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen); major depressive disorder; dysphagia; and vascular dementia. During a review of Resident 23's H&P dated 1/06/2026, the H&P indicated, Resident 23 does not have the capacity to understand and make medical decisions. During a review of Resident 23's MDS dated [DATE], the MDS indicated, Resident 23 had severely impaired cognition. The MDS also indicated, Resident 23 walks independently without the use of any mobility devices to get around. 5. During a review of Resident 26's admission record, the record indicated Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: essential (primary) hypertension (HTN- high blood pressure without a single identifiable cause); hyperlipidemia; unspecified dementia; spinal stenosis (the bony tunnels inside your spine are getting too narrow, which crowds and pinches the nerves running through them); and depression, unspecified (a diagnosis used when a person has symptoms of depression that cause real distress or trouble in daily life). During a review of Resident 26's H&P dated 5/06/2026, the H&P also indicated Resident 26 does not have the capacity to understand and make medical decisions. During a review of Resident 26's MDS dated [DATE], the MDS indicated, Resident 26 had severely impaired cognition. The MDS also indicated Resident 26 uses either a walker or a wheelchair for mobility/to get around. 6. During a review of Resident 27's admission record, the record indicated Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: metabolic encephalopathy (a general term that describes a brain disease, damage or malfunction; brain function is disturbed); T2DM; dysphagia; abnormalities of gait and mobility ([gait - a person's manner of walking] and [mobility - ability to move freely and easily]); acute kidney failure (when kidneys suddenly cannot remove waste from the blood); During a review of Resident 27's H&P dated XXX, the H&P indicated, Resident 27 has the capacity to understand and make medical decisions. During a review of Resident 27's MDS dated [DATE], the MDS indicated, Resident 27 has moderately impaired cognition (make poor decisions, cues and supervisions required). The MDS also indicated, Resident 27 walks independently without the use of any mobility devices to get around. 7. During a review of Resident 33's admission record, the record indicated Resident 33 was admitted to the facility on [DATE] with the following diagnoses: psychotic disturbance, mood disturbance, and anxiety (a complex psychological condition where a person is struggling with reality, emotional regulation, and intense worry); hyperlipidemia; essential (primary) HTN; cerebral aneurysm (a weak, bulging spot on an artery in the brain that fills with blood); reduced mobility; delusional disorders (a mental health condition where a person has fixed, false beliefs [delusions] that last for one month or longer); and unspecified glaucoma (a condition in which there is a build-up of fluid in the eye which presses on the retina [senses the light and sends images] and the optic nerve [sends the images received from retina to the brain] causing vision loss and blindness). During a review of Resident 33's H&P dated 9/04/2025, the H&P indicated, Resident 33 had fluctuating (changing a lot and going up and down in an irregular way) capacity to understand and make medical decisions. During a review of Resident 33's MDS dated [DATE], the MDS indicated, Resident 33 had severely impaired cognition. The MDS also indicated, Resident 33 uses walker and wheelchair, for mobility/to get around. 8. During a review of Resident 39's admission record, the record indicated Resident 39 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: severe protein-calorie malnutrition (a serious medical condition caused by a deep lack of food, calories, and protein dangerous lack of enough protein, calories, or both in the diet); unspecified dementia; hyperlipidemia; vascular dementia; essential (primary) hypertension; anxiety disorder; epilepsy, unspecified, not intractable (a long term brain disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells); major depressive disorder; and unspecified osteoarthritis, unspecified site (joint cartilage is breaking down, causing pain or stiffness, but the chart lacks the exact joint location or the specific cause). During a review of Resident 39's H&P dated 3/29/2026, indicated Resident 39 does not have the capacity to understand and make medical decisions. During a review of Resident 39's MDS dated [DATE], the MDS indicated, Resident 39 has severely impaired cognition. The MDS also indicated, Resident 39 walks independently without the use of any mobility devices to get around. 9. During a review of Resident 45's admission record, the record indicated Resident # was admitted to the facility on [DATE] with the following diagnoses: polyneuropathy; vascular dementia; essential HTN; hyperlipidemia; anemia (a health condition where your blood does not have enough healthy red blood cells or hemoglobin); lack of coordination (an inability to work together smoothly or move the body with proper balance and control); and reduced mobility. During a review of Resident 45's H&P dated 8/06/2025, the H&P indicated, Resident 45 does not have the capacity to understand and make medical decisions. During a review of Resident 45's MDS dated [DATE], the MDS indicated, Resident 45 has severely impaired cognition. The MDS also indicated, Resident 45 uses a walker and wheelchair for mobility/to get around. 10. During a review of Resident 53's admission record, the record indicated Resident 53 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: unspecified dementia; anxiety disorder; essential (primary) hypertension; gastro-esophageal reflux disease (GERD - a common condition where the stomach acid repeatedly flows back into the esophagus [a tube that connects your mouth and stomach]); and dysphagia. During a review of Resident 53's H&P dated 11/19/2025, the H&P indicated, Resident 53 does not have the capacity to understand and make medical decisions. During a review of Resident 53's MDS dated [DATE], the MDS indicated, Resident 53 has severely impaired cognition. The MDS also indicated, Resident 53 walks independently without the use of any mobility devices to get around. 11. During a review of Resident 55's admission record, the record indicated Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: T2DM; reduced mobility; lack of coordination; dysphagia; bacteremia (the presence of bacteria in the bloodstream, which can be transient [short time] and resolve on its own, or lead to a serious infection like sepsis if the immune system is overwhelmed); hyperlipidemia; essential (primary) hypertension; unspecified mood disorder (when a person has significant emotional or mood symptoms, but those signs do not fit the exact rules for a specific condition); unspecified dementia; major depressive disorder; GERD; benign prostatic hyperplasia without lower urinary tract symptoms (a non-cancerous enlargement of the prostate gland that occurs commonly as men age). During a review of Resident 55's H&P dated 4/09/2026, the H&P indicated, Resident 55 has an end-stage (the final phase of a progressive, terminal illness or chronic condition) dementia. During a review of Resident 55's MDS dated [DATE], the MDS indicated, Resident 55 has severely impaired cognition. The MDS also indicated, Resident 55 uses mobility device, a wheelchair, to get around. 12. During a review of Resident 57's admission record, the record indicated Resident 57 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: metabolic encephalopathy; T2DM; acute respiratory failure with hypoxia (a sudden, life-threatening condition where your lungs cannot transfer enough oxygen into your blood); asthma (a chronic lung disease that causes your airways to swell, narrow, and fill with mucus, leading to difficulty breathing, wheezing, coughing, and chest tightness); lack of coordination; dysphagia; essential (primary) hypertension; hyperlipidemia; GERD; anemia; unspecified dementia; and muscle weakness. During a review of Resident 57's H&P dated 7/15/2026, the H&P indicated, Resident 57 does not have the capacity to understand and make medical decisions. During a review of Resident 57's MDS dated [DATE], the MDS indicated, Resident 57 has severely impaired cognition. The MDS also indicated, Resident 57 walks independently without the use of any mobility devices to get around. 13. During a review of Resident 60's admission record, the record indicated Resident 60 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: hemiplegia and hemiparesis; protein-calorie malnutrition; muscle weakness; dysphagia; chronic kidney disease, unspecified (longstanding disease of the kidneys leading to renal failure); essential (primary) hypertension; hyperlipidemia; unspecified dementia; vascular dementia; depression; delusional disorder; anxiety disorder; During a review of Resident 60's H&P dated 9/03/2025, the H&P indicated, Resident 60 does not have the capacity to understand and make medical decisions. During a review of Resident 60's MDS dated [DATE], the MDS indicated, Resident 60 has severely impaired cognition. The MDS also indicated, Resident 60 walks independently without the use of any mobility devices to get around. 14. During a review of Resident 65's admission record, the record indicated Resident 65 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Parkinson's disease; osteomyelitis of vertebra (swelling or infection that occurs in the bones of the spine); anemia; hyperlipidemia; polyneuropathy; and GERD. During a review of Resident 's65 H&P dated 5/14/2026, the H&P indicated, Resident 65 does not have the capacity to understand and make medical decisions. During a review of Resident 65's MDS dated [DATE], the MDS indicated, Resident 65 has severely impaired cognition. The MDS also indicated, Resident 65 walks independently without the use of any mobility devices to get around. 15. During a review of Resident 82's admission record, the record indicated Resident 82 was admitted to the facility on [DATE] with the following diagnoses: T2DM; protein-calorie malnutrition; essential (primary) hypertension; muscle weakness; anemia; hyperlipidemia; chronic kidney disease; difficulty in walking; lack of coordination; and dysphagia. During a review of Resident 82's H&P dated 6/20/2026, the H&P indicated, Resident 82 had fluctuating capacity to understand and make medical decisions. During a review of Resident 82's MDS dated [DATE], the MDS indicated, Resident 82 had severely impaired cognition. The MDS also indicated, Resident 82 uses a mobility device, walker, to get around. 16. During a review of Resident 101's admission record, the record indicated Resident 101 was admitted to the facility on [DATE] with the following diagnoses: dysphagia; unspecified dementia; essential (primary) hypertension; hyperlipidemia; major depressive disorder; and BPH. During a review of Resident 101's H&P dated 7/04/2026, the H&P indicated, Resident 101 does not have the capacity to understand and make medical decisions. During a review of Resident 101's MDS dated [DATE], the MDS indicated, Resident 101 had severely impaired cognition. The MDS also indicated, Resident 101 walks independently without the use of any mobility devices to get around. 17. During a review of Resident 106's admission record, the record indicated Resident 106 was admitted to the facility on 5e/27/2022 and readmitted on [DATE] with the following diagnoses: protein-calorie malnutrition; asthma; T2DM; lack of coordination; dysphagia; reduced mobility; muscle weakness; essential (primary) hypertension; hyperlipidemia; unspecified dementia; vascular dementia; GERD; and anemia. During a review of Resident 106's H&P dated 4/21/2026, the H&P indicated, Resident 106 does not have the capacity to understand and make medical decisions. During a review of Resident 106's MDS dated [DATE], the MDS indicated, Resident 106 had severely impaired cognition. The MDS also indicated, Resident 106 uses a wheelchair for mobility/to get around. 18. During a review of Resident 107's admission record, the record indicated Resident 107 was admitted to the facility on [DATE] and readmitted [DATE] with the following diagnoses: hemiplegia and hemiparesis; T2DM; lack of coordination; protein-calorie malnutrition; hyperlipidemia; BPH; essential HTN; and anemia. During a review of Resident 107's H&P dated 12/08/2025, the H&P indicated, Resident 107 had fluctuating capacity to understand and make medical decisions. During a review of Resident 107's MDS dated [DATE], the MDS indicated, Resident 107 was cognitively intact (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). The MDS also indicated, Resident 107 walks independently without the use of any mobility devices to get around. 19. During a review of Resident 129's admission record, the record indicated Resident 129 was admitted to the facility on [DATE] with the following diagnoses: T2DM; essential (primary) hypertension; delusional disorder; hyperlipidemia; unspecified dementia; psychotic disturbance, mood disturbance and anxiety. During a review of Resident 129's H&P dated 6/11/2025, the H&P indicated, Resident 129 had fluctuating capacity to understand and make medical decisions. During a review of Resident 129's MDS dated [DATE], the MDS indicated, Resident 129 had severely impaired cognition. The MDS also indicated, Resident 129 uses a wheelchair for mobility/to get around. During a facility tour on 7/27/2026 at 1:22 PM, a laptop computer sitting on top of Treatment Cart (a mobile workstation used by nurses to securely store, organize, and administer wound care supplies, dressings, topical mediations, and diagnostic tools safely from one resident's room to another) A was observed unattended. Treatment Cart A was parked in the hallway against the wall between Nursing Station 1 and room [ROOM NUMBER]. When surveyor got closer to the laptop computer, two stacks of binder clipped 8.5 inch by 11 inch papers and one stack of loose 8.5 inch by 11 inch papers were found tucked under the laptop computer. When combined, all of the papers found under the laptop computer were three-quarters inch thick. When surveyor looked at the documents quickly, the surveyor found medical records of the following residents: Residents 7, 9, 13, 23, 26, 27, 33, 39, 45, 53, 55, 57, 60, 65, 82, 101, 106, 107 and 129. A total of 19 residents' medical records were found tucked under the laptop computer sitting on the Treatment Cart unattended. LVN 8 arrived at the location where the Treatment Cart A was parked. LVN 8 stated LVN 8 kept/placed the medical records of the 19 residents under the laptop computer sitting on top of Treatment Cart A because I believe that they (medical records) are safer there; to my knowledge they are safe to be there underneath the computer. Both the surveyor and LVN 8 reviewed each page of the residents medical records and confirmed the fthat the residents' medical charts contained the following information about the residents. Binder Clip #1 (total of 25 pages) Resident 9's medical records contained resident's name, date of birth , diagnoses, and treatment plan. Resident 27's medical records contained resident's name, date of birth , diagnoses, and treatment plan.Resident 45's medical records contained resident's name, date of birth , diagnoses, treatment plan and several black and white pictures of Resident 45's wounds.Resident 65's medical records contained resident's name, date of birth , diagnoses, treatment plan and several black and white pictures of Resident 65's wounds.Resident 101's medical records contained resident's name, date of birth , diagnoses, and treatment plan. Resident 106's medical records contained resident's name, date of birth , diagnoses, treatment plan and several black and white pictures of Resident 106's wounds. Resident 107's medical records contained resident's name, date of birth , diagnoses, treatment plan and several black and white pictures of Resident 107's wounds.Resident 129's medical records contained resident's name, date of birth , diagnoses, and treatment plan. Binder Clip #2 (total of 37 pages) Resident 7's medical records contained resident's name, date of birth , diagnoses, treatment plan and several black and white pictures of Resident 7's wounds.Resident 13's medical records contained resident's name, date of birth , diagnoses, and treatment plan. Resident 23's medical records contained resident's name, date of birth , diagnoses, treatment plan and several black and white pictures of Resident 23's wounds. Resident 26's medical records contained resident's name, date of birth , diagnoses, and treatment plan. Resident 33's medical records contained resident's name, date of birth , diagnoses, and treatment plan. Resident 39's medical records contained resident's name, date of birth , diagnoses, and treatment plan. Resident 53's medical records contained resident's name, date of birth , diagnoses, and treatment plan. Resident 55's medical records contained resident's name, date of birth , diagnoses, treatment plan and several black and white pictures of Resident 55's wounds. Resident 57's medical records contained resident's name, date of birth , diagnoses, treatment plan and several black and white pictures of Resident 57's wounds. Resident 60's medical records contained resident's name, date of birth , diagnoses, and treatment plan. Resident 82's medical records contained resident's name, date of birth , diagnoses, and treatment plan. Loose Pages (total of 10 pages) Nursing assignments for 7/27/2026 During the same interview and record review, LVN 8 stated that LVN 8 violated the HIPAA law when all 19 residents' medical records were left under a laptop computer unattended. LVN 8 stated HIPAA is a privacy and confidentiality law that prohibits healthcare workers from sharing residents' personal and medical information. LVN 8 also stated that LVN 8 violated residents' right to privacy and confidentiality when all 19 residents' medical records were left under a laptop computer unattended. LVN 8 stated the medical records may be stolen and used to impersonate the residents, and fraudulently open financial accounts such as credit cards and bank accounts. LVN 8 stated residents will be upset, they might feel scared that their information may be used fraudulently, and [residents] will not trust us anymore. During a review of LVN 8's employee file, indicated LVN 8 completed in-service education on HIPAA course on 7/16/2026. During an interview of 7/30/2026 at 9:10 AM with 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), DSD stated that the medical records of 19 residents found under a laptop computer sitting on top of Treatment Cart A unattended was not acceptable because anyone can grab the medical records.steal the information.to open bank accounts, apply for government assistance. DSD stated that LVN 8 violated HIPAA when the medical records of 19 residents where kept under a laptop computer instead of a safe spot.nurse's station and medical records office. DSD stated the potential harm that may happen to all 19 residents are identify theft, open bank accounts fraudulently, use residents information for financial gain; will feel hurt and unsafe in the facility because they might feel they are not protected.they feel vulnerable. During an interview on 7/30/2026 at 10:38 AM with the RN Supervisor (RNS) 1, RNS 1 stated HIPAA law is to protect the privacy of residents.do not show [medical records] to other people unless they are designated to care for the residents. RNS 1 stated that medical records are safely kept at the nursing stations, never under the laptop computer on top of the Treatment Cart, anyone can access the laptop computer and it [computer] is open to the public. RNS 1 stated all 19 residents may feel their privacy was opened, they will feel bad, upset, increase their medical condition like anxiety, depression.may feel like they will sue the facility. A review of the facility's 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 Resident Rights with a review date of 1/01/2025 indicated, privacy and confidentiality including the right to privacy in his/her specific oral, written, and electronic communications. A review of the facility's P&P titled Education Requirements-medical Records Manual-HIPAA with a review date of 1/01/2026 indicated, to ensure that all employees receive necessary and appropriate training with regard to the privacy and security of protected health information (PHI) to carry out their functions on behalf of the facility.

Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Residents 106, 117, and 129) were free from physical restraints (a physical method or device used to limit a person's movement or freedom) for staff convenience to treat the residents' medical symptoms without a physician's order, consent, and according the facility's policy and procedures (P&P) titled, Restraints, last revised 5/1/2026. The facility staff positioned Residents 106, 117, and 129 beds against the walls. This failure resulted in restricting the residents' free movement, increased the risk of physical function decline, and increased the risk of entrapment (when a resident becomes trapped in the gaps of a bed system) by their beds potentially leading to accidents, asphyxiation (when a person cannot breathe normally), and death for Residents 106, 117, and 129. Findings: 1. During a review of Resident 106's admission Record, dated 7/30/2026, the admission Record indicated Resident 106 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), toxic encephalopathy (a term for brain dysfunction or damage caused by exposure to toxic substances), and chronic obstructive pulmonary disease (a long-term lung condition that damages the airways and makes it difficult to breathe). During a review of Resident 106's History and Physical (H&P), dated 4/21/2026, the H&P indicated Resident 106 does not have the capacity to understand and make decisions. During a review of Resident 106's Minimum Data Set (MDS - a resident assessment tool), dated 6/4/2026, the MDS indicated Resident 106's experiences difficulty in cognitive skills in new situations. The MDS also indicated Resident 106 requires maximal staff assistance (helper does more than half the effort) when rolling left and right in bed. During a review of Resident 106's Order Summary Report, dated 7/30/2026, the Order Summary Report did not indicate a physician's order to place Resident 106's bed against the wall and also did not indicate any physician's orders to apply restraints on Resident 106. During a concurrent observation and interview on 7/27/2026 at 9:48 AM with Certified Nursing Assistant (CNA) 1 in Resident 106's room, Resident 106 was lying in bed with the left side of the bed positioned against a wall. CNA 1 stated Resident 106's bed is too close to the wall and should not be positioned against the wall. CNA 1 further stated the bed positioning could be considered a restraint because Resident 106 would not be able to get out of bed on the left side. CNA 1 stated the bed positioning is trapping Resident 106 in bed. During a concurrent observation and interview on 7/27/2026 at 10:05 AM with LVN 6 in Resident 106's room, Resident 106 was lying in bed with the left side of the bed positioned against the wall of the room. LVN 6 stated the positioning of the bed against the wall could be restricting Resident 106's movement. LVN 6 further stated the purpose of the bed being positioned against the wall is to prevent Resident 106 from falling off the left side of the bed. LVN 6 further stated restraints require physician's orders. 2. During a review of Resident 117's admission Record, dated 7/30/2026, the admission Record indicated Resident 117 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including dementia, reduced mobility (limitation in independent, purposeful physical movement or walking ability), and hypertension (a condition where the force of blood pushing against artery walls is consistently too high). During a review of Resident 117's H&P, dated 7/30/2026, the H&P indicated Resident 117 does not have the capacity to understand and make decisions. During a review of Resident 117's MDS, dated [DATE], the MDS indicated Resident 117 has severe cognitive impairment of thinking and memory. The MDS also indicated Resident 117 requires maximal assistance when rolling left and right in bed. During a review of Resident 117's Order Summary Report, dated 7/30/2026, the Order Summary Report did not indicate a physician's order to place Resident 117's bed against the wall. It also did not indicate any physician's orders for restraints. During a concurrent observation and interview on 7/27/2026 at 9:41 AM with CNA 2 in Resident 117's room, Resident 117 was lying in bed with the left side of the bed positioned against the wall of the room. CNA 2 stated Resident 117's bed is positioned against the wall and should be moved away from the wall towards the middle of the room. CNA 2 stated Resident 117's bed should not be positioned against the wall because it restricts Resident 117 from getting out of bed on the left side. During a concurrent observation and interview on 7/27/2026 at 10:08 AM with LVN 7 in Resident 117's room, Resident 117 was lying in bed with the left side of the bed positioned against the wall of the room. LVN 7 stated Resident 117's bed should not be positioned against the wall because Resident 117 won't be able to get out of bed on the left side and this could be considered a restraint. 3. During a review of Resident 129's admission Record, dated 7/30/2026, the admission Record indicated Resident 129 was admitted to the facility on [DATE] with diagnoses including dementia, hypertension, and dorsalgia (back pain). During a review of Resident 129's H&P, dated 6/11/2025, the H&P indicated Resident 129 has fluctuating capacity to understand and make decisions. During a review of Resident 129 MDS, dated [DATE], the MDS indicated Resident 129 is rarely/never understood. The MDS also indicated Resident 129 requires moderate assistance (helper does less than half the effort) to roll left and right in bed. During a review of Resident 129's Order Summary Report, dated 7/30/2026, the Order Summary Report did not indicate a physician's order to place Resident 129's bed against the wall. It also did not indicate any physician's orders for restraints. During a concurrent observation and interview on 7/27/2026 at 9:36 AM with CNA 3 in Resident 129's room, Resident 129 was lying in bed with the left side of the bed positioned against the wall of the room. CNA 3 stated Resident 129's bed is always positioned against the wall and was also against the wall last week. During a concurrent observation and interview on 7/27/2026 at 10 AM with LVN 6 in Resident 129's room, Resident 129 was lying in bed with the left side of the bed positioned against the wall of the room. LVN 6 stated Resident 129's bed is positioned against the wall because Resident 129 is at risk for falls. LVN 6 stated Resident 129 will not fall on the left side of the bed because it is positioned against the wall. LVN 6 further stated if Resident 129 were able to walk, Resident 129 would not be able to get out of bed on the left side because it is against the wall. During an interview on 7/30/2026 at 8:40 AM with the Director of Staff Development (DSD), the DSD stated, Residents' beds should not be placed against the walls of their rooms because that would be considered a physical restraint and that would put the resident at risk for entrapment. Entrapment is when a resident can't get out. It could be dangerous to the resident because if there is an emergency they would not be able to get out. The DSD further stated before the resident's bed can be positioned against the wall, there should be informed consent from the resident/resident's responsible party, a physician's order, assessments, and a care plan. During an interview on 7/30/2026 at 8:50 AM with the DSD, the DSD stated after reviewing Resident 106, Resident 117, and Resident 129's medical records, the DSD could not find informed consents, physicians' orders, assessments, or care plans regarding these residents' beds being placed against their rooms' walls. During an interview on 7/30/2026 at 10:56 AM with the Director of Nursing (DON), the DON stated the definition of a restraint is something that restricts a resident's mobility and movement. The DON stated the facility must not unnecessarily restrain residents because it is against their residents' rights. The DON further stated unnecessarily restraining residents could cause the residents to suffer from accidents. The DON stated before a physical restraint is applied on a resident, the facility must first do an assessment, an interdisciplinary team (IDT - a group of healthcare professionals from different departments) meeting, obtain a physician's order, obtain informed consent, and create a care plan for the restraint. The DON stated a resident's bed positioned against the wall could be considered a restraint because it restricts their movement. During an interview on 7/30/2026 at 2:56 PM with the DON, the DON stated after reviewing Resident 106, Resident 117, and Resident 129's medical records, the DON could not find informed consents, IDT meeting notes, care plans, or education provided regarding these residents' beds placed against the walls. During a review of the facility's P&P titled, Restraints, last revised 5/1/2026, the P&P indicated, The Facility will ensure that restraints will not be imposed for purposes of discipline or convenience. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention. Physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the residents' body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. This may include bed rails, beds against walls, restrictive clothing, etc. An assessment will be completed by a Registered Nurse prior to the application of any device that restricts movements or access to one's body. Restraints will only be used pursuant to a physician's order. Before any type of restraint is used, the Licensed Nurse will verify that informed consent has been obtained from the resident/responsible party and that the resident/responsible party was educated regarding the risks and benefits of restraint used. Care plans for residents with restraints will reflect the type of restraint to be used. The IDT will monitor the resident for any adverse effects of the use of restraints.

Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Residents 46, 113, and 117) received the treatment and services necessary to prevent or heal pressure ulcers (PU - localized damage to the skin and/or underlying tissue usually over a bony prominence) according to the manufacturer's undated guidelines for the Drive-branded LALM titled, Drive - Harmony - True Low Air Loss Tri-Therapy Mattress Replacement System, the facility's policy and procedures (P&P) titled, Support Surface Guidelines, last reviewed 5/1/2026, and undated manufacturer's guidelines for the Wellell-branded LALM titled, Wellell - Procare Elite - User Manual, undated when:1. Resident 46's Low Air Loss Mattress (LALM - a specialized medical support surface designed to prevent and treat skin ulcers by combining alternating pressure with a steady low-volume airflow) was not set consistent with Resident 46's weight. 2. Resident 113's LALM was not removed from Resident 113's bed after the physician's order was discontinued. 3. Resident 117's LALM was not set consistent with Resident 117's weight and was in place without an active physician's order. This failure placed Residents 46, 113, and 117 at increased risk of poor wound healing and increased their risk for the development of new PUs.Findings: 1. During a review of Resident 46's admission Record, dated 7/30/2026, the admission Record indicated Resident 46 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and contractures (the severe tightening and shortening of muscles and other soft tissues that cause joints to become stiff and restrict normal movement) to the right and left knees. During a review of Resident 46's History and Physical (H&P), dated 6/3/2026, the H&P indicated Resident 46 does not have the capacity to understand and make decisions. During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool), dated 5/17/2026, the MDS indicated Resident 46 has severe cognitive impairment of thinking and memory. The MDS indicated Resident 46 has impairment to both sides of their lower extremities (hips, knees, ankles, and feet). The MDS also indicated Resident 46 requires maximal assistance (helper does more than half the effort) when rolling left and right in bed. The MDS also indicated Resident 46 is at risk of developing PUs. During a review of Resident 46's Weights and Vitals Summary, dated 7/30/2026, the Weights and Vitals Summary indicated Resident 46's weight on 7/1/2026 was 81 pounds (lbs- unit of measurement). During a review of Resident 46's physician's order, dated 3/13/2025, the physician's order indicated Resident 46 must have a LALM in place for skin management and to monitor for the proper setting (setting per resident weight or comfort) every shift. During a concurrent observation and interview on 7/27/2026 at 1:03 PM with Treatment Nurse (TN) 1 in Resident 46's room, Resident 46 was lying on top of a LALM while in bed. The Drive-branded LALM machine was turned on and the setting was set at 260 pounds. TN 1 stated the setting of the LALM was incorrect and was too high for the resident's weight. TN 1 stated Resident 46 weighs 81 lbs and the LALM should be set to the resident's most recent weight to function properly. TN 1 further stated if the LALM is not set at the correct setting, Resident 46 may develop further skin breakdown and develop PUs. 2. During a review of Resident 113's admission Record, dated 7/30/2026, the admission Record indicated Resident 113 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels), and hypertension (a condition where the force of blood pushing against artery walls is consistently too high). During a review of Resident 113's H&P, dated 10/10/2025, the H&P indicated Resident 46 does not have the capacity to understand and make decisions. During a review of Resident 113's MDS, dated [DATE], the MDS indicated Resident 113 has severe cognitive impairment of thinking and memory. The MDS also indicated Resident 113 requires maximal assistance when rolling left and right in bed. The MDS also indicated Resident 113 is at risk of developing PUs. During a review of Resident 113's Order Listing Report, dated 7/31/2026, the Order Listing Report indicated Resident 113 had a physician's order to apply a LALM for skin management that was initiated on 1/9/2025 and discontinued on 2/7/2025. During a concurrent observation and interview on 7/27/2026 at 1:10 PM with TN 1 in Resident 113's room, Resident 113 was lying on top of a LALM while in bed. The Drive-branded LALM machine was turned on and a light was blinking indicating low pressure. TN 1 stated the LALM machine is malfunctioning. TN 1 further stated after reviewing Resident 113's medical record, the LALM should not be in place on Resident 113's bed because there is no active physician's order for the treatment. TN 1 stated administering a treatment of LALM without an order could lead to Resident 113 developing a PU because Resident 113 is receiving a treatment Resident 113 no longer needs. 3. During a review of Resident 117's admission Record, dated 7/30/2026, the admission Record indicated Resident 117 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), reduced mobility (limitation in independent, purposeful physical movement or walking ability), and hypertension (a condition where the force of blood pushing against artery walls is consistently too high). During a review of Resident 117's H&P, dated 7/30/2026, the H&P indicated Resident 117 does not have the capacity to understand and make decisions. During a review of Resident 117's MDS, dated [DATE], the MDS indicated Resident 117 has severe cognitive impairment of thinking and memory. The MDS also indicated Resident 117 requires maximal assistance when rolling left and right in bed. The MDS also indicated Resident 117 is at risk of developing PUs. During a review of Resident 117's Weights and Vitals Summary, dated 7/30/2026, the Weights and Vitals Summary indicated Resident 117's weight on 7/26/2026 was 101 lbs. During a review of Resident 117's Order Listing Report, dated 7/31/2026, the Order Listing Report indicated Resident 117 had a physician's order to apply a LALM for skin management that was initiated on 7/22/2025 and discontinued on 7/4/2026. During a review of Resident 117's physician's orders, dated 7/30/2026, the physician's orders indicated a new order was placed on 7/27/2026 at 6:16 PM to apply a LALM to Resident 117's bed for skin management. During a concurrent observation and interview on 7/27/2026 at 1:14 PM with TN 1 in Resident 117's room, Resident 117 was lying on top of a LALM while in bed. The Wellell-branded LALM machine was turned on and the setting was set to 360 lbs. TN 1 stated the setting of the LALM was incorrect and was too high for the resident's weight. TN 1 stated Resident 117 is 101 lbs and the LALM should be set to the resident's most recent weight to function properly. TN 1 further stated if the LALM is not set at the correct setting, Resident 117 may develop further skin breakdown and develop PUs. During an interview on 7/30/2026 at 10:50 AM with the Director of Nursing (DON), the DON stated the purpose of the LALM is for skin management and to help PU prevention and treatment. The DON stated a physician's order is required before placing a LALM on a resident's bed. The DON stated the setting of the LALM should be set to the resident's weight per manufacturer's guidelines. The DON stated the if the LALM settings are not set to the resident's weight, could result in the resident developing further skin breakdown. The DON further stated if the resident and/or the resident's responsible party requests to change the LALM setting for comfort, the resident and/or the resident's responsible party should be provided with education on the risks of going against the LALM manufacturer's guidelines, and this education should be documented in the resident's medical record. During an interview on 7/30/2026 at 11:30 AM with the Director of Staff Development (DSD), the DSD stated the purpose of the LALM is for the prevention and treatment of PUs. The DSD stated the correct setting of the LALM is the resident's current weight per manufacturer's guidelines. The DSD further stated after review of Resident 46 and 117's medical records, no documentation can be found indicating education was provided to the residents and/or residents' responsible party regarding the risks of changing the LALM setting against the manufacturer's guidelines. During a review of the facility's policy and procedures (P&P) titled, Support Surface Guidelines, last reviewed 5/1/2026, the P&P indicated, The facility will identify residents at risk for PUs and provide care and services to promote the prevention of PU development. The facility will implement measures to reduce tissue pressure that includes frequent repositioning, protective devices, and the use of support surfaces. Support surfaces: Low-air-loss mattresses are giant air-permeable pillows that are continuously inflated with air. During a review of the manufacturer's guidelines for the Drive-branded LALM titled, Drive - Harmony - True Low Air Loss Tri-Therapy Mattress Replacement System, undated, the manufacturer's guidelines indicated to adjust the LALM machine's pressure setting according to the weight and height of the patient. During a review of the manufacturer's guidelines for the Wellell-branded LALM titled, Wellell - Procare Elite - User Manual, undated, the manufacturer's guidelines indicated to adjust the LALM machine's pressure setting according to the weight and height of the patient.

Based on observation, interview, and record review, for one of five residents (Resident 15) who had a diagnosis of protein-calorie malnutrition (lack of proper nutrition)., the facility failed to:1. Ensure a resident with a gastrostomy tube (GT - a tube that is passed through the abdominal wall to the stomach used to provide nutrition) received the tube feeding as ordered by the physician.2. Restart the tube feeding pump once the enteral feeding was stopped for at least 26 minutes. This deficient practices resulted the tube feeding (is a medical method used to deliver liquid nutrition directly into a person's gastrointestinal (GI-[stomach/intestine] tract) not infusing into Resident 15 and the pump was alarming and had the potential to result in the resident to not receive the adequate nutrition .Findings: A review of Resident 15's admission Record indicated the facility admitted to the resident on 7/5/2024 and readmitted the resident on 9/30/2025 with diagnoses of, but not limited to, dysphagia (difficulty swallowing), protein-calorie malnutrition and dementia (a progressive state of decline in mental abilities). A review of Resident 15's Minimum Data Set (MDS - a resident assessment tool), dated 5/1/2026, indicated the resident had severely impaired (never/rarely made decisions) cognitive skills for daily decision making. The MDS also indicated the resident required substantial to total assistance with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated the resident had a feeding tube and received 51% or more of their calories from the tube feeding. A review of Resident 15's Physician Order, dated 5/7/2026, indicated to administer - Osmolite 1.5 (medical liquid food0 at 45 cubic centimeters (cc - unit of measurement) per hour for 20 hours via pump per G tube. to provide 900 ml/1350 kcals/56 g protein via enteral pump from 2 PM to 10 AM. During an observation on 7/28/2026 at 9:03 AM, Resident 15's feeding pump was observed alarming and with an alert on the screen reading Notice Pump Inactive. The screen also read Pump has been idle for 10 minutes. Press Continue. The enteral feeding bottle was dated 7/27/2026 and timed at 2 PM. There appeared to be about 300 ccs left in the bottle. During a concurrent interview and observation on 7/28/2026 at 9:19 AM (16 minutes later), at Resident 15's bedside with Licensed Vocational Nurse (LVN) 2, Resident 15's enteral feeding pump was observed paused and alarming. LVN 2 stated the feeding pump was scheduled to stop at 10 AM. LVN 2 further stated LVN 2 was not aware that the feeding pump was alarming and did not know why the feeding pump was paused. LVN 2 if Resident 15's feeding was stopped at 10 AM or even an hour later at 11 AM, Resident 15 would not receive his full dose of enteral feeding. LVN 2 further stated not receiving the full ordered dose could lead to Resident 15 having nutrition declining and losing weight. During an interview on 7/30/2026 at 1:08 PM, the Director of Nursing (DON) stated Resident 15's enteral feeding was ordered to start at 2 PM and stop at 10 AM for a total of 20 hours. The DON also stated staff can pause a resident's tube feeding when providing care or medication administration and staff should restart the feeding as soon as possible. The DON further stated the resident could suffer inadequate caloric intake if the feeding isn't restarted right away. A review of facility's policy and procedures titled, Tube Feeding/TPN, reviewed 1/1/2026, indicated the purpose was to ensure that the Facility meets the nutritional guidelines and resident's nutritional requirements per physician orders.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free sexual abuse (non-consensual sexual contact of any type with a resident) for one of one sampled resident (Resident 1) according to the facility's policy and procedures (P&P) titled, Abuse Prevention and Prohibition Program dated 6/25/2025.On 7/21/2026 at around 11PM, Resident 1 complained to Licensed Vocational Nurse (LVN) 1 that Certified Nursing Assistant (CNA) 1 sexually abused Resident 1. This deficient practice resulted in CNA 1 remaining in the facility and continued to provide care to residents on 7/21/2026 and 7/22/2026 for a total of 15 hours and 30 minutes increasing the potential risk for abuse for the residents in the facility.Findings; During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/10/2026 with diagnoses that included Diabetes Mellitus type 2 (DM-2 a long term condition, often developed due to poor lifestyle choices, characterized by difficulty in blood sugar control and poor wound healing) and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/10/2026, the MDS indicated Resident 1 had moderate cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 60 used wheelchair for mobility. The MDS indicated Resident 1 needed staff maximum assistance for eating and fully dependent on staff for eating and activities of daily living (ADL- sitting/standing, oral hygiene, personal hygiene toileting hygiene, shower/bath, lower body dressing, and toilet transfer). During an interview with CNA 1 on 7/24/2026 at 12:20pm, CNA 1 stated that on 7/21/2026 at around 11:02pm Resident 1 pushed the call light and CNA 1 went right away to help Resident 1. CNA 1 stated Resident 1 requested his incontinence brief to be changed. CNA 1 stated CNA 1 politely asked Resident 1 if Resident 1 was wet (urine), but Resident 1 got upset and told CNA 1 that CNA 1's job was to change Resident 1's incontinence brief. CNA 1 stated CNA 1 then uncovered Resident 1, however, Resident 1 refused for CNA 1 to change Resident 1's incontinence brief and threw the call light towards CNA 1 and asked CNA 1 to send someone else. CNA 1 stated that CNA 1 did not touch Resident 1 or Resident 1's incontinent brief and CNA 1 left Resident 1's room. CNA 1 stated CNA 1 informed LVN 1 of the afore mentioned incident. CNA 1 stated that on 7/21/2026 at around 11:30 pm, Registered Nurse (RN) 1 called CNA 1 and informed CNA 1 that Resident 1 was alleging that CNA 1 sexually abused Resident 1. CNA 1 stated RN 1 informed CNA 1 that CNA 1 was removed from Resident 1 and that CNA 1's assignment was changed to provide care to other residents for rest of the shift (11pm - 7pm shift). CNA 1 stated that CNA 1 completed/worked the entire shift on 7/21/2026 from 11 pm to 7 am (7/22/2026) and left the faciity on 7/22/2023 at 7 am. CNA 1 stated that CNA 1 came back to the facility, to work and provided care to residents on 7/22/2026 from 11 pm till 7 am (7/23/2026). CNA 1 stated that on 7/24/2026, the Assistant Administrator (AADM) contacted CNA 1 and asked CNA 1 to come and meet with AADM at the facility in facility. CNA 1 stated she met with AADM on 7/24/2026) in the AADM in AADM's office regarding the incident with Resident 1 on 7/21/2026. CNA 1 sated that CNA 1 might have been suspended. During a telephone interview with Resident 1 on 7/24/2026 at 1:59pm, Resident 1 stated, that on 7/21/2026 at 11 pm, I needed to be changed so I push call light and I told her (CNA 1) that I need to be changed (provide incontinence [the loss of urine and feces control] care. She (CNA 1) argued why someone else didn't change me (Resident 1). Then she touched my penis (male body part that passes urine from inside of the body to outside) really hard. I reported it to night supervisor (licensed nurse), don't remember the name. She (CNA 1) did not open the (incontinence brief) but touched my penis. During a review of CNA 1's electronic timecard for the month of 7/2026, indicated CNA 1 clocked in to work on the following dates and time: On 7/21/2026 - CNA 1 clocked in the facility at 10:44 pm and clocked out for the shift at 7:01 am.On 7/22/2026 - CNA 1 clocked in the facility at 10:57 pm and clocked out for the shift at 7:00 am. During a review of the facility's Nursing Staffing Assignment and Sign In Sheet dated 7/21/2026, ,indicated CNA 1 was assigned to provide care to a total 16 residents including Resident 1 on 7/21/2026 from 11pm to 7am.During a review of Resident 1's Nurse's Note dated 7/21/2026 at 11:40 pm, indicated Registered Nurse (RN) 1 documented that, Charge nurse (LVN 1) reported to RN supervisor (RN 1) that a resident (Resident 1) want to speak to supervisor. I went to speak to (Resident 1) and asked what he (Resident 1) wanted to speak to me about. (Resident 1) had a complaint about a CNA (CNA 1) allegedly touching him inappropriately in his penis. I told the resident that I was sorry about what he had experienced and I will assign a new CNA to the room (Resident 1). During a review of the facility's Nursing Staffing Assignment and Sign In Sheet dated 7/22/2026 from 11pm to 7 am, indicated CNA 1 was not assigned Resident 1, however, CNA 1 was assigned to provide care to 18 residents. During a review of the facility's 5-day summary report titled Report, dated 7/29/2026, indicated, After investigation was complete and based on the interviews and statements from resident, roommate and staff interviewed, It was determined that allegation could not be substantiated based on the fact that CNA was inside room for a very short period of time and did not get to touch patient that night. During an interview on 7/24/2026 at 3:14 pm with RN 1, RN 1 stated RN 1 and LVN 1 were working on 7/21/2026 from 11 pm to 7am. RN 1 stated that LVN 1 told RN 1 that Resident 1 accused CNA 1 of sexually abusing Resident 1 on 7/21/2026 at around 11:30 pm. RN 1 stated that, I (RN 1) changed (CNA 1's) assignment to provide care to other residents for rest of the shift. RN 1 stated that on 7/21/2026 at 11:30 pm, RN 1 telephoned and informed the Director of Nursing (DON) that Resident 1 was alleging that CNA 1 sexually abused Resident 1 and that CNA 1 was removed from Resident 1 and was reassigned to provide care to other residents. RN 1 stated the DON did not give RN 1 further guidance or instructions. During an interview on 7/24/2026 at 3:33 pm with AADM and the DON, the AADM stated, We are aware that we should have suspended the CNA (CNA 1) right away to protect (Resident 1) and we missed it. We suspended the CNA 1 today (7/24/2026). The DON stated, CNA 1 should have been suspended right after the sexual abuse allegation incident. The DON stated that on 7/24/2026, the facility Administrator called CNA 1 to come to the facility for a meeting regarding incident. The DON stated CNA 1 was removed from Resident 1, however, CNA 1 remained in the facility, and continued to provide care to other residents in the facility. The DON stated that on 7/21/2026 at around 11:30 pm, CNA 1 was removed from Resident 1, however, CNA 1 was reassigned to provide care for other residents in the facility. The DON stated CNA 1 was not suspended or removed from the facility and that CNA 1 worked the entire shift on 7/21/2026. The DON stated that on 7/21/2026 night, CNA 1 returned to work in the facility on 7/22/2026 and worked from 11pm to 7am. The DON stated, but I understand that per policy we should have suspended CNA 1 right after the incident (sexual abuse allegation). During a review of the facility's policy and procedures (P&P) titled, Abuse Prevention and Prohibition Program dated 6/25/2025, the P&P indicated, Facility Staff members accused of committing abuse, neglect or mistreatment against a resident are suspended until the investigation is complete and the findings have been reviewed by the Administrator. Staff members alleged to have committed abuse, neglect or mistreatment against a resident will not be reinstated to their regular assignment until the investigation is complete and the allegation is unsubstantiated.

Based on observation, interview, and record review, the facility failed to report allegation of sexual abuse within two hours to the Department of Public Health and Adult Protection Services (APS) for one of one sampled resident (Resident 1), according to the facility's policy and procedures (P&P) titled, Abuse Prevention and Prohibition Program dated 6/25/2025. This deficient practice had the potential for Resident 1 and other residents in the facility to experience/suffer abuse.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/10/2026 with diagnoses that included Diabetes Mellitus type 2 (DM-2 a chronic condition, often developed due to poor lifestyle choices, characterized by difficulty in blood sugar control and poor wound healing) and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/10/2026, the MDS indicated Resident 1 had moderate cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated that Resident 60 used wheelchair. MDS indicated that Resident 1 needed maximum assistance for eating and fully dependent on staff for eating and activities of daily living (ADL- sitting/standing, oral hygiene, personal hygiene toileting hygiene, shower/bath, lower body dressing, and toilet transfer). During a review of a document, Intake Report (document faxed by facility to California Department of Public Health [CDPH]), a telephone report was made to law enforcement on 7/23/2026 at 1:40 am regarding the Alleged sexual abuse incident. Intake Report indicated, On July 21, 2026, during the 11pm-7am shift, female C.N.A. responded to call light in room [ROOM NUMBER]A. Resident asked C.N.A. to change his diaper. According to the resident, C.N.A. allegedly touched his penis while checking his diaper. C.N.A. denies open/remove diaper and did not expose any part of the resident's body. Resident allegedly told C.N.A to stop touching him and after a short discussion between the two, the C.N.A. left the room without changing the resident. C.N.A. states resident no longer wanted diaper changed so she left the room. Resident requested to speak to RN Supervisor, and after describing the alleged incident, another C.N.A. changed his incontinent brief. During an interview with CNA 1 on 7/24/2026 at 12:20pm, CNA 1 stated that on 7/21/2024 at around 11:02pm Resident 1 pushed the call light and CNA 1 went right away to help Resident 1. CNA 1 stated Resident 1 requested his incontinence brief to be changed. CNA 1 stated CNA 1 politely asked Resident 1 if Resident 1 was wet (urine), but Resident 1 got upset and told CNA 1 that CNA 1's job was to change Resident 1's incontinence brief. CNA 1 stated CNA 1 then uncovered Resident 1, however, Resident 1 refused for CNA 1 to change Resident 1's incontinence brief and threw the call light towards CNA 1 and asked CNA 1 to send someone else. CNA 1 stated that CNA 1 did not touch Resident 1 or Resident 1's incontinent brief and CNA 1 left Resident 1's room. CNA 1 stated CNA 1 informed LVN 1 of the aforementioned incident. CNA 1 stated that on 7/21/2026 at around 11:30 pm, Registered Nurse (RN) 1 called CNA 1 and informed CNA 1 that Resident 1 was alleging that CNA 1 sexually abused Resident 1. CNA 1 stated RN 1 informed CNA 1 that CNA 1's assignment was changed for rest of the shift (11pm - 7pm shift). CNA 1 stated that CNA 1 completed/worked the entire shift on 7/21/2026 from 11 pm to 7 am (7/22/2026) and left the faciity on 7/22/2023 at 7 am. CNA 1 stated that CNA 1 came back to the facility, to work and provided care to residents on 7/22/2026 from 11 pm till 7 am (7/23/2026). CNA 1 stated that CNA 1 was in the facility the same day (7/24/2026) to meet with the Assistant Administrator (AADM) regarding the incident and might have been suspended.During an interview on 7/24/2026 at 1:07 pm with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Any type of abuse occurred in the facility should be reported to department of public health and law enforcement within 2 hours. During a telephone interview with Resident 1 on 7/24/2026 at 1:59pm, Resident 1 stated, that on.7/21/2026 at 11 pm, I needed to be changed so I push call light and I told her (CNA 1) that I need to be changed (provide incontinence [the loss of urine and feces control] care. She (CNA 1) argued why someone else didn't change me (Resident 1). Then she touched my penis really hard. I reported it to night supervisor (licensed nurse). I don't remember the name. She (CNA 1) did not open the (incontinence brief) but touched my penis. During an interview on 7/24/2026 at 3:14 pm with Registered Nurse (RN) 1, RN 1 stated RN 1 and LVN 1 were working on 7/21/2026 from 11 pm to 7am. RN 1 stated that LVN 1 told RN 1 that Resident 1 accused CNA 1 of sexually abusing Resident 1 on 7/21/2026 at around 11:30 pm. RN 1 stated RN 1 telephoned and informed the Director of Nursing (DON) that Resident 1 was alleging that CNA 1 sexually abused Resident 1 and that CNA 1 was removed from Resident 1 and was reassigned to provide care to other residents. During an interview on 7/24/2026 at 3:33 pm with AADM (Assistant Administrator) and DON, AADM stated, We (facility) are aware that we should have reported the sexual abuse incident to department of public health and law enforcement within 2 hours, per policy. But we missed it (Resident 1 alleging that CNA 1 sexually abused Resident 1), DON stated, We understand the sexual abuse allegation occurred on 7/21/2026 at around 11:30 pm but we didn't report to the department of public health until 7/23/2026 at around 2:22 pm. I understand that per our (facility) policy we should have reported the incident to public health department and law enforcement within 2 hours. During a review of the facility's policy and procedures (P&P) titled, Abuse Prevention and Prohibition Program dated 6/25/2025, the P&P indicated, Special Considerations for Reporting Suspected Incidents of Criminal Sexual Abuse - The Administrator then acts to ensure the following steps are taken: The proper authorities and individuals are notified immediately or within two (2) hours, including but not limited to law enforcement, the Attending Physician, the resident's representative, the state survey agency, and adult protective services.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent elopement (when a resident leaves the facility grounds or a designated safe area without the staff knowing and/or without the supervision the resident needs) for one of three sampled residents (Resident 1) who was assessed at risk for wandering (walking around without a clear purpose) and elopement by failing to: 1. Accurately assess and identify elopement risk. The facility's Wandering & Elopement assessment dated [DATE] indicated a Low Probable Risk even though Resident 1 demonstrated repeated exit seeking, wandering, and attempts to elope on [DATE]. RN 2 stated the assessment was inaccurate and should have reflected a Moderate Actual Risk (is where a hazard is present and has a fair or intermediate likelihood of occurring). 2. Identify the sliding door in Resident 1's room and in Rooms 126, 128, 130, 132, 134, 136, and 138 as a potential elopement route and evaluate the need for an alarm or other safety device on this exit, despite the resident's repeated exit seeking behavior. 3. Identify the two patio gates at the back of the facility that leads to Avenue 1 and Street 2 as a risk and did not install alarms prior to Resident 1's elopement. 4. Implement the interventions outlined in the Elopement Risk/Wanderer Care Plan (CP - is a structured, individualized document created by healthcare professionals in collaboration with the patient to outline specific health conditions, treatment goals, and necessary services) to ensure the resident is properly evaluated for the need for increased supervision and close monitoring, including continuous visual observation. 5. Revise and strengthen elopement interventions despite Resident 1 demonstrating repeated and escalating exit seeking behaviors during both the 7 a.m.-3 p.m. and 3 p.m.-11 p.m. shifts on [DATE]. As a result of these deficient practices, Resident 1 eloped from the facility on [DATE] between 7:54 a.m. and 8:30 a.m. and was not found by facility staff. At approximately 11 p.m. on [DATE], an unidentified individual called 911 (the telephone number used to reach emergency medical, fire, and police services) after finding Resident 1 on the street. Emergency responders reported that the resident had been robbed, beaten, and set on fire. Paramedics (are advanced allied health professionals in the Emergency Medical Services (EMS) system who provides critical,, life-saving prehospital care to patients) found Resident 1 lying unconscious on the ground with burns to the neck, shoulders, face, scalp, and back, and with swelling of the face and tongue. The resident was transported to General Acute Care Hospital (GACH 2), arriving on [DATE] at 12:23 a.m., and was subsequently transferred to GACH 3. On [DATE] at 9:45 a.m., Resident 1 expired at GACH 3. On [DATE] at 5:04 PM and while onsite, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADMIN) and Director of Nursing (DON) due to the failure to properly supervise Resident 1 and not have effective interventions in place to prevent elopement. On [DATE] between 7:54 a.m. and 8:30a.m., Resident 1 eloped from the facility. On [DATE] at about 11 p.m., emergency responders found the resident on the street, unconscious, robbed, beaten, and burned. The resident was taken to GACH 2 and transferred to GACH 3 on [DATE], where the resident passed away. On [DATE] at 6:48 p.m., while onsite at the facility, the SSA removed the IJ in the presence of the ADMIN and DON, after the facility submitted an acceptable IJ Removal Plan (IJRP- interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. Although the IJ was removed, the facility remained out of compliance with F689 (is a federal regulation for long-term care facilities (nursing homes) under the Centers for Medicare & Medicaid Services (CMS) at a scope and severity level G, meaning actual harm occurred but the situation was no longer at the Immediate Jeopardy level. The acceptable IJRP included the following summarized actions: 1. On [DATE] Resident 1 eloped and did not return to the facility. Resident 1 died on [DATE]. 2. On [DATE], the Registered Nursing Consultant (RNC) immediately in-serviced (educate) the DON on monitoring and supervising residents for safety and elopement, Dementia Care, Supervision of Dementia Residents, and Elopement and wandering. 3. On [DATE] and [DATE], the DON immediately placed six (6) residents (Residents 6, 7, 8, 9,10, and 11) identified as at risk for elopement/wandering and on thirty-minute rounding (monitoring/supervising) until reassessments were completed and care plans were fully updated. The intervention of close monitoring was removed from Residents 6, 7, 8, 9 ,10, and 11 care plans and thirty-minute rounding was added to the care plans. 4. On [DATE] and [DATE], the Medical Record Director (MRD), and the RNC, immediately reviewed and audited the care plans for Residents 6, 7, 8, 9 ,10, and 11 at risk of elopement/wandering to verify that interventions were current, updated and revised, individualized, and reflected the resident's current behavior status. 5. On [DATE] and [DATE], the Interdisciplinary Team (IDT- a collaborative group of professionals from diverse fields such as doctors, nurses, therapists, and social workers who work together, sharing expertise to provide comprehensive, integrated care for a patient's complex physical and psychological needs), Director of Staff Development (DSD) Consultant and RNC, immediately completed individualized Wandering and Elopement Risk Assessments for Residents 6, 7, 8, 9 ,10, and 11 who were at risk for elopement/wandering. 6. On [DATE] at 10 a.m., a contracted vendor installed alarms at Gates 4, 5, 6, and 7 [[NAME] Street Gate (Gate 4), [NAME] gate to side yard (Gate 5), Gate to side yard (Gate 6), and [NAME] Street Gate (Gate 7)]. On [DATE] at 4:30p.m., the contracted vendor tested and verified that all four gate alarms were fully operational. 7. On [DATE] and [DATE], the RNC immediately notified all attending physicians for Residents 6, 7, 8, 9, 10, and 11, who were identified as being at risk for elopement/wandering, to obtain updated physician orders supporting the revised care plan interventions listed above. During the same period, the RNC and the DSD Consultant conducted in-service training for two Certified Nursing Assistants (CNAs), one Registered Nurse Supervisor (RN), and one Licensed Vocational Nurse (LVN). The training covered: (a) elopement prevention and intervention techniques; (b) proper use and documentation of close monitoring procedures; (c) strategies for de escalating exit seeking behavior; and (d) immediate reporting requirements when resident behaviors escalate (someone's actions or emotions start small but slowly get stronger or more intense). 9. On [DATE] and [DATE] Nurse Consultant and DSD Consultant educated 64 Licensed Nurses, Certified Nursing Assistants and Nursing supervisors on their duty to escalate unresolved behavioral risks to the care plan team, DON, ADMIN, and physician. 10. On [DATE] at 10 a.m., all facility elopement alert systems were audited by Maintenance Consultant and [NAME] President of Construction and Physical Plant (VP). The following systems were audited with the following:a. Wander Guard Door Alarms (are electronic security systems designed for healthcare and senior living facilities to prevent residents with Alzheimer's, dementia, or cognitive impairments from wandering away from safe areas) were labeled and checked for functionality for the six (6) doors [Door #1 (Lobby Door), Door #2 (Stairwell), Door #3 (Emergency Exit 1), Door # 4 (Emergency Exit 2), Door #5 (Activity/Dining room), and Door #6 (Emergency Exit 3)] b. Maintenance consultant and VP labeled perimeter gates along with matching interior facility alarm that sounds when the gate is opened. The following four (4) perimeter gates and alarm were tested for functionality and passed [[NAME] Street Gate (Gate 4), [NAME] gate to side yard (Gate 5), Gate to side yard (Gate 6), and [NAME] Street Gate (Gate 7)] c. A facility-wide environmental safety audit was completed by Maintenance Consultant and VP of all exits, stairwells, and common areas. Seven (7) Exit doors (Front Door, Stairwell, Elevator, Kitchen Back Door, Rehab Room back door, Medical Records back gate, and Garage Gate /pedestrian door) were audited for working alarms and appropriate signage (e.g., STOP signs, visual barriers) all passed the audit. d. Each alarm was labeled and tested with the gate number it is assigned by the VP with the following findings. Staff were able to respond within one minute. The perimeter gates are locked but can be pushed open for emergency egress. e. Sliding door stoppers were installed on sliding doors in resident rooms and inspected by maintenance consultant and VP. 12. On [DATE] at 2 p.m., door alarms were installed and inspected on all exterior facing sliding doors in resident rooms that access patios and/or balconies by maintenance consultant and The sliding door stoppers with reinforcements and visual cues for residents to prevent elopement. The facility staff are able to remove the door stoppers in the event of an emergency. The sliding doors are not emergency evacuation exits and will not prohibit exit in case of an emergency. 13. On [DATE] at 2:30 PM, stoppers and alarms were installed on facility windows by maintenance consultant. 14. On [DATE] at 3 PM, resident rooms (Rooms 1, 2, 3, 4, 5, and 6) for identified higher risk elopement residents were audited by VP with the following findings: a. room [ROOM NUMBER]: Metal stopper in place for sliding door, door alarm in place and functional - no window present b. room [ROOM NUMBER]: 2 windows with metal stoppers in place (x2-twice) and alarms in place and functional (x2) - no sliding door present. c. room [ROOM NUMBER]: Metal stopper in place for sliding door, door alarm in place and functional - no window present. d. room [ROOM NUMBER]: Metal stopper in place for sliding door, door alarm in place and functional - no window present. e. room [ROOM NUMBER]: Metal stopper in place for sliding door, door alarm in place and functional - no window present. f. room [ROOM NUMBER]: Metal stopper in place for sliding door, door alarm in place and functional - no window present. 15. On [DATE], the RNC updated the facility's policy and procedures on elopement prevention, risk identification upon admission, and escalation procedures to include H. If the resident does not return safely the facility will call surrounding hospitals, notify the RP and Medical Doctor (MD-physician) search the area and etc. and Staff will upload the residents photo upon admission to our Electronic Medical Records and Document if resident refuses to take a photo at the facility during admission and readmission. Sixty-four (64) Nursing Staff were in-serviced on the updated Elopement and Wandering Policy and Procedure. Findings: A review of Resident 1's General Acute Care Hospital (GACH 1) Psychiatry (A field of medicine that focuses on understanding, diagnosing, and treating mental, emotional, and behavioral disorders) Consult Note dated [DATE], indicated that Resident 1 was admitted to GACH 1 on [DATE] for decreased oral intake and unintentional weight loss. The psychiatric consultation was requested due to the resident's increased confusion. The consultation notes further indicated that Resident 1 lacked capacity to make medical decisions. The psychiatry consultants noted that Resident 1 had a one-to-one sitter (1:1 - a staff member or trained companion assigned to provide continuous bedside supervision to ensure the patient's immediate safety). The consultants documented that Resident 1 appeared confused and was alert and oriented only to name/self (oriented x1). They also noted that Resident 1 required constant redirection due to frequent attempts to get out of bed. A review of Resident 1's admission record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure (the sudden loss of kidney function that impairs the ability to filter waste, balance fluids, and regulate electrolytes), cirrhosis of the liver (late stage, often irreversible scarring of liver tissue), dementia (a decline in cognitive functioning -memory, language, problem solving, and thinking that interferes with daily life), anxiety (excessive and persistent worry or fear that disrupts functioning), protein calorie malnutrition (a deficiency of essential macronutrients needed to meet the body's requirements), restlessness (excessive, non purposeful movement or pacing), and agitation (including verbal aggression). A review of Resident 1's Change in Condition (COC - is a sudden or significant deviation from a patient's baseline physical, cognitive, or functional status. It signifies an acute deterioration or improvement requiring intervention) form dated [DATE] at 10:02 a.m. showed that Resident 1 was identified as an elopement risk starting that morning. Resident 1 was alert and oriented to one area, newly admitted on [DATE], verbally responsive, and able to walk without assistance. The resident was observed to be anxious and frequently wanting to leave the facility. A review of Resident 1's Wandering & Elopement Risk Assessment, dated [DATE] at 10:10 AM, indicated that Resident 1 had not eloped but was assessed as a moderate elopement risk under section D due to recent observable wandering that was not easily ended or redirected. However, under section G on Wandering & Elopement Assessment Risk Score indicated Resident 1 was a Low Probable Risk for elopement. A review of Resident 1's Physician Progress Note dated [DATE] at 1:23 p.m. showed that Resident 1 had increasing confusion, agitation, and significant dementia. The note stated that Resident 1 primary language is not English, appeared confused, could not participate in a goal directed conversation, and appeared disorganized. The physician documented that Resident 1 could not make needs known and did not have the mental capacity to make medical decisions. A review of Resident 1's Elopement Risk/Wanderer Care Plan (CP), initiated on [DATE], indicated that Resident 1 was at risk for wandering due to exit seeking behavior, new admission status, and verbalizations of wanting to leave the facility. The care plan goals included ensuring that Resident 1 did not leave the facility unattended and that the facility maintained the resident's safety. Interventions included addressing the resident's wandering behavior by walking with the resident or attempting to redirect the resident from inappropriate behaviors, as well as evaluating the resident for the need for additional supervision and providing close monitoring. A review of Resident 1's facility Order Summary Report for [DATE] indicated the following physician orders:On [DATE], monitoring of the Wanderguard (an electronic safety device worn as a bracelet or anklet to help prevent residents with cognitive impairment from wandering or eloping) on the right ankle every shift.On [DATE], monitoring of the Wanderguard's functionality every shift using a tester. A review of Resident 1's Nurses Notes dated [DATE] at 9:44 p.m. indicated that Resident 1 was ambulatory (to walk) and required limited assistance with activities of daily living (ADLs, such as bathing, dressing, and toileting) during this shift. The progress notes documented multiple episodes (number not specified) of wandering, and a Wanderguard was placed on the resident's right ankle. The notes further indicated that Resident 1 had several episodes of agitation (number not specified) during the 3 p.m. to 11 p.m. shift, characterized by attempts to hit staff during efforts to redirect the resident back to the room when the resident was attempting to exit the facility. The RN was notified. A review of Resident 1's facility Situation Background Assessment Recommendation (SBAR- a tool used in healthcare to improve patient safety by enabling fast, accurate, and concise information transfer between clinicians) dated [DATE] at 9:44 p.m. indicated that Resident 1 was restless, pacing, grimacing, which was documented as a new change in behavior. The SBAR noted that the physician was informed, no new orders were received, and no additional interventions were documented. A review of Resident 1's Nurses Notes dated [DATE] at 11:09 p.m. indicated that Resident 1 displayed multiple episodes of wandering (number not specified) during the 3 p.m. to 11 p.m. shift and attempted to elope from the facility. The note further indicated that the registered nurse supervisor was made aware of the situation, and no new interventions were received at that time. A review of Resident 1's Medication Administration Record (MAR) for [DATE] indicated that on [DATE], during the day shift (7 a.m. to 3 p.m.), the resident manifested five episodes of anxiety-related behaviors manifested by (m/b) agitation. The MAR further indicated that the resident exhibited an additional five episodes of anxiety-related behaviors during the evening shift (3 p.m. to 11 p.m.). The MAR further indicated, by check mark, that Resident 1 exhibited wandering behavior during the 3 p.m. to 11 p.m. shift. A review of Resident 1's COC dated [DATE] at 8:44 a.m. indicated that the resident was identified as an elopement case that morning. The Medication Nurse reported that Resident 1 could not be found in his room. All staff searched for the entire facility but were unable to locate the resident. The facility called 911, and a missing person report was filed with the Los Angeles Police Department (LAPD). A review of Resident 1's Nurses Notes dated [DATE] at 10:57 a.m. indicated that the resident had been very agitated during the previous overnight shift (11 p.m. to 7 a.m.) and repeatedly expressed a desire to go home. On [DATE] at approximately 7:40 a.m., a certified nursing assistant (CNA) assisted Resident 1 by setting up breakfast in the resident's room. At around 7:50 a.m., a Restorative Nursing Assistant (RNA, an advanced certified nursing assistant who provides specialized rehabilitative care), reported seeing Resident 1 sitting on the bed. At approximately 8:20 a.m., a charge nurse entered Resident 1's room to administer medications and observed that the resident was not present. The sliding door in Resident 1's room was found open. Facility staff immediately initiated a search of the building and surrounding areas, including all resident rooms, restrooms, the backyard, and the garage. The notes indicated that Closed-Circuit Television (CCTV, a video surveillance system) footage was reviewed; however, Resident 1 was not seen existing through the main entrance or any other door. The same Resident 1's Nurses Notes indicated Resident 1's family member (FM 1) was notified. FM 1 reported that Resident 1 had expressed a desire to go home on the previous day ([DATE]) and confirmed that the resident had significant memory impairment and was very confused. Emergency services and law enforcement were notified to file a missing person report. Resident 1's attending physician was also informed of the situation. The Nurses Notes concluded with: At the time of this report, all staff members continued to search for the resident. A review of the Los Angeles Fire Department (LAFD) Patient Care Report dated [DATE] at 12:02 a.m. showed that Emergency Medical Services (EMS- It is a comprehensive system providing out-of-hospital, acute medical care and transportation for victims of sudden illness or injury) arrived on scene at 12:09 a.m. and found Resident 1 lying on the street with police present. EMS could not identify the resident or locate any identification. Resident 1 had second (partial-thickness burn) damages the outer layer (epidermis) and part of the underlying layer (dermis) of the skin, causing severe pain, redness, swelling, and blistering) and third-degree (is a severe medical emergency that destroys all layers of the skin-the epidermis and dermis-and can damage underlying fat, muscle, and bone) burns on the neck, face, shoulders, and back. Police suspected that a substance had been thrown on the resident and the resident had been set on fire. EMS noted that the resident's airway (the pathway that allows air to travel in and out of the lungs for respiration) was compromised, with swelling and burn injuries. Resident 1 was hot to the touch, unresponsive, and had labored breathing. EMS assisted breathing with a Bag-Valve-Mask (BMV-a handheld medical device used in emergency care to provide positive pressure ventilation (PPV-a technique where a machine (ventilator) forces air into the lungs to assist or replace breathing) to patients who are not breathing or breathing inadequately) and inserted an oropharyngeal airway (is a curved, rigid, plastic, or rubber medical device inserted into the mouth of an unconscious or unresponsive patient). An intraosseous (IO- inside a bone) line (access - is a medical technique used in emergencies to deliver fluids and medications directly into the marrow of a bone ) was placed in the left lower leg, and 500 milliliters (mL) of normal saline (NS- is a sterile solution used widely in clinical settings for intravenous (IV-inside a vein) hydration, wound irrigation, and drug dilution). The cause of injury was documented as burn/chemical/fire exposure. After interventions, EMS transported the resident to the nearest trauma center (GACH 2) due to airway compromise (obstruction/any blockage (foreign body, swelling, or trauma) preventing air from entering or leaving the lungs) and paramedic judgment. A review of Resident 1's GACH 2 Emergency Department physician notes dated [DATE] at 12:56 a.m. indicated the following: Resident 1 arrived with severe burn injuries. The onset was estimated to be about one hour prior. Burns were located on the face, back, circumferential neck, and shoulders, with swelling, redness, and loss of mobility. The resident had a bracelet from the convalescent facility on the left wrist. Symptoms were severe and worsening, with smoke inhalation, shortness of breath, and altered mental status. The incident occurred in the street. Paramedics (a highly trained allied health professionals who provides advanced, prehospital emergency medical care, stabilization, and transportation for critical patients) reported they found Resident 1 unconscious on the roadside with burns to the neck, shoulders, face, scalp, and back. They placed an oral airway (a device used to maintain an open, unobstructed airway in unconscious patients)_ and assisted breathing (The therapeutic process uses a machine (ventilator or respirator) to help move air into and out of the lungs when a patient cannot breathe adequately on their own). The scalp had widespread partial thickness burns (damage the epidermis and part of the dermis, causing blisters, intense pain, swelling, and moist, red skin), hair was singed (hair that has been superficially or lightly burned, scorched), and the face and tongue were swollen. EMS was unable to obtain intravenous (IV - inside a vein) access and placed an intraosseous (IO- administered by entering a bone) line in the right lower leg before transporting the resident to the hospital. The emergency department physician at GACH 2 documented that Resident 1 had 35% total body surface area burns: 25% second degree burns (partial thickness injuries damaging the outer layer of skin and part of the underlying layer, causing intense pain, swelling, redness, and blistering) and 10% third degree burns (full thickness injuries destroying both skin layers; these burns may be painless due to nerve damage). The entire back was blackened with partial-thickness burns. Due to swelling and airway compromise, the resident required an escharotomy (an emergency surgical procedure involving incisions through thick, leathery burn tissue to relieve pressure) of the neck by trauma surgery and was intubated (having a tube inserted into the body, most commonly the trachea (windpipe), to maintain an open airway and support breathing, typically via a ventilator during surgery, emergency, or critical illness). Four liters of lactated Ringers (LR - fluid used for hydration and resuscitation [is the emergency medical process of reviving a person from apparent death, unconsciousness, or correcting acute physiological failures (sudden, life-threatening deteriorations in body function where an organ or system can no longer maintain normal homeostasis, demanding immediate medical intervention to prevent death), such as stopped breathing or heart function]) were given for burn resuscitation (the critical time -sensitive treatment used to manage severe burn injuries by replacing lost fluids). After intubation and escharotomy, the physician arranged transfer to a burn center (GACH 3). Air ambulance was contacted with a 10-minute estimated arrival time. The physician documented providing 65 minutes of critical care. A review of Resident 1's the facility Nurses Notes dated [DATE] at 1:15 p.m. indicated that a Registered Nurse Supervisor (RN) received a telephone call from a unit coordinator at GACH 2, who reported that Resident 1 had been found in a burned building. A review of Resident 1's the facility Nurses Notes dated [DATE] at 4:53 p.m. indicated that GACH 3 contacted the facility and informed staff that Resident 1 had expired at GACH 3 on [DATE] at 9:45 a.m. During an interview on [DATE] at 10:50 a.m., the DON stated that Resident 1 was last seen by RNA 1 inside the resident's room on [DATE] at 7:50 a.m., during breakfast time. The DON stated that LVN 1 discovered Resident 1 missing at approximately 8:15 a.m. on [DATE], when LVN 1 entered the resident's room to administer medications. The DON further stated she received a call on [DATE] at approximately 12 a.m. (midnight) from RN 3, who informed her that RN 3 had received a call from GACH 2 requesting that Resident 1's face sheet be electronically sent because the resident was going to be transferred to GACH 3. During an interview on [DATE] at 12:43 p.m., LVN 1 stated that on [DATE] at approximately 8:10 a.m. to 8:15 a.m., he (LVN 1) was standing near the entrance of Resident 1's room preparing medications to administer to the resident. LVN 1 stated that when he entered the room to speak with Resident 1 before administering the medications, the resident was not inside the room or in the bathroom located within the room. LVN 1 stated he observed that the balcony sliding door and screen door in Resident 1's room were slightly ajar. LVN 1 reported that he immediately notified RN 2 and the desk nurse, LVN 2, and that RN 2 initiated Code 11 (an emergency procedure used when a resident is missing from their assigned location). LVN 1 stated that Resident 1 was new to the facility and spoke only his native language. On the same interview, LVN 1 stated that during the 7 a.m. to 3 p.m. shift on [DATE], Resident 1 had been pacing back and forth in the hallways looking for exits from the facility. According to LVN 1, the resident appeared agitated, frustrated, and repeatedly verbalized a desire to leave while attempting to exit the facility multiple times (numbers not specified). LVN 1 stated that Resident 1 unsuccessfully attempted to leave through the front lobby reception exit door, the laundry room exit door, and the kitchen area exit door. LVN 1 further stated that due to the resident's exit-seeking behavior, a Wanderguard device was placed on Resident 1's ankle. During an interview on [DATE] at 12:47 p.m., Registered Nurse Supervisor (RN) 2 stated that the facility first identified Resident 1 as an elopement risk on [DATE] after the resident stated that he wanted to go home. RN 2 further stated that on that date, the facility determined that Resident 1 required a Wanderguard. RN 2 stated that several CNAs (names not recalled) and an RNA (name not recalled) monitored Resident 1 on a one to one (1:1) basis during the morning and after breakfast. RN 2 stated that the 1:1 monitoring was discontinued after the Wanderguard device was applied to Resident 1 on [DATE] morning. RN 2 also stated that the sliding doors in Resident 1's room did not have alarms connected to the Wanderguard system (is a specialized electronic security solution used in hospitals, nursing homes, and memory care facilities to prevent residents with cognitive impairments from wandering away from safe areas) and therefore would not alert staff if the resident attempted to exit through that door. RN 2 further stated that no alarms sounded to alert staff when Resident 1 eloped on [DATE]. During a phone interview on [DATE] at 2:14 p.m., Registered Nurse Supervisor (RN) 1 stated she received report from GACH 1 on [DATE] regarding Resident 1, and GACH 1 informed her that the resident was an elopement risk. RN 1 stated that Resident 1 walked very well without a mobility device and liked to wander around the facility. She stated that Resident 1 would enter other residents' rooms and sit in a chair next to their beds. RN 1 stated that at some point on [DATE], Resident 1 exited through the back door onto the facility's patio, and a CNA brought the resident back inside. RN 1 further stated that on another occasion on that day ([DATE], time not recalled), Resident 1 exited the facility, and she and another nurse (name not recalled) brought the resident back inside. RN 1 also stated she contacted Family Member (FM) 1 and asked whether FM 1 or another family member could come to the facility to stay with Resident 1 due to the resident's agitation. During an observation and interview on [DATE] at 2:17 p.m. with Maintenance Supervisor (MS) 1, MS 1 stated that Resident Rooms 126, 128, 130, 132, 134, 136, and 138 had sliding doors and screens that did not have alarms and provided access to the outside patio located at the back of the facility. MS 1 stated that the facility's outside patio had two exits leading to two public streets, [NAME] Avenue and [NAME] Street. MS 1 further stated that the two gates leading from the patio could be opened from the inside but not from the outside. During an interview on [DATE] at 2:47 p.m., RN 3 stated that on [DATE] (time not recalled), she received a call from GACH 2 informing her that an unidentified individual had found Resident 1 on a street (name of street not recalled). RN 3 stated that GACH 2 requested that Resident 1's face sheet and order summary be faxed to them. RN 3 further stated that GACH 2 informed her that Resident 1 would be transferred to GACH 3 because the resident had sustained burns. During an interview on [DATE] at 9:41 a.m., CNA 1 stated he had heard from staff (unable to recall who) that Resident 1 was ambulatory and had an elopement risk. CNA 1 stated that on [DATE] morning, no CNA was assigned specifically to monitor Resident 1 for safety or to prevent wandering or elopement. CNA 1 stated that RN 2 instructed him to check on Resident 1. CNA 1 reported that he went to the resident's room and observed Resident 1 ambulating inside the room. CNA 1 stated he asked Resident 1 to sit on the bed and then brought the resident's breakfast tray, placing it on the bedside table. CNA 1 stated he left Resident 1 seated on the bed and was away from the room for about 10 minutes. When he returned, Resident 1 was standing in the room. CNA 1 stated the resident went into the restroom and changed clothes, switching from short pants to long pants. CNA 1 stated he directed Resident 1 to sit back on the bed and encouraged him to eat breakfast, noting that the resident appeared fine and smiled at him. CNA 1 stated that the last time he saw Resident 1 was at 7:50 a.m., on [DATE]. CNA 1 further stated that he then proceeded to attend the facility's staff huddle (A quick, informal meeting where people gather closely to share updates or plan something) at Nursing Station 1 at approximately 8:15 a.m. on [DATE], and that the huddle lasted about 20 minutes. During an interview on [DATE] at 10:27 a.m., CNA 2 stated that she ar[TRUNCATED]

Based on interview and record review, the facility failed to follow their infection control policy and procedure (P&P) for two of three sampled residents (Resident 1 and 2), by failing to report the positive COVID cases to the State Agency (SA). This deficient practice had the potential to spread infection to the residents, visitors, and the community. Findings:During a review of Resident 1's admission Record dated 8/29/25 indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), hyperlipidemia (HLD - a condition characterized by elevated levels of lipids (fats) in the bloodstream) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's MDS, dated [DATE], indicated Resident 1 had severe cognitive (thinking, reasoning, learning, judgment) impairment and required partial to substantial assistance from staff for toileting, bathing, dressing and personal hygiene. During a review of Resident 2's admission Record dated 8/29/25 indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, HTN, HLD, and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 2's MDS, dated [DATE], indicated Resident 2 had moderate cognitive (thinking, reasoning, learning, judgment) impairment and required substantial assistant to dependance on staff for toileting, bathing, dressing and personal hygiene. During an interview with concurrent record review on 8/28/25 at 4:10 pm with Director of Nursing (DON) the Resident 2's nurses notes dated 8/2/25 were reviewed. The DON verified the resident had had a change of condition, was tested for COVID on that day and was found to be positive. During an interview with concurrent record review on 8/28/25 at 4:01 pm with DON Resident 1's nurses note for 8/4/25 were reviewed. The note indicated the resident had a change of condition with a fever and had a COVID test at the facility before she was transferred to the hospital which was negative. Further review of nurses noted dated 8/8/25 indicated the resident was readmitted on that date and tested COVID upon admission. The DON stated the cases were within seven days of each other and should have been reported to the SA. During a review of the facility's policy and procedures titled Infection Prevention and Control Program , reviewed 1/24/25, Duties and Responsibilities. Notify appropriate government agencies of reportable contagious or infectious diseases.

Based on interview, and record review, the facility failed to ensure:1) Licensed Vocational Nurse (LVN) 1 verified all medications, including controlled substance medications, received from pharmacy were checked and accounted for accuracy.2) LVN 2 and LVN 5 did not sign the narcotic count sheets ahead of time indicating that they (LVN 2 and LVN 5) actually counted and confirmed with the oncoming licensed nurse that the narcotics count was accurate/correct during shift change narcotics count. These deficient practices of not verifying medications received from pharmacy were accurate and not signing out on the narcotic sheets without counting/verifying with another licensed nurse present had the potential for diversion of narcotics. Findings: During a record review, the facility's In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) dated 5/09/2025 indicated, several LVNs and RNs received education on Medication Order and Receiving. The education's lesson plan indicated all licensed nurses verify and document medications, including controlled substance, were received. The lesson plan also indicated that all licensed nurses will promptly report any discrepancies and omissions to the pharmacy and the charge nurse/supervisor. During a record review, the facility pharmacy receipt dated 8/20/2025, indicated the pharmacy receipt was signed by LVN 1 on 8/21/2025. During a record review, the facility pharmacy receipt dated 8/21/2025, indicated the pharmacy receipt was signed by a licensed nurse on 8/21/2025 at 6:24 PM. During a record review, LVN 1's timecard dated 8/16/2025 through 8/31/2025 of, indicated, LVN 1 clocked in on 8/20/2025 at 11:04 PM and clocked out on 8/21/2025 at 7:58 AM. During a record review, the Notice of Investigatory Suspension letter addressed to LVN 1 dated 8/21/2025, indicated, LVN 1 was suspended effective 8/21/2025. During a record review, the facility document titled One on One Education/Retraining (a type of training where a professional trainer guides a single individual through a session, tailoring the program to their specific goals, needs, and fitness level) dated 8/21/2025, indicated, LVN 1 received education on Receiving Controlled Medications. The lesson plan for retraining education indicated that a nurse signs for the medications received from pharmacy and inspects the medications and reconciles controlled substance orders.against what has been received from the pharmacy. During a record review, the Pharmacy's Management record, dated 8/22/2025, indicated, while the medication (tramadol) did appear on the packing slip (pharmacy receipt), it was unfortunately not in the delivery bag. We have since located the medication and ensured it was redelivered to [the facility]. During a record review, the facility Medication Cart 1 Narcotic Sheet dated 8/25/2025, indicated LVN 2 had already signed out on the narcotic sheet before the end of LVN 2's shift. During a record review, the Medication Cart 1 Narcotic Sheet dated 8/25/2025, indicated LVN 5 had already signed out on the narcotic sheet before the end of LVN 5's shift. During a concurrent record review and interview on 8/25/2025 at 10:53 AM with LVN 5, Medication Cart 2 narcotic sheet dated 8/25/2025, was reviewed. When LVN 5 was asked why a narcotic sheet require two licensed nurses' signatures on it, LVN 5 stated their signatures tell everyone they both checked the medications together and everything is accounted for. Medication Cart 2 narcotic sheet dated 8/25/2025 indicated LVN 5 had already signed the narcotic sheet ahead of time and before end of LVN 5's shift. LVN 5 was asked why the 8/25/2025 narcotic sheet was signed ahead of time, LVN 5 stated it was a mistake. LVN 5 stated the narcotic sheet should have been signed at the end of the shift, around 3 pm today (8/25/25) with another nurse. LVN 5 stated the signatures of two licensed nurses on the medication cart 2 narcotic sheet indicated the signatures of the nurses verify they counted the medications together. LVN 5 also stated the potential harm to Resident 1 when the medication cart 2 narcotic sheet was signed ahead of time that the medication may be missing, the resident has to wait for the medication replacement causing resident additional pain and discomfort. During a concurrent record review and interview on 8/25/2025 at 12:14 PM with LVN 2, LVN 2 was asked if it was acceptable to sign the narcotic sheet ahead of time, LVN 2 stated no.if the narc sheet is signed ahead of time, then it means the nurse didn't really check the medications with another nurse. Medication Cart 1 narcotic sheet for 8/25/2025 was signed by LVN 2 ahead of time. LVN 2 was asked why LVN 2 signed the medication cart 1 narcotic sheet ahead of time, LVN 2 stated that was a mistake. LVN 2 also stated the potential harm to the resident when the medication cart 1 narcotic sheet was signed ahead of time the resident's med may be missing.causing the resident to have increased pain and suffering.may need additional pain medication when the resident's pain is not relieved by the pain medication replacement. During an interview on 8/25/2025 at 12:14 PM with LVN 2, LVN 2 stated the licensed nurse who received medication delivery from the dispensing pharmacy did not check to verify against the pharmacy receipt against what medications were actually delivered to the facility. LVN 2 stated, there is a high chance which medications actually came, and which ones did not come. During an interview on 8/25/2025 at 1:24 PM with Registered Nurse Supervisor (RNS) 1, RNS 1 stated, it is important to check the medications received against the pharmacy receipt to verify and account for all the medications received.sometimes the wrong information is on the receipt - wrong name for wrong medication. During a phone interview on 8/25/2025 at 2:04 PM with LVN 1, LVN 1 stated when receiving medication delivery (brown bag) from pharmacy, make sure everything that is on the pharmacy receipt matches with the medications being delivered. LVN 1 stated when LVN 1 received the delivery bag from the pharmacy on 8/21/2025 between approximately 4:40 am and 4:45 am, I looked at the bubble packs (a medication packaging system that contains individual doses of medication per bubble) then I signed the receipt, it looked right to me that's why I signed the receipt. LVN 1 stated that before LVN 1 handed the medication key to the next shift nurse at the end of LVN 1's shift (11 pm to 7 am), LVN 1 realized there was one medication missing, tramadol (a strong narcotic medication used to treat moderate to severe pain). LVN 1 stated LVN 1 panicked when LVN 1 realized tramadol was not in the brown bag I asked my two co-workers if they received any narcotics from the pharmacy.both said no. LVN 1 also stated LVN 1 called the pharmacy, but no one answered so LVN 1 left a message, the facility's Director of Nursing (DON) was immediately notified about the missing tramadol. LVN 1 was suspended for only one day on 8/21/2025 my drug test was negative, and the narcotic was found.on 8/21/2025. When asked if LVN 1 knew the whereabouts of the narcotic tramadol, LVN 1 stated the Director of Nursing (DON) told LVN 1 that the tramadol was delivered to another facility. During an interview on 8/25/2025 at 3:19 PM with DON, DON confirmed LVN 1 notified the DON right away about the missing narcotic, tramadol on 8/21/2025 as [LVN 1] was getting ready to leave at the end of [LVN1's] shift. DON also confirmed and stated LVN 1 was suspended pending their investigation because the medication was a Class IV Controlled Substance and that we couldn't find the [tramadol]. DON stated LVN 1's suspension was lifted after the narcotic tramadol was found on 8/21/2025 by the pharmacy staff. DON stated the narcotic, tramadol, was delivered to another facility by mistake by the pharmacy staff. DON stated the expectations from licensed nurses when receiving any type of medication from pharmacy was for nurses to check the pharmacy receipt against the medications received, after confirming verification, the nurses can then sign the receipt. DON stated signing the narcotic sheet ahead of time is not part of the facility policy, the nurse does not know if there are any situations happening that may cause the count to be inaccurate. DON added when the oncoming and outgoing nurses signed on the narcotic sheet, that means both nurses counted the narcotics and that they endorsed (gave report to) on each other. DON confirmed there were two nurses (LVN 2 and LVN 5) who signed out of the narcotic sheets ahead of time. During a record review, 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 Medication Storage in the Facility - Controlled Medication Storage with an effective date of 01/2022, indicated, Two licensed nurses do a physical inventory of all controlled substances at each shift change and documented on the narcotic sheet. During a record review, the facility's undated P&P titled Medication Storage in the Facility -Ordering and Receiving Non-Controlled Medications from the Dispensing Pharmacy indicated, A licensed nurse who received medications delivered by the pharmacy verifies medications received and promptly reports discrepancies and omissions to the to the issuing pharmacy and the supervisor.

Based on observation, interview, and record review the facility failed to provide care and services to prevent an avoidable accident from occurring for one of three sampled residents (Resident 1) by failing to: 1. Ensure Restorative Nursing Assistant 1 (RNA 1-nursing aide program that helps residents maintain their function and joint mobility) implemented the Activities of Daily Living (ADL- include eating, dressing, getting into or out of a bed or chair) Care Plan to transfer Resident 1 from a shower chair (is an assistive device designed to help people who have limited mobility or physical strength when bathing) to the bed using a Hoyer lift (a mechanical device used to safely transfer individuals with limited mobility) on 7/26/2025 between 8 am to 9 am. 2. Ensure RNA1 provided two-person physical assistance (help from two person) to transfer Resident 1 from a shower chair to the bed on 7/26/2025 between 8 am to 9 am as indicated in the ADL Care Plan initiated on 6/9/2025. 3. Ensure RNA1 followed the facility policy and procedures (P&P) titled Transfer of Residents reviewed on 1/24/2025, to transfer Resident 1 from the shower chair to the bed on 7/26/2025 between 8 am to 9 am. On 7/26/2025 at 8:50 am, RNA 1 independently (by himself) transferred Resident 1 who was totally dependent (reliant on) on all ADLs including chair to bed transfer, Resident 1's left lower leg was caught inside the metal bed frame. As a result, on 7/26/2025 at 10:20 am, Resident 1 sustained a bluish discoloration (refers to any change in the natural skin tone), skin trauma (a physical injury caused by an external force or violence, or an event that causes significant mental or emotional damage), and slight swelling to left mid shin (front parts of the leg). The facility transferred Resident 1 to a general acute care hospital (GACH) for further evaluation, treatment, and was diagnosed with multiple broken bones of the left leg.Findings: During a record review, Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 2/14/2025 and re-admitted on [DATE] with diagnoses that included hemiplegia (partial or total paralysis [extreme form of weakness and nerve dysfunction] and hemiparesis (weakness on one side of the body), reduced mobility (reduced ability to move freely), muscle weakness, lack of coordination (a lack of voluntary control and coordination of muscle movements), aphasia (inability to comprehend or formulate language), and a history of healed traumatic fracture. During a review of Resident 1's Care Plan Report initiated on 6/9/2025 indicated Resident 1 ADL self-care performance deficit related to activity intolerance, hemiplegia, impaired balance Care Plan, it indicated the resident (Resident 1) requires dependent assistance by two staff and Hoyer lift to move from chair to bed/bed to care. During a record review, Resident 1's History and Physical (H&P) dated 6/20/2025, indicated Resident 1 did not have the capacity to understand and make decisions. During a record review, Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/7/2025 indicated Resident 1's cognition (The mental ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 1 was totally dependent for all activities of daily living (ADL - eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, putting on /taking off footwear, and personal hygiene), rolling left to right, moving from sitting to lying position, and vice versa and chair to bed transfer. The MDS further indicated Resident 1's ability to go up and down a curb and/or up and down one step was not attempted due to safety concerns. During a record review, Resident 1's Pain Assessment record dated 7/26/2025 at 9:05 am., indicated Resident 1 with left shin skin discoloration related to left leg stuck in bed frame, Resident 1 with acute (of sudden onset) aching pain of 3/10, and received Tylenol (medication used primarily to relieve mild to moderate pain) for pain During a record review, Resident 1's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Evaluation record dated 7/26/2025 at 10:11 am, indicated Resident 1 had skin discoloration (refers to any change in the natural skin tone) on the left shin area with slight swelling and suffered mild pain of three out of 10 (3/10- numerical pain assessment tool where zero is no pain and 10 is severe pain). The COC indicated Resident 1 suffered bruising, swelling over joint or bone. The COC indicated that during transfer from shower chair to bed (Resident 1) became combative and move her legs and the left leg got stuck on the bed frame under the bed and sustained skin discoloration, slight swelling, and mild pain. The COC indicated a medical doctor (MD) was informed and a new order received for a stat (now) x-ray of the left knee, left shin, left fibula (the outer bone of the two bones in the lower part of the leg), and left tibia (the inner bone of the two bones in the lower part of the leg). During a record review, Resident 1's Skin Observation Checks record dated 7/26/2025 at 10:20 am, indicated first observation that Resident 1 had bluish discoloration, skin trauma (a physical injury caused by an external force or violence, or an event that causes significant mental or emotional damage), and slight swelling to left mid shin (front parts of the legs). The Skin Observation Checks record indicated that an RNA/CNA (Restorative Nurse Assistant - is a certified nursing assistant (CNA) who focuses on helping patients regain and maintain their physical abilities and independence) transferred Resident 1 to shower chair and that the resident's left leg was accidentally stuck to the bed frame. During a record review, Resident 1's Skin Weekly Assessment record dated 7/26/2025 at 11:41 am, indicated the initial and current treatment plan to the left mid-shin with skin trauma, slight swelling, bluish discoloration with pain was to apply cold compress (the application of a chilled or frozen material to the body to reduce swelling or inflammation) to affected area every 15 minutes interval. The Skin Weekly Assessment record further indicated Resident 1 with left lower extremity (LLE) with pitting edema plus 2 (+2 - a condition where fluid accumulates in the tissues, causing swelling with an indentation of 3-4 millimeters [mm- unit of measurement] in depth) and left mid shin with bluish discoloration. During a record review, Resident 1's Progress Notes dated 7/26/2025 at 2:51 pm, indicated Resident 1 was transferred to GACH due to butterfly (a type of fracture where a large, triangular or wedge-shaped fragment of bone breaks off, resembling a butterfly's wings) spiral fracture (the break spirals around the bone's axis, often caused by a twisting force) of the shaft of the tibia, fracture of the fibula, and tiny fracture in the lateral malleolus (the side of the bony prominence on the outer side of the ankle), nondisplaced fracture in the lateral malleolus, and distal fracture shaft of the tibia. During a record review, Resident 1's Situation Background Assessment Recommendation (SBAR - is a structured communication framework used in healthcare settings to ensure clear and concise information exchange between healthcare professionals) dated 7/27/2025 at 6:50 pm, indicated Resident 1 sustained fractures to the proximal tibia, lateral malleolus, spiral/butterfly fragment in the shaft and that the resident with new pain (not quantified). The SBAR indicated that a physician was notified, X-ray ordered, and Resident 1 to have an orthopedic (the branch of medicine dealing with the correction of deformities of bones or muscles) appointment after 3 weeks. During a record review, Resident 1's Nursing Home to Hospital Transfer Form dated 3/2/2025 (incorrect date should be 7/26/2025), indicated Resident 1 received Tylenol 325 milligrams (mg - unit dose) for pain on 7/26/2025 at 1:30 pm for pain level of 3/10. The Nursing Home to Hospital Transfer Form indicated that on 7/26/2025 at 3:04 pm., Resident 1 was transferred to GACH due to butterfly spiral fracture on tibia and fibula to the left leg. During a record review, Resident 1's X-ray of the left tibia and fibula (two long bones located in the lower leg) dated 7/26/2025 2025 and with service date of 7/26/2025 indicated evidence of multiple fractures of the proximal fibula, lateral malleolus and spiral/ butterfly fracture in the shaft of the tibia. During a record review, Resident 1's of x-ray of the left ankle dated 7/26/2025 and with service date of 7/26/2025, indicated a nondisplaced fracture in the lateral malleolus. During a record review, Resident 1's Electronic Medication Administration Record (e- MAR) dated 7/1/2025 - 7/31/2025, indicated Resident 1 received Tylenol 325mg two tablets for pain on 7/26/2025 at 9 am and 1:30 pm. During a record review, Resident 1's GACH Discharge Information record dated 7/27/2025 at 4:36 pm, indicated Resident 1 presented to the emergency room with left lower extremity pain after her leg was stuck in a bed rail yesterday (7/26/2025). Discharge Information record indicated Resident 1 had Acute, comminuted (where the bone breaks into multiple fragments), mildly displaced fracture of the mid to distal left tibial shaft, and acute comminuted and minimally displaced fracture of the proximal left fibular shaft. The Discharge Information record indicated that Resident 1 has a fracture of her (Resident 1) tibia and fibula in her in the left leg. This was splinted by the emergency department. She should have an orthopedic surgeon evaluate her soon. During a facility tour on 8/11/2025 at 11:45 am., Resident 1 was observed asleep in bed with a leg cast (a rigid, supportive shell, often made of plaster or fiberglass, used to immobilize and protect a fractured or surgically treated leg or knee while it heals) wrapped with ace bandage (a type of elastic bandage used to provide compression and support to injured body parts like ankles, knees, or wrists) covering the left leg from below the left knee to her foot. During an interview on 8/11/2025 at 12:10 pm, RNA 1 stated that on 7/26/2025 between 8 am to 9 am, Resident 1 was totally dependent on care, was seated on a shower chair at the bedside waiting to be transferred back to bed. RNA 1 stated that Certified Nurse Assistant (CNA) 2 was also present at the resident's bedside. RNA 1 stated he (RNA1) wrapped his arms under Resident 1's underarms, bear hugged Resident 1, lifted Resident 1 from the shower chair and then began to transfer Resident 1 from the shower chair to the resident's bed. RNA 1 stated that midway during the transfer, Resident 1 became combative, uttering (saying) words her primary language, and he (RNA 1) continued with transferring the resident (Resident 1) to bed. RNA 1 stated he (RNA 1) laid Resident 1 in bed and noticed that Resident 1's left lower leg was stuck inside the metal bed frame. RNA 1 stated that CNA 2 did not assist with transferring Resident 1 to bed. RNA 1 stated he (RNA1) left CNA 2 at the bedside with Resident 1 and called Licensed Vocational Nurse (LVN) 2 for assistance. RNA 1 stated LVN 2 removed Resident 1's left lower leg that was still stuck on the metal bed frame. RNA 1 stated LVN 2 called Registered Nurse 1 (RN) 1 to come and assess Resident 1's left leg. During an interview on 8/11/2025 at 12:35 pm CNA 2 stated she (CNA2) was standing at the foot of Resident 1's bed and RNA 1 instructed to stand by just in case he needed assistance with transferring Resident 1 from shower chair to the bed. CNA 2 stated Resident 1 was non weight bearing (cannot support weight) on bilateral lower extremities (lower limbs) and was non-ambulatory (unable to walk) prior to the left leg bed injury on 7/26/2025. During an interview on 8/11/2025, RN 1 stated that on 7/6/2025 at approximately 8:30 am, RNA 1 summoned her to Resident 1's room to see something but did not elaborate why. RN 1 stated she immediately went to Resident 1's room and found Resident 1 lying in bed with the resident's feet dangling on the left edge of the bed. RN 1 stated she noticed Resident 1 had redness and slight swelling to the left lower leg. RN 1 stated she knows and understands the word pain in Resident 1's primary language, Resident 1 said pain. RN 1 stated she performed a full body assessment on Resident 1, notified doctor, received and carried out stat orders including x-rays, and gave Resident 1 Tylenol for pain. RN 1 stated the x-ray results indicated fractures to the left lower leg, and she immediately notified the physician of the x-ray results. RN 1 stated the physician gave an order to transfer Resident 1 to GACH for higher level of care.RN 1 stated Resident 1 was transferred to acute care on 7/26/2025 at 3:04 pm. During an interview on 8/12/2025 at 12:20 pm, Director of Staff Development (DSD) stated Resident 1 was totally dependent (requiring full reliance on caregivers for basic needs like mobility, hygiene, and feeding) on staff for care and the resident required 2-person assist with a Hoyer lift for transfers which is in accordance with the facility policy to safely transfer residents. During an interview on 8/12/2025 at 3:30 pm, Director of Staffing (DON) stated Resident 1's injuries were preventable if the staff utilized an assistive device (Hoyer lift) to safely transfer Resident 1 from shower chair to the bed. During a record review, the facility policy and procedures (P&P) titled Transfer of Residents reviewed on 1/24/2025, indicated, a mechanical lift is used on any resident unable to independently pivot (to turn or rotate) or transfer. The P&P titled indicated, Purpose: To provide the form of transfer best suited to the residents' needs and maintain resident safety during the procedure. One person pivot transfer (Resident must be able to bear weight. Make sure the resident's feet are on the floor

Based on interview and record review, the facility failed to complete annual performances evaluations (the review and evaluation of an individual's or organization's performance over a 12-month period), annual skills competencies (the measurable or observable knowledge, skills, abilities, and behaviors critical to successful job performance), and trainings for five out of five employees (Licensed Vocational Nurse 1 [LVN1], LVN2, Certified Nursing Assistant 2 [CNA2], Houskeeper, and Housekeeping Supervisor). These deficient practices had the potential for residents not to receive the appropriate level of care needed, affecting quality of care and potentially leading to resident harm. Findings: During an interview on [DATE] at 9:22 a.m., LVN 1 stated she did not remember the date of her last annual performance evaluation, annual skills competencies, the date of fire safety card, or the date of her last annual physical. LVN 1 stated it was very important to complete annual skills competencies so that she could remain competent with caring for residents. LVN 1 stated if annual competencies were not completed annually the nurses could forget how to properly care for the residents. During an interview on [DATE] at 12:17 p.m., CNA 2 stated she had been a CNA for 9 years. CNA 2 stated her last in-service for skin care was on the date of interview ([DATE]). CNA 2 stated she did not remember the date she completed sexual harassment or abuse training. During an interview on [DATE] at 8:24 a.m., LVN 2 stated he could not remember his last annual skills competencies, or annual performance evaluation. LVN 2 stated he gave the DSD his renewed CPR card. LVN 2 stated he could not remember the dates he completed sexual harassment training, or a background check. LVN 2 stated it was important to complete skills competencies so that he did not forget how to properly care for residents, resident safety, and to be competent with caring for all his residents. During an interview and concurrent record review on [DATE] at 10:08 a.m., the Housekeeping Supervisor stated she was not aware that outside contracted housekeepers were supposed to have employee files kept in the facility. A review of the Housekeeping Supervisor employee file indicated no trainings, annual competencies, or vaccination records. During an interview on [DATE] at 10:37 a.m., Director of Staff Development (DSD) stated sexual harassment training was renewed every two years, fire safety, and cardio-Pulmonary resuscitation (CPR - It is an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) cards are renewed every two years. DSD stated abuse training was completed quarterly and as needed and performance evaluations annual skills competencies were completed by DSD or the Director of Nursing (DON) yearly/annually. DSD stated the outside housekeeping contractor was responsible to complete abuse and sexual harassment training for the contracted housekeeping staff. DSD stated it was very important that all employee files be kept updated to ensure all training, licenses, CPR cards, and Fire safety cards, so that the nurses and the facility complied with the requirements. DSD stated it was important for all training to be updated to ensure that the nurses could provide the best care for all the residents. DSD stated all the staff documents, including trainings, licenses, vaccination records, physicals, were supposed to be kept in the employee files. During a concurrent record review with DSD on [DATE] from 10:37 a.m., the employee files indicated: 1. LVN 1: nurses license was expired, no annual performance evaluation, annual skills competencies in employee file, fire safety card, annual physical, TB skin test, vaccination records, or background check. 2. LVN 2: CPR card had expired, updated sexual harassment training, expired abuse training (when was the expiration date?), and no annual performance evaluation. 3. CNA 2: no sexual harassment training and last abuse training was on [DATE]. 4. Housekeeper: No annual competencies. 5. Housekeeping Supervisor: No There were no trainings sexual harassment, abuse or annual competencies. During an interview on [DATE] at 11:48 a.m., the Administrator stated all employees working in the facility were supposed to have an employee file with all documents up to date kept in the facility. The administrator stated it was important for all employees working in the facility to have a file on hand so that the employee was identifiable if an incident happened. During an interview on [DATE] at 2:45 pm, the DON stated that all employee files were supposed to be updated. The DON stated if competencies were not completed annually, the nurses could forget how to complete important tasks which could harm the residents. During a record review, the facility policy and procedures titled Performance Evaluations dated ,d+[DATE], indicated, Employees may receive periodic performance reviews. The review will generally be conducted by their supervisor. The first performance evaluation may be conducted annually, on or around their anniversary date. The frequency of performance evaluations may vary depending upon length of service, job position, past performance, changes in job duties or recurring performance problems.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1. Walk in refrigerator shelves were cracked and rusted. 2. Food stored on rusted shelves in the walk-in refrigerator. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of bacteria from one object to another) that could lead to foodborne illness medically compromised residents who receive and eat food from the kitchen. Findings: During an initial kitchen tour observation of the walk-in refrigerator on 5/13/2025 at 7:40 AM, a total of four shelves were rusted in various places on the shelves, ready to cook foods were stored on or directly under the rusted shelves. During an interview on 5/13/2025 at 7:42 AM, [NAME] 3 stated, the racks are rusty in the main refrigerator. During an interview on 5/13/2025 at 8:03 AM, [NAME] 2 stated, the racks in the refrigerator need to be replaced because they are rusty. During a concurrent observation and interview on 5/13/2025 at 9:14 AM, Dietary Supervisor DS stated DS's first day to work as the dietary supervisor is today (5/13/2025). DS stated DS will take action to improve the situation with the rusted racks in the refrigerator area. During a concurrent observation and interview on 5/15/2025 at 10:26 AM, Administrator (ADM) stated, the racks in the refrigerator need to be replaced because they are rusty. During a record review, the facility Policy and Procedures (P&P) titled Food Storage, reviewed on 1/24/2025, indicated Food items will be stored, thawed, and prepared in accordance with good sanitary practice.

Based on observation, interview, and record review the facility failed to: 1. Maintain and ensure patient care bathrooms were in safe operating condition for 2 of 2 sampled bathrooms. 2. Maintain and ensure the kitchen ice machine was in safe operating condition, two of three food preparation tables, one of four food worming trays, four of four food storage racks, and the overhead light in the walk-in freezer, were in safe operating condition. These deficient practices had the potential to result in staff being unable to meet the needs of residents in a timely and safe manner. Findings: 1. During observation of the shared bathroom between rooms [ROOM NUMBERS] on 05/13/25 at 1:28 p.m., the maintenance aide observed with the surveyor and confirmed by stating the toilet was running constantly after flushing, and the toilet seat was very loose and broken. During an observation of the bathroom in room [ROOM NUMBER] on 05/13/25 at 1:44 p.m., the maintenance aide observed with the surveyor and confirmed by stating the bathroom's hot water faucet was constantly running and would not turn off and the toilet seat was discolored and broken. During an interview on 05/13/25 at 2:21 p.m., with Maintenance Aide. Stated he had been employed with the facility for 1 month. The maintenance aide stated he would make rounds daily to check for repairs. The maintenance aide state he did not have any documents or records to show what needed to be repaired in the facility, or documents to show which rooms he rounded on daily. The maintenance aide stated there was a maintenance repair log at each nurse's station. The maintenance aide stated if the residents continued to use the toilet with a broken toilet seat, the residents could fall and get injured. During a review of the maintenance repair log at nurses' stations 1 and 2 on 05/13/25 at 2:21 p.m., there were no repairrequests for the bathroom sink and toilet in room [ROOM NUMBER], or for the toilet in room [ROOM NUMBER]. During an interview on 05/14/25 at 8:08 a.m., the housekeeper stated she had been working for the facility for 3 years. The housekeeper stated she was responsible for cleaning the patient's room and bathrooms daily in the morning and as needed. The housekeeper stated if the toilet and the sinks were broken, she would report it to the maintenance aide right away. The housekeeper stated if the residents used the broken toiled seat, it was very dangerous, and the patient could fall and get injured. During an interview on 05/14/25 at 10:08 a.m., the DON stated the maintenance supervisor was out on medical leave. The DON stated the maintenance aide was covering the facility for minor repairs only. The DON stated if the facility needed major repairs an outside company would be utilized. A review of the facilities policy titled Resident Rooms and Environment with a reviewed date of 1/24/2025, indicated: Purpose: To provide residents with a safe, clean, comfortable, and homelike environment. A review of the facilities policy titled Maintenance Services with a reviewed date of 1/24/25, indicated: Policy: The maintenance department maintains all areas of the building, grounds, and equipment. Procedure: I. The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. 46843 2. During an initial kitchen tour observation, rust was observed on four of four racks in the main refrigerator where food was stored. The ice maker was observed to be not working, one out of four of the food warmers was not working, one of three food preparation tables (the large table) were unsteady and appeared to be weak, one out of three food preparation tables was missing, and there is no light in the walk-in freezer. During an interview on 5/13/2025 at 7:42 AM [NAME] 3 stated the ice maker had been broken since the prior weekend (5/10/2025 and 5/11/2025). [NAME] 3 stated no ice was purchased on 5/10/2025 and 5/11/2025. [NAME] 3 stated one of four warmer trays were broken, and the warmer tray to the far left had not been working for the last four weeks. [NAME] 3 stated the four racks in the main refrigerator were rusty. [NAME] 3 stated the light in the walk-in-freezer was not working. During an interview on 5/13/2025 at 8:03 AM [NAME] 2 stated the ice maker had been broken over the weekend and it had been hot. [NAME] 2 stated no one bought any ice during the weekend. [NAME] 2 stated one of four food warmer trays had been broken the one to the far left does not work. It has not been working for the last four weeks. [NAME] 2 stated the racks in the refrigerator needed to be replaced because they were rusty. [NAME] 2 stated there was no light in the walk-in freezer. [NAME] 2 stated the door on the freezer would get stuck and kitchen staff would have to leave something in the doorway to stop it from closing when kitchen staff went inside to get food. [NAME] 2 stated the food preparation table was weak and could break at any moment because one of the legs of the table was loose. [NAME] 2 stated the small food preparation table broke about three weeks prior, and it had never been replaced. During an interview on 5/13/2025 at 8:03 AM [NAME] 1 stated the light in the walk-in freezer did not work, and the ice machine was broken. [NAME] 1 stated the food preparation tables were old and unsteady. During a concurrent observation in the facility kitchen and interview on 5/13/2025 at 9:14 AM, the Dietary Supervisor (DS) stated the day of interview (5/13/2025) was the DS' first day as dietary supervisor and the DS would take action to improve the situation with the rusted racks in the refrigerator area and all other broken equipment including the ice maker, the week food preparation table, the missing light in the walk-in freezer, and the missing food preparation table. During a concurrent observation in the facility kitchen and interview on 5/14/2025 at 7:26 AM, the Maintenance Aide (MA) stated he was aware of the ice maker being broken since Saturday 5/10/25. The MA stated he had contacted a company to come out and service the machine to see if they could make it work. The MA stated he was aware of the table being broken, and the food warmer was mentioned to him, and was going to look at the food warmer to determine if it could be fixed. The MA stated he was also aware of the rusted racks and was waiting for approval to purchase new ones. The MA stated he did not keep a record of the reports, and would just makes notes here and there to remind him of what needed to be fixed. During a concurrent observation in the facility kitchen and interview on 5/15/2025 at 10:26 AM, the Administrator (ADM) stated the kitchen equipment had to be fixed or replaced. The ADM stated the ice machine was broken, one of four food warming trays was broken, the racks could not be painted because they needed to be replaced due to rust, and the food preparation tables needed to be replaced because one had already broken, and the other was weak. A review of the facility's Policy and Procedure (P&P) titled Maintenance Services dated 1/24/2025, indicated Purpose: G. Establishing priorities in providing repair service; J. Maintaining all mechanical, electrical, and patient care equipment in safe operating condition; III. The Director of Maintenance is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Equipment is repaired or replaced as necessary to ensure the safety and welfare of residents and employees. Non-critical equipment is equipment whose failure would interrupt standard operational services. Examples include the following: Dietary equipment. 1. Notify the administrator of needed routine equipment replacement or repairs. 2. For minor equipment/replacements (less than 500), contact local vendors/contractors to perform the work. Consult the regional maintenance manager or RVP with questions about equipment or repairs above $500.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced dignity and respect in full recognition of resident's individuality by failing to ensure that the urinary collection bag was covered with a privacy bag for two of two sampled residents (Residents 41 and 54) This deficient practice had the potential to affect Resident 41 and 54's self-esteem and self-worth. Findings: a. During a record review, Resident 41's Admission Record indicated the facility admitted Resident 41 on 3/20/2025 with diagnoses including acute kidney failure (AKF- a sudden and often reversible decline in kidney function), encephalopathy (a problem with the brain, affecting how it works), and hypertension (HTN - elevated blood pressure). During a record review, Resident 41's Minimum Data Set (MDS - a resident assessment tool) dated 3/23/2025, indicated Resident 41 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 41 required extensive staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an observation on 5/14/2025, at 7:52 A.M., in Residents 41's room, Resident 41's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) bag was seen hanging from the bed frame without a dignity cover. During a concurrent observation and interview on 5/14/2025, at 7:56 A.M., with Certified Nursing Assistant (CNA) 3, in Residents 41's room, Resident 41's urinary catheter bag was observed without a dignity bag cover. CNA 3 stated Resident 41's urinary catheter bag did not have a privacy (dignity) bag over it and needed to have one for privacy. CNA 3 stated that not having a privacy bag over Residents 41's urinary catheter bag may cause Resident 41 to feel embarrassed, uncomfortable and not feel good overall. During a concurrent observation and interview on 5/14/2025, at 8:21 A.M., with Treatment Nurse (TN), in Residents 41's room, Resident 41's urinary catheter bag was observed without a dignity bag covering it. TN stated Resident 41's urinary catheter needed to be covered with a dignity bag for Resident 41's dignity by not having Resident 41's urine be exposed to ensure that Resident 41's dignity is maintained. During an interview on 5/16/2025, at 5:28 P.M., with the Director of Nursing (DON), the DON stated that catheter needed to be covered with a dignity bag to provide Resident privacy. The DON stated if there is no dignity bag on the resident's catheter, it may affect the residents' psychosocial (involving both psychological and social aspects) wellbeing. 46843 b. During a record review of Resident 54's admission record, indicated Resident 54 was admitted to the facility on [DATE], with diagnoses that included, pressure ulcer (also known as bedsore or pressure sore, is damage to the skin and underlying tissue caused by prolonged pressure, due to lying or sitting in one position for too long), of right heel (the back part of the foot), depression (a persistent state of sadness or lack of interest in things that you used to enjoy). During a record review of Resident 54's MDS, dated [DATE], indicated Resident 54's cognition (the mental ability to make decisions of daily living) was severely impaired. Resident required substantial/maximal assistance with all activities of daily living (ADLs) bed mobility, transfer, eating, toilet use and personal hygiene. During a record review of Resident 54's care plan regarding urinary catheter initiation date 4/22/2025 indicated indwelling foley catheter is to remain in privacy bag and catheter leg strap on at all times. During observation in Resident 54's room on 5/13/2025 at 9:53 AM, Resident 54's indwelling catheter bag was full of yellow urine like fluid and visible to anyone entering or passing by the door of Resident 54's room. During an interview on 5/13/2025 at 9:57 AM, CNA 1 (Resident 54's CNA) stated she (CNA 1) indwelling catheter should be covered for privacy and dignity. CNA 1 stated she will cover the bag right now. During an interview on 5/13/2025 at 8:54 AM, Director of Staff Development (DSD) stated the proper way to care for residents with indwelling catheters should have dignity bags to cover. The DSD stated the dignity bag is placed over the indwelling catheter bag to provide the resident with privacy and dignity, so that no one can tell that she has a Foley catheter inserted. During an interview on 05/13/25 at 8:54 AM the Director of Nursing (DON) stated the CNA should put a privacy cover over the indwelling catheter bag to protect the residents dignity. During a record review, the facility In-service (training) lesson plan on preserving patient dignity and privacy dated 3/25/25 at 1:30 PM, indicated: Objective Staff will be able to state the importance of providing residents with courtesy, respect, privace and dignity at all times. Purpose To ensure that staff will provide privacy and dignity to patients and will address them appropriately. Course Contents Privacy refers to freedom from intrusion. Dignity - being worthy of respect. Respect-consideration or thoughtfulness. Patients have the right: 3. Be treated with dignity at all times like when they are in the dining room during meals time or even in the room, During a record review, the facility policy and procedures (P&P) titled Privacy and Dignity reviewed 1/24/2025, indicated, Purpose: To ensure that care and services provided by the Facility promote and/or enhance privacy, dignity and overall quality of life. Policy: The Facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality. Procedure: VI. The Facility respects the residents' private space and property. IX. The following rights to privacy are a part of the admission agreement and the resident is informed of these rights during the admission process A. Residents are afforded a right to privacy and confidentiality. X. Resident rights to privacy and confidentiality of medical information and the clinical record is outlined in HP - 01 - Form A - Notice of privacy practices.

Based on observation, interview and record review, the facility's interdisciplinary team (IDT-- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to ensure one out of one sampled residents (Resident 44) was assessed determined capable to self-administer medication left at the bedside and, had a physician's order for self-administrations. This deficient practice had the potential for duplicity, overdose, and consumed by confused wandering resident which could lead to an adverse reactions, unnecessary hospitalization and possible poor health outcomes. Findings: During a record review, Resident 44's admission record indicated Resident 44 was admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that include atrial fibrillation (Afib-an irregular and often very rapid heart rhythm), hypertension (a medical condition characterized by persistently elevated blood pressure), congestive heart failure (CHF- a condition where the heart cannot pump enough blood to meet the body's needs), type 2 diabetes (DM II-) and peripheral vascular disease (PVD- a slow and progressive disorder of the blood vessels). During a record review, Resident 44's Minimum Data Set (MDS - a resident assessment tool) dated 03/29/2025 indicated the resident 44's cognition (The mental ability to make decisions of daily living) was intact, Resident 44's required supervision or touching assistance for eating and setup partial moderate assistance for oral hygiene. During a facility tour on 5/13/2025 at 11:24 AM, Resident 44's bedside table was observed to have a tube of triamcinolone Acetonide cream (a topical corticosteroid medication used to treat a variety of skin conditions characterized by inflammation and itching). During a concurrent interview, Resident 44 stated she (Resident 44) uses the topical corticosteroid cream when she is itching, and that a physician prescribed the topical corticosteroid cream. During an interview on 5/16/2025 at 2:20 PM Resident 44 stated the resident's family member brought the topical corticosteroid cream for Resident 44 because the resident was itching. During an interview on 5/16/2025, at 2:22 9M, licensed vocational nurse (LVN) 7 stated LVN 7 was unaware Resident 44 had the topical corticosteroid at bedside, LVN 7 stated Resident 44 did not have a physician's order to self-administer the topical corticosteroid and the topical corticosteroid should not be left at the bedside where it is easily accessible, LVN 7 stated Resident 44 had an existing order for Fexofenadine (an oral medical used to relieve itching associated with certain allergic conditions) 180 (dose) mg (unit of measure) taken daily for itching. During an interview on 5/16/2025 at 2:25 PM, Director of Nursing (DON) stated Residents are only allowed for have medications (meds) at the bedside if they have been assessed to be cognitively able and physically have demonstrated that they can safely able to self administer medication(s) and must have a physician approval, DON stated medication at bedside should be in a locked container. DON further stated medications should not be left at bedside, because of the risk of duplicity that can lead to an overdose. DON stated a confused wandering Resident may consume the medications which could lead to an adverse reactions, unnecessary hospitalization and possible poor health outcomes. During a record review, the facility policy and procedures titled Medication- Self-Administration dated 1/24/2025, indicated .Residents are provided with the opportunity to self-administer medication when determined by assessment they are capable to do so by the attending physician and the interdisciplinary team. If the resident is assessed as clinically appropriate for medication self-administration by the IDT, the licensed nurse obtains a physician's order for self-administration of selected medications. Self-administered medications will be placed in a secure drawer or cabinet that is easily accessible to the Resident.

Based on interview and record review, the facility failed to complete a change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) in accordance with the facility policy and procedures (P&P) titled Change of Condition Notification revised 1/24/2025 for one of three sampled residents (Resident 47). This deficient practice had the potential to result in the delay of necessary care for Resident 47. Findings: During a record review, Resident 47's Admission Record indicated the facility admitted Resident 47 on 7/5/2024 and was readmitted on [DATE] with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and hypertension (HTN - elevated blood pressure). During a record review of Resident 47's Minimum Data Set (MDS - a resident assessment tool) dated 4/30/2025, indicated Resident 47 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 47 required extensive staff assistance with activities of daily living (ADLs- 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 5/16/2025, at 7:20 A.M., with the Registered Nurse Supervisor (RNS) 1, Resident 47's electronic nursing progress notes dated 4/15/2025 at 9:43 P.M. was reviewed. RNS 1 stated the nursing progress notes dated 4/15/2025 at 9:43 P.M., indicated that unidentified Licensed Vocational Nurse noticed Resident 47's urine had sediments (tiny particles or matter that collect at the bottom of a urine sample. This can include things like crystals, bacteria, blood cells, or even debris from the urinary tract), was light yellow in color and had clumps (clots or sediment, which may require medical attention). RNS 1 stated the nursing progress note indicated Resident 47 had a COC, however, there was no documented evidence that a COC was completed for Residents 47. RNS 1 stated a COC is supposed to be completed at the time when the sign and symptoms of a COC is noticed/identified. RNS 1 stated the COC needs to be completed to help closely monitor how the residents is doing, if the resident is getting worse, especially specifically to the problem area that was observed or noted. RNS 1 stated not monitoring a resident's condition may lead to the resident having sepsis (a life-threatening medical emergency that occurs when the body's extreme response to an infection damages its own tissues and organs) or getting hospitalized . During an interview, on 5/16/2025, at 5:32 P.M., with the Director of Nursing (DON), the DON stated that a COC needs to be completed immediately a problem with a resident is identified to ensure that treatment is provided on time. The DON stated that if a COC is not done, there would be a lack of communication among the staff and the care delivery time may not be provided within the time frame which may cause further decline in the resident's emotional status and/or other health care conditions. During a record review, the facility's P&P, titled, Change of Condition Notification revised 1/24/2025, indicated, Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. Definition: An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. I. Members of the interdisciplinary Teams (IDT) are expected to report and document signs and symptoms that might represent an ACOC. II. The facility will promptly inform the resident, consult the resident's attending physician, and notify the residents legal representative when a resident endures a significant change in their condition caused by, but not limited to: b. A significant change in the resident's physical, cognitive, behavioral or functional status.

Based on interview and record review, for one of four residents (Resident 45), the facility failed to: 1) Complete a Preadmission Screening and Resident Review (PASRR - a screening evaluation used to determine whether placement in a long-term care facility is appropriate for the resident) Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment when Resident 45 was readmitted on [DATE]. 2) Notify the mental health agency (A mental health agency that provides and is responsible for mental health services. These services can include a range of interventions, assessments, diagnosis, treatment, and counseling, delivered in various settings to support mental health or treat mental/behavioral disorders) promptly after Resident 45 was newly diagnosed with dementia and anxiety disorder on 4/10/2025 and Alzheimer's disease on 4/18/2025. 3) Develop a care plan after Resident 45 was diagnosed with dementia, anxiety disorders (a condition of excessive worry about daily issues and situations) and Alzheimer's disease (a common type of dementia that affects memory, thinking and behavior). These deficient practices of failing to complete PASRR Level I assessment, notify the mental health authority promptly and create care plans related to the diagnoses of dementia, anxiety disorder, and Alzheimer's disease for Residents 45 put Resident 45 at risk for not identifying possible serious mental illness during Resident 45's re-admission on 4/10/2025 and providing interventions tailored to Resident 45's nursing care needs. Findings: During a record review, Resident 45's face sheet (Admission Record - a document containing demographic and diagnostic information) indicated, Resident 45 was admitted to the facility on [DATE] and was readmitted on [DATE] with the following medical diagnoses: Alzheimer's disease, unspecified dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder. During a record review, Resident 45's Minimum Data Set (MDS - a resident assessment tool) dated 4/24/2024, indicated, Resident 45 had a severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a record review, Resident 45's Care Plan (a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) did not indicate any care plans were created for Resident 45 after the onset (start) of medical diagnoses of dementia, anxiety disorder, and Alzheimer's disease. During a record review, Resident 45's History and Physical (H&P - a physician's complete patient examination) dated 4/10/2025, indicated, Resident 45 did not have the capacity to understand and make decisions. During a record review, Resident 45's Diagnosis Report (a report that contains all of patient's diagnoses, onset [start] date of diagnosis, and date when the diagnosis was resolved) indicated Resident 45's Alzheimer's diagnosis onset was on 4/18/2025, unspecified dementia on 4/10/2025, major depressive disorder on 4/10/2025, and anxiety disorder on 4/10/2025. During an interview and concurrent record review with Minimum Data Set Coordinator (MDSC - adequately assessing nursing home residents' needs and coordinating personalized, resident-driven care based on those assessments) nurse, MDSC-Assistant (MDSC-A) and the Director of Nursing (DON) on 5/16/2025 at 9:35 AM, MDSC stated MDSC Assistant (MDSC-A) was responsible for ensuring PASSR Level I was completed when Resident 45 was readmitted . MDSC-A stated, I have not received official responsibility to do PASRR Level I. During a record review with the DON, Resident 45's electronic health record was reviewed. The DON stated the admission nurse is responsible, but most of the PASRR Level I when not completed, the DON will complete PASSR Level 1. The DON stated, yes, it would quality for Level I screening, but it was not done when asked if Resident 45's dementia and anxiety disorder were diagnosed on [DATE] and Alzheimer's disease diagnosed on [DATE] qualify for a PASRR Level I screening. The DON also stated, after reviewing Resident 45's with surveyor, that Resident 45 did not have care plans created for dementia, anxiety disorder nor Alzheimer's disease. During a record review, the facility policy and procedures (P&P - explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Preadmission Screening and Resident Review revised on 7/01/2023, indicated, All individuals . must have a PASRR . prior to the facility accepting the admission. The facility ensures that PASRR Level I is completed .prior to admission to determine if they [residents] have a serious mental illness . The facility also conducts PASRR Level I screening for current residents who have a mental illness .

Based on observation, interview and record review, the facility failed to identify and evaluate accident risks and provide a safe environment to prevent accidents for one of four sampled residents (Resident 4). Resident 4, who was diagnosed with dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), was a high fall risk, and cognition was severely impaired, the facility failed to: 1. Notify the physician of Resident 4's behavior of crawling out of bed as indicated in the resident's care plan for [MEDICATION(S)] (anti-psychotic medication) 2. Ensure the resident's call light was within reach as indicated in the resident's fall care plan. 3. Implement the facility's fall prevention program to provide Resident 4 a floor mat as indicated in the facility's policy on falling star program. These deficient practices resulted in Resident 4's fall on June 2, 2021 and Resident 4 was observed sitting on the floor with a laceration to the right eyebrow which measured 0.6 centimeters (cm) by 0.6 cm. and required skin treatment daily for 14 days. Findings: A review of Resident 4's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including history of falling, dementia and [CONDITION(S)] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). A review of Resident 4's Morse Fall Risk Assessment, dated May 5, 2021 indicated Resident 4 had a score of 75, which was a high risk for falls (score of >45 indicates score of high risk). The fall risk assessment included Resident 4's mental status indicating resident forgets limits or overestimates ability to ambulate safely. A review of the Fall Care Plan dated May 6, 2021 indicated Resident 4 had a problem related to status post (previous) right [CONDITION(S)]. The care plan interventions indicated to anticipate and meet the resident's needs, be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The interventions indicated Resident 4 needed prompt response to all requests for assistance and to follow facility fall protocol. According to a review of the Physician's Orders dated May 6. 2021, Resident 4 received [MEDICATION(S)] 25 milligrams (mg) by mouth two times a day for [CONDITION(S)] (a condition that affects the way your brain processes information, causes you to lose touch with reality), manifested by unknown behavior. A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated May 8, 2021, indicated Resident 4 had severe cognitive impairment and required extensive assistance for bed mobility, personal hygiene, total dependence for toilet use and was only able to stabilize with staff assistance. The MDS indicated Resident 4 had a history of a fall within the last month. A review of Resident 4's [MEDICATION(S)] (an anti-psychotic drug) Care Plan, dated May 14, 2021, indicated Resident 4 would be free of [CONDITION(S)] drug complications. The care plan interventions indicated to monitor behavior every shift (did not include specific behavior), discuss with the physician Resident 4's behaviors and document adverse reactions such as frequent falls and behavior symptoms not usual to the person. During an observation on June 2, 2021 at 2:12 PM, Resident 4 was sitting on the floor in the doorway of her room. Resident 4 stated, All day she no come. I go home. Upon inspection of Resident 4's room, the call light was out of the resident's reach, hung above the bed over the overhead light. There was no floor mat or bed alarm in place. During an observation on June 2, 2021 at 2:20 PM, Treatment Nurse/Licensed Vocational Nurse 2 (LVN 2) arrived to Resident 4's room and called for help. Resident 4 stated, I'm not crazy. LVN 2 noted the small laceration on Resident 4's right eyebrow, measuring 0.6 cm x 0.6 cm, with purple discoloration. LVN 2 stated, This is new. LVN 2 then stated and confirmed the call light was hung over the overhead light and should be within Resident 4's reach. During the observation, LVN 2 administered first aid to Resident 4's laceration to the right eyebrow. A review of the Post Fall Assessment, dated June 2, 2021, indicated the physician ordered for Resident 4 to receive a daily 14-day skin treatment to the right eyebrow. During an observation on June 2, 2021 at 2:30 PM, Resident 4 was noted with no falling star emblem on a blue wrist band nor a star next to Resident 4's name sign outside the room. During this same observation, LVN 3 arrived at Resident 4's room, assisted the resident to standing with a front wheel walker (FWW), and walked with Resident 4 back to her bed with standby assistance. During a concurrent interview, when asked about a floor mat or bed alarm for the resident, LVN 3 stated there was no floor mat or bed alarm in place and left Resident 4's room. During an observation on June 2, 2021 at 2:35 PM, Resident 4 was observed crawling out of bed, through the FWW and out to the hallway. A review of the Un-witnessed Fall report, dated June 2, 2021, indicated Resident 4 had a small skin abrasion on the side of the right eyebrow which measured 0.6 cm x 0.6 cm) noted with scant bleeding. Resident 4 complained of a little pain on skin area and refused to take pain medication. During an interview on June 2, 2021 at 2:48 PM, LVN 3 stated Resident 4's behavior of crawling out of bed had been going on for a couple days. LVN 3 stated and verified there was no documentation the physician was notified regarding Resident 4's behavior of crawling out of bed and sitting in the hallway. During an interview on June 2, 2021 at 3:20 PM, the social service worker (SSW) stated she noticed Resident 4 constantly verbalizing wanting to go home and crawling out to the hallway. The SSW further stated Resident 4 was not safe to go home. When asked if the behavior was documented or reported to the family or physician, the SSW stated she did not document Resident 4's behavior and did not notify the family or physician. On June 2, 2021 at 4 PM, during an interview, the administrator (ADM) stated, We will notify the doctor right away. During an interview with the Director of Staff Development (DSD) on July 20, 2021 at 9:27 AM, the DSD stated staff did not notify physicians or resident's responsible party and use Changes in Condition form on the computer to document adverse reactions such as frequent falls and behavior symptoms not usual to the person. During an interview on July 26, 2021 at 4:11 PM, when asked about the falling star emblem not observed for Resident 4, the DSD stated Resident 4 was not a high fall risk upon admission. A review of the facility's policy titled, Fall Prevention Program, dated December 2016, indicated if on admission, a risk for fall was identified, initiate use of fall prevention and reduction program according to fall risk score. All precautions on the falls care plan should be implemented to protect the resident. Care plans should include treatment prescribed by the physician and interventions, such as, monitoring medication review and alarms should be implemented. This same policy indicated the Falling star program: The falling star emblem will be placed and/or located at: Head of bed, assistive devices such as wheelchairs, walkers, etc.; outside the resident's room on the name sign; wristband; bed and/or chair alarms; non-skid floor mat. Environment: Bed height, Support and Mattresses: landing mattress may be use for fall prevention next to bed to decrease injuries. Bed Alarm systems: These are designed to warn nursing staff that patients or residents who should not attempt to leave their bed unassisted are doing so. Evaluate and choose alarm systems based on such features as loudness, built-in time delays, ease of use, etc.

Based on observation, interview, and record review, the facility failed to ensure the resident received supervision and assistance device to prevent elopement (unsupervised wandering which results in a resident leaving the nursing home facility), for one of two sampled residents (Resident 1). For Resident 1, who wore a Wanderguard (a device placed on the resident's extremity used to alert the staff of an elopement attempt) and was wheelchair bound, the resident was able to roll herself more than 150 feet from the facility's lobby to open the double glass doors, down to the ramp, then hit her head on the wall at the end of the ramp without staff intervention. This deficient practice resulted in Resident 1's sustaining a closed head injury (blow to the head) with left medial (middle) orbital (around the eye) fracture, forehead abrasion (skin cut) requiring skin adhesive for closure, knee contusion (tissue damage) with left patella (kneecap) fracture, pain, and required care at the general acute care hospital (GACH). Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility, on 9/11/13, with [DIAGNOSES REDACTED]. A review of Resident 1's Physician Order, dated 6/30/18, indicated the physician ordered for a placement of Wanderguard and monitoring for wandering behavior every shift. A review of the Minimum Data Set (an assessment and care-screening tool), dated 7/8/18, indicated Resident 1 was moderately impaired in cognition. According to the MDS, Resident 1 required supervision with bed mobility, transfer, and eating, and limited assistance with walking, dressing, toilet use, and personal hygiene. According to a review of the Initial History and Physical, dated 8/6/18, Resident 1 did not have the capacity to understand and make decisions. A review of the Physical Therapy (PT) Discharge Summary, dated 9/24/18, indicated Resident 1 required minimal assist with bed mobility, transfers, and bed mobility. Resident 1 was able to walk 50 feet using a two-wheeled walker with minimal assist. A review of Resident 1's Progress Notes, dated 10/4/18 at 3:02 p.m., indicated, The registered nurse received patient (Resident 1) on her wheelchair without assistance. Noted patient having behaviors of continuously wandering and trying to elope. Verbally educated to reality, but still very confused and stated she needed to go home. Alert and confused, getting aggressive and violent when nurses stopped her to go out or brought her back to activity room or her room. Patient has order of Wanderguard alarm in working condition, answered promptly to prevent unassisted elopement. A review of Resident 1's Progress Notes, dated 10/4/18 at 7:50 p.m., indicated Heard another alarm from front door, paged nurses to check front door and ran to the door, three nurses get to the door right away but patient already slid down to the end of slope still sitting on her wheelchair. Noted bleeding left eye lid and nose. Resident 1 complained of pain on both knees. Skin laceration on left eye lid 1 cm (centimeter) length, open skin on both side of her nose, both knees with skin redness. A review of Resident 1's Physician Order, dated 10/4/18, at 8:33 p.m., indicated to transfer Resident 1 to the emergency room (ER) of the GACH, status [REDACTED]. A review of the GACH emergency department record, dated 10/5/18, indicated Resident 1 had an abrasion to left frontal head, ecchymosis (bruising) noted left frontal head, and 1 cm laceration to left forehead. Resident 1 had an abrasion to the left hand and a small abrasion to the right knee. Resident 1 had some pain and swelling associated with abrasion to the left knee. Resident 1's left frontal head abrasion was 1 cm in length and was repaired with skin adhesive. Resident 1's differential (diagnoses) included, but not limited to, closed head injury (blow to the head), knee contusion (injured tissue), patella fracture, facial fracture, facial contusion, and lacerations to name a few. Resident 1 had pain with range of motion to the left lower extremity. Resident 1 was placed on a knee immobilizer and had x-ray that demonstrated a non-displaced [MEDICAL CONDITION] patella. CT scan showed a left medial orbital wall fracture. According to the facility's letter, dated 10/5/18, Resident 1 was admitted back to the facility at 3 a.m., no surgery necessary, a knee brace was applied (not indicating which side of the knee). A review of Resident 1's Physician Phone Order, dated 10/5/18, indicated to give two tablets of Tylenol 325 milligrams (mg) by mouth every six hours for pain management on the left orbital and patella fracture for seven days. The treatment orders for upper nose, left eye, the right and left knee skin abrasion, indicated to cleanse with normal saline (NS, salty water), pat dry, and apply [MEDICATION NAME] (antibiotic) ointment and leave open to air one time daily, for 14 days. On 10/22/18, at 9:29 a.m., Resident 1 was interviewed with the Assistant Director of Nursing (ADON) providing translation. Resident 1 could not remember the circumstances surrounding her alleged elopement and subsequent injuries. Resident 1 was observed to have a cast to the left leg from the mid-thigh extending to the ankle. Resident 1 was observed to have a Wanderguard to the right wrist. On 10/22/18, at 9:51 a.m., the Physical Therapist 1 (PT 1) was interviewed. PT 1 stated prior to Resident 1's incident of elopement and subsequent injuries, she was able to walk with minimal assistance. After the incident, Resident 1 was non-weight bearing because of the cast to the left leg. PT 1 stated Resident 1 cannot walk. On 10/22/18, at 10:30 a.m., the Registered Nurse Supervisor 1 (RNS 1), the first responder after Resident 1's alleged elopement, was interviewed over the phone. RNS 1 stated on the day of the alleged elopement, She (Resident 1) was wandering. She wants to go to some place from before, in Korea. RNS 1 stated she placed Resident 1 in a wheelchair and was closely monitoring her. RNS 1 stated Resident 1 was last seen sometime before 8 p.m., on 10/4/18, at the nurses' station. While RNS 1 was allegedly in another resident's room, she heard the Wanderguard® alarm sound. RNS 1 stated she responded to the alarm very fast, few minutes. When RNS 1 made it to the front door of the facility, Resident 1 was at the end of the ramp, which is sloped. Resident 1 was sitting in the wheelchair and was presumed to have hit the wall at the end of the ramp. Resident 1 was bleeding from a laceration to the left eyebrow and was complaining of knee pain for which she was medicated. Resident 1 was transferred to the GACH. RNS 1 did not have an explanation as to how Resident 1 was able to trigger the Wanderguard® alarm, open the facility front door while in the wheelchair, and allegedly elope, without staff intervention. On 10/22/18, at 11:26 a.m., the facility was observed with the Administrator. The Administrator stated the nurse's station where Resident 1 was allegedly last seen was approximately 150 feet from the facility's lobby. The lobby was approximately 28 feet in length to the double glass doors, the entrance to the facility. From the entrance to the facility to the street, the ramp was approximately 40 feet in length. The Administrator had no explanation as to how Resident 1 was able to allegedly travel, via wheelchair, the distance from the nurses' station to the lobby and to the front doors, trigger the Wanderguard® alarm, elope, and have an accident at the end of the ramp, without staff intervention. The facility's policy titled, Elopement Risk Reduction Approaches, revised (MONTH) (YEAR), was concurrently reviewed with the Administrator. The policy indicated to create activity zones with recreational opportunities, such as multi-sensory theme boxes that residents can explore with staff encouragement. Provide cueing to help residents to orient themselves (e.g., memory boxes, recognizable personal furnishings, large signs or pictures). Install non-intrusive alarm systems that alert staff to resident exiting. Post signs at exterior doors to alert visitors that residents with dementia may try to leave with them. The Administrator confirmed these approaches indicated by the policy were not implemented; the Administrator did not have an explanation. On 10/22/18, at 12:01 p.m., the Director of Nursing (DON) was interviewed. The DON stated and confirmed there was no care plan for elopement risk prior to the incident. The DON stated a elopement risk care plan should have been developed, in accordance with the interdisciplinary team recommendations. The care plans must be developed and implemented with resident-specific interventions. The DON did not have an explanation for not having an elopement risk care plan. A review of Resident 1's Wander and Elopement Risk Assessment, dated 7/8/18, was concurrently reviewed with the DON. The DON stated and confirmed this wander and elopement risk indicated Resident 1 had a low risk for wandering and elopement. The DON confirmed the assessment was not updated to reflect Resident 1's high risk for wandering, requiring a Wanderguard®, but should have been updated. The DON had no explanation. The facility's policy titled, Elopement Risk Reduction Approaches, revised (MONTH) (YEAR), was concurrently reviewed with DON. The policy indicated accompany wandering residents on their journeys when supervision was required to ensure safety or encourage a meaningful, alternate activity. Help non-cognitively impaired residents to understand wandering as a symptom of dementia. Develop a care plan and an update process to promote choice, mobility and safety. Base the care plan on assessments and family and caregiver involvement. The DON confirmed there was no documented evidence these approaches indicated by the policy were implemented. A review of the facility's policy titled, Wandering and Elopement, revised 6/1/17, indicated the facility would identify residents at risk for elopement and minimize any possible injury as a result of elopement. The purpose was to enhance the safety of residents of the facility.

Based on interview and record review, the facility failed to ensure sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one of two sample residents (Resident 1), including: 1. Failure to involve Resident 1 and Resident 1's son (Family Member 1) regarding a sudden decision by Physician 1 to transfer Resident 1 to General Acute Care 1 (GACH 1), when the nursing staff was no aware of any urgent medical need for Resident 1's sudden transfer. 2. Failure to question Physician 1 when Physician 1, came to the facility to personally pick up Resident 1, without Resident 1's knowledge and approval, as Resident 1 was confused and unable to make decisions, and without Family Member 1's knowledge. 3. Failure to implement the facility's policy on Transfer and Discharge by not transferring or discharging a resident if necessary for the resident's welfare and the resident's needs cannot be met in the facility, by not providing the resident with reasonable advance notice of the transfer or discharge before it occurred, by not notifying the family of the resident transfer, by the Director of Social Services or designee not assisting in coordination of Resident 1's care upon discharge. As a result on [DATE], Resident 1's was discharged to a lower level of care (Assisted Living Facility - ALF) when Resident 1 needed skilled care. Family Member 1 was anxious not knowing Resident 1's whereabouts until [DATE] (a total of 13 days), when GACH 3 notified Family Member 1 Resident 1 was admitted to Intensive Care Unit (ICU). Resident 1 expired at GACH 3 on [DATE]. Findings On [DATE], an unannounced visit was made to the facility to investigate a complaint Discharge/Transfer and Quality of Care. On [DATE], at 11 a.m., during an interview, Family Member 1 stated he was looking for Resident 1 and the facility informed him Resident 1 went to GACH 1, however, after inquiring at GACH 1, Family Member 1 was told by GACH 1 Resident 1 was never evaluated or admitted there. After notifying the facility, Family Member 1 was told they did not know where Resident 1 was transferred. When Family Member 1 called the office of Physician 1 (attending physician), he was told Resident 1 was transferred to GACH 2. Family Member 1 called GACH 2 and was told Resident 1 was never brought to GACH 2. Family Member 1 called Physician 1's office again and was told Resident 1 was at GACH 1. Family Member 1 considered Resident 1 a missing person and reported her missing to the Police Department. Family Member 1 did not hear from Physician 1 again. Family Member 1 was anxious about the whereabouts and condition of Resident 1 for approximately two weeks until on [DATE], GACH 3 notified him Resident 1 had been admitted in critical condition to the ICU. A review of the Record of Admission (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Record of Admission listed Family Member 1 and two other relatives as the contact persons with the contact information. The POLST (physician's orders [REDACTED]. A review of the Initial History and Physical dated ,[DATE] (year no legible), completed by Physician 1, indicated Resident 1's [DIAGNOSES REDACTED]. Resident 1 did not have the capacity to understand and make decisions, Family Member 1 was documented as the surrogate decision maker. A review of the physician's orders [REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool) dated [DATE], indicated Resident 1 was assessed as having memory problems and unable to make decisions. Resident 1 required limited assistance with one-person physical assist with bed mobility, transfers, walking, eating, toilet use and personal hygiene. Resident 1 needed a wheelchair and a cane for mobility. A review of the Physician's Progress Record dated [DATE], indicated Resident 1 was status [REDACTED]. A review of the nursing Interdisciplinary Progress Notes dated [DATE], timed at 7:42 a.m., Resident 1 was found lying on the floor in the hallway. The resident sustained [REDACTED]. A review of the nursing Interdisciplinary Progress Notes dated [DATE], timed at 2:34 p.m., indicated Physician's Assistant 1 (PA 1) called and stated Physician 1 arranged Resident 1 transfer to GACH 1 for admission and the ambulance was on its way. PA 1 stated Physician 1 notified Family Member 1 of the transfer. A review of the nursing Interdisciplinary Progress Notes dated [DATE], timed at 4:10 p.m., indicated Resident 1 was picked up by Physician 1. At 6:12 p.m., Physician 1 called and stated he (Physician 1) transferred Resident 1 to GACH 1 for a percutaneous endoscopic gastrostomy (PEG) tube insertion (procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus). A review of the Physician's Telephone Order dated [DATE], indicated Resident 1 was to be transferred to GACH 1 for evaluation due to multiple falls, weakness, increased confusion, weight loss (10 pounds in one month), and aggression. A review of the Discharge Summary by Physician 1 dated [DATE], indicated Resident 1 was evaluated and treated for [REDACTED]. A review of the facility's policy on Transfer and Discharge, revised [DATE], indicated the facility may transfer or discharge a resident if necessary for the resident's welfare and the resident's needs cannot be met in the facility. - The facility staff would provide the resident with reasonable advance notice of the transfer or discharge before it occurs. - Documentation of written or telephone acknowledgement of the resident's transfer by the resident's personal representative may occur after the transfer in an emergency situation. Should it become necessary to make an emergency transfer of discharge to a hospital or other related institution, the Facility would: - Notify the receiving facility that the transfer was being made; - Notify the resident's personal representative; The Director of Social Services of his or her designee would assist in determining: - Coordination of care between various caregivers and agencies; - Preparation needed by the resident and/ or family/ responsible party for discharge. A review of GACH 3's ED (Emergency Department) notes dated [DATE], indicated Resident 1 presented to the ED with altered mental status and difficulty breathing. Resident 1 was bedbound and non-verbal and there was limited information obtained from the (two) caregivers who brought her to ED. Resident 1's reason for admission was respiratory depression,[MEDICAL CONDITION] (a life-threatening condition in which the body is fighting a severe infection that has spread via the bloodstream) and [MEDICAL CONDITION]. The problem list included dehydration, underweight, terminal ulcer of the sacrum, severe protein-calorie malnutrition, [MEDICAL CONDITIONS] ([MEDICAL CONDITION] -bacteria resistant to many different antibiotics) of the urine and nares (nose). Resident 1 was placed on supportive care and died on [DATE]. On [DATE] at 4 p.m., during an interview, the Director of Nursing (DON) stated there was no communication with GACH 1 regarding Resident 1 transfer. Resident 1 was transferred to Physician 1's office for treatment and was later sent to an unknown Board and Care facility. The DON further stated staff did not know where Resident 1 was when Family Member 1 inquired about the resident's whereabouts. On [DATE], at 12 p.m., during an interview, the Administrator stated the facility contacted GACH 1 three days after transfer, and since Resident 1 was not admitted there was presumed discharged . During the investigation, the Evaluator made several attempts to interview Physician 1 and PA 1; however, Physician 1 and PA 1 did not return the calls.

Based on observation, interview, and record review, the facility staff failed to ensure the residents were free from accident hazards as is possible for three out of 30 sampled residents (Residents 4, 5, and 15) and two of 18 random sampled residents (RSRs 31 and 39), including: 1. Failure to verify residents' diet order with the dietary meal card for Residents 4, 5, and 15. 2. Failure to ensure Residents 4, 5, and 15's meal cards were checked for accuracy prior to serving meal to prevent the potential of aspiration (inhalation of food, liquid, or vomit into the lungs) 3. Failure to supervise Resident 4, 15, RSR 31 and RSR 39, who had a [DIAGNOSES REDACTED]. 4. Failure to apply a self-release belt to Resident 2 who had a history of [REDACTED]. These deficient practices placed the residents at risk of choking/aspiration and fall. On September 8, 2017, at 4:58 p.m., an immediate jeopardy (IJ, a situation in which the provider'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 called under F323 in the presence of the facility Administrator, Director of Nursing, and Quality Assurance Nurse. An acceptable plan of action was accepted on September 10, 2017 at 7:10 pm. and was validated through observation, interview and record review to verify compliance. The acceptable P(NAME) included: 1. The Speech Therapist (PT) evaluated Resident 4 for swallowing and aspiration on September 7, 2017 with revision made to Resident 4's care plan on September 8, 2017. 2. The Registered Dietitian (RD) reviewed Resident 15's diet to ensure correct diet texture. 3. The RD provided an in-service to the Dietary Service Supervisor (DSS) on September 9, 2017 regarding following the physician orders [REDACTED]. 4. The ST evaluated Resident 5 on September 8, 2017. 5. The Director of Nursing (DON) in-serviced the licensed staff and Certified Nursing Assistant (CNA) regarding diet order changes, accuracy of diet consistencies, and diet order communication protocol. 6. Immediate chest X ray (diagnostic test) were completed for Residents 4, 5, and 15 on September 8, 2017. 7. The Registered nurse (RN) completed assessments on September 8, 2017 to ensure Residents 4, 5, 15 did not have signs and symptoms of aspiration. 8. The DSS started monitoring the tray line on September 9, 2017 to ensure the diets were served per physician order. 9. The RD and DSS began providing in-service education to dietary staff for diet order accuracy policy and procedure 10. The licensed Nursing staff developed and implemented care plans for aspiration risks for Residents 4, 5 and 15 on September 8, 2017. 11. Residents 4 and 15 were placed on feeding assistance program to monitor aspiration precaution as of September 9, 2017. 12. The ST provided in-service education to licensed nursing staff, CNA, and Restorative Nursing Assistant (RNA) regarding monitoring residents at risk for aspiration. 13. The ST and Occupational Therapist (OT) conducted dining round on September 10, 2017, and shall conduct dining round on a weekly basis. 14. The licensed nursing staff identified other residents with dysphagia/risk for aspiration and developed and/or revised care plans addressing aspiration risk on September 9, 2017. The immediate jeopardy was removed on September 10, 2017 at 7:20 p.m. when the facility was able to demonstrate knowledge of how to: 1. Manage residents with aspiration risk. 2. Achieve diet accuracy and monitor signs and symptoms of aspiration. 3. Follow the physician's diet orders. 4. Communicate with other member of the health care team regarding diet changes and implement care plans interventions. Findings: a. On September 5, 2017 at 12:30 p.m., during lunch observation Resident 4's meal card was noted to include fortified mechanical soft finely chopped meat and vegetables. Resident's plate was noted to include chicken with rice, melons, cole slaw salad, and noodle soup. Resident was sitting without a staff member assisting her with lunch. Resident's meal tray did not include ice cream as ordered. Upon closer look, the chicken was not finely chopped as ordered rather it had big pieces of chicken. It was observed that the resident was not consuming much of the meal, and when asked why the resident was pointing to her throat and speaking in her native language. LVN 9 who would assist the resident on and off, placed a piece of chicken on the fork and gave it to the resident. Resident placed the piece of chicken in her mouth and started to slowly chew the piece of chicken. When asked why the resident was not eating, LVN 9 stated that the resident did not like the taste. On September 5, 2017 at 12:40 p.m., during interview, Social Services Designee who also spoke the resident's native language stated that the resident usually eats well, but today didn't like the taste. When asked why the resident was pointing to her neck area when asked to eat, Social Services Designee stated that the resident was saying that she was not able to swallow the food. During this time while eating with the assistance of LVN 9, as the resident was chewing the chicken, the resident started coughing when she tried to swallow the chicken. Resident not being able to swallow the chicken, spit out the piece of chicken. LVN 9 still continued in assisting the resident to eat. On September 5, 2017 at 12:45 p.m., during interview, LVN 9 stated that the residents diet was supposed to be chopped smaller because of difficulty for swallowing. On September 6, 2017 at 11 a.m. during an interview Speech Therapist (ST 1) stated that that the resident had an evaluation done on February 15, 2017 and the resident was recommended to be placed on puree diet with thin liquid due to risk of aspiration and chocking, and was on puree till April of 2017. On April 11, 2017 the resident's diet was changed to mechanical soft finely chopped. ST 1 stated that the nursing was supposed to notify her if the resident needed to have a re-evaluation. ST 1 further stated that looking at the percent of meals consumed by the resident due to history of dysphagia and poor intake will consider a re-evaluation. On September 7, 2017 at 10:15 a.m., during an interview LVN 2 stated if resident has limited mobility with one person assist , the assistant will need to always be there by the resident. The assistant should not attend to other residents while attending to Resident 4. On September 7, 2017 at 10:52 a.m., during an interview, registered nurse (RN 1) stated that when a resident's meal intake is low, certified nursing assistants (CNA's) will notify the nurses and nurses will notify the physician. Further RN 1 stated that the resident's low intake should have been followed up with. On September 7, 2017 at 1:30 p.m., during an interview ST 1 stated that the resident had been re-evaluated by ST and the resident's diet was downgraded to puree due to difficulty swallowing. Review of the admission record, indicated Resident 4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's quarterly Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated August 21, 2017, indicated the resident had severely impaired cognition for daily decision making. Resident 4 had the ability to understand makes self understood. Resident 4 required extensive assistance for ADL's including eating with one person physical assist. A review of Resident 4's physicians orders for the month of September 2017, included an order dated July 8, 2015 for indicating fortified mechanical soft finely chopped meat/vegetable no added salt diet. Review of Resident 4's care plan dated February 15, 2017 indicated that the resident needs therapeutic diet related to high blood pressure, CVA (cerebrovascular accident is a sudden episode that occurs when the blood supply to part of the brain is interrupted or when a blood vessel in the brain bursts, spilling blood into the spaces surrounding brain cells) with left sided hemiparesis (weakness of one entire side of the body). The goals section indicated that the resident will receive appropriate diet and consume between 75-100% of meals. The interventions section of the care plan indicated to provide diet as ordered fortified mechanical soft finely chopped vegetables and meat, to monitor meal consumption and offer substitutes if resident consumes less than 50% of meal, and supplement as ordered ice cream at lunch and dinner. A review of progress note by the ST dated September 6, 2017 indicated that Resident 4 was observed during lunch time on September 6, sitting up in wheelchair in the dining room. Resident was served mechanical soft finely chopped diet. Resident was able to feed self with excessive mastication time and then spitting out instead of swallowing. Further stated that the resident had poor intake, which was communicated with nursing and requested for ST evaluation order. Review of ST evaluation and plan of treatment dated September 7, 2017 indicated that the clinical impressions were that the resident was moderate to severe impaired oral phase, mild pharyngeal swallow, puree diet recommended at this time. Risk factors indicated that due to the documented impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for aspiration, dehydration and further decline in function. The recommendations were to change diet to puree consistency with thin liquids. Review of physician's telephone order dated September 8, 2017 indicated to do a chest x-ray stat due to possible aspiration. Review of radiology report dated September 8, 2017, indicated that there was a slight left lower lobe pneumonia. Review of physician's telephone order dated September 9, 2017, indicated to transfer to the acute hospital via ambulance due to slight lower lobe pneumonia. b. Review of the admission record, indicated Resident 5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 5's history and physical dated December 12, 2016 indicated that the resident was admitted to acute related to severe dehydration, acute renal failure and after she stopped eating GT was placed. It further indicated that the resident had left sided weakness due to CVA, and had [DIAGNOSES REDACTED]. A review of Resident 5's quarterly Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated August 14, 2017, indicated the resident had severely impaired cognition for daily decision making. Resident 5 had the ability to understands and make self understood, was totally dependent on staff for transferring, locomotion on and off unit, toilet use, bathing, and eating with one person physical assist. It further indicated that the resident had impairment on both lower extremities. On September 8, 2017 at 7:45 a.m., during breakfast observation, with the presence of CNA 5, Resident 5 was noted to be in bed with breakfast tray set on the bedside tray table. Meal tray included a pureed eggs and bread. Resident stated she did not like the food and it was choking her. Resident 5 further stated she wanted water, and continued to state that she was choking. During this time the CNA 5 stated that the resident can't have water because the resident has GT. CNA 5 then went to ask RN 2 who also was not sure wether the resident can receive water, and there were no physicians orders indicating wether the resident could receive any type of fluids. QA nurse stated nursing will need to clarify it with he physician. On September 8, 2017 at 9:10 a.m., during interview, ST 2 stated that he did an ST evaluation for Resident 5 and the resident was having difficulty in swallowing and will need to be picked up by ST and provided with swallowing therapy. ST 2 further stated that the resident holds food and when swallowing, the reflex is delayed and increases the risk for aspiration. For now the resident will be placed on NPO (nothing by mouth) and the ST will pick up the resident. ST 2 stated that the residents should receive an ST evaluation once a year or as needed if any changes occur. When the weight is dropped ST will need to be notified, IDT will be done. The resident should have had a ST evaluation before she was placed on PO. ST 2 further stated the resident will be picked up due to being at risk for aspiration and also the diet needs to be looked at. On September 8, 2017 at 1 p.m., during lunch time observation, Resident 5 was noted to be sitting in her reclining wheelchair in the hallway in front of the nurses station 1 with her lunch tray in front of her on the tray table. During an interview certified nurses aid (CNA 5) stated that she fed the resident, and the resident ate about 10 %, but did not like the food. QA nurse stated the resident should not have anything by mouth due to being placed on NPO. During the same time, when asked why was the resident still receiving PO when the order was placed for NPO, RN 2 stated that he was busy and did not have time to carry out the order. RN 2 further stated that he will go and remove the lunch tray from in front of the resident because resident is NPO. On September 13, 2017 at 9 a.m., during in interview, Quality Assurance Nurse (QA) stated that the resident was sent out to the acute care hospital for abnormal labs. On September 13, 2017 at 9:45 a.m., during an interview, when asked about aspiration precaustions, MD 1 stsated that he was not notified regarding those specific concerns. MD 1 further stated that he agreed that providing the wrong diet is not right, but sometimes it happens. A review of Resident 5's care plan with an effective date of February 14, 2017, indicated that the resident had [DIAGNOSES REDACTED] of left side related to CVA with limited range of motion on both ankle. The goals section indicated that the resident will maintain functional level within limitations of [DIAGNOSES REDACTED]. The interventions section of the care plan indicated therapy evaluation and treatment per physician order. A review of Resident 5's physician orders [REDACTED]. A review of Resident 5's physician telephone order dated September 8, 2017 at 10:30 a.m., indicated to discontinue PO diet, NPO and trial PO with speech therapist, dietary evaluation for [DEVICE] feeding adjustment. A review of another order for Resident 5 indicated to perform a chest x-ray stat due to possible aspiration. A review of radiology report dated September 8, 2017 indicated that the resident had slight lower lobe infiltrate. Review of physician's orders [REDACTED]. A review of the facility's revised policy and procedure dated June 1, 2017 and titled, Therapeutic Diets, indicated the dietary manager will periodically review the resident's tray card and the physician's dietary orders to ensure that the information is consistent. c. A review of Resident 2's admission record, indicated Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's quarterly Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated September 6, 2017, indicated the resident had moderately impaired cognition for daily decision making. On September 5, 2017 at 11:45 a.m., during observation, Resident 2 was noted in the dining room sitting in her wheelchair. Upon closer look, it was observed that the resident was without the self release belt on as ordered. When asked about why the resident's self release belt was not secured on the resident, registered nurse (RN 1) stated that the resident does not have the capacity in making a decision to remove the belt, further the resident did not have a safety awareness. RN 1 further stated that the resident should have the belt on specially since she had a fall in February 2017 and is a fall risk. A review of Resident 2's care plan dated February 5, 2017, indicated that the resident had an actual incident on fall on the floor. The interventions section of the care plan indicated to apply self release belt while in wheelchair to safety and prevent injury. A review of the physician orders [REDACTED]. Informed consent obtained from resident's family. A review of 72 hour post fall observation and assessment indicated that the resident had a fall on February 3, 2017. Review of the facility's policy and procedure with a revision date of June 1, 2017 titled Response to Falls indicated that the purpos of the policy was to ensure the facility responds quickly and appropriately to resdient falls in a manner that addresses both the resdient's immediate needs and longer-term fall prevention. d. A review of the admission record indicated Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated August 24, 2017 indicated Resident 15 had moderately impaired cognition for daily decision making and required supervision and set-up while eating. On September 8, 2017 at 7:45 a.m., during a general observation, Resident 15 was sleeping in bed. Resident 15's breakfast tray was on the bedside table. The lid of the entrée was removed. The meal card indicated the breakfast was a Regular NAS (no added salt) diet. Resident had one whole pastry and one boil egg on the plate. A review of the physician's orders [REDACTED]. A review of the Diet Order that LVN 4 was using to match the meal card with was dated September 6, 2017 that indicated Resident 15 had an order for [REDACTED]. However, Resident received a regular NAS diet instead. On September 8, 2017 at 11:00 a.m., during an interview, Dietary Service Supervisor (DSS) stated Resident 15 should have received a mechanical soft finely chopped diet. DSS further stated that the nurses are to match the diet orders with the meal card and tray for accuracy when the food cart comes out of the kitchen and before the trays are passed out to the residents. On September 8, 2017 at 11:15 a.m., when asked for a copy of the meal card that was on the breakfast tray (Regular NAS), DSS bought a copy of the corrected meal card. Upon further interview, DSS stated she saw the diet on the Diet Order was for mechanical soft finely chopped, NAS diet and DSS revised the meal card. On September 8, 2017 at 11:30 a.m., during an interview, Dietary Aid 1 (DA 1) stated she called for the diet that is on the meal card. On September 8, 2017 at 11:50 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated she did not have time to check each tray with each diet order. On September 8, 2017, at 4:58 p.m., an immediate jeopardy (IJ) was called in the presence of the facility Administrator, Director of Nursing, and Quality Assurance Nurse. The accepted plan of action included to place Resident 15 on a feeding assistance program to monitor dietary intake and aspiration precaution as of September 9, 2017. On September 9, 2017 there was a Physician order [REDACTED]. A review of the Speech Therapy Evaluation and Plan of Treatment report dated September 9, 2017, Speech Therapist recommended a puree consistencies and nectar thick liquids and with close supervision. On September 9, 2017 during a lunch observation from 12:18 p.m. to 12:53 p.m. in the dining room, Resident 15 was observed eating lunch unassisted. The Director of Nursing (DON) was also in the dining room feeding another resident. On September 9, 2017 at 12:55 p.m., during a telephone interview in the presence of the DON, Quality Assurance Nurse reminded the DON of the intervention that was in placed to ensure Resident 15 was assisted with meals. DON stated the resident was ok to eat by herself. A review of the facility's revised policy and procedure dated June 1, 2017 and titled, Therapeutic Diets, indicated the dietary manager will periodically review the resident's tray card and the physician's dietary orders to ensure that the information is consistent. A review of another facility's undated policy and procedure and titled, Aspiration Precaution-Clinical Guidelines, indicated the risk factors for aspiration included to check for history of dysphagia, aspiration and recurrent aspiration pneumonias. A review of another facility's revised policy and procedure dated June 1, 2017 and titled, Aspiration Precautions, indicated residents identified at risk for aspiration, exhibiting signs of impaired swallowing, or displaying symptoms of potential aspiration will have aspiration precautions implemented. Aspirations precautions will be written in the resident's plan of care. Aspirations precautions included to assist with feeding and supervision as indicated in the resident's plan of care. e. A review of the admission record indicated RSR 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RSR 31's MDS dated [DATE], indicated the resident had moderately impaired cognition for daily decision making. RSR 31 required extensive assistance with one person assist during meal. RSR 31 was on a mechanically altered diet (required change in texture of food or liquids). A review of RSR 31's History and Physical Report completed on November 19, 2016, indicated the resident had a [DIAGNOSES REDACTED]. The report also indicate RSR 31 did not have the capacity to understand or make decisions. A review of RSR 31's physician order [REDACTED]. On September 9, 2017 from 12:18 p.m. to 12:50 p.m., during dining observation to validate the facility's POA in regards to the IJ, RSR 31 was sitting at a table in the dining room and eating independently. RSR 31 was observed coughing at times. At 12:50 p.m., during a concurrent interview, CNA 5 sat down next to RSR 31 and stated that RSR 31 required assistance with feeding. On September 11, 2017 at 8:04 a.m., during an interview, the QA nurse stated that RSR 31 should have been supervised during lunch on September 9, 2017. On September 11, 2017 at 11:10 a.m., the Health Information Director (HID) was unable to provide a care plan addressing RSR 31's dysphagia. A review of RSR 31's chest R-ray results dated September 11, 2017, indicated modest right lower lobe pneumonia. A review of RSR 31's physician order [REDACTED]. On September 12, 2017 at 2:30 p.m., during an interview regarding the facility's Quality Assessment and Assurance (QAA) committee, the administrator and the QA nurse stated that the QAA committee did not identify concerns regarding nursing staff supervision of residents with a [DIAGNOSES REDACTED]. The Administrator also stated that the QAA committee did not identify concerns regarding the monitoring of residents with aspiration risk. A review of another facility's undated policy and procedure and titled, Aspiration Precaution-Clinical Guidelines, indicated the risk factors for aspiration included to check for history of dysphagia, aspiration and recurrent aspiration pneumonias A review of the facility's revised policy dated June 1, 2017 and titled Aspiration Precautions indicated residents at risk for aspiration will have measures implemented to reduce risk. Residents at risk for aspiration will be identified on admission, quarterly, with a change in condition, and daily observation. The attending physician will be notified when a resident displays signs and symptoms of potential aspiration, including: coughing or choking while eating or drinking, slow eating, taking multiple swallows of a single mouthful of food, weight loss because of slow eating or lack of appetite, and weak cough. Residents identified at risk for aspiration, exhibiting signs of impaired swallowing, or displaying symptoms of potential aspiration will have aspiration precautions implemented. Aspirations precautions will be written in the resident's plan of care. Aspirations precautions included to assist with feeding and supervision as indicated in the resident's plan of care. f. A review of the admission record indicated RSR 39 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of the monthly physician order [REDACTED]. A review of RSR 39's care plan dated March 17, 2016 indicated the resident had aspiration risk. The care plan did not include a goal, measurable objectives, and interventions to address RSR 39 risk for aspiration. A review of another care plan dated March 17, 2016, indicated RSR 39 had oro-pharyngeal dysphagia (refers to problems with moving food from the oropharynx into the esophagus). The care plan interventions indicated aspiration precautions: seated upright 75 to 90 degrees for all oral intake, remain upright for completion of meals, small bites/sips, slow feeding rate, chin tuck, alternate solids/liquids, check for pocketed foods, and one to one supervision during meal. The care plan did not include a goal or measurable objectives and timeframe to prevent aspiration. A review of RSR 39's monthly physician order [REDACTED]. A review of RSR 39's MDS dated [DATE], indicated the resident had severe impaired cognition for daily decision making. RSR 31 required extensive assistance with one person assist during meal. RSR 31 was on a mechanically altered diet (required change in texture of food or liquids) and therapeutic diet. On September 5, 2017 from 12:30 p.m. to 1 p.m., during a dining observation, RSR 39 was sitting on the geriatric chair (a large, padded, reclining chair), leaning to her right side and eating independently. RSR 39 was observed coughing at times. At 1 p.m., a nursing staff member sat down to assist the resident with her meal. On September 7, 2017 at 10:18 a.m., during an interview, LVN 2 stated that if a resident's assessment indicated he/she required assistance during meal, then a nursing staff member needed to present and assist the resident until he/she finished eating. On September 12, 2017 at 2:30 p.m., during an interview regarding the facility's Quality Assessment and Assurance (QAA) committee, the Administrator and the QA nurse stated that the QAA committee did not identify concerns regarding nursing staff supervision of residents with a [DIAGNOSES REDACTED]. The Administrator also stated that the QAA committee did not identify concerns regarding the monitoring of residents with aspiration risk. A review of another facility's undated policy and procedure and titled, Aspiration Precaution-Clinical Guidelines, indicated the risk factors for aspiration included to check for history of dysphagia, aspiration and recurrent aspiration pneumonias A review of the facility's revised policy dated June 1, 2017 and titled Aspiration Precautions indicated residents at risk for aspiration will have measures implemented to reduce risk. Residents at risk for aspiration will be identified on admission, quarterly, with a change in condition, and daily observation. The attending physician will be notified when a resident displays signs and symptoms of potential aspiration, including: coughing or choking while eating or drinking, slow eating, taking multiple swallows of a single mouthful of food, weight loss because of slow eating or lack of appetite, and weak cough. Residents identified at risk for aspiration, exhibiting signs of impaired swallowing, or displaying symptoms of potential aspiration will have aspiration precautions implemented. Aspirations precautions will be written in the resident's plan of care. Aspirations precautions included to assist with feeding and supervision as indicated in the resident's plan of care.

Based on interview and review, the Medical Director failed to ensure the facility's policies and procedures on Restorative Nursing Assistant (RNA) program, Contracture Prevention, Range of Motion (ROM) exercise, Change of Condition Notification, Range of motion, physician's orders [REDACTED]. This deficient practices resulted in negative outcomes, including: 1. An immediate jeopardy (IJ, a situation in which the provider'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) on Aspiration risk and choking potential for three of 30 sampled residents (Residents 4, 5, and 15) and two random sampled residents (RSRs 31 and 39). 2. A Substandard Quality of Care (SQC) on range of motion and contractures for four of 30 sampled residents (Residents 1, 21, 26, and 28). 3. A Substandard Quality of Care on unplanned weight loss for eight of 30 sampled residents (Residents 5, 6, 12, 14, 15, 16, 17, and 30). 4. Dehydration in one of 30 sampled residents (Resident 5). (Cross refer F322, F323, F325, F328, and F520) Findings: During the survey from September 5 through September 13, 2017, more than 25 deficient practices were identified including: assessment, quality of care issues (weight loss, dehydration, decline in ROM, choking hazard and aspiration risk), nursing services (insufficient staffing to assist residents during meals, competency of RNAs, pharmacy services, environment (dining space not meeting residents' needs), and administration (implementation of facility policies and procedures). On September 13, 2017 at 10 a.m., a telephone interview was conducted with the Medical director in the presence of the survey team, the Director of Nursing (DON), and the Quality Assurance (QA) Nurse. The Medical Director stated that he was involved in the development and implementation of the facility's policies and procedures and ensured policies and procedures were communicated to the nursing staff. The deficient practices were discussed as follow: Weight Loss The Medical Director stated that the facility's policy and procedure to prevent weight loss indicated to check the residents' weights and notify the physician if indicated, and notify the physician if a resident ate 40 to 50 percent of his/her meal for timely intervention. The Medical Director stated the goal of the facility's policy was to maintain the residents within their ideal body weight. The Medical Director also stated that weight loss was discussed during meetings and that the number of residents with weight loss had decreased in the facility. The Medical Director stated that he will discuss identified concerns with the administrator and DON. Dehydration: The Medical Director stated that residents' hydration status was related to oral intake. The Medical Director stated that the nursing staff was responsible for notifying the physician if a resident had poor oral intake. The physician would then order blood test and intravenous hydration therapy. When asked about the facility's hydration program and his involvement in the implementation of the policy, the Medical Director stated that the facility did not have an issue with residents' hydration status, so there was no need to evaluate the effectiveness of the hydration program. Other Identified deficient practices (decline in ROM, competency skills of RNAs, insufficient staffing, accuracy of diet). A review of the facility's revised policy dated June 1, 2017 and titled QAA program- Role of Medical Director, Attending Physician indicated the Medical Director and attending physicians work to intergrate the QAA program standards into their overall performance and providion of services. The medical director is to ensure the requisite level of quality and providion of medical services are provided by the facility.

Based on observation, review of documents, resident and staff interviews, the facility failed to have an effective Quality Assessment and Assurance (QAA) committee program that identifies residents quality of care issues, develop plan of action and implement system to prevent decline in range of motion, potential accident hazards, and significant weight loss. These deficient practices resulted in negative residents' outcomes, including: 1. An immediate jeopardy (IJ, a situation in which the provider'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) on aspiration risk and choking potential for three of 30 sampled residents (Residents 4, 5, and 15) and random sampled residents (RSRs 31 and 39). 2. A system failure on range of motion and contractures management for three of 30 sampled residents (Residents 1, 26, and 28). 3. A substandard quality of care on unplanned weight loss for eight of 30 sampled residents (Residents 5, 6, 12, 14, 15, 16, 17, and 30). The facility failed to identify deficient practices and develop Quality Assessment and Assurance (QAA) plans of action that was sufficient to meet the scope and complexity of the services provided (Cross refer F318, F323, and F325). Findings: On September 12, 2017 starting from 2 p.m. to 3:10 p.m., an interview was conducted with the facility administrator (ADM), the Director of Nursing (DON), and the QA Nurse regarding the facility's QAA committee. When the ADM was asked how issues were brought to the attention of the QAA committee, he stated that he conducted monthly staff meeting, he maintained an open dialog with staff members, families, and residents, and inquired about data from each department. The ADM also stated that he was responsible for developing action plans for issues that were brought up during the QAA meetings. The following deficient practices were discussed as follow: Choking hazard and aspiration risk An immediate jeopardy situation was identified under accident hazards and called on September 8, 2017 at 4:58 p.m. The IJ was abated on September 10, 2017 at 7:20 p.m. The concerns related to residents at risk for aspiration were discussed. The ADM stated the QAA committee did not identify concerns related to accuracy of residents' food texture, supervision of residents, with [DIAGNOSES REDACTED]. The ADM stated that the QAA committee should have known the potential of choking/aspiration for residents with swallowing problems. (CROSS REFER F323) Weight Loss The survey team identified eight of 30 sampled residents with weight loss concerns. According to the facility CMS 672 report, there was zero resident in the facility with unplanned significant weight loss/gain. The ADM stated that the QAA committee was using the facility's quality measure indicator to evaluate the facility's performance with weight loss. The QAA identified weight loss as an issue. As part of the QAA action plan, the ADM hired a new Registered Dietitian, who was responsible for assessing residents' nutritional status and assisting with kitchen operations. According to the ADM, there were less residents identified with weight loss (28 percent) in August 2017 compared to July 2017 (39 percent). The ADM, however, stated the QAA committee did not identify concerns related to monitoring of residents' nourishment intake, care planning addressing weight loss, notification of poor meal intake or residents' weight loss to the physician and RD, monitoring of meal substitution, and evaluation of RD's interventions. The ADM stated that the QAA committee should have known about the concerns. (CROSS REFER F325) Insufficient staff to assist residents during meals The ADM stated that the QAA committee did not identify concerns related to staff member's assistance during meals. The QAA was not aware that some residents had to wait up to 40 min to be assisted with their meals. The ADM stated that the QAA committee should have known about the insufficient staffing concern. (CROSS REFER F353) Decline in ROM The survey team identified three of 30 sampled residents with declined in ROM. According to the facility CMS 672 report, there were 33 residents in the facility with contractures, 8 residents developed contractures since being admitted to the facility. The ADM stated the QAA committee did not identify concerns related to joint mobility assessment by the rehabilitation department, skills competency of the RNAs, facility's policy on notifying the rehabilitation department and the physician regarding decline in ROM, qualification of the rehabilitation department coordinator to attend interdisciplinary care meeting, and licensed vocational nursing staff assessing the residents' joint mobility without supervision. The ADM stated that the QAA committee should have known about the concerns. (CROSS REFER F318) Dining space not meeting residents' needs The ADM stated that the QAA committee identified concerns regarding residents' dining space being small to meet the residents' needs. The ADM stated that the issue was brought up in past during QAA meeting, but no action plan had been developed. (CROSS REFER F464) Pharmacy Services The ADM stated that the QAA committee did not identify concerns related to the storage of medication under temperature control. The ADM stated that the QAA committee should have known that the facility did not have a tracking system to ensure that the medications were stored under proper temperature control. (CROSS REFER F431) A review of the facility's revised policy and procedure dated June 1, 2017 and titled Quality Assessment & Assurance Program indicated the facility implements and maintains an ongoing, facility-wide QAA program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. The goal of the QAA program is to provide a mean to identify and resolve present and potential negative outcomes related to resident care and safety.

Based on observations, interviews, and record reviews, the facility failed to prevent unplanned weight loss for 8 of 30 sampled residents (Residents 5, 6, 12, 14, 15, 16, 17, and 30) by failing to: 1. Ensure the Registered Dietitian (RD) completes an annual nutritional assessment for Residents 16 and 17, completes a nutritional assessment upon readmission for Resident 15, and a quarterly nutritional assessment for Residents 5 and 12. 2. Ensure residents were provided with nourishment (high protein, Magic Cup (a frozen dessert for those with special dietary needs), high calorie smoothies, and ice cream) as ordered by physician, and continuously and accurately monitored for the residents nourishment status for Residents 6, 12, 14, 15, 16, 17, and 30. 3. Monitor and document the percentages of nourishment consumed and notify the appropriate staff members when nourishments were refused for Residents 6, 12, 14, 15, 16, 17, and 30. 4. Notify the physician and the RD regarding Resident 14's five pounds weight loss, in a month, and failed to notify the physician regarding Resident 30's six pounds weight loss, in two weeks, as indicated in the facility's policies and procedure for Assessment and Management of Resident Weights and Change of Condition Notification. 5. Ensure the RD would evaluate the effectiveness of the interventions used to prevent Resident 14's continued weight loss and modify interventions as appropriate. 6. Supervise Resident 14 during meals as indicated in her comprehensive assessment. 7. Notify the physician, RD, and Dietary Service Supervisor (DSS) regarding Residents 5, 6, 14, 15, and 16 poor meal and nourishment intake (less than 50%). 8. Continuously assess, monitor, and evaluate the nutritional status by means of weekly weight records and inform the physician and/or Registered Dietitian or Dietary Service Supervisor for timely interventions when the residents experienced unplanned weight loss (Residents 15 and 16). 9. Ensure the Restorative Nursing Assistant (RNA) would not document Resident 17's nourishment intake, if not provided. 10. Develop a plan of care to include measurable goals and interventions to maintain nutritional parameters for Residents 5, 12, 14, 15, 16, 17, and 30, who experienced unplanned weight loss. 11. Ensure the dietary staff prepared fortified diets for Residents 12, 16, and 30, per physician's orders [REDACTED]. 12. Ensure the residents who periodically refuse a meal and/or have meal intakes less than 75 % were provided or offered meal substitutes (Resident 12, 14, 16, and 17). 13. Ensure Resident 16 and 17's names are included on the Nourishment Percentage Intake sheets 14. Conduct a Weight Variance meeting for Residents 14 and 16, who had unplanned significant weight loss, as indicated in the facility policy and procedure for Nutrition and Weight Variance Committee. These deficient practices resulted in: 1. An unplanned significant weight loss of 18 pounds (lbs.) (13.23 percent), in three months, for Resident 14, who was transferred to a General Acute Care Hospital (GACH) for an evaluation, due to poor appetite and weakness. 2. An unplanned significant weight loss of 15 pounds (7.7 percent) in one month for Resident 5. 3. An unplanned significant weight loss of 17 pounds (12.87 percent), in three months, for Resident 6 4. An unplanned significant weight loss of eight pounds (7.6 percent), in one month, for Resident 15 5. An unplanned significant weight loss of 13 pounds (14.9 percent), in six months, for Resident 16 6. An unplanned progressive weight loss of 10 pounds, in six months, for Resident 17 7. An unplanned significant weight loss of 6 pounds, in two weeks, for Resident 30 These deficient practices had the potential for complications associated with altered nutritional status for Residents 5, 6, 12, 14, 15, 16, 17, and 30. Findings: a. According to the admission record, Resident 14 arrived at the facility on April 24, 2017 with [DIAGNOSES REDACTED]. A review of Resident 14's admission Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated April 30, 2017, indicated the resident made herself understood and was able to understand others. Resident 14 required limited one-person physical assistance with eating. The MDS also indicated the resident was to receive a mechanically altered (require change in texture of food) and a therapeutic diet (a meal plan that controls the intake of certain foods or nutrients). The resident weighed 134 pounds and measured 62 inches tall. Resident 14's quarterly MDS, dated [DATE], also indicated the resident required limited one-person physical assistance with eating. Resident 14 now weighed 123 pounds. This was an 8.21% unplanned weight loss. A review of Resident 14's weights records indicated the following: 1. On June 2, 2017, Resident 14 weighed 136 pounds. 2. On July 2, 2017, Resident 14 weighed 127 pounds. This was a weight loss of 9 pounds (6.6 percent) in one month. A review of the RD's Nutritional Progress Notes, dated July 6, 2017, indicated Resident 14 had a significant weight loss of 9 lbs. in 30 days (6.6% weight loss). The RD's recommendation included high calorie/protein smoothies (a thick, smooth drink of fresh fruit pureed with milk, yogurt, or ice cream) with meals and 120 milliliters (ml) of Resource 2.0 (a calorically dense, high nitrogen, complete liquid formula) at 8 p.m. The goal was for Resident 14 not to have further significant weight loss and to monitor for significant weight changes. 3. On August 1, 2017, Resident 14 weighed 123 pounds. This was a four pounds weight loss from July 2, 2017 and 13 lbs. weight loss from June 2, 2017. 4. On September 1, 2017, Resident 14 weighed 118 pounds. This was a five pounds weight loss from August 1, 2017 and 18 lbs. weight loss from June 2, 2017 (13.23% in three months). A review of Resident 14's physician orders [REDACTED]. 1. Mechanical soft, no concentrated sweet finely chopped diet, with nectar thick liquids, dated April 24, 2017. 2. High calorie/protein smoothies with meals, dated July 7, 2017 3. Resource 2.0 (nourishment) 120 milliliters (ml) give orally every evening, dated July 7, 2017. A review of Resident 14's quarterly nutritional assessment completed by the DSS on July 28, 2017, indicated the resident was able to feed herself independently. Resident 14 weighed 127 lbs. and measured 62 inches tall. Resident 14 had a six % significant weight loss. The nutritional assessment also indicated Resident 14's weight loss was a desirable weight loss and the resident was still above her ideal body weight range (99 to 121 pounds). Resident 14 was to be weighed weekly for one month. A review of Resident 14's Nourishment Percentage Intake Record for the months of August 2017 and September 2017 did not indicate how much of the high calorie/protein smoothies the resident consumed. Resident 14's Meal Intake flow sheet, for the month of August 2017, did not indicate whether she was offered a meal substitute, when she ate less than 75% (percent) of the meal. Resident 14's Meal Intake flow sheet from September 1, 2017 to September 5, 2017, indicated the following: 1. Breakfast - 3 of 5 days, Resident 14 consumed less than 75 % 2. Lunch - 4 of 4 days Resident 14 consumed less than 75 % and 1 day was blank (no documentation). 3. Dinner - 5 of 5 days Resident 14 consumed less than 75 % Resident 14's care plans did not address her loss of appetite or the significant weight loss. On September 5, 2017 at 4:52 p.m., Resident 14 was lying in bed and drinking a liquid. In a concurrent interview, Resident 14's family member (FM) 1 stated the drink was a nourishment (blend of different type of beans) brought from home to help with the resident's nutrition. FM 1 stated Resident 14 had a decreased appetite and appeared to be losing weight. FM 1 also stated she was not notified of Resident 14's weight loss. On September 6, 2017 at 7:37 a.m., Resident 14 was sitting in bed with the head of bed elevated. Resident 14 was eating breakfast independently. There was no high calorie/protein smoothie on her tray, as ordered. There was no staff member present to assist Resident 14 with her meal. On September 6, 2017 at 7:37 a.m., during an interview, the DSS stated a Weight Variance meeting to address Resident 14's weight loss was not done. The DSS further stated Resident 14's weight loss was desirable, because the resident was above her ideal body weight. Resident 14's unplanned weight loss was not discussed with the physician or the resident's responsible party. The DSS also stated Resident 14's physician orders, for high calorie/protein smoothie, meant it was to be provided with her meals. The DSS stated she did not know how the Certified Nursing Assistants (CNAs) were monitoring and documenting Resident 14's high calorie/protein smoothie intake. On September 6, 2017 at 11:35 a.m., during an interview, CNA 3 stated she had been assigned to Resident 14 since the resident's admission to the Skilled Nursing Facility (SNF). CNA 3 stated Resident 14 was not receiving high calorie/protein smoothies with her meals. CNA 3 also stated the Restorative Nursing Assistants (RNAs) were responsible for documenting the nourishment intake. On September 6, 2017 at 12 p.m., during an interview, Licensed Vocational Nurse (LVN) 7 stated he was unable to determine how much high calorie/protein smoothie Resident 14 consumed with each meal. LVN 7 also stated he reviewed Resident 14's meal intake from September 1, 2017 to September 5, 2017, and was unable to provide documented evidence a meal substitute was offered (per the facility's policy and procedure) when the resident meal intake was less than 50%. On September 6, 2017 at 12:15 p.m., during a dining observation, Resident 14 was sitting at a table eating independently. There were no staff members to assist Resident 14 with her meal. After eating a cookie, Resident 14 refused to eat her main meal. At 12:42 p.m., Resident 14 started eating again, after LVN 8, who spoke the resident's primary language, started assisting the resident with her meal. Resident 14 stopped eating again when LVN 8 left (less than five minutes after arriving). At 1:12 p.m., Resident 14 refused to eat. In a concurrent interview, CNA 3 stated Resident 14 ate 30 % of her meal. On September 6, 2017 at 1:11 p.m., during an interview, LVN 7 stated Resident 14 required a staff member's assistance with meals as indicated in the MDS dated [DATE]. On September 6, 2017 at 2:30 p.m., during an interview, the RD stated he evaluated Resident 14's nutritional status on July 7, 2017, two days after the resident triggered for significant weight loss (6% weight loss in one month). The RD stated his recommendations were to add high calorie/protein smoothies with meals and 120 milliliters (ml) of Resource 2.0 at 8 p.m. The RD stated his procedure, and/or practice, was to meet with the facility staff on a monthly basis to evaluate the effectiveness of the interventions. The RD also stated he visited the facility on September 5, 2017, but did not re-evaluate Resident 14's interventions. The RD stated the nursing staff did not notify him of Resident 14's five-pound weight loss on September 1, 2017. The RD stated he would have evaluated the Resident 14's nutritional status, on September 5, 2017, if he had been notified of the continued weight loss. The RD stated he was not aware of Resident 14's poor meal intake from September 1, 2017 to September 5, 2017. The RD reviewed Resident 14's Meal Intake record for the month of July 2017, August 2017, and September 2017, and stated he was unable to determine how much high calorie/protein smoothies Resident 14 consumed. On September 7, 2017 at 10:18 a.m., during an interview, LVN 2 stated if the licensed nursing staff assessed that a resident needed physical assistance with meals, a staff member was required to be present during meals. On September 7, 2017 at 4:37 p.m., during an interview, the Health Information Director (HID) stated she reviewed Resident 14's care plans, but was unable to provide a care plan addressing Resident 14's weight loss. On September 7, 2017 at 5:30 p.m., during an interview, the DSS stated Resident 14's quarterly nutritional assessment recommended weekly weights for one month. The DSS also stated the recommendation for the weekly weights were not carried out. On September 8, 2017 at 3 p.m., during an interview, LVN 7 stated the facility's procedure was to reweigh the resident if he/she had a five pounds or greater weight loss in one month, and notify the physician. LVN 7 stated the facility's policy and procedure was not followed, when Resident 14 lost 5 pounds from August 1, 2017 to September 1, 2017. LVN 7 also stated Resident 14's physician was not notified of the five pounds weight loss. On September 7, 2017, Resident 14 was transferred to the GACH due to a decreased appetite and generalized weakness. A review of Resident 14's History and Physical report completed at the GACH, indicated Resident 14 was admitted due to an acute (sudden, rapid) worsening condition. Resident 14 was dehydrated and her blood sugar poorly controlled. Resident 14 had poor oral intake and continued to lose weight. Resident 14's [DIAGNOSES REDACTED]. A review of the facility's policy and procedure dated August 1996 and titled, Recording Meal Percentages, indicated if any resident refuses a meal, or the food eaten is less than 75%, the charge nurse shall be notified, and a substitute food from the same food group is offered to the resident. If the substitute is refused, a nourishment or meal replacement will be offered. Nursing staff are to indicate whether the substitutes were consumed or rejected and are to document all substitutions. A review of the facility's policy and procedure dated August 1996 and titled Weights, Care Plan indicated individualized resident care plans are developed by the Interdisciplinary team (IDT), and implemented by the appropriate team members, based on a comprehensive resident assessment. The care plan identifies any problems with a resident's nutritional status/weight, appropriate interventions and realistic goals. A review of the facility's revised policy and procedure dated June 1, 2017 and titled Assessment and Management of Resident Weights indicated if the weight is less than or greater than five pounds from the previous weight, immediately re-weigh and have a licensed nurse verify the accuracy of the weight. The Director of Nursing Services (DNS) or licensed nurse will report weight changes in the medical record and on the 24-hour report, notify the physician and dietitian of significant weight changes, and document the notification in the nurses' notes. Residents with significant weight changes will be weighed at least weekly and discussed at the-resident-at-risk or other clinical meetings to determine the possible causes of the weight gain or loss including goals for care. The IDT care plan will be updated to reflect individualized goals and approaches for managing the weight changes. A review of the facility's revised policy and procedure dated June 1, 2017 and titled Change of Condition Notification indicated the licensed nurse would notify the resident's attending physician when there is a change in weight of five pounds or more within a 30-day period unless the patient's physician has stated a different stipulation in writing. The licensed nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition as soon as possible. A review of the facility's revised policy and procedure dated June 1, 2017 and titled Nutrition and Weight Variance Committee indicated the weight of residents will be monitored for variance and the nutrition & weight variance committee, made up by IDT members, will meet monthly to assess and review any residents identified as at risk for unplanned weight loss. Prior to each meeting, the Director of Nursing Services (DNS) or designee will compile a list of residents who are at risk for, or in need of, weight change. Residents that meet the following criteria may be included on the list for discussion: a persistent weight loss over a period of 3 months, two percent weight change in one week, five percent weight change in 3 months. Objectives of the nutrition & weight variance committee may include identifying behaviors in the feeding environment that may be contributing to weight loss/gain. Residents on the list will be reviewed monthly until their weight has stabilized. A review of the facility's revised policy and procedure dated June 1, 2017 and titled Nutrition/Hydration Management indicated the concept of nutrition management is an interdisciplinary process. The key components of this system are developing an individual nutrition program based on individual assessed needs, identifying instances of unplanned weight loss or gain, and ongoing assessment, monitoring, and evaluation of the effectiveness of the nutrition/hydration management program. A comprehensive care plan is developed by the IDT that addresses nutrition/hydration and an individualized nutrition/hydration management program based on individualized assessed need. A review of the facility's revised policy and procedure dated June 1, 2017 and titled Physician order [REDACTED]. Other pertaining to other health care disciplines will be transcribed onto the appropriate communication system of that discipline. Whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order. b. According to admission record, Resident 30 arrived at the facility on August 16, 2017 with [DIAGNOSES REDACTED]. Resident 30's admission MDS dated [DATE], indicated the resident had intact cognitive skills for daily decision-making. Resident 30 required limited one-person physical assistance with eating. The MDS also indicated the resident was on a mechanically altered (require change in texture of food) and therapeutic diet. The resident weighed 123 pounds and measured 63 Inches tall. A review of Resident 30's History and Physical report completed on August 24, 2017, indicated the resident had the capacity to understand and make decisions. A review of Resident 30's nutritional assessment dated [DATE], indicated dietary recommendations included high calorie smoothies three times a day with meals and one packet of [MEDICATION NAME] (a drink mix that delivers additional supplemental to the diet) every for 28 days. The goal/plan was for Resident 30 not to have a significant weight change. A review of the physician orders, nurses notes, and Medication Administration Record [REDACTED]. A review of Resident 30's physician orders [REDACTED]. 1. Fortified mechanical soft, no concentrated sweet, no added salt, finely chopped diet, dated August 31, 2017. 2. High calorie smoothies with meals, three times a day, dated August 31, 2017. A review of the diet order communication form dated August 31, indicated Resident 30 had his diet changed to fortified mechanical soft, no concentrated sweet, no added salt, finely chopped diet and high calorie smoothie with meals. 3. Four ounce nourishment between meals at 10 a.m. and 2 p.m., dated August 16, 2017 4. [MEDICATION NAME] (a solution used to treat loss of appetite and weight loss) 40 milligrams (mg) per 1-milliliter (ml) suspension, give 400 mg/10 ml oral every day for appetite stimulant, dated August 16, 2017. A review of Resident 30's weight records indicated the following: 1. On August 16, 2017, Resident 30 weighed 126 pounds. 2. On September 1, 2017, Resident 30 weighed 120 pounds. This was a of 6 pound weight loss in 2 weeks. On September 7, 2017 at 12:15 p.m., during a tray line observation in the kitchen, a meal card for Fortified Puree diet (a diet providing additional supplements) was listed on the resident's tray card. The dietary staff member called for Puree diet instead of Fortified Puree. On September 7, 2017 at 12:45 p.m., during an interview, the DSS stated the fortified diet would require extra margarine added to the meal for extra calories. DSS further stated the dietary staff did not prepared the margarine separately in a pot. On September 8, 2017 at 4:30 p.m., during an interview, the Dietary Cook stated the margarine was added to the fortified diet before, but residents complained the food was too greasy, so they stopped fortifying the food. On September 8, 2017 at 4:45 p.m., during an interview, the DSS stated she made the call to stop fortifying the food since residents were complaining that the food was too greasy. The DSS further stated she notified the previous RD about her decision to stop fortifying the food. On September 8, 2017 at 5:15 p.m., during an interview, the RD stated he was not aware the dietary staff had stopped fortifying the food. RD further stated he had been recommending fortified diets for resident with weight loss. On September 11, 2017 at 7:52 a.m., during an observation, Resident 30 was lying in bed, awake, alert, and oriented to person, place, and time. Resident 30's breakfast tray did not include the high calorie smoothie. On September 11, 2017 at 8:11 a.m., during an interview, LVN 7 stated Resident 30 had lost weight, but the Weight Variance meeting regarding the weight loss had not yet been conducted. LVN 7 also stated the resident's weekly weights were not done per policy. LVN 7 was unable to provide documented evidence a care plan was developed with goal and measurable objectives that addressed Resident 30's weight loss. On September 12, 2017 at 7:55 a.m., during an observation, Resident 30's breakfast tray did not contain the high calorie smoothie. LVN 8 confirmed the resident's card read, Smoothie times two. On September 12, 2017 at 9:57 a.m., during an interview, the DSS stated Resident 30's high calorie smoothie was missed during breakfast. On September 30, 2017 at 9:30 a.m., during an interview, CNA 6 stated the between meal nourishments would be documented on the Nourishment Percentage Intake form. CNA 6 was unable to determine if Resident 30 was receiving the nourishment, because the resident's name was not included on the list of residents receiving nourishment. CNA 7 also stated she was unable to determine how much of the high calorie smoothie Resident 30 consumed with each meal. On September 30, 2017, during a concurrent interview, LVN 7 stated he was unable to determine if Resident 30 was receiving the high calorie smoothie and the nourishment as ordered by the physician. A review of the facility's undated policy and procedure titled, Fortified Diet, indicated food fortification programs are designed to assist in preventing undesirable weight loss and maintaining skin integrity. This protocol is recommended for residents with low meal intake, moderate to high weight loss and/or low body weight, pressure sores, as part of a total treatment plan and pressure sore protocol, and for prevention to predicted weight loss. Food fortification programs may be initiated when determined necessary by the Interdisciplinary Team (IDT), physician (MD), Registered Dietitian (RD) and/or Dietetic Technician, Registered (DTR). Communications of the recommended program are provided in writing to the dietary department upon initiating and obtaining physician's orders [REDACTED]. Changes may be made to the protocol, by the DSS, under the guidance of the RD according to resident's needs, tolerance and preferences. Nutritional progress notes document the reason for fortification, measurable goals, and program specifics including nutritional contribution, acceptance, and progress made. This provides approximately 600-800 calories and 20-30 grams of protein in addition to the daily menu. A review of the facility's revised policy dated June 1, 2017 and titled Physician order [REDACTED]. Other orders, pertaining to other health care disciplines, will be transcribed onto the appropriate communication system of that discipline. Whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order. A review of the facility's revised policy dated June 1, 2017 and titled Change of Condition Notification indicated the licensed nurse would notify the resident's attending physician when there is a change in weight of five pounds or more within a 30-day period unless the patient's physician has stated a different stipulation in writing. The licensed nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition as soon as possible. A review of the facility's revised policy and procedure dated June 1, 2017 and titled Assessment and Management of Resident Weights indicated if the weight is less than or greater than five pounds from the previous weight, immediately re-weigh and have a licensed nurse verify the accuracy of the weight. The Director of Nursing Services (DNS) or licensed nurse will report weight changes in the medical record and on the 24-hour report, notify the physician and dietitian of significant weight changes, and document the notification in the nurses' notes. Residents with significant weight changes will be weighed at least weekly and discussed at the-resident-at-risk or other clinical meetings to determine the possible causes of the weight gain or loss including goals for care. The IDT care plan will be updated to reflect individualized goals and approaches for managing the weight changes. c. According to admission record, Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 12's MDS dated [DATE], indicated the resident had intact cognitive skills for daily decision-making. Resident 12 required assistance with set-up and supervision with eating. The MDS also indicated the resident was on a mechanically altered and therapeutic diet. A review of Resident 12's History and Physical report completed on November 30, 2016, indicated the resident had the capacity to understand and make decisions. A review of Resident 12's quarterly nutritional assessment dated [DATE], indicated the resident's current diet was adequate and appropriate at this time. Resident 12 was still within the ideal body weight range and to continue with plan of care. A review of Resident 12's weights records indicated the following: 1. On April 2, 2017, Resident 12 weighed 86 lbs. 2. On May 2, 2017, Resident 12 weighed 81 pounds. This was a 5 lbs. weight loss in one month. A review of Resident 12's physician orders [REDACTED]. 1. Fortified Pureed diet, dated June 8, 2015. 2. High calorie/protein smoothie four ounces at 2 p.m., dated May 19, 2017. 3. Snack twice a day at 10 a.m. and 2 p.m. 4. Resource 2.0 (nourishment) 120 cubic centimeter (cc) give orally four times a day with medication pass, dated July 19, 2016. 4. Ice cream at lunch and dinner, dated August 19, 2015. A review of Resident 12's care plan conference summary dated July 19, 2017 did not indicate the DSS and/or the RD participated in the meeting. The section addressing Resident 12's oral and nutritional status was left blank. A review of Resident 12's care plans did not indicate the licensed nursing staff developed a care plan with goal and measurable objectives addressing Resident 12's weight loss prior September 6, 2017. On September 6, 2017 at 7:48 a.m., during an observation, Resident 12 was lying in bed sleeping. Resident 12's breakfast tray was by the bed. Resident 12 ate less than 25 % of her breakfast tray. Pureed sausage link was list on the tray card, but not observed on the tray. On September 6, 2017 at 3:45 p.m., during an interview in the presence of LVN 8 as the interpreter, Resident 12 stated she did not like pureed food because it did not taste good. Resident 12 stated she wanted food that tasted sweet and spicy. On September 7, 2017 at 7:42 a.m., during an observation, Resident 12 was lying in bed sleeping. Resident 12's breakfast tray was by the bed. Resident 12 ate less than 10 % of her breakfast tray. On September 7, 2017 at 12:40 p.m., during an observation, Resident 12 was in bed with her lunch tray in front of her. Ice cream was list on the tray card, but was not observed on the lunch tray. On September 7, 2017 at 12:47 p.m., during an interview, the RD stated Resident 12's weight was stable. The RD stated he had not evaluated Resident 12's nutritional status because her weight did not flagged in the system. The RD also stated the DSS should have consulted with the RD before writing Resident 12's quarterly assessment summary notes on April 3, 2017. The RD reviewed Resident 12's meal intake records from July 2017 to September 2017 and stated he was unable to determine if a meal substitute was offered to the resident when her meal intake was less than 50 percent. On September 7, 2017 at 1:17 p.m., during an interview, CNA 7 stated Resident 12's lunch tray did not include ice cream. CNA 7 also stated Resident 12's lunch tray sometimes included ice cream and sometimes did not. A review of Resident 12's nutritional assessment, from April 2016 to April 2017, indicated the RD had not completed the resident annual nutritional assessment. A review of the Nourishment Percentage Intake form from August 13, 2017 to September 8, 2017, indicated Resident 12 refused her nourishment every day, but two days (August 30, 2017 and September 8, 2017 at 2 p.m.). On September 7, 2017 at 5:30 p.m., during an interview, the DSS stated the nursing staff did not notify her of Resident 12's nourishment refusal. The DSS was unable to provide documented evidence the RD and/or the DSS assessed Resident 12's nutritional status after April 3, 2017. On September 8, 2017 at 8 a.m., during an interview, LVN 7 stated he was unable to determine if the nursing staff offered a meal substitution when Resident 12's meal intake was poor. LVN 7 stated he reviewed the nourishment intake form and was unable to determine if Resident 12 refused the snack or the high calorie protein. On September 7, 2017 at 12:45 p.m., during an interview, the DSS stated the fortified diet would require extra margarine added to the meal for extra calories. DSS further stated the dietary staff did not prepared the margarine separately in a pot. On September 8, 2017 at 4:30 p.m., during an interview, the Dietary Cook stated the margarine was added to the fortified diet before, but residents complained the food was too greasy, so they stopped fortifying the food. On September 8, 2017 at 4:45 p.m., during an interview, the DSS stated she made the call to stop fortifying the food since residents were complaining

Based on observation, interview and record review, the facility failed to provide frequent visual monitoring and assistance to meet Resident 1's health care and safety needs at all times. This resident who speaks and understands Korean only was a high risk resident for falls for 1 of 1 resident (Resident 1). The facility nursing staff failed to develop and implement a plan of care and nursing interventions to address the resident of not using his call light, getting out of bed unassisted and ambulating without assistance and not wanting to bother the nursing staff for assistance. These deficient practices resulted in the resident frequently getting out of bed without the use of his front wheel walker and without assistance from the staff. The resident fell and fractured his left hip on September 26, 2010. Findings: According to the admission record Resident 1 was admitted on [DATE], with [DIAGNOSES REDACTED]. According to the National Institute of Neurological disorders and Stroke, dated January 5, 2011, Parkinson's disease (PD) belongs to a group of conditions called motor system disorders, which are the result of the loss of dopamine. The four primary symptoms of PD are tremor, or trembling in hands, arms, legs, jaw and face; rigidity, or stiffness of the limbs and trunk; bradykinesia, or slowness of movement; and postural instability, or impaired balance and coordination. As these symptoms become more pronounced, patients may have difficulty walking, talking or completing other simple tasks. Source: http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_disease.htm The plan of care dated June 25, 2010, indicated a [DIAGNOSES REDACTED]. The nursing interventions were to assist the resident with activities of daily living, and to monitor the resident's environment for special needs to protect the resident from injuries and provide the resident with padded side rails. The Minimum Data Set (MDS) for Nursing Home Resident Assessment and Care Screening, dated July 7, 2010, indicated the resident's primary language is Korean. The resident's cognitive skills for daily decision-making were moderately impaired. The resident ambulated with an unsteady gait and required extensive assistance with his bed mobility, transferring, toilet use and personal hygiene. The resident was frequently incontinent of bladder elimination. The resident required full bed side rails on all opened sides of his bed. Further review of the Minimum Data Set indicated the resident's medical conditions made the resident's cognitive skills and activities of daily living, mood and behavior patterns unstable. According to the MDS, dated [DATE], under Physical Functioning and Structural Problems with Activities of Daily Living self-performance indicated extensive assistance; the resident can perform part of the activities of daily living (ADLs), but requires provided assistance three or more times with the activities of daily living. According to Wikipedia, the free encyclopedia dated January 11, 2011 basic Activities of Daily Living (ADLs) consist of self-care tasks, personal hygiene and grooming, dressing and undressing, feeding and ambulating. The health professionals routinely refer to the ability or inability to perform ADLs as a measurement of the functional status of a person, particularly in regards to people with disabilities and the elderly. Source: http://en.wikipedia.org/wiki/Activities_of_daily living A review of the Initial History and Physical, dated June 25, 2010, indicated the resident does not have the capacity to understand and make decisions due to Parkinson's disease. A review of the physician's orders [REDACTED].), every 12 hours, three times a day, orally. According to the resident's Fall Risk assessment dated [DATE], the staff determined Resident 1 to be high risk for falls, with risk factors that included intermittent confusion/poor safety awareness, balance problems while standing/walking; and required the use of assistive devices, a front wheel walker or a wheelchair. According to the Restorative Nursing Assistant Notes, dated September 21, 2010, the resident was able to ambulate in the facility's corridor, with two or three rest periods, approximately 40 to 60 feet with a one person assists. The Restorative Nursing Assistant (RNA) Job Description, dated July 23, 2010, indicated a RNA is a nursing assistant trained to help nurses in restoring mobility to patients. The RNA helps the patient perform basic day-to-day activities such as bathing, dressing, eating and walking. The RNA duties are very essential in patient recovery. A record review of the 3 p.m. to 11 p.m. Supervisor Registered Nurse I (RN I) Nursing Notes, dated September 26, 2010, at 7 p.m. indicated Supervisor Registered Nurse I entered the resident's room and observed the resident's right upper side rail up and the right lower side rail down. The resident was observed at his bedside, on his right side in a sitting position on the floor. Supervisor Registered Nurse I, stated she assessed the resident and the resident was assisted back to bed with help. Supervisor Registered Nurse I observed swelling on the resident's left outer thigh and the physician was notified. The resident's attending physician gave a verbal telephone order for a STAT (emergency) x-ray of the left femur and left hip. The left hip x-ray dated, September 26, 2010, indicated an acute left intertrochanteric fracture with mild displacement and a lesser trochanteric fragment (left hip fracture). During an interview on October 8, 2010, at 1:30 p.m., the Director of Physical Therapy stated the resident requires one person to assist with ambulation and when using his front wheel walker. During an interview and observation on October 8, 2010 at 2 p.m., Resident I, was observed lying flat in bed without padded side rails and all side rails were up. The resident's bed was not in a low position, and no floor pad cushions were placed on the floor next to the bed. There was no observation of the resident's front wheel walker in the room at the bedside. The resident was Korean speaking and the Director of Social Services interpreted for the surveyor. The resident stated he did not use his call light for assistance to get out of bed. The resident stated he climbed out of his bed to go to the bathroom and tried to get back into his bed and fell . The surveyor asked the resident the day of his fall, did he use his front wheel walker to go to the bathroom. The resident did not answer the question. The resident stated, "I did not want to bother anyone for help." On October 8, 2010, at 2 p.m., during an observation in the resident's room, the Maintenance Supervisor measured the distance from the corner of the right side of the resident's bed to the bathroom door was nine feet. In an interview on October 8, 2010 at 2:35 p.m., Restorative Nursing Assistant I (RNA I) stated the resident was not able to ambulate without assistance. The resident requires one person to assist when ambulating with his front wheel walker and the resident's wheelchair was used for wheeling him to the patio and back to his room. A review of the Physical Therapy plan of care, dated August 16, 2010, indicated problems related to the resident's impaired mobility, and decreased strength, endurance and balance, gait, and a problem with coordination, positioning and joint mobility limitations. The physical therapy's interventions were neuromuscular re-education (posture control instructions), gait training, and therapeutic exercises. Further review of the physical therapy plan of care indicated no target date as to when the physical therapy interventions would be met. During an interview on October 8, 2010 at 3 p.m., with Supervisor Registered Nurse 2 (RN 2), she stated the resident was high risk for falls and would get out of bed and go to the bathroom and not ask for help. Registered Nurse 2 stated the resident did not have a plan of care with nursing interventions to address the resident not using his call light for assistance to get out of bed. There was no visual monitoring system in place for the resident, to prevent a fall, when the resident got of his bed without assistance. In an interview on October 8, 2010, at 3:30 p.m., with Certified Nursing Attendant I (CNA I), assigned to Resident I on September 26, 2010, said "After dinner I looked into the resident's room and the resident was lying down and all the side rails were up." CNA I said, "Around 7 p.m., I went to the Nursing Station sat down to start charting and someone paged me to the resident's room". CNA I stated when he arrived to the resident's room LVN I and RN I were putting the resident back into bed and RN I was speaking Korean to the resident and immobilized the resident's left leg. The plan of care dated July 8, 2010, indicated a problem with bed mobility, transferring and ambulation and locomotion and the resident requires extensive assistance. The nursing interventions were to assist the resident in transferring and activities of daily living, and to observe safety precautions and assist in ambulation. Review of the resident's clinical record revealed there was no plan of care that addressed the resident was not using his call light to ask for assistance with his bed mobility, transferring and toilet use. Also, there were no nursing interventions on how to approach the resident's not using his call light and not asking for help from the nursing staff, because the resident did not want to bother anyone. During a telephone interview on October 20, 2010 at 11:15 a.m., with Supervisor Registered Nurse I, she stated she speaks Korean/English. On September 26, 2010 at 7 p.m., during rounds she observed the resident on his right side on the floor and told the resident not to move and she called out for assistance to place the resident back to his bed. Supervisor Registered Nurse I, stated she required three persons to assist, two persons lifting the resident and one person with a hand underneath the resident's buttocks for support. Supervisor Registered Nurse I stated the resident's lower right side rail was down and the upper right side rail was up. The surveyor asked Supervisor Registered Nurse I if she was aware that Resident I was high risk for falls? Supervisor Registered Nurse I stated, "No." The surveyor asked Supervisor Registered Nurse I, when the resident uses his call light what does he requests from the nursing staff? Supervisor Registered Nurse I stated, "He wants water or he wants to go to the bathroom. The resident will use his front wheel walker alone to go to the bathroom." In a telephone interview on October 20, 2010, at 3 p.m. with Licensed Vocational Nurse I (LVN I) on the 3 p.m. to 11 p.m. shift, he stated he was passing medications and heard an overhead voice page STAT (emergency) to Resident I's room and he immediately ran to the resident's room. LVN I stated sometimes the resident's side rails would be down because the resident is alert. LVN I stated on September 26, 2010 at 7 p.m., he saw the resident's lower right side rail down and the upper right side rail up. During a telephone interview on October 20, 2010 at 3:20 p.m., Certified Nursing Attendant 2 (CNA 2), stated on September 26, 2010 at 7 p.m. he heard a STAT (an emergency) call for Resident I and went to his room and saw the resident on the right side of his bed on the floor and his lower right side rail was down. Certified Nursing Attendant 2 stated Registered Nurse I and Vocational Licensed Nurse I were in the room with the resident when he arrived to the resident's room. The plan of care, dated June 25, 2010, indicated Resident 1 was at risk for falls and injury related to Parkinson's disease, hypertension, diabetes with a sliding scale, and hypertensive medications, Norvasc, Amiodarone HCL and Diovan. The nursing interventions were side rails up and locked for safety and protection. According to the acute hospital's Physical and History, dated September 27, 2010, Resident I was admitted on [DATE], due to a fall and a broke left hip. The resident's left lower extremity was shortened and externally rotated. The resident had a status [REDACTED]. The acute hospital's Operative Report, dated September 28, 2010, indicated a preoperative [DIAGNOSES REDACTED]. The resident underwent [REDACTED].