Every finding on record at Palazzo Post Acute

Based on observation, interview, and record review, facility failed to ensure one of three sample resident (Resident 1)'s privacy was respected whenRespiratory therapy (RT) 1 did not introduce himself and asked for permission before entering Resident 1's room.In addition, Certified Nursing Assistant (CNA) 1 did not knock on the door, introduced himself and asked for permission before entering room [ROOM NUMBER] and room [ROOM NUMBER].These deficient practices resulted in residents' privacy being not respected and negatively affecting their care.1.During a review of Resident 1's admission record dated 7/24/2026, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included but not limited to chronic pain, anxiety disorder (a condition that a person feels very worried, scared, or nervous much more often and much more strongly than most people, these feelings are hard to control and can make everyday life difficult), opioid dependence (a condition when a person's body gets used to taking opioid drugs [pain medicines], and can't feel normal without them) and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 7/13/2026, the MDS indicated Resident 1's cognition (ability to think, remember and reason for daily decision making) was intact. During an observation on 7/22/2026 at 12:05 pm in Resident 1's room, RT 1 entered the room, after he saw me and Resident 1, RT 1 stated, he is here to do breathing treatment for Resident 1's roommate. During an interview on 7/22/2026 at 12:40 pm in Resident 1's room with Resident 1, Resident 1 stated she does not feel she has privacy, staff entered her room without asking. During an interview on 7/22/2026 at 1:20 pm with RT 1, RT 1 stated he said knock knock but forget to introduce himself and asked for permission before entering Resident 1's room. Sometimes, he moves too fast. RT 1 further stated he should knock on the door, introduce himself and ask for permission before entering residents' room. 2.During an observation on 7/22/2026 at 1:05 pm on the hallway, CNA 1 entered room [ROOM NUMBER] and room [ROOM NUMBER] without knocking, introduce himself and ask for permission. During an interview on 7/22/2026 at 1:10 pm with CNA 1, CNA 1 stated before entering a resident's room, staff should knock on the door, introduce themselves, and ask for permission, but he didn't do that, his action affects residents' privacy. During an interview on 7/22/2026 at 1:26 pm with CNA 2, CNA 2 stated before entering resident's room, staff should knock on the door, introduce themselves, and ask for permission to enter. Failing to do it affects residents' privacy. During an interview on 7/22/2026 at 1:35 pm with LVN 1, Licensed Vocational Nurse (LVN) 1 stated, when staff enter a resident's room, they should knock on door, introduce themselves, tell the residents why they are here and ask for permission to enter the room to respect all residents' privacy. During an interview on 7/22/2025 at 1:45 pm with Director of Nursing (DON), DON stated, staff, both nurses and RTs, should respect residents' privacy, when entering any residents' room, staff should knock on the door, introduce themselves, and ask for permission. Failing to do so affects resident's right of privacy and negatively affects resident's care. During a review of facility's policy and procedures (P&P) titled dignity, dated 10/2025, the P&P indicated staff must announce their presence before entering a resident's room.

Based on observation, interview, and record, facility failed to ensure proper hand hygiene, when Certified Nursing Assistant (CNA) 1 observed entered and exited room [ROOM NUMBER] without performing hand hygiene and then immediately entered room [ROOM NUMBER] without performing hand hygiene again. This deficient practice increases the risk of transmitting infections among residents in room [ROOM NUMBER] and room [ROOM NUMBER].During an observation on 7/22/2026 at 1:05 pm at the hallway, CNA 1 entered and exited room [ROOM NUMBER] without performing hand hygiene, then immediately entered room [ROOM NUMBER] without sanitizing hands. During an interview on 7/22/2026 at 1:10 pm with CNA 1, CNA 1 stated, he did not wash his hand inside room [ROOM NUMBER] or room [ROOM NUMBER], he forgot to use hand sanitizer outside of the rooms. CNA 1 stated his action can cause infection control issues. During an interview on 7/22/2026 at 1:26 pm with CNA 2, CNA 2 stated hand hygiene is important for prevention of spread of infections, staff should have perform hand hygiene before and after entered resident's room. During an interview on 7/22/2026 at 1:35 pm with Licensed Vocational Nurse (LVN) 1, LVN 1 stated hand washing is important for infection control, all staff should follow their policy, and not doing proper hand hygiene can increase the risk of spread of infections. During an interview on 7/22/2026 at 1:45 pm with Director of Nursing (DON), the DON stated staff should perform hand hygiene before and after entering the resident's room, especially in between the residents' rooms. Failed to do so will increase the risk of spreading infection among residents.During a review of the facility's policy and procedure (P&P) titled handwashing/ hand hygiene, dated 10/2025, the P&P indicated, hand hygiene should be performed before touching a resident; after touching a resident; after touching the resident environment or belonging.

Based on observation, interview, and record review, the facility failed to ensure four of four dumpsters were completely closed and not overfilled with trash.This failure had the potential to result in pests (organisms that cause harm to humans such as flies, cockroaches, and rodents) entering the facility and spreading diseases to residents.Findings:During a concurrent observation and interview on 6/22/26 at 7:58 a.m. in the outdoor garbage area, with the Dietary Manager (DM), four of four dumpster lids were partially open. The DM stated that garbage containers had to be completely closed when not in use, to prevent pests from getting inside. The DM stated open garbage containers attracted pests and that residents could get sick from diseases that pests spread. During an interview on 6/25/26 at 8:59 a.m. with the Administrator (ADM), the ADM stated that the city's trash pickup did not occur as regularly scheduled on the previous Friday, 6/19/26, because it was a holiday. The ADM stated that several days passed with no trash pickup from the city. During a concurrent interview and record review on 6/25/26 at 10:41 a.m., the facility's P&P titled, Garbage Disposal Policy, revised May 2025, was reviewed with the DM. The DM reviewed the P&P and stated that dumpsters were not to be filled beyond capacity to ensure that the lid could be completely closed.During a review of the facility's P&P titled, Garbage Disposal, revised May 2025, the P&P indicated for trash containers to be emptied regularly to prevent overflow.

Based on interviews, and record review, the facility failed to maintain ongoing competency for restorative nursing assistants (RNAs) by failing to, ensure a restorative nursing assistants training program was developed and implemented. This failure had the potential to compromise nursing competence among restorative nursing assistants which could adversely affect the quality and safety of care provided to residents.Findings:During an interview on 6/24/2026 at 12:45 PM with the Director of Staff Development (DSD), the DSD stated that restorative nursing assistants weighed the residents as part of their job description and daily assignments. The DSD stated that all in-service education provided to the staff were written and posted on the facility's Annual Staff Development Education calendar.During an interview on 6/25/2026 at 9:40 AM with RNA 1, RNA 1 stated that they (RNAs) did weigh the residents but could not remember the last time she was given an education on weighing residents.During an interview on 6/25/2026 at 11:27 AM with the Director of Nursing (DON), the DON stated RNAs were required to receive appropriate training to ensure competence in their duties and one of their primary responsibilities was weight assessment. The DON stated that all in service trainings were scheduled and outlined in the facility's Annual Staff Development Education calendar.During a review of the facility's Annual Staff Development Education calendar for 2025 and 2026, the calendars indicated that the monthly topics provided by the DSD to the staff did not include topics on weight assessment.During a review of the RNA job description, dated 9/2011, the job description indicated that under the supervision of the rehabilitation department, DON, DSD and licensed nurses, the RNA was responsible for providing nursing care using the restorative nursing approaches learned through training and actual demonstration. The job description indicated the RNA's general role and responsibilities included weighing the residents monthly and as needed on a regular basis based on facility policy. During a review of the facility's policy and procedure (P&P) titled, In-service Education Policy, the P&P indicated, the facility will provide ongoing in-service education and training to ensure all employees maintain the knowledge and skills necessary to provide safe, quality, and regulatory-compliant resident care. To ensure staff are competent in performing their job responsibilities and remain current with federal, state and facility requirements, required in-service education will be provided during orientation, annually and as needed based on resident care needs or identified competency gaps.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 8 and Resident 13) reviewed for dialysis (a medical treatment that acts as an artificial kidney, filtering waste products, toxins, and excess water from the blood when a person's kidneys can no longer perform these tasks properly) received dialysis services consistent with professional standards of practice by failing to:-Ensure Resident 8 did not miss dialysis appointments due to transportation on 5/16/2026.-Ensure the licensed nurses (in general) conducted the pre (before) and post (after) dialysis assessments for Resident 8 and Resident 13.-Ensure Resident 13 did not receive more than 1000 milliliters (ml, a unit of measurement) of fluid per day as ordered by Resident 13's physician.These failures had the potential to delay critical treatment, compromise the accuracy of dialysis orders, and place Resident 8 and Resident 13 at risk for injury, fluid overload (is a condition where the body accumulates too much fluid, leading to swelling, high blood pressure, and potential heart and lung complications), infection, or other complications. Findings: a. During a review of Resident 8's admission Record, the admission Record indicated the facility readmitted the resident on 5/19/2026, with diagnoses that included metabolic encephalopathy (brain dysfunction caused by an chemical imbalance in the blood), end stage renal failure (ESRD, irreversible kidney failure), and diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's Care Plan Report dated 2/13/2026, the Care Plan Report indicated Resident 8 needed hemodialysis related to ESRD. The Care Plan Report indicated a nursing intervention to assist the resident with dialysis pick up every Tuesday, Thursday, and Saturday of every week. During a review of Resident 8's Order Summary Report dated 3/6/2026, the Order Summary Report indicated for Resident 8 to receive dialysis on Tuesday, Thursday, and Saturday. During a review of Resident 8's History and Physical (H&P) dated 3/8/2026, the H&P indicated the resident had the capacity to make and understand complex decisions. During a review of Resident 8's Order Summary Report dated 4/21/2026, the Order Summary Report indicated to assist Resident 8 with curbside pickup outside of the facility every Tuesday, Thursday, and Saturday for dialysis services. During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 5/12/2026, the MDS indicated the resident required supervision (helper provides verbal cues or steadying assistance as resident completes activity) from staff to complete activities of daily living (ADLS, activities a person performs daily such as bathing, dressing, and toileting). The MDS indicated the resident received dialysis. During a review of Resident 8's Progress Note, dated 5/14/2026, the Progress Note indicated resident refused to attend a routinely scheduled dialysis appointment (5/14/2026). The Progress Note indicated that the Facility Medical Director (FMD) ordered a make-up dialysis and for the Social Services Department to arrange for transportation. During a review of Resident 8's Progress Note dated 5/15/2026, the Progress Note indicated resident left the facility for a make-up dialysis. The Progress Note indicated a Dialysis Communication Record was provided. During a review of Resident 8's Progress Note dated 5/15/26, the Progress Note indicated the resident left the facility for a make-up dialysis. During a review of Resident 8's Progress Note, dated 5/15/2026, the Progress Note indicated the resident returned from make-up dialysis the same day (5/15/2026). During a review of Resident 8's Progress Note, dated 5/16/2026, the Progress Note indicated Resident 8 missed a routinely scheduled dialysis appointment (5/16/2026) due to transportation not arriving. The Progress Note indicated the facility Medical Director was made aware that the staff (unidentified) would follow up the following Monday (5/18/26) to schedule a same-day make-up dialysis appointment. During a review of Resident 8's Progress Note, dated 5/18/2026, the Progress Note indicated a make-up dialysis was scheduled for 5/18/26 at 2 PM and for the Social Services Department to arrange for transportation. During a review of Resident 8's Order Details dated 5/18/2026, the Order Details indicated Received an order, may transfer out to hospital due to 2x [twice] missed dialysis treatment. During a review of Resident 8's Transfer Form dated 5/18/2026, the Transfer Form indicated an unplanned transfer to General Acute Care Hospital (GACH1) at 5:05 PM for missed dialysis. During an interview on 6/24/2026 at 10:55 AM with Licensed Vocational Nurse 6 (LVN6), LVN 6 stated it was important for residents (in general) to go to their dialysis appointments as scheduled. LVN 6 stated toxins (poisonous) build up in the body and fluid overload (a condition where the body accumulates too much fluid) can occur if residents missed their dialysis. During a concurrent interview and record review on 6/24/2026 at 10:55 AM with LVN6, Resident 8's Dialysis Communication Record was reviewed. LVN 6 reviewed the Dialysis Communication Record binder and was unable to find any pre/post dialysis assessments for the make-up dialysis on 5/15/2026. LVN 6 stated the record was used to track significant changes in residents' baseline (in general) after dialysis and would monitor compliance with the prescribed dialysis treatment. During an interview on 6/24/2026 at 11:14 AM with the Social Services Director (SSD), the SSD stated the facility arranged transportation based on the residents' (in general) dialysis schedule. The SSD stated residents (unidentified) had sometimes missed dialysis appointments due to transportation issues. During an interview on 6/24/2026 at 11:34 AM with Registered Nurse 1 (RN 1), RN 1 stated missed dialysis could cause shortness of breath from fluid overload and abnormal labs, which could lead to hospitalization. RN 1 stated Resident 8 did not go to dialysis on 5/14/2026 but was able to go to a make-up dialysis on 5/15/2026. RN 1 stated Resident 8 was supposed to resume the regularly scheduled dialysis on 5/16/2026, but that appointment was missed. RN 1 stated the make-up dialysis was on 5/18/2026, but Resident 8 did not go to that make-up dialysis and was instead sent to GACH 1. During an interview and record review on 6/24/2026 at 11:34 AM with RN1 Resident 8's Dialysis Communication Record was reviewed. RN 1 reviewed the blank Dialysis Communication Record and stated that the form should have been filled out before the resident left for dialysis and when the resident came back from dialysis. RN 1 stated the Dialysis Communication Record was part of the dialysis assessment which included cognitive (mental) status, vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), breath sounds, and access site (a surgically created site used to remove and return blood during HD). During an interview on 6/24/2026 at 1:44 PM with the Social Services Specialist (SSS), the SSS stated transportation was not arranged for Resident 8's make-up dialysis appointment on 5/18/26. The SSS stated transportation should have been arranged. During a concurrent interview and record review on 6/24/2026 at 2:09 PM with the Director of Nursing (DON) the facility's policy and procedure (P&P) titled, Transportation, Appointment Arrangement and Scheduling Policy revised May 2026 was reviewed. The DON reviewed the P&P and stated Resident 8 did not go to the make-up dialysis appointments on 5/16/2026 and 5/18/2026 due to transportation issues. The DON stated missing scheduled dialysis sessions increased the risk of fluid overload, resulting in swelling and difficulty breathing. During a review of the facility's P&P titled, Transportation, Appointment Arrangement and Scheduling Policy, revised May 2026, the P&P indicated social services were responsible for coordinating appointments, transportations, and communication. During a concurrent interview and record review on 6/24/26 at 2:09 p.m., the facility's policy and procedure (P&P) titled, Hemodialysis Residents, revised May 2025, was reviewed with the Director of Nursing (DON. The DON reviewed the P&P and stated staff should have documented in the Dialysis Communication Record for the make-up dialysis on 5/15/26. During a review of the facility's P&P titled, Hemodialysis Residents, revised May 2025, the P&P indicated a Dialysis Communication Record is initiated and sent to the dialysis center each appointment. The P&P indicated to ensure the Dialysis Communication Record is received upon return to the facility. b. During a review of Resident 13's admission Record, the admission Record indicated the facility originally admitted Resident 13 on 3/18/2025 and was readmitted on [DATE] with diagnoses including end stage renal disease end stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that filters waste and excess fluid from the blood] stop functioning on a permanent basis), and dependence on hemodialysis. During a review of Resident 13's H&P dated 3/19/2025, the H&P indicated Resident 13 had fluctuating capacity to understand and make decisions. During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from setting up (helper sets up or cleans up, resident completes activity) to moderate assistance (helper does less than half the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS indicated Resident 13 was on hemodialysis. During a review of Resident 13's Order Summary Report dated 3/2/2026, the Order Summary Report indicated Resident 13 had a physician order for the following: Dialysis Center at Hemodialysis Center 1 (HDC1) with chair time 12:15 PM to 3:45 PM every Monday, Wednesday, and Friday; notify Dialysis Center of any abnormalities noted before and after each dialysis treatment; notify doctor of any significant changes in residents condition before and after dialysis treatment; obtain post dialysis weights from the dialysis center; review post dialysis notes special instructions and new orders and fluid restrictions 1000 milliliter (ml) per day. During a concurrent interview and record review on 6/24/2026 at 3:15 PM with RN 1 and LVN 2, Resident 13's Dialysis Communication Record (form of communication between the facility and the hemodialysis center) dated 6/1/2026 to 6/23/2026 were reviewed. The Dialysis Communication Record indicated missing the Dialysis Communication Record dated 6/12/2026. RN 1 stated and validated Resident 13's hemodialysis was completed on 6/12/2026. Both RN 1 and LVN 2 stated that the facility was supposed to provide the Dialysis Communication Record with the resident when the resident went for dialysis appointment and the dialysis center was supposed to provide information regarding the resident's care and sent it back with the resident after dialysis. RN 1 stated it was important to get the Dialysis Communication Record back since the Dialysis Communication Record was a form of communication between the facility and the dialysis center in regards with Resident 13's dialysis care. During an interview on 6/25/2026 at 7:42 AM with the DON, the DON stated it was important to have the Dialysis Communication Record when the resident would come back from dialysis appointment since that form was the facility's and dialysis center's form of communication regarding resident's dialysis care. During a review of the facility's P&P, titled, Hemodialysis Residents, reviewed on 5/21/2026, P&P indicated that the facility would provide residents with safe, accurate and appropriate care, assessments and interventions to improve resident outcomes in coordination/collaboration with dialysis center. P&P also indicated that the DCR was initiated and sent to the dialysis center each appointment and facility staff would ensure that DCR was received upon return. During a concurrent interview and record review on 6/24/2026 at 3:15 PM with RN 1 and LVN 2, Resident 13's Progress Notes from 6/1/2026 to 6/23/2026 were reviewed. Resident 13's Progress Notes indicated missing documentation when Resident 13 left the facility for the dialysis appointment on the following dates: 6/3/2026, 6/8/2026, 6/10/2026, 6/12/2026, 6/15/2026, 6/19/2026 and 6/22/2026. Both RN 1 and LVN 2 stated the need of documenting when a resident (in general) would go out for an appointment and validated all seven missing documentations. During an interview on 6/25/2026 at 7:42 AM with the DON, the DON stated that nursing staff (in general) were supposed to document if a resident would go out for an appointment to be able to document the facility's assessment of the resident before a resident would leave. During a review of the facility's P&P, titled, Signing Residents Out, reviewed on 5/21/2026, P&P indicated that all residents leaving the premises must be signed out and signed in upon return to the facility. During a review of the facility's P&P, titled, Hemodialysis Residents, reviewed on 5/21/2026, P&P indicated that the facility would provide residents with safe, accurate and appropriate care, assessments and interventions to improve resident outcomes in coordination/collaboration with dialysis center. During a review of the facility's P&P, titled, Charting and Documenting, reviewed on 5/21/2026, P&P indicated that all services provided to the resident, progress toward goals or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. During a concurrent interview and record review on 6/25/2026 at 10:07 AM with RN 1, Resident 13's fluid intake from 6/1/2026 to 6/23/2026 were reviewed. Resident 13's fluid intake indicated more than 1000 ml of fluid on the following dates: 6/9/2026 (total of 1080 ml), 6/12/2026 (total of 1500 ml), 6/16/2026 (total of 1070 ml), and 6/18/2026 (total of 1080 ml). RN 1 stated Resident 13 was supposed to receive 1000 ml fluid per day per physician order. RN 1 stated that if Resident 13 was non-compliant with the fluid restriction, the assigned certified nursing assistant (in general) was supposed to notify the charge nurse, and they need to report to the physician via change of condition. During an interview with Resident 13 and Certified Nursing Assistant 3 (CNA 3) on 6/25/2026 at 10:27 AM, Resident 13 and CNA 3 stated not knowing that Resident 13 was on fluid restriction of 1000 ml per day. During an interview on 6/25/2026 at 10:35 AM with the DON, the DON stated that Resident 13 was supposed to have a fluid restriction of 1000 ml per day and that if a resident (in general) was taking more than the ordered fluid restriction, nurses (in general) were supposed to be made aware and report to the physician via change of condition to be able to provide the proper care to the resident due to Resident 13 was at risk for fluid imbalances and overload. During a review of the facility's P&P, titled, Hemodialysis Residents, reviewed on 5/21/2026, P&P indicated that the facility would provide residents with safe, accurate and appropriate care, assessments and interventions to improve resident outcomes. During a review of the facility's P&P, titled, Fluid Restriction Management Policy, reviewed on 5/21/2026, P&P indicated that facility to ensure safe and effective management or resident requiring fluid restrictions by maintaining physician-ordered fluid limits, preventing complications related to fluid imbalance and promoting interdisciplinary communication. P&P also indicated that significant variances from the prescribed fluid restriction and non-compliance should be documented and reported to the physician. During a review of the facility's P&P, titled, Change in Condition, reviewed on 5/21/2026, P&P indicated that facility would promptly assess, document, and communicate any significant change in a resident's condition to ensure appropriate interventions are implemented and resident needs were addressed.

Based on observation, interview, and record review, the facility failed to ensure care was provided in a manner that promoted or enhanced dignity and respect for two of 20 sampled residents (Resident 4 and Resident 41) by failing to:-Ensure barber services were provided for Resident 4, resulting in the resident not receiving grooming care needed to maintain personal dignity and appearance.-Ensure the facility communicated with Resident 41 regarding an active Out on Pass (OOP) order dated [DATE], resulting in the resident not being informed of the authorized pass and not being provided the opportunity to participate in planning and exercising their personal rights related to temporary leave from the facility.These failures resulted in Resident 4 not receiving needed grooming services to maintain dignity and appearance, and resulted in Resident 41 not being informed of an active Out on Pass (OOP) order dated [DATE], depriving the resident of the opportunity to participate in their care decisions and exercise personal rights. Findings: a. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest, essential hypertension (high blood pressure), difficulty in walking and hydronephrosis (a condition where one or both kidneys swell). During a review of Resident 4's History and Physical dated [DATE], the History and Physical indicated Resident 4 had the capacity to understand all decisions. During a review of Resident 4's Care Plan Report dated [DATE], the Care Plan Report indicated Resident 4 had decreased self-care ability. The Care Plan Report indicated to provide Resident 4 with assistance with personal care to improve hygiene and grooming. During a review of Resident 4's Minimum Data Set, (MDS-a resident assessment tool) dated [DATE], the MDS indicated Resident 4 had no acute changes in mental status. The MDS indicated Resident 4 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for oral hygiene, upper body dressing and personal hygiene. During a concurrent observation and interview on [DATE] at 11:08 AM with Resident 4 inside resident's room, Resident 4 had uneven, overgrown facial hair and a noticeably unkempt appearance due to long hair. Resident 4 stated he (Resident 4) wanted to be shaved and groomed but had not seen the barber. During an interview on [DATE] at 9:23 AM with the Certified Nursing Assistant 9 (CNA 9), CNA 9 stated Resident 4'S facial hair was not neatly shaped, and haircut was not provided to the resident. During an interview on [DATE] at 12:23 PM with the Social Services Director (SSD), the SSD stated daily rounding was conducted by the facility leaders using the checklist form as a quality of care and safety rounds. During an interview on [DATE] at 7:47 AM with the Director of Nursing (DON), the DON stated that Resident 4's care should include proper grooming to support the resident's dignity and promote the overall sense of well being. During a review of the facility's policy and procedure (P&P) titled, Dignity, the P&P indicated each resident is cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights. Residents are encouraged to maintain personal grooming styles. b. During a review of Resident 41's admission Record, the admission Record indicated the facility admitted the resident on [DATE], with diagnoses including but not limited to hepatic encephalopathy (a decline in brain function caused by severe liver disease or liver failure) liver cirrhosis (permanent scarring of healthy liver tissue, usually caused by long-term damage like excessive alcohol use, viral hepatitis, or fatty liver disease ) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 41's untitled history and physical document dated [DATE], the untitled history and physical document indicated Resident 41was stable, alert, and oriented with no evidence of confusion. During a review of Resident 41's MDS dated [DATE], the MDS indicated Resident 41 made herself understood and understood others. The MDS indicated Resident 41's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) is intact. The MDS indicated Resident 41 participated in his care. During a review of Resident 41's Psychiatric Note dated [DATE], the Psychiatric Note indicated Resident 41 had the desire to go out on pass and to go to the store and handle personal concerns such as going to Social Security (a government program funded, provides financial support when retired). The Psychiatric Note indicated that Resident 41 may go out on pass according to the facility policy. The psychiatric note indicated Resident 41's behavior was table. During a review of Resident 41's Psychiatric Note dated [DATE], the Psychiatric Note indicated Resident 41 had a desire to go out on pass to go to the store and handle personal concerns such as going to social security office with a friend. The Psychiatric Note indicated that Resident 41 may go out on pass according to the facility's policy. The Psychiatric Note indicated Resident 4's behavior was stable. During a review of Resident 41's Order Summary Report dated [DATE], the Order Summary Report indicated Resident 41 had a physician's order, authorized to go out on pass for therapeutic purposes not to exceed four hours for one time dated [DATE]. During an interview on [DATE] at 8:46 AM, with Resident 41 in Resident 41's Room, Resident 41stated he (Resident 41) informed the nurses (unidentified) about wanting to go outside and was waiting for physician's OOP order. During an observation and interview on [DATE] at 2 PM, with Resident 41 at the facility's patio, Resident 41 appeared frustrated, as evidenced by facial grimacing and a disappointed tone of voice while stating he (Resident 41) had been waiting for one week to go out on pass. Resident 41 stated it was important for him to go out because it made him feel independent while residing at the facility. Resident 41 stated he (Resident 41) was still mobile and capable of making his own decisions. Resident 41 stated he (Resident 41) hoped that the nurses have been working on the order for him to go out and pass. During an interview on [DATE] at 3:37 PM with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated the OOP was important for residents (general) for their morale and allowed them to be normal while residing at the facility. During an interview on [DATE] at 3:44 PM with the Activities Director (AD), the AD stated if OOP was ordered by a physician, it was communicated to the resident (general). The AD stated the facility's social services assist with OOP accommodations. During a concurrent interview and record review on [DATE] at 3:56 PM, with the Director of Nursing (DON), Resident 41's physician's OOP order dated [DATE] was reviewed. The DON stated that the physician's OOP order dated [DATE] was an active order and should have been communicated to Resident 41. The DON stated it was important to accommodate Resident 41's personal preferences to achieve his own independent choices. During a concurrent interview and record review on [DATE] at 3:56 PM with the Social Service Director (SSD) Resident 41's physician's order dated [DATE] reviewed. The SSD stated upon admission, residents (in general) were made aware of the OOP was available to them. The SSD stated her (SSD) perception was the order had expired on [DATE]. The SSD stated that Resident 41's OOP order was active and should have been communicated to Resident 41 and cause no delay. The SSD stated there was a communication gap between social worker service and Resident 41. The SSD stated Resident 41 should not have been waiting with an active order. During review of the facility's policy and procedure (P&P) titled, Communication Policy, dated [DATE], the P&P indicated that the facility is committed to promoting timely respectful, and effective communication among employees, residents, families, physicians, and other healthcare providers to sup ort safe, high-quality resident's (general) care. During review of the facility's policy and procedure (P&P) titled, Resident's Rights, dated [DATE], the P&P indicated policy statement that employees shall treat all residents with kindness, respect, and dignity. The P&P indicated policy interpretation and implementation, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to communication with and access to people and services, both inside and outside the facility and be informed of their care planning and treatment.

Based on observation, interview, and record review the facility failed to provide an environment that was free from accident hazards for one of seven sampled residents (Resident 82) by failing to: -Ensure Resident 82 did not have unattended veterinary liniment gel (medication applied to the skin designed to relieve muscle and joint pain in animals) container at bedside. This failure had the potential to result in unsafe medication administration to Resident 82.Findings:During a review of Resident 82's admission Record, the admission Record indicated the facility originally admitted Resident 82 on 12/15/2021 and was re-admitted on [DATE] with diagnoses including osteoarthritis (OA-common joint disease that occurs when the cartilage- that cushions the ends of bones wears down over time), spondylosis (spinal OA) and occipital neuralgia (type of nerve pain/headache).During a review of Resident 82's Minimum Data Set (MDS- a resident assessment tool) dated 3/23/2026, the MDS indicated Resident 82 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from set up (helper sets up, resident completes activity) assistance from staff to being independent (resident completed the activity by themselves with no assistance from a helper) for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene).During a review of Resident 82's VB-Nursing-Self Administration of Medication Screen for Clinical Appropriateness (VB-NSAMSCA) dated 5/12/2026, the VB-NSAMSCA indicated Resident 82 may not self-administer medications.During a review of Resident 82's History and Physical (H&P) dated 5/13/2026, the H&P indicated Resident 82 had fluctuating capacity to make and understand decisions.During a concurrent observation and interview on 6/22/2026 at 10:55 AM with Resident 82 and Restorative Nursing Assistant 1 (RNA 1), inside Resident 82's room, observed a white veterinary liniment gel container unattended at bedside. Resident 82 stated she (Resident 82) would apply the gel daily due to her (Resident 82) joint pain. RNA 1 stated that the facility was aware that Resident 82 had been using the gel.During a concurrent interview and record review on 6/22/2026 at 11:09 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 82's Order Summary Report was reviewed. Resident 82's Order Summary Report indicated no physician order for veterinary liniment gel. LVN 1 stated Resident 82 was not supposed to have it (veterinary liniment) at bedside unattended and with no physician orders due to Resident 82 did not have capability to self-administer medications.During an interview with the Director of Nursing (DON) on 6/24/2026 at 8:39 AM, the DON stated it was important not to have unattended usage of medication at bedside due to the possibility of unsafe use of medication. The DON stated all medications were to be prescribed by the physician.During a review of facility's P&P, titled, Administering Medications reviewed on 5/21/2026, the P&P indicated that medications in the facility were to be administered in a safe and timely manner, and as prescribed.During a review of the facility's P&P titled, Self-Administration of Medications reviewed on 5/21/2026, the P&P indicated that any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.During a review of the facility's P&P titled, Safety and Supervision of Resident Self-Administration of Medications reviewed on 5/21/2026, the P&P indicated under safety measures that medications shall be stored in a secure location approved by the facility.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 66) reviewed for urinary catheter (a flexible tube inserted into the bladder to drain urine) received appropriate catheter treatment and services by failing to: -Ensure Resident 66's urinary catheter tubing did not have sediment (particles that may be indicative of an infection). This failure had the potential to result in the backflow of urine into Resident 66's bladder, which could cause urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract), and could negatively impact the delivery services provided to Resident 66.Findings:During a review of Resident 66's admission Record, the admission Record indicated the facility originally admitted Resident 66 on 9/22/2016 and re-admitted the resident on 5/19/2026 with diagnoses including paraplegia (paralysis of the legs and lower body), neurogenic bladder (dysfunction of the bladder) and urogenital implants (a medical device placed inside the body to support urinary functions). During a review of Resident 66's Order Summary Report dated 2/8/2023, the Order Summary Report indicated to change Resident 66's urinary drainage bag as needed for infection, obstruction, or when the closed system (the tip of the catheter inserted into the bladder, to the bag which catches urine, is closed and should not be disconnected) was compromised. During a review of Resident 66's Order Summary Report dated 2/8/2023, the Order Summary Report indicated to flush the urinary catheter with 30 milliliters (ml, a unit of measurement) of normal saline solution (NSS) as needed for obstruction, sediments and hematuria (blood in the urine). During a review of Resident 66's Order Summary Report dated 2/8/2023, the Order Summary Report indicated to monitor the urinary catheter for signs and symptoms of UTI such as amber color urine, foul urine odor, poor urine output and sediment every shift. During a review of Resident 66's Order Summary Report (list of physician orders) dated 1/11/2024, the Order Summary Report indicated to cleanse Resident 66's suprapubic catheter (is a tube inserted through the lower abdomen into the bladder to drain urine when normal urination is not possible) site with normal saline solution (NSS), pat dry, and apply dry dressing daily and as needed (PRN) every 8 hours. During a review of Resident 66's History and Physical (H&P) dated 5/21/2026, the H&P indicated Resident 66 had the capacity to make and understand decisions-medical and daily needs. During a review of Resident 66's Minimum Data Set (MDS- a resident assessment tool), dated 5/30/2026, the MDS indicated Resident 66 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from dependent (helper does all the effort) to set up (helper sets up, resident completes activity) assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS indicated Resident 66 had a urinary catheter. During a review of Resident 66's Care Plan Report dated 6/17/2026, the Care Plan Report indicated Resident 66 was at risk for recurrent UTI. The Care Plan Report indicated nursing interventions included to flush the urinary catheter with 30 mLs of NSS as needed for obstruction, sediments, and hematuria. The Care Plan Report indicated to ensure the urinary catheter tubing was free of kinks and to monitor sediments and consistency of the urine. During an interview on 6/23/2026 at 1:02 PM with Resident 66, inside the resident's room, Resident 66 stated feeling uncomfortable in her (Resident 66) lower abdomen area and requested to check the urinary catheter tubing. During a concurrent observation and interview on 6/23/2026 at 2:17 PM with Certified Nursing Assistant 7 (CNA 7), inside Resident 66's room, observed Resident 66's urinary tubing had some dried sediments inside the urinary catheter tubing and yellowish colored urine was cloudy and stuck in the tubing, unable to drain to the urinary catheter collection bag. CNA 7 stated urine was supposed to be free flowing and draining to the urinary catheter collection bag. During an interview with the Treatment Nurse 1 (TX 1) on 6/23/2026 at 2:24 PM, TX1 stated urine should be flowing freely into the urinary catheter collection bag and tubing should not have any sediments. TX 1 stated she (TX 1) was supposed to check it daily and flush the tubing per physician order and has not had any time to check the resident until now. During an interview with the Director of Nursing (DON) on 6/24/2026 at 8:39 AM, the DON stated that the licensed nurses (in general) were supposed to flush the urinary catheter tubing if urine was not draining properly and if there were any sediments in the tubing and added that it is important to monitor and check urinary catheter due to risk of infection. During a review of facility's policy and procedures (P&P) titled Urinary Catheter and Bedside Drainage Bag reviewed on 5/21/2026, the P&P indicated that facility shall provide appropriate care and maintenance of urinary catheters and bedside drainage bags according to physician orders, infection prevention standards and resident needs. P&P also indicated that facility would ensure that the draining tubing was free from kinks, loops or obstructions.

Based on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the spread of infections by failing to:1. Ensure the staff wore full personal protective equipment (PPE-mask, gown, eye protection, gloves) per facility policy and procedures (P&P) titled , Enhanced Barrier Precautions (EBP) reviewed on 5/21/2026. By failing to ensure Certified Nursing Assistant 3 (CNA 3) wore a gown when providing personal basic care to Resident 97 who was on enhanced barrier precautions (EBP-infection control strategy for nursing home, requiring gowns and gloves to be used during high-contact care for residents with or at high risk for multidrug-resistant organisms [MDRO]).2. Ensure one out of one pill crushers located at the nurse's station was kept clean. These failures had the potential risk of medication cross contamination from the pill crusher and negatively impact residents' safety and to result in the spread of disease and infection to residents, visitors, and facility staff.Findings: During a review of Resident 97's admission Record, the admission Record indicated the facility originally admitted Resident 97 on 8/3/2023 and re-admitted on [DATE] with diagnoses including aphasia (language disorder, affecting speaking and understanding language), dysphagia (difficulty swallowing food or liquid) and gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration). During a review of Resident 97's History and Physical (H&P), dated 2/18/2026, the H&P indicated Resident 97 lacked the ability to make healthcare decisions. During a review of Resident 97's Order Summary Report (OSR-list of physician orders) dated 4/27/2026, the OSR indicated Resident 97 was on EBP. The OSR indicated that gloves and a gown were needed during direct contact patient care to prevent MDRO transmissions. During a review of Resident 97's care plan dated 4/27/2026, care plan indicated Resident 97 was at risk for MDRO infection related to GT with interventions for facility staff to wear gowns and gloves while performing any care activity where close contact with the resident is expected to occur such as bathing, peri-care, assisting with toileting, changing incontinence briefs and mobility assistance. During a review of Resident 97's Minimum Data Set (MDS- a resident assessment tool), dated 5/23/2026, the MDS indicated Resident 97 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from moderate (helper does less than half the effort) to dependent (helper does all the effort) assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of facility's document titled, Residents on EBP, undated, facility's document indicated Resident 97 was on EBP. During a concurrent observation and interview on 6/25/2026 at 10:27 AM with Registered Nurse 1 (RN 1) and CNA 3, inside Resident 97's room, CNA 3 was observed assisting Resident 97 with personal basic care and repositioning Resident 97 in the bed without wearing a gown. CNA 3 stated Resident 97 was on EBP and CNA 3 was supposed to wear a gown when assisting Resident 97's care. RN 1 stated it was important to wear a gown and gloves during close contacts due to possible infection control issues. During an interview on 6/25/2026 at 2:22 PM with Infection Preventionist Nurse (IPN), the IPN stated that when providing direct care to Resident 97, facility staff were supposed to wear gowns and gloves due to possible transmission of infection and Resident 97 was at high risk for MDRO infection. During an interview on 6/25/2026 at 3:20 PM with the Director of Nursing (DON), DON stated facility staff were supposed to wear gowns and gloves due to possible transmission of infection and Resident 97 was at high risk for MDRO infection. During a review of the facility's policy and procedure (P&P), titled, Enhanced Barrier Precautions (EBP) , reviewed on 5/21/2026, the P&P indicated that facility staff were to wear gown and gloves during high-contact resident care activities, including but not limited to dressing, bathing, and hygiene assistance, wound care, changing linens, toileting assistance, device care and transfers requiring extensive physical assistance. During a review of the facility's P&P titled, Infection Prevention and Control Program reviewed on 5/21/2026, the P&P indicated that facility was to establish, maintain, and provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Findings: During a concurrent observation and interview on 6/25/2026 at 10:31 AM with Licensed Vocational Nurse (LVN) 5 in the nurses' station, a pill crusher was observed with a reddish-brown color on the hinges and dark powder residue. LVN 5 stated that the pill crusher was dirty and required to be cleaned to prevent cross contamination of medications. During an interview on 6/25/2026 at 10:45 AM, with the Infection Preventionist Nurse (IPN), the IPN stated that the facility had an infection control program and practices such as monitoring of adherence to infection prevention standards, with a focus on safety and sanitation practices. During an interview on 6/25/2026 at 11:27 AM, with the Director of Nursing (DON), DON stated nurses were responsible for cleaning pill crushers to prevent medication cross contamination and non-medication items are prohibited in the medication rooms. During a review of the facility's P&P titled, Cleaning and disinfecting medical equipment, the P&P indicated that reusable medical equipment was to be cleaned and disinfected between resident use to reduce the risk of infection and maintain a safe environment.

Based on interview and record review, the facility failed to implement and maintain an effective infection prevention and control program for one of five sampled residents (Resident 77) reviewed for immunizations, by failing to:1. Ensure to re-offer Resident 77 the pneumococcal (Pneumonia [PNA]-infection that inflames air sacs in one or both lungs which may fill with fluid) vaccine yearly, in accordance with facility policy and procedures (P&P) titled Pneumococcal Vaccine reviewed by the facility on 5/21/2026 and the current standards of practice. This failure placed Resident 77 at a higher risk of acquiring and transmitting vaccine-preventable respiratory infections, including influenza and pneumonia, to other residents, visitors and staff within the facility.Findings:During a review of Resident 77's admission Record, the admission Record indicated the facility originally admitted Resident 77 on 5/18/2021 and was re-admitted on [DATE] with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing) and heart failure (a chronic condition in which the heart does not pump blood as well as it should). During a review of Resident 77's History and Physical (H&P), dated 1/29/2026, the H&P indicated Resident 77 had the capacity to make and understand medical decisions. During a review of Resident 77's Minimum Data Set (MDS- a resident assessment tool), dated 5/10/2026, the MDS indicated Resident 77 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from set up (helper sets up, resident completes activity) assistance from staff to being independent (resident completed the activity by themselves with no assistance from a helper) for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a concurrent interview and record review on 6/25/2026 at 9:13 AM with the Infection Preventionist Nurse (IPN), Resident 77's immunization record was reviewed via CAIR (California Immunization Registry: secure web-based system that stores immunization records for children and adults in California) as of 6/25/2026. Resident 77's immunization record indicated last PNA vaccine was received on 2/3/2016 with recommendation for a second dose of PNA vaccine. Resident 77's medical record was reviewed, indicated PNA vaccine declination forms were signed on 5/20/2021 and 3/12/2023. The IPN stated that she (IPN) was supposed to re-offer PNA vaccine at least yearly and Resident 77 was at risk for PNA. The IPN stated the importance of offering and providing PNA vaccines to facility resident to provide residents protection against PNA. During an interview on 6/25/2026 at 9:31 AM with Resident 77, Resident 77 stated wanting to have PNA vaccine. During a review of facility's P&P, titled, Pneumococcal Vaccine reviewed by the facility on 5/21/2026, the P&P indicated that facility would offer pneumococcal vaccines to all residents to aid in preventing PNA infections. P&P also indicated administration of the PNA vaccines or revaccinations will be made in accordance with the current CDC (Centers for Disease and Prevention) recommendations. During a review of the facility's P&P titled, Infection Prevention and Control Program reviewed on 5/21/2026, the P&P indicated that the facility was to establish and maintain a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observation, interview, and record review, the facility failed to ensure accurate accountability of a controlled medication (medication with a high potential for abuse; medication use and possession of are controlled by the federal government) for one of three inspected medication carts (Medication Cart 1-Med Cart 1) by failing to: 1. Ensure Med Cart 1 had accurate documentation of Resident 28's Methadone Hydrochloride (HCI) [a controlled medication used to treat severe, long-lasting pain] medication on narcotic and hypnotic record (NHR- a document indicating continuous inventory and administration of controlled substances) after Licensed Vocational Nurse 4 (LVN 4) administered methadone HCI to Resident 28 on 6/25/2026 at 8:07 AM. This failure had the potential to result in controlled medications misuse, and diversion (the illegal or unauthorized shifting of prescription drugs from their intended, legal path into the wrong hands for recreational use, addiction, or profit).Findings: During a review of Resident 28's admission Record, the admission Record indicated the facility originally admitted Resident 28 on 11/21/2025 and re-admitted the resident on 6/1/2026 with diagnoses including bilateral lower limb (legs) cellulitis (bacterial skin infection), (chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe) and opioid (highly addictive, powerful type of medication to treat severe pain) dependence. During a review of Resident 28's History and Physical (H&P), dated 12/29/2025, the H&P indicated Resident 28 had complete ability to make and understand decisions. During a review of Resident 28's Order Summary Report (OSR-list of physician orders), dated 6/1/2026, the OSR indicated Resident 28 had a physician order for Methadone HCI oral 10 milligrams (mg), give 11 tablets to equal 110 mg total by mouth one time a day for pain management and hold if sleepy or if respiratory rate is less than 12 per minute. During a review of Resident 28's Minimum Data Set (MDS- a resident assessment tool), dated 6/8/2026, the MDS indicated Resident 28 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from moderate (helper does less than half the effort) to supervision (helper provides verbal cues, touching and/or contact guard assistance as resident completes activity) assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a concurrent observation of a narcotic count of med cart 1, interview, and record review on 6/25/2026 at 11:29 AM with LVN 4 , two methadone HCI bubble packs (packaging in which the medications are organized and sealed between a cardboard backing and clear plastic cover)(1 of 2 bubble pack and 2 of 2 bubble pack) were observed, both bubble packs were observed with two remaining doses of methadone HCI. A review of Resident 28's methadone HCI for 1 of 2 and 2 of 2 NHRs dated 6/25/2026, indicated both NHRs were supposed to have three remaining doses left. A review of Resident 28's methadone HCI administration history dated 6/25/2026, indicated methadone HCI was administered at 8:07 AM. LVN 4 stated he (LVN 4) forget to sign both 1 of 2 and 2 of 2 NHRs for methadone HCI when it was administered to Resident 28 on 6/25/2026 at 8:07 AM. LVN 4 stated when removing controlled medication, he (LVN 4) was supposed to sign and document under the NHR when methadone HCI was removed for accounting purposes. During an interview on 6/25/2026 at 3:20 PM with the Director of Nursing (DON), the DON stated that facility nurses were supposed to sign and document in the NHR as soon as removing a controlled medication for proper handling and accurate accounting of the controlled medication. During a review of facility's policy and procedures (P&P) titled Controlled Medication Count Policy reviewed on 5/21/2026, the P&P indicated facility staff were to ensure the safe storage, accurate accounting, and proper handling of controlled medication while preventing diversion and maintaining regulatory compliance. The P&P also indicated under responsibilities that licensed nurses were to perform and document accurate controlled medication counts and report discrepancies immediately.

Based on observation, interview, and record review, the facility failed to ensure to document itemized list of personal property for one of three sampled residents (Resident 2) upon admission. This failure had the potential for loss or misappropriation of Resident 2's personal property items and to cause moral distress to Resident 2.Findings: During a record review of the face sheet Resident 2 was admitted to the facility on [DATE] with diagnoses of polyneuropathies (a condition where multiple peripheral damaged nerves throughout the body causing numbness in hands and feet), chronic pain syndrome (a condition where persistent pain beyond the typical healing time), anxiety (feelings of unease, worry, or fear), major depression (persistent sadness, loss of interest and pleasure), opioid dependence (a physical adaptation to regular opioid use where the body requires the drug to function normally and prevent withdrawal symptoms), vascular dementia (a decline in thinking and memory skills caused by restricted or blocked blood flow to the brain), with psychotic disturbance (a collection of symptoms where a person loses touch with reality). During a review of Resident 2's Minimum Data Set (MDS, resident assessment tool) dated 4/15/2026, the MDS indicated Resident 2 was cognitively (mental ability to make decisions of daily living) intact during Brief Interview for Mental Status (BIMS, an assessment tool for brain's complex mental processes involved in gaining knowledge and comprehension). The BIMS score was 14 (person able to verbalize needs and understands concepts). MDS indicated Functional Abilities (ability to move body and perform acts like dressing, walking) of Resident 2 required supervision with eating, oral hygiene, upper body dressing, moderate assistance (helper does less than half the effort) with toileting and, and substantial/maximal assistance (helper does more than half the effort) with transfers from bed to chair, to toileting, and showering. During a concurrent observation and interview on 5/29/2026 at 11:15 p.m. with Resident 2, Resident 2 stated that she had brought a lot of her personal belongings in six boxes and four suitcases that the facility stored outside her room in a separate closet of the facility. Resident 2 stated that she had lost a second set of bed sheets and pillowcases, a TV screen and a small white box with jewelry in it, worth forty thousand dollars was gone. Resident 2 stated that she had her closet, a pocket shoe organizer, hanging on the back of the door and nightstand full of items. Resident 2 stated the staff never went over the contents of her boxes and suitcases to record what exactly she had upon admission. During a concurrent interview and record review on 5/29/2026 at 1:21 p.m. with Director of Nursing (DON) Resident 2's Inventory of Personal Effects (personal belongings list) dated 4/9/2026 was reviewed. The Inventory of Personal Effects indicated 12 boxes, four luggage cases, one black plastic bag, two bedside plastic drawers, a cellphone and a tablet. The personal belongings list did not indicate the individual items in each box or luggage, and the form was not signed by the staff and Resident 2. The DON stated there are other lists of Resident 2's personal effects that came from previous facility, which was not signed by staff and Resident 2 as well. DON stated, We should do it (inventory), one by one all the items to be accounted for. We must open each box and confirm it with resident. DON did not state the importance of accounting for each item belonging to residents. DON stated that the admitting Registered Nurse (RN) is responsible for filling out the inventory on admission of Resident 2. During a review of policy and procedures (P&P) Personal Property dated 5/21/2026, the P&P indicated that, the residents personal belongings and clothing are inventoried and documented upon admission and updated as necessary.

Based on observation, interview and record review the facility failed to maintain a clean and comfortable environment for one of three sampled residents (Resident 3). This failure resulted in Resident 3's room area to remain cluttered with the resident care items on the dresser, resident's personal blanket left on the bed frame out of the resident's reach alongside an empty Glucerna shake bottle and white paper bag with old crackers, as well as, a wedge a triangular-shaped orthopedic pillow, usually made of firm foam, designed to elevate specific parts of your body) on the floor.Findings: During a review of Resident 3's admission Record, dated 5/29/26, indicated the resident was admitted to the facility on [DATE] with diagnoses including muscle weakness, need for assistance with personal care, diabetes mellitus type two (DMII - a disorder characterized by difficulty in blood sugar control and poor wound healing), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 3's History and Physical (H&P) indicated the resident had capacity to make complex decisions. During a review of Resident 3's Minimum Data Set (MDS - resident assessment tool), dated 4/13/26, indicated the resident cognition (ability to think, understand and make daily decisions) was intact. The same MDS indicated Resident 3 was dependent to requiring maximal assist from staff with activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and bed mobility. During an observation with concurrent interview on 5/29/26 at 12:25 pm with Resident 3 in her bed area, the bed side table was observed cluttered with items for personal care (incontinence pads, two packages of incontinence briefs, a glove and comb) with the drawer left open. In the area behind the resident's bed a wedge pillow was on the floor, and the resident's personal blanket was bunched up on the bedframe under the raised head of the bed, an empty bottle of Glucerna (nutritional shake) and an crumbled white paper bag with old crackers were also observed on the bed frame and the floor was noted to be sticky. The Resident verified the observations and stated that they (facility) don't seem to clean as they should, often leaving a mess. Resident 3 stated that she needs assistance for most tasks. During an observation with concurrent interview on 5/29/26 at 12:36 pm, with Certified Nursing Assistant (CNA) 1 in Resident 3's room, CNA 1 verified the clutter and mess around the resident's bed. CNA 1 stated she (CNA 1) does not know how those (Resident 1's) items got under the head of the bed and on the floor and that those items should not be under the bed and on the floor. CNA 1 then began removing the items and tiding up Resident 1's area. During a review of the facility's policy and procedures, Homelike Environment, reviewed 5/21/26, indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encourage to use their personal belonging to the extent possible.

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment for one of three sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 picked up a call light (device for residents to call for help) from the floor and placed it on the bed sheet without cleaning it. This failure had the potential for Resident 1 to be in unsanitary environment and be exposed to disease-causing germs.Findings: During a record review of Resident 1's admission Record, the admission record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses of fracture of right femur and pubis (fracture of right thigh and pelvic bones), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control), major depressive disorder (mood disorder that causes persistent sadness, loss of interest, and physical symptoms). During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool) dated 5/5/2026, the MDS indicated Resident 1 was cognitively (the mental ability to make decisions of daily living) intact during Brief Interview for Mental Status (BIMS, an assessment tool for brain's complex mental processes involved in gaining knowledge and comprehension) and score was 13 (person able to verbalize needs and comprehend). Under Functional Abilities (ability to move body and perform acts like dressing, walking), the MDS indicated that Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting and showering, and substantial/maximal assistance (helper does more than half the effort) with transfers from bed to chair, and toilet. During a concurrent observation and interview on 5/29/2026 at 9:14 a.m. with Resident 1, Resident 1 stated he does not usually call for help, I get up and walk myself and walk with my walker. They have a call light for emergencies. When asked to press the call light Resident 1 could not reach the call light. During concurrent observation and interview 5/29/2026 9:24 p.m. with LVN 1 in Resident 1's room, LVN 1 stated that Resident 1's call light was on the floor and not within the resident's reach. LVN 1 was observed to pick up the call light from the floor and placed the call light on the bed sheet without cleaning it. LVN 1 stated she should have cleaned the call light first before putting it on the sheet. LVN 1 stated it is important to keep it clean to prevent contamination of bed linen. During a review of policies and procedures (P & P) Infection Prevention and Control dated 5/21/2026, the P & P indicated, the purpose to maintain safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled resident (Resident 1) has call light (device to press to call and ask for help) within reach. This failure had the potential for Resident 1 to be unable to ask and receive help as needed. Findings: During a record review of the admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of fracture of right femur and pubis (fracture of right thigh and pelvic bones), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control), major depressive disorder (mood disorder that causes persistent sadness, loss of interest, and physical symptoms). During a review of the Minimum Data Set (MDS, resident assessment tool) dated 5/5/2026, the MDS indicated Resident 1 was cognitively intact during Brief Interview for Mental Status (BIMS, an assessment tool for brain's complex mental processes involved in gaining knowledge and comprehension) and score was 13 (person able to verbalize needs and comprehend). The MDS indicated Functional Abilities (ability to move body and perform acts like dressing, walking) of Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting and showering, and substantial/maximal assistance (helper does more than half the effort) with transfers from bed to chair, and toilet. During a concurrent observation and interview on 5/29/2026 at 9:14 a.m. with Resident 1, Resident 1 stated he does not usually call for help, I get up and walk myself and walk with my walker. They have a call light for emergencies. When asked to press the call light Resident 1 could not reach the call light. During concurrent observation and interview 5/29/2026 9:24 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that Resident 1's call light was on the floor and was not within the resident's reach. LVN 1 stated, it was important to have call light to call help if needed, and everybody was responsible for ensuring call lights were within reach during the rounds. During a record review of care plan (CP) for Resident 1 with Focus area At high risk for falls, dated 5/01/2026, the CP indicated that Call light within reach and answered promptly. Encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. During record review the facility's policy and procedures (P & P) titled Answering the Call Light dated 5/21/2026, the P & P indicated that, the purpose to ensure timely responses to the residents' requests and needs and to ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on interview and record review the facility failed to ensure one of six sampled Certified Nursing Assistants (CNA) (CNA 3) had an active license when working an 11pm to 7am shift on [DATE].This failure resulted in CNA 3 not meeting the requirements of the federal regulation for nurse aide registry certification and had the potential to effect the quality of care received for her assigned residents.During a concurrent interview and record review on [DATE] at 4:30 pm with Director of Nursing (DON) CNA 3's L & C (Licensing & Certification) Verification Detail Page, undated, from CNA 3's personnel file was reviewed. The page indicated CNA 3's license status was active, employable with expiration date of [DATE], which the DON verified.During a concurrent interview and record review on [DATE] at 4:30 pm with the DON a search was done on the California Department of Public Health (CDPH) website to verify CNA 3's certification status on the registry. The search results indicated No data was found that matches your search criteria. Please try again, which the DON verified, stating she is aware CNA 3 had applied for a renewal of her certification and that it takes a long time. During a concurrent interview and record review on [DATE] at 4:30 pm with the DON the nursing assignment and attendance sign-in sheets for 11pm to 7am night shift on [DATE] were reviewed. The attendance and assignment sheets indicated CNA 3 had worked that shift and signed in on the attendance sheet. The DON verified the information and stated that situation happened because the Charge Nurse that night was trying to find someone to cover for a CNA call off on the next shift so they would not be short staffed. CNA 3 was well known to the Charge Nurse and had a reputation for helping whenever the facility needed her to come in and cover a shift. The Charge Nurse had made an honest mistake, by calling CNA 3 to work, and CNA 3 knowingly worked that night shift without having an effective/valid CNA certification. During a telephone interview on [DATE] at 11:28 am with the Director of Staff Development (DSD), the DSD stated when a CNA's certification has lapsed and they are in the process of getting it renewed they are taken off the monthly schedule. She further stated CNA 3 was informed of what she could or could not do on an expired certification. On the night shift of [DATE] the evening shift Charge Nurse called CNA 3 directly not noticing she had been removed from the schedule. CNA 3 should have also known when she went to clock in the system would not let her clock in - they are removed from the payroll until they have a valid certification.During a review of the facility's Job Description Title: Certified Nursing Assistant (CNA), updated [DATE], indicated Position Summary.The Certified Nursing Assistant (CNA) provides essential personal care and support to residents, ensuring their comfort and well-being. Knowledge, Skills, Abilities & Qualifications. 1. Valid Certified Nursing Assistant (CNA) certification is required. 10. Understanding and adherence to relevant regulations, policies and procedures.

Based on observation, interview, and record review the facility failed to create and implement a Care Plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the individual needs for one of three sample residents (Resident 1) care plan, by failing to: 1. Create and implement a care plan on 11/29/2025 when the resident displayed aggressive behavior and was placed on 1:1supervision (one staff member always stays with one patient to keep them from harming others or themselves). 2. Create and implement a care plan on 12/8/2025 when the resident was readmitted to the facility from the GACH (General Acute Care Hospital) after being evaluated for increased agitation with aggression. These deficient practices had the potential to delay and affect the quality of care and services Resident 1 received.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/10/2025 and readmitted on [DATE] with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), current episode depressed (a serious mood disorder causing persistent sadness), severe, with psychotic(severe mental illness where the individual's thoughts and perceptions are so out of sync with those around them that they have trouble functioning in daily life) features, paranoid schizophrenia (your brains wiring gets crossed, making you intensely suspicious [paranoid], hearing things that are not there [hallucinations, often voices], and strong beliefs [delusions, thinking you're being plotted against], leading to confused thinking and difficulty handling daily life), unspecified mood affective disorder (your emotions go swinging beyond the normal ups and downs affecting daily life), and other psychoactive substance abuse ( a drug, herb, or chemical that changes how your brain works), uncomplicated. During a review of Resident 1's History and Physical (H&P) dated 12/9/2025, the H&P indicated Resident 1 did not have the capacity (ability) to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment tool) dated 11/11/2025, the MDS indicated Resident 1 had moderate cognitive (ability to think, understand, learn, and remember) impairment (reduced). During a review of Resident 1's behavior notes dated 11/29/205 at 4:12 PM, the note indicated Resident 1 was observed to be spitting to the nurse that is currently taking care of him. During a review of Resident 1's Situation Background Assessment and Recommendation (SBAR) Summary for Providers dated 11/29/2025 at 4:25 PM, the SBAR indicated Resident 1 was placed on 1:1 supervision per MD (Medical Doctor) orders. During a review of Resident 1's comprehensive (complete) care plans for 11/29/2025, the comprehensive care plans indicated a care plan for Resident 1's aggressive behavior and 1:1 supervision was not implemented. During a review of Resident 1's nursing progress notes dated 11/29/2025 at 11:15 PM, the notes indicated Resident 1 had a physician's order to transfer the resident to to the GACH. The notes indicated the resident was sent the GACH for further evaluation for increased agitation episode. During a review of Resident 1's progress notes dated 12/8/2025 at 5:24 PM, the notes indicated the resident was readmitted to the facility. During a review of Resident 1's comprehensive (complete) care for 12/8/2025, the comprehensive care plans indicated a care plan for Resident 1's aggressive behavior was not implemented. During a concurrent interview and record review on 12/16/2025 at 11:29 AM, with Licensed Vocational Nurse (LVN) 1, Resident 1's Behavior Note dated 11/29/2025 4:12PM, Resident 1's SBAR Summary for Providers dated 11/29/2025 4:25PM, and complete care plans were reviewed. LVN 1 stated a care plan should have been implemented when there was a significant changes or regression (a return to a former or less developed state) to achieve the most optimal plan of care for Resident 1 with the most recent baseline of behaviors. LVN 1 stated if a care plan was not updated it would not be 100 percent accurate on monitoring Resident 1's behavior and that it was not in the best interest of Resident 1 since it did not represent the resident's most current plan of care. During an interview on 12/16/2025 at 12:23 PM with Registered Nurse (RN)1, RN1 stated the importance of a care plan was to have a plan of care with interventions that outlined certain steps for resident care. RN 1 stated if there were changes in the resident's condition or if a resident returned from the GACH the care provided might not have appropriate interventions without an updated care plan. RN 1 stated care plans were created on a case-to-case basis and based on resident assessments (the process of evaluating someone to understand their condition). During a concurrent interview and record review on 12/16/2025 at 12:37 PM, with LVN 2, Resident 1's Behavior Note dated 11/29/2025, SBAR Summary dated 11/29/2025 and complete care plans were reviewed. LVN 2 stated any licensed nurse could have updated a care plan. LVN 2 stated care plans could be updated as needed, with any changes or anything different in the residents' care. LVN 2 stated updated care plans were important to ensure the care and interventions staff provided for Resident 1 were current. LVN 2 stated Resident 1 was displaying inappropriate behavior on 11/29/2025 and was placed on 1:1 supervision and confirmed that information was not on the care plan. LVN 2 stated interventions should have been added to Resident 1's care plan so staff caring for Resident 1 was aware. LVN 2 stated care plans that were not updated would not have current communication to staff on a resident's status. During an interview on 12/16/2025 at 2:33 PM with the Director of Nursing (DON), the DON stated care plans were to be updated if there were any new interventions or if there was a change of condition in a resident. The DON stated care plans were important to update to ensure needed interventions were in place and were appropriate and resident centered. The DON stated if the care plan was not created/updated, there would not be proper interventions in place. The DON stated 1:1 monitoring was an important intervention and should have been on the care plan for Resident. The DON stated, we missed adding the intervention to his care plan and Resident 1's care plan was not updated when he returned from GACH to the facility. During a review of the facility's job description titled, Registered Nurse (RN) Supervisor dated 11/1/2024, the job description indicated, RN Supervisor conducts assessments to identify changes in the resident's physical or psychological conditions and adjust the care plans accordingly. During a review of the facility's job description titled, Charge Nurse LVN dated 11/1/2024, the job description indicated, Contributes to formulation/review of nursing care plans weekly and PRN. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 1/23/2025, the P&P indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change. The P&P indicated The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay.

Based on observation, interview, and record review the facility failed to protect one of three sampled residents (Resident 1) from physical abuse (any intentional act causing injury or trauma to another person by way of bodily contact) by failing to: -Ensure Certified Nursing Assistant 2 (CNA2) notified Registered Nurse 2 (RN2) that Resident 1 was agitated (to be visibly worried, upset, or restless, often showing this feeling through your movements or voice, like fidgeting or speaking in a tense way) when CNA1 did not allow Resident 1 to go smoke on 9/9/2025 at approximately 1AM. -Ensure Resident 2 did not hit Resident 1 who was blind on the left jaw (the lower part of the face below the mouth) on 9/9/2025 at 1AM. On 9/9/2025 at approximately 1AM, Resident 1 wanted to go smoke and CNA2 told Resident 1 to sit down. Resident 1 became agitated Resident 2 thought Resident 1would hit CNA2 and Resident 2 hit Resident 1 on Resident 1's left jaw. As a result, on 9/9/2025 at 1AM Resident 2 hit Resident 1 on the jaw causing Resident 1 to experience pain in the jaw and required an x-ray (medical imaging that uses radiation to take pictures of the inside of your body). Findings: 1.During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 7/26/2025 and readmitted Resident 1 on 8/26/2025 with diagnoses of lack of coordination, blindness of both eyes, schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's History and Physical (H&P), dated 7/26/2025, the H&P indicated Resident 1 had no capacity (ability) for decision-making. The H&P indicated Resident 1 had a history of nicotine dependence (your brain and body rely on nicotine from tobacco or vaping products to feel normal and avoid withdrawal). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/2/2025, the MDS indicated Resident 1 had the ability to make himself (Resident 1) understood, and had the ability to understand others. During a review of Resident 1's Care Plan Report dated 8/12/2025, the Care Plan Report indicated the CNAs (in general) would monitor Resident1 for unsafe smoking practices. The Care Plan Report indicated the CNAs (in general) would notify the charge nurse immediately if it was suspected Resident 1 violated the facility's smoking policy. During a review of Resident 1's Progress Note dated 9/9/2025 at 1 AM, the Progress Note indicated Resident 1 became agitated and Resident 2 hit Resident 1 because Resident 2 believed Resident 1 was going to hit the sitter (CNA2). The Progress Note indicated Resident 2's hand landed on Resident 1's jaw. The Progress Note indicated the facility staff (unidentified) separated Resident 1 and Resident 2. During a review of Resident 1's Progress Note, dated 9/9/2025 at 2:59 AM, the Progress Note indicated Resident 1 became agitated around 1 to 1:15 AM on 9/9/2025 and stood up from the bed. The Progress Note indicated the sitter (CNA2) approached Resident 1 and tried to calm Resident 1 down. The Progress Note indicated Resident 2 moved from his bed to his wheelchair and swung his hand and hit Resident 1 on the jaw. The Progress note indicated a Registered Nurse (RN2) and Charge Nurse (LVN2) separated Resident 1 and Resident 2 with the help of the sitter (CNA2). The Progress Note indicated Resident 2 was later moved (unknown time) to another room. The Progress Note indicated Resident 1 wanted to smoke and the RN (RN2) explained to Resident 1 the facility's designated smoking times. During a review of Resident 1's Radiology (the medical specialty that uses imaging techniques, such as X-rays) Results Report, dated 9/9/2025 at 2:15 PM, indicated the reason for the study was jaw pain and the results of the x-ray was no fracture (broken bone). During a review of Resident 1's Progress Note, dated 9/12/2025 at 3:57 PM, the Progress Note indicated the Interdisciplinary Team (IDT - group of people from different professions who work together by sharing knowledge and methods to solve a complex problem) met to discuss what happened on 9/9/2025 when Resident 2 hit Resident 1. The Progress Note indicated Resident 1 wanted to go to the smoking patio around 1 AM (date not indicated) and the sitter told Resident 1 it was not time for smoking. The Progress Note indicated Resident 2 shouted at Resident 1, kneeled on his (Resident 2) wheelchair, wheeled himself (Resident 2) toward Resident 1 and struck (hit) him (Resident 1) on the left jaw with his (Resident 2) right hand. The Progress Note indicated Resident 2 believed Resident 1 had struck the sitter and that Resident 2 felt he had a sense of duty to intervene (step in) in defense of the sitter because he (Resident 2) believed a man (in general) should hit a woman (in general). 2.During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 7/2/2025 and readmitted Resident 2 on 7/29/2025 with diagnoses of type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), blindness in the left eye, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's H&P dated 7/3/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to make himself (Resident 2) understood and had the ability to understand others. 3.During a revied of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 6/12/2025, and readmitted Resident 3 on 8/31/2025 with diagnoses of unsteadiness on feet, and displaced intertrochanteric fracture of right femur (a severe break in the upper part of your right thigh bone that caused the broken pieces to shift out of their correct position). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had the ability to make himself (Resident 3) understood and usually had the ability to understand others. During a review of Resident 3's H&P, dated 7/29/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decision. During an interview on 9/16/2025 at 10:53 AM with Resident 1 in Resident 1's room, Resident 1 stated Resident 2 hit him on the face last week (exact date not known). Resident 1 stated Resident 2 told him to shut up and stated he (Resident 1) did not know why Resident 2 hit him (Resident 1). Resident 1 stated he (Resident 2) just hit me. Resident 1 stated he (Resident 1) was blind and knew it was Resident 2 who hit him because he (Resident 1) recognized Resident 2's voice. Resident 1 stated he (Resident1) was angry at Resident 2 for hitting him (Resident 1). During an interview on 9/16/2025 at 11:42 AM with Resident 2 in Resident 2's room, Resident 2 stated he (Resident 2) heard the CNA (CNA, unidentified) told Resident 1 to sit down because Resident 1 was going to fall. Resident 2 stated he (Resident 2) saw Resident 1 get up and the CNA (unidentified female) stood in front of Resident 1. Resident 2 stated he (Resident 2) saw Resident 1 make threats and pushed the CNA (unidentified female). Resident 2 stated he (Resident 2) saw Resident 1 make a fist to hit the CNA (unidentified female) so he (Resident 2) got on his wheelchair by placing his knees on the seat of the wheelchair facing the back of the wheelchair and wheeled himself backwards in the wheelchair toward Resident 1. Resident 2 stated he (Resident 2) hit Resident 1 because I had to hit him (Resident 1). Resident 2 stated he (Resident 2) deliberately hit Resident 1 because his (Resident 1) behavior warranted him (Resident 2) to hit Resident 1. Resident 2 stated the incident began when Resident 1 wanted to smoke early in the morning (unknown date). Resident 2 stated he hit Resident 1 because he (Resident 2) was brought up to protect women referring to the female CNA (undentified) who was trying to prevent Resident 1 from falling. During an interview on 9/16/2025 at 12:04 PM with LVN 1, LVN 1 stated he (LVN1) received a report from the night charge nurse (LVN 2) during the morning shift change on 9/9/2025. LVN 1 stated LVN 2 reported an incident between Resident 1 and Resident 2. LVN 1 stated LVN 2 reported Resident 1 had been agitated because he (Resident 1) wanted to smoke outside of the facility's designated smoking hours. LVN 1 stated Resident 1 and Resident 2 were in a room with a sitter (CNA2) in the Resident 1 and Resident 2's room because Resident 1 and Resident 2 were at risk for a fall. During an interview on 9/16/2025 at 12:28 PM with the Director of Nursing (DON) and Director of Staff Development (DSD), the DON stated she (DON) received a call from the facility on 9/9/2025 approximately between 1:30AM and 2 AM. The DON stated she (DON) interviewed LVN 2 and RN 2 over the phone. The DON and the DSD stated the incident began when Resident 1 wanted to smoke outside of the facility's designated (officially chosen) smoking hours which were from 9 AM to 8:30 PM daily. The DON stated Resident 2 reported he (Resident 2) wanted to protect CNA 2 from Resident 1 who was agitated after CNA 2 tried to educate Resident 1 about the facility's smoking hours. The DON stated Resident 1 attempted to get up and CNA 2 positioned herself (CNA 2) to prevent Resident 1 from falling. During an interview on 9/16/2025 at 12:56 PM with CNA 2, CNA 2 stated Resident 1 wanted to smoke in the early morning of 9/9/2025 and she (CNA2) tried to get out of bed. CNA 2 stated Resident 1 was blind and at risk for falling so CNA 2 tried to keep Resident 1 from getting up. CNA 2 stated Resident 2 thought Resident 1 was going to hit her (CNA 2). CNA 2 stated Resident 2 got up, and CNA 2 called for help. CNA 2 stated Resident 2 then hit Resident 1. During an interview on 9/16/2025 at 1:24 PM with Resident 3, Resident 3 stated he (Resident 3) was awake on the night when Resident 2 hit Resident 1. Resident 3 stated Resident 1 had been very rough with the staff and Resident 1 had been aggressive. During an interview on 9/16/2025 at 1:35 PM with LVN 2, LVN 2 stated he (LVN2) was the Charge Nurse on the night/early morning of 9/9/2025. LVN 2 stated he (LVN2) heard a call for help and went to the room where Resident 1 and Resident 2 were located. LVN 2 stated CNA 2 tried to keep Resident 1 from falling. LVN 2 stated he (LVN2) saw Resident 2 hit Resident 1 on 9/9/2025 approximately 1 AM in the morning. During an interview on 9/16/2025 at 1:44 PM with RN 2, RN 2 stated he (RN2) heard a commotion (a sudden, noisy, and confusing burst of activity) coming from Resident 1 and Resident 2's room and he (RN2) went to investigate. RN 2 stated he (RN2) observed CNA 2 positioned between Resident 1 and Resident 2. RN 2 stated Resident 1 was agitated because he (Resident 1) wanted to smoke. RN 2 stated he (RN2) gave Resident 1 Tylenol (over-the-counter medicine that relieves mild to moderate pain and reduces fever) because Resident 1 complained of an aching jaw pain that was rated at 3 out of 10 (mild pain [0 means no pain and 10 means having the worst pain]). During a review of the facility's policy and procedure (P&P), titled Identifying Types of Abuse, last reviewed 1/23/2025, the P&P indicated the facility's employees were expected to identify different types of abuse that may occur against residents as part of the facility's abuse prevention strategy. The P&P indicated abuse of any kind is strictly prohibited (not allowed). The P&P indicated a type of abuse is resident to resident and includes, but not limited to hitting, slapping, biting, punching, or kicking. During a review of the facility's policy and procedure (P&P), titled Abuse Prevention Program, last reviewed 1/23/2025, the P&P indicated the facility's residents have the right to be free from abuse including mental and physical abuse. The P&P indicated the facility would protect residents from abuse by anyone including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. The P&P indicated the facility staff would require staff training/orientation for abuse prevention, identification and reporting of abuse, stress management and handling of verbal or physically aggressive resident behavior. The P&P indicated the facility would implement (put into place) measures to address factors that may lead to abusive situation including helping staff to understand how cultural, religious, and ethnic (a group of people who share a common cultural background, which can include things like their language, traditions, ancestry, religion, or way of life, often passed down through generations) can lead to misunderstandings and conflict.

Based on observation, interview, and record review the facility failed to supervise two of three residents (Resident 1 and Resident 2) by failing to: -Ensure Certified Nursing Assistant 2 (CNA2) notified Registered Nurse 2 (RN2) that Resident 1 was agitated (to be visibly worried, upset, or restless, often showing this feeling through your movements or voice, like fidgeting or speaking in a tense way) when CNA1 did not allow Resident 1 to go smoke on 9/9/2025 at approximately 1AM. -Ensure Resident 2 did not hit Resident 1 who was blind on the left jaw (the lower part of the face below the mouth) on 9/9/2025 at 1AM. -Ensure Resident 1 and Resident 2 had adequate supervision to prevent Resident 2 from hitting Resident 1 on his jaw. On 9/9/2025 at approximately 1AM, Resident 1 wanted to go smoke and CNA2 told Resident 1 to sit down. Resident 1 became agitated Resident 2 thought Resident 1would hit CNA2 and Resident 2 hit Resident 1 on Resident 1's left jaw. As a result, on 9/9/2025 at 1AM Resident 2 hit Resident 1 on the jaw causing Resident 1 to experience pain in the jaw and required an x-ray (medical imaging that uses radiation to take pictures of the inside of your body). Findings: 1.During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 7/26/2025 and readmitted Resident 1 on 8/26/2025 with diagnoses of lack of coordination, blindness of both eyes, schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's History and Physical (H&P), dated 7/26/2025, the H&P indicated Resident 1 had no capacity (ability) for decision-making. The H&P indicated Resident 1 had a history of nicotine dependence (your brain and body rely on nicotine from tobacco or vaping products to feel normal and avoid withdrawal). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/2/2025, the MDS indicated Resident 1 had the ability to make himself (Resident 1) understood, and had the ability to understand others. During a review of Resident 1's Care Plan Report dated 8/12/2025, the Care Plan Report indicated the CNAs (in general) would monitor Resident1 for unsafe smoking practices. The Care Plan Report indicated the CNAs (in general) would notify the charge nurse immediately if it was suspected Resident 1 violated the facility's smoking policy. During a review of Resident 1's Progress Note dated 9/9/2025 at 1 AM, the Progress Note indicated Resident 1 became agitated and Resident 2 hit Resident 1 because Resident 2 believed Resident 1 was going to hit the sitter (CNA2). The Progress Note indicated Resident 2's hand landed on Resident 1's jaw. The Progress Note indicated the facility staff (unidentified) separated Resident 1 and Resident 2. During a review of Resident 1's Progress Note, dated 9/9/2025 at 2:59 AM, the Progress Note indicated Resident 1 became agitated around 1 to 1:15 AM on 9/9/2025 and stood up from the bed. The Progress Note indicated the sitter (CNA2) approached Resident 1 and tried to calm Resident 1 down. The Progress Note indicated Resident 2 moved from his bed to his wheelchair and swung his hand and hit Resident 1 on the jaw. The Progress note indicated a Registered Nurse (RN2) and Charge Nurse (LVN2) separated Resident 1 and Resident 2 with the help of the sitter (CNA2). The Progress Note indicated Resident 2 was later moved (unknown time) to another room. The Progress Note indicated Resident 1 wanted to smoke and the RN (RN2) explained to Resident 1 the facility's designated smoking times. During a review of Resident 1's Radiology (the medical specialty that uses imaging techniques, such as X-rays) Results Report, dated 9/9/2025 at 2:15 PM, indicated the reason for the study was jaw pain and the results of the x-ray was no fracture (broken bone). During a review of Resident 1's Progress Note, dated 9/12/2025 at 3:57 PM, the Progress Note indicated the Interdisciplinary Team (IDT - group of people from different professions who work together by sharing knowledge and methods to solve a complex problem) met to discuss what happened on 9/9/2025 when Resident 2 hit Resident 1. The Progress Note indicated Resident 1 wanted to go to the smoking patio around 1 AM (date not indicated) and the sitter told Resident 1 it was not time for smoking. The Progress Note indicated Resident 2 shouted at Resident 1, kneeled on his (Resident 2) wheelchair, wheeled himself (Resident 2) toward Resident 1 and struck (hit) him (Resident 1) on the left jaw with his (Resident 2) right hand. The Progress Note indicated Resident 2 believed Resident 1 had struck the sitter and that Resident 2 felt he had a sense of duty to intervene (step in) in defense of the sitter because he (Resident 2) believed a man (in general) should hit a woman (in general). 2.During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 7/2/2025 and readmitted Resident 2 on 7/29/2025 with diagnoses of type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), blindness in the left eye, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's H&P dated 7/3/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to make himself (Resident 2) understood and had the ability to understand others. 3.During a revied of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 6/12/2025, and readmitted Resident 3 on 8/31/2025 with diagnoses of unsteadiness on feet, and displaced intertrochanteric fracture of right femur (a severe break in the upper part of your right thigh bone that caused the broken pieces to shift out of their correct position). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had the ability to make himself (Resident 3) understood and usually had the ability to understand others. During a review of Resident 3's H&P, dated 7/29/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decision. During an interview on 9/16/2025 at 10:53 AM with Resident 1 in Resident 1's room, Resident 1 stated Resident 2 hit him on the face last week (exact date not known). Resident 1 stated Resident 2 told him to shut up and stated he (Resident 1) did not know why Resident 2 hit him (Resident 1). Resident 1 stated he (Resident 2) just hit me. Resident 1 stated he (Resident 1) was blind and knew it was Resident 2 who hit him because he (Resident 1) recognized Resident 2's voice. Resident 1 stated he (Resident1) was angry at Resident 2 for hitting him (Resident 1). During an interview on 9/16/2025 at 11:42 AM with Resident 2 in Resident 2's room, Resident 2 stated he (Resident 2) heard the CNA (CNA, unidentified) told Resident 1 to sit down because Resident 1 was going to fall. Resident 2 stated he (Resident 2) saw Resident 1 get up and the CNA (unidentified female) stood in front of Resident 1. Resident 2 stated he (Resident 2) saw Resident 1 make threats and pushed the CNA (unidentified female). Resident 2 stated he (Resident 2) saw Resident 1 make a fist to hit the CNA (unidentified female) so he (Resident 2) got on his wheelchair by placing his knees on the seat of the wheelchair facing the back of the wheelchair and wheeled himself backwards in the wheelchair toward Resident 1. Resident 2 stated he (Resident 2) hit Resident 1 because I had to hit him (Resident 1). Resident 2 stated he (Resident 2) deliberately hit Resident 1 because his (Resident 1) behavior warranted him (Resident 2) to hit Resident 1. Resident 2 stated the incident began when Resident 1 wanted to smoke early in the morning (unknown date). Resident 2 stated he hit Resident 1 because he (Resident 2) was brought up to protect women referring to the female CNA (undentified) who was trying to prevent Resident 1 from falling. During an interview on 9/16/2025 at 12:04 PM with LVN 1, LVN 1 stated he (LVN1) received a report from the night charge nurse (LVN 2) during the morning shift change on 9/9/2025. LVN 1 stated LVN 2 reported an incident between Resident 1 and Resident 2. LVN 1 stated LVN 2 reported Resident 1 had been agitated because he (Resident 1) wanted to smoke outside of the facility's designated smoking hours. LVN 1 stated Resident 1 and Resident 2 were in a room with a sitter (CNA2) in the Resident 1 and Resident 2's room because Resident 1 and Resident 2 were at risk for a fall. During an interview on 9/16/2025 at 12:28 PM with the Director of Nursing (DON) and Director of Staff Development (DSD), the DON stated she (DON) received a call from the facility on 9/9/2025 approximately between 1:30AM and 2 AM. The DON stated she (DON) interviewed LVN 2 and RN 2 over the phone. The DON and the DSD stated the incident began when Resident 1 wanted to smoke outside of the facility's designated (officially chosen) smoking hours which were from 9 AM to 8:30 PM daily. The DON stated Resident 2 reported he (Resident 2) wanted to protect CNA 2 from Resident 1 who was agitated after CNA 2 tried to educate Resident 1 about the facility's smoking hours. The DON stated Resident 1 attempted to get up and CNA 2 positioned herself (CNA 2) to prevent Resident 1 from falling. During an interview on 9/16/2025 at 12:56 PM with CNA 2, CNA 2 stated Resident 1 wanted to smoke in the early morning of 9/9/2025 and she (CNA2) tried to get out of bed. CNA 2 stated Resident 1 was blind and at risk for falling so CNA 2 tried to keep Resident 1 from getting up. CNA 2 stated Resident 2 thought Resident 1 was going to hit her (CNA 2). CNA 2 stated Resident 2 got up, and CNA 2 called for help. CNA 2 stated Resident 2 then hit Resident 1. During an interview on 9/16/2025 at 1:24 PM with Resident 3, Resident 3 stated he (Resident 3) was awake on the night when Resident 2 hit Resident 1. Resident 3 stated Resident 1 had been very rough with the staff and Resident 1 had been aggressive. During an interview on 9/16/2025 at 1:35 PM with LVN 2, LVN 2 stated he (LVN2) was the Charge Nurse on the night/early morning of 9/9/2025. LVN 2 stated he (LVN2) heard a call for help and went to the room where Resident 1 and Resident 2 were located. LVN 2 stated CNA 2 tried to keep Resident 1 from falling. LVN 2 stated he (LVN2) saw Resident 2 hit Resident 1 on 9/9/2025 approximately 1 AM in the morning. During an interview on 9/16/2025 at 1:44 PM with RN 2, RN 2 stated he (RN2) heard a commotion (a sudden, noisy, and confusing burst of activity) coming from Resident 1 and Resident 2's room and he (RN2) went to investigate. RN 2 stated he (RN2) observed CNA 2 positioned between Resident 1 and Resident 2. RN 2 stated Resident 1 was agitated because he (Resident 1) wanted to smoke. RN 2 stated he (RN2) gave Resident 1 Tylenol (over-the-counter medicine that relieves mild to moderate pain and reduces fever) because Resident 1 complained of an aching jaw pain that was rated at 3 out of 10 (mild pain [0 means no pain and 10 means having the worst pain]). During a review of the facility's policy and procedure (P&P), titled Identifying Types of Abuse, last reviewed 1/23/2025, the P&P indicated the facility's employees were expected to identify different types of abuse that may occur against residents as part of the facility's abuse prevention strategy. The P&P indicated abuse of any kind is strictly prohibited (not allowed). The P&P indicated a type of abuse is resident to resident and includes, but not limited to hitting, slapping, biting, punching, or kicking. During a review of the facility's policy and procedure (P&P), titled Abuse Prevention Program, last reviewed 1/23/2025, the P&P indicated the facility's residents have the right to be free from abuse including mental and physical abuse. The P&P indicated the facility would protect residents from abuse by anyone including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. The P&P indicated the facility staff would require staff training/orientation for abuse prevention, identification and reporting of abuse, stress management and handling of verbal or physically aggressive resident behavior. The P&P indicated the facility would implement (put into place) measures to address factors that may lead to abusive situation including helping staff to understand how cultural, religious, and ethnic (a group of people who share a common cultural background, which can include things like their language, traditions, ancestry, religion, or way of life, often passed down through generations) can lead to misunderstandings and conflict.

Based on interview and record review the facility failed to implement the care plan interventions to prevent falls for one of three sampled residents (Resident 1). For Resident 1, the facility failed to anticipate Resident 1 ' s needs during transfer from the toilet to the wheelchair on 2/19/25. This deficient practice resulted in Resident 1 sliding off the wheelchair and fell to the floor. Resident 1 had the potential to sustain injury because of the fall. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 1/9/25 and re-admitted on [DATE] with diagnoses including abnormalities of gait and mobility, lack of coordination and need for assistance with personal care. During a review of Resident 1 ' s Care Plan initiated on 1/9/25 indicated Resident 1 was at risk for falls related to history of falling, impaired gait/balance. The Care Plan goal indicated Resident 1 will minimize risk of falls or injuries for 90 days. The care plan interventions included adapt environment to meet the resident ' s safety needs, anticipate and meet the residents needs and assist will all transfers or ambulation. During a review of the Minimum Data Set (MDS, a resident assessment tool dated) 1/16/25 indicated Resident 1 was cognitively intact. Resident 1 needed substantial assistance (helper does more than half the effort) with sit to stand, chair/bed-to-chair transfer and toilet transfer. During a review of the Fall Risk assessment dated [DATE] at 7:40 a.m., indicated Resident 1 was wheelchair bound and needed assistance with elimination. The Assessment indicated Resident 1 was high risk for fall. During a review of the Change in Condition dated 2/19/25 at 4 a.m., indicated Resident 1 fell from the wheelchair while coming out of the bathroom on 2/19/25. Resident 1 stated the certified nursing assistant (CNA) did not handle the wheelchair properly and was rough. The notes indicated Resident 1 had no injury. The primary physician was notified and gave order for X-ray of the left shoulder, bilateral elbows and left hip. During a review of the x-ray result dated 2/20/25 at 3:32 p.m., indicated Resident 1 had no injuries. During a review of the Interdisciplinary Risk Management Review Note dated 2/21/25 at 3:36 p.m., indicated Resident 1 had a witnessed fall on 2/19/25. The Note indicated Resident 1 was not properly positioned in the wheelchair .while being pushed in wheelchair which cause her (Resident 1) to slide off and land on the floor. During a concurrent interview on 6/17/25 at 10:09 a.m., Resident 1 ' s fall incident dated 2/19/25 was reviewed with licensed vocational nurse (LVN 1). LVN 1 stated on 2/19/25, Resident 1 was in the bathroom and was assisted from the toilet to the wheelchair by the CNA. LVN 1 stated Resident 1 was not properly positioned in the wheelchair and when CNA pushed the wheelchair out of the bathroom, Resident 1 slide off the wheelchair and fell to the floor. LVN 1 stated Resident 1 ' s primary physician was notified and gave order for x-ray of the shoulder, elbow and hips. LVN 1 stated Resident 1 should be seated properly in the wheelchair .with her back all the way to the back of the wheelchair. LVN 1 stated Resident 1 had no injuries. During an interview on 6/17/25 at 12:10 p.m., the director of nursing (DON) stated on 2/19/25, Resident 1 was transferred from the toilet to the wheelchair. Resident 1 was sitting close to the edge of the seat of the wheelchair, slid off and fell on the floor. DON stated the CNA should have fixed how Resident 1 was sitting in the wheelchair. During a review of the facility's policy and procedures titled Safety and Supervision of Residents reviewed on 1/23/25, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. The Policy indicated the individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The same Policy indicated implementing interventions to reduce accident risks and hazards included providing training as necessary and ensuring that interventions are implemented. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered reviewed on 1/23/25, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interview and record review, the facility failed to identify and ensure one of three closed record residents (Resident 75), who had an amputation site (surgical removal of part of the body, left lower leg), acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body), and a right lateral malleous (bony projection of the ankle) with arterial ulcer (injury to skin or underlying tissue caused by poor circulation, which in turn was caused by arterial insufficiency [reduced blood flow by the artery]) on the right lower leg, received necessary care and services in accordance with professional standards of practice by failing to: -Assess upon admission or on [DATE], and document the condition, description, and measurements of Resident 75's right lateral malleous arterial ulcer of the right lower leg, as documented on the Admission Data Collection form dated [DATE]. -Develop a comprehensive and person-centered Care Plan to include the Physician's Order for treatment to Resident 75's right lateral malleous arterial ulcer. - Follow the Physician's Order for treatment to Resident 75's right lateral malleous lower leg arterial ulcer (a painful, deep sore or wound in the skin of the lower leg or foot), cleanse with normal saline (a mixture of sodium chloride [salt] and water), pat dry, apply Medi honey (supports the removal of necrotic tissue and aids in wound healing), cover with dry dressing, every day shift for 21 days. -Assess respiratory status for accurate rate of oxygen administration and monitor Resident 75 for any changes in condition (shortness of breath), per the Continuous Oxygen Therapy care plan developed on [DATE]. As a result, Resident 75 did not receive treatment to the right lateral malleous arterial ulcer of the right lower leg for over two weeks and was transferred to General Acute Care Hospital (GACH) 2 for altered level of consciousness (ALOC, resident is not as awake, alert, or able to understand or react to the surrounding environment). At the GACH 2, Resident 75 complained of shortness of breath, required four liters per minute of oxygen via nasal cannula (NC, a device that gives you additional [supplemental] oxygen through your nose) with 92% oxygen saturation (amount of oxygen traveling through the body in your red blood cells, normal oxygen saturation for a healthy adult between 95% and 100%) and complained of right ankle pain. The GACH 2 Emergency Department Note dated [DATE], indicated Resident 75 developed soft tissue ulceration (formation of a break on the skin or on the surface of an organ) overlying the side of the smaller thinner calf bone (lateral malleous) with underlying osteomyelitis (inflammation or swelling of bone tissue that is usually the result of an infection), abnormal accumulation of fluid in the pleural space (the cavity between the lungs and chest wall) with pulmonary edema (fluid builds up in the lungs) and adjacent atelectasis (collapse of the whole lung or an area of the lung). Resident 75 died three days later on [DATE]. Findings: A review of General Acute Care Hospital (GACH) 1 Hospitalist Progress Note dated [DATE], indicated Resident 75 was status post cardiac arrest (heart attack) and received two thoracenteses (procedure to remove fluid or air from around the lungs) with the last procedure on [DATE]. The GACH 1 progress note indicated Resident 75 was on three antibiotics for a diabetic infection of the left foot with questionable osteomyelitis (bone infection). A review of Resident 75's GACH 1 Complex Case Manager Note dated [DATE], indicated the resident needed placement for physical therapy and wound care at the amputation site (surgical removal of part of the body, left lower leg). The note indicated Resident 75 should be able to return home with the help of family when independent. A review of Resident 75's GACH 1 Physician's Transfer Orders form dated [DATE], indicated the resident had hypoxia (oxygen levels in the blood are lower than normal) when sleeping and required oxygen at two liters per minute when awake during the daytime. The Transfer Orders indicated the resident was not on antibiotics during to the transfer. According to a review of the Admission Record to the facility Resident 75 was admitted on [DATE], with diagnoses including non-pressure chronic ulcer of the right lower leg (caused by poor circulation, which in turn was caused by venous or arterial insufficiency), after care following surgical amputation of the left lower leg and acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body). A review of Resident 75's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated [DATE], indicated Resident 75's cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment) was dependent on facility staff with showering and transfers. The MDS indicated Resident 75 had one arterial ulcer (right leg), a surgical wound with application of nonsurgical dressings (left leg amputation) and required oxygen therapy. A review of Resident 75's Admission Data Collection form documented by the Admission Nurse dated [DATE], indicated Resident 75 had clear lung sounds, no shortness of breath, and had 98% oxygen saturation on room air. The Admission Data Collection form indicated the resident was not on antibiotics, was a full code (if a person's heart stopped beating and/or they stopped breathing, all procedures would be provided to keep them alive), and had a right ankle diabetic ulcer. The Admission Data Collection form did not indicate Resident 75's right lateral malleous with arterial ulcer to the lower right leg. A review of the Physician's Order dated [DATE], indicated for Resident 75 to receive treatment on the right lateral malleous with arterial ulcer (a painful, deep sore or wound in the skin of the lower leg or foot), cleanse with normal saline (a mixture of sodium chloride [salt] and water), pat dry, apply Medi honey (supports the removal of necrotic tissue and aids in wound healing), cover with dry dressing, every day shift for 21 days. According to a review of Resident 75's Treatment Administration Record (TAR), Resident 75 received treatment to the right lateral malleous with arterial ulcer on [DATE]. Further review of the TAR indicated the resident did not receive the Physician's Ordered treatment from ,d+[DATE] to [DATE] (14 days). A review of Resident 75's History and Physical (H&P) dated [DATE], indicated Resident 75 had the capacity to understand and make decisions. A review of the Physician's Order dated [DATE], indicated Resident 75 was to receive oxygen at two liters per minute via NC continuously. May titrate up to three liters per minute, every shift for hypoxemic respiratory failure. A review of Resident 75's Admission Data Collection Form documented by the Treatment Nurse (Licensed Vocational Nurse 8) dated [DATE], indicated a head-to-toe assessment was completed, four days after admission. The form indicated the resident denied pain, wound care was rendered (but there was no indication of the location of the wound) and tolerated well. The Admission Data Collection form indicated the resident had a left below the knee amputation (BKA) with staples and a skin abrasion (the surface layers of the skin [epidermis] has been broken) on the left flank (space between the lowest rib and hip). The Admission Data Collection form documented by the Treatment Nurse did not indicate a right ankle diabetic ulcer on the Admission Data Collection form dated [DATE] documented by the Admission Nurse, nor did it indicate the condition, description, or any measurements of the right lateral malleous with arterial ulcer to the lower right leg. A review of a care plan dated [DATE] indicated Resident 75 wanted to return the the community. The care plan intervention indicated to assess discharge plan needs with the resident and Interdisciplinary Team members. According to a review of Resident 75's Continuous Oxygen Therapy care plan developed on [DATE], for the resident's acute respiratory failure with hypoxia, the goal indicated for the resident to have no signs or symptoms of poor oxygen absorption. The care plan interventions indicated to monitor for signs and symptoms of respiratory distress and assess respiratory status for rate, depth, and ease and report to the doctor. A review of Medication Administration Record (MAR) dated [DATE] indicated Resident 75 received two liters of oxygen via nasal cannula and on the evening shift the resident's oxygen saturation was 98%, but the oxygen inhalation section indicated 96%. The MAR dated [DATE] indicated on the morning shift Resident 75's oxygen saturation was 98% but the oxygen inhalation was 96% and during the night shift (same date) the oxygen saturation was 98% and oxygen inhalation was 97%. This indicated discrepancies in the monitoring of the resident's respiratory status. A review of Resident 75's At Risk for Skin Breakdown care plan developed on [DATE] (almost three weeks after admission), for the resident's right lower leg with scattered arterial ulcers, had a goal for the resident to minimize the risk of skin breakdown every day. The care plan interventions indicated handling the resident gently during care, keep skin clean, dry, and comfortable at all times, and report any redness or open area. The care plan did not include the Physician's Order to provide treatment every day for 21 days to the right lateral malleous with arterial ulcer of the resident's right lower leg. A review of Resident 75's Social Services Note dated [DATE], indicated discharge planning was in progress with the resident's family member and the discharge plan was to go to a lower level of care. A review of Resident 75's Weekly Wound Note dated [DATE], indicated the resident's right lateral malleous with arterial ulcer of the resident's right lower leg had scant amount of serosanguineous (contains both blood and liquid part of blood [serum]) exudate (fluid that leaks out of blood vessels into nearby tissues), the surrounding skin condition was normal, and not painful. The Weekly Wound Note indicated all needs were attended to and there were no signs or symptoms of infection. According to a review of the TAR dated [DATE], Resident 75's right lateral malleous with arterial ulcer of the resident's right lower leg was provided treatment. This indicated the resident did not receive treatment for the arterial ulcer for over one month, as the last treatment documented was [DATE]. Further review of the TAR indicated Resident 75 did not receive the Physician's Ordered treatment from [DATE] to [DATE]. A review of Resident 75's Weekly Wound Note dated [DATE], indicated the resident's right lateral malleous with arterial ulcer of the resident's right lower leg had scant amount of serosanguineous exudate, the surrounding skin condition was fragile (which indicated a change). The Weekly Wound Note indicated all needs were attended to and there were no signs or symptoms of infection. A review of the MAR dated [DATE] for the morning shift indicated there was no documentation regarding Resident 75's oxygen saturation. For the afternoon shift the MAR indicated the resident received oxygen at two liters per minute, the oxygen saturation was 97% and under oxygen inhalation was 98%. A review of Resident 75's Nursing Progress Note dated [DATE] at 11:05 AM, indicated the resident was alert and oriented, did not have signs or symptoms of acute distress or pain, and the resident's vital signs were within normal limits. The Nursing Progress Note indicated the resident was receiving oxygen via NC (with no documentation regarding the amount of oxygen administered to the resident) and the oxygen saturation was 97%. A review of the Change of Condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, or functional abilities) Record dated [DATE] at 8:15 PM, indicated Resident 75 was found on the floor in a supine position (lying on the back or with the face upward). The COC indicated the resident did not have shortness of breath and was on continuous oxygen. The COC indicated under the vital signs portion the resident had an oxygen saturation of 97% and was on room air. The COC indicated at 8:25 PM, Resident 75 was noted with altered level of consciousness (the resident is not as awake, alert, or able to understand or react to the surrounding environment) and the facility obtained doctor's orders to send the resident out for a computerized tomography scan (CT, diagnostic imaging procedure to produce images of the inside of the body) of the head. According to a review of the Physician's Order dated [DATE], Resident 75 was to be transferred to the GACH due to altered level of consciousness. A review of the GACH 2 Emergency Department Note dated [DATE], indicated Resident 75 presented with cough, congestion and required four liters per minute of oxygen via NC at baseline (this indicated the facility should have given the resident four liter of oxygen continuously). The ED Note indicated an x-ray of the chest was done with findings including bilateral pleural effusions (abnormal accumulation of fluid in the pleural space) with pulmonary edema and adjacent atelectasis (collapse of the whole lung or an area of the lung). The note indicated an x-ray of the right ankle was done with findings including soft tissue ulceration (formation of a break on the skin or on the surface of an organ) overlying the lateral malleous (the bone on the outside of the fibula) with underlying lateral malleous osteomyelitis. A review of Resident 75's GACH 2 H&P Note dated [DATE], indicated the resident complained of shortness of breath required four liters of oxygen via NC with 92% oxygen saturation and complained of right ankle pain due to osteomyelitis. A review of Resident 75's GACH 2 Discharge Summary Note dated [DATE], indicated the resident was admitted to GACH 2 with shortness of breath and right ankle pain. The Note indicated a diagnoses of acute respiratory failure with hypoxia, severe bilateral pleural effusion, and chronic osteomyelitis. The note indicated the resident expired (the last emission of breath, death) on [DATE] (three days after transfer from the facility). During a concurrent interview and record review, on [DATE] at 11:58 AM with the Quality Assurance (QA) Nurse, Resident 75's Physician's Order Report dated [DATE] was reviewed. The QA Nurse stated the treatment order for the resident's right lateral malleous with arterial ulcer of the resident's right lower leg should have been clarified with the physician. The QA Nurse stated instead of the treatment order indicating every 21 days for 21 days, the order should have indicated every day for 21 days. During a review of Resident 75's Admission Data Collection Form dated [DATE], the QA Nurse stated the licensed nurse did not perform an accurate assessment for Resident 75 and was missing some assessments on the form. The QA Nurse stated there was no admission assessment regarding Resident 75's right lateral malleous with arterial ulcer of the resident's right lower leg. During a concurrent interview and record review, on [DATE] at 12 PM, a review of Resident 75's TAR dated [DATE] and [DATE] were reviewed. The QA Nurse stated the first treatment for the right lateral malleous with arterial ulcer of the resident's right lower leg given to Resident 75 was on [DATE] and no other treatment was provided for the remainder of the month. The QA Nurse stated if the treatment was not documented then the treatment was not provided, and based on the TAR, the treatment was not given to Resident 75. The QA Nurse stated treatment for the month of April was documented on [DATE] and not documented on any other day. The QA Nurse stated the TAR looked like the staff was providing treatment every 21 days. During an interview on [DATE] at 12:16 PM, when asked about the importance of Resident 75's care plan for the right lateral malleous with arterial ulcer of the resident's right lower leg, the Director of Nursing (DON) stated the purpose of the care plan was to identify Resident 75's wounds and identify interventions for those wounds. The DON stated if the care plan was not initiated upon admission, the facility could not show what interventions were carried out for each wound, and the outcome could result in the resident having an infection. On [DATE] at 12:45 PM, during an interview, when asked about the Physician's Order for Resident 75's treatment of the right lateral malleous with arterial ulcer of the resident's right lower leg, the Medical Director (MD) stated the treatment order should have been clarified with the physician because the facility follows a protocol when writing orders. The MD stated instead of the treatment order indicating every 21 days for 21 days, the order should have indicated every day for 21 days. During a concurrent interview and record review on [DATE] at 3:17 PM with LVN 4, Resident 75's Physician's Order Report dated [DATE] was reviewed. LVN 4 stated the protocol was to provide treatment every day and the facility staff would re-evaluate on the 21st day. LVN 4 stated the frequency, and the schedule type was incorrect on the order and the order should have been clarified with the physician. During a review of Resident 75's TAR, dated [DATE] and [DATE], LVN 4 stated if the treatment was not documented, then the treatment was not done. LVN 4 stated, It was not okay that the treatment was not provided, as this could cause Resident 75's wound to get worse or infected and could cause pain. During an interview on [DATE] at 3:48 PM, the MD stated the treatment for osteomyelitis was six weeks of antibiotics unless the source of the osteomyelitis was known. The MD stated for Resident 75 the osteomyelitis was in the left leg and that was why the resident underwent a BKA. The MD stated after surgery, if there were no complications, then antibiotics would not be needed and that was why Resident 75 was not transferred to the facility with antibiotic orders. The MD stated once the infection was gone, the treatment was to discontinue antibiotics and let the resident heal. During an interview on [DATE], with LVN 8 (treatment nurse) who completed Resident 75's Admission Data Collection Form on [DATE], stated upon admission Resident 75 had scattered ulcers, and a lateral malleous arterial ulcer to the right lower leg. LVN 8 stated the resident's right lower leg ulcers were not documented on the Admission Assessment completed by LVN 8 and was not an accurate assessment because the Admission Data Collection Form did not reflect all of Resident 75's wounds. When asked about the Physician's Order for Resident 75's treatment, LVN 8 stated the Physician's Order was incorrect, as LVN 8 obtained the order from the MD and stated the order was inputted incorrectly. LVN 8 stated it was important to clarify the physician's orders and if the resident did not receive the treatment as ordered, the resident was at risk for infection. A review of the facility's undated policy and procedures (P&P) titled, Admission Assessment and Follow Up: Role of the Nurse, indicated steps to conduct an admission assessment include a list of active medical diagnoses and patient problems, especially those most related to reasons for admission to the facility and those affecting function, quality of life, ability to participate in activities, and to socialize. The policy indicated to include current medications and treatment, to reconcile the list of medications from the medications history, admitting orders, and the previous MAR from previous institution according to established procedures. The policy indicated to contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. A review of the facility's undated P&P titled, Care Plans, Comprehensive Person-Centered, indicated the interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The policy indicated the care plan interventions were chosen only after gathering proper sequencing of events, careful consideration of the relationship between the residents problem areas and their causes, and relevant clinical decision making. The policy indicated when possible, interventions address the underlying source of the problem area, not just symptoms or triggers. A review of the facility's P&P titled, Treatment Nurse - LVN Job Description, dated [DATE], indicated to provide treatment and therapeutic services per the physician's orders and to meet with and solicits advice from the Medical Director, DON, and wound care consultants concerning care of residents.

Based on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had dementia (loss of memory, thinking and reasoning), had a history of fall, and was a high risk for falls, received care and services to prevent falls and injuries. The facility failed to: -Complete an accurate Fall Risk Assessment upon admission on [DATE], to identify underlying medical conditions that may increase the risk of injury from falls, per facility policy titled Fall Risk Assessment. -Develop and implement a care plan for Resident 1's unsafe behavior in his attempts to be independent beyond his abilities and his noncompliance to use the call light. -Notify the physician of Resident 1's fall on [DATE], including the change of condition of mostly sleeping and not eating. -Implement the facility's policy and procedure titled, Assessing Falls and Their Causes to evaluate for possible injuries (after Resident 1's fall on [DATE]), notify the physician, and observe for possible complications of fall. As a result, on [DATE] (36 days after admission to the facility) at 1 AM, Resident 1 was found on the floor by Certified Nursing Assistant (CNA) 2, who placed the resident back in bed. On [DATE], at 5:15 PM, Resident 1 was in his wheelchair, pale and unresponsive, Cardiopulmonary Resuscitation (CPR, an emergency procedure to restore breathing and blood circulation) was initiated and 911 was called. The paramedics (a healthcare professional whose primary role is to provide advanced emergency medical care for critical and emergent residents or patients) announced Resident 1 dead at 5:40 PM on [DATE]. Findings: A review of the Admission Record (Face Sheet) indicated the facility admitted Resident 1 on [DATE], with diagnoses including fall, unsteadiness on feet, and dementia. Resident 1 was also diagnosed with dementia, [CONDITION(S)] (CHF- when heart cannot pump enough blood), diabetes mellitus (DM-when blood sugar is too high), and [CONDITION(S)] (HLP- an abnormally high fat in the blood). A review of the Fall Risk assessment dated [DATE], indicated Resident 1 had one - two falls in the past three months, was chair bound, and had a balance problem while standing and walking. The fall risk assessment indicated Resident 1 had a total score of nine and a score of 10 or greater indicated the resident should be considered a high risk for potential falls. A review of Care Plan for Falls dated [DATE] indicated Resident 1 was at risk for falls and injuries related to poor balance, unsteady gait, history of falls, poor safety awareness, and dementia. The care plan interventions indicated to maintain supervision and vigilance at all possible times, monitor for sedation (a state of calm or sleep), dizziness, unsteady standing and sitting balance, encourage resident to call for assistance before attempting to transfer or ambulate if able, and follow facility fall protocol. The care plan did not indicate a floor mat. A review of the Physical Therapy (PT) Evaluation and Plan of Treatment dated [DATE], indicated Resident 1 presented to the hospital after being found down by his neighbor sustaining an unwitnessed fall in his home. The evaluation indicated Resident 1 felt unsteady while standing or walking, and worried about falling. The evaluation summary indicated Resident 1 was at risk for decreased ability to return to prior living environment, at risk for falls, further decline in function, and limited out of bed activities. According to a review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated [DATE], Resident 1 had mildly impaired cognition (trouble remembering, learning new things, or making decisions) and required extensive assistance with one person assist for transfer, bed mobility, walk in room, walk in corridor and toilet use. A review of Resident 1's Interdisciplinary Team (IDT) Review dated [DATE] at 4:10 PM, indicated the IDT met with Resident 1 at his bedside regarding an unwitnessed fall incident on [DATE]. Resident 1 reported to Licensed Vocational Nurse 2 (LVN2) that he had a fall, and stated, I tried to stand from the bed, and I fell and landed on my right side. Resident 1 complained of pain on his right ribs and bilateral (both sides) shoulders. The IDT review notes indicated Resident 1 was a new admit, had difficulty adjusting to new environment, needed reinforcement with use of call light for assistance, and had unsafe behavior by attempting independence beyond his ability. A review of Resident 1's Medical Record indicated there was no care plan initiated regarding the resident's unsafe behavior in his attempts to be independent beyond his abilities nor his noncompliance to use the call light. A review of the Post Fall Risk assessment dated [DATE], indicated Resident 1 was chair bound, had a balance problem while standing and walking, had decreased muscular coordination, required use of assistive devices, and was on antihypertensive (medication to reduce high blood pressure), hypoglycemic (medication to reduce high blood sugar), and [CONDITION(S)] (medication that affect mental state) medications. The fall risk assessment indicated Resident 1 had a total score of 14 and should be considered a high risk for potential falls. A review of the Order Administration Note dated [DATE], indicated Resident 1 complained of pain on both shoulders and the right side of the rib area. The pain was rated at ,d+[DATE] (pain rating scale from zero to ten, zero indicating no pain, 10 indicating the worst pain possible pain). According to a review of Resident 1's Medication Administration Record (MAR) [DATE] timed at 7:35 AM., [MEDICATION(S)] ([MEDICATION(S)] Acetaminophen- a controlled drug used to relieve moderate to severe pain) ,d+[DATE] milligrams (mg) was administered to Resident 1. A review of the Nursing Progress Notes dated [DATE] indicated Resident 1 was awake, alert to self, and had extreme reality disorientation and confusion. A review of the Order Administration Note dated [DATE] at 4:48 AM, indicated Resident 1 complained of body pain rated at an eight. The note indicated non-pharmacological interventions (non-medication interventions) were ineffective and [MEDICATION(S)] ,d+[DATE] mg was administered. A review of Change of Condition (COC) note dated [DATE] indicated around dinner time, Resident 1 was observed in the hallway sitting in his wheelchair next to his room, with his head down. The notes indicated Resident 1 did not respond when questioned, then tactile stimuli (activation of sensory receptor by a touch stimulus) was rendered via chest rub. Resident 1 remained unresponsive. The COC notes indicated a code blue (an emergency code used to describe the critical status of a patient) was announced and 911 was called. Before 911 arrived, Resident 1 became coherent and verbally responsive. Further review of the COC notes indicated Resident 1 did not require hospital transfer. A review of the Care Plan dated [DATE] indicated Resident 1 appeared passed out in the hallway and when assessed had elevated blood pressure. A review of the Nursing Progress Notes dated [DATE] indicated Resident 1 was in bed, arousable, stable with no distress, and no complaints of pain. A review of Resident 1's Orders-Administration Notes dated [DATE] at 1:13 AM by LVN 1 indicated Certified Nurse Assistant 2 (CNA2) reported that Resident 1 was in his room, laying on pillows and blankets on the floor, as if he slid off the bed. CNA2 assisted Resident 1 back to his bed. A review of the Medical Records indicated there was no documentation or evaluation of Resident 1's injuries from the fall on [DATE]. In addition, there was no notification to Resident 1's physician regarding the fall, and no monitoring was conducted after Resident 1's fall on [DATE]. Further review of the medical records indicated there was no Post Fall Risk Assessment completed for Resident 1 and his fall risk care plan was not revised. A review of Resident 1's Nursing Progress Note dated [DATE], indicated at 5:15 PM, CNA4 was preparing dinner for Resident 1 and observed Resident 1 in his wheelchair, pale and sleeping. The note indicated Resident 1 was unresponsive and unable to be stimulated by tactile and verbal commands. A code blue was announced, CPR was initiated and 911 was called. Further review of the progress notes indicated at 5:40 PM, the paramedics announced Resident 1 dead. During an interview on [DATE] at 1:46 PM, the Director of Nursing (DON) stated, normally the charge nurses or RNs were required to assess the residents after fall and the licensed nurses were required to notify the physician. The DON stated it was required to initiate a Change of Condition (COC) form when a resident claimed a fall occurred or in the event of an unwitnessed fall. The DON stated in this instance, there was no COC created for Resident 1's fall on [DATE]. The DON stated there was no physician notification documented after Resident 1's fall and that after every fall, staff were required to start neuro-check and resident 72 hours of monitoring. The DON confirmed that a neuro-check and 72-hours monitoring were not performed for Resident 1. The DON stated LVN 1 was assigned to Resident 1 on [DATE] when the alleged incident occurred and LVN 1 failed to comply with post fall procedures. During a telephone interview with Registered Nurse Supervisor 3 (RN3) on [DATE] at 1:55 PM, RN3 stated that on [DATE] during the 3PM-11 PM shift, Resident 1 had an episode of unresponsiveness, and had high blood pressure of ,d+[DATE] mmHg (millimeters of mercury). RN3 stated Resident 1's physician was notified and issued new orders for lab work and medication for high blood pressure. RN3 stated Resident 1 was given dinner and that he was able to consume his food. During a telephone interview on [DATE] at 11:59 AM, CNA2 stated on [DATE] she was assigned to Resident 1 during 11PM - 7AM shift. CNA2 stated, At the beginning of my shift I went inside Resident 1's room, he was in his bed. I made his bed, and I left to assist other residents. CNA2 stated, I took a 10-minute break at 2 AM and another CNA came and asked me to check on Resident 1. When we both went inside his room, we saw Resident 1 on the floor. He was on top of the sheets and pillows. CNA2 stated, We assisted him back to his bed and made sure he was [MEDICATION(S)]. CNA2 stated she informed LVN 1 about the incident, and the next day when she returned to work, she learned Resident 1 had expired. On [DATE] at 10:18 AM, during an interview, the Quality Assurance Nurse (QA) stated, We were not aware of the resident's unwitnessed fall on [DATE]. The DON and I did not find out about it until the surveyor brought it to our attention. The QA stated LVN 1 did not communicate this incident sufficiently with the management. The QA stated, I am not sure if any licensed staff informed the resident's physician about this incident and usually it would be documented in COC the physician was notified. During an interview on [DATE] at 11:06 AM, CNA1 stated, On [DATE] (after the fall on ,d+[DATE]), I was assigned to the resident during the morning shift. The resident (Resident 1) slept all morning and woke up around 12 PM. He did not want to eat. The resident was sleepy and did not eat breakfast or lunch. CNA1 stated, I did not report the resident's poor appetite to any of the charge nurses that day. During an interview on [DATE] at 12:53 PM, the DON stated she was present in the facility on [DATE] when Resident 1 passed away. The DON stated, It was around 5 PM the code blue was announced in the facility, LVN3 had already started the CPR in the resident's room. The DON stated the paramedics arrived and continued CPR for another ,d+[DATE] minutes prior to announcing that Resident 1 had expired. During a telephone interview with CNA4 on [DATE] at 8:20 AM, CNA4 stated, On [DATE] I was working the 3 PM-11 PM shift and assigned to the resident (Resident 1). I asked the resident if he would like for me to change his briefs and he said no. CNA4 stated, The resident was on his wheelchair, and he was sleeping. When I started passing the dinner trays at 5 PM, I went to feed the resident, I could not wake him up to begin feeding. This was not normal, so I called LVN3 and RN3 right away. On [DATE] at 2:40 PM, during a telephone interview, the DON stated Resident 1's Fall Risk assessment dated [DATE] with score of nine was inaccurate. The DON stated Resident 1 was admitted to the facility with a personal wheelchair and the Fall Risk Assessment upon admitted d [DATE] did not acknowledge that Resident 1 had an assistive device. The DON stated if this fact was properly documented, Resident 1's fall risk score would have been identified as a 10, thereby finding Resident 1 as a high risk for fall. During a telephone interview with RN1 on [DATE] at 4:20 PM, RN1 stated, I called LVN1, and we both assessed the resident. We did not observe any skin injuries. After the assessment, I asked LVN1 to do the proper post fall documentations. RN1 stated all licensed nurses are required to follow post fall procedures and to complete Fall Risk Assessment and Change of Condition. Staff are required to contact the physician and responsible party, update plan of care, perform resident's Neuro-check and 72-hour monitoring and complete Pain Assessment. RN1 stated none of these procedures were performed after Resident 1's fall on [DATE]. During a telephone interview on [DATE] at 11:51 PM, the QA stated there was no care plan initiated as it relates to Resident 1's unsafe behavior in his attempts to be independent beyond his abilities and his noncompliance to use the call light. QA stated, We could have added a care plan for that behavior. During an interview with Director of Staff Development (DSD) on [DATE] at 12:21 PM, DSD stated LVN1's last day of work at the facility was on [DATE] during her night shift from 11PM-7AM. The DSD stated LVN1 refused to release her phone number to the facility, nor did she provide the registry consent to give her phone number to the facility. The DSD stated, On [DATE] when the resident (Resident 1) had an unwitnessed fall, I was not aware of it, and I was not notified about it. I tried to contact LVN1 several times through the registry and there was no response. The DSD stated the facility started to investigate regarding Resident 1's fall on [DATE] once it was brought to their attention by the surveyor. On [DATE] at 9:44 AM, during a telephone interview, LVN3 stated, I worked 16 hours on [DATE] and at 9 AM, I observed the resident (Resident 1) asleep and I had to wake him up in order to give him his medications. LVN3 stated that CNA1 informed her that Resident 1 did not eat breakfast but planned to eat at lunch. LVN3 stated Resident 1 in fact did not eat lunch either. LVN3 stated she did not contact Resident 1's physician regarding his lack of appetite on [DATE] and that, I should have informed my DON that the resident did not eat breakfast or lunch on [DATE]. During a telephone interview with Resident 1's Physician on [DATE] at 10:36 AM, the physician stated Resident 1 had baseline dementia, he was able to answer yes or no questions, but he was not able to make medical decisions. The physician stated he was not aware of Resident 1's fall that occurred on [DATE] and the facility's staff did not notify him about the fall. The physician stated he visited Resident 1 a couple of days prior to [DATE]. He received a call from the facility's staff on [DATE] reporting Resident 1's death. The physician stated, I was surprised since I just saw the resident a few days before his death. I have told the facility's staff they can call me anytime, even at 2 AM. Depending on the resident's condition after a fall, I would normally order neuro check and 72 hours monitoring. The physician stated in the event a resident hit his head during a fall, he must be transferred to hospital for further evaluation. The physician stated if a resident complained of pain after a fall, x-rays will be ordered, and staff did not notify him that Resident 1 refused to eat his breakfast and lunch and was sleepy on [DATE]. The During a telephone interview with Resident 1's physician on [DATE] at 9:06 AM, the physician stated staff failed to report Resident 1's change of condition for fall to him on [DATE]. The physician stated, I spoke to the facility's staff and I told them if you know a resident is a high risk for fall, put a floor mat next to them. The physician confirmed that Resident 1 did not have an order for floor mat. The physician stated, If I was notified about Resident 1's fall prior to his death, I would have ordered floor mats for him. A review of the facility's policy and procedure titled, Assessing Falls and Their Causes, revised on ,d+[DATE], indicated the purpose of this procedure was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of fall. If a resident had just fallen or was found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. Obtain and record vital signs as soon as it is safe to do so. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. The policy indicated to notify the resident's attending physician and family in an appropriate time frame. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall and will document findings in the medical record. Document any observed signs and symptoms of pain, swelling, bruising, deformity and/or decreased mobility, and any change in level of responsiveness / consciousness and over all function. Note the presence or absence of significant changes. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services. When a resident falls the following information should be recorded in the resident`s medical record: Assessment data, including vital signs and any obvious injuries, notification of physician and family as indicated, completion of fall risk assessment, appropriate interventions taken to prevent future falls. A review of the facility's policy and procedure titled, Falls, revised ,d+[DATE] indicated the staff will evaluate and document falls that occur while the individual is in the facility, for example when and where they happen, any observations of the event, etc. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of fall. After a first fall, the staff should watch the individual rise from a chair without using his or her arms, walk several paces, and return to sitting. If the individual has no difficulty or unsteadiness, further evaluation may not be needed. If the individual has difficulty or is unsteady in performing this test, additional evaluation should occur. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident was stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. A review of an undated policy and procedure titled, Fall Risk Assessment, indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered fall prevention plan based on relevant assessment information. Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls. The staff will seek to identify environmental factors that may contribute to falling such as lighting and room layout. A review of an undated policy and procedure titled, Falling Star Program, indicated it was the facility protocol to ensure resident safety and provide an environment free of any hazards. The facility will ensure that all residents that are high risk for fall will have an appropriate individualized care plan that will address their needs. An initial plan of care will be developed, and interventions will be implemented to minimize risks and prevent falls. In the event of a fall incident, a licensed nurse will perform a head-to-toe assessment of the resident and will conduct a post-fall intervention to determine the root cause and the possible immediate interventions to implement to ensure resident safety. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, dated [DATE], the licensed nurse shall notify the resident's physician when there has been an accident or incident involving the resident, significant change involving the resident's physical, emotional or mental condition.

Based on interview and record review, the facility failed to provide an environment free of accident hazards and supervision for one of two sampled residents, (Resident 3), who was a high fall risk and had history of falls with fracture (broken bones). On 10/16/2021, at 9 AM, the Certified Nursing Assistant 1 (CNA 1) assisted the resident to the activity room, where Resident 3 remained alone, unsupervised. As a result, at 9:20 AM, Resident 1 was found in the activity room, lying on her left side near her wheelchair, and complained of moderate pain to the left hip and left thigh. On 10/17/2021, Resident 3 was diagnosed with a left hip fracture requiring transfer to General Acute Care Hospital (GACH) on 10/18/2021. Findings: A review of the Admission Record indicated Resident 3, a [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including history of falling, wedge compression fracture T9-T10 vertebra (a fracture in the front part of the [MEDICATION(S)], pelvis vertebra), wedge compression fracture of lumbar vertebra (a fracture in the front part of the lumbar vertebra), [CONDITION(S)] (bones become weak and brittle). A review of Resident 3's Fall Risk assessment dated [DATE], indicated Resident 3 had a balance problem while standing, walking, and required the use of assistive devices. The fall risk assessment indicated Resident 3 was a high risk for falls. A review of Resident 3's care plan dated 6/23/2021, indicated Resident 3 was at risk of self-care deficit due to inability to participate in any independent activity of daily living related to impaired cognition, impaired physical mobility, impaired balance, limited mobility, and limited range of motion. The care plan indicated Resident 3 required extensive assistance with most of her activities of daily living. A review of Resident 3's care plan for history of falls, poor balance and decrease in functional status developed 6/23/2021, included the interventions to assist with all transfers or ambulation, call light within reach and answered promptly, encourage the resident to use it for assistance as needed. The care plan intervention indicated Resident 3 needed prompt response to all request for assistance and encourage the resident to call for assistance before attempting to transfer or ambulate if able. According to a review of Resident 3's care plan for osteopenia (bone loss), [CONDITION(S)] (weak and brittle bones), and [CONDITION(S)] ([CONDITION(S)] joint disease) developed 6/23/2021, Resident 3 was at risk for pathological fracture (a break in a bone caused by underlying disease). The care plan interventions included to assist the resident during transfer safely, maintain safe and hazard free environment, handle gentle when positioning, and place call light within reach. A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 6/30/2021, indicated Resident 3 required extensive assistance (staff provide weight-bearing support) with one person assist for bed mobility, dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 3 was not steady for surface-to-surface transfer, between bed and chair, wheelchair, and standing position. A review of Resident 3's Medication Administration Record dated 8/1 - 8/31/2021 and 9/1 - 9/30/2021, indicated Resident 3 was being monitored for muscle weakness, tender and sore muscles. A review of Resident 3's Change of Condition (COC) notes dated 10/16/2021, indicated at 9:20 AM, the Activities Assistant reported to the Registered Nurse (RN 1) that Resident 3 was found in the activity room, lying on her left side near her wheelchair, and complained of moderate pain to the left hip and left thigh. The charge nurse medicated Resident 3 for pain, with frequent visual checks done by staff for safety. The COC indicated when the physician was notified, he ordered for X-ray (a photographic or digital image of the internal composition of a part of the body) of bilateral hips, pelvis, and left thigh. According to a review of the Radiology Report, dated 10/17/2021, Resident 3 suffered a comminuted left intertrochanteric fracture (a break with multiple pieces and fracture lines in the hip) and superolateral displacement of the distal fragment (bone breaks into two or more pieces and moves out of alignment). During an observation and interview with Resident 3 on 10/18/2021 at 9:20 AM, Resident 3 was awake, alert, Spanish speaking and stated no one paid any attention her. Resident 3 stated sometimes the staff yell at her. Resident 3 grabbed her left leg and stated she fell in the activities room on 10/16/2021 in the morning, and she was having pain. A review of Residents 3's Progress Notes dated 10/18/2021, indicated the Medical Doctor was notified of Resident 3's x-ray results and gave new orders to transfer Resident 3 to the General Acute Care Hospital for evaluation (two days after the fall). A review of the GACH History and Physical (H&P) dated 10/19/2021, indicated Resident 3 was admitted to the GACH on 10/18/2021 from a nursing home where she fell , developed left sided pain and was brought to the hospital due to a left hip fracture, awaiting orthopedic consult. During an interview with Registered Nurse (RN 1) on 10/19/2021 at 10 AM, Registered Nurse 1 (RN 1) stated she was working day shift on 10/16/2021 and around 9:20 AM she was paged to go to the activities room because a resident fell on the floor. The receptionist went on his break and the activities assistant went to cover the receptionist break. RN 1 stated, At the time no one was inside the activities room supervising the resident (Resident 3). RN 1 stated she went to assess Resident 3 and assisted the resident back to the wheelchair and back to bed. Resident 3 was complaining of a pain rated at level of 6 out of 10 pain (moderate pain). RN 1 stated the charge nurse gave Resident 3 Tylenol (pain medication) and notified the Medical Doctor of the fall. The Medical Doctor ordered for Resident 3 to receive x-rays. During an interview with Director of Nurses (DON) on 10/19/2021 at 11 AM., she stated she did not know why Resident 3 was left alone in the activities room. During an interview with Activities Director (AD) on 10/20/2021 at 1 PM, he stated he did not work on the weekends, but if there were residents in the activities room, then a staff member should always be inside the activities room. On 10/20/2021 at 1:15 PM, during a telephone interview with the Activities Assistant (AA), he stated the morning of the fall on 10/16/2021 was a busy day, and he was asked to cover the receptionist that went on break. The Activities Assistant stated at the time, he was checking people in to the facility, answering the phones, and he saw Resident 3 in the activities room by herself. The AA stated he was unsure why the CNA left Resident 3 inside the activities room, but she was not supposed to leave her in the activities by herself. The AA stated, he could see Resident 3 in the activities room attempting to get up, so he went to get the RN 1 and when they went into the activities room, Resident 3 was already on the floor. During a telephone interview with Certified Nurse Assistant (CNA 1) on 10/21/2021 at 11:20 AM, CNA 1 stated she assisted Resident 3 out bed into the wheelchair as requested by the resident. Resident 3 told her she wanted to go inside the activities room and to sit her by a table. CNA1 stated the activities door was open, and she could see there was someone outside the activity room, at the reception desk but failed to notify anyone that she was leaving the resident inside the activities room. A review of the GACH Orthopedic Surgery Consultation Note dated 10/21/2021, indicated Resident 3 benefitted from surgical fixation of the left hip fracture but she had a change in condition. Resident 3 had significantly worsening difficulty breathing and required continuous face mask with high flow oxygen. During an interview with the Administrator (ADM) on 10/22/2021 at 11 AM, the ADM stated someone should have been inside the activities room with Resident 3 because it was good practice. The ADM stated the CNA left Resident 3 in the activity room and the fall was not reported. A review of the GACH Neurology Consult dated 10/25/2021, indicated Resident 3 was transferred to the Intensive Care Unit due to [CONDITION(S)] (unexpected loss of heart function). Resident 3 was intubated (a flexible plastic tube into the windpipe to maintain an open airway) and sedated. Neurology was consulted for [CONDITION(S)] like activity with irregular movement of upper body, [MEDICATION(S)] a couple of seconds. No history of seizures. During a telephone interview on 11/1/2021 at 9:30 AM, the DON stated Resident 3's care plans did not address that the resident needed to be supervised to prevent falls. A review of the facility's policy and procedure titled, Falls and Fall Risk Managing, revised March 2018, indicated the staff will identify interventions related to the resident's specific risks and try to prevent the resident from falling and try to minimize complications from falling. The staff with the input of attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. A facility policy was requested regarding supervision in the activity room, it was n

Based on interview and record review, the facility failed to ensure its residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates this is not possible for one of 19 sampled residents (Resident 21), who was assessed at risk for weight loss, was provided with timely nutritional intervention to prevent continuous significant weight loss, including: 1. Failure to monitor Resident 21's meal consumption to develop and implement effective nutritional interventions. 2. Failure to re-weigh Resident 21 when on (MONTH) 26, (YEAR), the weight indicated a loss of 17 pounds in one week. 3. Failure to implement the nutritional plan of care by not notifying the attending physician regarding Resident 1's progressive and significant weight loss and by not providing the resident with a fortified diet (foods to which extra nutrients have been added). 4. Failure to follow Resident 21's preference to eat in her room to promote increased food consumption. 5. Failure to notify the RD of Resident 21's low pre-[MEDICATION NAME] level (indicative of malnutrition) and the significant weight change on (MONTH) 26, (YEAR) and the poor meal intake. 6. Failure to implement the facility's policy on Weight Loss Interventions by not implementing alternative means of nutrition and interventions. As a result, by (MONTH) 10, (YEAR), Resident 21 sustained a progressive severe significant weight loss of 30 pounds (a 17.72 % of the body wail) in two months Findings: A review of the Admission Record indicated Resident 21 was originally admitted to the facility on (MONTH) 2, (YEAR) and readmitted on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care planning tool), dated (MONTH) 1, (YEAR), indicated Resident 21 cognitive (ability to learn, reason, understand, make decisions, and make needs known) skills for daily decision-making was moderately impaired and required limited assistance from staff with eating. Resident 21 was assessed at nutritional risk due to [DIAGNOSES REDACTED]. A review of the Admission Nutritional assessment dated (MONTH) 10, (YEAR), by the Registered Dietitian (RD) indicated Resident 21's daily nutritional requirements were as follows: 1265 to 1540 calories, 66 to 99 grams protein, and 1375 to 1650 cubic centimeters (cc) of fluid. The document indicated Resident 21 had increased nutritional needs related to wound healing. There was no further RD documentation. A review of the blood test dated (MONTH) 10, (YEAR), indicated Resident 21's Pre-[MEDICATION NAME] level was 9 milligrams per deciliter (mg/dL - reference range from 17 to 31 mg/dL). A review of the Nutritional Status Care Plan dated (MONTH) 11, (YEAR) indicate the goals were for Resident 21 to eat 75 to 100% of meals and not have significant weight loss. The interventions included offering food preferences, fortified meals (foods to which extra nutrients have been added) and notifying the physician of any significant weight changes. A review of the physician's orders [REDACTED]. A review of the Interdisciplinary Weight Management Care Plan dated (MONTH) 26, (YEAR), indicated Resident 21 had lost 17 pounds in one week, possibly due to an error. The recommendation was to re-weigh Resident 1 in a week. There was no documented evidence Resident 21 was re-weighed in one week to rule out an error in weight. A review of the Licensed Nurses Progress Note dated (MONTH) 26, (YEAR) indicated Resident 21 ate 25-50% of the meals served, wanted solid food, and did not want baby (pureed) food. The note also indicated a registered nurse (RN) was made aware. A review of Resident 21's Weight Management Update completed by the IDT dated (MONTH) 16, (YEAR), indicated the resident oral (by mouth) intake was 25-50%. The notes indicated the resident's weight loss continued to trend down rapidly with refusal to poor meal intakes and to continue with weekly weights. A physician's orders [REDACTED]. The resident did not receive a fortified diet as per plan of care. A review of the Certified Nursing Assistants Activities of Daily Living (CNAs ADL) Tracking Form from (MONTH) 16, (YEAR) to (MONTH) 10, (YEAR), indicated Resident 21's meal intake varied from episodes of refusal to 80 % meal consumption. A review of the Monthly Weight Record of Vital Signs form indicated Resident 21 weighed 169 pounds and was 5.1 feet tall on admission (December 10, (YEAR)). On (MONTH) 2, (YEAR), Resident 21 weighed 149 pounds, a weight loss of 20 pounds in less than a month. On (MONTH) 10, (YEAR), Resident 21 weighed 139 pounds, a weight loss of 30 pounds, 17.75% body weight, a severe weight loss in two months. There was no documented evidence Resident 21's progressive severe weight loss was relayed to the physician as indicated in the plan of care and to the RD for re-evaluation of Resident 21's diet and nutritional interventions. On (MONTH) 11, (YEAR), at 11:26 a.m., during a telephone interview with the Registered Dietician (RD) in the presence of the Director of Nursing (DON), the RD stated Resident 21 should be in weekly weights for weight monitoring. RD stated fortified diet would be considered for residents with poor dietary intake. RD also stated Resident 21 was on high alert list for severe weight loss. RD was not aware Resident 21 lost 30 pounds in two months. The RD last assessment was (MONTH) 10, (YEAR). The DON informed the RD Resident 21 was not on weekly weights. During an interview on (MONTH) 11, (YEAR), at 11:43 a.m., Restorative Nurse Assistant 2 (RNA 2) stated Resident 21 did not want to be in the feeding program in the dining room with other residents. RNA 2 stated the resident would refuse to eat or would eat 30 % when in the dining room. RNA 2 also stated the DON and the Dietary Service Supervisor (DSS) were aware of Resident 21's eating preference but did not remove the resident from the dining room. RNA 2 further stated Resident 21 would eat 80% of her food when in the room. During an interview on (MONTH) 11, (YEAR), at 12:07 p.m., Certified Nursing Assistant 3 (CNA 3) stated Resident 21 Resident 21 liked to eat in her room and did not like eating in the dining room. During an interview on (MONTH) 11, (YEAR), at 3:03 p.m., the DON stated Resident 21 did not like pureed diet. The DON stated Resident 21 was on RNA feeding program held in the dining room. The DON confirmed Resident 21's physician was not notified of the severe weight loss and could not explain the lack of nutritional interventions including notification of the RD for recommendations to prevent weight loss. A review of the facility's policy and procedures titled, Weight Loss Interventions, dated (MONTH) 2, (YEAR), indicated always do an intervention, consider appetite stimulant, and if unable to halt weight loss, consider higher level of care. The policy indicated failure to implement alternative means of nutrition and or hydration would result in unavoidable weight loss, unavoidable skin issues, malnutrition, and death. The policy indicated to consider distraction when eating in dining room, and food texture change.

Based on observation, interview and record review, the facility failed to ensure pain management was provided to one of 19 sampled residents (Resident 6), who had pain, including: 1. Failure to develop a comprehensive plan of care for pain management for Resident 6, who had a [DIAGNOSES REDACTED]. 2. Failure to ensure Restorative Nursing Assistants (RNA) report to the licensed nurses regarding Resident 6 was not receiving passive range of motion exercises to her lower extremities due to pain in her lower extremities. 3. Failure to administer as needed pain medication as ordered by the physician. 4. Failure to implement the facility's policy and procedures on Pain Assessment and Management for multi-disciplinary (involving several disciplines in an approach to a problem) care process that included assessing for pain, effectively recognizing the presence of pain, identifying and addressing the underlying causes of pain, developing and implementing approaches to pain management, monitoring for effectiveness of interventions and modifying approaches as necessary. As a result, Resident 6 had an unrelieved pain and had not received passive range of motion exercises to her lower extremities from (MONTH) 1 to 10, (YEAR), (a total of 10 days), which increased the risk for further decline in range of motion (ROM, full movement of a joint, usually its range of flexion (bending) and extension (stretching out)). Findings: On (MONTH) 10, (YEAR) at 10:51 a.m., during a wound treatment observation on Resident 6's left lower leg, Resident 6 was observed to flinch with facial grimacing and exhibited guarded behavior when Licensed Vocational Nurse 2 (LVN 2) touched the skin. LVN 2 stated Resident 6 was sensitive to touch and was difficult to re-position due to pain in the lower extremities. A review of admission records indicated Resident 6 was admitted to the facility on (MONTH) 21, 2013 and readmitted on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated (MONTH) 2, (YEAR) indicated Resident 6 had occasional pain rated at 6 (numeric scale of 1 to 10 (10 as severe pain)). Resident 6 was assessed to have severely impaired cognition (the mental action or process of acquiring knowledge and understanding). Resident 6 was totally dependent on staff for transfers and toilet use, and she required extensive assistance from staff with bed mobility, dressing and personal hygiene. On (MONTH) 11, (YEAR) at 8:59 a.m., Restorative Nursing Assistant 1 (RNA 1) was observed in Resident 6's room and was about to start range of motion exercises (ROM, full movement of a joint, usually its range of flexion (bending) and extension (stretching out)) on her upper extremities (arms). RNA 1 observed Resident 6 was able to perform flexion and extension exercise with 10 repeats without difficulty or signs of discomfort and pain. RNA 1 stated that he provided upper extremities exercises but not to the lower extremities because of Resident 6's pain. RNA 1 stated that he was unsure of whether Resident 6 was medicated for pain prior to the ROM exercises. RNA 1 further stated Resident 6 always had lower extremity pain. During a concurrent interview with Resident 6, she stated that Right now it is regular pain. When asked to rate the pain from 1 to 10 (numeric scale), one being the least pain and 10 the worst, Resident 6 stated 7. Resident 6 stated when she received pain medications, the pain goes down a little but she is not completely relieved. On (MONTH) 11, (YEAR) at 11:05 a.m., Resident 6 was observed seated on her wheelchair in her room. The wheelchair was observed without a foot rest. During a concurrent interview with Resident 6, she stated she was unable to lift her legs while seated on the wheelchair. When asked what happens if the wheels on the wheelchair hit her legs, the resident stated it will hurt. On (MONTH) 11, (YEAR) at 11:06 a.m. Certified Nurse Assistant 2 (CNA 2) was observed to enter Resident 6's room, walked over to Resident 6 and started pushing her on her wheelchair. The wheelchair's left wheel was observed to rotate and hit Resident 6's foot. Resident 6 was observed to shout how followed by facial grimacing. CNA 2 was observed to straighten the resident's wheel, moved Resident 6's left foot and continued to transport Resident 6 out of the room. CNA 2 did not ask how Resident 6's feel when she shouted and/or her facial grimacing. A review of Resident 6's physician's orders [REDACTED]. 1. RNA to perform passive range of motion (PROM) exercises to bilateral lower extremity (BLE) once a day seven (7) times a week, ordered (MONTH) 15, (YEAR). 2. [MEDICATION NAME] 50 milligrams (mg) 1 tablet by mouth twice a day (BID) for pain management was started on (MONTH) 23, (YEAR). 3. Tylenol 325 mg 2 tablets by mouth every 6 hours as needed (PRN) for mild pain [MEDICATION NAME] 10-325 mg 1 tablet by mouth every 6 hours as needed for severe pain. 4. Fleer 5 mg 1 tablet by mouth before sleep (HS) for muscle spasm. A review of Resident 6's Medication Administration Record [REDACTED]. There was no other as needed (PRN) pain medications administered to Resident 6 from (MONTH) 1 to 10, (YEAR). A review of Resident 6's RNA treatment documentation from (MONTH) 1, 2, 3, and 4, (YEAR), indicated Resident 6 refused BLE, PROM exercises due to a lot of pain. From (MONTH) 5, 6, 7, 8, 9, and 10, (YEAR), Resident 6 refused BLE, PROM exercises. During a follow-up interview with RNA 1 on (MONTH) 11, (YEAR) at 12:05 p.m. he stated he took care of Resident 6 on (MONTH) 1, (YEAR) to (MONTH) 4, (YEAR) and again on (MONTH) 8, (YEAR) to (MONTH) 10, (YEAR). RNA 1 stated Resident 6 refused lower extremities ROM exercise because Resident 6 said she had a lot of pain. A review of Resident 6's RNA treatment documentation with RNA 1, indicated there was no reason for refusal of the ROM exercise from (MONTH) 8, (YEAR) to (MONTH) 10, (YEAR). RNA 1 stated he did not document the reason, however he stated it is the same reason all the time, it's about her pain. When asked if he checked Resident 6 was receiving pain medications prior to ROM exercises, RNA 1 stated he checked the previous day if the resident took her pain medications but Resident 6 stated the pain was the same. When asked if he reported Resident 6's pain, RNA 1 stated he reported to the charge nurse and he could not remember the name of the charge nurse. When asked if he reported to the charge nurses the past two days, he stated he did not report to anybody. RNA 1 further stated when a resident refuses exercises and there was a pattern of constant refusal, he needed to report to the physical therapist. When asked if he had reported to the physical therapist, RNA 1 stated No. During an interview on (MONTH) 11, (YEAR) at 12:13 p.m., Licensed Vocational Nurse 3 (LVN 3) stated she worked on (MONTH) 8, (YEAR), but was not informed by the RNA that Resident 6 had refused ROM exercises because of pain. During an interview with RNA 2 on (MONTH) 11, (YEAR) at 12:15 p.m., she stated she worked from (MONTH) 5, (YEAR) to (MONTH) 7, (YEAR) and took care of Resident 6. RNA 2 stated Resident 6 refused ROM exercises because She has a lot of pain on her legs. RNA 2 stated that during the times she would stretch the resident's legs she would complained of pain. When asked about the reason for the refusal of BLE PROM exercise not documented on (MONTH) 5 (YEAR) to (MONTH) 7, (YEAR), RNA 2 stated It's because of pain. RNA 2 stated she reported to charge nurse on (MONTH) 7, (YEAR) about the resident's pain. When asked whether she checked to see if Resident 6 was pre-medicated prior to ROM exercise, RNA 2 stated Yes, but even though pain medications were administered, the resident still complained of pain in her legs. RNA 2 stated When we push her into the dining room, she complains of leg pain. She says she has a lot of pain. On (MONTH) 11, (YEAR) at 12:23 p.m., during an interview and review of Resident 6's clinical record with Registered Nurse 2 (RN 2), RN 2 confirmed there was no pain medication given to Resident 6 from (MONTH) 1 to 10, (YEAR) (a total of 10 days). RN 2 stated Resident 6 was at risk for pain due to [DIAGNOSES REDACTED]. RN 2 stated that a resident's comprehensive care plan was needed to evaluate for pain and to keep the resident free from pain. RN 2 stated a care plan enumerates the [DIAGNOSES REDACTED]. RN 2 stated Resident 6 did not have those in place and Will initiate a care plan today. A review of clinical records also indicated during the last interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) meeting dated (MONTH) 26, (YEAR), the section regarding pain was left blank. A review of the facility's policy and procedure revised (MONTH) (YEAR) and titled, Pain Assessment and Management indicated pain management was a multi-disciplinary care process that included assessing for pain, effectively recognizing the presence of pain, identifying and addressing the underlying causes of pain, developing and implementing approaches to pain management, monitoring for effectiveness of interventions and modifying approaches as necessary.

Based on observation, interview, and record review, the facility failed to ensure one of 19 sampled residents (Resident 48), who was assessed as a high risk to develop pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) and was admitted without pressure ulcers, received the necessary care and services to prevent pressure ulcer from developing, including: 1. Failure to have an accurate Daily Body Check Report that reflected and identified Resident 48's skin condition. 2. Failure to implement the facility's policy on Prevention of Pressure Ulcers, by not having an appropriate assessment and that changes in condition are recognized, evaluated, addressed, and reported to the practitioner, physician, and family. As a result, by (MONTH) 10, (YEAR), Resident 48 was identified with a deep tissue injury (DTl - localized damage to the skin and underlying soft tissue usually over a bony prominence. DTI is, A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. NPAUP, 2002) to the left leg, above the ankle. Findings: On (MONTH) 10, (YEAR), at 9:20 a.m., during an observation of Resident 48's shower preparation, Certified Nurse Assistant 1 (CNA 1) removed waffle boots (for pressure relief on the heel) from Resident 48's feet. Resident 48 was noted to have a dry deep brown skin discoloration to the left leg above the ankle, measuring approximately two by two 2 centimeters (cm) and a dressing over the left inner foot. CNA 1 and Restorative Nursing Assistant 2 (RNA 2) confirmed observation of the deep brown skin discoloration. On (MONTH) 10, (YEAR) at 10:14 a.m., during observation of treatment of [REDACTED]. LVNs 1 after inspecting the area indicated Resident 48 had a DTI to left lateral lower leg caused by pressure. LVN 2 stated upon admission Resident 48 only had a wound on the left inner foot (not a bony prominence). LVNs 1 and 2 were not aware Resident 48 had developed a deep tissue injury (DTI) after admission. A review of the Admission Record indicated Resident 48 was readmitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A review of the Nursing Admission assessment dated (MONTH) 18, (YEAR), indicated Resident 1 had no skin injury to left leg above the ankle. A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated (MONTH) 3, (YEAR), indicated Resident 48's cognition (ability to think, make decisions, understand, learn, and make needs known) was severely impaired and was totally dependent from staff for bed mobility, transfers, toilet use, and personal hygiene. The MDS indicated Resident 48 did not have pressure ulcers. A review of the Braden Scale (pressure ulcer risk assessment tool) dated (MONTH) 18, (YEAR), indicated Resident 48 was at high risk for pressure ulcer due to very limited sensory perception, moisture (wetness), bed confinement, and complete immobility (not able to move). A review of the Care Plan developed for pressure ulcer prevention dated (MONTH) 18, (YEAR), had a goal for Resident 48 not to develop pressure ulcers. The interventions included nurses to check heel protectors and heel cradle (equipment to keep the bed linen off the resident's feet). A physician's orders [REDACTED]. A review of the Daily Body Check Report forms from (MONTH) 1, (YEAR) to (MONTH) 10, (YEAR) (41 days), indicated the resident's skin had no skin injury. There was no documentation of a DTI on the left foot. During an interview on (MONTH) 10, (YEAR), at 10:23 a.m., LVN 1 stated Certified Nurse Assistants (CNAs) are supposed to inform the licensed nurses of any skin changes on the residents. LVN 1 stated Registered Nurses (RNs) performed resident skin assessment on admission. LVN 1 also stated CNAs performed skin assessment on every shower day and report any abnormal findings After the DTI on Resident 48's left foot was brought to LVN 1's attention, a Wound Skin Healing Record dated (MONTH) 10, (YEAR), indicated Resident 48 had a DTI black/brown necrotic (dead) tissue to the left lateral lower foot measuring two by one cm, identified on (MONTH) 10, (YEAR). During an interview on (MONTH) 11, (YEAR), at 11:24 a.m., the Director of Nursing (DON) stated the treatment nurses performed skin sweeping (inspection) one day a week. The DON was not able to explain why Resident 48's DTI to lower left leg above the ankle was not identified. A review of the facility's policy and procedure revised on (MONTH) 2010, titled, Prevention of Pressure Ulcers, indicated the facility should have a system and procedure to assure assessments are timely and appropriate, and that changes in condition are recognized, evaluated, addressed, and reported to the practitioner, physician, and family. The document also indicated to routinely assess and document the condition of the resident's per facility wound and skin care program for any signs and symptoms of irritation or breakdown.

Based on observation, interview, and record review, the facility failed to ensure the environment was safe and free from accident hazards for all residents, when six of six sampled residents (Residents 1, 2, 3, 4, 5, 6) became alcohol intoxicated on multiple occasions with the facility staff aware, and measures to control this activity were not implemented. Specifically, the facility failed to: ? Fully investigate how alcohol was entering the facility and getting to the individual residents, so that preventative measures could be implemented. ? Revise resident care plan interventions to prevent instances of intoxication, encourage behavioral change, and provide specific interventions for managing the intoxicated resident to prevent self-injury and/or injury to others. ? Develop strategies for staff to intervene as soon as alcohol intake by residents was suspected (before intoxication occurred). ? Develop strategies for staff to safely manage intoxicated residents to prevent injury to staff, as well as to other residents. ? Ensure staff was trained in the identification of signs and symptoms of intoxication, the assessment skills required to support the conclusion of intoxication, and the related documentation required. ? Ensure staff was trained in the management of the intoxicated resident, and/or management of the belligerent, hostile, and/or threatening intoxicated resident. ? Respond to the expressed concerns about residents ' alcohol consumption from licensed staff, some of whom were afraid of the residents. Alcohol intoxication is known to cause poor judgment, irrational behavior, uncoordinated body movements, and dehydration (inadequate body fluids). The facility ' s combined failures contributed to, or resulted in: A sexual assault of Resident 1 by Resident 2, both of whom were intoxicated on September 17, 2014 (Reference tag F223). On September 17, 2014, the sexual abuse of Resident 1 by Resident 2 while intoxicated (Reference tag F223). On September 4, 2014 at 1:30 a.m., while intoxicated, Resident 5 became " very agitated and abusive " to staff and other residents, and the police had to be contacted for safety of staff and residents. On September 10, 2014, around 8 p.m., Resident 4 was seen drinking and later asked for sleeping medication, which was administered without assessment prior to giving. At 10 p.m. Resident 4 had to be given intravenous fluids for hydration (Reference tag F329). Resident 3 sustained a first degree burn (redness that is painful) from hot soup she spilled on herself while intoxicated on [DATE]. On September 17, 2014, Resident 6 was drinking and allegedly smoking unsupervised in a male residents room, and on September 25, 2014, she was again drinking in the facility, leading to an unsafe environment. Residents 1, 2, 3, 4, 5, and 6 were intoxicated on the facility premises, on numerous occasions, from alcohol suspected to be provided by Resident 2 and Resident 5. All of these residents were on prescribed medications that were not to be administered while using alcohol (Reference tag F329). Because these violations presented an immediate jeopardy situation to residents' health and safety, Immediate Jeopardy was called on September 25, 2014, at 5:15 p.m., with the facility Administrator and the director of nursing. The Immediate Jeopardy was abated on September 27, 2014, at 4:05 p.m. with the Administrator and the Chief Operating Officer, when the facility presented an acceptable plan of correction that specified: Resident 2 and 5 were discharged . On September 25, 2014, the Administrator, DON and SSD immediately reassessed all residents for possession of contraband/prohibited items and marijuana/illicit drugs and found to have no possession. Resident room checks initiated for contraband when necessary. The facility revised and/or implemented the following policies and procedures: House Rules, Abuse prevention policies, Contraband and Prohibited items, Use of Marijuana and Illicit Drugs, Pre-Admission Screening, Supervision of residents, Resident Safety, Investigating and Reporting unexplained injuries, Quality Assurance Committee and Quality Assurance Subcommittee; House Rules. House Rules will be included in the Admission package. Inservices were given to all staff regarding House Rules, numerous abuse prevention policies, Contraband/Prohibited Items, Use of Marijuana/Illicit Drugs, Pre-Admission Screening, Supervision of Residents, Resident Safety, Investigating and Reporting Unexplained Injuries, Quality Assurance Committee and Quality Assurance Subcommitte to ensure compliance and promote safety. The Admission Coordinator/Administrator/DON will ensure residents' appropriateness for skilled nursing facility setting. Resident behaviors will be regularly monitored, include the interdisciplinary team (IDT), responsible party, and the resident's physician, and care plans updated accordingly. In addition to the regularly scheduled IDT meetings, the IDT shall meet when there are individual resident complaints, issues (actual or potential), suspicions, allegations or confirmed violations of facility policies and procedures and House Rules. The facility's QAPI/CCC committee will be involved. The Compliance Director will do a monthly random interview with residents about allegation of abuse and review risk management program with emphasis on complaints to ensure timeliness of investigation, reporting, and intervention. The Social Service Consultant will review random charts on a monthly basis with emphasis on discharge planning and resident's non-compliance to the facility's House Rules. The Administrator provided: * Copies of all revised policies and procedures, including the implementation of The Contraband or Prohibited Items put in place dated September 2014. Revised their HOUSE RULES based on the plan of correction they had given to the Department. * A log titled Contraband/Prohibited Items Log was put in place dated September 2014. * The policy and procedure titled "Use of Marijuana and/or Illicit drugs dated September 2014 was put in place. * The policy and procedure dated September 2014 for Investigating Unexplained Injuries was put in place. Findings: On September 22, 2014, an investigation of an entity reported incident was conducted for the sexual assault of Resident 1 by Resident 2 that occurred on September 17, 2014. 1a. A review of the general acute care hospital (GACH) Consultation Report dated July 6, 2013, indicated Resident 1 had recurrent admissions to the hospital for alcoholic toxicity and withdrawal. According to the admission record to this skilled nursing facility (SNF), Resident 1 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's care plan dated September 15, 2013, indicated the resident had a history of [REDACTED]. The resident when drunk shows evidence of aggressive behavior, making up stories and yelling in the hallway in a loud voice. The goals were to maintain lifestyle without alcohol daily and to have no injury from his drinking of alcohol daily. The approaches included monitor resident's behavior, comfort manipulative behavior, set limits, educate and inform resident about the policy and procedure, rules and regulations of the facility especially prohibition of alcohol. A review of Resident 1's Initial History and Physical dated June 10, 2014, indicated the resident had the capacity to understand and make decisions. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognitive patterns were intact and had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) that occurred daily. The overall presence of behavioral symptoms had impact on the resident by significantly interfering with the resident's care and had impact on others by significantly intruding on the privacy or activity of others. A review of Resident 1's care plan dated September 9, 2014, indicated Resident 1 has episodes of drinking alcohol inside the facility and had potential for withdrawal symptoms. The goals were for the resident to not take drugs other than it is directed and prescribed by the physician, will maintain a lifestyle without alcohol and drug abuse daily. The approaches were to monitor for resident's behavior and discuss any observation with him, confront manipulative behavior, and set limits. Educate and inform resident about "policy, rules and regulations" of the facility especially prohibition of alcohol. The only approach added was to monitor resident ' s out on pass privileges and possessions of alcohol. There were no specific approaches to indicate what monitor meant, or what was to be done to prevent the possession of alcohol or what the consequences were. The care plan was updated on September 17, 2014, to include another episode of drinking in the facility. There was no evidence the nursing staff had evaluated, updated or developed different approaches from 2013 to ensure Resident 1's environment was as safe as possible. A review of the physician's orders [REDACTED]. If resident comes back positive for alcohol with behavioral changes, please send to urgent care for evaluation dated September 1, 2014. A review of the Physician Telephone Orders for Resident 1 indicated on September 4, 2014, at 1:30 a.m. the physician ordered to transfer Resident 1 to the hospital to rule out "alcohol consumption." At 2:10 p.m. the physician ordered may go out on pass with family members only. At 3:30 p.m., the physician ordered to transfer to the GACH for evaluation of "general weakness" and slurred speech via ambulance dated September 4, 2014. On September 22, 2014, at 6:35 p.m., during an interview with Resident 1, he was observed sitting in his room in a wheelchair, alert, and oriented to person, place, time, and events. He stated he was drinking alcohol in the patio with two other residents (2, 6). He stated that Resident 2 knew how to leave the building without being noticed, and was strong enough to get through the security gate and go to the liquor store down the street. He said Resident 2 provided liquor to other residents. He said the director of nursing (DON) knew about it because she saw the empty bottle of vodka. He said after drinking and being intoxicated, at about 11 p.m., he and Resident 2 were sitting in his room watching pornographic videos, and Resident 2 sexually assaulted him. Resident 1 said he yelled for help and staff came to the room and stopped Resident 2's assault on him. On September 24, 2014, at 3:15 p.m., during an interview with the Social Service Designee (SSD), she stated the sexual assault on Resident 1 and both residents being intoxicated was discussed during the department heads' stand-up meeting on September 18, 2014, the day after the sexual assault. She stated that when she talked to Resident 1 he told her Resident 2 had sexually assaulted him. When asked if she had done any counseling to Resident 1 after the incident, she was unable to provide any written documentation regarding her discussion with Resident 1. 1b. A review of the admission record indicated Resident 2 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of a Resident Care Plan dated October 28, 2013, indicated Resident 2 needs to be monitored during smoking activity. The goal was for the resident not to sustain burns/injuries and fire hazards prevented daily. The approaches included to constantly remind resident not to smoke "in room" due to danger of fire, staff were to monitor smoking, and not to allow resident to keep lighter and cigarettes. A review of the physician's Progress Record dated August 11, 2014, indicated Resident 2 was noted to be non-compliant with smoking regulations. The resident had been warned verbally on several occasions; the staff were concerned and informed the physician; will discuss with staff. A review of Resident 2's Social Services Quarterly notes dated August 12, 2014, indicated safety issues regarding smoking paraphernalia (cigarettes, lighter, matches) was explained and reinforced from time to time. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 2's cognitive patterns were moderately impaired, and he was independent for walking in the room, corridor and on and off the unit. A review of Resident 2's Resident Care Conference Review notes dated September 11, 2014, indicated the areas reviewed were resident's rights and drinking liquor. The notes indicated as part of the interdisciplinary team (IDT) duties, the facility will protect the resident and others for any dangers when they were intoxicated as before; the resident was aware of consequences of drinking positively and negatively. A review of Resident 2's Licensed Personnel Progress Notes dated September 17, 2014, at 11:30 p.m., indicated he was received alert, intoxicated, and aggressive. Resident 2 came to Registered Nurse 1 (RN 1) with aggressive behavior. The resident went back towards his room, punching the walls of the hallway and was yelling. The resident was slamming the door of his room several times and was yelling and cursing at everybody. The Licensed Personnel Progress Notes dated September 17, 2014, at 11:40 p.m., indicated the police department came and tried to contain Resident 2, however, he was still aggressive and yelling at the LAPD. He tried to attack the policemen, but was contained and put to the ground. At 11:45 p.m., the resident was transported to the GACH, still in aggressive state. The Resident Transfer Record dated September 18, 2014, indicated the reason for transfer was behavioral management with [DIAGNOSES REDACTED]. A review of Resident 2's GACH Emergency Department Report notes dated September 18, 2014, indicated the chief complaint was combative behavior, brought in by rescue ambulance and police department for hitting a staff at the nursing home. The resident was aggressive, agitated, spitting, cursing, would not answer any questions and was combative in the emergency room . The notes indicated that in the nursing home the resident punched another resident. The resident stated that he wanted to get out and he was going to try to hurt people. In the hospital, the resident was diagnosed with [REDACTED]. 1c. According to the admission record, Resident 6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 6's Minimum Data Set (MDS), an assessment and care screening tool, dated August 22, 2014, indicated the resident had severe impairment for cognitive patterns, no mood and behavior signs and symptoms, independent for locomotion on and off the unit, and used walker and wheelchair for mobility devices. The Resident Care Plan for monitoring Resident 6 during smoking activity dated May 22, 2014, indicated the goal was for the resident not to sustain burns/injuries and fire will be prevented daily. The approaches included to constantly remind resident not to smoke in her room due to danger of fire, staff to monitor smoking, and not to allow the resident to keep lighter and cigarettes. A review of Resident 6's Resident Care Conference Review notes dated August 26, 2014, indicated the IDT addressed the resident ' s refusal to take medications, and her drinking alcohol, including drinking inside the facility. The notes indicated that she denied that she was drinking and the facility policy and protocol was brought to her awareness; they would "continue to monitor." There was another care plan for Resident 6 for episodes of drinking alcohol inside the facility and the potential for withdrawal symptoms dated September 25, 2014. The goal was for Resident 6 not to take anything other than that directed and prescribed by the physician, and to maintain a lifestyle without alcohol. The approaches included to monitor for resident's behavior and discuss any observations with her, confront manipulative behavior, and set limits. Educate and inform resident about policy, rules and regulations of the facility especially prohibition of alcohol, and monitor resident's out on pass privileges and possessions of alcohol. The care plan did not have specific interventions to protect Resident 6 from future incidents, what "set limits" were, and what and how the staff were to monitor. A review of Resident 6's Licensed Personnel Progress Notes entries for August 2014 and September 2014 indicated there was no documentation of the incidents regarding the alcohol intake of the resident, of use of any illegal drugs as indicated in the Resident Care Conference Review notes dated August 26, 2014, or the IDT notes that addressed the issue of drinking of alcohol. There was no written evidence that the facility had conducted a thorough investigation as to where Resident 6 was getting alcohol or pot in order to prevent a harmful environment. There was no evidence that administrative staff had acted to prevent further incidents of an unsafe environment when it was known that Resident 6 was not able to make safe decisions by allowing her to be in male residents' rooms who were also known to have alcohol in the facility. There was no evidence that administrative staff had investigated the statement of Resident 1 regarding Resident 6 drinking alcohol with him and Resident 2 outside his bedroom (patio) on September 17, 2014. There was no documentation regarding Resident 6's smoking of pot on September 17, 2014, as indicated by Resident 1 during his interview. Resident 6's care plans that were in place were not implemented as indicated, and there was no evidence that the facility was implementing their own House Rules to protect residents from an unsafe environment. The lack of information was validated during interviews with the director of nursing on September 22, 2014, at 5:35 p.m., and on September 25, 2014, at 3:20 p.m., and by the interviews with the administrator on September 25, 2014, at 2:45 p.m., and on September 25, 2014, at 8:15 p.m. On September 24, 2014, at 3:40 p.m., during an interview Registered Nurse 1 (RN 1), who works from 3 p.m. to 11:30 p.m., she was asked about some of the incidents of drinking and/or smoking pot in the facility. She gave examples of residents who had been intoxicated at times in the facility, without specific dates. RN 1 gave an oral and written declaration that the interview was true, as follows: Resident 3: RN 1 stated that she had smelled alcohol on Resident 3 (no specific date given), who had to be transferred to the hospital due to intoxication of alcohol. RN 1 also stated Resident 3 had an accident and suffered a first degree burn because she was intoxicated. A review of the Admission Information Sheet for Resident 3 indicated she was admitted on [DATE], and readmitted on [DATE], with depression. A review of Resident 3 ' s Licensed Personnel Progress Notes dated September 3, 2014, indicated at 8 p.m. the certified nursing assistant reported to the director of nursing and RN supervisor that Resident 3 was "more weak." The notes indicated at 8:15 p.m. this was reported to the physician, who ordered to transfer the resident to the emergency room (ER) for "general weakness." A review of the Pain Assessment Flow Sheet dated September 3, 2014, at 9 p.m., prior to being sent to the ER, indicated Resident 3 complained of low back pain and was given Norco (narcotic) 1 tab together with Trazadone (hypnotic for sleep). A review of Resident 3's record revealed a care plan dated September 3, 2014, for episodes of drinking alcohol inside the facility. A review of the Emergency Department Report (ER) dated September 3, 2014, indicated the resident had no complaints, but was sent for "general weakness." The ER record indicated upon arrival at 10:30 p.m., the resident stated she wanted her Norco and Ativan, and doesn't know why she was sent there. The Norco and Ativan were given according to the ER record. There was no indication in the ER record that the facility had informed the ER staff that Resident 3 was intoxicated prior to sending her to the ER. On September 4, 2014, the Resident Care Conference Review meeting notes were regarding drinking liquor. It was documented that the regulations regarding no drinking in the facility were reviewed; the nurses found a bottle of alcohol in Resident 3's room. The IDT discussed health issues about drinking alcohol while taking narcotics and other medicines. The Licensed Personnel Progress Notes dated September 10, 2014, at 9:30 p.m. indicated the CNA reported to the charge nurse that the resident spilled her hot soup on her body - and ice pack was applied. The Licensed Nursing 24 Hour Care form dated September 10, 2014, indicated the resident had a first degree burn, and smelled of alcohol. Two bottles of alcohol mixed in soda were found and confiscated in Resident 3's room. On September 25, 2014, at 3:20 p.m., during an interview with the DON, she was unable to explain details about the burn incident or about why Resident 3 was last hospitalized . She could not provide documented evidence that a thorough investigation was completed for each incident. There was no evidence that there was a thorough investigation into how Resident 3 got the alcohol, no evidence that the plans developed were implemented to prevent further harm to her, and no evidence that there were consequences to her actions as indicated in the House Rules. On September 25, 2014, at 7:40 p.m., during an interview with Resident 3, she was lying in bed and admitted to excessive drinking of alcohol once in a while. She also stated that she got burned once because she had too many drinks. Resident 5: During the September 24, 2014 interview with RN 1, she stated that on the same night of Resident 3's intoxication (no time given), she observed Resident 5 spray a strong perfume, and she believed it was to mask the smell of alcohol, the same smell as on Resident 3. She said Resident 5 was talkative, had a flushed face, and smelled of alcohol. On another occasion she saw Resident 5 drinking alcohol with a visitor in his room. She said she told the visitor that he was not allowed to drink alcohol in the facility, and that Resident 5 was also not allowed to drink alcohol. She said she believed that Resident 5 drinks alcohol two to three times a month, and that he distributed alcohol to other residents but could not prove it because she never caught him in the act. She said that she reported this to management, and usually reports drinking to the administrator and the DON. She said that the CNAs stated that some residents were smoking marijuana but she never witnessed it, but reported to the DON. A review of Resident 5's Initial History and Physical indicated he has the capacity to understand and make decisions. His Admission Information Sheet indicated he was admitted on [DATE], and readmitted [DATE]. He has a history of drug and alcohol abuse, a history of being suicidal, is a paraplegic (legs are paralyzed), and uses a wheelchair. On July 26, 2014 at 2 p.m. Resident 5 received a pass to go out for three hours only. At 6 p.m. the police were notified. At 10:30 p.m. the resident was observed with Resident 2 in the parking lot. Refused to come into the station until 11:30 p.m. When he came in he refused to have his vital signs checked or be assessed and denied that he was gone for more than three hours and violated his pass. Resident 5' care plan dated September 1, 2014, indicated at risk for attempts to go out of the facility due to episode of getting out without permission. The goal was will not go out of the facility daily. The approaches included remind resident not to go out of the facility without consent, check on whereabouts on a routine basis, and inform all staff regarding his history of elopement. On August 16, 2014, the Licensed Personnel Progress Notes indicated the resident went out on pass with friends, and returned with friends, with eyes red and seemed drunk. On September 3, 2014, at 8:30 p.m. the Licensed Personnel Progress Notes indicated the physician ordered to send Resident 5 to the hospital for the condition of "general weakness." At 9:30 p.m., the resident had left the facility without permission, and was missing. Staff searched and the police were contacted. At 11:45 p.m. the resident was returned to the facility by the police, "agitated and intoxicated." He was in the patio, refused to go to the hospital, and was verbally abusive to the staff. "Monitored" by CNAs. The Licensed Personnel Progress Notes indicated Resident 5's behavior continued on September 4, at 1 a.m. The resident was on the patio "drinking alcohol." The alcohol was confiscated after the resident drank the last of the alcohol in the bottle. The CNAs continued to monitor the resident on the patio. At 1:30 a.m., the resident was on the patio with other residents and was very agitated and abusive to all the nursing staff. The resident didn't want staff there and continued to be abusive. At 1:45 a.m., the notes indicated Resident 5 was still abusive and noncompliant with the facility's policy (for drinking) and refused to go to his room. Staff called the police for assistance, and police came at 2 a.m.; the resident was still abusive. At 2:15 a.m. police left after talking to the resident; the resident wheeled around the facility into other resident rooms "disturbing and affecting" other residents. Continued to monitor for residents' safety. At 4:15 a.m., resident refused to sign out AMA (against medical advice) and wanted to talk to his doctor first; requested to be discharged . The resident's loud aggressive and abusive behavior and cursing towards residents and staff continued through 7 a.m., according to the notes. A review of Resident 5's care plan dated September 4, 2014, indicated he was at risk for alcohol intoxication, at risk for repeat alcohol abuse, staff observed resident drunk, and episodes of getting out of the facility. The approaches included to monitor behavior, set limits, educate about policy, rules and regulations of the facility especially prohibition of alcohol and drug abuse, monitor out on pass privileges and possessions of alcohol and substance. Resident 5 had another care plan dated September 4, 2014, for verbal behavior of threatening others, screaming at others, yelling at staff, and cursing at others. The goal was the resident will remain relaxed and cooperative daily. The approaches included monitor the time and day behavior occurs, set limits and remain firm. The approaches were not specific for monitoring, what "limits" were, or what the consequences were to prevent future incidents from occurring. On September 4, 2014, a Resident Care Conference Review was held to address Resident 5's behavior toward staff, alcohol drinking inside the facility, leaving the facility without a pass, and regarding him providing alcohol to other residents, according to other residents' allegations. It was documented he denied it. There was no documented evidence that the facility staff were providing a safe environment for Resident 5, other residents who were on the patio with him when he was drinking (not identified), or other residents within the facility. There was no evidence that the facility attempted to prevent Resident 5 from leaving the facility and returning to the facility with alcohol or returning intoxicated. There was no evidence that his behavior was being monitored and that the facility was controlling or preventing avoidable hazardous situations by and with Resident 5. There was no evidence that the care plans that were developed were implemented to protect Resident 5, other residents, or staff. The care plans were not updated when not effective, to manage Resident 5's noncompliance and unsafe behaviors, including no consequences for his noncompliance and disregard for other residents and staff. There was no evidence that the facility had implemented their own House Rules. During an interview with the DON on September 22, 2014, at 5:35 p.m., and on September 25, 2014, at 3:20 p.m., she stated that she was aware of an incident in February 2014, where Resident 5 was smoking marijuana in the facility, but did not know other residents who were smoking marijuana. When asked if this issue had been investigated and addressed, she said it had, but when asked to provide written evidence of what actions nursing staff were to implement, she was not able to provide any documentation. She stated the facility had no policy and procedure for the management of residents and controlled substance abuse. She could not provide documented evidence that administrative staff had acted upon staff concerns to prevent further avoidable incidents or hazards to Resident 5 or other residents. A review of the Licensed Personnel Progress Notes dated September 17, 2014, indicated that at 8:50 p.m., Resident 5 requested to be discharged (D/C) home, and was D/C to home at 11:05 p.m. Resident 4: During the September 24, 2014 interview with RN 1, she stated on the same night that she saw Resident 5 and the visitor drinking, she saw Resident 4 drinking alcohol with Resident 5. She said that Licensed Vocational Nurse 1 (LVN 1), who worked the 3 p.m. to 11 p.m. shift with her, also smelled alcohol on Resident 4, and it was reported to the physician. The physician ordered intravenous fluids be given to Resident 4 for "hydration" and she went to sleep. When asked about the incidents, RN 1 could not provide evidence that she attempted to prevent Resident 4, who did not have the capacity to understand or make safe decisions, from entering Resident 5 ' s room, who was suspected of providing alcohol to other residents. A review of the acute care hospital's clinical record prior to Resident 4's admission in the facility dated August 26, 2014, indicated alcohol abuse with an onset date of March 21, 2014 and June 19, 2014. According to the skilled nursing facility admission record, Resident 4 was admitted on [DATE], with [DIAGNOSES REDACTED]. According to the Initial History and Physical dated August 29, 2014, Resident 4 did not have the capacity to understand and make decisions. A review of the History and Physical from the general acute care hospital (GACH) dated September 1, 2014, indicated Resident 4 was admitted to the GACH to evaluate for danger to self by running out of the nursing home into the traffic. The resident had a high blood sugar greater than 600. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognitive patterns were moderately impaired and needed supervision in all of activities of daily living. A review of the Licensed Personnel Progress Notes dated September 10, 2014, indicated at 8 p.m., Resident 4 was seen drinking in Resident 5's room. Resident 4 asked for sleeping pills and the charge nurse noticed alcohol on her breath when talking. Advised resident not to enter the room of Resident 5 next time for her own safety. At 9:10 p.m., reported the incident to the physician. At 10 p.m., started intravenous (IV) hydration. A review of the Psychotropic PRN/Hypnotic Medication Pre-Administration Intervention Record on September 24, 2014, Ambien 5 milligrams (

Based on observation, interview, and record review, the facility failed to ensure that significant adverse drug reactions are minimized, and failed to prevent potential adverse drug interactions from occurring for six of six residents (1, 2, 3, 4, 5, 6), including but not limited to the failure to: 1. Ensure residents who were prescribed psychoactive medications (any chemical substance that changes brain function and results in alterations in perception, or consciousness), and narcotics [MEDICATION NAME] medication were not allowed access to and consumed alcohol that had the potential for adverse drug reactions. 2. Monitor residents's behavior in an attempt to control access to alcohol and prevent the supply of alcohol to other residents in the facility to prevent adverse drug reactions. Because these violations presented an immediate jeopardy situation to residents' health and safety, Immediate Jeopardy was called on September 25, 2014, at 5:15 p.m., with the facility Administrator and the director of nursing. The Immediate Jeopardy was abated on September 27, 2014, at 4:05 p.m. with the Administrator and the Chief Operating Officer, when the facility presented an acceptable plan of correction. (Cross Reference to tag F323) Findings: On September 22, 2014, at 12:42 p.m., the Department received an entity reported incident that Resident 1 alleged Resident 2 sexually abused him on September 17, 2014, at 11 p.m. in Resident 1's room. The police department was called and took Resident 2 away from the facility in handcuffs. Resident 2 was sent to the general acute care hospital (GACH) for behavioral management. The report indicate both residents were intoxicated. a. According to the admission record, Resident 1 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Consultation Report from the GACH dated July 6, 2013, indicated the resident had recurrent admissions to the hospital for [MEDICAL CONDITION], alcoholic toxicity and withdrawal, and renal (kidney) failure. A review of the Initial History and Physical dated June 10, 2014, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's care plan dated July 14, 2014, indicated resident had episodes of anxiety manifested by verbalization of feeling of anxiousness and restlessness and was on an anti-anxiety medication. The goal of the care plan was for the resident to demonstrate a decrease in anxiety as evidenced by reduction or absence of manifested behavior. The interventions included to observe the resident closely for significant side effects such as sedation, drowsiness, ataxia (unsteady gait), dizziness, nausea, vomiting, confusion, headache, blurred vision, and skin rash, special attention not to administer the medications (sedatives or hypnotics) with alcohol and to monitor the effectiveness and side effects. Resident 1 had the following physician's orders [REDACTED]. 1. Tylenol #3 (Tylenol with [MEDICATION NAME]), 300 milligrams (mg) per 30 mg. Take one tablet by mouth every four hours as needed for headache dated September 10, 2014. Tylenol with [MEDICATION NAME] is a narcotic [MEDICATION NAME] (potent pain medications used for severe pain relief). The adverse drug reaction includes sedation, light-headedness, euphoria (a feeling or state of intense excitement and happiness) and dysphoria (is opposite of euphoria). The concomitant use of the medication with alcohol will cause toxicity to the liver and may decrease the therapeutic effect of the medication (Nursing Drug handbook, 2015, Pages 367-369) 2. [MEDICATION NAME] 500 mg one tablet by mouth twice a day for [MEDICAL CONDITION] disorder dated July 18, 2013. [MEDICATION NAME] is a medication used for [MEDICAL CONDITION] disorder and the adverse drug reaction includes anxiety, headache, depression and the use of alcohol may cause severe sedation (Nursing Drug handbook, 2015, Pages 831-832) A review of the Physician Telephone Orders for Resident 1 indicated on September 4, 2014, at 1:30 a.m. the physician ordered to transfer Resident 1 to the hospital to rule out "alcohol consumption." At 2:10 p.m. the physician ordered may go out on pass with family members only. At 3:30 p.m., the physician ordered to transfer to the GACH for evaluation of "general weakness" and slurred speech via ambulance dated September 4, 2014. A review of the Medication Administration for the month of September 2014 indicated the resident received the medications as ordered by the physician. On September 22, 2014, at 1:41 p.m. and 3:15 p.m., Resident 1 was observed sitting in the wheelchair alert and oriented to person, place and events. During an interview at the time of the observation he stated he was drinking alcohol in the patio with Resident 2 and Resident 6 and other Residents 3, 4, and 5. Resident 1 also stated that Resident 2 knew how to leave the building (facility) unnoticed to bring alcoholic beverage from the nearby liquor store down the street. According to Resident 1 he was drinking vodka with Resident 2 and other residents. Resident 1 also stated the director of nursing (DON) knew because she came and took the bottle away. According to the plan of care dated September 15, 2013, Resident 1 had a history of [REDACTED]. Residents mix the alcohol with juice and soda. The residents when drunk show evidence of droopy eyes, flushed face, aggressive behavior, making up stories and goes in the hallway in yelling and loud voice. The goals stated on the care plan were to maintain lifestyle without alcohol daily and to have no injury from his drinking of alcohol daily. The approaches/interventions included monitor resident's behavior, comfort manipulative behavior, set limits, educate and inform resident about the policy and procedure, rules and regulations of the facility especially prohibition of alcohol. The facility did not implement the interventions on this plan of care and on the plan of care dated July 14, 2014. Resident 1 continued to consume alcohol in the facility. The licensed nursing staff continued to administer medications not to be administered with alcohol in the presence of adverse effects. On September 22, 2014, at 5:35 p.m., during an interview the DON stated Resident 2 was transferred to the general acute care hospital (GACH) for behavioral management and did not return to the facility yet. On September 24, 2014, at 3:15 p.m., during an interview the Social Service Designee (SSD), stated during staff meeting she found out both Residents 1 and 2 were in Resident 1's room and they were intoxicated. Resident 1 complained and charged Resident 2 for attempted rape. On September 25, 2014, at 2:45 p.m., during another interview the Administrator stated they (the facility) do not have policy and procedure in place regarding drinking of alcohol and smoking of marijuana. They only have "House Rules" that residents are not permitted to use alcoholic beverages in the facility. b. According to the admission record, Resident 2 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a comprehensive assessment tool) assessment dated [DATE], indicated the resident had moderately impaired cognitive skills (inability to lean remain focused and remember), trouble falling or staying asleep or sleeping too much every two to six days, no behavioral symptoms, was independent for most of the activities of daily living (ADL) such as bed mobility, transfer, walking in the room and corridor, locomotion on and off the unit, dressing eating, and personal hygiene, had an ([MEDICAL CONDITION]), and was always continent for bladder. A review of the physician's orders [REDACTED]. 1. MS-Contin ([MEDICATION NAME]) 45 mg by mouth every 12 hours for pain management dated December 19, 2013. MS-Contin is a narcotic controlled drug with a warning to avoid alcohol (Nursing Drug handbook, 2015, Pages 973). 2. [MEDICATION NAME] 4 mg by mouth daily, one hour prior to wound treatment for [REDACTED]. [MEDICATION NAME] is an opioid [MEDICATION NAME] controlled drug and the use of alcohol may cause additive effects (Nursing Drug handbook, 2015, Pages 711-712). 3. [MEDICATION NAME] 100 mg by mouth at bedtime for pain adjunct dated May 14, 2014. [MEDICATION NAME] is an antidepressant and the use of alcohol may enhance depression (Nursing Drug handbook, 2015, Pages 122). 4. [MEDICATION NAME] 40 mg by mouth daily for depression manifested by verbalization of feeling of hopelessness dated June 4, 2014. [MEDICATION NAME] is also an antidepressant and the use of alcohol may increase central nervous system (CNS) depression (Nursing Drug handbook, 2015, Pages 630-632). A review of the medication records indicated there was no documentation that medications were not given as ordered. A review of Resident 2's Resident Care Conference Review notes dated September 11, 2014, indicated the areas reviewed were resident's rights and drinking liquor. The notes indicated as part of the interdisciplinary team (IDT) duties, the facility will protect the resident and others for any dangers when they were intoxicated as before; the resident was aware of consequences of drinking positively and negatively. A review of the Resident Transfer Record dated September 18, 2014, for the September 17, 2014, transfer indicated the reason was for behavioral management with [DIAGNOSES REDACTED]. c. During the investigation, other residents who had access to alcohol and consumed unlimited amount of alcohol while taking medications that have adverse effects if taken with alcohol were the following: 1. Resident 3. A review of the physician's orders [REDACTED]. (1). [MEDICATION NAME] five milligrams (mg) - 325 mg by mouth every four hours as necessary (PRN) not to exceed three grams per 24 hours for moderate pain dated August 27, 2014. [MEDICATION NAME] is Schedule III (is the list of controlled drug as defined by the United States Controlled Substances Act) controlled drug and its side effects include sedation, mental cloudiness, impaired mental and physical performance. The use of alcohol may produce additive central nervous system effects and increase the risk for liver toxicity (Nursing Drug handbook, 2015, Pages 704-705). (2). [MEDICATION NAME] 20 mg by mouth daily for depression manifested by verbalization of feelings and anxiousness dated August 27, 2014. [MEDICATION NAME] and antidepressant and the use of alcohol may produce additive CNS effects and increase the risk for liver toxicity (Nursing Drug handbook, 2015, Pages 338-341). (3). [MEDICATION NAME] 150 mg, give 75 mg by mouth at bedtime for depression manifested by inability to sleep (record number of hours of sleep). Monitor for adverse side effects of antidepressant medications dated August 27, 2014. [MEDICATION NAME] is antidepressant medication and its adverse drug effects include confusion, tremor, anger and nightmares. The use of alcohol may enhance CNS depression (Nursing Drug handbook, 2015, Pages 1414-1416). (4).[MEDICATION NAME] mg by mouth at bedtime as necessary for [MEDICAL CONDITION] dated August 27, 2014.[MEDICATION NAME] hypnotic sedative drug with whose adverse effect included loss of memory, complex sleep related behaviors daytime drowsiness hangover and lethargy (The use of alcohol may enhance CNS depression (Nursing Drug handbook, 2015, Pages 1481-1483). (5). [MEDICATION NAME] 0.5 mg by mouth every four hours as necessary for anxiety. [MEDICATION NAME] is an anti-anxiety medication and its adverse drug reactions included sedation, drossiness, disorientation and depressing. The use of alcohol may enhance CNS depression (Nursing Drug handbook, 2015, Pages 874-875). A review of the Medication Records indicated the medications were administered to the resident as ordered. There was no documentation in the record that any medications were held due to an assessment prior to giving the medications as ordered, which led to the following: A review of Resident 3's Licensed Personnel Progress Notes dated September 3, 2014, indicated at 8 p.m. the certified nursing assistant reported to the director of nursing and RN supervisor that Resident 3 was "more weak." The notes indicated at 8:15 p.m. this was reported to the physician, who ordered to transfer the resident to the emergency room (ER) for "general weakness". A review of the Pain Assessment Flow Sheet dated September 3, 2014, at 9 p.m., prior to being sent to the ER, indicated Resident 3 complained of low back pain and was given [MEDICATION NAME] (narcotic) 1 tab together with [MEDICATION NAME] (hypnotic for sleep). A review of Resident 3's record revealed a care plan dated September 3, 2014, for episodes of drinking alcohol inside the facility. A review of the Emergency Department Report (ER) dated September 3, 2014, indicated the resident had no complaints, but was sent for "general weakness". The ER record indicated upon arrival at 10:30 p.m., the resident stated she wanted her [MEDICATION NAME] and [MEDICATION NAME], and doesn't know why she was sent there. The [MEDICATION NAME] and [MEDICATION NAME] were given according to the ER record. There was no indication in the ER record that the facility had informed the ER staff that Resident 3 was intoxicated prior to sending her to the ER. On September 4, 2014, the Resident Care Conference Review meeting notes were regarding drinking liquor. It was documented that the regulations regarding no drinking in the facility were reviewed; the nurses found a bottle of alcohol in Resident 3's room. The IDT discussed health issues about drinking alcohol while taking narcotics and other medicines. On September 24, 2014, at 3:40 p.m., during an interview Registered Nurse 1 (RN 1), who works from 3 p.m. to 11:30 p.m., she stated that she had smelled alcohol on Resident 3 (no specific date given), who had to be transferred to the hospital due to intoxication of alcohol. RN 1 also stated Resident 3 had an accident and suffered a first degree burn because she was intoxicated. A review of Resident 3's Licensed Personnel Progress Notes dated September 10, 2014, at 9:30 p.m. indicated the CNA reported to the charge nurse that the resident spilled her hot soup on her body - and ice pack was applied. The Licensed Nursing 24 Hour Care form dated September 10, 2014, indicated the resident had a first degree burn, and smelled of alcohol. Two bottles of alcohol mixed in soda were found and confiscated in Resident 3's room. 2. Resident 4. A review of the physician's orders [REDACTED]. (1). [MEDICATION NAME] 100 mg by mouth twice a day for [MEDICAL CONDITION] manifested by suspicious to his surroundings dated August 26, 2014. [MEDICATION NAME] is an antipsychotic medication whose side effects included orthostatic [MEDICAL CONDITION] (severe lowering of blood pressure in standing position), dizziness. The use of alcohol may enhance CNS depression (Nursing Drug handbook, 2015, Pages 1203-1204). (2). [MEDICATION NAME] 250 mg by mouth at bedtime manifested by mood swing for [MEDICAL CONDITION] disorder dated September 5, 2014. [MEDICATION NAME] is an anti-convulsion medication whose adverse drug reactions included dizziness, tremor, depression and emotional upset. The use of alcohol may cause excessive CNS depression (Nursing Drug handbook, 2015, Pages 1437-1439). (3).[MEDICATION NAME] mg by mouth at bedtime as necessary for [MEDICAL CONDITION] dated September 5, 2014.[MEDICATION NAME] hypnotic sedative drug with whose adverse effect included loss of memory, complex sleep related behaviors daytime drowsiness hangover and lethargy. The use of alcohol may enhance CNS depression (Nursing Drug Handbook, 2015, Pages 1481-1483). A review of the Medication Record indicated the medications were administered to the resident as ordered. The nursing staff administered medications when the resident had been drinking alcohol, leading to the potential of adverse drug reactions. During an interview on September 24, 2014, at 3:40 p.m., RN 1 stated that one night (no date given) she saw Resident 4 drinking alcohol with Resident 5. She said that Licensed Vocational Nurse 1 (LVN 1), who worked the 3 p.m. to 11 p.m. shift with her, also smelled alcohol on Resident 4, and it was reported to the physician. The physician ordered intravenous fluids be given to Resident 4 for "hydration" and she went to sleep, according to RN 1. A review of the Licensed Personnel Progress Notes dated September 10, 2014, indicated at 8 p.m., Resident 4 was seen drinking in Resident 5's room. Resident 4 asked for sleeping pills and the charge nurse noticed alcohol on her breath when talking. The charge nurse advised resident not to enter Resident 5's next time for her own safety. At 9:10 p.m., reported the incident to the physician. At 10 p.m., started intravenous (IV) hydration. A review of the [MEDICAL CONDITION] PRN/Hypnotic Medication Pre-Administration Intervention Record on September 10, 2014, [MEDICATION NAME] milligrams (hypnotic sleeping aid) was administered at 9 p.m. (after drinking alcohol). There was no indication that licensed nursing assessed the resident as safe to receive her 9 p.m. sleeping pill. On September 25, 2014, at 7:50 p.m., during an interview with Resident 4, she admitted she had been drinking in the facility. 3. Resident 5. A review of the physician's orders [REDACTED]. (1). [MEDICATION NAME] 10 mg by mouth at bedtime manifested by striking out at staff and suspicious to his surroundings for paranoid [MEDICAL CONDITION] dated February 26, 2014. [MEDICATION NAME] is an antipsychotic medication whose side effects included abnormal gait, orthostatic [MEDICAL CONDITION] and dizziness. The use of alcohol may increase CNS depression (Nursing Drug Handbook, 2015, Pages 1037-1039). (2). [MEDICATION NAME] 10 mg by mouth three times a day as necessary for spasm dated August 25, 2014. [MEDICATION NAME] is Schedule IV controlled drug use to manage anxiety. The use of alcohol cause additive CNS effects listed medication (Nursing Drug Handbook, 2015, Pages 435-437). (3). [MEDICATION NAME] 10 mg per 325 mg by mouth every three hours as necessary not to exceed three grams of [MEDICATION NAME] once a day for moderate to severe pain dated August 25, 2014. [MEDICATION NAME] is a Schedule III (is the list of controlled drug as defined by the United States Controlled Substances Act) controlled drug and its side effects include sedation, mental cloudiness, impaired mental and physical performance. The use of alcohol may produce additive central nervous system effects and increase the risk for liver toxicity (Nursing Drug handbook, 2015, Pages 704-705). (4).[MEDICATION NAME] mg by mouth as necessary at bedtime for [MEDICAL CONDITION] dated September 6, 2014.[MEDICATION NAME] hypnotic sedative drug with whose adverse effect included loss of memory, complex sleep related behaviors daytime drowsiness hangover and lethargy. The use of alcohol may enhance CNS depression (Nursing Drug Handbook, 2015, Pages 1481-1483). A review of the Medication Record indicated the medications were administered to the resident as ordered. On August 16, 2014, the Licensed Personnel Progress Notes indicated the resident went out on pass with friends, and returned with friends, with eyes red and seemed drunk. A review of Resident 5's care plan dated September 4, 2014, indicated he was at risk for [MEDICAL CONDITION], at risk for repeat [MEDICAL CONDITION], staff observed resident drunk, and episodes of getting out of the facility. The approaches included to monitor behavior, set limits, educate about policy, rules and regulations of the facility especially prohibition of alcohol and drug abuse, monitor out on pass privileges and possessions of alcohol and substance. The care plan did not address medications given when intoxicated. Resident 5 had another care plan dated September 4, 2014, for verbal behavior of threatening others, screaming at others, yelling at staff, and cursing at others. The approaches included monitor the time and day behavior occurs, set limits and remain firm. The approaches were not specific for monitoring, what "limits" were, or what the consequences were to prevent future incidents from occurring. The care plan did not address medications given when intoxicated. On September 4, 2014, a Resident Care Conference Review was held to address Resident 5's behavior toward staff, alcohol drinking inside the facility, leaving the facility without a pass, and regarding him providing alcohol to other residents, according to other residents' allegations. It was documented he denied it. There was no discussion regarding the hazards of medications given with alcohol. On September 3, 2014, at 8:30 p.m. the Licensed Personnel Progress Notes indicated the physician ordered to send Resident 5 to the hospital for the condition of "general weakness." At 9:30 p.m., the resident had left the facility without permission, and was missing. Staff searched and the police were contacted. At 11:45 p.m. the resident was returned to the facility by the police, "agitated and intoxicated." He was in the patio, refused to go to the hospital, and was verbally abusive to the staff. The Licensed Personnel Progress Notes indicated Resident 5's behavior continued on September 4, at 1 a.m. The resident was on the patio "drinking alcohol." At 1:30 a.m., the resident was on the patio with other residents (facility did not identify) and was very agitated and abusive to all the nursing staff. The resident didn't want staff there and continued to be abusive. At 1:45 a.m., the notes indicated Resident 5 was still abusive and noncompliant with the facility's policy (for drinking) and refused to go to his room. Staff called the police for assistance, and police came at 2 a.m.; the resident was still abusive. At 2:15 a.m. police left after talking to the resident; the resident wheeled around the facility into other resident rooms "disturbing and affecting" other residents. The resident's loud aggressive and abusive behavior and cursing towards residents and staff continued through 7 a.m. During the September 24, 2014, at 3:40 p.m. interview with RN 1, she stated that on the same night of Resident 3's intoxication (no time given), she believed Resident 5 was drinking because he smelled of alcohol. She said Resident 5 was talkative, had a flushed face, and smelled of alcohol. On another occasion she saw Resident 5 drinking alcohol with a visitor in his room (no date given). She told the visitor alcohol was not allowed, and Resident 5 was also not allowed to drink alcohol. She said she believed that Resident 5 drinks alcohol two to three times a month, and that he distributed alcohol to other residents but could not prove it because she never caught him in the act. 4. Resident 6. A review of the physician's orders [REDACTED]. (1). [MEDICATION NAME] 5/325 mg by mouth every four hours as needed for pain dated August 9, 2013. [MEDICATION NAME] 5/325 mg by mouth every four hours as necessary (PRN) not to exceed three grams per 24 hours for moderate pain dated August 27, 2014. [MEDICATION NAME] is Schedule III (is the list of controlled drug as defined by the United States Controlled Substances Act) controlled drug. Its adverse effects included sedation, mental cloudiness, and impaired mental and physical performance. The use of alcohol may produce additive central nervous system effects and increase the risk for liver toxicity (Nursing Drug handbook, 2015, Pages 704-705). (2). [MEDICATION NAME] 10 mg by mouth daily for depression manifested by verbalization of sadness dated May 25, 2014. [MEDICATION NAME] is an antidepressant medication and its adverse drug reactions included suicidal behavior. The use of alcohol may produce additive central nervous system effects and increase the risk for liver toxicity (Nursing Drug handbook, 2015, pages 540-542). A review of the Medication Record indicated the medications were administered to the resident as ordered. Resident 6's Minimum Data Set (MDS), an assessment and care screening tool, dated August 22, 2014, indicated the resident had severe impairment for cognitive patterns. A review of Resident 6's Resident Care Conference Review notes dated August 26, 2014, indicated the IDT addressed the resident's refusal to take medications, and her drinking alcohol, including drinking inside the facility. The notes indicated that she denied that she was drinking and the facility policy and protocol was brought to her awareness; they would "continue to monitor". There was no indication that the IDT addressed adverse drug reactions when mixing alcohol with medications. There was another care plan for Resident 6 for episodes of drinking alcohol inside the facility and the potential for withdrawal symptoms dated September 25, 2014. The goal was for Resident 6 not to take anything other than that directed and prescribed by the physician, and to maintain a lifestyle without alcohol. The approaches included to monitor for resident's behavior and discuss any observations with her, confront manipulative behavior, and set limits. Educate and inform resident about policy, rules and regulations of the facility especially prohibition of alcohol, and monitor resident's out on pass privileges and possessions of alcohol. The care plan did not have specific interventions to protect Resident 6 from adverse drug reactions from mixing alcohol with medications. On September 25, 2014, at 3:47 p.m., during an interview with Licensed Vocational Nurse 2 (LVN 2), she stated residents that she knew had drinking problems included Residents 1, 3, 4, and 6. She also stated she talked to the residents regarding the alcohol drinking problem. Some of them like Resident 1 admit the use of alcohol and others denied. LVN 2 stated she had observed these residents intoxicated, and most of the time they were verbally abusive. She said she reported this to the DON. While Residents 1, 2, 3, 4, 5 and 6 received medications as ordered, and appeared to have unlimited access and consumption to alcohol, the facility interdisciplinary team (IDT) that included the physician, did not develop or implement a plan to control and prevent the adverse effects when residents continued to mix alcohol consumption and taking medications.

Based on observation, interview, and record review, the facility failed to ensure that Resident 1 was free from sexual abuse by Resident 2, who was intoxicated and would not leave Resident 1's room. The facility failed to enforce House Rules that prohibited intoxication and uninvited residents in others' rooms, and failed to implement care plans for behavior,which led to the unwanted sexual abuse of Resident 1. Findings: On September 22, 2014, at 12:42 p.m., the Department received from the facility an entity reported incident (ERI) that one resident (Resident 1) alleged another resident (Resident 2) was sexually abusive towards him on September 17, 2014, at 11 p.m. inside Resident 1's room. The report indicated the police department was called and took Resident 2 away in handcuffs. Resident 2 was taken to the hospital, returned back to the facility and was readmitted on [DATE]. Resident 2 was sent for behavioral management to the general acute care hospital (GACH) on September 18, 2014. The report also stated the residents were intoxicated. Resident 1 A review of the Consultation Report from the general acute care hospital (GACH) dated July 6, 2013, indicated Resident 1 had recurrent admissions to the hospital for [MEDICAL CONDITION] and alcoholic toxicity and withdrawal. According to the skilled nursing facility (SNF) admission record, Resident 1 was admitted to the facility on July 17, 2013, with [DIAGNOSES REDACTED]. A review of Resident 1's care plan dated September 15, 2013, which was still current, indicated he had a history of [REDACTED]. When the resident is drunk, he shows aggressive behavior, making up stories and goes in the hallway and yells in a loud voice. The goals were to maintain lifestyle without alcohol daily and to have no injury from his drinking of alcohol daily. The approaches included to monitor the resident's behavior and discuss any observation with him, confront manipulative behavior, and set limits (non-specific). Educate and inform resident about the prohibition of alcohol. The Initial History and Physical dated June 10, 2014, indicated Resident 1 had the capacity to understand and make decisions. There was a care plan dated September 9, 2014, for Resident 1's episodes of drinking alcohol inside the facility. The care plan was updated on September 17, 2014, and included the dinking with Resident 2 in his room. A review of the Minimum Data Set (MDS), an assessment and care screening tool, dated September 10, 2014, indicated the resident's cognitive patterns were intact, and had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) that occurred daily. The MDS section for behavior indicated the symptoms significantly interfered with Resident 1's care, and significantly intruded on the privacy or activity of others. The resident required limited assistance from staff and normally used a walker and wheelchair as mobility devices. Resident 2 According to the admission record, Resident 2 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment and care screening tool, dated August 12, 2014, indicated the resident's cognitive patterns were moderately impaired and was independent with transfers and walking. A review of Resident 2's Resident Care Conference Review document dated September 11, 2014, indicated the areas reviewed were resident's rights and drinking liquor. The interdisciplinary team (IDT) were to "protect the resident and others for any dangers when they were intoxicated." The document indicated that the resident was aware of consequences of drinking positively and negatively. A review of the Licensed Personnel Progress Notes dated September 17, 2014, at 11:30 p.m., indicated Resident 2 was alert, intoxicated, and aggressive. Resident 2 came to Registered Nurse 1 (RN 1) with aggressive behavior. The resident went back towards his room, punching the walls of the hallway and was yelling. The resident was slamming the door of his room several times and was yelling and cursing at everybody. Resident 2 tried to attack the LAPD officers, was contained and put to the ground and transported to the GACH, still in aggressive state. On September 22, 2014, at 6:35 p.m., during an interview, Resident 1 was observede sitting in his room in his wheelchair, alert and oriented to person, place, time, and events. During an interview at this time, Resident 1 stated that on the night of the incident, he was drinking alcohol on the patio outside of his room with two other residents (2, 6). Resident 1 stated that he and Resident 2 went to his room and were watching a pornographic video. Resident 2 came between his legs, put his hands inside his pants in his scrotal area, squeezed his arms and kissed, licked, and sucked his left cheek. When Resident 1 was explaining, he was very hyper and agitated, and said he wanted Resident 2 to stop. So he yelled for help, told Resident 2 to stop, but Resident 2 didn't stop until the certified nursing assistant (CNA 1) intervened. Resident 1 stated he was afraid that Resident 2 was going to come back to the facility, and said he asked the administrator to provide a nurse or security outside his room. On September 24, 2014, at 3:15 p.m., during an interview with the Social Service Designee (SSD), she stated that she found out about the sexual abuse incident between Resident 1 and Resident 2 during the department head stand-up meeting on the next morning, September 18, 2014. She said when she spoke to Resident 1 after the incident, he told her Resident 2 attempted to rape him in his room. When asked if she had done any counciling as her position as SSD, she stated not yet. She could not provide documentation regarding her conversation with Resident 1. During an interview with RN 1 on September 24, 2014, at 3:40 p.m., she stated she was working on September 17, 2014 when the sexual assault occurred. She said Resident 2 came to her at the nursing station after the incident. Resident 2 was walking, going to his room, mad, yelling, slamming the door, and was agitated. She said Resident 2 then came back to the nursing station where CNA 1 was talking about the incident, and Resident 2 was about to hit CNA 1, until RN 1 told CNA 1 to move away. RN 1 said she told Resident 2 to calm down, and he placed his left hand on her lower back area and pressed and pulled her towards him. She said she was on the phone with the director of nursing (DON) at the time, so the DON was aware of the incident. She said the licensed vocational nurse (LVN 1) intervened, and Resident 2 went back to his room yelling, screaming, agitated, and slammed the door. She said she asked LVN 1 to call the police. RN 1 was crying at times during the interview, and said that if Resident 2 was readmitted to the facility, she would be forced to resign. There were no physician orders that indicated Resident 1 or Resident 2 could receive alcohol. This was verified during a review of both residents' records on September 24, 2014, at 3:40 p.m., with RN 1. On September 24, 2014, at 7 p.m., and September 25, 2014, at 2:45 p.m., during interviews with the administrator, he said they had conducted an investigation regarding the incident between Resident 1 and Resident 2 on the evening of September 17, 2014. He said they could not substantiate the sexual abuse because CNA 1's statement was different from Resident 1's. When the administrator was asked if he thought this was abuse when CNA 1 explained his observation of Resident 2 grabbing Resident 1's shoulders, and Resident 1's request to CNA 1 to get Resident 2 off of him because he was trying to "rape" him, the administrator stated he couldn't substantiate the abuse because the stories were different. He stated they do not have a policy and procedure in place regarding excessive drinking of alcohol, but have "House Rules" dated September 2014. During the above interviews, the administrator could not provide written evidence that there had been a thorough investigation into all of the facts surrounding the sexual abuse of Resident 1 by Resident 2. The administrator said that Resident 1 had asked him to provide security or a nurse outside his room because he was afraid of Resident 2. The administrator said that he had never promised he would provide security outside Resident 1's room. He stated that they were not planning on readmitting Resident 2. The administrator was informed that during the Department's investigation it was determined from interviews of staff and the facility's documentation, that alcohol and/or marijuana use was a problem in the facility, and was a precursor to the agressive behavior of the residents. There was no evidence provided by the administrator to demonstrate that the House Rules were followed by the facility, including consequences for the residents' actions as indicated in the House Rules. The "House Rules" dated September 2014 were reviewed and included the following: The facility does not allow the possession of alcohol and prohibits residents from drinking or offering alcoholic beverages to other residents. The consumption and use of alcohol will not be tolerated and residents in violation will be asked to make other living arrangements. Any behavior which is a threat to oneself or others is grounds for eviction. The use, possession, sale of illicit and illegal drugs in the facility is prohibited. You should not be under the influence of drugs or alcohol while at the facility. You must not be under the influence of drugs or alcohol when you return to the facility. Residents are not allowed to be in another resident ' s room if not invited by the occupant of the room. Profane or improper language is prohibited. On September 25, 2014, at 3:47 p.m., during an interview with LVN 2 she stated that the residents would scream and curse at you when you attempt to address their drinking issues, and that they were verbally abusive most of the time when they were intoxicated. On September 25, 2014, at 5:30 p.m., during an interview with LVN 2 and LVN 3, the stated that Resident 1 was verbally abusive, which they reported to management. They also stated that they do not document some incidents or any behavioral changes to the residents because management does nothing about it. They stated that the drinking of alcohol and smoking of marijuana had been going on for about seven months and everybody knows it. On September 26, 2014, at 5:30 p.m., during a telephone interview with CNA 1 regarding the incident on September 17, 2014, he stated Resident 1's call light was on, and he was yelling for help. When CNA 1 opened Resident 1's bedroom door, he saw Resident 2 fall onto his back, and Resident 1 was sitting in his wheelchair, and yelling that Resident 2 was trying to rape him. Resident 1 asked him to get Resident 2 out of the room. Resident 2 got up and grabbed Resident 1's shoulders, and CNA 1 told Resident 2 to let go of Resident 1, and Resident 1 was yelling. Resident 2 then let go of Resident 1 and started yelling at CNA 1, with his face a couple of inches from his face. CNA 1 went to nursing station 2 to report, and Resident 2 followed him there, and started yelling and punching the walls. Cross Reference to tags F226, F323, and F329

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment and/or abuse by intoxicated residents, and failed to ensure that staff were trained to address problematic intoxicated and combative residents, and failed to identify and thoroughly investigate incidents caused by intoxicated residents to prevent and protect residents from further abusive behaviors for two of six residents, with the potential for other residents to be abused (1, 2). Findings: On September 22, 2014, at 12:42 p.m., the Department received from the facility an entity reported incident that one resident (Resident 1) alleged another resident (Resident 2) was sexually abusive towards him on September 17, 2014, at 11 p.m. inside Resident 1's room. The police department was called and took Resident 2 away in handcuffs. Resident 2 was taken to the hospital, returned back to the facility and was readmitted on [DATE]. Resident 2 was sent for behavioral management to the general acute care hospital (GACH) on September 18, 2014. The report also stated the residents were intoxicated. A review of Resident 1's care plan dated September 15, 2013, which was still current, indicated he had a history of [REDACTED]. When drunk, he shows evidence of aggressive behavior, making up stories and goes in the hallway and yells in a loud voice. The goals were to maintain lifestyle without alcohol daily and to have no injury from his drinking of alcohol daily. The approaches included to monitor the resident's behavior and discuss any observation with him, confront manipulative behavior, and set limits (non-specific). Educate and inform resident about the prohibition of alcohol. The Initial History and Physical dated June 10, 2014, indicated Resident 1 had the capacity to understand and make decisions. There was a care plan dated September 9, 2014, for Resident 1 ' s episodes of drinking alcohol inside the facility. The care plan was updated on September 17, 2014, which included an episode of drinking with another resident (Resident 2) in his room. The Minimum Data Set (MDS), an assessment and care screening tool, dated September 10, 2014, indicated the resident's cognitive patterns were intact, no mood signs and symptoms, and had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) that occurred daily. The MDS section for behavior indicated the symptoms significantly interfered with Resident 1's care, and significantly intruded on the privacy or activity of others. According to the admission record, Resident 2 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment and care screening tool, dated August 12, 2014, indicated the resident's cognitive patterns were moderately impaired, no behavioral symptoms, and was independent with transfers and walking. A review of Resident 2's Resident Care Conference Review document dated September 11, 2014, indicated the areas reviewed were resident's rights and drinking liquor. The interdisciplinary team (IDT) were to "protect the resident and others for any dangers when they were intoxicated." The document indicated that the resident was aware of consequences of drinking positively and negatively. A review of the Licensed Personnel Progress Notes dated September 17, 2014, at 11:30 p.m., indicated Resident 2 was alert, intoxicated, and aggressive. Resident 2 came to Registered Nurse 1 (RN 1) with aggressive behavior. The resident went back towards his room, punching the walls of the hallway and was yelling. The resident was slamming the door of his room several times and was yelling and cursing at everybody. At 11:40 p.m., the police department (LAPD) came and Resident 2 tried to attack the LAPD officers, was contained and put to the ground; at 11:45 p.m., the resident was transported to the GACH, still in aggressive state. There were no physician orders that indicated Resident 1 or Resident 2 could receive alcohol. The Emergency Department Report dated September 18, 2014, indicated Resident 2 was admitted for combative behavior. The resident was aggressive, agitated, spitting, cursing, would not answer any questions and was combative in the emergency room . The resident stated that he wanted to get out (of the hospital) and he was going to try to hurt people. The resident was diagnosed with [REDACTED]. On September 22, 2014, at 6:35 p.m., during an interview Resident 1 stated that he and two other residents (2, 6) were drinking alcohol before he was sexually assaulted by Resident 2. On September 24, 2014, at 3:15 p.m., during an interview with the Social Service Designee (SSD), she stated that she found out about both residents being intoxicated on September 17, 2014, during the department head stand-up meeting on the next morning, September 18, 2014. The SSD stated that she did not know of any other residents who were intoxicated that night except the two involved (Resident 1 and 2). Resident 1 told her Resident 2 attempted to rape him in his room. When asked if she had done any investigation or counciling as her position as SSD, she stated no because the administrator was the abuse coordinator and would do the investigation. The SSD stated she knew that both residents were drinking alcohol. When asked is she had documented her actions or interventions, she stated she did not document anything yet. On September 24, 2014, at 7 p.m., and September 25, 2014, at 2:45 p.m., during interviews with the administrator, he gave conflicting information regarding the knowledge of residents being intoxicated in the facility. He said they had conducted an investigation regarding drinking issues in the facility. He said they had conducted an investigation regarding the incident between Resident 1 and Resident 2 on the evening of September 17, 2014, but could not substantiate the sexual abuse because CNA 1's statement was different from Resident 1's. When CNA 1's evidence was presented to the administrator regarding Resident 2 grabbing Resident 1's shoulders in the presence of CNA 1, and Resident 1 stating to CNA 1 to get Resident 2 off of him and that Resident 2 was trying to "rape" him, he still stated the stories were different. The administrator stated they do not have a policy and procedure in place regarding excessive drinking of alcohol and smoking of marijuana. They only have "House Rules", which were created and dated September 2014. During the interviews on September 24 and 25, 2014, when asked to provide documented evidence of the investigation or any counciling regarding excessive drinking or smoking pot, he was not able to provide any investigation except for the incident between Resident 1 and Resident 2 on the evening of September 17, 2014. A review of the facility's Investigation Report dated September 17, 2014, indicated there was no written evidence that there had been a thorough investigation into all of the facts surrounding the sexual abuse of Resident 1 by Resident 2. During the Department's investigation it was determined that the alleged alcohol and/or marijuana use in the facility was a precursor to the agressive behavior of residents. The administrator could not provide evidence that there was a thorough investigation by the facility as to how or where residents were getting alcohol into the facility; there was no evidence that residents' activity of noncompliance was monitored once they were known to violate house rules of no alcohol. There was no evidence provided by the administrator to demonstrate that the House Rules were followed by the facility, including consequences for the residents' actions as indicated in the House Rules. The "House Rules" dated September 2014 were reviewed and included the following: The facility does not allow the possession of alcohol and prohibits residents from drinking or offering alcoholic beverages to other residents. The consumption and use of alcohol will not be tolerated and residents in violation will be asked to make other living arrangements. Any behavior which is a threat to oneself or others is grounds for eviction. The use, possession, sale of illicit and illegal drugs in the facility is prohibited. You should not be under the influence of drugs or alcohol while at the facility. You must not be under the influence of drugs or alcohol when you return to the facility. Residents are not allowed to be in another resident ' s room if not invited by the occupant of the room. Profane or improper language is prohibited. A review of the Investigation Report Regarding Allegation of Sexual Abuse (undated) with the administrator on September 25, 2014, at 2:45 p.m., indicated Resident 2 had an incident of drinking alcohol with " other residents " on September 4, 2014. " One resident brought alcohol and offered drinks to other residents, including Resident 2. " When the administrator was asked who the other residents were, he could not say. When asked who the resident was that was providing alcohol to other residents, he said he didn ' t know. He stated he suspected it was Resident 5. On September 25, 2014, at 3:20 p.m., during an interview with the DON, she stated sometime in February 2014, there was an incident regarding Resident 5 smoking marijuana in the facility. When asked to provide the facility's investigation and actions in this matter, she was not able to provide any documentation. On September 25, 2014, at 3:47 p.m., during an interview with Licensed Vocational Nurse 2 (LVN 2), she stated she knew of four residents who had drinking problems (Residents 1, 3, 4, and 6). She stated that the residents would scream and curse at you when you attempted to address their drinking issues. She stated that they were verbally abusive most of the time when they were intoxicated. When asked if she was given any in-service regarding how to protect herself or residents from alcohol or drug intoxicated residents, or assaultive behavior, she said there was no in-service that was given to her. On September 25, 2014, at 5:30 p.m., during an interview with LVN 2 and LVN 3, they stated they did not know who the abuse coordinator of the facility was. According to LVN 2 and LVN 3, Resident 1 was verbally abusive, which they reported to management. They also stated that they do not document some incidents or any behavioral changes to the residents because management does nothing about it. They stated that they used to have behavior monitoring but not anymore because they feel helpless and hopeless. LVN 2 and LVN 3 stated that the drinking of alcohol and smoking of marijuana had been going on for about seven months that they knew and heard of. They also stated that everybody knows it, but would not give specific resident names or incident dates. At 6 p.m., during an interview with LVN 2, she stated if she was assaulted by an intoxicated resident, she would fight back. When asked if she was given any in-service regarding how to protect herself or residents from alcohol or drug intoxicated residents, or assaultive behavior, she said there was no in-service that was given to her. She stated that everybody knows about the residents who are intoxicated or smoking pot. And, the residents have friends that visit and get drunk; she said she reports it to administration right away. On September 26, 2014, at 5:30 p.m., during a telephone interview with CNA 1 regarding the incident on September 17, 2014, he stated Resident 1's call light was on, and he was yelling for help. When CNA 1 opened Resident 1's bedroom door, he saw Resident 2 fall onto his back, and Resident 1 was sitting in his wheelchair, and yelling that Resident 2 was trying to rape him. Resident 1 asked him to get Resident 2 out of the room. Resident 2 got up and grabbed Resident 1's shoulders, and CNA 1 told Resident 2 to let go of Resident 1, and Resident 1 was yelling. Resident 2 then let go of Resident 1 and started yelling at CNA 1, with his face a couple of inches from his face. CNA 1 slowly walked towards the door and Resident 2 followed him out the door, went to Station 2, and started yelling and punching the walls. Cross Reference to tags F223 and F323