Every finding on record at Palos Verdes Health Care Center

Based on interviews and record reviews, the facility failed to ensure a safe discharge for one of three sampled residents (Resident 3), who was admitted to the facility on [DATE] with diagnoses subarachnoid hemorrhage (when a tiny blood vessel on the outside of the brain pops and leaks blood), falls, and fracture of the skull (a crack or a break in the hard bone of your head that protects your brain) and was discharge two days later to a board and care (a small, residential home that provides 24-hour room, meals, and non-medical personal assistance for people who need help with daily routines) facility. Facility failed to:1. Ensure an Interdisciplinary (IDT group of health care professionals who work together on the same plan of care) meeting was held to assess Resident 3's cognitive (ability to think, understand, learn, and remember), medical, physical, and psychosocial (emotional wellbeing) needs prior to discharging the residents to a lower level of care.2.Ensure Resident 3 care needs, clinical condition, wound treatment requirements, and resident representative notification were properly reviewed and communicated prior to transfer to a lower level of care.3. Ensure reasonable and appropriate attempts were made to meet the resident's needs, including addressing the resident's refusal of wound care and his expressed desire to come and go from the facility.4. Ensure Resident 3 health records contained sufficient documentation supporting the basis for the discharge, including the specific resident needs that could not be met, the facility's attempts to meet those needs, and the services available at the receiving board and care facility to meet those needs.These failures resulted in Resident 3 being transferred to a board and care without proper discharge planning by the facility. On 8/7/2026 Resident 3 was found by Emergency Medical Service (EMS-a system that provides urgent pre-hospital medical care and transport for serious illnesses and injuries) laying on his right side on the sidewalk with altered mental status ([AMS] a person is not thinking, acting, or reacting the way they normally do). Resident 3 was transported to General Acute Care Hospital (GACH) on 8/7/2026.This placed Resident 3 at risk for experiencing falls, harsh weather conditions, environmental dangers including motor vehicle accidents, and assault.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including subarachnoid hemorrhage, cerebral infarction (lack of adequate blood supply to the brain ) falls, fracture of the skull (a crack or a break in the hard bone of your head that protects your brain).During a review of Resident 3's Minimum Data Set (MDS a resident assessment tool) dated 7/22/2026, the MDS indicated Resident 3 had moderate cognitive impairment. The MDS indicated Resident 3 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for toileting hygiene, shower, upper and lower body dressing and personal hygiene.During a review of Resident 3's Order Summary Report dated 7/21/2026, the Order Summary Report indicated left forearm burn wound, cleanse/irrigate with normal saline ( wound cleanser) then Vashe solution (wound cleanser), apply honey gel and cover with dry dressing daily and as needed.During a review of Resident 3's Progress Notes dated 7/22/2026 at 1:09 p.m., the Progress Notes indicated Resident 3 was discharged to a board and care facility for a lower level of care. The notes indicated that the resident wanted to perform his own dressing changes, was shown how to do them, and was advised to use gloves to prevent infection.During a review of Resident 3's Notice of Transfer/discharge date d 7/22/2026, the notice indicated the transfer or discharge was appropriate because the resident's health had improved sufficiently and no longer required the services provided by the facility.During an interview on 8/12/2026 at 1:30 pm with the Director of Nursing (DON), the DON stated Resident 3 was admitted to the facility on [DATE] from a GACH. The DON stated Resident 3 was independent with his care needs and he was transferred to a board and care because he required a lower level of care. The DON stated Resident 3 had a wound on his left forearm and required daily dressing changes. The DON stated Resident 3 was discharged from the facility on 7/22/2026 and the admission Coordinator was the one who initiated the discharge. The DON explained the discharge process was initiated and coordinated by the appropriate clinical and administrative personnel based on the resident's clinical needs and the facility's discharge planning procedures. She stated that the resident's medical condition, nursing needs, medications, treatments, functional status, and other care needs had to be reviewed to determine whether the proposed receiving setting was appropriate to meet the resident's needs. She stated that the discharge process required proper review, communication, documentation, and coordination before the resident left the facility. The DON stated that, prior to discharge or transfer, the facility should ensure the receiving facility was able to meet the resident's care needs, that the necessary medical information and orders were communicated, and that the resident and/or responsible party, along with other appropriate individuals, were involved in the discharge process as applicable. The DON stated the admission Coordinator should not have initiated the discharge independently and the appropriate discharge process should have been followed with involvement of IDT and administration. The DON stated inappropriate discharges could place Resident 3 in an inappropriate or unsafe setting that may not be able to meet his medical, nursing, or supervision needs. The DON stated an inappropriate discharge could result in a disruption in the resident's continuity of care, medications, treatments, physician follow-up, or other services required by the resident. The DON stated that failure to follow the discharge process could result in the resident and/or responsible party not receiving the required information or notices and could result in the facility failing to properly coordinate the resident's transition to the receiving facility. The DON stated the facility was responsible for ensuring Resident 3's discharge was appropriately planned, coordinated, and documented before the resident was transferred to another setting.During an interview on 8/12/2026 at 1:43 p.m., the Admissions Coordinator (AC), the AC stated she submitted a referral on 7/22/2026 for Resident 3 to a board and care facility after Resident 3 expressed a desire to leave the facility and come and go as he pleased on passes. She stated Resident 3 wanted greater freedom to leave and return as he wished. The AC stated because of the resident's request, she searched for a board and care placement and submitted a referral on his behalf. She stated Resident 3 was accepted by the board and care facility the same day (7/22/2026). The AC stated Resident 3's resident representative (RR 1) was made aware of the proposed placement. She acknowledged she should not have initiated the discharge process independently and should have referred Resident 3's request to the appropriate nursing, clinical, and administrative personnel for review and follow up instead of independently searching for a placement and submitting the referral.During a concurrent interview and record review on 8/12/2026 at 2:00 pm with the Treatment Nurse (TN), Resident 3's Wound assessment dated [DATE] was reviewed, the Wound Assessment indicated, the wound was located on the resident's left forearm and measured approximately seven centimeter (cm- unit of measurement) in length by two cm in width, depth unstageable (unable to determine) with approximately 50 percent (%) slough (a soft, moist layer of dead tissue and 50 % granulation tissue ( growth of new, tiny blood vessels that fill in an open wound as it heals). The TN stated there was a small/light amount of serosanguineous (fluid is a light pink, watery liquid that drains from a wound) drainage and no odor. The TN stated she did not perform wound care on 7/22/2026 because Resident 3 had been discharged from the facility. The TN stated she was not informed Resident 3 was being discharged . The TN stated under the facility's discharge process, when a resident with an active wound was discharged , she provided the resident with wound care supplies for approximately three days and educated or demonstrated to the resident how to perform dressing changes until the home health nurse arrived or assessed the resident. The TN stated because she was unaware Resident 3 was being discharged , she was unable to perform a final wound assessment, determine the condition of the left forearm wound at discharge, provide wound care supplies, or provide wound care education. She stated the wound treatment remained ordered and was still required at the time Resident 3 was discharged . The TN stated she did not know whether a report regarding the resident's left forearm wound and ongoing wound care treatment had been provided to the receiving board and care facility and could not confirm whether the facility received the wound care orders or instructions needed to continue treatment. She stated Resident 3 could miss required wound treatments and the wound could worsen. She stated inadequate or interrupted wound care could result in increased drainage, infection, delayed healing, or deterioration of the wound, and without wound care supplies, instructions, and follow up, treatment could be delayed until the receiving facility or home health nurse became aware of the resident's needs.During a telephone interview on 8/12/2026 at 4:00 p.m. with RR 1, RR 1 stated she was never notified by the facility that Resident 3 was being transferred to a board and care facility. She stated she learned of the transfer only when RR 2 contacted her and told her Resident 3 had been moved to a board and care. RR 1 stated on 8/5/2026, Resident 3 called and said the board and care facility was asking him to leave. She stated Resident 3 then took a bus to a park, where police later found him unconscious and transported him to a GACH. RR 1 stated she later received a call from the GACH notifying her Resident 3 had been admitted . She stated that when she visited Resident 3 at the GACH, she was informed he had experienced a stroke (a medical emergency that happens when blood flow to a part of the brain is cut off). RR 1 stated currently Resident 3 was unable to communicate effectively, had difficulty speaking, was unable to ambulate, and was currently unable to walk.During a review of Resident 3's Emergency Department (ED) Provider Notes dated 8/7/2026, the ED notes indicated, resident brought in Fire Department from street with chief complaint of altered mental status ([AMS] a sudden or gradual change in a person's normal thinking, awareness, attention, or level of consciousness), noted involuntary (uncontrolled) movements on right side arm and face.During a review of Resident 3's GACH discharged Summary dated 8/13/2026, GACH discharged Summary indicated resident was presented to ED on 8/7/2026 with AMS and right facial/right upper extremity involuntary movements concerning focal seizure (abnormal electrical impulses). The summary indicated magnetic resonance imaging (MRI- medical test that make clear pictures of the inside of the body) showed left temporal lobe (part of the brain) abnormality suggesting an unusual parenchymal hematoma measuring six cm by 1.5 cm by 2.7 cm.During a review of the facility's policy and procedure (P&P) titled Discharge Summary and Plan, dated 2016, the P&P indicated The post-discharge plan will be developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and will include: e. How the IDT will support the resident or representative in the transition to post-discharge care; f. What factors may make the resident vulnerable to preventable readmission; and g. How those factors will be addressed.

Based on interview and record review, the facility failed to report an allegation of verbal abuse in a timely manner for one of two sampled residents (Resident 1). The facility failed to:1. Report allegation of verbal abuse in a timely manner. Resident 1 reported the verbal abuse to Certified Nursing Assistant (CNA) 1 on 3/28/2026 at 5:00 a.m. CNA 1 reported it to Licensed Vocational Nurse (LVN)1 on 3/28/2026 at around 5:30 a.m. LVN 1 then reported the the allegation to Registered Nurse Supervisor (RNS)1 on 3/28/2026 at 7:15 a.m. SOC 341 ( Report of Suspected Dependent Adult -Elder Abuse- California form used by mandatory reporters to officially report suspected abuse, neglect, or financial exploitation of elders 65 years and above) indicated it was faxed on 3/28/2026 at 2:20 p.m.to California Department of Public Health (CDPH).2.Follow the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating, which indicated allegations of abuse should be reported immediately (immediately is defined as within two hours of an allegation involving abuse per P&P).These failures had the potential to delay the State agency's investigation and placed Resident 1 at risk for further occurrences of abuse.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or reduced control on one side of the body) following cerebral infarction (stroke-blood flow to a part of the brain is interrupted by a blockage or burst vessel) and major depressive disorder ( mental health condition characterized by persistent feeling of sadness).During a review of Resident 1's History and Physical (H&P) dated 10/16/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues) with eating, and substantial / maximal assistance (helper does more than half the effort) with transferring to and from a bed to chair or wheelchair. The MDS indicated Resident 1 had the ability to understand others and express his ideas and wants.During a review of Resident 1's Progress Notes dated 3/28/2026 timed at 5:21 a.m., the Progress Notes indicated Resident 1 stated Resident 2 was antagonizing him and was calling him names like, Faggot, and Cry Baby. The Progress Notes indicated the author of the Progress Notes was LVN 1.During the review of Resident 1's Progress Notes dated 3/28/2027 at 7:27 a.m., the Progress Notes indicated LVN 1 reported to Registered Nurse Supervisor (RNS) 1 that Resident 1 and Resident 2 should have a room change due to alleged name calling directed at Resident 1. The notes also indicated RNS 1 will speak with both Resident 1 and Resident 2.During a review of Resident 1's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, understand, learn, and remember] behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 3/28/2026 timed at 10:09 a.m., the COC indicated around 9:30 a.m. to 10:00 a.m. RNS 1 interviewed Resident 1 and Resident 2. The COC indicated Resident 2 allegedly threatened Resident 1 by saying, I will kill you. The COC indicated the Administrator, Director of Nursing, physician and family were notified.During a review of Resident 1's Care Plan titled, Resident 1 reports anger, irritation, or dislike towards Resident 2's yelling, insults, name calling and verbal threats, initiated on 3/30/2026. The Care Plan interventions included maintaining a safe environment for all patients and separating patient.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), diabetes mellitus, pleural effusion( abnormal buildup of excess fluid between the thin membranes lining the lungs and the chest cavity), and dependence on renal dialysis( patient must use a machine or a specialized treatment to filter their blood regularly because their kidneys stopped working well).During a review of Resident 2's H&P dated 3/26/2026, the H&P indicated Resident 2 had fluctuating 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 express ideas and wants and understand others. The MDS indicated Resident 2 required supervision with eating and substantial /maximal assistance with transferring to and from the bed to chair or wheelchair.During a review of Resident 2's COC dated 3/28/2026 and timed at 10:20 a.m., the COC indicated around 9:30 a.m. to 10:00 a.m. Resident 1 stated Resident 2 was allegedly threatening him by saying, I will kill you. The COC indicated Resident 2 stated he did not say anything and Resident 1 started to scream. The COC indicated Resident 2 told Resident 1 to be quiet in a language other than English.During a review of Resident 2's Care Plan titled, The Resident has the potential to be verbally aggressive, alleged threatening words, I will kill you, to Resident 1 initiated 3/28/2026, the Care Plan indicated to intervene before agitation escalates by guiding away from sources of distress.During a review of Resident 2's Progress Notes dated 3/29/2026 at 12:52 p.m., the Progress Notes indicated Resident 2 left the facility against medical advice (AMA-patient leaving a facility before the physician recommends discharge).During an interview on 4/1/2026 at 10:54 a.m., CNA 2 stated that he learned about the incident between Resident 1 and Resident 2 at 7:15 a.m. on 3/28/2026, when LVN 1 informed him that the two residents had been fighting. CNA 2 stated staff must report any allegation of abuse immediately and that he would report such allegations to his charge nurse. CNA 2 stated everyone in the facility is a mandated reporter of abuse and that the interaction between Resident 1 and Resident 2 constituted verbal abuse.During a telephone interview on 4/1/2026 at 11:07 a.m., with LVN 1, LVN 1 stated Resident 1 and Resident 2 were arguing during her shift on 3/28/2026 at around 6:00 a.m. LVN 1 stated CNA 1 informed her during the 5:30 a.m. medication pass that Resident 1 and Resident 2 were arguing. LVN 1 stated she went to speak with both residents and learned from Resident 1 that Resident 2 had been calling him names (faggot and cry baby). LVN 1 stated she informed RNS 1, who arrived around 7:15 a.m. on 3/28/2026, to request a room change for both residents because they were arguing. LVN 1 stated she did not separate the residents immediately because she believed only the Social Service Director (SSD) or RNS 1 could authorize room changes. LVN 1 stated staff should report allegations of abuse to the abuse coordinator or the Director of Nursing (DON) immediately and separate the residents.During a telephone interview on 4/1/2026 at 11:48 a.m., with CNA 1, CNA 1 stated he answered Resident 1's call light on 3/28/2026 at around 4:30 a.m. CNA 1 stated Resident 1 complained that Resident 2 was cursing at him and speaking to him rudely. CNA 1 stated he reported the incident to LVN 1 around 5:00 a.m. on 3/28/2026. CNA 1 stated any allegations of abuse should be reported immediately to avoid further occurrence of abuse. CNA 1 stated staff should separate residents involved in an altercation immediately for their safety. CNA 1 stated Resident 1 and Resident 2 were not separated immediately. CNA 1 stated the incident involved verbal abuse between the two residents. CNA 1 stated if residents were not separated immediately after an alleged resident to resident altercation, they may be at risk of injury or further abuse.During a concurrent observation and interview on 4/1/2026 at 12:15 p.m. in Resident 1's room, Resident 1 sat on his bed. Resident 1 stated he never engaged in conversation with Resident 2. Resident 1 stated Resident 2 called him chicken, chavala (a Spanish word for woman), not a man, and screamed at him. He stated Resident 2 told him he would go to his bed and kick his behind when he was alone in the room. Resident 1 stated he could no longer ignore the behavior and reported it to CNA 1 early in the morning on 3/28/2026 at approximately 5:00 a.m. Resident 1 also stated he told the SSD that he felt depressed about the incident on 3/28/2026 and about having to move rooms when it was not his fault.During interviews on 4/1/2026 at 9:00 a.m. and again at 2:29 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated the alleged resident altercation occurred during the 11:00 p.m. to 7:00 a.m. shift on 3/27/2026. RNS 1 stated that around 7:15 a.m. to 7:30 a.m. on 3/28/2026, LVN 1 informed her Resident 1 and Resident 2 were having misunderstandings and that one of them should receive a room change. RNS 1 stated she did not report the incident immediately because she believed it was a misunderstanding rather than abuse. She stated she did not talk to both residents right away for the same reason. RNS 1 stated at 8:00 a.m. on 3/28/2026, Resident 2 was asleep, and she chose not to interview Resident 1 because she was concerned Resident 2 might wake up and become aggressive. RNS 1 stated Resident 2 had a strong personality, spoke loudly, could become rude, and was not sociable. RNS 1 stated she was aware the alleged abuse occurred at 5:30 a.m. on 3/28/2026. RNS 1 also stated that staff should report allegations of abuse immediately so the facility can investigate promptly, and Resident 1 and Resident 2 should have been separated immediately. She stated failing to separate the residents could escalate the situation and lead to injury. RNS 1 stated that not reporting an allegation of abuse immediately could place Resident 1 in danger and at risk of emotional distress.During a review of facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating, revised 4/2021, the P&P indicated allegations of abuse, neglect, exploitation, misappropriation of resident property is suspected should be reported immediately to the administrator and to other officials according to state law. The P&P indicated immediately is defined as within two hours of an allegation involving abuse.Cross Reference F600.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from verbal abuse. The facility failed to:1.Separate Resident 1 and Resident 2 immediately when Licensed Vocational Nurse (LVN) 1 was notified by Certified Nursing Assistant (CNA) 1 about the alleged verbal abuse and altercation between Resident 1 and Resident 2 on 3/28/2026 at 5:30 a.m.2.Follow the facility's policy and procedures (P&P) titled, Resident to Resident Altercation, which indicated the staff will separate the residents if two residents are involved in an altercation and identify what happened.These failures had the potential to put Resident 1 at risk for further verbal abuse, unnecessary anxiety and fear from Resident 2.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or reduced control on one side of the body) following cerebral infarction (stroke-blood flow to a part of the brain is interrupted by a blockage or burst vessel) and major depressive disorder ( mental health condition characterized by persistent feeling of sadness).During a review of Resident 1's History and Physical (H&P) dated 10/16/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues) with eating, and substantial / maximal assistance (helper does more than half the effort) with transferring to and from a bed to chair or wheelchair. The MDS indicated Resident 1 had the ability to understand others and express his ideas and wants.During a review of Resident 1's Progress Notes dated 3/28/2026 timed at 5:21 a.m., the Progress Notes indicated Resident 1 stated Resident 2 was antagonizing him and was calling him names like, Faggot, and Cry Baby. The Progress Notes indicated the author of the Progress Notes was LVN 1.During the review of Resident 1's Progress Notes dated 3/28/2027 at 7:27 a.m., the Progress Notes indicated LVN 1 reported to Registered Nurse Supervisor (RNS) 1 that Resident 1 and Resident 2 should have a room change due to alleged name calling directed at Resident 1. The notes also indicated RNS 1 will speak with both Resident 1 and Resident 2.During a review of Resident 1's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, understand, learn, and remember] behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 3/28/2026 timed at 10:09 a.m., the COC indicated around 9:30 a.m. to 10:00 a.m. RNS 1 interviewed Resident 1 and Resident 2. The COC indicated Resident 2 allegedly threatened Resident 1 by saying, I will kill you. The COC indicated the Administrator, Director of Nursing, physician and family were notified.During a review of Resident 1's Care Plan titled, Resident 1 reports anger, irritation, or dislike towards Resident 2's yelling, insults, name calling and verbal threats, initiated on 3/30/2026. The Care Plan interventions included maintaining a safe environment for all patients and separating patient.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), diabetes mellitus, pleural effusion( abnormal buildup of excess fluid between the thin membranes lining the lungs and the chest cavity), and dependence on renal dialysis( patient must use a machine or a specialized treatment to filter their blood regularly because their kidneys stopped working well).During a review of Resident 2's H&P dated 3/26/2026, the H&P indicated Resident 2 had fluctuating 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 express ideas and wants and understand others. The MDS indicated Resident 2 required supervision with eating and substantial /maximal assistance with transferring to and from the bed to chair or wheelchair.During a review of Resident 2's COC dated 3/28/2026 and timed at 10:20 a.m., the COC indicated around 9:30 a.m. to 10:00 a.m. Resident 1 stated Resident 2 was allegedly threatening him by saying, I will kill you. The COC indicated Resident 2 stated he did not say anything and Resident 1 started to scream. The COC indicated Resident 2 told Resident 1 to be quiet in a language other than English.During a review of Resident 2's Care Plan titled, The Resident has the potential to be verbally aggressive, alleged threatening words, I will kill you, to Resident 1 initiated 3/28/2026, the Care Plan indicated to intervene before agitation escalates by guiding away from sources of distress.During a review of Resident 2's Progress Notes dated 3/29/2026 at 12:52 p.m., the Progress Notes indicated Resident 2 left the facility against medical advice (AMA-patient leaving a facility before the physician recommends discharge).During a telephone interview on 4/1/2026 at 11:07 a.m., with LVN 1, LVN 1 stated Resident 1 and Resident 2 were arguing during her shift on 3/28/2026 at around 6:00 a.m. LVN 1 stated CNA 1 informed her during the 5:30 a.m. medication pass that Resident 1 and Resident 2 were arguing. LVN 1 stated she went to speak with both residents and learned from Resident 1 that Resident 2 had been calling him names (faggot and cry baby). LVN 1 stated she informed RNS 1, who arrived around 7:15 a.m. on 3/28/2026, to request a room change for both residents because they were arguing. LVN 1 stated she did not separate the residents immediately because she believed only the Social Service Director (SSD) or RNS 1 could authorize room changes. LVN 1 stated staff should report allegations of abuse to the abuse coordinator or the Director of Nursing (DON) immediately and separate the residents. LVN 1 stated keeping both residents in the same room after an alleged resident to resident altercation could escalate the verbal conflict and lead to potential harm.During a telephone interview on 4/1/2026 at 11:48 a.m., with CNA 1, CNA 1 stated he answered Resident 1's call light on 3/28/2026 at around 4:30 a.m. CNA 1 stated Resident 1 complained that Resident 2 was cursing at him and speaking to him rudely. CNA 1 stated he reported the incident to LVN 1 around 5:00 a.m. on 3/28/2026. CNA 1 stated staff should separate residents involved in an altercation immediately for their safety. CNA 1 stated Resident 1 and Resident 2 were not separated immediately. CNA 1 stated the incident involved verbal abuse between the two residents. CNA 1 stated if residents were not separated immediately after an alleged resident to resident altercation, they may be at risk of injury or further abuse.During interviews on 4/1/2026 at 9:00 a.m. and again at 2:29 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated the alleged resident altercation occurred during the 11:00 p.m. to 7:00 a.m. shift on 3/27/2026. RNS 1 stated that around 7:15 a.m. to 7:30 a.m. on 3/28/2026, LVN 1 informed her Resident 1 and Resident 2 were having misunderstandings and that one of them should receive a room change. RNS 1 stated she did not report the incident immediately because she believed it was a misunderstanding rather than abuse. She stated she did not talk to both residents right away for the same reason. RNS 1 stated at 8:00 a.m. on 3/28/2026, Resident 2 was asleep, and she chose not to interview Resident 1 because she was concerned Resident 2 might wake up and become aggressive. RNS 1 stated Resident 2 had a strong personality, spoke loudly, could become rude, and was not sociable. RNS 1 stated she was aware the alleged abuse occurred at 5:30 a.m. on 3/28/2026. RNS 1 also stated that staff should report allegations of abuse immediately so the facility can investigate promptly, and Resident 1 and Resident 2 should have been separated immediately. She stated failing to separate the residents could escalate the situation and lead to injury. RNS 1 stated that not reporting an allegation of abuse immediately could place Resident 1 in danger and at risk of emotional distress.During a concurrent observation and interview on 4/1/2026 at 12:15 p.m. in Resident 1's room, Resident 1 sat on his bed. Resident 1 stated he never engaged in conversation with Resident 2. Resident 1 stated Resident 2 called him chicken, chavala (a Spanish word for woman), not a man, and screamed at him. He stated Resident 2 told him he would go to his bed and kick his behind when he was alone in the room. Resident 1 stated he could no longer ignore the behavior and reported it to CNA 1 early in the morning on 3/28/2026 at approximately 5:00 a.m. Resident 1 also stated he told the SSD that he felt depressed about what happened to him on 3/28/2026.During a review of facility's policy and procedure (P&P) titled, Resident-to-Resident Altercation, revised 12/1016, the P&P indicated All altercations including resident-to-resident abuse will be investigated and reported to the nursing supervisor, Director of Nursing, and to the Administrator. The P&P indicated the staff will separate the residents, will implement measures to calm the situation, and identify what might led to the aggressive conduct on the part of one or more individuals.During a review of facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating, revised 4/2021, the P&P indicated allegations of abuse, neglect, exploitation, misappropriation of resident property is suspected should be reported immediately to the administrator and to other officials according to state law. The P&P indicated immediately is defined as within two hours of an allegation involving abuse.

Based on interview and record review the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2) did not experience loss of dignity during an incontinent brief change after a bowel movement.This failure resulted in Resident 1 feeling humiliated and fearful that CNA 1 could have access to his personal information, and Resident 2 feeling anger, upset and violated.Findings:1. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including cerebral infarction (lack of adequate blood supply to the brain ), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left side, and brain compression (a life threatening condition where increased pressure inside the rigid skull damages brain tissue).During a review of Resident 1's History and Physical (H&P), dated 11/12/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 12/16/2025, the MDS indicated Resident 1 was dependent (helper does all the effort) on nursing staff for toileting, showering, personal hygiene, oral hygiene and dressing. The MDS indicated Resident 3 was always incontinent (inability to control voluntary bodily functions, typically urination or defecation) to urine and bowel movements.During an interview on 3/25/2026 at 12:25 p.m. with Resident 1, Resident 1 stated Certified Nursing Assistant (CNA) 1, wiped him hard while cleaning him after a bowel movement. Resident 1 stated CNA 1 was digging in his rectum. Resident 1 stated he told CNA 1 to stop and to get out of his room and CNA 1 laughed at him. Resident 1 stated he felt violated, upset, mad and wanted to kill CNA 1.During an interview on 3/25/2026 at 2:50 p.m. with CNA 1, CNA 1 stated he was assigned to Resident 1 on 3/22/2026 and on 3/23/2026. CNA 1 stated Resident 1 is able to communicate and accused him of inserting his fingers in his rectum.During an interview on 3/27/2026 at 2:08 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 3/25/2025 the Responsible Party (RP) of Resident 1 was visiting at the facility. LVN 1 stated the RP reported to LVN 1 that Resident 1 was violated while being cleaned by CNA 1. LVN 1 stated the RP stated CNA 1 was digging too deep in Resident 1's anal area and when Resident 1 said stop, CNA 1 did not stop. 2. During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of including generalized muscle weakness, lack of coordination (the ability to use different parts of the body together smoothly and efficiently), difficulty in walking, and end stage renal disease (irreversible kidney failure).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had the ability to express ideas and wants. The MDS indicated Resident 2 needed substantial to maximal assistance (helper does all the effort) with toileting, showering, and dressing. The MDS indicated Resident 2 was frequently incontinent of urine. The MDS indicated Resident 2 was always incontinent of bowel movements.During a review of Resident 2's H&P dated 3/26/2026, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions.During an interview on 3/25/2026 at 12:50 p.m. with Resident 2, Resident 2 stated CNA 2 wiped him with force and place two fingers in his rectum in the shower. Resident 2 stated CNA 2 put his fingers in his rectum four times while being cleaned. Resident 2 stated he felt humiliated and is afraid CNA 2 will find out his personal information and where he lives.During an interview on 3/25/2026 at 1:04 p.m. with CNA 2, CNA 2 stated on 3/19/2026 he was assigned to Resident 2. CNA 2 stated Resident 2 had a bowel movement and needed to be cleaned. CNA 2 stated he placed Resident 2's bed flat removed his diaper and used wipes to clean his perineal area. CNA 2 stated Resident 2 was tense during cleaning and was instructed to relax. CNA 2 stated after he placed Resident 2 back to bed.During an interview on 3/27/2026 at 3:31 p.m. with the Director of Nursing (DON), the DON stated on 3/25/2026 Resident 2's Family Member (FM) 1 reported CNA 2 was rough and put two fingers in Resident 2's rectum. The DON stated the proper handling and the right way to clean resident is to explain to the residents before you touch them and ask if they are comfortable with you touching them. The DON stated if a resident is uncomfortable and says stop, the CNA should call the charge nurse immediately and explain to the resident again the reason for cleaning, changing the diaper and repositioning. The DON stated residents' could have a loss of dignity, trust and could be afraid of male nurses touching them.During a review of the facility's policy and procedure (P&P), titled Quality of Life - Dignity, date revised 8/2009, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.During a review of the facility's policy and procedure (P&P), titled Resident Rights, date revised 12/2019, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence, be treated with respect, kindness, and dignity.

Based on observation, interview, and record review, the facility failed to1.Ensure that the water temperature reached the required 160 degrees Fahrenheit ( F- unit of temperature) for proper sanitation when washing residents' laundry in two of three facility washing machines.This failure had the potential to cause cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products), exposing residents' laundry to bacteria, viruses, and other harmful microorganisms due to inadequate sanitization.2. Review and update facility's policies and procedure for Infection Prevention and Control Program (IPCP- structured, evidence-based plan used in the facility to stop the spread of germs and protect residents and staff) annually.This failure had the potential to not address current infection trends leading to higher rates of infection in the facility.Findings: 1.During an observation on 2/11/2026 at 12:40 p.m. in the laundry room, two washing machines were running. The temperature gauge used to monitor the water temperature was reading 85 degrees F. During a review of the Daily Washer Temperature Log dated 2/1/2026 last revised on 2/11/2026, the Washer Temperature Log indicated the water temperature should be between 140 degrees F to 160 degrees F. The washer temperature log indicated that the water temperature ranged between 85 degrees F to 106 degrees F for the month of February. During an interview on 2/11/2026 at 12:45 p.m. with the Laundry Aide, Laundry Aide stated she checks the thermometer when the washer begins its cycle and then records the temperature on the log. The Laundry Aide stated the Laundry Supervisor instructed her only to record the temperature and did not tell her to report if the temperature failed to reach 140 degrees F to 160 degrees F. She stated when clothes were not sanitized properly, there was a risk of spreading germs (organisms that can cause disease) to the residents. During a concurrent observation and interview on 2/12/2026 at 12:10 p.m. with the Maintenance Supervisor (MS) in the laundry room, the MS used a hand held thermometer to manually check the water temperature of a running washing machine. The MS stated the water temperature was only 80 degrees F and that he would need to adjust the water heater. The MS stated the water temperature must reach 160 degrees F to kill germs and that there was a possibility of cross contamination when the temperature does not reach 160 degrees F. During a review of the facility's policy and procedure (P&P) titled Washer Temperature, (undated) the P&P indicated Nursing homes must follow strict laundry protocols to prevent infection, including proper sorting, handling, washing, and storage of linens, in compliance with Centers for Disease Control and Prevention (CDC), Occupational Safety and Health Administration (OSHA), and Centers for Medicare and Medicaid Services (CMS) guidelines. 1. Infection Control and Handling: Laundry in nursing homes can carry pathogens from blood, urine, stool, and other body fluids. To minimize risk, soiled linens must be handled carefully: avoid shaking, use leak-proof bags or carts, and transport separately from clean linens to prevent cross-contamination. Staff should wear personal protective equipment (PPE) such as gloves, gowns, and masks when handling contaminated laundry (CDC, OSHA, Western State Design). 2. Sorting and Collection: Linens should be sorted into categories such as infectious, non-infectious, and heavily soiled. Staff must be trained to segregate items properly, and containers should be labeled with biohazard symbols when necessary (OSHA). Contaminated laundry should never be transported through common areas without containment. 3. Washing and Disinfection: CMS and CDC guidance recommend hot water washing at temperatures above 160 degrees F (71 degrees C) for at least 25 minutes. 2. During a concurrent interview and record review on 2/12/2026 at 10:34 a.m. with the Infection Preventionist Nurse (IPN), facility's policy for Infection Prevention and Control Program revised on 6/8/2022 was reviewed. IPN stated he did not know the policy for IPCP needed to be reviewed annually and update as needed. IPN stated it was the responsibility of the Director of Nursing (DON) to review the policy for IPCP. IPN stated reviewing the policy can help prevent transmission of diseases in the facility. During a concurrent interview and record review with the DON on 2/12/2026 at 12:57 p.m., the facility's IPCP policy was reviewed. The DON stated the Infection Prevention and Control Program policies were last reviewed in 2022. The DON stated the IPN, Medical Records Department, and the DON were responsible for reviewing the facility's policies. The DON stated failing to review and update the IPCP policies may result in the facility providing care that was not aligned with current infection prevention and control standards During a review of facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, revised 6/8/2022, the P&P indicated the facility will review its IPCP at least annually and update as needed.

Based on observation and interview, the facility failed to ensure the trash receptacle outside the kitchen was covered, not overflowing, and properly disposed of.This failure had the potential to attract pests and rodents, pose health risks, and result in infection control violations.Findings:During a concurrent observation and interview on 2/09/2026 at 8:40 a.m. with [NAME] 1, the garbage dumpster outside the kitchen was observed to be completely open, with black trash bags overflowing from it. [NAME] 1 stated that this was the kitchen's garbage dumpster.During an interview on 2/11/2026 at 3:50 p.m. with the Registered Dietitian (RD), the RD stated garbage dumpsters must be kept completely closed. The RD stated an open and overflowing dumpster could attract insects and rodents, potentially leading to infestation.During an interview on 2/12/2026 at 1:13 p.m. with the Director of Nursing (DON), the DON stated the garbage dumpster should not be overflowing with trash and must remain covered. The DON stated improper disposal of trash could attract unwanted pests and insects.

Based on observation, interview, and record review, the facility failed to provide sufficient dietetic (concerning diet and nutrition) oversight for 46 out of 46 sampled residents. The Dietary Supervisor was not working full-time, and the Registered Dietitian was functioning only on a consulting basis. This lack of oversight was evidenced by lapses in food service delivery, including kitchen staff not following the scheduled menu for pureed diets , inaccuracies in therapeutic diets, inadequate maintenance of essential kitchen equipment such as the ice machine and dishwashing machine, and deficiencies in food safety and sanitation practices.These failures had the potential to compromise residents' safety and nutritional status through possible transmission of foodborne illness, incorrect delivery of physician ordered therapeutic diets, and increased risk of aspiration (accidental breathing food, liquid, or saliva into the airway and lungs instead of swallowing into the esophagus and stomach) due to improper food texture.Findings:During the annual recertification survey from 2/9/2026 to 2/12/2026, multiple issues surrounding the delivery of dietetic services were not met in relation to:1.The oversight of food safety, sanitation, and storage of food in the kitchen (Cross reference F 812).2.Ice machine not clean and sanitary (Cross reference F 908 and F 812).3. Dish washing machine was not reaching the correct temperature for a low temperature dishwasher (Cross reference F 812).4. [NAME] 1 failed to follow scheduled and planned menu for Resident 16 and 41 diets (Cross reference F 803)5. Dietary Aide failed to ensure the coconut cake distributed during tray line for two residents (Resident 16 and 41) had the correct texture according to their therapeutic diets (cross reference F 803).During an interview on 2/9/2026 at 11:45 a.m., the Dietary Supervisor (DS) stated he worked only on weekends and was serving as a part time Dietary Supervisor in the facility. He stated the last full time Dietary Supervisor resigned on 1/28/2026.During review of DS's Time Detail Report (work hour log) dated 1/31/2026 (Saturday) to 2/6/2026 (Friday), the Time Detail Report indicated the DS worked for 15 hours for a week.During an interview on 2/11/2026 at 2:54 p.m. with the Administrator (ADM), the ADM stated the DS only worked part time and only during the weekends. The ADM stated there was a dietary supervisor last January 2026 but he only lasted for two weeks. The ADM stated there was a contracted registered dietician and would come once a week in the facility. The ADM stated the facility did not place an advertisement to hire a full-time DS and rely only on using word by mouth (passing of information, news, recommendations from a person to person through spoken, oral communication). The ADM stated it was important to have a full time Dietary Supervisor in the kitchen to oversee operations and ensure that regulatory requirements were followed.During an interview on 2/11/2026 at 3:50 p.m. with the Registered Dietician (RD), RD stated the kitchen should have a full-time DS to provide an oversight and to ensure the kitchen follows the food and safety regulations.During a review of facility's Job Description of Food and Nutrition Services (FNS) Director dated 2018, the Job Description of FNS Director indicated the supervisor will confer regularly with the Administrator, Director of Nursing, and Dietary Consultant and keep them informed of the problems and progress of Food and Nutrition Service Department. Cross Reference F803,F812 and F908.

Based on observation, interview and record review, the facility failed to ensure four of 44 sampled residents (Resident 2, Resident 32, Resident 16 and Resident 41) received meals according to the scheduled dietary menu and prescribed diet textures. The facility failed to:1.Ensure Resident 2 and 32 were provided with a pureed fortified meal as scheduled on the facility's dietary menu.2.Ensure Resident 16 and Resident 41 receive the correct texture and consistency of coconut cake during tray line on 2/10/2026 according to their prescribed diet.These failures had the potential to put Resident 2, Resident 32, Resident 16 at risk for not meeting their nutritional needs and Resident 41 at risk for aspiration (accidental breathing of food, fluids, or stomach contents into the airway and lungs instead of the esophagus).Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of but not limited to seizures(a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), dysphagia(difficulty swallowing), aphasia (a disorder that makes it difficult to speak), and hypertension(HTN-high blood pressure) During a review of Resident 2's Physician Progress Note, dated 11/22/2025 the Physician Progress Note indicated Resident 2 does not have the capacity to understand and make decisions. The Physician Progress Note indicated Resident 2 was at risk for but limited to malnutrition (health problems that may arise due to lack of nutrients), weight variance, and dehydration (abnormally low fluid levels in the body). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 1/29/2026, the MDS indicated Resident 2 needed partial to moderate assistance with eating and rolling from left to right. The MDS indicated Resident 2 needed substantial to maximal assistance with oral hygiene, toileting, dressing and personal hygiene. The MDS indicated Resident 2 was dependent on nursing staff with showering, putting on and taking off shoes, and transferring. The MDS indicated Resident 2 received a mechanically altered diet that required a change in texture of food or liquids. The MDS indicated Resident 2 was provided with a therapeutic diet while a resident at the facility. During an interview on 2/9/2026 at 12:51 p.m., with Dietary Aide, (DA) 1 stated Resident 2 and Resident 32 were served a pureed diet (foods that are blended, whipped, or mashed into a smooth, thick, pudding-like consistency, requiring no chewing) mixed vegetables, pureed rice and pureed Salisbury steak. During a review of the facility's menu dated 2/9/2026, the facility's menu indicated the lunch meal to be served was pork chops with gravy, herbed rice, mixed vegetables, dinner roll with margarine, coconut cake and a beverage. During an interview on 2/9/2026 at 1:52 p.m. with [NAME] (CK) 1, CK 1 stated there were three slices of Salisbury steak stored in a clear bag in the refrigerator. CK 1 stated she made a mistake and apologized for deciding on her own to serve the Salisbury steak. CK 1 stated she was supposed to serve pork chops as listed on the menu. CK 1 stated the residents would not be happy if they did not receive the food items listed on the menu. CK 1 stated residents expect to receive what was scheduled, and some may refuse to eat if the served meal does not match the posted menu. CK 1 stated that even residents who are not alert are supposed to receive the same food that was on the menu. During an interview on 2/12/2026 at 3:12 p.m. with the Director of Nursing (DON), the DON stated that [NAME] 1 should have followed the recommended menu. The DON stated residents could end up in the hospital or experience an upset stomach if the recommended menu was not followed. During a review of the facility's Policy and Procedure (P&P), titled Menus, dated 10/2027, the P&P indicated .Deviations from posted menus are recorded (including the reason for the substitution and/or deviation) and archived. 2.During a tray line observation on 2/10/2026 at 12:00 p.m., Resident 41 received coconut cake in a regular texture (normal diet with no restrictions on the size, shape, or hardness of food) and Resident 16 received coconut cake in a mince and moist texture (finely chopped, ground, or mashed into small, soft and uniform pieces). Resident 41's meal tray ticket indicated a diet of mechanical soft diet (consists of moist, tender-textured foods that require minimal chewing which is ideal for individuals with chewing or swallowing difficulties) and Resident 16's meal tray ticket indicated pureed diet( consist of foods that are blended, mashed, or whipped until they reach a completely smooth, pudding like consistency with no lumps, seeds or chunks). During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia( difficulty in swallowing), and colostomy status(a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body). During a review of Resident 16's History and Physical (H&P) dated 2/1/2026, the H&P indicated Resident 16 did not have the capacity to understand and make decisions. During a review of Resident 16's Order Summary Report dated 2/11/2026, the Order Summary Report indicated a physician order of controlled carbohydrate (CCHO- meal plan that involves a steady amount of carbohydrates at each meal and snack to help manage blood sugar levels) mechanical soft texture with nectar / mildly thick consistency diet(moist, tender finely diced or ground foods combined with beverages thick enough to pour slowly to aid with swallowing). During a review of Resident 16's Care Plan titled, Alteration in Nutrition due to Current Diet Order, initiated 12/24/2025 and revised on 1/10/2026, the Care Plan goal indicated Resident 16 will have no significant weight loss or gain within thirty days. The Care Plan interventions included providing CCHO Soft Mechanical with nectar thick liquid and provide diet as ordered. During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was admitted on [DATE] to the facility with diagnoses including dysphagia, DM, unspecified dementia (a progressive state of decline in mental abilities), and benign neoplasm of meninges (a non-cancerous tumor that grows on the protective membranes surrounding the brain and spinal cord). During a review of Resident 41's H&P dated 5/1/2025, the H&P indicated Resident 41 did not have the capacity to understand and make decisions. During a review of Resident 41's Order Summary Report dated 5/13/2025, the Order Summary Report indicated a physician order of Regular diet with mechanical soft texture. During a review of Resident 41's Care Plan titled, Nutrition and Hydration Deficit, initiated 5/13/2025 and revised on 5/21/2025, the Care Plan goal indicated Resident 41 will consume 80 percent of each meal. The Care Plan interventions included providing diet as ordered and adhering to resident's food preferences by dietary department within diet order. During an interview on 2/10/2026 at 2:09 p.m. with Dietary Aide (DA) 1, DA 1 stated one of his responsibilities was to place dessert and drinks during tray line. DA 1 stated he was confused and placed the coconut cake with mince and moist consistency who was on pureed diet and placed a regular consistency coconut cake to Resident 41 who was on mechanical soft diet. DA 1 stated he should have checked each dessert or removed the lid before setting them on the residents' trays, DA 1 stated residents had the potential to choke or aspirate their food if the wrong texture of food was provided. During an interview on 2/11/2026 at 3:50 p.m. with the Registered Dietician (RD), RD stated inaccurate therapeutic diets, incorrect food texture can run the risk of aspiration to residents. RD stated the kitchen staff should follow the menu because it was reviewed and approved by the RD to ensure residents' nutritional needs were met. During a review of facility's policy and procedure (P&P) titled, Diet Orders, dated 2018, the P&P indicated Diet orders as prescribed by the physician will be provided by the Food and Nutrition Services Department. The P&P indicated the Dietary Supervisor or [NAME] will make or adjust the diet profile and tray card as prescribed.

Based on observation, interview and record review, the facility failed to ensure facility's dishwashing machine was maintained in a safe and operational condition. The facility failed to:1.Ensure the dishwashing machine's temperature was running at the recommended temperature of 120 degrees Fahrenheit ( F- unit of measurement).This failure had the potential to increase the risk of cross- contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and food-borne illnesses (any illness resulting from eating contaminated/spoiled foods) among the residents.Findings:During a concurrent observation and interview on 2/9/2026 at 8:50 a.m., with the Dietary Aide (DA)1, DA 1 ran the dish washing machine and temperature gauge read 104 F. DA 1 stated it was okay to still use the dishwasher even though the temperature gauge was not reaching 120 degrees F as long as the chemical sanitation (using test strips to check the level of sanitizer during the final rinse of the dish washer) was within the range of 50 to 100 parts per million (PPM- a way to measure very small amounts of substance like a sanitizer).During an observation and interview on 2/9/2026 at 11:45 a.m., with the Dietary Supervisor (DS), DS stated the dish washer should read 120 F to properly sanitize and kill the bacteria present on the dishes and utensils. Observed DA 1 ran the dishwasher five times and the temperature gauge did not reach 120 F. Observed the temperature gauge read 110 F after five cycles were run.DS stated he did not know the dishwasher was not working till today (2/9/2026) at 10:30 a.m. and would call a service provider. DA 1 stated residents could get sick of food-borne illnesses if the temperature gauge of the dish washing machine was not 120 F. DS stated they will use disposable utensils and food containers/ plates for today's lunch (2/9/2026).During a subsequent observation on 2/9/2026 at 2:29 p.m., dishwashing machine temperature gauge read 102 F when DA 1 ran a cycle.During an interview on 2/9/2026 at 2:47 p.m. with the Administrator (ADM), the ADM stated the DS notified him around 11:00 a.m. today (2/9/2026) about the dish washer not reaching the required temperature and would call a service provider to check the dishwashing machine.During an interview on 2/11/2026 at 3:50 p.m. with the Registered Dietician (RD), RD stated the dishwasher not reaching the recommended temperature of 120 F should be reported and addressed to ensure dishes will be cleaned properly and to prevent food-borne illnesses among residents.During a review of facility's policy and procedure (P&P) titled, Dishwashing Machine Use, revised 3/2010, the P&P indicated, the operator of the dish washing machine will check the temperature using the machine gauge with each dishwashing machine cycle and inadequate temperatures should be reported to the supervisor and corrected immediately. The P&P indicated if hot water does not meet requirements, stop the use of dishwashing immediately until the temperature is adjusted.Cross Reference F812

Based on interview and record review the facility failed to ensure:1. Two of five residents (Resident 4 and Resident 6) were provided education regarding the risks and benefits of refusing influenza (flu - a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) and pneumococcal (pneumonia - an infection/inflammation in the lungs) vaccines (medications used to prevent diseases).2. One of five residents (Resident 19) was not given the influenza and pneumococcal vaccine.This failure had the potential to result in residents from making informed decisions regarding refusal of influenza and pneumococcal vaccine, increasing the risk for vaccine-preventable illness, complications, hospitalization, and transmission of infection within the facility.Findings:1.a. During a review of Resident 4's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 4 on 9/14/2024 and was re-admitted on [DATE] with diagnoses including frontal lobe (part of the four major lobes in the human brain) and executive function deficit following cerebral infarction (blocked blood flow to the brain resulting in tissue death)During a review of Resident 4's history and physical (H&P) dated 11/12/2025, the H&P indicated Resident 4 does not have the capacity to understand and make decisions.During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 12/16/2025, the MDS indicated Resident 4 cognition (ability to think and make decisions) was severely impaired.During a review of Resident 4's care plan titled Risk for adverse reaction or discomfort related to Covid and flu immunization received on 10/3/2025 dated 9/16/2025, the care plan indicated to educate the resident and responsible party on the purpose of the Covid and flu vaccine, possible side effects, and the importance of vaccination in preventing Covid and influenza disease.During a concurrent interview and record review on 2/11/2026 at 1:30 p.m. with the Licensed Vocational Nurse (LVN)1 Resident 4's immunization screening was reviewed. Resident 4 immunization record indicated influenza vaccination was given on 10/3/2025 and the vaccination informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was received over the phone by the responsible party. LVN 1 stated there was no documentation the resident's responsible party was given education for the vaccine. LVN 1 stated the importance of providing education to the resident and the responsible party was to explain the risks of not receiving the vaccine and benefits of receiving the vaccine.During a concurrent interview and record review on 2/11/2026 at 2:50 p.m. with the Infection Preventionist Nurse (IPN), Resident 4's immunization screening was reviewed. The IPN stated vaccination education was not given. The IPN stated the resident's responsible party should have been educated for the influenza vaccine. The IPN stated the importance of providing education was to explain the risk and benefits of the vaccine.1.b. During a review of Resident 6's Face Sheet (admission Record), the Face Sheet indicated the facility admitted Resident 6 on 1/17/2026 with diagnoses including end stage renal disease (ESRD -irreversible kidney failure)During a review of Resident 6's history and physical (H&P) dated 11/17/2026, the H&P indicated Resident 6 had capacity to understand and make decisions.During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 1/23/2026, the MDS indicated Resident 6 cognition was moderately impaired. The MDS indicated Resident 6 did not receive influenza for the flu season of October 1, 2025 - March 31, 2026, and the pneumococcal vaccination. The MDS indicated the influenza, and pneumococcal vaccine was offered and was refused.During a review of Resident 6 physician orders, dated 1/17/2026, the physician's order indicated to administer flu vaccine 0.5 cc (cubic centimeters, unit of volume), intramuscular (IM), give one time as consent obtained. The physician's order indicated the resident may have annual influenza vaccine and pneumococcal vaccine.During a concurrent interview and record review on 2/11/2026 at 1:30 p.m. with the Licensed Vocational Nurse (LVN) 1, Resident 6's immunization screening was reviewed. Resident 6 immunization record showed the last influenza vaccine was given on 11/2022. LVN 1 stated there were no informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) or documentation the resident was given education for both vaccines. LVN 1 stated the importance of providing education to the resident was to explain the risks of not receiving the vaccine and benefits of receiving the vaccine. LVN 1 stated if the resident does not receive immunizations, the resident would be at an increased risk of exposure to the flu and pneumonia virus and development of other virus-related complications.During a concurrent interview and record review on 2/11/2026 at 2:50 p.m. with the Infection Preventionist Nurse (IPN), Resident 6's immunization screening was reviewed. The IPN stated vaccination education was not offered or given. The IPN stated the flu season was from October 1st to March 31st and the resident should have been educated and offered the influenza vaccine. The IPN stated an informed consent should have been obtained on admission for influenza and pneumonia but there was no informed consent obtained. The IPN stated the importance of providing education was so that the resident was informed that there could be an increased risk of exposure to the virus and development of other virus-related complications.During a review of the facility's policy and procedure (P&P) titled Infection Prevention and Control Influenza and Pneumococcal immunizations revised 6/8/2022, indicated Influenza immunization will be offered to current residents and newly admitted residents annually during the flu season.The resident/resident representative will be provided information related to the risks of potential side effects and benefits of being immunized prior to the resident receiving the vaccination. This will be accomplished via the Vaccination Information Sheet from the CVC. The resident record will reflect the provision of education and the administration or refusal of the immunization, or non-administration due to the medical contraindication, precaution or other reason for non-administration of the vaccine.Residents >[AGE] years of age and those age [AGE]-64 with chronic medical conditions or other risk factors, who have not previously received pneumococcal vaccine, or whose previous vaccination history is unknown are offered pneumococcal vaccination.2. During a review of Resident 19's Face Sheet (admission Record), the Face Sheet indicated the facility admitted Resident 19 on 1/26 /2026 with diagnoses including syncope (fainting or passing out).During a review of Resident 19's history and physical (H&P) dated 1/26/2026, the H&P indicated Resident 19 had partial capacity to understand and make decisions.During a review of Resident 19's Minimum Data Set (MDS - a resident assessment tool) dated 1/30/2026, the MDS indicated Resident 6 did not receive the influenza vaccine and the reason was the vaccine was offered and declined. MDS indicated the resident's pneumococcal vaccine was not up to date and was offered and declined.During a review of Resident 19's physician orders, dated 1/26/2026 indicated the resident was capable of giving informed consent. The physician's order indicated to administer flu vaccine 0.5 cc (cubic centimeters, unit of volume), intramuscular (IM), give one time as consent obtained. The physician's order indicated may have annual influenza vaccine and pneumococcal vaccine.During a concurrent interview and record review on 2/11/2026 at 1:30 p.m. with the Licensed Vocational Nurse (LVN)1 Resident 19's immunization screening was reviewed. Resident 19 immunization record showed no documentation for immunizations. LVN 1 stated there was no documentation of the vaccine being administered on the medication administration record (MAR) for Resident 19. LVN 1 stated the importance of giving the vaccine was for residents to increase their immune system when in contact with the virus. LVN 1 stated when the vaccine was not provided, the resident would be at an increased risk of exposure to the flu and pneumonia virus and development of other virus-related complications.During a concurrent interview and record review on 2/12/2026 at 9:00 a.m. with the Infection Preventionist Nurse (IPN), Resident 19's immunization screening was reviewed. The IPN stated the licensed nurse was responsible for offering the vaccine upon admission to the facility. The IPN stated there was a vaccination informed consent in the resident's physical chart signed and dated on 1/27/2026 by a Registered Nurse (RN). The IPN stated the importance of giving the vaccine was to prevent the risk for vaccine-preventable illness. The IPN stated if the resident does not receive the vaccine there would be an increased risk of exposure to the virus and development of other virus-related complications.During a review of the facility's policy and procedure (P&P) titled Infection Prevention and Control Influenza and Pneumococcal immunizations revised 6/8/2022, indicated Influenza immunization will be offered to current residents and newly admitted residents annually during the flu season. Flu season typically covers October 1 through March 31 each year.Residents >[AGE] years of age and those age [AGE]-64 with chronic medical conditions or other risk factors, who have not previously received pneumococcal vaccine, or whose previous vaccination history is unknown are offered pneumococcal vaccination.

Based on observation, interview and record review, the facility failed to store food in a safe and sanitary manner for 44 out of 46 sampled residents in the facility. The facility failed to:1.Ensure reach in refrigerator had an internal thermometer that was in working condition. 2.Ensure dish washing machine was maintained and operated at the proper recommended temperature of 120 degrees Fahrenheit (F- unit of measurement).3.Ensure the ice machine was clean and sanitary.4.Ensure [NAME] (CK) 2 washed her hands after touching the lid of a step on trash can before stirring the soup in the stove.5.Ensure an open brown bag of flour and an open bag of pasta were stored in a sanitary manner in the dry storage area.These failure had the potential to cause cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products), infestation ( presence of an unusually large number of insects or animals in a place that can cause damage or disease) and put residents at risk for developing food-borne illnesses (any illness resulting from eating contaminated/spoiled foods).Findings:1.During an initial kitchen observation and interview on 2/9/2026 at 8:20 a.m. with [NAME] (CK) 1, observed reach in refrigerator had no internal thermometer but external digital display read 39 F. Observed the internal thermometer was cracked and reading remained 30 F despite being left out in the kitchen counter for several minutes. CK 1 stated the thermometer was broken.During an interview on 2/9/2026 at 12:15 p.m. with the Dietary Supervisor (DS), the DS stated the kitchen staff used only the external digital display of temperature of refrigerators and freezer. DS stated the internal thermometer of the refrigerator was broken and he will buy a new thermometer.During a subsequent interview on 2/9/2026 at 1:50 p.m. with CK 1, CK 1 stated the kitchen staff had been relying and using the external digital temperature displayed on the freezer and refrigerators for three years and had never used the internal thermometer inside the freezer and refrigerators for temperature check. CK 1 stated she never checked the internal thermometer and only relied on the temperature reading displayed outside of the refrigerator. CK 1 stated it was important to check the internal thermometer to ensure the food items stored are in the correct and right temperature to prevent food-borne illnesses among the residents.During an interview on 2/11/2026 at 3:50 p.m. with the Registered Dietician (RD), the RD stated not having an internal thermometer inside a refrigerator was not standard practice. RD stated broken thermometer should be replaced and the external temperature should not be followed because in case the digital thermometer breaks down there will be a second thermometer to rely on ensuring safety of the food items stored in the refrigerator. RD stated food spoilage can happen if the kitchen was only relying on the external digital thermometer leading to food-borne illness among the residents.During an interview on 2/12/2026 at 1:13 p.m. with the Director of Nursing (DON), the DON stated internal thermometer was important to use for refrigerator to ensure a reliable way to check the temperature and prevent food spoilage which can lead to food-borne illnesses.During a review of facility's policy and procedure (P&P) titled, Food Storage, dated 2010, the P&P indicated every refrigerator should be equipped with an internal thermometer.2. During a concurrent observation and interview on 2/9/2026 at 8:50 a.m., with the Dietary Aide (DA) 2, DA 2 ran the dish washing machine and temperature gauge read 104 F. DA 2 stated it was okay to still use the dishwasher even though the temperature gauge was not reaching 120 F as long as the chemical sanitation (using test strips to check the level of sanitizer during the final rinse of the dish washer) was within the range of 50 to 100 parts per million (PPM- a way to measure very small amounts of substance like a sanitizer).During an observation and interview 2/9/2026 at 11:45 a.m., with the Dietary Supervisor (DS), DS stated the dish washer should read 120 F to properly sanitize and kill the bacteria present on the dishes and utensils. Observed DA 2 ran the dishwasher five times and the temperature gauge did not reach 120 F. Observed the temperature gauge read 110 F after five cycles were run. DS stated he did not know the dishwasher was not working till today (2/9/2026) at 10:30 a.m. and would call a service provider. DA 1 stated residents could get sick of food-borne illnesses if the temperature gauge of the dish washing machine was not 120 F. DS stated they will use disposable utensils and food containers/ plates for today's lunch (2/9/2026).During a subsequent observation on 2/9/2026 at 2:29 p.m., dishwashing machine temperature gauge read 102 F when DA 2 ran a cycle.During an interview on 2/9/2026 at 2:47 p.m. with the Administrator (ADM), the ADM stated the DS notified him around 11:00 a.m. today (2/9/2026) about the dish washer not reaching the required temperature and he would call a service provider to check the dishwashing machine.During an interview on 2/11/2026 at 3:50 p.m. with the Registered Dietician (RD), the RD stated the dishwasher not reaching the recommended temperature of 120 F should be reported and addressed to ensure dishes will be cleaned properly and to prevent food-borne illnesses among residents.During a review of facility's P&P titled, Dishwashing Machine Use, revised 3/2010, the P&P indicated, the operator of the dish washing machine will check the temperature using the machine gauge with each dishwashing machine cycle and inadequate temperatures should be reported to the supervisor and corrected immediately. The P&P indicated if hot water does not meet requirements, stop the use of dishwashing immediately until the temperature is adjusted.3. During an observation in the kitchen on 2/9/2026 at 9:45 a.m. with Dietary Aide (DA) 2, yellow residue was found in the paper towel that was used to wipe the lid of the ice machine. Observed dirt and black areas inside the ice machine.During an interview on 2/9/2026 at 2:10 p.m. with DA 2, DA 2 stated the ice machine was dirty if there was a yellow residue on the paper towel after wiping the inside of the ice machine. DA 2 stated the ice machine was serviced and cleaned by a service provider two months ago. DA 2 stated he cleaned the ice machine 2 or 3 days ago and an outside company will take the machine apart and clean it. DA 2 stated residents can be exposed to food -borne illnesses if the ice machine was not clean and sanitary.During an interview on 2/12/2026 at 9:45 a.m. with the Maintenance Supervisor (MS), the MS stated he removed the ice and cleaned the interior and exterior of ice machine yesterday by wiping it with clean towels. MS stated the ice machine should be taken apart and serviced by a technician to completely clean it.During an interview on 2/12/2026 at 9:50 a.m. with the Administrator (ADM), the ADM stated the ice machine was serviced and cleaned last September 2025 and the facility will throw away all the ice and will not be used for the residents. The ADM stated the facility will buy ice for residents' use. ADM stated the ice machine will be checked and cleaned by an outside provider today.During an interview on 2/11/2026 at 3:50 p.m. with the RD, RD stated the ice machine should be clean and sanitary. RD stated the ice machine should be clean and sanitized by the maintenance department and kitchen staff should be able to clean exterior portion of the ice machine. RD stated there should be someone in the facility responsible for sanitizing and cleaning it periodically or once a month. RD not cleaning or sanitizing the ice machine can lead to food-borne illnesses among residents.During an interview on 2/12/2026 at 11:09 p.m. with Infection Preventionist Nurse (IPN), IPN stated dirty and unsanitary ice machine can place residents at risk for legionella infection (type of bacteria found in water that causes serious lung infection).During a review of facility's P&P titled Ice Machine Cleaning Procedures, dated 2018, the P&P indicated the ice machine needs to be cleaned monthly.4. During an observation on 2/10/26 at 11:50 a.m. with CK 2, CK 2 threw a spoon in a step on trash can by lifting its lid and proceeded to stir a pot in the stove without doing handwashing.During an interview on 2/10/2026 at 12:45 p.m. with CK 2, CK 2 admitted that she threw a spoon in the trash can by lifting the lid of the step on trash can and then went back to stir the soup in the stove without doing handwashing.CK 2 stated she should have washed her hands after touching the lid of the trash can and should be careful in observing infection control measures. CK 2 stated resident can get sick from food-borne illnesses and can be a risk for cross contamination if hand washing was not performed after touching the lid of the trash can.During an interview on 2/12/2026 at 1:13 p.m. with the DON, the DON stated cross contamination leading to food-borne illnesses would occur if CK 2 did not wash her hands after touching the lid of the trash can to throw a spoon. The DON stated CK 2 should have washed her hands before touching the ladle to stir the soup.During a review of facility's P&P titled Handwashing Procedure, dated 2018, the P&P indicated hands should be washed after touching the lid or the trash can to prevent spread of infection.5.During an initial kitchen tour observation and interview on 2/9/2026 at 8:20 a.m. with CK 1 in the dry storage area of the kitchen, open brown bag of flour and open unsealed bag of pasta were found on one of the shelves. CK 1 stated the open bag of flour should have been transferred into a sealed plastic bin to ensure freshness and prevent insects going into the open bag of flour.During an interview on 2/9/2026 at 1:50 p.m. with CK 1, CK 1 stated the open bag of pasta should have been stored in a sealed plastic bag and the open bag of flour should be in a plastic, tight sealed container to ensure their freshness and keep the pest away from the food.During an interview on 2/11/2026 at 3:50 p.m. with the RD, RD stated the flour should be stored in a plastic bin or sealed plastic bag to keep food debris or other organisms from going into them which can put residents at risk for food-borne illnesses.During a review of facility's P&P titled Food Storage, dated 2018, the P&P indicated Dry storage area should have plastic containers with tight-fitting lids used for storing flour, cereals, and sugar. The P&P indicated leftover food is stored in covered containers or wrapped carefully and securely.

Based on observation, interview, and record review, the facility failed to:1. Ensure adequate room size and space to support the comfort and well being of one of 46 sampled residents (Resident 34).This failure had the potential to negatively impact Resident 34's quality of life by limiting his ability to move freely and safely within his living space.2. Ensure 18 of 24 residents' rooms (room [ROOM NUMBER], 102, 103, 104, 106, 107, 108, 109, 110, 116, 118, 215, 217, 219, 221, 223, 229, 231) met the requirements of 80 square feet for each resident.This failure had the potential to result in inadequate provision of safe nursing care and a lack of privacy for residents.Findings:During a review of Resident 34's admission Record dated 2/12/2026, the admission Record indicated Resident 34 was admitted to the facility on [DATE] with the diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and cerebrovascular accident (CVA stroke, loss of blood flow to a part of the brain).During a review of Resident 34's History & Physical (H&P), dated 10/16/2025, the H&P indicated Resident 34 had the capacity to understand and make decisions.During a review of Resident 34's Minimum Data Set (MDS-resident assessment tool) dated 1/16/2026, the MDS indicated Resident 34's cognition (ability to think, understand, learn, and remember)was intact. The MDS indicated Resident 34 needed substantial/maximal assistance (helper does more than half the work) with activities of daily living (ADLs- like dressing, bathing and personal hygiene).During an interview on 2/12/2026 at 8:52 a.m. in Resident 34's room, Resident 34 stated his room was way too small and that it was intended for only one person. Resident 34 stated he does not leave his room often because it takes too much time to move his belongings out of the way in order to exit.During a concurrent interview and record review on 2/12/2026 at 11:56 a.m. with the Administrator (ADM), reviewed of the facility's Waiver Request on Room Variance (WRRV), dated 2/09/2026, which indicated the facility had 18 rooms measuring less than the required 80 square feet per resident. The WRRV stated the requested variance would not compromise the health, welfare, or safety of residents. The following rooms were identified:room [ROOM NUMBER] (2 beds) 152.39 sq. ft., room [ROOM NUMBER] (2 beds) 155.28 sq. ft., room [ROOM NUMBER] (2 beds) 157.92 sq. ft., room [ROOM NUMBER] (2 beds) 159.00 sq. ft., room [ROOM NUMBER] (2 beds) 152,37 sq. ft., room [ROOM NUMBER] (2 beds) 156.49 sq. ft., room [ROOM NUMBER] (2 beds) 152.37 sq. ft., room [ROOM NUMBER] (2 beds) I 54.21 sq. ft. , room [ROOM NUMBER] (2 beds) 154.21 sq. ft. , room [ROOM NUMBER] (2 beds) 157,69 sq. ft. , room [ROOM NUMBER] (2 beds) 156.36 sq. ft. , room [ROOM NUMBER] (2 beds) 151.02 sq. ft, room [ROOM NUMBER] (2 beds) 151.02 sq. ft. , room [ROOM NUMBER] (4 beds) 318.55 sq. ft. , room [ROOM NUMBER] (2 beds) 150.12 sq. ft. , room [ROOM NUMBER] (2 beds) 149.98 sq. ft. , room [ROOM NUMBER] (2 beds) 147.29 sq, ft. , room [ROOM NUMBER] (2 beds) 147.29 sq. ft The ADM stated the rooms were small and that the facility does its best to ensure residents were comfortable.During a review of the facilities policy and procedure (P&P) titled Accommodation of Needs dated 3/2021, the P&P indicated, our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom.

Based on interview and record review, the facility's Quality Assessment and Assurance (QAA a group of people developing and monitoring quality compliance) Committee, failed to ensure effective oversight of facility operations and failed to ensure implementation of the 2025 Plan of Correction (POC) addressing deficient practices identified during the previous 2025 recertification survey.This failure resulted in repeat deficiencies in food storage, food preparation, and sanitation, as well as failure to ensure required annual in-service training for Certified Nursing Assistants (CNAs) was completed.Findings:During a review of the facility's Statement of Deficiencies, dated 5/18/2025, the statement of deficiencies indicated the following repeat deficiencies in food storage, preparation and sanitation and in the required yearly in-service training (education) for the CNA's.During a concurrent interview and record review on 2/12/2026 at 11:42 a.m. with the Administrator (ADM), the facility's Quality Assurance and Performance Improvement (QAPI a data driven proactive approach to improvement used to ensure services are meeting quality standards) plan was reviewed. The ADM stated that QAPI was a program the facility uses to track issues and implement improvements to enhance residents' quality of life. The ADM stated there were deficiencies cited during last year's survey related to the kitchen and CNA education, and stated the facility was not currently working on those areas. The ADM stated the facility would begin addressing these issues to ensure resident safety.During a review of the facility's policy and procedure (P&P) titled Quality Assurance Performance Improvement (QAPI) Program dated 11/2017, the P&P indicated The QAPI program is an integrated, comprehensive organizational-wide methodology used to continuously examine, refine. And revise processes and systems to meet or exceed the needs of those we serve. It is the integration of fundamental management approaches, improvement efforts, tools, and training and is driven by the results of the facility annual assessment findings. It is the policy that a functional QAPI program is maintained to monitor and evaluate the quality of resident's care and services, pursue methods to improve quality and all areas of organizational functioning, and to promote safety by using a systematic problem identification and resolution process. The facility QAPI program incorporates the findings in the annual facility assessment into key elements of the program.

Based on interview and record review, the facility failed to ensure two Certified Nursing Assistants (CNAs) had completed required annual competency evaluations.This failure had the potential to result in residents receiving inadequate care and services due to staff not demonstrating current competency.Findings:During a concurrent interview and record review on 2/12/2026 at 11:06 a.m. with the Director of Nursing (DON), the employee file for CNA 3 was reviewed. The file contained no documentation showing completion of the annual competency. The DON stated CNA 3 did not complete the annual competency and confirmed that annual competencies were required each year. The DON stated that without completing the annual competency, CNA 3 would lack updated knowledge and accountability.During a review of the facility's policy and procedure (P&P) titled Competency of Nursing Staff, dated 3/2025, the P&P indicated All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. In addition, licensed nurses and nursing assistants employed ( or contracted) by the facility will participate in a facility-specific, competency-based staff development and training program and demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.

Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 4), who had limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and limited mobility, received appropriate treatment and services to increase ROM, prevent further decline, and maintain or improve mobility.This failure had the potential to place Resident 4 at increased risk for further ROM decline and the development of contractures (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff).Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to cerebral infarction (the death of brain tissue resulting from lack of blood supply), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (paralysis of one side of the body) and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 12/16/2025, the MDS indicated Resident 4 never and rarely made decisions regarding task of daily life. The MDS indicated Resident 4 was dependent on nursing staff for rolling from left to right, transferring, toileting, showering, dressing and hygiene. The MDS indicated Resident 4 received zero days of the Restorative Nursing Program([RNA] nursing aide program that helps residents to maintain their function and joint mobility).During an interview on 2/12/2026 at 12:40 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that Resident 4 did not have any physician orders for Restorative Nursing Assistant (RNA) services. LVN 1 stated Resident 4 should have RNA services due to left sided weakness. LVN 1 stated she did not see any current orders for RNA. LVN 1 stated Resident 4 has a care plan addressing mobility deficits. LVN 1 stated Resident 4 had been seen by Physical Therapy (PT a health profession focused on restoring, maintaining, and promoting optimal physical function and mobility) and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) but could not recall when those services were last provided.During a review of Resident 4's Care Plan, titled Mobility Deficit, date initiated 6/29/2025, the Care Plan indicated Resident 4 will be referred to the RNA program as prescribed. During an interview on 2/12/2026 at 2:01 p.m. with Restorative Nursing Aide (RNA) 1, RNA 1 stated Resident 4 had previously been receiving RNA services. RNA 1 stated that after Resident 4 was re admitted from the hospital, no new order for RNA services was received, and the services were not resumed.During an interview on 2/12/2026 at 2:06 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 4 previously had orders for RNA services. The DOR stated that after Resident 4 was readmitted from the hospital, nursing did not reorder RNA services for Resident 4.During an interview on 2/12/2026 at 3:14 p.m. with the Director of Nursing (DON), the DON stated Resident 4 went to the hospital for surgery, and the licensed nursing staff did not re order RNA services upon the resident's return. The DON stated that Resident 4 should be receiving RNA services and that without them, the resident is at risk of becoming more contracted.During a review of the facility's policy and procedure (P&P), titled Restorative Nursing Services, date revised 7/2017, the P&P indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence.Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care .

Based on observation, interview, and record review, the facility failed to ensure that the recommended ankle brachial index (ABI- painless test that measures blood pressure in your ankles and arms) with arterial doppler (non-invasive, painless ultrasound test that uses sound waves to evaluate blood flow) for one of 15 sampled residents (Resident 6) was completed as ordered on 1/28/2026 for a right second toe diabetic ulcer (open sore, commonly on the bottom of the foot, affecting resident with diabetes).This failure resulted in Resident 6 experiencing emotional distress due to uncertainty about whether his toe might require amputation( surgical or traumatic removal of a limb or extremity (arm, leg, finger, toe).Findings:During an observation on 2/9/2026 at 10:05 a.m., at Resident 6's bedside. Resident 6's right second toe was observed to be swollen, black in color with a small amount of blood.During a review of Resident 6's admission Record dated 2/11/2026, the admission Recorded indicated Resident 6 was admitted to the facility on [DATE] with diagnosis including heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), tinea pedis (foot fungus), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 6's History and Physical (H&P) dated 1/17/2026, the H&P indicated Resident 6 had the capacity to understand and make decisions.During a review of Resident 6's Minimum Data Set (MDS-resident assessment tool) dated 1/23/2026, the MDS indicated Resident 6's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 6 needed partial/moderate assistance (helper does less than half the work) with activities of daily living (ADL's like dressing, bathing and personal hygiene).During a review of Resident 6's Treatment Administration Record (TAR) dated 2/1/2026, the TAR indicated Resident 6 was being treated for a right second toe diabetic ulcer and to clean with normal saline pat dry apply betadine (kills germs, prevents infection) daily.During a review of Resident 6's Care Plan titled Altered Skin Integrity dated 1/23/2026 revised on 1/30/2026 the Care Plan indicated Resident 6 had right foot tinea pedis (fungal infection of the feet). The Care Plan indicated to have a wound consult and follow-up treatment as indicated.During an interview on 2/10/2026 at 8:04 a.m. with Resident 6, Resident 6 stated about three weeks ago his right second toe began hurting and that it had since started turning black. Resident 6 stated he was worried that his toe might have to be cut off.During a concurrent interview and record review on 2/10/2026 at 3:17 p.m. with the Treatment Nurse (TXN), Resident 6's wound doctor's (Dr.) progress note dated 1/28/2026 was reviewed. The progress note indicated Resident 6 had a recommendation for an ABI and arterial doppler for his right second toe diabetic ulcer. The TXN stated she was responsible for ensuring the recommendation from the wound care doctor was completed and acknowledged she must have missed it. The TXN stated that the resident's right second toe could worsen, become infected, and potentially require amputation if not properly evaluated.During an interview on 2/12/2026 at 2:20 p.m. with the Director of Nursing (DON), the DON stated she had been made aware that the recommended ABI and arterial doppler for Resident 6's right second toe diabetic ulcer had not been completed, and that it should have been done on 1/28/2026. The DON stated there was a possibility of a missed diagnosis. The DON stated she had assessed Resident 6's right second toe, noted it was black, and acknowledged that the resident might require amputationDuring a review of the facility's policy & procedure (P&P) titled Physicians Orders dated 2/2014, the P&P indicated verbal, written and telephone orders may be accepted from each residents physician. The receiving nurse will carry out the order and print the medication or treatment record. The new order will be communicated to the responsible party/agent, charge nurse, pharmacy, and other departments as indicated.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 5) was free of chemical restraints (use of medication to control a patient's behavior or restrict the patient's movement and not required to treat the medical symptom).The facility failed to:1.Ensure Resident 5 was provided with non-pharmacological interventions (intervention that does not primarily use medicine) before administering as needed (prn) psychotropic medication (any drugs that affects the brain activities associated with mental processes and behavior) of Ativan (Lorazepam- medicine used to treat anxiety)2.Ensure psychotropic medication used as a prn for Resident 5 did not exceed 14 days.These failures had the potential to put Resident 5 at risk for adverse consequences (unintended, harmful events attributed to the use of medication) due to unnecessary prolonged use of psychotropic medication affecting Resident 5's quality of life.Findings:During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety disorder ( emotion characterized by feelings of tension and worried thoughts), and major depressive disorder( a serious mental health conditions characterized by a persistently low mood, deep sadness).During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 1/15/2026, the MDS indicated the resident had moderately impaired cognition (a person has noticeable difficulties with memory, language, or thinking skills ) and required substantial/ maximal assistance ( helper does more than half the effort ) with bathing, dressing, toileting hygiene and oral hygiene.During a review of Resident 5's History and Physical (H&P) dated 1/11/2026, the H&P indicated Resident 5 had a fluctuating capacity to understand and make decisions and was able to make decisions for daily living activities.During a review of Resident 5's Order Summary Report dated 2/8/2026, the Order Summary Report indicated a physician order of Ativan (Lorazepam) .5 milligram (mg.- unit of measurement) by mouth every six hours as needed for anxiety manifested by restlessness with indefinite duration (no stop date).During a review of Resident 5's Care Plan titled, Resident noted with behavior of anxiety manifested by restlessness and constant yelling, initiated on 2/9/2026, the Care Plan indicated Resident 5 was on lorazepam 0.5 mg. every 6 hours. The Care Plan goal indicated Resident 5 will have less than one episode per week. The Care plan indicated interventions that included administering lorazepam as needed and attempting to refocus behavior to something positive when Resident 5 was exhibiting the behavior.During a concurrent interview and record review on 2/11/2026 at 11:11 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 5's Order Summary Report and Medication Administration Record dated February 2026 were reviewed. LVN 3 stated a physician order of Ativan 0.5 mg. every six hours as needed for anxiety manifested by restlessness dated 2/8/2026 had no stop date and had an indefinite duration. LVN 3 stated there were no non-pharmacological interventions documented in the MAR before administering Ativan prn. LVN 3 stated non-pharmacological interventions should be provided to the resident like repositioning, dimming lights, or providing water before a prn psychotropic medication like Ativan was administered to the resident. LVN 3 stated provision of non- pharmacological interventions can prevent Resident 5 from taking Ativan unnecessarily which can make him sleepy and drowsy preventing him from participating in his activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a concurrent interview and record review on 2/11/2026 at 3:32 p.m. with the Director of Nursing (DON), Resident 5's Order Summary Report was reviewed. The DON stated the physician order of Ativan 0.5 mg every 6 hours as needed for anxiety manifested by restlessness should have a stop date and the duration should be 14 days. The DON stated the licensed nurses should assess the behavior, offer non-pharmacological interventions before administering Ativan because there was a potential for side effects like fall, confusion and can be unnecessary medicine if administering without attempting to use non-pharmacological interventions. The DON stated Ativan can be a chemical restraint because staff were administering the medicine to quiet Resident 5 down instead of providing non-pharmacological interventions first. The DON stated there should be 14 days stop date for prn Ativan to ensure the resident will not be addicted (very strong urge to do or use something that is very hard to stop or control) to the medicine and develop side effects like drowsiness, dizziness, dry mouth, confusion and sedation which can prevent him from participating in ADLs.During a review of facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, revised 12/2016, the P&P indicated The duration of prn antipsychotic (a type of medication prescribed to treat mental health problem) medications will be indicated in the order. The P&P indicated diagnoses alone do not warrant the use of antipsychotic medications and should only be considered if the behavioral interventions have been attempted.

Based on interviews and record review, the facility failed to ensure missing personal items belonging to one of one sampled resident (Resident 47), including colored pencils and pens used for activities and a personal bottle of hot sauce, were located or replaced.This failure had the potential to result in Resident 47 experiencing frustration or depressed mood due to the facility not returning or replacing the missing items. Findings:During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to major depressive disorder(mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), quadriplegia (paralysis from the neck down, including legs, and arms), bed confinement and chronic pain.During a review of Resident 47's Physician Progress Notes, dated 11/22/2025, the Physician Progress Note indicated, Resident 47 had the capacity to understand and make decisions. During a review of Resident 47 Minimum data Set (MDS- a resident assessment tool) dated 11/11/2025, the MDS indicated Resident 47 was dependent on nursing staff for showering and transferring. The MDS indicated Resident 47 needed substantial to maximal assistance from nursing staff with toileting, dressing, and rolling from left to right.During an interview on 2/09/2026 at 10:11 a.m., Resident 47 stated he was missing pens, pencils, and a bottle of hot sauce. Resident 47 reported he had informed Scheduler (SCHED) 1 about the missing items, and SCHED 1 told him last week that she would work on replacing them. Resident 47 stated he previously had mechanical pencils with red lead, and when he returned from his shower, the pens and pencils were gone. Resident 47 stated he originally had two bottles of hot sauce, but now only one remained.During an interview on 2/11/2026 at 12:29 p.m., Certified Nursing Assistant (CNA) 2 stated that Resident 47 had colored pencils and that sometimes his belongings fall onto the floor.During an interview on 2/11/2026 at 2:18 p.m. with Scheduler (SCHED) 1, SCHED 1 stated that last week Resident 47 informed her he was missing pens and pencils. SCHED 1 stated she was working with the activity assistant and was waiting for funds to replace the items. SCHED 1 stated she should have notified the social worker so an investigation could be initiated and the missing items replaced. SCHED 1 stated she instead thought she would purchase pens and pencils for activities and did not document a grievance or inform the social worker. SCHED 1 stated she would replace the missing items today (2/11/2026). SCHED 1 stated missing property would make Resident 47 feel bad if it was not replaced.During an interview on 2/12/2026 at 3:09 p.m. with the Director of Nursing (DON), the DON stated that SCHED 1 was supposed to notify the social worker (SW) regarding missing items. The DON stated that the SW was responsible for interviewing the resident regarding any missing or lost property. The DON stated SCHED 1 should have communicated updates to the resident about the missing items so the resident would not feel ignored.During a review of the facility's policy and procedure (P&P) titled Theft and Loss, date revised 4/2021, the P&P indicated It is the policy of this facility to assure each resident's right to retain and use personal possessions, as space permits, unless those possessions infringe on the rights, health or safety of other patients. This facility will take reasonable preventive measures to prevent loss or damage of resident's possessions. suspected theft or loss will be reported in the following manner, items under $25.00, loss of theft shall be reported on the Social Services referral form and given to Social Services Staff.

Based on interview and record review, the facility failed to honor one of four sampled residents' (Resident 38) right to self determination by not accommodating Resident 38's request to have a shower.This failure had the potential to negatively impact Resident 38's quality of life.Findings:During an interview on 2/10/2026 at 9:59 a.m., Resident 38 stated she wanted a shower, but staff refused to provide one, and she had not received a shower for some time.During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Parkinson's disease without dyskinesia ( a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), unspecified dementia (a progressive state of decline in mental abilities), unsteadiness of feet, and history of falling.During a review of Resident 38's Minimum Data Set(MDS- a resident assessment tool) dated 11/12/2025, the MDS indicated Resident 38 had severely impaired cognitive ability to think, learn, remember, use judgement and make decisions) skills and required partial/moderate assistance (helper does less than half the effort to complete the activity) with bathing/showering, and personal hygiene.During an interview on 2/11/2026 at 1:02 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 38 refused to have a shower and did not have a shower last week, but bed bath was provided to the resident. CNA 1 stated Resident 38 asked for a shower yesterday (2/10/2026) but it was late to be provided to the resident, and it was not Resident 38's shower day. CNA 1stated Resident 38's schedule for shower were Mondays, Wednesdays and Fridays. CNA 1 stated it was her mistake because she did not notify the charge nurse or the incoming shift CNA about Resident 38 requesting for a shower. CNA 1 stated Resident 38 did not need to wait for her shower day to have a shower because it should be provided to a resident regardless of their shower schedule. CNA 1 stated she should have given Resident 38 a shower when she requested it or notified the next incoming shift CNA or the charge nurse that she wanted to have a shower to ensure Resident 38's request was honored and provided. CNA 1 stated not providing a shower to Resident 38 when she requested for it can violate resident's right to choose because her preference to have shower yesterday was not honored.During an interview on 2/12/2026 at 1:09 p.m. with the Director of Nursing (DON), the DON stated Resident 38 should have been given a shower by CNA 1 regardless of resident's schedule for shower. The DON stated not providing a shower when a resident requested can violate resident's rights and Resident 38 will think that nobody cares about her needs in the facility.During a review of facility's policy and procedure (P&P) titled, Resident Self Determination and Participation, revised 2/2021, the P&P indicated Each resident is allowed to choose activities, and schedule health care that are consistent with his or her interest, values, assessments and plans of care including personal care needs.

Based on interview and record review the facility failed to ensure:a. Education was provided about the benefits and risks of the COVID-19 (an illness caused by the coronavirus and affects the lungs and breathing and can make other parts of the body sick) vaccine for one of five residents (Resident 4) and/or the resident's representative.b. One of five staff (Dietary Aide 1) had documentation containing information demonstrating the staff member had been screened, provided with COVID-19 vaccine education, was offered the vaccine and had their current vaccination status recorded.This failure had the potential to result in residents and staff remaining unprotected against COVID-19, increased risk of serious illness, delayed identification of vaccine status, and missed opportunities to prevent the spread of infection within the facility.Findings:a. During a review of Resident 4's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 4 on 9/14/2024 and was re-admitted on [DATE] with diagnoses including frontal lobe (part of the four major lobes in the human brain) and executive function deficit following cerebral infarction (cerebral infarction - blocked blood flow to the brain resulting in tissue death).During a review of Resident 4's history and physical (H&P) dated 11/12/2025, the H&P indicated Resident 4 does not have the capacity to understand and make decisions.During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 12/16/2025, the MDS indicated Resident 4 had severely impaired cognitive skills for daily decision making.During a concurrent interview and record review on 2/11/2026 at 1:30 p.m. with the Licensed Vocational Nurse (LVN)1 Resident 4's immunization screening was reviewed. Resident 4 immunization record indicated COVID-19 vaccination was given on 10/3/2025 and the vaccination informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was received over the phone from the responsible party on 9/17/2025. LVN 1 stated there was no documentation the resident's responsible party was given education for the vaccine. LVN 1 stated the importance of providing education to the resident and the responsible party was to explain the risks of not receiving the vaccine and benefits of receiving the vaccine.During a concurrent interview and record review on 2/11/2026 at 2:50 p.m. with the Infection Preventionist Nurse (IPN), Resident 4's immunization screening was reviewed. The IPN stated vaccination education was not given. The IPN stated the resident's responsible party should have been educated for the COVID-19 vaccine. The IPN stated the importance of providing education was to explain the risk and benefits of the vaccine.b. During a concurrent interview and record review interview on 2/11/2026 at 2:50 p.m. with the Infection Preventionist Nurse (IPN). Dietary Aide (DA) 1 had no documentation of COVID-19 vaccine, or COVID-19 vaccine education. The IPN stated no COVID-19 vaccine had been offered. The IPN stated the risk to the resident if staff do not have vaccine was transmitting the virus.During a review of the facility's policy and procedure (P&P) titled COVID-19, Prevention and Control revised 4/4/2025, indicated All health care providers will be provided information regarding the requirement to receive the COVID-19 vaccine.The IP nurse or a facility designated staff shall obtain and document the current vaccination status of all health care providers including but not limited to COVID-19 immunization.

Based on observation, interview, and record review, the facility failed to ensure the resident, who was transported to a shower room, did not get hit by a shower room door and sustain an injury to a left great toe for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA 1) requested assistance to hold the door to Shower room [ROOM NUMBER] while he was pulling Resident 1 on a shower chair into the Shower room [ROOM NUMBER]. 2. Ensure CNA 1 and Licensed Vocational Nurse (LVN 1) reported Shower room [ROOM NUMBER]'s door malfunctioning by documenting about it in the Maintenance Logbook. 3. Ensure CNA 1 and LVN 1 reported to the Maintenance Supervisor (MS) that the door to Shower room [ROOM NUMBER] was not staying wide open to transport the residents safely through the Shower room [ROOM NUMBER]. 3. Ensure MS followed the facility's policy and procedure (P&P) titled, Maintenance Service, which indicated The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. These deficient practices resulted in Resident 1 left great toe hit by door to Shower room [ROOM NUMBER] and sustaining a fracture (broken bone) of the left medial (middle) cortex of the left fourth proximal (closer to center of the body) phalanx (small toe bone) and a left great toe laceration (skin tear). On 11/16/2024 Resident 1 was transferred to a general acute care hospital (GACH) where the resident had the left great toe sutured (a medical thread used by doctors to stitch up a wound or cut). Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline mental abilities) and osteoporosis (disorder of bone density and structure). During a review of Resident 1's Minimum Date Set ([MDS]- a resident assessment tool), dated 10/4/2024, the MDS indicated Resident 1 had impairment in cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting, personal hygiene, and lower body dressing. During a review of Resident 1's Change of Condition ([COC]- documentation of a resident's sudden change from regular state of being) assessment dated [DATE], the COC assessment indicated Resident 1's physician was notified of Resident 1 had left great toe hit by a shower room door on 11/6/2024 at 10:30 a.m. During a review of Resident 1's Physician's Orders Summary Report for November 2024, the Physician's Orders Summary Report indicated an order dated 11/6/2024 to transfer Resident 1 to the emergency room (ER) via ambulance (a vehicle that transports people who are sick or injured to the hospital in an emergency) for a left great toe wound treatment. During a review of Resident 1's Radiology (x-ray-imaging that creates pictures of the inside of the body) Final Report, the Radiology Final Report dated 11/6/2024 at 1:58 p.m., indicated Resident 1 had the distal medial cortex of the left fourth proximal phalanx fracture. During a review of Resident 1's Emergency Department (ED) Discharge Instructions from the GACH dated 11/6/2024, the ED Discharge Instructions indicated to remove the resident's left foot sutures in seven to 10 days. During a review of Resident 1's Interdisciplinary Team ([IDT]- group of different professionals working together in a case, all collaborating to provide the best care for a patient) Skin Note dated 11/7/2024, the IDT Skin Note indicated Resident 1 was transferred to the GACH for 11/6/2024 or the left foot wound evaluation and treatment and was transferred back to the facility the same day (11/6/2024) with intact sutures on a left great toe wound (laceration). During a review of CNA 1's written statement dated 11/7/2024, CNA 1's written statement indicated CNA 1 was pulling Resident 1 on a shower chair into Shower room [ROOM NUMBER] while using my right foot to stop the door then the resident's left foot was accidentally hit by the door. During a review of the facility's Maintenance Logbook for the period of time from 7/26/2024 -11/20/2024 located at Nurses Station 1, the Maintenance Logbook indicated no documentation regarding Shower room [ROOM NUMBER]'s door malfunctioning. During a review of Resident 1's Nurses Progress Notes dated 11/22/2024, the Nurses Progress Notes indicated there were four sutures removed from Resident 1's great left toe laceration and Resident 1 received Tylenol (medication used to relieve pain) for pain management. Resident 25 was not able to state the pain level but had a facial grimacing (a facial expression that usually conveys pain) indicating the resident was in pain. During an observation on 11/22/2024 at 9:20 a.m., of Resident 1's left great toe wound (laceration) dressing change, Resident 1's left great toe wound was observed being without redness or swelling. During an interview with CNA 1 on 11/22/2024 at 9:35 a.m., CNA 1 stated on 11/6/2024 he was transporting Resident 1 on a shower chair to Shower room [ROOM NUMBER], and while trying to pull him inside, the door to the shower room would not stay open, causing the door to hit Resident 1's left foot. CNA 1 stated he should have requested help while attempting to pull Resident 1 into the shower room to avoid the door striking Resident 1's left foot. CNA 1 stated that he verbally informed LVN 1 about the malfunctioning door of Shower room [ROOM NUMBER], but he did not record it in the Maintenance Logbook. CNA 1 stated it was the facility's policy to document broken equipment in the maintenance logbook. CNA 1 acknowledged that he should have documented about malfunctioning shower door in the Maintenance Logbook. CNA 1 stated the incident with Resident 1 could have been avoided if the door to Shower room [ROOM NUMBER] had been working properly. During an interview with LVN 1 on 11/22/2024 at 10:20 a.m., LVN 1 stated Shower room [ROOM NUMBER]'s door had a stopper (device used to keep a door open or closed) that prevented the door from being fully opened or stay open, so staff needed to use their foot to keep the door propped open. LVN 1 stated CNA 1 should have requested someone to hold the door for him while he was pulling Resident 1 on a shower chair into the shower room, which could have prevented Resident 1's foot from being struck. LVN 1 stated that she did not consider reporting the shower room door failure to stay open because it had always functioned that way, and she did not see it as being broken since the door stopper was a part of the door. LVN 1 stated she did not think the shower room door was a problem until it hit Resident 1's foot. During an interview on 11/22/2024 at 11:27 a.m., the MS stated room [ROOM NUMBER]'s shower door was closing automatically unless someone was holding door open. MS stated that the week before Resident 1's accident on 11/6/2024, he was informed that there was an issue with the room [ROOM NUMBER]'s shower door. MS stated on 11/5/2024, he removed the door stopper to allow the door to open wider, but someone (unknown) reattached it. During a concurrent interview and record review on 11/22/2024 at 12:45 p.m., Registered Nurse Supervisor (RNS) stated due to the accident on 11/6/2024 Resident 1 sustained a wound (laceration) to the left great toe that required suturing. RNS stated that CNA 1 should have asked for assistance to keep door open while transporting/pulling Resident 1 on a shower chair into the shower room to prevent the accident. RNS 1 stated CNA 1 should have documented in the Maintenance Logbook that Shower room [ROOM NUMBER]'s door was not staying open and was malfunctioning. After reviewing the Maintenance Logbook, RNS 1 stated there was no documentation regarding the malfunctioning Shower room [ROOM NUMBER]'s door. During an interview on 11/22/2024 at 1:01 p.m., the Administrator (ADM) stated when there were equipment issues or repairs needed, staff was expected to document these problems in the Maintenance Logbook. The ADM stated that CNA 1 should have reported (documented) the issue with the Shower room [ROOM NUMBER]'s door, as this could have prevented the accident involving Resident 1. During a review of the facility's policy and procedure (P&P) titled, Maintenance Services, revised 12/2009, the P&P indicated, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Maintaining the building in good repair and free from hazards. During a review of the facility's P&P titled Homelike Environment, revised 2/2024, the P&P indicated, Residents are provided with a safe, clean, comfortable, and homelike environment.

Based on interview, and record review, the facility failed to ensure the resident, who was transported from the medical appointment in a facility van did not fall backwards in a wheelchair and sustained injury for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Driver 1 secured Resident 1 in the van using a four-point straps (secures a wheelchair with four straps attached to the wheelchair at four separate securement points and attached to the vehicle at four separate anchor points) when the resident was in a wheelchair while being transported back to the facility after a medical appointment in the facility's van. 2. Ensure Certified Nursing Assistant (CNA 1) who accompanied Resident 1 to her medical appointment was educated on how to properly secure Resident 1 using the four-point straps and the seatbelts (a strap going over the shoulder and torso) when resident was in a wheelchair while being transported in the facility's van. 3. Ensure CNA 1 verified Driver 1 secured Resident 1 in a van with four-point straps and a seatbelt before heading back to the facility after a medical appointment. 4. Ensure CNA 1 and Driver 1 followed the facility's policy and procedure (P&P) titled, Transportation/Appointments revised 2020, which indicated, Employees and their passengers who are driving/riding in a vehicle on facility business purposes must wear a seat belt at all times in which the car is being operated. Wheelchair is properly strapped. As a result, Resident 1's wheelchair tilted back and hit her head on the van lift when Driver 1 made a left turn towards the facility, which was on a slight uphill slope. Resident 1 was transferred to a general acute care hospital (GACH) on 10/1/2024 at 11:04 a.m. Resident 1 sustained a right occipital (the back of the head) scalp laceration (a cut or tear in the skin or underlying tissue) and hematoma (a pool of mostly clotted blood that forms in an organ, tissue or body space), neck sprain (a soft tissue injury that occurs when a ligament [attach bone to bone] in a joint {two or more bones are connected} is stretched too far or torn) and a right shoulder sprain. Resident 1 was discharged from GACH on 10/1/2024 at 6:56 p.m., to Resident 1's home. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD]-irreversible kidney failure), muscle weakness, difficulty walking, lack of coordination (the ability to use different parts of the body together smoothly efficiently), right arm pain, osteoporosis (a condition in which the bones become weak and brittle), and malaise (a general feeling of discomfort, illness, or lack of wellbeing). During a review of Resident 1's History and Physical (H&P), dated 9/21/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS]- federally mandated resident assessment tool), dated 9/24/2024, the MDS indicated Resident 1 had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues) from nursing staff with eating. The MDS indicated Resident 1 needed partial to moderate assistance (helper does less than half the effort) from nursing staff with oral hygiene and rolling from left to right in bed. The MDS indicated Resident 1 needed substantial to maximal assistance (helper does more than half the effort) from nursing staff with toileting, showering, and upper body dressing. The MDS indicated Resident 1 was dependent (helper does all the effort) on nursing staff with lower body dressing, putting on and taking off footwear, the ability to sit and stand, and the ability to transfer from the bed to the chair. During an interview on 10/10/2024 at 11:58 a.m., with CNA 1, CNA 1 stated that on 10/1/2024 at approximately 10:20 a.m., after Resident 1's medical appointment she called the facility driver (Driver 1), to inform Resident 1 was done with the medical appointment and was ready to be picked up. CNA 1 stated Driver 1 placed Resident 1 on the lift located at the back of facility's van and lifted Resident 1 up inside the van facing forward towards the front of the van. CNA 1 stated she saw Driver 1 strap a gray seatbelt over the Resident 1's lap. CNA 1 stated she (CNA1) sat in the front passenger seat. CNA 1 stated Driver 1 shut the van's back door and got into the driver's seat. CNA 1 stated when approaching the facility, Driver 1 made a left turn towards the facility, which was on a slight uphill slope. CNA 1 stated she heard a loud bang sound at the back of the van with Resident 1 yelling for help. CNA 1 stated Driver 1 stopped the van went to open the side door of the van. CNA 1 stated Resident 1 wheelchair was tilted in a straight back position with resident lying on the floor of the van still strapped in the wheelchair with the gray seatbelt over the Resident 1's lap. Resident 1's head was touching the van's lift and continue yelling and verbalizing My head, my head, I think it is bleeding. CNA 1 stated she told Driver 1 to open the van's lift door at the back and to go get help inside the facility. CNA 1 stated Resident 1's head was bleeding from the back of the head. CNA 1 stated she (CNA 1) took off her jacket to add pressure to the back of Resident 1's head to stop the bleeding. CNA 1 stated after the fall, she noticed Resident 1's wheelchair was not anchored to the van floor using the four-point strap. CNA 1 stated she asked Driver 1 to remove the wheelchair from under Resident 1 while she was holding Resident 1's back and both legs. CNA 1 stated Driver 1 removed the wheelchair from under Resident 1. CNA 1 stated Registered Nurse Supervisor (RNS 1) and Licensed Vocational Nurse (LVN 1) came to the van and informed them (RNS 1 and LVN 1) Resident 1 was bleeding on the back of her head. CNA 1 stated LVN 1 called 911 (medical emergency number) and assessed Resident 1. CNA 1 stated Resident 1 remained alert. CNA 1 stated she should have ensured Resident 1's wheelchair was anchored in the van during the resident's transport back to the facility. CNA 1 stated she failed to check if Resident 1's wheelchair was anchored and strapped securely. CNA 1 stated she was not familiar with the straps used to secure the wheelchair during transport in the facility van. CNA 1 stated this was her first time to escort a resident to a medical appointment and did not check Resident 1 to make sure Resident 1 was strapped in the wheelchair with a seatbelt and her wheelchair was anchored to the van floor using the four-point straps. During an interview on 10/10/2024 at 12:51 p.m., with Restorative Nurse Assistant (RNA) 1, RNA 1 stated when transporting a resident in the van, the driver puts the resident wheelchair on the lift and lift resident up inside the van. RNA 1 stated the resident should be facing forward (front of the van). RNA 1 stated the driver should hook up the wheelchair two straps in the back and two straps in the front of the wheelchair and apply a seatbelt over the resident. RNA 1 stated the driver should check the four-point straps to make sure the straps were secured. RNA 1 stated the driver must ensure the four-point straps were secured to ensure safety in the event the driver will abruptly stop the van. RNA 1 stated if the resident was not properly strapped and secured in the wheelchair the resident will fall from the wheelchair. During an interview on 10/10/2024 at 1:27 p.m., with Driver 1, Driver 1 stated on 10/1/2024 at 10 a.m., CNA 1 called him to pick up Resident 1 from her medical appointment. Driver 1 stated he put Resident 1 on the lift and into the van. Driver 1 stated he put the gray seatbelt over the Resident 1's lap and drove back to the facility. Driver 1 was unable to answer when asked if Resident 1's wheelchair was anchored to the van floor by using a four-points straps, two in the front of the wheelchair and two in the back of the wheelchair and a seat belt. Driver 1 stated, upon driving to the facility's parking lot, he heard a bang at the back of the van. Driver 1 stated Resident 1 was yelling for help. Driver 1 stated he realized he did not secure the wheelchair to the van floor. Driver 1 stated he did not hook the straps on the four points of the wheelchair. Driver 1 stated CNA 1 told him to open the back door of the van and to call RNS 1 and LVN 1. Driver 1 stated the wheelchair was tilted straight back. Driver 1 stated CNA 1 asked him to remove the wheelchair from under Resident 1's body. Driver 1 stated RNS 1 and LVN 1 came and checked Resident 1 for any injury and called 911. Driver 1 stated 911 came immediately to assist Resident 1. Driver 1 stated he failed to use the four-point straps that were provided for use when transporting a resident. During an interview on 10/10/2024 at 1:58 p.m., with LVN 1, LVN 1 stated on 10/1/2024 the facility receptionist came to the nurses' station and stated Resident 1 needed assistance in the van. LVN 1 stated he told RNS 1 to grab the crash cart (a portable cart that contains emergency medical equipment, drugs, and supplies for treating sudden, severe medical problems). LVN 1 stated when he approached the van, he saw CNA 1 applying pressure on the back of Resident 1's head. LVN 1 stated Resident 1 was bleeding from the back of the head and verbalized pain 8 out 10 on a zero to ten pain scale (a numeric pain scale with zero meaning no pain and 10 meaning the worst pain imaginable). LVN 1 stated RNS 1 came with the crash cart and stayed with Resident 1. LVN 1 stated he then called 911. LVN 1 stated before Resident 1 left for the medical appointment on 10/1/2024, he checked to make sure Resident 1 was safe. LVN 1 stated he made sure Resident 1 was strapped using the four-point strap. LVN 1 stated before Resident 1 left the facility he verified the four-point contact on the wheelchair and checked the straps to make sure the resident was strapped in properly. During an interview on 10/10/2024 at 2:32 p.m., with the Administrator (Adm), the ADM stated he did a verbal training with facility staff on transporting residents using the facility's van. (unknow date) Adm stated he bought new straps and explained the use of the straps and how to properly anchor the wheelchair safely in the van. Adm stated he did a return demonstration (teaching strategy that involves the learner demonstrating their understanding or mastery of a skill or concept by performing it themselves) with the staff on how to secure the four-point straps to the wheelchair. Adm stated Driver 1 did not strap Resident 1 in the wheelchair using the four-point straps/contacts of the wheelchair and use of a seatbelt on 10/1/2024. Adm stated Resident 1 was no longer a resident at the facility and was not coming back to the facility. Adm stated Resident 1 was discharged from GACH to her home on 10/1/2024. During a review of Resident 1's Physician's Order Summary, dated 10/1/2024, the Physician's Order summary indicated Resident 1 had an order to be transferred to GACH for further evaluation after the fall in a van during transportation. During a review of the Facility's Investigation Report, dated 10/1/2024, the Facility's Investigation Report indicated, Driver 1 turned left into the facility's parking lot on an uphill slope and when the driver stepped on the brakes Resident 1's wheelchair toppled backwards causing Resident to fall with the wheelchair and hit the floor of the van. The facility's Investigation Report indicated, Driver 1 admitted that he failed to properly secure Resident 1's wheelchair and had been trained on how to properly secure residents' wheelchairs to prevent accidents and or injuries. During a review of Resident 1's emergency room report (GACH records), dated 10/1/2024 timed at 3:36 p.m., the emergency room report indicated, Resident 1 had a right occipital scalp laceration and hematoma, neck sprain and a right shoulder sprain. The GACH records indicated Resident 1 was given Norco ([Hydrocodone-Acetaminophen] medication used to relieve moderate to severe pain) 5-325 milligram ([mg] a unit of measurement) one tablet for pain. The GACH records indicated after the wound of Resident 1's head on the right back of the head was cleaned, there were two small lacerations less than one centimeter ([cm] unit of measurement) each. During a review of the facility's P&P titled, Transportation/Appointments revised 2020, the P&P indicated, Employees and their passengers who are driving/riding in a vehicle on facility business purposes must wear seat belts at all times in which the car is being operated. Wheelchair is properly strapped. During a review of Four-Point Straps instruction attached to the straps (undated), the instructions indicated To attach buckle hook to proper anchor point, attach strap hook to second anchor point, place strap overload, insert end of strap through buckle and pull it to eliminate slack, push lever closed to secure strap, keep fingers clear of mechanism, to release strap open lever.

Based on observation, interview, and record review the facility failed to implement infection control practices to prevent the spread and transmission of multidrug resistant organism (MDROs- microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) in the facility for 11 out of 11 sampled residents by failing to: 1.Ensure personal protective equipment (PPE-equipment used to prevent or minimize exposure to hazards) was accessible and readily available to staff while providing direct care to residents at high risk of acquiring MDRO. 2. Ensure 11 residents were placed on Enhance Barrier Precaution (EBP- use of a gown and gloves for residents with wounds, indwelling devices such as a urinary catheter (a flexible tube that collects urine from the bladder and to a drainage bag), gastrostomy tube (GT-a tube inserted through the wall of the abdomen directly into the stomach for food and medication administration) and tracheostomy (a surgical opening in the neck for breathing). a. Resident 247 who had a left heel deep tissue injury (DTI- when blood flow to an area is diminished or absent causing a pressure injury). b. Resident 246 who had an indwelling urinary catheter, colostomy (surgical opening for large intestine through the belly to allow stool to leave the body through the large intestine) and stage 4 (full thickness [damages extend below all layers of the skin] skin and tissue loss) pressure ulcer (localized damage to the skin and/or underlying soft tissue) on the sacral area (bottom of the spine) extending to buttocks and back. c. Residents 36, 37,38, 1, 9 and 346) who had GTs. d. Resident 1 who had a tracheostomy, and a Stage 3 (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) pressure ulcer. e. Residents 96 and 246 with stage 4 pressure ulcers g. Resident 17 with an open wound on the right hip i. Resident 42 who had a pressure ulcer on the sacrum, right and left buttocks, right and left heel. 3.Ensure there was a signage for isolation posted or isolation cart (where personal protective equipment was stored with gown and gloves), placed outside residents' rooms before entering the residents' room to alert staff and visitors of EBP and prevent the spread of infection. 4. Have policies and procedures regarding the application of EBP for residents known to be colonized (presence of microorganism) with MDRO and residents with open wounds and/or indwelling medical devices. 5.Develop comprehensive EBP care plan for 11 residents with open wounds and indwelling medical devices such as indwelling urinary catheter, tracheostomy, and GT. On 5/16/2024 at 3:11 p.m., the Administrator (ADM), and the Director of Nursing (DON), were notified of an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious, injury, harm, impairment, or death to a resident) due to the facility's failure to implement infection control practices to prevent the spread and transmission of MDRO. On 5/17/2024 at: 3:31 p.m., the facility submitted an acceptable IJ Removal Plan. On 5/17/2024 at 6:45 p.m., the IJ was removed after on-site validation of the implementation of the IJ Removal Plan through observations, interviews, and record review. The IJ Removal Plan included the following: 1.Resident 247,246,36,37,38,1,9,346,96,17 and 42 were placed on EBP. EBP signages were posted on all the resident's rooms and isolation carts were available outside each room. 2. All residents identified had a physician order with reason for EBP. 3. Comprehensive plan of care were initiated for all 11 identified residents. 4. Self-responsible residents were informed of EBP, and resident representatives were informed for residents who were not responsible. 5. In-services with teach back were initiated to all staff regarding EBP. 6.On 5/16/2024 EBP policy and procedure was initiated and reviewed by Interdisciplinary Team (IDT-team members from different departments working for the resident's benefit) which included the ADM, the DON, the Social Services Designees, the Activities Director, the Infection Preventionist (IP), the Director of Staff Development (DSD) and representatives from the rehabilitation department. 7. The DON in serviced the IP designee for the following identified noncompliance: Line listing (a table that contains key information about each case in an outbreak [sudden rise in the incidence of a disease]), infection control rounding, and EBP. 8. EBP brochures were available to families, visitors, vendors, and staff at the front lobby of the facility. 9.Adherance monitoring of EBP including donning (putting on) of PPE during high contact activities will be performed by IP, charge nurse, and Registered Nurse supervisor daily every shift. 10. The DON and/or designee will perform random adherence monitoring for all facility staff until substantial compliance was observed. 11. Adherence monitoring tool will be kept in a binder upon completion and will be reviewed weekly by IDT to ensure identification of need for continued education of all staff. Facility staff will be in serviced as needed. 12. Possible admission inquiry to the facility will be reviewed by DON, Admission coordinator, and or Administrator for MDRO, wounds, indwelling medical devices and EBP will be initiated accordingly. 13.Residents admitted without wound and or indwelling medical devices but acquire during facility stay will be placed on EBP. Findings: 1. A review of Resident 247's Admission Record indicated, Resident 247 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (mild loss of strength on one side of the body) following cerebral infarction (when blood flow to the brain is disrupted), type II diabetes mellitus (abnormal blood sugar), difficulty in walking, and muscle weakness. A review of Resident 247's Physician Order Summary Report dated 5/15/24, indicated Resident 247 had a diagnosis of left heel deep tissue injury. The Physician Order Summary Report indicated apply heel protectors to bilateral heels daily. A review of Resident 247's History and Physical (H&P) dated 5/18/24 indicated Resident 247 had the capacity to understand and make decisions. During an observation on 5/14/2024 at 8:30 a.m., outside Resident 247's and 246's room there was no EBP signage and no isolation cart readily available for staff to use before entering the residents' room. During an observation on 5/15/2024 at 4:30 p.m., outside Resident 247's room, the Physical therapist (PT- licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) 1 was behind the closed privacy curtain at Resident 247's bedside. PT 1 was observed walking out from behind the closed privacy curtain wearing only gloves, and no gown. During an interview on 5/15/24 at 5:00 p.m., with PT 1, stated she was wearing gloves when providing physical therapy treatment to Resident 247. PT 1 stated she should have worn a gown and gloves to prevent the risk of cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) to other residents, and staff. During an interview on 5/16/2024, at 2:04 p.m., with the Infection Prevention Nurse (IPN), the IPN stated, Residents 247, 246, 36, 37, 38, 1, 9, 346, 96,17 and 42 were not on EBP. The IPN stated PPEs should be readily accessible to staff who care for these residents. The IPN stated unfortunately, there were no PPEs available in front of residents' rooms, for staff to use before entering the rooms. The IPN stated if staff did not follow the EBP there will be an increased risk of infection cross-contamination from affected residents to staff, other residents, and the community. The IPN stated he had not implemented EBP for Resident 247,246 ,36, 37, 38, 1, 9, 346, 96 17 and 42 with wounds and indwelling medical devices. The IPN stated residents with indwelling urinary catheters, g-tubes, tracheostomy, and draining wounds should all be placed on EBP. The IPN stated there were no EBP care plans for all 11 residents with open wounds and indwelling medical devices. The IPN also stated the facility did not have any policies and procedures on the application of EBP for residents with MDRO and those with open wounds and/or indwelling medical devices. 2. A review of Resident 246's Admission Record indicated Resident 246 was admitted to the facility on [DATE] with diagnoses including paraplegia (no feeling in lower body), type II diabetes mellitus, Stage 4 pressure ulcer on the left heel, Stage 4 pressure ulcer unspecified part of the back, Stage 4 pressure ulcer of the sacral (lower back) Stage 4 pressure ulcer of the right buttock, Stage 4 pressure ulcer of the right heel, rash and other nonspecific skin eruptions, indwelling urinary catheter and a colostomy. A review of Resident 246's H&P dated 4/29/2024 indicated Resident 246 had the capacity to understand and make decisions. A review of Resident 246's Physician Order Summary Report dated 4/27/2024 indicated cleanse left ischium (lower hip), and right buttock pressure ulcer with Normal Saline (cleansing solution), pat dry, pack lightly with calcium alginate ( type of wound dressing, cleanse left lower extremity extending to foot, right foot with hibiclens( cleansing solution), pat dry, apply bacitracin (antibiotic), nystatin powder ( antibiotic), cover with xerofoam ( type of dressing) every day shift. A review of Resident 246's Treatment Administration Record (TAR) dated 5/1/2024 indicated Resident 246 had a left ischium (lower hip bone) pressure ulcer stage 4, left lower extremity extending to left foot pressure ulcer stage 4, right lower extremity extending to right foot pressure ulcer stage 4, right buttock pressure injury stage 4, right ischium pressure injury stage 4, dorsal pressure injury stage 4, indwelling urinary catheter, and colostomy. 3. A review of Resident 346 Admission Record indicated Resident 346 was admitted to the facility on [DATE] with diagnoses including GT, type 2 diabetes mellitus, abnormalities of gait (trouble walking) and mobility. A review of Resident 346's H&P dated 5/13/2024 indicated Resident 346 has the capacity to understand and make decisions. During an observation on 5/15/2024 at 8:35 a.m., outside Resident 346's room there was no EBP signage and no isolation cart, were readily available before entering the residents' room. 4. A review of Resident 96's Admission Record indicated Resident 96 was admitted to the facility on [DATE] with diagnoses including GT, type II diabetes mellitus, abnormalities of gait and mobility. A review of Resident 96's H&P dated 4/25/2024 indicated Resident 96 has the capacity to understand and make decisions. During an observation on 5/15/2024 at 8:35 a.m., outside Resident 96's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. During an observation on 5/15/2024 at 10:30 a.m., the Treatment Nurse performed wound care on Resident 96 only wearing gloves and not the complete PPE required for EBP. During an observation on 5/15/2024 at 3:00 p.m., Occupational Therapist (OT- profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) 1 wore gloves while performing active range of motion exercises (AROM- full movement potential of a joint [where two bones meet]) to Resident 96 but without wearing a gown. During an interview on 5/16/2024 at 11:06 a.m., OT 1 stated he was not aware Resident 96 was on EBP. OT 1 stated, he should have worn the complete PPE including gloves and gown when performing AROM to Resident 96. During an interview on 5/16/2024 at 2:17 p.m., the DON stated if infection control practices were not observed such as EBP, there was a high risk for cross contamination and the possibility of spreading MDROs to other residents and staff. 5. A review of Resident 38's Admission Record, the Admission Record indicated Resident 38 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including right hip open wound, atrial fibrillation (an irregular and very rapid heart rhythm), muscle wasting and atrophy (the wasting or thinning of muscle mass due to disuse or nerve problems). A review of Resident 38's Progress Notes, dated 7/1/2023, indicated, Resident 38 had the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 4/9/2024, indicated Resident 38 was independent with eating and oral hygiene. The MDS indicated Resident 38 needed set up or clean up assistance with toilet hygiene, upper body dressing, repositioning from sitting to lying, lying to sitting on the side of the bed, sitting to standing, transferring from bed to chair, and transferring to the toilet. The MDS indicated Resident 38 needed supervision or touching assistance with showering, rolling from left to right, transferring to the shower and walking. The MDS indicated Resident 38 needed partial and moderate assistance with lower body dressing, putting on and taking off footwear and personal hygiene. The MDS indicated Resident 38 required nutrition through a feeding tube (a medical device that delivers liquid nutrition). The MDS also indicated Resident 38 received care for a surgical wound. During an observation on 5/15/2024 at 8:35 a.m., outside Resident 38's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. During an interview on 5/16/2024 at 12:01 p.m., with Resident 38 in the hallway, Resident 38 stated he received wound care dressing changed weekly with a special dressing on the right hip. Resident 38 stated on 5/15/2024 the treatment nurse (name unknown) only wore gloves when she did Resident 38 wound care dressing change. During an interview on 5/16/2024 at 12:03 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she never wears a gown when she changed Resident 38's wound dressing. 6. A review of Resident 37's Admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including GT, and gastroesophageal reflux disease (GERD-condition in which the stomach contents move up into the esophagus [food pipe]). A review of Resident 37's MDS dated [DATE] indicated Resident 37 had severe cognitive (ability to think, understand, learn, and remember) impairment in daily decision making. The MDS indicated Resident 37 was dependent (helper does all the effort) in oral hygiene, upper body dressing, eating and dependent with shower/bathe self, lower body dressing. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 37's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. 7. A review of Resident 36's Admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including GT, GERD, and dementia (loss of memory, language, problem-solving and other thinking abilities). A review of Resident 36's MDS dated [DATE] indicated Resident 36 had moderate cognitive impairment for daily decision making. The MDS indicated Resident 36 was dependent for personal hygiene, toileting, and shower/bathing. The MDS indicated Resident 36 had a feeding tube. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 36's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. 8. A review of Resident 17's Admission Record indicated Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including difficulty walking, and open wound to the right hip. A review of Resident 17's H&P dated 1/31/2024 indicated Resident 17 had the capacity to understand and make decisions. A review of Resident 17's MDS dated [DATE] indicated Resident 17 had intact cognitive skills with daily decision making. The MDS indicated Resident 17 required partial to moderate assist with lower body dressing and set up help with toileting and independent with eating. A review of Resident 17's TAR dated 4/30/2024 indicated Resident 17 had an open wound to the right hip. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 17's room there was no EBP signage and no isolation cart for use to enter Resident 17's room, to prevent the spread of infection. 9. A review of Resident 9's Admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including GT, and intellectual disabilities. A review of Resident 9's H&P dated 2/28/2024 indicated Resident 9 does not have the capacity to understand and make decisions. A review of Resident 9's MDS dated [DATE] indicated Resident 9 had severe cognitive impairment for daily decision making. The MDS indicated Resident 9 had a feeding tube. A review of Resident 9's Treatment Administration Record dated 4/30/24 indicated Resident 9 has a GT. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 9's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. 10. A review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses including left and right buttock Stage 3 (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) pressure ulcers (localized damage to the skin and or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure), left lower leg open wound, tracheostomy, and GT. A review of Resident 1's H&P dated 1/6/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's MDS dated [DATE] indicated Resident 1 was dependent on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, personal hygiene, rolling from left to right. The MDS indicated, Resident 1 had a feeding tube. The MDS indicated Resident 1 received treatments to the skin and pressure ulcer/injury with the application of a nonsurgical dressing. The MDS indicated Resident 1 received tracheostomy care. During an observation on 5/16/2024 at 9:05 a.m., outside Resident 1's room, there was no EBP signage and no isolation cart, readily available for use to enter the residents' room. 11. A review of Resident 42's Admission Record, the Admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses including pressure ulcers on the sacral (located below the lumbar spine and above the tailbone), right buttock, left buttock, right heel, and left heel. A review of Resident 42's MDS, dated [DATE], indicated Resident 42's had intact cognitive status and decision-making skills. The MDS indicated, Resident 42 required partial/moderate assistance (helper does less than half the effort) for oral hygiene, toileting hygiene, and upper body dressing. During an observation on 5/14/2024 at 11:48 a.m., outside Resident 42's room there was no EBP signage and no isolation cart, readily available. During a concurrent observation and interview on 5/16/2024, at 11:12 a.m., with LVN 1, LVN 1 entered Resident 42's room holding a medication cup, without wearing gloves or a gown. LVN 1 did not perform hand hygiene prior to entering the room. LVN 1 stated, she was not aware Resident 42 was on of EBP. LVN 1 stated she did not remember if she received in-service training on EBP in the past. A review of California Department of Public Health (CDPH) report titled Enhanced Barrier Precaution for Skilled Nursing Facilities (SNF), 2022 indicated the Centers for Disease Control and Prevention (CDC) introduced Enhanced Barrier Precautions, which recommended gown and glove use for nursing home residents with wounds and indwelling devices during specific high-contact resident care activities associated with MDRO transmission and the use of EBP as a routine approach to infection control in SNF. https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Enhanced-Standard-Precautions.pdf A review of Centers for Disease Control and Prevention report indicated Indwelling medical devices and wounds are risk factors for colonization (the presence of microorganisms on or within body sites without detectable clinical signs and symptoms) with a MDRO dated 5/20/2024. The report indicated once colonized residents can serve as sources of transmission within the facility. The expansion of EBP for all residents with wounds or indwelling medical devices was intended to protect high-risk individuals from acquiring and serving as a source of transmission if they became colonized. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html#:~:text=Enhanced%20Barrier%20Precautions%20are%20intended%20to%20provide%20an%20approach%20for,indwelling%20medical%20devices%20or%20wounds). 44898 49889

Based on interview and record review, the facility failed to ensure the resident, who had a history of wandering (a person that roams around and becomes lost or confused about their location) and aggressive behavior (hitting and yelling at others), had 1:1 monitoring (staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act) for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was monitored for wandering behavior to prevent Resident 1 from physical harm to self and others. 2. Ensure staff followed Resident 1's Care Plan (CP), titled Resident with wandering episodes to constantly monitor the resident's whereabouts and maintain a safe and hazard free environment. 3. Ensure staff followed the facility's policy and procedure (P&P), titled, Wandering and Elopements (departs the health care facility unsupervised and undetected) to prevent Resident 1 from sustaining injury. These deficient practices resulted in Resident 1 sustained a bump on her forehead for unknown reason on 8/29/23 and on 9/5/2023 Resident 1 sustained a laceration (a deep cut or tear in skin or flesh) to her left eyebrow, subsequently Resident 1 was transferred to a General Acute Care Hospital (GACH) on 9/5/2023 for evaluation and treatment for sustained injuries (laceration to her left eyebrow). Findings: During a review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and anxiety disorder (mental illness causing persistent fear and/or worry). During a review of Resident 1's History and Physical (H/P), dated 6/9/2023, the H/P indicated, Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set [(MDS), a standardized assessment and screening tool], dated 6/13/2023, The MDS indicated, Resident 1 had difficulty communicating some words or finishing thoughts but was able if prompted or given time. The MDS indicated Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with bed mobility and extensive assistance (resident involved in activity, staff provide weight-bearing support), transferring, dressing, toilet use, personal hygiene and had utilized a wheelchair as a mobility (ability to move) device. During a review of Resident 1's Change of Condition (COC) form, dated 8/29/2023, indicated, on 8/29/2023 at 10:00 a.m. Certified Nurse Assistant (CNA 2) observed a bump (a lump on the body caused by a blow) on Resident 1's head during morning care. CNA 2 reported her observation to the charge nurse, the License Vocational Nurse (LVN 2). The COC indicated LVN 2 informed Nurse Practitioner ([NP- a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) who ordered Computerized Tomography ([CT] diagnostic imaging procedure) scan of the brain/head. During a review of Resident 1's Nurses Progress Notes (PN) dated 9/1/2023, indicated Resident 1 was readmitted from GACH .CT scan of the brain/head result was negative. During a review of Resident 1's Change of Condition (COC) form, dated 9/5/2023, indicated Resident 1 was found at the employee lounge by the Maintenance Supervisor (MS) at 4:45 a.m. The MS informed LVN 2 and CNA 2 right away and asked for help. Resident 1 was assessed by LVN 2 and observed to have a laceration on a left eyebrow with bleeding. Resident 1 was alert but severely confused, denied pain but with facial grimacing (a facial expression in which your mouth and face are twisted in a way that shows pain). LVN 2 called 911 (emergency phone number) and Resident 1 was transferred to GACH on 9/5/2023 for evaluation and treatment of left eyebrow laceration. During a review of Resident 1's GACH emergency department discharge summary (DS) dated 9/5/2023 at 7 a.m., indicated Resident 1 was treated for closed head injury (happen when there was an injury to the head with no break in the skull), and laceration of left eyebrow requiring three sutures (a stitch used to close a wound). During a review of Resident 1's Care Plan (CP), titled Resident with wandering episodes dated 7/2023, the CP interventions indicated, constant monitoring of Resident 1's whereabouts and maintain a safe and hazard free environment. During a concurrent interview and record review of monitoring log with CNA 1 on 9/7/2023 at 10:35 am, CNA 1 stated Resident 1 continues to wander around the facility and get loss but have not observed Resident 1 going into other residents' rooms. CNA 1 stated the staff will redirect Resident 1 when she wanders in the facility. CNA 1 stated she was assigned to provide Resident 1 with 1:1 monitoring from 9/5/23-9/7/23 from 3 p.m.-11:30 p.m. shift (afternoon shift). CNA 1 stated Resident 1's family sat with her (Resident 1) during the 7 a.m.-3 p.m. (day shift) when the resident returned from the hospital on 9/5/2023. CNA 1 stated it was the facility's responsibility to monitor the resident whereabouts. CNA 1 stated the 1:1 monitoring log was used to document what Resident 1 was doing, and her whereabouts but she (CNA 1) was not aware of how often she was supposed to document on the 1:1 monitoring log. CNA 1 stated on 9/5/23 she documented on the monitoring log every 30 minutes, afterwards she did it every hour. CNA 1 stated she documented Resident 1's 1:1 monitoring on her own paper for 9/5/23 and 9/6/2023. CNA 1 stated she was not provided with a 1:1 monitoring log when she asked the Director of Nursing (DON). During a concurrent interview and record review with CNA 1 on 9/7/2023 at 10:38 a.m., reviewed CNA 1's 1:1 monitoring log for 9/5/23 indicated no documentation of Resident 1 observation from 10 a.m.-4 p.m. on 9/5/2023 and no documentation of observation from 8 pm-10 pm on 9/6/23. Concurrently CNA 1 stated Resident 1 was not provided 1:1 monitoring for the entire 24-hour period. During an interview on 9/7/2023 at 11:18 am the MS stated that on 9/5/2023 at 4:45 a.m. he was walking in the hallway by Station 1 and saw Resident 1's walker in front of the employee lounge. The MS stated he saw Resident 1 in the employee lounge getting a paper towel to wipe blood from her face. The MS stated he yelled for help and walked out of the employee's lounge to alert the staff. The MS stated CNA 2 and LVN 2 came to the employee lounge to assist Resident 1. The MS stated he found Resident 1 alone in the employee lounge with no staff present. During a concurrent interview and record review on 9/7/2023 at 11:18 am, with DON, Resident 1's monitoring logs from 7/24/2023 thru 8/2023 was reviewed. Concurrently DON stated 8/15/2023 was the last day of 1:1 monitoring logs for Resident 1 and was unable to provide additional 1:1 monitoring logs for the month of August. DON stated Resident 1 was not provided with 1:1 monitoring for the entire 24-hour period (7 am to 7am the following day) after 8/15/2023 because the facility could not afford it. Resident 1 1:1 monitoring was stopped on 8/15/2023. DON stated, it was the facility's responsibility to provide 1:1 monitoring for Resident 1 and try to enlist the help from the family. DON stated, Resident 1 still wandering especially at night. During a concurrent interview and record review on 9/7/2023 at 11:36 am, with LVN 1, stated Resident 1 strikes out at staff and does not listen to staff redirection. LVN 1 stated Resident 1 wanders into other residents' rooms with her front wheel walker ([FWW-it's useful if you need some help bearing weight as you move, or if lifting a standard walker is hard for you). LVN 1 stated she has witnessed Resident 1 wandering into another resident's room on 9/4/23. LVN 1 stated Resident 1 appears disoriented at times and wanders around in other places. LVN 1 stated on 9/5/2023 Resident 1 was on 1:1 monitoring because she was hard to control, and the monitoring was put in place after she came back from the hospital on 9/5/2023. LVN 1 stated when a resident was put on 1:1 monitoring, staff should observe the resident, redirect the resident and staff should be always with resident. After reviewing the monitoring log, LVN 1 stated there were no 1:1 monitoring logs on 9/5/2023 from the previous shifts (11pm-7 am). During a concurrent interview and record review on 9/7/2023 at 12:09 p.m., with the DON, the DON stated Resident 1 was placed back on 1:1 monitoring on 9/5/2023 to ensure Resident 1 was safe. The DON stated the monitoring logs were to document Resident 1 behaviors such as wandering, striking out at the staff, refusal of care and served as a confirmation the resident was being monitored. The DON stated staff should fill out the 1:1 monitoring log when residents are being monitored. The DON stated Resident 1 should have a 1:1 monitoring log beginning 9/5/2023. The DON stated constant monitoring means all the time (24 hours 7 days a week). After reviewing 1:1 monitoring logs the DON stated Resident 1's monitoring logs were initiated on 9/7/2023. The DON stated there should have been a log that started on 9/5/2023. The DON stated there was no documentation for the 1:1 monitoring for 9/5/2023 and 9/6/2023 for the night shift. The DON stated Resident 1 was removed from 1:1 monitoring from 8/15/2023 to 9/5/2023 because the facility could not afford it. The DON stated Resident 1's 1:1 monitoring log stopped after 8/15/23. During a concurrent interview and record review on 9/7/2023 at 2:17 pm with the Administrator (Admin), the Admin stated that for wandering residents the facility ensures that those residents are on 1: 1 monitoring and maintain a monitoring log. Admin stated Resident 1 should have 1:1 monitoring for the entire 24-hour period. Resident 1's monitoring logs were reviewed with the Admin, and the Admin stated the 1:1 monitoring log dated 8/15/2023, was not for the entire a 24-hour period and documentation reflects only observations from 12:00 midnight to 7:00 am. The Admin stated the 1:1 monitoring should be done for 24-hour period and should be documented on the monitoring log. The Admin stated the purpose of the monitoring log was to monitor Resident 1 continuously. The Admin stated signed 1:1 monitoring log indicates staff had a visual contact of the Resident 1 whereabouts. The Admin stated if there was not documentation the monitoring was not done. The Admin stated the monitoring log should be carried over during shift change and handoff to the next staff from the next shift. During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, dated 2019, the P&P indicated, residents will have minimal complications associated with the management of altered or impaired behavior. During a review of the facility's P&P titled, Wandering and Elopements, dated 2019, the P&P indicated The facility will identify residents who are at risk of unsafe wandering and strive to prevent the residents from harm while maintaining the least restrictive environment for residents. During a review of the facility's P&P titled, Routine Resident Checks, dated 2013, the P&P indicated, staff shall make routine resident checks to help maintain resident safety and well-being.

Based on observation, interviews, and record review, the facility failed to ensure the resident, who had a history of physical aggressive behavior towards staff and wandering (a person that roams around and becomes lost or confused about their location) behavior did not physically abuse another resident for one of two residents (Resident 2). The facility failed to: 1. Ensure Resident 1 was assessed and supervised for wandering behavior to prevent the resident from physically attacking Resident 2. 2. Develop a comprehensive care plan (CP) for Resident 1's aggressive behavior towards staff, refusal of care, and wandering behavior with interventions to prevent Resident 1 from physically abusing other residents. 3. Inform Resident 1's psychologist (a specialist who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) of Resident 1's aggressive behavior, including striking out at staff, refusing care, and wandering per facility's P&P titled, Change in a Resident's Condition or Status. 4. Ensure staff followed the facility's policy and procedure (P&P) titled, Abuse and Neglect Clinical Protocol, to implement measures to address the needs of Resident 1 to minimize the possibility of resident-to-resident abuse. 5. Ensure staff followed P&P titled, Wandering and Elopements to prevent Resident 1 from physically harming Resident 2. These failures resulted in Resident 1 wandering into Resident 2's room on 7/24/23 and having a physical altercation with Resident 2. Resident 1 pushed Resident 2 down leading to Resident 2's fall and sustaining a left-hand, left elbow, and right forearm (right lower arm) contusion (bruise). Resident 2 was subsequently transferred to a General Acute Care Hospital (GACH) for evaluation and treatment for sustained injuries. Findings: A review of Resident 1's Admission Record (AR), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and causes a break with reality) and anxiety disorder (mental illness causing persistent fear and/or worry). A review of Resident 1's History and Physical (H&P), dated 6/9/23, indicated, Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set [(MDS), a standardized assessment and screening tool), dated 6/13/23, indicated Resident 1 had difficulty communicating some words or finishing thoughts but was able if prompted or given time. The MDS indicated Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with bed mobility, transferring, dressing, toilet use, and personal hygiene. A review of Resident 1 physician's order dated 6/9/23 indicated the order for Seroquel (a medication used to treat mental and mood conditions) 25 milligrams [(mg) a measure of weight] tablet to administer 12.5 mg by mouth two times a day for schizophrenia manifested by striking out. A review of Resident 1's Change of Condition (COC) form, dated 7/7/23, and timed at 1:21 a.m. indicated, that on 7/7/2023 at 8:20 a.m. Resident 1's onset of COC included refusal of care. A review of Resident 1's Progress Notes (PN), dated 7/7/23, and timed at 2:44 p.m., indicated, Resident 1 was awake, refused to be changed, and continued to be agitated. The PN indicated staff talked to Resident 1 three times encouraging to change, but Resident 1 refused. A review of Resident 1's CP dated 7/2023 and titled, Use of psychotropic medication [(Seroquel) related to diagnosis of Schizophrenia, indicated to monitor/record occurrences of Resident 1's behavior symptoms including pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff and others, and document per facility protocol. A review of Resident 2's Admission Record, indicated Resident 2 was admitted on [DATE] and readmitted on [DATE], with diagnoses including encephalopathy (a brain disease that affects function), hypertension (HTN - high blood pressure) and anxiety disorder. A review of Resident 2's H&P, dated 4/5/22, indicated, Resident 2 could make needs known but could not make medical decisions. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 required limited assistance with bed mobility, transferring, dressing, toilet use and personal hygiene. A review of Resident 2's COC dated 7/24/23 at 9:30 a.m. indicated on 7/24/23 at 9:30 a.m. Resident 2 called out for help because Resident 1 had entered Resident 2's room where they got into an altercation and Resident 1 pushed Resident 2 to the ground resulting in Resident 2 injuring her left hand, left elbow, and right forearm. The COC indicated Resident 2's physician was notified and ordered for Resident 2 to be transferred to GACH. A review of Resident 2's GACH Emergency Department discharge summary (DS) dated 7/24/23 at 3:00 p.m., indicated Resident 2 was treated for fall and hand contusions. GACH records indicated Resident 2 had an X-Ray (an imaging study that shows the details of bones and soft tissue) on 7/24/23 timed at 11:37 a.m., indicating no fracture (broken bone). The DS indicated Resident 2 should treat left hand with ice, compression (adding pressure to reduce swelling) and elevation (lifting above heart level to reduce swelling). During an observation on 7/27/23 at 9:45 a.m., in Resident 2's room, Resident 2 was observed in bed with bruises on a left hand and left elbow. During an interview on 7/27/23 at 10:00 a.m., in Resident's 2's room, Resident 2 stated on the day of the altercation (7/24/23) she was in bed when Resident 1 opened her door came in and closed the door behind her (Resident 1). Resident 2 stated Resident 1 went to her (Resident 2's) closet and started removing clothes. Resident 2 stated she got out of bed to stop Resident 1. Resident 2 stated that Resident 1 then knocked her to the ground and began hitting her. Resident 2 further stated she yelled for help, but nobody responded for at least 20 minutes. Resident 2 stated, she felt helpless and in fear for her life. Resident 2 stated, I thought I was going die. Resident 2 stated that the Social Services Worker (SSW) finally entered her room and saw her on the ground. Resident 2 stated she told SSW she was attacked by Resident 1. Resident 2 stated that SSW left the room to get help. Resident 2 stated staff came into her room and removed Resident 1. She was then transferred to GACH for further evaluation. Resident 2 stated she sustained bruises to her left hand and elbow. Resident 2 stated, she felt helpless during the attack, especially when nobody was responding to her yelling for help. During an observation on 7/27/23 at 10:00 a.m., in Resident 1's room the resident was on 1:1 monitoring (to provide continuous observation for an individual patient for a period of time during an acute physical or mental illness) by facility staff. During an observation on 7/27/23 at 10:25 a.m. in Resident 1's room Resident 1 was verbally aggressive towards the surveyor's attempt to interview her. Resident 1 was yelling, screaming, and demanding that the surveyor leave her room immediately and close the door. During an interview on 7/27/23 at 11:30 a.m., with a certified nursing assistant (CNA) 2, CNA 2 stated staff were in a huddle (a short, stand-up meeting with all staff, that is done at the beginning of each shift) in the rehabilitation room when Housekeeping staff (HSKG 1) came and informed staff Resident 1 and Resident 2 were on the floor. CNA 2 stated when she arrived to Resident 2's room Resident 1 was sitting on Resident 2's bed while Resident 2 was still on the floor. CNA 2 stated Resident 1 was aggressive towards staff when they were trying to remove her from Resident 2's room. CNA 2 further stated Resident 1 had been wandering in the facility and had aggressive behavior towards staff. CNA 2 stated, Resident 1 should have been supervised and monitored often to prevent Resident 1 from wandering to another resident's room and causing injury and harm. During an interview on 7/27/23 at 12:38 p.m. the SSW stated Resident 1's behaviors included striking out to staff, wandering, and refusing care. During a concurrent interview and Resident 1's record review on 7/28/23 at 10:00 a.m., with the DON, the DON confirmed there was no assessment completed for Resident 1's wandering behavior. The DON stated Resident 1's wandering behavior should have been addressed to have interventions in place to ensure Resident 1, the facility's residents, and staff stayed safe. The DON stated if wandering behaviors are not addressed there would be resident to resident altercations and injuries like what happened between Resident 1 and Resident 2 on 7/24/23. During an interview on 7/31/23 at 10:18 a.m. with Resident 2, the resident stated, she felt helpless and afraid for her life during the attack on 7/7/23. Resident 2 stated when the SSW arrived to the room, she asked what she (Resident 2) was doing on the floor. Resident 2 stated she feels there was a decline in her socialization with staff and other residents since the attack. Resident 2 stated she does not want to go outside of her room to play bingo. On 7/31/23 at 12:10 p.m. during a concurrent interview and record review with the DON Resident 1's Medication Administration Record (MAR), dated July 2023 was reviewed. The MAR indicated from 7/1/23 to 7/7/23 Resident 1 exhibited behaviors of itching, picking skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, delusions (false belief or judgment about external reality), hallucination (an experience involving the apparent perception of something not present), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), aggression (hostile or violent behavior or attitudes toward another readiness to attack or confront), refusal of care. The MAR indicated Resident 1 had these behaviors two times on 7/1/23, once on 7/2/23, two times on 7/3/23, once on 7/4/23, and once on 7/5/23. The DON acknowledged that Resident 1's physician was not notified Resident 1 exhibited behaviors on 7/1/23, 7/2/23, 7/3/23, 7/4/23 and 7/5/23. Concurrently during an interview, the DON stated when a resident exhibits aggression, striking out, and hitting behavior the doctor should be notified because resident's behavior could get worse and there could be a resident-to-resident altercations, and injuries. The DON stated, when there was a resident-to-resident altercation, the residents should be separated immediately and make sure that they are safe. During an interview on 7/31/23 at 1:07 p.m. with the psychologist (Psych), who evaluated Resident 1 and Resident 2 after the altercation on 7/7/23, the Psych stated Resident 1 was calm during the evaluation and did not recall the incident. The Psych stated Resident 2 was calm but told her (the Psych) she felt like the facility did not keep her protected and that is why the incident occurred. The Psych stated she was never notified of any behaviors Resident 1 was exhibiting. The Psych stated she should have been notified even if Resident 1 exhibited one instance of physical aggression or striking out behavior. The Psych stated, striking out at staff or residents, refusing care, and wandering would be considered a negative behavior and should be reported to the Psych immediately to prevent negative outcomes to the residents and staff. A review of the facility policy titled, Abuse and Neglect Clinical Protocol, revised 2018, indicated the management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, intervention and Monitoring, dated 2019, the P&P indicated, the interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 2021, the P&P indicated, the facility will promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). During a review of the facility's P&P titled, Wandering and Elopements, dated 2019, the P&P indicated, the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on observation, interview, and record review, the facility failed to ensure they had a Registered Nurse (RN) at least eight consecutive hours a day, seven days a week from 5/8/2023 to 6/5/2023 (28 days) to provide residents with required care and services to 41 residents residing at the facility and to one of two sampled resident (Resident 1), who had a pressure ulcers (a localized injury to the skin and underlying tissue resulting from prolonged pressure) to the left heel infected with Methicillin-resistant Staphylococcus aureus [(MRSA)-a type of bacteria that is resistant to most antibiotics {medication used to treat infections caused by bacteria}] and was not receiving ordered intravenous [(IV) administered into the veins] antibiotics (medication to treat infection), Vancomycin [an antibiotic used against resistant strains of streptococcus and staphylococcus (single cell microorganisms that cause infections and diseases)] on 5/29/2023, 5/31/2023, and 6/2/2023 (total of 3 doses). 1. This deficient practice placed 41 residents at risk not receiving care and services under RN ' s scope of practice, including residents ' assessment in case of change of condition (COC), carry out physicians ' orders requiring RN ' s implementation, providing the licensed vocational nurse and non-licensed staff supervision to ensure the care and services were delivered as required. 2. This deficient practice resulted in Resident 1 not receiving three doses of IV Vancomycin and being transferred to a general acute care hospital (GACH) on 6/3/2023 for evalution and treatment. 3. This deficient practice placed Resident 1 at risk of developing a super infection (infection occurring after or on top of an earlier infection), sepsis (serious complication of an infection), and death. On 6/2/2023 at 5:34 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ) situation (a situation in which the facility ' s non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) due to lack of RN at the facility at least eight consecutive hours a day, seven days a week starting on 5/8/2023. The IJ was called in the presence of the Business Manager (BM), Facility Owner (FO), Charge Licensed Nurse (CN) and Medical Records Director (MRD). On 6/6/2023 at 1:46 p.m., the facility provided with an Immediate Jeopardy Removal Plan (IJRP) containing the following summarized immediate corrective actions: 1. On 6/3/2023, Resident 1 was transferred to GACH for further evaluation per physician ' s order. 2. On 6/6/2023, RN 1 was hired and immediately started to work on 6/6/2023. RN 1 will provide services at least eight hours a day within a 24-hour period. RN 1 will work 16-hour shifts on 6/6/2023, 6/7/2023, and 6/8/2023. RN 1 will administer medications per physician ' s orders in a timely manner. 3. Facility hired a Director of Nursing (DON) with a start date of 6/8/2023. 4. Facility will continue to utilize contracted staffing registry agencies to provide the facility at least one registered nurse and or licensed nurse daily at least eight hours a day within a 24-hour period. 5. The facility hired a contractual DON with a start date on 6/8/2023 and will continue to utilize DON and a registered nurse from registry on a contractual basis indefinitely until a permanent RN and DON were hired. 6. The facility will not admit new residents until cleared by the Department of Public Health. 7. On 6/5/2023, an in-service was initiated to all staff on who to immediately contact/communicate surrounding daily operations of the facility in the absence of the Administrator and DON. Staff were provided with copies of contact information and contact information was as posted at each nursing station. 8. The DON and or designee will monitor facility compliance daily surrounding services of a RN at least eight hours a day to provide the care requested for all residents at the facility. 9. Any non-compliance issue will be corrected immediately by the DON or designee; reports and findings will be discussed during the daily department heads and or members of interdisciplinary team (team members from different disciplines) for immediate resolution. 10. The Administrator and or designee will do trending/analysis on RN hours daily for at least eight hours a day within 24-hour period and will report to the monthly QAPI (Quality assurance and performance improvement) committee for further evaluation and for recommendations. If there have been no concerns for a period of three months, the item will be removed from the agenda. Findings: During a concurrent observation and interview on 6/1/2023, at 2:30 p.m., with Licensed Vocational Nurse (LVN 1), while touring the facility, the RN was not observed to be present. LVN 1 stated, we do not have an RN working today. During a concurrent interview and record review, on 6/1/2023, at 4:00 p.m., with LVN 1, the facility ' s Nursing Staffing Assignment and Sign-In Sheet dated 6/1/2023 was reviewed. LVN 1 stated, the Assignment sheet indicated there was no RN working on 6/1/2023 on 7 a.m.-3:30 p.m., 3 p.m. -11:30 p.m. and 11:00 p.m.-7 a.m., shifts. During an interview on 6/1/2023, at 4:30 p.m., LVN 1 stated we are calling the nursing staffing registry and requesting for them to send us an RN. LVN 1 stated only an RN must administer IV medications. During an observation on 6/2/2023, at 10:00 a.m., while touring the facility, an RN was not observed to be present in the facility. During a concurrent interview and record review, on 6/2/2023, at 12:00 p.m., with LVN 1, the facility ' s Nursing Staffing Assignment and Sign-In Sheet dated 6/2/2023 was reviewed. LVN 1 stated, the Assignment sheet indicated there was no RN scheduled to work on 6/2/2023 on 7 a.m.-3:30 p.m., 3 p.m. -11:30 p.m., and 11:00 p.m.-7 a.m., shifts. During a review of the facility ' s nursing Staffing Assignment and Sign-In Sheets (SASIS) for the date range from 5/8/2023 to 6/2/2023, the SASIS indicated the following number of hours the RN worked in 24 hours period starting 5/8/2023: 1. On 5/8/2023 and 5/9/2023, there was no documentation to indicate RN signed in for work on any of three shifts, including 7 a.m. to 3 pm, 3 p.m. to 11 a.m. or 11 pm to 7 a.m. 2. On 5/11/2023, RN worked from 6 p.m. to 10 p.m., a total of four hours in 24 hours period. 3. On 5/12/2023, RN worked from 5 p.m., to 9 p.m. a total of 4 hours in 24 hours period. 4. On 5/13/2023, RN worked 6 p.m. to 10 p.m., a total of four hours in 24 hours period. 5. On 5/14/2023, RN worked from 5 p.m. to 9 p.m., a total of four hours in 24 hours period. 6. On 5/16/2023, RN worked from 3 p.m. to 8:30 p.m., a total of five and half hours in 24 hours period. 7. On 5/17/2023, RN worked from 5 p.m. to 9 p.m., a total of four hours in 24 hours period. 8. On 5/19/2023, RN worked from 3:27 p.m. to 8:57 p.m., a total of five hours and 17 minutes in 24 hours period. 9. On 5/20/2023, RN worked zero hours in 24 hours period. 10. On 5/21/2023, RN worked from 12:29 p.m. to 5:44 p.m., a total of five hours and 14 minutes in 24 hours period. 11. On 5/23/2023, RN worked from 5:00 p.m. to 9:00 p.m., in 24 hours period. 12. On 5/24/2023, RN worked zero hours in 24 hours period. 13. On 5/25/2023, RN worked from 2:48 p.m. to 8:00 p.m. a total of five hours and 12 minutes in 24 hours period. 14. On 5/29/2023, RN worked from 4:00 p.m. to 9:06 p.m., a total of five hours and 6 minutes in 24 hours period. 15. On 5/31/2023, RN worked zero hours in 24 hours. 16. On 6/1/2023, RN worked zero hours in 24 hours. 17. On 6/2/2023, RN worked zero hours in 24 hours. During a review of Resident 1 ' s Admission Record (Face sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (damage or disease that affects the brain), PU of the left heel, pressure induced deep tissue damage [(DTI) a form of PU affecting the layer of tissue that rests beneath the skin, the skin above will be intact {not broken} but will look purple or red] of the right heel, PU to the left ischium (hip bone near buttocks area) chronic (persistent, long lasting illness) kidney disease and diabetes mellitus type 2 (a condition in which the body fails to process glucose (sugar) correctly). During a review of Resident 1 ' s History and Physical (H&P), dated 10/11/2022, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 2/17/2023, the MDS indicated Resident 1 ' s cognitive (relating to the mental process of knowing, learning, and understanding things) skills for daily decision-making was severely impaired. The MDS indicated Resident 1 required an extensive one-person physical assistance with bed mobility and total dependence of one to two persons on transfers, dressing, toilet use and personal hygiene. The MDS indicated Resident 1 was at risk of developing further pressure ulcers/injuries. During a review of Resident 1 ' s Physician Order (PO) dated 5/18/2023, the PO indicated an order for x-ray of the right calcaneus (heel bone) to rule out osteomyelitis (infection of the bone). During a concurrent interview with Licensed Vocational Nurse 2 (LVN 2) and review of Resident 1 ' s PO dated 5/24/2023, the PO indicated an order for Vancomycin Hydrochloride (HCL) 750 milligrams ([mg]- unit of measurement) IV every 48 hours Resident 1 ' s infected with MRSA left heel PU confirmed by LVN 2. During a review of Resident 1 ' s PO dated 6/2/2023, the PO indicated an order to transfer Resident 1 to GACH for infected non-healing pressure ulcer to left heel and left ischium. During a review of Resident 1 ' s Intravenous Therapy Medication Record (IVMR), the IVMR indicated Resident 1 was administered IV Vancomycin 750 mg on 5/25/2023 at 6 p.m., and 5/27/2023 at 6 p.m. During a review of Resident 1 ' s Medication Administration Record (MAR), dated May 2023, the MAR indicated Resident 1 was administered Vancomycin 750 mg IV on 5/25/2023 at 6:00 p.m. and 5/27/2023 at 6:00p.m. During an interview on 6/2/2023 at 10:28 a.m., with the facility ' s owner (FO), the FO stated he fired the Director of Nursing (DON) on 5/31/2023. The FO stated there was no RN currently employed by the facility. The FO stated the new DON will start on 6/8/2023. The FO stated he was a physician and would take the responsibilities of the RN until one was hired. During an interview on 6/2/2023 at 11:41 a.m. with the Licensed Vocational Nurse (LVN 1), LVN 1 stated facility had the DON in 10/2022. LVN 1 stated the DON would stay around four hours and would come and go throughout the shift. LVN 1 stated the DON resigned around November or December 2022. During an interview on 6/2/2023, at 12:00 p.m., with LVN 2, LVN 2 stated Resident 1 ' s MAR indicated the last documented administration of Vancomycin IV 750 mg was on 5/27/2023 at 6:00 p.m. LVN 2 stated based on Resident 1 ' s PO, Resident 1 should have received next Vancomycin dose on 5/29/2023 at 6:00 p.m., 5/31/2023 at 6:00 p.m., and 6/2/23 at 6:00 p.m. before the resident transferred to GACH on 6/3/23. LVN 2 stated only a registered nurse can administer IV medications and the facility had no RN scheduled to work since 5/29/2023. LVN 2 stated, failure to administer ordered Vancomycin IV medication to Resident 1, can result in further infection, sepsis including death. LVN 2 stated, Resident 1 ' s attending physician was not informed of missed three doses of IV Vancomycin. LVN 2 stated since there was no RN or the DON in the facility, she (LVN 2) did not know what to do regarding missed Vancomycin doses. During an interview on 6/2/2023 at 4:50 p.m. with Resident 1 ' s primary care physician (PCP), the PCP stated the Vancomycin IV medication should have been given every 48 hours as ordered. The PCP stated missed dosed can put Resident 1 at risk for reoccurrence of a pressure ulcer infection and rehospitalization . The PCP stated he might order additional wound cultures (test to find germs that can cause infection) and laboratory tests. During a concurrent observation and interview on 6/2/2023, at 4:52 p.m., with LVN 2, in the medication room, no Vancomycin IV medication in the IV medication cart was observed. LVN 2 stated, there was no Vancomycin IV medication available in the facility, and she would need to contact the pharmacy to dispense the Vancomycin IV medication to the facility. During a review of the facility ' s policy and procedure (P/P) titled, Administering Medications revised 4/2019, the P/P indicated medications should be administered in a safe and timely manner, and as prescribed. During a review of the facility ' s policy and procedure (P/P) titled Director of Nursing Services revised 8/2006, the P/P indicated the nursing services department is under the direct supervision of a Registered Nurse.

Based on observation, interview, and record review, the facility failed to ensure the resident, who had an order for an intravenous [(IV) administered through the vein) administration of Vancomycin [(antibiotic)- medication to treat infections] 750 milligrams [(mg)- unit of measurement] every 48 hours for infected pressure ulcers [(PU)-induced injury that breaks down the skin and underlying area due to prolonged pressure], received medication every 48 hours without omission (a failure to do something) for one of one sampled resident (Resident 1). The facility failed to: 1. Ensure Resident 1 was administered Vancomycin 750 mg IV every 48 hours as ordered for a PU on the right heel, left ischium (hip bone near buttocks area) and left heel infected with Methicillin Resistant Staphylococcus aureus [(MRSA)-a type of bacteria that is resistant to most antibiotics {medication used to treat infections caused by bacteria]) on 5/29/2023, 5/31/2023 and 6/2/2023. This failure resulted in Resident 1 not receiving needed antibiotics as ordered and placed Resident 1 at risk for worsening of infections of the right heel, left ischium and left heel leading to a possible sepsis (a life-threatening emergency from the body's extreme response to infection) and death. On 6/2/2023 at 5:34 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy [(IJ) a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Business Manager (BM), Facility Owner (FO), the Licensed Nurse in charge (CN) and the Medical Records Director (MRD). On 6/6/2023 at 1:46 PM, the facility provided CDPH with an Immediate Jeopardy Removal Plan (IJRP) containing the following summarized immediate corrective actions: 1. On 6/3/2023, Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation per physician's order. 2. On 6/6/2023, the registered nurse (RN 1) was hired and immediately started to work on 6/6/2023. RN 1 will provide services at least eight hours a day within a 24-hour period. RN 1 will work 16-hour shifts on 6/6/2023, 6/7/2023 and 6/8/2023 until a permanently hired the Director of Nursing (DON) will start working on 6/8/23. RN 1 will administer medications per physician's orders in a timely manner. 3. The facility permanently hired DON with a start date of 6/8/2023. On 6/6/2023 at 2:52 p.m., while onsite and after verification of the facility's implementation of the IJ removal plan corrective actions through observation, interviews, and record review the Department accepted the removal plan and removed the IJ, in the presence of the operational administrator/consultant (OC), BM and RN 1. Findings: A review of Resident 1's Admission Record (AR) indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), PU of the left heel, pressure induced deep tissue damage (a form of PU affecting the layer of tissue that rests beneath the skin, the skin above will be intact [not broken] but will look purple or red) of the right heel, chronic (persistent, long lasting illness) kidney disease and diabetes mellitus type 2 (condition when the body cannot regulate blood sugar). A review of Resident 1's History and Physical (H&P), dated 10/11/2022, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set [(MDS), a standardized assessment and care screening tool], dated 2/17/2023, indicated Resident 1 had an impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 required an extensive assistance from staff for bed mobility with at least a one-person assistance and was totally dependent on staff for transfers, dressing, toilet use and personal hygiene with at least a one to two persons assistance. The MDS indicated Resident 1 was at risk of developing further PU. A review of Resident 1's Physician Order (PO), dated 5/18/2023, indicated for Resident 1 to have two views X-ray (imaging that creates pictures of the inside structures of the body) of the resident's right calcaneus (large bone forming the heel) to rule out osteomyelitis (infection in the bone). A review of Resident 1's PO, dated 5/24/2023, indicated an order to give Vancomycin IV 750 mg IV every 48 hours for bacterial infections. A review of Resident 1's Intravenous Therapy Medication Record (IVMR), indicated Vancomycin 750 mg was administered to Resident 1 on 5/25/2023 and 5/27/2023. A review of the facility's Order Listing Report (OR), dated 6/1/2023, indicated Resident 1's physician order for Vancomycin 750 mg IV every 48 hours for bacterial infection was active and current. During a concurrent observation and interview on 6/1/2023, at 2:30 p.m., with Licensed Vocational Nurse (LVN) 1, while touring the facility, a registered nurse (RN) was not observed to be present. LVN 1 stated, we do not have an RN working today. During a concurrent interview and record review, on 6/1/2023, at 4:00 p.m., with LVN 1, the facility's Nursing Staffing Assignment and Sign-In Sheet dated 6/1/2023 was reviewed. LVN 1 stated, the Assignment sheet indicated there was no RN working on 6/1/2023 for the following shifts: 7 a.m.-3:30 p.m., 3 p.m. -11:30 p.m. and 11:00 p.m.-7 a.m. During an interview on 6/1/2023, at 4:30 p.m., with LVN 1, LVN 1 stated we are calling the nursing staffing registry and requesting for them to send us an RN. LVN 1 stated only an RN must administer IV medications. During an observation on 6/2/2023, at 10:00 a.m., while touring the facility, an RN was not observed to be present in the facility. During a concurrent interview and record review, on 6/2/2023, at 12:00 p.m., with LVN 1, the facility's Nursing Staffing Assignment and Sign-In Sheet dated 6/2/2023 was reviewed. LVN 1 stated, the Assignment sheet indicated there was no RN scheduled to work on 6/2/2023 on the following shifts: 7 a.m.-3:30 p.m., 3 p.m. -11:30 p.m., and 11:00 p.m.-7 a.m. During a concurrent interview and record review, on 6/2/2023, at 12:00 p.m., with LVN 2, Resident 1's Medication Administration Record (MAR), dated May 2023 was reviewed. LVN 2 stated the MAR indicated the last documented administration of Vancomycin IV 750 mg was on 5/27/2023. LVN 2 stated Resident 1's physician's order indicated Resident 1 should have received doses of Vancomycin on 5/29/2023 and 5/31/2023. LVN 2 stated Resident 1 was scheduled to receive another dose tonight (6/2/2023) at 6:00 p.m. LVN 2 stated only a registered nurse can administer IV medications and currently there has not been any RN at the facility since 5/29/2023. LVN 2 stated Resident 1 has missed two scheduled doses of the Vancomycin IV medication on 5/29/2023 and 5/31/2023, and this puts Resident 1 at risk for further infection, possible sepsis, and death. LVN 2 stated, I did not inform the physician and I do not know what to do because we do not have an RN in the facility or a DON. During an interview on 6/2/2023 at 11:16 a.m., with the Facility Owner (FO), the FO stated in the current absence of a facility Administrator, he was responsible for all operations in the facility. The FO stated the facility currently did not have the services available which would be provided by a DON or RN, because the facility did not have a DON nor an RN, which included administering IV medication. The FO stated he would inform and apologize to Resident 1's Primary Medical Doctor (PMD) of the missed medication doses. The FO, who is a physician, stated that he would, if needed, administer the IV medication to Resident 1. The FO stated that he was a doctor and could do anything a Registered Nurse can including administering IV medication. During an interview on 6/2/2023 at 12:00 p.m., with the FO, the FO stated he would not be administering IV Vancomycin to Resident 1. FO stated he would seek out an RN to provide services and administer IV medications. During an interview on 6/2/2023 at 4:50 p.m. with Resident 1's Primary Medical Doctor (PMD) the PMD stated the IV Vancomycin should have been given as ordered. The PMD stated Resident 1 was at risk for worsening infections of the right heel, left ischium and left heel, rehospitalization and needed modification of the planned treatment due to the failure to administer IV Vancomycin medications as ordered. The PMD stated as a result, Resident 1 will need an additional wound cultures [test to find germs (such as bacteria or a fungus) that can cause an infection]. During a concurrent observation and interview on 6/2/2023, at 4:52 p.m., with LVN 2 the Vancomycin IV was not observed to be present in the IV Medication cart. LVN 2 stated, Vancomycin IV was not stocked in the facility, and she would need to contact the facility's pharmacy to dispense it. A review of Resident 1's PO, dated 6/2/2023, indicated to transfer Resident 1 to GACH for inspection of non-healing pressure ulcer and left infected buttock wound. A review of Resident 1 GACH H&P dated 6/3/2023, the H&P indicated Resident 1 was admitted to GACH on 6/3/2023 with an infected PU to bilateral (both) calcaneal and left ischium PU. The GACH H&P indicated Resident 1 would need a consult (assessment and care from a specially trained physician) from the Infectious Disease [(ID) a medical doctor that specializes in the cause of a disease to determine what kind of bacteria causes the disease], a consult of a vascular surgeon (specialists who are highly trained to treat diseases of the blood vessels), a wound care (medical doctor and team specialized in the diagnosis and treatment of wounds) consult, a nephrology (medical doctor specializing in kidneys) consult, and may need a Peripherally Inserted Central Catheter [(PICC) line- tube that is inserted into a vein in the upper arm and into a large vein above the right side of the heart]. A review of Resident 1's ID's consultation notes from the GACH, dated 6/4/2023, indicated Resident 1 was admitted to GACH for worsening infection of both feet pressure ulcers. The ID's note further indicated Resident 1 was assessed to have bilateral infected foot ulcers with possible osteomyelitis. Resident 1 was started on antibiotics (medications used to treat infections) including Rocephin, Vancomycin, and Flagyl. During a review of the facility's policy and procedure (P/P) titled, Administering Medications, revised on 4/2019, the P/P indicated the following: medications are administered in a safe and timely manner and as prescribed, only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so, the Director of Nursing supervises and directs all personnel who administers medications and/or have related functions, staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions, medications are administered in accordance with prescriber orders, including any required time frame, medications are administered within one (1) hour of their prescribed time, unless specified ( for example, before and after meals). During a review of the facility's P/P titled, Adverse Consequences and Medication Errors, revised April 2014, the P/P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional providing services, an example of medication errors include: omission (a drug ordered but not administered).

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) were free from repeated verbal and physical abuse and exploitation (the action or fact of treating someone unfairly to benefit from it) (Resident 1). Certified Nursing Assistant 1 (CNA 1) threw water in Resident 1's face and took pictures of Resident 1 without his permission, knowing the resident did not want his picture taken. The Director of Staff Development (DSD) threaten Resident 1 with her tone of voice and was rude (offensively impolite or ill-mannered) to him, while they both continued to taunt (unkind remarks made to intentionally annoy and upset someone) the resident, which resulted in Resident 1 being sad and depressed with crying spells. This deficient practice resulted in Resident 1 enduring ongoing taunting by CNA 1 and the DSD resulting in the resident expressing sadness and being placed on an antidepressant (a medication used to reduce feelings of hopelessness and sadness). On 5/28/2021 at 6:15 p.m., the Department declared an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident and the situation created a need for an immediate corrective action) due to the facility's failure to have a system that ensures abuse does not occur and recur. The facility's Director of Nursing (DON) was notified of the immediacy and seriousness of the residents' health and safety being threatened. On 6/2/2021 at 4:43 p.m., the administrator (ADM) provided an acceptable POA for correction of the IJ. The POA included the following: 1. Immediate suspension on 5/28/2021, of CNA 1 and the DSD from the facility. 2. Education in-service will be provided to the staff on HIPPA (a law that protects patient health information from being released without the patient's consent or knowledge) regulations by the DON. 3. Resident 1 was reassured for comfort and safety while in the facility and was informed of the final investigation results. 4. An Interdisciplinary Team ([IDT] a group of healthcare professionals developing care needs to meet the resident's needs and goals) meeting was conducted and Resident 1's care plan review regarding the resident's behaviors of sadness and depression. 5. All residents assigned to CNA 1 were interviewed by the ADM. 6. In-services shall be ongoing to all staff on a monthly basis and as needed regarding abuse prevention and proper reporting to agencies, with emphasis on timely reporting of incidents to the department within 24 hours if the abuse resulted without an injury and 2 hours if the abuse resulted an injury. 7. All corrective actions will be completed on 6/2/2021. On 6/2/2021 at 4:43 p.m., while onsite, after the POA was verified as implemented by observation, interviews and record review, the ADM was notified and the IJ was lifted. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's History and Physical (H/P), dated 1/18/2021, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 3/23/2021, the MDS indicated Resident 1 had impairment to left side of his body and required limited assistance with a one to two-person physical assist with transfers, toileting and personal hygiene. The MDS indicated Resident 1 utilized a wheelchair for mobility. During a review of Resident 1's Social Services note (SSN), dated 4/20/2021, the SSN indicated Resident 1 reported twice on the same day (4/20/2021) of being bullied (seeking to hurtfully tease, threat or abuse someone) by CNA 1. The SSN indicated the Administrator was made aware and the facility's abuse protocol was initiated. During a review of the Resident 1's physician's progress note (PPN), dated 4/22/2021 and timed at 11:20 a.m., the PPN indicated an evaluation by the Nurse Practitioner ([NP] a nurse with additional education and training in a specialty area) was done. The PPN note indicated Resident 1 was feeling depressed because he could not see his family and was prescribed [MEDICATION(S)] an antidepressant [reduce feelings of hopelessness and sadness] medication) 5 milligrams ([mg] a unit of measurement) for depression (characterized by persistent feelings of sadness and hopelessness). During a review of Resident 1's physician's telephone orders, dated 4/22/2021 and timed at 11:25 a.m., the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's care plan, dated 4/22/2021 and titled, Altered mood state of Depression as manifested by expressing sadness and crying all the time, the care plan indicated for the staff to monitor Resident 1's whereabouts and observe his behavior, listen attentively, allow ventilation (to verbalize a strong emotion) of feelings, stay with the resident when the resident was feeling depressed, medications as ordered and call Resident 1's physician if the medications are ineffective after 30 days. During a review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MAR, dated 4/26/2021 and timed at 3 p.m., Resident 1 was sad due to not being able to do anything for himself and had concerns about his safety in the facility. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's nursing progress note (NPN), dated 4/29/2021 and untimed, the NPN indicated the facility could not locate any of Resident 1's family members or friends. The NPN indicated Resident 1 stated a desire to be transferred to another skilled nursing facility (SNF). During a review of Resident 1's SSN, dated 4/29/2021, the SSN indicated Resident 1's psychological needs were assessed due to displaying a negative reaction towards a staff member and Resident 1 verbalized not really feeling safe in the facility. During a review of Resident 1's MAR for the month of 5/2021, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's NPN, dated 5/6/2021 and timed at 3:49 p.m., as a late entry, the NPN indicated on 4/29/2021, Resident 1 alleged he was abused by a CNA (CNA 1) and the abuse incident was reported to the local authorities. During a review of Resident 1's care plan, dated 5/6/2021 and titled, Resident is emotional and has fear of two (2) staff members in the facility due to alleged abuse (as per Resident 1's statement), the care plan indicated for Resident 1 to receive a psychiatric consult (an evaluation by a psychiatrist, who is a physician specializing in diagnosing and treating mental health) and treatment as ordered, for the staff to reassure the resident not to be afraid, report any bullying and any verbal abuse and to respect the resident's rights and inform the resident of the facility's policies and procedures. During a review of Resident 1's NPN, dated 5/12/2021 and timed at 6:39 p.m., the NPN indicated the DSD walked pass Resident 1's room and Resident 1 asked the DSD Why are you here? The NPN indicated the DSD was working near Resident 1's room. During a review of Resident 1's NPN, dated 5/27/2021 and timed at 10:21 a.m., as a late entry, according to the NPN on 5/23/2021 the Registered Nurse Supervisor (RNS) stated Resident 1 entered another resident's room to visit when CNA 1 took pictures of Resident 1 sitting in his wheelchair while attempting to enter the other resident's room. During a review of CNA 1's employee file (EF), the EF indicated CNA 1 was hired at the facility on 4/2/2019 and had a performance evaluation ([PE] evaluation of an employee's work based on their job responsibilities) dated on 7/3/2019. CNA 1's PE indicated CNA 1 was opinionated (one's own personal views, beliefs, or judgments) needed guidance, reminders, had poor communication skills with a language barrier. The EF indicated CNA 1's PE, dated 4/2/2021 indicated CNA 1 had poor communication skills, had a language barrier and was always mistaken as being rude. The EF, dated 4/25/2021, indicated CNA 1 was suspended for an allegation of abuse against Resident 1 which occurred on 4/20/2021. Further review of CNA 1's EF, indicated CNA 1 was on a 180-day diversion (change in use or purpose of activity or behavior) agreement with the CNA Licensing agency (an agency that licensed and oversees CNAs), with an effective date of 12/3/2020 through 5/31/2022. During a review of the DSD EF, the EF indicated the DSD, a licensed vocational nurse, was hired at the facility 5/18/2018 and had a PE dated 5/18/2020. According to the DSD's PE, the DSD would easily lose her temper at times but was able to recover after losing her temper. During an interview on 5/28/2021 at 10:41 a.m., Resident 1 stated a week prior, he was sitting outside of his room in his wheelchair when the DSD walked up to him and stated, Move, go to your room. Resident 1 stated at times the DSD would tell him to move. Resident 1 stated six months prior, the DSD physically kicked him and stated, This is my house. Resident 1 stated CNA 1 was the boss of the facility. Resident 1 stated he did not feel good and safe in the facility because the DSD always bothered him. Resident 1 stated CNA 1 took pictures of him, had shown the pictures to the DSD while laughing at Resident 1. Resident 1 stated CNA 1 would always take pictures of him without his permission. Resident 1 stated while crying CNA 1 always took pictures of him and treated him badly and stated he was tired of it. During an interview on 5/28/2021 at 12:40 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on 5/12/2021, she observed Resident 1 sitting in his wheelchair outside of his room when the DSD walked by and Resident 1 stated to the DSD, Why are you here. LVN 1 stated she informed Resident 1 that the DSD must work in the entire building and was helping pass the lunch trays. LVN 1 stated Resident 1 and the DSD did not get along. During interviews on 5/28/2021 at 12:56 p.m., 1:22 p.m. and 1:32 p.m., the Social Services Designee (SSD) stated Resident 1 would say the F word to CNA 1 and the DSD when he was being provoked (purposely annoy and/or to anger someone) and bullied by them. The SSD stated on 4/20/2021, CNA 1 was instructed not to confront Resident 1. According to the SSD, Resident 1 informed her when the DON and her (SSD) were not present in the facility, CNA 1 and the DSD were mean towards him and would bully him. The SSD stated on 5/23/2021 between 11:30 a.m. to 12:30 p.m., Resident 1 was wheeling himself in the hallway and wanted to say hello to a resident on Nursing Station 2, when CNA 1 began taking pictures of Resident 1 on her personal cellular phone. The SSD stated after CNA 1 took pictures of Resident 1, she sent the pictures to the DSD. The SSD stated the DSD was not working in the facility on that day and the DSD sent the pictures of Resident 1 to LVN 2. The SSD stated LVN 2 had shown the pictures of Resident 1 to the RNS and the RNS informed CNA 1 that taking pictures of a resident without their consent was a violation. The SSD stated, The abuse towards the resident (Resident 1) must stop. During interviews on 5/28/2021 at 1:15 p.m. and 1:30 p.m., the DON stated approximately a month prior she had instructed CNA 1 to stay away from Resident 1 and the DON stated she suspended CNA 1 one year ago for tying a resident to his wheelchair. The DON stated she reported CNA 1 and the DSD to the Administrator (ADM), but he did not discipline the DSD and CNA 1. The DON stated the ADM would not allow her to discipline the DSD and CNA 1 due to the CNA being close friends with the DSD. The DON stated the DSD usually protects CNA 1 because they are close friends. The DON stated she asked the ADM if he had reported the resident's (Resident 1) abuse to the Department, the ADM stated, No. The DON stated, while crying, This is not good. During an interview on 5/28/2021 at 1:38 p.m., CNA 1 stated on 5/23/2021 at approximately 12:10 p.m., she was walking towards in the hallway and Resident 1 was wheeling himself to a resident's room. CNA 1 stated the family of the resident in that room did not want any male resident visitors. CNA 1 stated she reported to LVN 2 Resident 1 had entered a resident's room, but LVN 2 ignored her. CNA 1 stated she then took pictures of Resident 1 for proof to show LVN 2. CNA 1 was asked if the facility allowed staff to take pictures of residents using a personal device, CNA 1 stated she knew she should not have taken pictures of Resident 1. CNA 1 stated she had not taken pictures of any other residents in the facility. CNA 1 stated since LVN 2 ignored her, so she texted the pictures of Resident 1 to the DSD for advice. CNA 1 stated the DSD was not working that day and was not in the facility. CNA 1 was asked why she did not inform the RNS about Resident 1 entering another resident's room, since the RNS was in the facility and was in charge. CNA 1 stated she did not speak with the RNS at all. CNA 1 stated she knew taking pictures of residents was a HIPPA violation. CNA 1 stated she was suspended on 4/26/2021 through 5/5/2021 regarding an allegation of abuse of throwing water in Resident 1's face. During an interview on 5/28/2021 at 2:46 p.m., the DSD stated Resident 1 did not have any family and the resident did not like her because she was strict. The DSD stated a week prior, Resident 1 was sitting in his wheelchair in the middle of the hallway and she asked Resident 1 to move. The DSD stated Resident 1 would always ask her why she was there, and would state, You are not the boss. The DSD stated she was instructed by the ADM to ignore Resident 1 because she and Resident 1 would have arguments and Resident 1 was stubborn and angry. The DSD stated she did not mean to hurt Resident 1 and stated she was aware she was too loud sometimes. The DSD stated on 5/23/2021, she was in the facility but left the facility at approximately 12 p.m., when CNA 1 called her and stated Resident 1 was arguing with her (CNA 1) in the hallway and stopping her (CNA 1) from doing her work. According to the DSD, CNA 1 texted her pictures of Resident 1 and asked what should be done. The DSD stated she then texted the pictures of Resident 1 to LVN 2 for LVN 2 to check out Resident 1, but LVN 2 did not respond to her text. The DSD was asked did she instruct CNA 1 to notify the RNS about Resident 1, the DSD stated, No. The DSD stated she knew sending pictures of a resident on a personal device was inappropriate. The DSD stated she did not call LVN 2 or the RNS on that day to communicate with them regarding Resident 1. The DSD stated CNA 1 was her assistant. During a telephone interview on 5/28/2021 at 3:38 p.m., the NP stated Resident 1 was sad for over a month about not being able to see his family during the pandemic (an outbreak of a pandemic disease) and she prescribed Resident 1 [MEDICATION(S)] 5 mg for his sadness. During an interview on 5/28/2021 at 3:51 p.m., the Ombudsman (patient advocate) stated each time she visited the facility she observed Resident 1 being sad. During a telephone interview on 5/28/2021 at 5:23 p.m., the ADM was asked about CNA 1 and the DSD texting pictures of Resident 1, the ADM stated CNA 1 was recently suspended for one week after an allegation of abuse against Resident 1 but there were no witnesses. The ADM stated lately there has been a lot of simple allegations that were blown out of proportion. The ADM was asked how was CNA 1, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADM stated he informed CNA 1 and the DSD that taking pictures of Resident 1 was a HIPPA violation. The ADM was asked what was done to protect Resident 1, the ADM replied, What do you want me to do? The ADM was asked again what was done to protect the health and safety of Resident 1 and other residents in the facility from abuse, the ADM stated he would in-service CNA 1. During a concurrent observation and interview on 5/29/2021 at 4:13 p.m., Resident 1 stated he did not like the staff taunting him and taking pictures of him, as it was stressful. Resident 1 stated CNA 1 would always take pictures of him, even when he was outside smoking a cigarette. Resident 1 was observed crying while stating he cried a lot, did not feel good, and had lots of stress about CNA 1 and the DSD constantly bothering him. Resident 1 stated the ADM was aware of what the DSD and CNA 1 would do to him. According to Resident 1, the ADM reassured him he would suspend CNA 1. During an interview on 5/29/2021 at 4:22 p.m., the RNS stated the DSD was currently in the facility, while on suspension. The RNS stated before she could speak to the DSD, the DSD had abruptly left the facility. During a telephone interview on 5/30/2021 at 1:18 p.m., the ADM stated on 5/28/2021, he instructed the DON to suspend the DSD and CNA 1 indefinitely. The ADM was asked to expound on indefinitely and the ADM stated the DSD and CNA 1 would not be allowed to work in the facility until he received a final notice from the facility's corporate office. The ADM was asked why was the DSD allowed to return to the facility on [DATE] after being suspended on 5/28/2021 for an allegation of abuse. The ADM stated the DSD returned to the facility to pick up something. During an interview on 6/1/2021 at 12:23 p.m., the ADM stated on 5/24/2021, the Ombudsman asked him about CNA 1 taking pictures of Resident 1. According to the ADM, he told CNA 1, You already have a case pending and we were cited for it. Do you want me to fire you? The ADM stated he told CNA 1 and the DSD he promised the Ombudsman that CNA 1 and the DSD would never interact with Resident 1. The ADM was asked about the facility's investigative report after the incident. The ADM stated he did not interview Resident 1 and he did not have a statement from Resident 1. The ADM stated he did not report the abuse allegation that occurred on 5/23/2021 to the Department because he wanted to conduct his own investigation. During an interview on 6/1/2021 at 1:15 p.m., LVN 1 stated Resident 1 did not exhibit behaviors of anger outburst, striking out or swearing at the staff. LVN 1 stated Resident 1 would swear to identify items such as the f&^%ing chair. LVN 1 stated Resident 1 loved saying hi to other residents and would visit other residents, by going to the door of other residents' rooms, but Resident 1 would not enter the resident's room. During an interview on 6/1/2021 at 1:38 p.m., CNA 2 stated Resident 1 was nice but stubborn at times. According to CNA 2, Resident 1 would get upset when the DSD walked near him because Resident 1 stated the DSD would provoke (deliberately make (someone) annoyed or angry) him because the DSD did not like him. CNA 2 stated Resident 1 stated during the night, CNA 1 and the DSD would enter his room and taunt him. CNA 2 stated on 5/26/2021, at approximately 1 p.m., she observed the DSD assisting a family member to a room where Resident 1 was sitting in his wheelchair in the door entrance of his room. CNA 2 stated Resident 1 saw the DSD and gestured his hands in a motion which indicated for the DSD to get out of here, and the DSD was observed upset and walked towards Resident 1 and began yelling at Resident 1in his face. CNA 2 stated, The DSD should display professionalism and should not take things personally. During a review of the facility's revised policy and procedure (P/P), dated 12/2016 and titled, Abuse Prevention Program, the P/P indicated residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation, including but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual and physical or chemical restraint not required to treat the resident's symptoms. The P/P indicated the facility's Administration would protect residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. The P/P indicated the facility's Administration would identify and assess all possible incidents of abuse, investigate, and report any allegations of abuse within timeframes as required by federal requirements and protect residents during abuse investigations.

Based on interview and record review, the facility failed to ensure a call light (a means of communication for patients to their care providers that are outside of the patient's room) was within one of 12 residents (5) easy reach at all time to enable the resident to summon for help as needed. The facility failed to: 1. Implement an intervention to place a call light within reach, as outlined in Resident 5's plan of care for a left [MEDICAL CONDITION] (broken bone) with post-surgery for [REDACTED]. 2. Included Resident 5's evaluation of gait (manner of walking), balance and predisposing health conditions such as left [MEDICAL CONDITION], to accurately assess the resident for the risk of falls. 3. Develop a plan of care for the risk for falls based on the accurate assessment for the risk of falls with a time frame, measurable goals, and interventions. 4. Have a system in place to monitor Resident 5 every two hours to ensure the resident's safety and a call light placement within the resident's reach. 5. Implement the facility's policy and procedures on Falls and Fall Risk Assessment. As a result, on 3/29/19 at 1:50 a.m., while trying to reach for the call light on the floor, Resident 5 fell out of bed and sustained a right hip (region overlying the greater trochanter of the femur, or thigh bone) fracture (broken bone), and experienced unbearable pain in the right hip, hand, wrist and was transferred to a general acute care hospital (GACH) for the right hip ORIF surgery. Findings: A review of Resident 5's Admission Record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 5's Minimum Data Set (MDS) - a standardized assessment and care-screening tool, dated 6/17/18, and 6/10/19, indicated Resident 5 had an intact cognitive skill for daily decision making, was incontinent of bladder and bowel, required two staff members physical assistance for transfer and extensive assistance with one-person physical assistance with dressing, personal hygiene, toilet use and total assistance from staff with locomotion on and off the unit. The MDS indicated Resident 5 required a wheelchair and a mechanical lift for locomotion and transfers. A review of Resident 5's history and physical examination [REDACTED]. A review of Resident 5's Comprehensive Assessment, conducted by the licensed nurses and dated 6/14/18, indicated Resident 5 had a left hip surgical site without staples and was dependent on staff for functional activities. A review of Resident 5's Bowel and Bladder (B&B) Assessment form dated 6/14/18, 9/9/2018, and 12/9/18 indicated Resident 5 was incontinent in B&B and required assistance to the bathroom. A review of Resident 5's Fall Risk assessment dated [DATE], 12/9/18, and 3/3/19 indicated the resident's history of fall did not include in the assessments. The resident gait (manner of walking), balance, and predisposing health conditions such as left [MEDICAL CONDITION], were not included in the assessments for the risk for fall, resulting in the resident's total score of six, representing a low risk for falls. A review of Resident 5's physical therapy Weekly Progress Notes dated 6/25/18, 7/12/18, indicated the resident required two physical staff assistance with bed mobility, sitting balance due to left [MEDICAL CONDITION], the risk for fall-related to general body weakness, poor safety awareness, unsteady gait, limited mobility, and impaired gait. The notes indicated the goal for Resident 5 was to be free from falls or injury and that nursing staff had to provide a visual check every two hours or as needed to ensure the resident's safety. A review of Resident 5's care plan for a left [MEDICAL CONDITION] with ORIF surgery, dated 6/24/18, indicated that one of the nursing interventions was to place a call light within the resident's reach to enable the resident to access the call light to summon for help as needed. A review of Resident 5's licensed nurses' progress notes dated 3/29/19 at 1:50 a.m. indicated Resident 5's yelling for help was overheard, and a certified nursing assistant (CNA 1) ran to the resident's room. Resident 5 was found lying on the floor, next to her bed, on her right side of the body. In the progress note was documented Resident 5 was transferred back to bed with a mechanical lift and the help of three staff members. In the note was documented Resident 5 slid down because she wanted to go pee and complained of serve pain in her right hand, wrist, and right hip. The progress notes indicated the resident's physician was notified, and the order for x-ray (a photographic image of the internal composition of a part of the body) of the right hip, hand wrist to roll out fracture was obtained. The same licensed nurse's notes indicated the resident was administered [MEDICATION NAME] 10/325 milligram (pain medication) for severe pain, the call light was placed within the resident's reach, and the ice pack applied to right hip. A review of the physician's orders [REDACTED]. A review of the x-ray results dated 3/29/19 at 9:56 a. m. indicated Resident 5 had an acute right [MEDICAL CONDITION]. A review of Resident 5's clinical record indicated a physician's orders [REDACTED]. m., to transfer the resident to a general acute care hospital (GACH) due to a right [MEDICAL CONDITION]. On the same date at 5:45 p.m., Resident 5 was transferred to GACH for further evaluation and care. A review of Resident 5's readmission record dated 4/8/19 indicated the resident was readmitted to the facility with the [DIAGNOSES REDACTED]. A review of the comprehensive resident assessment dated [DATE] at 4:40 p.m. indicated Resident 5 had the right hip with staples on the surgical site. A review of the fall risk assessment dated [DATE] indicated a total score of 15. A score of 10 or above represented a high-risk fall. On 03/14/20, at 10:16 a. m., during an interview, the resident stated she had a fall in her room. The resident said her adult brief was wet and had to be changed. The resident reported she was yelling for help; however, nobody came to change her diaper. The resident stated the door to her room was closed. The resident continued to say that after continues yelling for help, she noted her call light on the floor and was trying to reach for it. In her attempt to reach for the call light, she fell on the floor on her right side and injured her right hip. The resident stated she experience unbearable pain on the right side of the body. The resident stated she was transferred to GACH, where she had her surgery. On 3/14/20, at 3:26 p m., during an interview, the director of nursing (DON) stated that staff reported that Resident 5 had fallen in her room. DON acknowledged that the investigation about the resident's fall was not conducted and stated that staff from the night shift was given an in-service regarding Resident 5's fall. On 3/14/20, at 4:22 p.m., during an interview, the licensed vocational nurse (LVN 1) stated she heard from another staff about Resident 5 has fallen in her room because the resident needed to use the bathroom. LVN 1 stated Resident 5 could not get out of bed without assistance. On 3/14/20, at 6:39 p.m., during an interview, the administrator stated that the current DON started to work recently, and the formal DON had to investigate Resident 5's fall but did not do it. The administrator stated Resident 5 was transferred to GACH after her x-ray indicated the resident sustained [REDACTED]. On 3/15/20, at 9:38 a.m., during a telephone interview with a certified nursing assistant (CNA 1), who worked 11 p.m. to 7 a.m. shift stated that on 3/29/19, around midnight she overheard Resident 5 screaming in her room. CNA 1 stated she went to Resident 5's room and found the resident lying on the floor on her right side. CNA 1, the resident was assisted back to bed with the use of a mechanical lift with the help of two other staff. CNA 1 stated Resident 5 was in severe pain and was crying continuously. CNA stated when Resident 5 was asked what happened, the resident said she was soaking wet and was yelling for help, and no one came, then she saw the call light on the floor and was trying to reach for it to summon for help and fall out of bed. When CNA was asked when the last time rounds were conducted, CNA stated the resident had to be monitored every two hours. However, she had no recollection at what time and how often the rounds were made. CNA 1 stated Resident 5 could not walk or get out of bed by herself and required assistance from staff. CNA stated the resident was incontinent of bowel and bladder. CNA 1 stated she kept Resident 5 clean and dry with the help of CNA 2. On 3/15/20, at 9:56 p.m., during an interview, CNA 2 stated when she heard Resident 5 yelling in her room, she ran to the room and found the resident lying on the floor on her right side. CAA 2 stated she tried to lift the resident but could not and used a mechanical lift with the help of another staff member. CNA 2 stated the resident was always incontinent and had to wear a diaper. CNA 2 stated Resident 5 be transferred from a bed to a wheelchair and from a wheelchair back to bed with the use of a mechanical lift and another staff member. CNA 2 stated the resident was crying and yelling because she was in pain. On 03/15/20, at 4:36 p.m., during a follow-up interview, the DON stated Resident 5 had to be assessed as a high risk for falls because the resident had a history of [REDACTED]. The DON stated that the nursing staff had to conduct rounds every two hours to ensure the residents had their call lights within easy reach. The DON stated Resident 5's room door should not be wholly close and had to be slightly opened for nursing staff to hear if the resident would call for help. A review of the facility's policy and procedures, titled Falls and Fall Risk, revised 3/18, indicated the licensed nurses should evaluate each resident's previous and current data and develop interventions specific to resident's risk and causes to prevent the resident from falling and to minimize complications from falling. According to this policy, the fall risk factors included poor grip strength, functional impairment, and incontinence. The policy also indicated that based on assessment information, a resident-centered fall prevention care plan should be established; the history of falls within ninety days shall be reviewed upon admission, and interventions to prevent falls shall be developed.

Based on observation, interview, and record review, the facility failed to follow its policy regarding the use of restraints (a measure or condition that keeps someone under control or within limits) and abuse for one of three sampled residents (Resident 1). Resident 1, who had a history of [REDACTED]. without physician's orders [REDACTED].>This deficient practice resulted in Resident 1's rights being violated by the facility using chemical and physical restraints, which had the potential to result in injury and resulted in mental anguish (severe mental or physical suffering) for Resident 1, as he was observed crying, screaming (why, why (in Spanish)) while the staff laughed at him. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's annual Minimum Data Set (MDS), a resident assessment and care screening tool, dated 6/16/19, indicated Resident 1's cognition (thought process) was impaired for decision-making, but was usually able to make needs known and usually able to understand others. According to the MDS, the resident was assessed as requiring limited assistance with bed mobility, transferring, locomotion on and off the unit, and limited assistance with personal hygiene. A review of Resident 1's care plan, initiated on 6/8/18 and last updated on 6/1/19, identified a problem of Impaired Communication related to being non-English speaking. The goal indicated that the resident's needs would be anticipated. The staff's approach included to provide ample time when communicating with Resident 1 and enlist family assistance. A review of Resident 1's care plan, initiated on 6/8/18 and last updated on 6/1/19, identified a problem of potential for changes of cognition (thought process) and ability to make decisions, due to dementia, [MEDICAL CONDITION](([MEDICAL CONDITION]) blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel) with at risk for increased confusion and forgetfulness. The goals indicated that Resident 1 would be able to retain and have no changes of memory and would participate with decision-making. The staff's interventions included to explain the purpose and procedures prior to rendering any care to Resident 1; reorient the resident to surroundings as needed, address the resident by name and reintroduce self before rendering care. A review of Resident 1's care plan, initiated on 6/8/18 and last updated on 6/1/19, identified a problem of Resident 1 having inappropriate behavior towards staff, other residents and direct caregiver, which included being verbally and physically abusive with behavior demonstrated by the resident as cursing and touching. The goals indicated the resident will be able to adjust to the environment and daily routine care provided by the staff/caregiver and the resident will be cooperative with the staff and allow assistance with daily ADLs (activities of daily living) and routine needs/care. The staff's interventions included to approach Resident 1 in a calm and friendly manner, explain purpose of procedures of care prior to rendering, monitor resident behavior and inform the physician for excessive episodes. Allow the resident time to calm down if behavior starts to escalate (increase). On 7/30/19 at 6:49 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated that Resident 1 was non-English speaking and that he wanders around in his wheelchair in the hallways of the facility. CNA 1 stated Resident 1 does not like to have his blood glucose (the amount of glucose (sugar) in the blood) tested and when the staff obtain the blood from the resident's finger, they do not always explain the procedure to him (the staff just pulls his hand). CNA 1 stated Resident 1 does not like when the staff does not explain procedures and force him to have his blood glucose checked. CNA 1 stated Resident 1 was not combative but acts out because the facility's staff do not tell him before they provide care. CNA 1 stated that the other staff members told him that Resident 1 was tied up by another CNA 2, but that he (CNA 1) was off work the day in question. On 8/2/19 at 2:13 p.m., during a telephone interview, the Administrator (ADM) stated that he was aware Resident 1 was being tied up in his wheelchair to the wall handrails by CNA 2. The ADM stated CNA 2 had been suspended due to tying up Resident 1. The ADM stated that an order for [REDACTED]. On 8/2/19 at 2:17 p.m., during an interview, the Social Services Director (SSD) stated that Resident 1 wanders around the facility in his wheelchair and was at risk for elopement, so his room was changed. The SSD stated Resident 1 was tied to the handrails because he was combative with staff and has been found outside the facility by staff in the past. The SSD stated that she has not follow-up with Resident 1 regarding the incident of being tied up with the bed linen because she does not speak Spanish. On 8/2/19 at 2:21 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that it was not good to restrain Resident 1 because of his combative and wandering behaviors. LVN 1 stated that she does not think Resident 1 deserves to be tied up and that she would be upset if her family member was tied up or restrained. LVN 1 stated that the staff should have given Resident 1 time to calm down if he was becoming combative (as per the care plan). LVN 1 stated she was on duty and saw Resident 1 tied up, but she was assigned to another resident and did not report the incident to the Director of Nursing (DON) or the ADM. On 8/2/19 at 2:54 p.m., during an interview, LVN 2 stated she saw Resident 1 tied in his wheelchair, because he tries to leave the facility and was combative because he does not like to have his blood glucose checked. LVN 2 stated she called the physician and obtained a telephone order for restraints PRN (as needed) for Resident 1 and also obtained consent from Resident 1's family member (FM 1). LVN 2 stated CNA 2 only tied Resident 1 for two days for a few minutes each time with the bed linens to the handrails in his wheelchair. LVN 2 stated that she notified the DON and the ADM of Resident 1 being tied up to the handrails with linens in his wheelchair because another resident (Resident 2) took photos of Resident 1 being tied to the wall. On 8/2/19 at 2:57 p.m., in a subsequent interview and a concurrent review of Resident 1's care plans, LVN 1 stated that a care plan was not created for the use of restraints because the restraints were used PRN. In addition, LVN 1 stated there was no care plan identified for Resident 1's risk of elopement. On 8/2/19 at 4:17 p.m., during an interview, FM 1 stated she never gave consent or signed any document regarding restraint use for her family member (Resident 1). FM 1 stated that she never received a telephone call from the facility requesting permission to restrain Resident 1 and she would never allow Resident 1 to be restrained under any circumstances. FM 1 while tearful, stated that two weeks prior Resident 1 had a low blood glucose level with bruises and scratches that were bleeding and the staff did not tell her about the injuries. FM 1 stated Resident 1 was crying and saying he was hurt. FM 1 stated that she is a physician and Resident 1 was her only family member and she would never consent for him to be restrained. On 8/2/19 at 4:46 p.m., during an interview, Resident 2, who was alert and oriented stated that on Friday 7/26/19 she saw CNA 2 tie Resident 1 in his wheelchair in the hallway by her (Resident 2) room. Resident 2 stated that she could hear Resident 1 crying loudly and speaking in Spanish. Resident 2 stated she had seen CNA 2 tie up Resident 1 approximately six or seven times and would leave him there for a few hours. Resident 2 stated CNA 2 was abusive and intimidating (having a frightening or threatening effect), that she (Resident 2) was afraid of retaliation (the action of harming someone in return for perceived wrongdoing (revenge)). Resident 2 stated since this incident, of Resident 1 being tied up, the facility's staff has harassed her repeatedly regarding reporting her findings to the Department of Public Health. A review of Resident 2's Minimum Data Set MDS, dated [DATE], indicated Resident 2 had no memory problems, no impairment in decision-making and was able to make needs known and be understood by others. The MDS indicated Resident 2 was assessed as requiring supervision with bed mobility, transferring, locomotion on and off the unit, eating and with personal hygiene. On 8/8/19 at 10 a.m., during an interview, with the assistance of an interpreter (a person who interprets, speech orally from one language to another), Resident 1 stated the facility's staff have tied him up and laughed at him. Resident 1 could not recall exactly which staff member, but stated the staff did not tell him why he had to be tied in his wheelchair. Resident 1 stated he felt sad and would cry when they tied him up in his wheelchair. On 8/8/19 at 10:10 a.m., during an interview, CNA 3 stated that Resident 1 can become aggressive when he does not understand when the staff are talking to him. CNA 3 stated that Resident 1 will state when he wants food or help with his ADLs. On 8/8/19 at 11 a.m., during an interview and a concurrent record review, LVN 2 stated that she obtained a verbal consent over the telephone for Resident 1's restraints from FM 1 (sic). LVN 2 confirmed that the consent was received on 7/10/19 because Resident 1 was displaying aggressive (ready or likely to attack or confront) behaviors toward staff and attempting to elope from the facility. LVN 2 stated that the Resident 1's physician (Physician 1) gave telephone orders for a vest restraint (restraints that are designed to secure a patient to either a seated position or a bed (design as a vest)) on 7/10/19. LVN 2 stated that when the orders were obtained 7/10/19 for the vest restraint the staff did not implement the orders on that day. LVN 2 stated she did not document Resident 1's aggressive behaviors on the licensed nursing progress notes; or drafted a care plan for Resident 1's aggressive behaviors and attempts to elope from the facility. LVN 2 stated no restraint assessment was completed for Resident 1 to be restrained. LVN 2 stated that the note of consent for Resident 1's restraints from FM 1 was obtained by the Director of Staff Development (DSD) on 7/26/19 in writing. LVN 2 stated she was not aware that tying Resident 1 in his wheelchair with bed linen was considered a restraint. In a subsequent interview and record review at 11:04 a.m., 8/8/19 in the presence of the DSD and LVN 2, FM 1 stated that she was not notified of Resident 1's aggressive behaviors and did not sign a consent document regarding the use of restraints. FM 1 stated that a blank consent was given to her by the DSD and she was told it was for [MEDICATION NAME] (([MEDICATION NAME]) a drug used to treat anxiety) to be given for Resident 1. FM 1 stated the DSD just told her to sign the consent and snatched the document away after obtaining the signature. On 8/8/19 at 11:28 a.m., during a telephone conference call, in the presence of the DON, DSD, and LVN 2, Resident 1's physician (Physician 1) stated that he was not aware that the staff were giving Resident 1 [MEDICATION NAME] IM (intramuscularly (into the muscle)) and restraining the resident for combative behavior. Physician 1 stated that when a resident was combative an order for [REDACTED]. Physician 1 stated that he did not received a call from LVN 2 requesting orders to restrain Resident 1 and that he was aware that it was against CMS (Centers for Medicare & Medicaid Services (CMS) oversees many federal healthcare programs, including skilled nursing facilities) regulations and violation of residents' rights to restrain a resident. Physician 1 stated that he, nor his Nurse Practitioner ((NP) an advanced practice RN who has additional responsibilities for administering patient care; prescribe medication, examine patients, diagnose illnesses, and provide treatment, much like a physician), never gave a PRN order for the use of [REDACTED] On 8/8/19 at 11:45 a.m., during a telephone interview, the NP stated she gave a telephone order for [MEDICATION NAME] once, but stated that she was aware that the order was for 14 days only and she signed that order. The NP stated she did give a telephone order for restraints PRN for Resident 1 at any time to LVN 2. On 8/8/19 at 12 p.m., during an interview and concurrent record review, the DON confirmed that Resident 1 did not have documents in his medical record regarding Resident 1's aggressive behaviors on the licensed nursing progress notes or care plans for Resident 1's aggressive behaviors or attempted elopement from the facility. The DON confirmed the NP's order for [MEDICATION NAME] for Resident 1, dated 7/26/19, and signed by the NP on 8/7/19, 12 days later. A review of an undated facility's policy titled, Restraints indicated restraints shall only be used for the safety and well-being of the residents only after other alternatives have been tried unsuccessfully. Restraints will only be used after the other alternatives have been tried unsuccessfully and with an informed consent from the resident, physician, and/or representative. Physical restraints shall not be used to limit resident mobility or for the convenience of staff. If the resident behavior is such that will result in injury to themselves or others and any form of restraint is utilized it shall be in conjunction with a treatment procedure designed to modify the behavioral problems for which the resident is restrained or as a last resort of attempted therapy. Restraints must be used as a last resort, and the resident medical records must indicate the events leading up to the necessity of restraints. The policy stipulated that orders for restraints will not be used for longer than twelve (12) hours. The use is not employed as punishment, for the convenience of staff, or as a substitute for supervision. The residents care plan must indicate the use of restraints, an order from the physician noted. A review of the facility's undated posted Resident Rights Poster indicated the resident had the right to be free from physical or chemical restraints imposed for purposes of discipline, convenience and not required to treat an individual's medical symptoms.

Based on observation, interview, and record review, the facility failed to implement its abuse policy as indicated in the facility's policy titled, Resident with Uncontrolled Behavior Issues, and a resident's care plan for close monitoring of whereabouts needed to ensure residents were protected and free from abuse for one of three sampled residents (Residents 2). Resident 1, who had a history of [REDACTED]. after being physically abusive towards Resident 2 resulting in injury of an opened wound that required care and treatment (Cross referenced to F689). This deficient practice resulted in Resident 2 being struck with a five (5) pound (lb.) metal paper hole punch by Resident 1. Resident 2 sustained a laceration (deep wound) to the right thigh, requiring a transfer to a general acute care hospital (GACH) for wound closure. Resident 2 stated she was fearful of Resident 1, as he continued to attempt to attack her once he was readmitted back to the facility after he injured her. Resident 1 was readmitted to the facility and placed on one-one close monitoring in which the facility failed to implement. A pattern of the facility's system failure to ensure a resident who required supervision was provided with one to one supervision, as per Resident 1's care plan for whereabouts to be monitored and the facility's policy for one-to-one supervision after Resident 1 was hostile (unfriendly, confrontational), aggressive and struck another resident (Resident 2). Resident 1 struck Resident 2 with a seven-pound metal paper hole puncher and one-to-one supervision was implemented to prevent injury and harm to other residents. On 6/28/19 at 3:33 p.m., an Immediate Jeopardy ((IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared for F600 and F689. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened and provided an acceptable plan of action (POA) on 6/29/19. The facility submitted a Plan of Action (POA) for the correction of the IJ which included the following: 1. On 6/28/19 an immediate action was taken by the DON to assign one -to-one supervision to monitor Resident 1's aggressive behavior to prevent harm to other residents. 2. Resident 1's care plan was reviewed revised, after the IDT (Interdisciplinary Team (a group a group of medical specialists that coordinate, collaborate, and plan the delivery of care for residents)) met, based on Resident 1's aggressive behavior (throwing items, striking, and sudden burst of temper). Behavior monitoring tool was utilized by the nursing department. 3. Resident 1's primary physician was notified and an order was obtained to transfer Resident 1 to another facility. Resident 1 was informed and agreed to the transfer. 4. Resident 1 was transferred to another facility to avoid further interactions with Resident 2 who feared for her safety. 5. The facility provided in-services to the facility's staff regarding resident aggressive behavior monitoring and interventions. All corrective actions will be completed by (MONTH) 8, 2019. On 6/29/19 at 2:38 p.m., after the team verified that the POA was implemented, both the DON and the ADM were notified and the IJ was lifted. Findings: A review of Resident 2's Nurses' Progress Note, dated 6/21/19 and timed at 1:20 p.m., indicated Resident 2 was at Nurses Station two and the charge nurse called for help, when Resident 2 was found sitting in a chair holding her bleeding right inner thigh. The Nurse's Progress Note indicated 911 (emergency services) was called right away and Resident 2 called the police herself. Resident 2 was assisted back to her room, but refused to be assessed and/or have vital signs (measurements of the body's most basic functions, such as body temperature, pulse rate (heart rate), respiration rate (rate of breathing) and blood pressure (pressure of circulating blood on the walls of blood vessels) checked. The progress note also indicated the staff attempted to keep Resident 2 calm and stayed with her until the paramedics arrived. The Nurse's Progress note indicated care and treatment for [REDACTED]. A review of Resident 2's Transfer Record, dated 6/21/19 and timed at 1:30 p.m., indicated Resident 2 was transferred by 911 after she was struck by Resident 1 with bleeding to Resident 2's right upper thigh. A review of Resident 1's Nurse's Progress note, dated 6/21/19 and timed at 2 p.m., indicated the physician was called and informed of Resident 1's behavior. The physician ordered for [MEDICATION NAME] one milligram (mg) (([MEDICATION NAME]) a medication used to treat anxiety to produce a calming effect). A review of Resident 2's GACH emergency department (ED) note, dated 6/21/19 and timed at 2:41 p.m., indicated Resident 2 arrived with a right leg laceration that was actively bleeding, after another person (Resident 1) threw a heavy machinery equipment five-hole paper punch weighing about 5 pounds, hitting her (Resident 2) on the right medial (middle) thigh. The patient (Resident 2) was assaulted, a sheriff was on the scene and a report was made. The patient (Resident 2) sustained a 5.5 centimeters (cm) laceration which was repaired with nine (9) sutures (synthetic braided thread used for repairing deep skin cut). A review of the Sheriff Department's Report, dated 6/21/19 indicated the sheriff's responded to a call regarding an assault with a deadly weapon (a paper puncher) by Resident 1 towards Resident 2. A large white metal paper puncher (approximately 18 inches in length and six inches in width) was confiscated (taken) from the facility as the weapon used to injure the victim (Resident 2). The report further indicated that the suspect (Resident 1) had been placed on a 5150 psychiatric hold (a temporary, involuntary psychiatric hold of individuals who present a danger to themselves or others due to signs of mental illness for three days). The report indicated Resident 1 had a history of [REDACTED]. The sheriff requested for a Mental Evaluation Team (MET) and upon their arrival to the facility the MET team took the suspect (Resident 1) to the psychiatric GACH on a 5150 hold. A review of Resident 2's Admission Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. and often unpredictably magnified). A review of Resident 2's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 5/30/19, indicated Resident 2 had no memory problems, impairment in decision-making, was able to make needs known and understood others. The MDS indicated Resident 2 was assessed as requiring supervision with bed mobility, transferring, locomotion on and off the unit, eating and with personal hygiene. A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. is reality), and disordered thinking and behavior), and [MEDICAL CONDITION] (severe mental disorder that cause abnormal thinking and perception). A review of Resident 1's quarterly MDS, dated [DATE], indicated Resident 1 had memory problems, impaired decision-making, was sometimes able to make needs known and usually understands others. Resident 1 was assessed as requiring extensive assistance with bed mobility, transferring, dressing, and limited assistance with locomotion on and off the unit, but requiring limited assistance with eating and personal hygiene. A review of Resident 1's care plan, initiated on 9/27/18, identified Resident 1 as having a problem with behavioral patterns of anxiety (a feeling of worry, or unease) as demonstrated by restlessness with agitation. The goal indicated that Resident 1's acute episodes of anxiety would be limited until the next review. The staff's interventions included to monitor Resident 1's anxious episodes every shift and document on the Medication Administration Record [REDACTED]. A review of Resident 1's MARs (from (MONTH) 2019- (MONTH) 2019), there was no documented evidence that the staff were monitoring and documenting Resident 1's anxious behaviors, as indicated in the resident's plan of care A review of Resident 1's care plan, initiated on 2/15/19, identified Resident 1 having problems with involvement in group activities due to his behavioral pattern of hitting, agitation and throwing things. The goal indicated that Resident 1 would continue to participate in activities five days per week. The staff's interventions including assisting the resident to attend activities of choice, involve the IDT and the family regarding the resident's behavior while in the activity and provide one to one supervision with the resident. A review of Resident 1's psychiatric (relating to mental illness or its treatment) follow-up, dated 2/23/19 indicated Resident 1 was a paranoid [MEDICAL CONDITION] with generalized anxiety disorder. The psychiatric follow-up indicated Staff reports that the resident still strikes at the nurses and gets agitated. Patient response to treatment unpredictable, easily agitated with staff and peers. A review of Resident 1's care plan initiated on 4/29/19, identified Resident 1 as having a problem with mood swings. The staff's interventions included to monitor Resident 1's whereabouts frequently, keep the resident away from other residents when agitated, approach the resident in a calm non-threatening manner, and monitor and document the number of agitation episodes. There was no documented evidence in the nurses progress notes and/or on the Medication Administration Records (MARs) to indicate that the staff were monitoring and documenting Resident 1's whereabouts. A review of Resident 1's Licensed Personnel Progress Note, dated 6/21/19 and timed at 7:15 p.m., indicated Resident 1 was kept on one-to-one care, the Department of Mental Health emergency staff arrived, as were called by the sheriff. At 11 p.m., on 6/21/19 a call was received from the psychiatric hospital for Resident 1's immediate transfer to the GACH psychiatric facility. A review of Resident 1's GACH clinical summary, dated 6/21/19 and timed at 10:08 p.m., indicated Resident 1 had a history of [REDACTED]. According to the psychiatric GACH notes, Resident 1 was angry at another resident (Resident 2) who used profanity (obscene language) towards him. On 6/27/19 at 2:23 p.m., during an observation of the facility's surveillance video, in the presence of the administrator (ADM), Resident 1 was seen pushing his wheelchair to the Nurses Station (2). Resident 1 suddenly grabbed the paper hole puncher off the desk and threw it at Resident 2 hitting her on the right thigh. Resident 2 was observed holding her right thigh and a staff member (Certified Nursing Assistant 2 (CNA 2)) was observed pushing Resident 1's wheelchair away from the nursing station, away from Resident 2. On 6/27/19 at 2:41 p.m., during an interview, CNA 1 stated that when Resident 1 becomes upset, he would become aggressive. CNA 1 stated that Resident 1 does not participate in activities because of the concern he (Resident 1) may hit other residents. During an observation on 6/27/19 at 3:10 p.m., the door to Resident 2's room was closed. Upon entering Resident 2's room, Resident 2 was observed lying in bed. A large purplish bruise (blood from damaged blood cells deep beneath the skin collects near the surface of the skin) was observed on Resident 2's right groin (area between the abdomen and the thigh) area to knee on the right leg with a gauze (a dressing or bandage used to cover the wound. During a concurrent interview, Resident 2 stated that Resident 1 had been harassing her since she was admitted to the facility. Resident 2 stated that she now keeps her room door closed so that Resident 1 could not come in and attack her again. Resident 2 stated that she was afraid Resident 1 was going to attack her again and that the facility's Director of nursing (DON) told her to stay away from Resident 1. Resident 2 stated that since the incident he has tried to come into her room, because the facility's staff do not keep an eye on him (Resident 1). Resident 2 stated that the incident occurred as she was signing a book in the Nursing Station to leave for a few hours out on pass (OOP). Resident 2 stated Resident 1 rolled up close to her in his wheelchair and she told him (Resident 1) to stay away from her and that was when he (Resident 1) picked up the paper hole puncher and threw it at her, hitting her in her leg that she had surgery on recently. Resident 2 stated that she screamed because it hurt and tore through her pants, cutting her leg. Resident 2 stated there was blood all over her pants and that she held her leg to try to stop the bleeding. Resident 2 further stated that when the paper hole puncher was thrown there were no facility staff around to protect her from him. Resident 2 stated that she told one of the charge nurses that Resident 1 had been following her, but nothing was ever done. Resident 2 stated that when he threw the paper puncher at her she called the sheriff department herself to report the assault and wanted Resident 1 to be arrested. Resident 2, while tearful, stated as a result of this abuse incident she was scared for her life and had terrible pain with bruises to her right leg. On 6/27/19 at 4:51 p.m., during an interview and concurrent review of the care conference notes (IDT), dated 6/25/19, the DON stated that she was not sure why Resident 1's agitation episodes were not being monitored each shift. During an interview with the DON, she stated that the IDT team met upon Resident 1's readmission and that Resident 1 only had this one incident of violent behavior, has not had any other problems (sic). On 6/27/19 at 5:13 p.m., during an interview, a Licensed Vocational Nurse (LVN 1) stated that she heard yelling and saw Resident 2 at the Nursing Station holding her thigh that was bleeding through her pants on 6/21/19. LVN 1 stated that Resident 2 refused to be touched by the staff and had called the police herself. LVN 1 stated that when Resident 1 was readmitted back from the 5150 psychiatric hold on 6/25/19, and no care plans had been created to address Resident 1's aggressive behavior. LVN 1 stated Resident 1 had been sent out of the facility in the past (3/23/19) for his aggressive behavior. LVN 1 stated that the care plans for Resident 1's aggressive behavior should have been initiated and updated. On 6/28/19 at 8:48 a.m., during an interview, the sheriff stated that a call was received on 6/21/19 about an assault at the facility between a suspect, a guy in his thirties, and a victim, a female in her sixties. The sheriff stated upon his arrival the victim was frantic (emotionally out of control) and reported being cut with a paper puncher. The sheriff stated he was surprised to see that the weapon was an actual seven-pound paper puncher. The sheriff stated that the weapon was confiscated from the facility and entered as evidence. The sheriff stated the suspect (Resident 1) was not able to answer any questions, and the victim (Resident 2) was transported to a hospital from the scene. On 6/28/19 at 2:22 p.m., during an interview, CNA 2 stated Resident 1 continued to try to attack Resident 2 after the incident on 6/21/19 upon his return back to the facility. CNA 2 stated that Resident 1 had prior incidents of throwing objects at other residents in the past, as well as hitting him (CNA 2) before. A review of the facility's policy titled, Resident Abuse dated 6/2000 indicated it is the policy of the facility to provide a safe environment for our residents. Each resident has the right to be free from verbal, sexual, physical, mental, and financial abuse, neglect or mistreatment, corporal punishment and involuntary seclusion. The abuse policy indicated the facility department heads are directly responsible for monitoring the delivery of care to assure that abuse or neglect was prevented.

Based on observation, interview, and record review, the facility failed to ensure that a resident, who had a history of [REDACTED]. Resident 1, who was not being monitored and/or supervised, became physically abusive toward another resident (Resident 2), resulting in an injury for Resident 2, and the facility failed to provide one-to-one supervision of Resident 1 to prevent further injury to Resident 2 and other residents. Resident 1, who was readmitted back to the facility after the abuse incident, continued to attempt to attack Resident 2 without being closely supervised. This deficient practice of lack of supervision resulted in Resident 1 throwing a metal paper hole punch at Resident 2. Resident 2 sustained a laceration (deep cut) to the right thigh (upper leg) that required a transfer to a general acute care hospital (GACH) for evaluation and treatment for [REDACTED]. A pattern of the facility's system failure to ensure a resident who required supervision was provided with one to one supervision, as per Resident 1's care plan for whereabouts to be monitored and the facility's policy for one-to-one supervision after Resident 1 was hostile (unfriendly, confrontational), aggressive and struck another resident (Resident 2). Resident 1 struck Resident 2 with a five-pound metal paper hole puncher and one-to-one supervision was implemented to prevent injury and harm to other residents. On 6/28/19 at 3:33 p.m., an Immediate Jeopardy ((IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared for F600 and F689. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened and provided an acceptable plan of action (POA) on 6/29/19. The facility submitted a Plan of Action (POA) for the correction of the IJ which included the following: 1. On 6/28/19 an immediate action was taken by the DON to assign one -to-one supervision to monitor Resident 1's aggressive behavior to prevent harm to other residents. 2. Resident 1's care plan was reviewed revised, after the IDT (Interdisciplinary Team (a group a group of medical specialists that coordinate, collaborate, and plan the delivery of care for residents)) met, based on Resident 1's aggressive behavior (throwing items, striking, and sudden burst of temper). Behavior monitoring tool was utilized by the nursing department. 3. Resident 1's primary physician was notified and an order was obtained to transfer Resident 1 to another facility. Resident 1 was informed and agreed to the transfer. 4. Resident 1 was transferred to another facility to avoid further interactions with Resident 2 who feared for her safety. 5. The facility provided in-services to the facility's staff regarding resident aggressive behavior monitoring and interventions. All corrective actions will be completed by (MONTH) 8, 2019. On 6/29/19 at 2:38 p.m., after the team verified that the POA was implemented, both the DON and the ADM were notified and the IJ was lifted. Findings: A review of Resident 2's Nurses' Progress Note, dated 6/21/19 and timed at 1:20 p.m., indicated Resident 2 was at Station 2 and the charge nurse paged for help. Resident 2 was found sitting in a chair holding her right inner thigh that was bleeding. The note indicated 911 (emergency services) was called right away and Resident 2 called the police herself. Resident 2 was assisted back to her room, but refused to be assessed and or have vital signs (measurements of the body's most basic functions, such as body temperature, pulse rate, respiration rate (rate of breathing) and blood pressure) checked. The staff attempted to keep Resident 2 calm and stayed with her until the paramedics arrived. The treatment to Resident 2 was done by the paramedics, the necessary information was given to the police officer, and the physician was informed of the reason for Resident 2's transfer to the GACH. The nurse's note also indicated Resident 2 was in no respiratory distress and refused pain medications. A review of Resident 2's Transfer Record, dated 6/21/19, and timed at 1:30 p.m., indicated Resident 2 was transferred by 911 after she was struck by Resident 1 and there was bleeding on the right upper thigh. A review of Resident 1's Nurse's Progress note, dated 6/21/19 and timed at 2 p.m., indicated the physician was called and informed of Resident 1's behavior. The physician ordered [MEDICATION NAME] 1 milligram (mg) (([MEDICATION NAME]) a medication used to treat anxiety to produce a calming effect). A review of Resident 2's GACH emergency department (ED) note, dated 6/21/19 and timed at 2:41 p.m., indicated patient (Resident 2) arrived with a right leg laceration (deep cut) that was actively bleeding, after another person (Resident 1) threw a heavy machinery equipment five-hole paper punch weighing about 5 pounds, hitting her (Resident 2) on the right medial (middle) thigh. The patient (Resident 2) was assaulted, a sheriff was on the scene and a report was made. The patient (Resident 2) sustained a 5.5 centimeters (cm) laceration which was repaired with nine (9) sutures (synthetic braided thread used for repairing deep skin cut). A review of the Sheriff Department's Report, dated 6/21/19 indicated the sherriff's responded to a call regarding an assault with a deadly weapon (a paper puncher) by Resident 1 towards Resident 2. A large white metal paper puncher (approximately 18 inches in length and six inches in width) was confiscated (taken) from the facility as the weapon used to injure the victim (Resident 2). The report further indicated that the suspect (Resident 1) had been placed on a 5150 psychiatric hold (a temporary, involuntary psychiatric hold of individuals who present a danger to themselves or others due to signs of mental illness for three days). The report indicated Resident 1 had a history of [REDACTED]. The sheriff requested for a Mental Evaluation Team (MET) and upon their arrival to the facility the MET team took the suspect (Resident 1) to the psychiatric GACH on a 5150 hold. The Sheriff's Report indicated due to Resident 1's mental capacity, Resident 1 was not booked into custody at that time. A review of Resident 2's Admission Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. and often unpredictably magnified). A review of Resident 2's Minimum Data Set, a resident assessment and care screening tool, dated 5/30/19, indicated Resident 2 had no memory problems, impairment in decision-making, was able to make needs known, and understood others. Resident 2 was assessed as requiring supervision with bed mobility, transferring, locomotion on and off the unit, eating and with personal hygiene. A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. is reality), and disordered thinking and behavior), and [MEDICAL CONDITION] (severe mental disorder that cause abnormal thinking and perception). A review of Resident 1's quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident 1 had memory problems, impaired decision-making, was sometimes able to make needs known and usually understands others. Resident 1 was assessed as requiring extensive assistance with bed mobility, transferring, dressing, and limited assistance with locomotion on and off the unit, but requiring limited assistance with eating and personal hygiene. A review of Resident 1's care plan, initiated on 9/27/18, identified Resident 1 as having a problem with behavioral patterns of anxiety (a feeling of worry, or unease) as demonstrated by restlessness with agitation. The goal indicated that Resident 1's acute episodes of anxiety would be limited until the next review. The staff's interventions included to monitor Resident 1's anxious episodes every shift and document on the Medication Administration Record [REDACTED]. A review of Resident 1's MARs, for the months of (MONTH) 2019 through (MONTH) 2019,there was no documented evidence that the staff were monitoring and documenting Resident 1's anxious behaviors, as stipulated in the resident's plan of care. A review of Resident 1's care plan, initiated on 2/15/19, identified Resident 1 having a problem with involvement in group activities due to his behavioral pattern of hitting, agitation and throwing things. The goal indicated that Resident 1 would continue to participate in activities five days per week. The staff's interventions including assisting the resident to attend activities of choice, involve the IDT and family regarding the resident's behavior while in the act and provide one to one supervision with the resident. A review of Resident 1's psychiatric (relating to mental illness or its treatment) follow-up, dated 2/23/19 indicated Resident 1 is a paranoid [MEDICAL CONDITION] with generalized anxiety disorder. The psychiatric follow-up indicated Staff reports Resident 1 still strikes at nurses and gets agitated. Patient response to treatment unpredictable, easily agitated with staff and peers. A review of Resident 1's care plan initiated on 4/29/19, identified Resident 1 as having a problem with mood swings. The staff's interventions included to monitor Resident 1's whereabouts frequently, keep the resident away from other residents when agitated, approach the resident in a calm non-threatening manner, and monitor and document the number of episodes. A review of Resident 1's Licensed Personnel Progress Note, dated 6/21/19 and timed at 7:15 p.m., indicated Resident 1 was kept on one-to-one care, the Department of Mental Health emergency staff arrived, as were called by the sheriff. At 11 p.m., on 6/21/19 a call was received from the psychiatric hospital for Resident 1's transfer to the GACH. A review of Resident 1's GACH clinical summary, dated 6/21/19 and timed at 10:08 p.m., indicated Resident 1 had a history of [REDACTED]. According to the psychiatric GACH notes, Resident 1 was physically restrained upon arrival due to his violent face to face interaction with the GACH's staff. The GACH's note indicated Resident 1 was angry at another resident (Resident 2) who used profanity (obscene language) towards him. A review of Resident 1's GACH clinical restraint form, dated 6/22/19 and timed at 8:40 a.m., indicated Resident 1 was rolling on the floor, biting and fighting GACH 2's staff. A review of Resident 1's Licensed Personnel Progress Note, dated 6/25/19 indicated Resident 1 was readmitted back to the facility from the GACH. A review of Resident 1's care conference review (IDT), dated 6/25/19 indicated the areas reviewed for Resident 1 included physician orders, diagnosis, advanced directive, resident rights, and [MEDICAL CONDITION] (irregular movement of a limb or of the body, caused by involuntary contraction of muscles). According to the resident care conference review, there were no remarks documented under behavior for Resident 1. On 6/27/19 at 11:42 a.m., during a telephone interview, the GACH's Registered Nurse (RN 1) stated that Resident 1 was placed on a 5150 hold for being a danger to others. RN 1 stated during Resident 1's admission at the GACH, Resident 1 was biting and hitting the psychiatric staff and he was placed in physical restraints with close monitoring every fifteen (15) minutes. RN 1 stated that Resident 1 needed close monitoring because he was strong and easily agitated and had many episodes of agitation. RN 1 stated when Resident 1 was having a disturbance, appropriate interventions must be put in place and that he must be protected from harming others. On 6/27/19 at 2:23 p.m., during an observation of the facility's surveillance video, in the presence of the administrator (ADM), Resident 1 was seen pushing his wheelchair to the Nurses Station on 6/21/19. Resident 1 suddenly grabbed the paper hole puncher off the desk, and threw it at Resident 2 hitting her on the right thigh. Resident 2 was observed holding her right thigh and a staff member (Certified Nursing Assistant 2 (CNA 2)) was observed pushing Resident 1's wheelchair away from the nursing station, away from Resident 2. On 6/27/19 at 2:41 p.m., during an interview, CNA 1 stated that when Resident 1 gets upset, he would become aggressive at times. CNA 1 stated when Resident 1 was upset, he would speak to the resident in Spanish and would usually calm him down. CNA 1 also stated that Resident 1 has hit facility staff before and that he has not seen Resident 1 hit any residents. CNA 1 stated that Resident 1 does not participate in activities because of the concern he (Resident 1) may hit other residents. During an observation on 6/27/19 at 3:10 p.m., the door to Resident 2's room was closed, upon entering Resident 2's room, Resident 2 was observed lying in bed. A large purplish bruise (an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) was observed on Resident 2's right groin (area between the abdomen and the thigh) area to knee on the right leg with a gauze (a thin translucent (permitting light to pass through) fabric of silk, linen, or cotton used to dress a wound) in place over the wound. On 6/27/19 at 3:12 p.m., during an interview, Resident 2 stated that Resident 1 had been harassing her since she was admitted to the facility. Resident 2 stated that she now keeps her room door closed so that Resident 1 could not come in and attack her again. Resident 2 stated that she was afraid Resident 1 was going to attack her again and that the facility's DON told her to stay away from Resident 1. Resident 2 stated that since the incident he has tried to come into her room, because the facility staff do not keep an eye on him (Resident 1). Resident 2 stated that the incident occurred as she was signing a book in the Nursing Station to leave for a few hours out on pass (OOP). Resident 2 stated Resident 1 rolled up close to her in his wheelchair and she told him (Resident 1) to stay away from her and that was when he (Resident 1) picked up a paper puncher and threw it at her, hitting her in her leg that she had surgery on recently. Resident 2 stated that she screamed because it hurt and tore through her pants, cutting her leg. Resident 2 stated there was blood all over her pants and that she held her leg to try to stop the bleeding. Resident 2 stated that she sat on a chair in the Nursing Station. Resident 2 further stated that when the paper punch was thrown there was no facility's staff around to protect her from him. Resident 2 stated that she told one of the charge nurses that Resident 1 had been following her, but nothing was done. Resident 2 stated that when he threw the paper puncher at her she called the sheriff department herself to report the assault and wanted Resident 1 to be arrested. Resident 2, while tearful, stated as a result of this incident she was scared for her life and had terrible pain with bruises to her right leg. During an interview on 6/27/19 at 4:03 p.m., in the presence of the director of staff development (DSD), the DON stated that Resident 1 was on one-to-one monitoring, but the nurses do not document, but just look at him (Resident 1) visually. The DON stated that since the incident on 6/21/19, Resident 1's room has been moved closer to the Nursing Station. According to the DON, whoever was sitting in the Nursing Station would keep an eye on him (Resident 1), because there was not enough staff for one person to be assigned to Resident 1 because it was a small facility. The DON stated that Resident 1 had periods of aggression, but he has not hit another resident, since the incident occurred with Resident 2. The DON stated the CNA assigned to care for Resident 1 would usually monitor Resident 1 in-between caring for the other residents. The DON stated that Resident 1 had anxiety episodes at times. On 6/27/19 at 4:51 p.m., during an interview and concurrent record review of the care conference review (IDT), dated 6/25/19, the DON stated that she was not sure why Resident 1's agitation episodes were not being monitored each shift. The DON stated that the IDT team met upon Resident 1's readmission and that Resident 1 only had this one incident of violent behavior, has not had any other problems (sic). The DON stated that Resident 1's care plans addressed his anxiety, but not Resident 1's aggression. On 6/27/19 at 5:13 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that she heard yelling and saw Resident 2 at the Nursing Station on holding her thigh that was bleeding through her pants on 6/21/19. LVN 1 stated that Resident 2 refused to be touched by the staff and had called the police herself. LVN 1 stated that when Resident 1 was readmitted back from the 5150 psychiatric hold, and no care plans had been created to address Resident 1's aggressive behavior. LVN 1 stated Resident 1 had been sent out of the facility in the past (3/23/19) for his aggressive behavior. LVN 1 stated that the care plans for Resident 1's aggressive behavior should have been initiated and updated. On 6/28/19 at 8:48 a.m., during an interview, the sheriff stated that a call was received on 6/21/19 about an assault at the facility between a suspect, a guy in his thirties, and a victim, a female in her sixties. The sheriff stated upon his arrival the victim was frantic (emotionally out of control) and reported being cut with a paper puncher. The sheriff stated he was surprised to see that the weapon was an actual five-pound paper puncher. The sheriff stated that the weapon was confiscated from the facility and entered into evidence. The sheriff stated the suspect (Resident 1) was not able to answer any questions, and the victim (Resident 2) was transported to a hospital from the scene. On 6/28/19 at 2:08 p.m., during an observation, Resident 1 was observed in the hallway of facility unmonitored by the staff, as per the IDT interventions, licensed personnel progress notes and the facility's policy and procedure. On 6/28/19 at 2:11 p.m., during an interview, the DON stated that Resident 1's assigned CNA (CNA 2) was taking care of other residents and was not observing Resident 1. In a subsequent observation at 2:12 p.m., on 6/28/19, CNA 2 was observed two doors down from Resident 1's room, providing care to another resident, and not monitoring Resident 1. On 6/28/19 at 2:22 p.m., during an interview, CNA 2 stated Resident 1 continued to try to attack Resident 2 on 6/21/19 after the incident and upon his return back to the facility. CNA 2 stated that Resident 1 had incidents of throwing objects at other residents in the past, as well as hitting him (CNA 2). On 6/28/19 at 3:57 p.m., during an observation, Resident 1 was observed in his room in his wheelchair with no facility's staff monitoring him. On 6/28/19 at 3:58 p.m., in a subsequent observation and interview, LVN 1 was on the telephone call in the nursing station. LVN 1 stated that she was aware that Resident 1 was supposed to be closely supervised and that she trying to keep an eye on Resident 1 but had to make a call and would get someone to monitor Resident 1. A review of the facility's policy undated policy titled, Resident with uncontrolled behavior issues indicated each resident would be provided safety while a resident of this facility. Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize the safety of others, the nurse supervisor and/or charge nurse must immediately provide one to one nursing supervision as needed to promote safety to other residents and staff.

Based on observation, interview, and record review, the facility failed to ensure there was a control solution (a liquid of a known sugar concentration used to test the accuracy of blood sugar readings) available to check the accuracy of AgraMatrix [MEDICATION NAME] Pro system glucometers (a device that measures blood sugar) readings, failed to test the accuracy of glucometers readings for ten consecutive days from [DATE] to [DATE] and failed to disinfect glucometers in accordance with the manufacturer's specified guidelines to not affect the accuracy of the test results. In the facility were 16 Insulin (a medication used to control blood sugar) dependent residents out of 38 total residents in the facility (1, 3, 4, 8, 9, 10, 13, 15, 22, 27, 28, 32, 33, 35, 37, 88). These deficient practices placed the residents at risk to receive doses of Insulin that were either too high or too low based on inaccurate glucometers readings leading to possible serious health complications including severe dizziness, coma, and death. Findings: On [DATE] at 09:46 AM during an interview, the licensed vocational nurse 1 (LVN) 1 stated there was no control solution kept in the medication carts (rolling carts where medications and testing supplies are kept). LVN 1 stated it is kept in the drug storage room. Concurrently, during the observation, of the medication storage room and both medication carts, there was not any glucometer control solution available. On [DATE] at 11:31 AM during an interview, the director of nursing (DON) confirmed there was no control solution in the facility because this facility's glucometers models do not require control solution for calibration. A review of the manufacturer's instructions for use, page 15 of the AgraMatrix [MEDICATION NAME] Pro Owner's Guide indicated that The AgraMatrix [MEDICATION NAME] Pro system has two different levels of control solution: normal and high . On [DATE] at 12:48 PM, during an interview, DON stated that she was mistaken about the requirements of the glucometer models which the facility was using. DON stated that she does not have any control solution because the lady that orders the glucometers said they do not need it. When asked how they could ensure the glucometers readings for blood sugar test were correct the DON replied they could not. When asked how the licensed nurses could ensure the residents were receiving accurate insulin dose (amount), DON replied I understand what you mean, but I do not know. On [DATE] at 01:43 PM, during an interview, the director of staff development (DSD) stated there was not currently any control solution present in the facility. DSD stated that the control solution was used by the night shift licensed nurses to calibrate the glucometers. A concurrent review of the calibration logs indicated that the glucometers have not been checked from [DATE] to [DATE]. The DSD stated that she understood the importance of the accuracy of glucometer readings and said if a resident receives an Insulin dose too high the resident might go into a coma.definition On [DATE] at 01:46 PM, during an interview, LVN 1 stated the night shift licensed nurses were responsible to calibrate the glucometers. LVN 1 stated she does not know why, but the facility's contracted pharmacy disposed their last bottle of control solution during their last onsite visit, and it was not replaced. On [DATE] at 1:57 PM, during an interview, DON stated that the facility's contracted pharmacy's staff disposed the control solution when they were last in the facility, however does not know why. DON stated it could have been expired. DON stated that she understands that accurate blood sugar readings are important to ensure the residents are receiving the correct Insulin dose. DON stated they have ordered more, but currently there is no control solution in the facility. DON stated that the facility has been using this brand of glucometers since she started to work in the facility about a year ago. On [DATE] at 4:02 PM, during a telephone interview, the contracted pharmacy's nurse consultant (NC) stated that her last visit to the facility was on [DATE]. NC stated that she does not have her report available regarding the visit to the facility on [DATE], and cannot comment on whether or not she discarded the control solution for the glucometers. NC stated that the pharmacy's policy is to immediately replace anything they discard or remove from the facility or medication carts, to ensure the facility was not without those items. NC states she does not know why the facility does have control solution available for testing their glucometers as they should have it at all times. b. On [DATE], at 11:40 AM, LVN 1 was observed disinfecting the AgraMatrix [MEDICATION NAME] Pro glucometer with Solimo brand disinfectant wipes. A review of the Solimo disinfectant wipes label indicated that the active ingredients were several ammonia-based disinfectants which were containing Polyhexanide amd/or [MEDICATION NAME]. During an interview, LVN 1 stated that this is the only form of disinfectant they use for their glucometers and other equipment. According to AgraMatrix [MEDICATION NAME] Pro glucometer manufacturer's guidelines on page 46, in order to avoid damage to the AgraMatrix [MEDICATION NAME] Pro System, to use only cleaners or disinfectants with the following active ingredients: water, soap, 70 percent (%) or less of [MEDICATION NAME] Alcohol, or a 1:10 dilution of Sodium Hypochlorite (household bleach) in water (prepared fresh before each cleaning). A review of AgraMatrix [MEDICATION NAME] Pro glucometer manufacturer's guidelines, page 47, under Harmful Substances indicated that Polyhexanide, [MEDICATION NAME], and prepared solutions or wipes containing a mixture of bleach and detergent could damage the AgraMatrix [MEDICATION NAME] Pro System and are not recommended for use. The survey team identified the facility did not have a control solution available to ensure accuracy for two of two glucometers, used to check blood sugar level for 16 Insulin dependent residents, and identified the glucometers were not checked for accuracy for 10 consecutive days from [DATE] to [DATE] and failed to disinfect their glucometers in accordance with the manufacturer's guidelines to prevent distraction of the glucometers which in turn could affect the accuracy of the glucometers reading and provide with inaccurate results of blood sugar test. An immediate Jeopardy (IJ) was called on [DATE] at 5:11 PM in the presence of administrator (ADM) and director of nursing (DON). The administrator provided a plan of correction that included the following: 1. The facility's contracted pharmacy to immediately replace their current model of glucometers with a new model that could be disinfected with their current supplies. 2. The facility's contracted pharmacy to deliver all related supplies, including control solution, to the facility as soon as possible. 3. DON to provide in-service training to all licensed staff who perform blood sugar testing on the operation of the new model to include the following: a. The licensed nurse on duty immediately. b. All other licensed staff by [DATE]. c. The licensed nurse on 11 PM to 7 am shift to calibrate glucometers every 24 hours. d. The licensed nurses to disinfect glucometers per the manufacturer's guidelines after each use. e. The licensed nurses to maintain a record of glucometers calibration results in a log book. 4. DON to monitor the results of the log book daily and randomly check the accuracy of the glucometer. 5. Identified problems or concerns would be brought to the attention of the Quality Assurance and Performance Improvement committee (QAPI - a committee of individuals charged with proactively attempting to identify and solve the facility's problems). On [DATE] at 7:00PM, the contracting pharmacy delivered two new Assure glucometers, a different model than previously used. A review of the manufacturer's instructions indicated that the disinfectant supplies used by the facility would be acceptable to use for this model. The facility performed a control solution test on both glucometers and both glucometers indicated that they were reading accurately. After the immediate action plan was accepted and verified on site, on [DATE] at 07:14 PM, the IJ was lifted during a meeting with the administrator and DON.

Based on observation, interview, and record review, the facility failed to: 1. Ensure a [MEDICAL CONDITION] medications (medications that affect brain activities associated with mental processes and behaviors) used to treat specific residents' conditions as diagnosed and documented in the clinical record for 14 out of 27 residents taking [MEDICAL CONDITION] medications (1, 5, 7, 16, 20, 21, 23, 24, 25, 28, 31, 36, 37, 88). 2. Ensure all orders for as needed ((PRN) - not given on a regular schedule) [MEDICAL CONDITION] medications were limited in duration to only 14 days for 10 out of 27 residents (12, 13, 16, 20, 25, 26, 34, 36, 37, 88). 3. Ensure residents' medication regimen was free from therapeutic duplication (using more than one medication from the same pharmacological class without documented clinical rationale) for 7 out of 27 residents (3, 8, 26, 28, 31, 35, 36). 4. Perform a gradual dose reduction ((GDR) - a periodic attempt to taper a medication in order to use the lowest effective dose or to discontinue the medication) or document clinical rationale as to why an attempt would be clinically contraindicated (likely to cause harm) for 21 out of 27 residents receiving [MEDICAL CONDITION] medications (1, 2, 3, 5, 7, 8, 10, 12, 13, 14, 20, 21, 23, 24, 25, 26, 28, 31, 34, 35, 36). 5. Adequately monitor residents for target behaviors (problem behaviors related to a resident's diagnosed condition) and/or adverse effects (unwanted, uncomfortable, or dangerous effects which may impair a resident's ability to function at their highest possible level of physical, mental, and psychosocial well-being) related to [MEDICAL CONDITION] medication use for 10 out of 27 residents receiving [MEDICAL CONDITION] drugs (1, 2, 7, 8, 10, 17, 31, 34, 35). These deficient practices placed the residents at risk for experiencing adverse effects related to the use of [MEDICAL CONDITION] medications including, but not limited to, dizziness, drowsiness, constipation, movement disorders, and death. Findings: 1. According to Resident 21's clinical record the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) A review of Resident 21's most current physician orders [REDACTED]. According to Resident 21's Psychotherapeutic Drug Summary Sheet the resident had no documented episodes of either target behavior since (MONTH) of (YEAR). There was no documented evidence the side effects of the medications were monitored or the use of non-pharmacological interventions to control target behaviors was attempted. According to the Minimum Data Set (MDS), a standardized assessment and care screening tool, the last GDR attempt for the [MEDICATION NAME] was on 9/22/18 and had not been documented as clinically contraindicated. However, review of Resident 21's clinical record indicated that the last documented attempt at a GDR for [MEDICATION NAME] was dated 2/6/18 and was declined due to benefits outweighed the risks with no further clinical rationale or insight given. According to Resident 21's clinical record the last GDR documentation for [MEDICATION NAME] was dated 1/23/2018. A review of the most recent psychiatric consult notes dated 3/2018 to 6/2018, indicated Resident 21 had a [DIAGNOSES REDACTED]. In these notes there were not documented any diagnostic criteria to support the [DIAGNOSES REDACTED]. According to monthly psychiatric consult the dose reduction was likely to impair Resident 21's functions or cause psychiatric instability, There was no additional clinical rationale documented. No more recent psychiatric notes for Resident 21 could be located. On 03/21/19 at 5:50 PM, during an interview, the director of staff development (DSD) stated that she described Resident 21's behaviors as mostly screaming and fidgeting with her hands. On 03/21/19 at 6:07 PM, during an Interview, Resident 21's responsible party ((RP) - someone designated by the resident to make decisions on their behalf) stated that he was not really familiar with [MEDICATION NAME] and did not remember being informed about side effects or risks regarding the use of [MEDICATION NAME]. RP stated that Resident 21's behaviors were what made it difficult for him to continue to care for her himself but does not believe they represented a danger to herself other residents. The RP stated that he was not aware of the facility used any non-pharmacological interventions (any attempt to control target behaviors by actions other than medication) for the resident. The RP stated he believes the [MEDICATION NAME] was mostly used to make it easier to provide care for the resident. The RP stated that other than depression, the resident had no history of other mental illnesses such as [MEDICAL CONDITION] or [MEDICAL CONDITION] disorder. On 03/22/19 at 8:53 AM, during an interview, a certified nurse assistant (CNA 4) stated that she provided care to Resident 21 on an inconsistent basis. CNA 4 stated that the CNAs are often shifted around between residents and she only cares for Resident 21 around once per week. CNA 4 stated that Resident 21 displayed behaviors every morning. CAN 4 stated when staff touch her the resident wants to scream. CNA 4 stated that the resident is calm later when she is in her chair and feels like the medication, she receives helps Resident 21 to stay calm makes and it easier for the facility's staff to provide care. CNA 4 stated that she does not believe Resident 21's target behaviors represented a risk of harm to herself or other residents or staff. CNA 4 stated that the resident's behaviors not aggressive. On 03/22/19 at 08:58 AM, during an interview, the licensed vocational nurse (LVN 1) stated she had taken care of Resident 21 for years and was consistently assigned to take care of the resident during 7 AM to 3 PM shift. LVN 1 described Resident 21's behaviors as being agitated, crying, and resistant when CNAs are providing care. LVN 1 stated the resident displays these behaviors every day. LVN stated she only documents when the resident is having the behaviors episode. When the resident is having them, she administers to the resident medication. If the behaviors occur at other times, LVN 1 stated she does not document about it anywhere in the resident's clinical record. LVN 1 stated that she does not believe Resident 21's behaviors present a danger to herself or others but believes that the medications she receives make it easier for staff to provide care to the resident. LVN 1 stated that non-pharmacological interventions used to control the target behaviors included to check if the resident was wet but does not know about any other non-pharmacological interventions from the resident's care plan. LVN 1 confirmed that attempts to use non-pharmacological interventions were not documented anywhere in the resident's clinical record, did not know where to document them or that it was even required to do so. 2. According to Resident 26's clinical record the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 26's physician order [REDACTED]. treat mental illness) 0.5 mg every six hours as needed for anxiety manifested by restlessness. A review of Resident 26's clinical record indicated that there was no documented evidence the resident ever received a psychiatric evaluation at any time during her stay at the facility. The clinical record did not contain diagnostic information, clinical insight, adequate physician's notes, or other rationale to support the [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. This order was not discontinued, restarted, or limited to 14 days at any time. According to the review of Resident 26's clinical record there was no documented evidence to indicate an attempt to perform a GDR or to provide clinical rationale for GDR contraindication for any of Resident 26's four [MEDICAL CONDITION] medication was done. A review of the behavior data on the [MEDICAL CONDITION] Drug Summary Sheets indicated that since (MONTH) (YEAR), Resident 26 had five episodes of restlessness, zero episodes of crying spells, zero episodes of [MEDICAL CONDITION] and three episodes of auditory hallucinations. There was no documented evidence the side-effects of the medication was monitored or the use of non-pharmacological interventions to control target behaviors was attempted before medication administration. On 03/22/19 at 09:19 AM, during an interview, CNA 5 stated Resident 26's target behaviors were that sometimes she responds to questions with answers that do not make sense and that sometimes she is talking to other people who are not there and also sees things that are not there. CNA 5 denied that Resident 26 cannot sit still or has crying spells. CNA 5 stated she informs the licensed nurse if she witnesses any of the target behaviors. CNA 5 stated the resident was easier to care for due to the medications the resident was receiving as she follows instructions better. CNA 5 stated the resident functions normally when engaged in activities and does not display any of the target behaviors. On 03/22/19 at 09:27 AM, during an interview, LVN 1 stated [MEDICATION NAME] was given as needed for the resident's confusion and prevent from falling when trying to get up in bed. LVN 1 stated Resident 26 gets sleepy after administration of [MEDICATION NAME] and that it makes her calm. LVN 1 stated the resident display restlessness about once per week, crying spells occur about twice a week. LVN 1 stated sometimes Resident 26 wants to finish conversations with people who are not there and asks us to wait for her to finish. LVN 1 stated the resident ''hears cats a lot of the time which are not there. LVN 1 stated that these behaviors only occur about once per week. LVN 1 stated that she only documents the behaviors if they are occurring at the same time, she is giving Resident 26 her medication, even if the CNAs or other staff tell her about the behaviors at other times. LVN 1 stated that the facility's staff try to convince Resident 26 to go to activities as a non-pharmacological intervention as she is calmer when she is around the other residents. LVN 1 stated that she does not document attempts to use non-pharmacological interventions anywhere in the clinical record. LVN 2 stated that she believes Resident 26's behaviors could be a risk to her own safety but not to other residents and that she believes that the resident would be worse without the medications. LVN 1 stated that the medications make it easier for the staff to provide care. 3. According to Resident 7's clinical record the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 7's most recent physician order [REDACTED]. A review of Resident 7's Psychotherapeutic Drug Summary Sheet indicated that in (MONTH) 2019, the resident had 37 episodes of restlessness and 30 episodes of sad facial expression. According to the physician's note, dated 2/19/19, Resident 7 had no depression and no anxiety. According to Resident 7's clinical record there was no documented evidence the psychiatric consult evaluated the resident and the clinical rationale to support Resident 7's psychiatric [DIAGNOSES REDACTED]. A review of Resident 7's [MEDICAL CONDITION] Medications Gradual Dose Reduction forms for [MEDICATION NAME] and Klonopin, signed by the physician, did not contained a date or any documentation that the GDR was initiated for the medication or that an attempt was clinically contraindicated. On 03/22/19 at 11:51 AM, during an interview, CNA 4 stated that she provides care for Resident 7 most days of the week. CAN 4 stated the resident seldom having episodes of restlessness. CNA 4 stated that she does observe Resident 7 with a sad facial expression that she attributes to her feet and not able to walk as well for the last two or three weeks. CNA 4 stated that she does report the sad facial expression to the licensed nurse when she observes it. On 03/22/19 at 11:56 AM, during an interview, LVN 1 stated she observes the resident's restlessness as screaming at the nurses, being easily angered, and complaining about a lot of things. LVN 1 stated she only documents the target behaviors if they occurred at the same time, she is giving Resident 7 her medication. LVN 1 stated the medications help the resident to function better. LVN 1 stated without medication Resident 7 would be more difficult to care for. On 03/22/19 at 12:10 PM, during an interview, Resident 7 stated that she is taking Klonopin because of a nurse that was giving her a hard time and because of general distress with the facility due to the way the DON treats her. Resident 7 stated she believes [MEDICATION NAME] was used to treat a neurological condition and not depression. Resident 7 stated she does not think she is depressed and does not remember signing an informed consent or being educated regarding the side effects and risks of new [MEDICAL CONDITION] medication. Resident 7 stated that she has only been evaluated by a psychiatrist at this facility once since she has been here in (MONTH) ?after she broke up with her boyfriend. Resident 7 stated she was not aware if her neurologist and the primary care medical team at the facility were working together or communicating to coordinate her care. Resident 7 stated rarely sees her physician (MD 1) or nurse practitioner (NP 1) in the facility. 4. On 03/21/19 at 11:01 AM, during a review, Resident 35's clinical record indicated that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. to regulate blood sugar.) A review of Resident 35's physician's orders [REDACTED]. [MEDICAL CONDITION] manifested by yelling and fighting with the staff, on 9/20/17 [MEDICATION NAME] (a mediation used to treat depression) 10 mg every day for depression manifested by sadness and isolative behavior and on 11/16/17 Klonopin (a medication used to treat mental illness) 1 mg twice daily for [MEDICAL CONDITION] manifested by yelling, screaming, and hitting staff. A review of Resident 35's most recent Psychiatric Evaluation dated 11/28/18 had the same assessment and plan as several previous visits and did not address the target behaviors or provide a clinical rationale for the use of three antipsychotic (a class of medications used to treat mental illness) medications together to treat similar behaviors. No other physician's progress notes or other documentation could be found to address the therapeutic duplication or to provide diagnostic criteria or clinical rationale to support Resident 35's psychiatric diagnoses. A review of Resident 35's Psychotherapeutic Drug Summary Sheet indicated under the Behavioral Data for combative behavior, yelling, screaming, and hitting staff, that the documentation of the number of episodes occurring between (MONTH) (YEAR) and (MONTH) 2019 was not consistent across the four medications being used to control these behaviors (i.e. since the target behaviors are all the same, we would expect to see the same number of episodes documented for all four medications). According to Psychotherapeutic Drug Summary in (MONTH) 2019, the number of episodes documented under [MEDICATION NAME] was zero, for Klonopin, it was 18, for [MEDICATION NAME], it was two, and [MEDICATION NAME] simply did not have a behavioral monitoring sheet within the clinical record. No documentation for the monitoring for side effects or the use of non-pharmacological interventions to control target behaviors could be found within the clinical record. A review of the GDR documentation indicated he dose of [MEDICATION NAME] was reduced from 100 mg twice daily to 50 mg twice daily on 9/19/18. On the same date, the GDR for [MEDICATION NAME] and [MEDICATION NAME] were declined with no specific clinical rationale provided. There was no physician's notes available with documentation why the dose of [MEDICATION NAME] could be reduced but not the other medications. Also, there was no documentation regarding a GDR attempt for [MEDICATION NAME] or Klonopin was available within the resident's clinical record. On multiple occasions throughout the survey and usually multiple times per day, Resident 35 was observed screaming, yelling, and cursing at staff who were trying to provide care to her. On 03/22/19 at 10:24 AM, during an interview, CNA 4 stated that she provides care to Resident 35 one to two times per week. CNA 4 stated the resident is okay some days, but is aggressive on others and that they usually leave the resident alone if she is aggressive and come back later to provide care. CNA 4 stated the resident's aggressive behaviors occur mostly when staff tries to provide care, but it can happen at any time. CNA 4 stated that Resident 35 tried to hit staff and yells things like get out of my face, leave me alone and sometimes swears at the staff when staff try to provide care. CNA 4 stated staff try to diffuse her behaviors by finding out what the resident wants and by giving her snacks. CNA 4 stated that snacks usually help to control her behaviors. CNA 4 stated she reports the resident behaviors to the licensed nurse right away whenever she observes it. On 03/22/19 at 11:00 AM, during an interview, LVN 1 stated that Resident 35 has aggressive episodes almost every day. LVN 1 stated the resident's behaviors are non-stop talking and yelling and trying to get out of bed. LVN 1 stated that she only documents the behaviors if they are occurring at the time when she is providing the resident her medication, even if the CNAs tell her that they occur at other times. LVN 1 could hot explain why there were different numbers of behavioral episodes documented for the different medications used for the same thing. LVN 1 stated that sometimes giving Resident 35 showers or food, drinks, cookies, etc . helps to calm her down. LVN 1 stated she does not document any non-pharmacological interventions used to control Resident 35's target behaviors. LVN 1 stated that she believes that the medications prevent the resident from causing harm to herself, other residents or staff and believes that the resident would get worse without the medications. 5. According to Resident 23's clinical record, the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) A review of the Resident 23's physician's orders [REDACTED]. According to the most recent psychiatric consult note dated 3/27/18, Resident 23 had episodes of crying spells, and feeling depressed, however there was no documentation about hitting behavior, what or who she was hitting, or any other [DIAGNOSES REDACTED]. The psychiatric consult note did not provide any diagnostic criteria or clinical rationale to support Resident 23's psychiatric diagnoses. There was no other physician' note or documentation available within the clinical record to provide a clinical rational for the resident's psychiatric diagnoses. A review of the Psychotherapeutic Drug Summary Sheet under behavioral data indicated that there were no documented episodes of hitting since (MONTH) of (YEAR) and no episodes of sad face since (MONTH) of (YEAR). Further review of the clinical record indicated that there was no documentation regarding side effects of the medication or the use of non-pharmacological interventions attempted to control target behaviors. A GDR was declined on 12/27/18, for [MEDICATION NAME], however no specific clinical rationale was provided and documented. According to Resident 23's clinical record there was no documented evidence an attempt was made to perform a GDR or document clinical rationale for why an attempt would be contraindicated for the [MEDICATION NAME]. On 03/22/19 at 9:49 AM, during an interview, CNA 3 stated she takes care of Resident 23 around 40 percent (%) of the time she works at the facility as her resident assignments change frequently. CNA 3 stated that Resident 23 was usually pretty calm and mostly likes to stay in her room and watch television, although sometimes she enjoys going to activities. CNA 3 stated she has not observed Resident 23 hitting any staff or other residents although she does yell and scream from time to time. CNA 3 stated that providing Resident 23 with additional food usually resolves those behaviors. CNA 3 stated she has not observed Resident 23 with sad face and stated the resident usually is sleepy or acts angry if she is hungry. CNA 3 stated that Resident 23's medications make her easier to talk to. On 3/22/19 at 10:01 AM, during an interview, LVN 2 stated she has taken care of Resident 23 for about a year. LVN 2 stated sometimes Resident 23 throws things at staff but this has not occurred in several months. LVN 2 stated that she observed Resident 23 with a sad face three to four times weekly although she does not document this anywhere in the clinical record. LVN 2 stated that the staff use multiple techniques to help make calm Resident 23 including: making sure the environment is safe, talking to her, or taking her to the restroom. LVN 2 confirmed that these non-pharmacological actions are not documented anywhere within the resident's clinical record. On 03/19/19 at 11:31 AM, during an interview, the DON stated I am sorry it is such a mess when referring to the facility's lack of organization and inability to produce records or documentation in a timely manner. The DON stated that while she was out on leave for three months, many things that should have been done did not get done. On 03/21/19 at 9:15 AM the DON was requested to provide the pharmacist's monthly medication regimen reports ((MRR) - the consultant pharmacist's monthly report to the facility's medical staff that identifies potential issues with the residents' drug therapy). A review of MRR for Resident 7, 21, 23, 26 and 35, indicated that in some cases the consultant pharmacist (PC) wrote specific recommendations to correct some of the lapses in documentation or regulatory compliance and in some cases did not. The PC provided recommendations to the prescribing physician to perform a GDR on certain medications, but not for all medications that would require it. There was no documentation with recommendations from the consultant pharmacist addressing questionable uses of [MEDICAL CONDITION] medications, PRN orders for [MEDICAL CONDITION] medications [MEDICATION NAME] longer than 14 days, therapeutic duplication in which the resident was prescribed multiple antidepressants (a group of medications used to treat depression) or antipsychotics (a group of medications used to treat mental illness) simultaneously without a clear clinical rationale, or the failure to properly document target behaviors, perform side-effect monitoring, or document non-pharmacological interventions in the residents' clinical records as required by their care plans. On 03/21/19 at 11:20 AM, during a telephone interview, the PC stated that in her professional opinion, [MEDICAL CONDITION] manifested yelling, screaming, and resisting care and restlessness are absolutely not adequate indications for the use of [MEDICAL CONDITION] medications, however we would need to clarify that with the psychiatrist directly. The PC stated that she knows some of the residents do need the medications because their behaviors are managed well by the medications. When asked if she addresses things like GDRs not being performed or the use of PRN orders for [MEDICAL CONDITION] medications for longer than 14 days in her reports, the PC responded that all she can do is give recommendations to the respective physicians. On 03/21/19 at 12:32 PM, during an interview, the DON stated that psychiatric evaluations were not done routinely for all residents receiving [MEDICAL CONDITION] medications. The DON stated there was nowhere else in the facility that psychiatrist's notes would be kept other than the resident's clinical record. On 03/22/19 at 11:13 AM, during an interview, the DON stated most of the residents were admitted with their current [MEDICAL CONDITION] drug therapy, however the facility will make a call to the attending physician for any behaviors such as hitting, yelling, refusing care, or not letting anyone in the room. The DON stated that any time a resident has these behaviors, the facility performs a reassessment of the resident and holds a care plan meeting to guide how the facility will manage the behaviors. The care plan should include monitoring for the behaviors and side effects of the medications as well as non-pharmacological interventions such as providing personalized care and asking the resident what they need. The DON stated that the nurses are required to document behaviors or side effects of [MEDICAL CONDITION] medications whenever they are observed. The DON also stated that the facility's nurses are required to document any attempts to use non-pharmacological interventions to address target behaviors and whether they were successful or not within the resident's clinical record. The DON stated that she cannot explain why behaviors, medication side effects, or non-pharmacological interventions were not consistently documented. The DON stated she does not know why certain residents receive psychiatric evaluations while others do not however agreed that certain residents who have not received them probably require them. On 03/22/19 at 12:34 PM, during an interview, the social services director (SSD) stated she was responsible for arranging psychiatric visits for a resident who required it and currently there are about 15 residents for whom an arrangement for psychiatrist visits needed. The SSD stated that some residents see psychiatrist outside the facility due to choice or insurance requirements, however for most residents the physician assistant (PA) from the psychiatrist's office visits the residents on site. The SSD stated the PA will come every few months, however she cannot remember the last time the psychiatrist came to the facility. The SSD stated the consult notes would be emailed to her after the visits, and currently she only has notes since (MONTH) or (MONTH) from last year, (YEAR). The SSD stated that as the notes have been emailed to her, they have been printed and given to the medical records department to be integrated into the residents' clinical records. A psychiatrist's notes, more recent than (MONTH) (YEAR) were requested from the SSD, however were not provided. The SSD also stated that during quarterly care planning meetings for the residents, target behaviors and non-pharmacological interventions are discussed with the clinical team and with input from the residents themselves or their responsible parties. The SSD stated that the resident's care plans for managing target behaviors include documenting the uses of non-pharmacological interventions in order to manage them and whether or not they were ultimately successful. A review of the facility's undated policy entitled Psychotherapeutic Drugs indicated that the policy had not been updated in order to guide compliance with the requirements for the use of [MEDICAL CONDITION] drugs since the most recent update to the State Operations Manual (SOM - a reference manual of the rules and regulations for operating a nursing home) in (MONTH) of (YEAR). Notably absent from the facility's policy was anything addressing the proper length of PRN orders, any mention of gradual dose reductions, or guidance on the proper prescribing of antipsychotic medications. On 03/22/19, at 1:58 PM, during an interview, the administrator stated that a resident care policy committee was responsible for the adoption of the facility's policies and meets annually, however may meet quarterly as needed when particular issues were identified. The administrator stated that the PC was responsible to help the facility adopt policies to guide compliance with the pharmacy regulations and attends the committee meetings quarterly. The administrator stated that the last meeting was [DATE]/15/19 but the provided sign-in sheet indicated that the PC was not present. The last committee meeting for which the PC's attendance could be verified was on 10/23/18 for an infection control meeting. The administrator stated that they did not discuss any pharmacy policy and procedures during that meeting as the topic was strictly infection control. The stated that he does not know when last time the facility's [MEDICAL CONDITION] drug use policy was updated. The administrator stated that he did not know when the last time the SOM was updated and does not like the new SOM in electronic only format. On 03/26/19 at 11:39 AM during an interview, the nurse practitioner (NP) stated that she works to provide primary medical care to the facility's residents with the medical director (MD 1). The NP stated that she agrees that there are several questionable uses of [MEDICAL CONDITION] medications in the facility. The NP stated that she does not understand why in many cases there were no physician's notes present in the residents' clinical records. The NP stated that the notes were typed by the provider electronically after each visit and should be integrated in to the record. The NP stated she relies on the psychiatric consult notes to direct psychiatric care and prescribe [MEDICAL CONDITION] drugs and stated that she does not specifically order psychiatric consults for the residents. The NP stated she does not know why some residents receive psychiatric consults while others do not. The NP stated that there is no communication between primary care medical staff at the facility and the professionals who provide psychiatric care for the residents. When asked about communication between psychiatrist office and herself, the NP stated there is none. The NP stated that most psychiatric medications were continued when residents first admitted . The NP stated the residents were sup(TRUNCATED)

Based on interview, and record review, the facility nursing staff failed to assess and report the skin condition of one sampled resident (Resident 1) upon admission to the facility and transfer to a general acute care hospital (GACH), which had the potential to result in the delay of care. Findings: During a review of the clinical record for Resident 1, the Record of Admission indicated the resident was readmitted to the facility on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. A review of the Comprehensive Resident assessment dated (MONTH) 30, (YEAR), the licensed nurse identified two pressure sores. A stage III on the sacral and a deep tissue injury (DTI) on the left heel. A review of the Minimum Data Set (MDS) Resident Assessment and Care Screening dated (MONTH) 6, (YEAR), Section M there was documentation of the pressure sore(s) or other skin problems. A review of the Skin Integrity Sheet dated (MONTH) 6, (YEAR), documented a sacral pressure stage III, 8 X 6 centimeters (cm) and a left heel DTI, 6 X 5 cm. A review of the Licensed Personnel Weekly Progress Notes and Licensed Nurse Record from (MONTH) 30, (YEAR) to (MONTH) 2, (YEAR), the licensed nurse documented on (MONTH) 30, (YEAR), the sacral stage II pressure sore. The license nurse documented the resident was seen by the wound physician on (MONTH) 13, (YEAR), at 2:30 p.m., (MONTH) 19, (YEAR), at 3 p.m., (MONTH) 24, (YEAR), at 2 p.m., and on (MONTH) 1, (YEAR), at 2 p.m. There was no documentation of the left heel DTI or any other skin conditions requiring treatment. A review of the physician orders [REDACTED]. However, there was no order to address the left heel DTI. A review of the Wound Consultant report dated (MONTH) 13, (YEAR), (MONTH) 19, (YEAR), (MONTH) 24, (YEAR), and on (MONTH) 1, (YEAR), the consult identified one stage III pressure sore on the sacral. A surgical debridement was performed and treatment orders written. A review of the Resident Transfer Record dated (MONTH) 2, (YEAR), the licensed nurse documented the sacral pressure sore as stage IV, a gastrostomy tube, and an indwelling catheter. A review of the GACH records dated (MONTH) 3, (YEAR), at 2:15 p.m., the wound nurse documented a stage IV sacral pressure sore, DTI left hip and left outer heel and ankle pressure sore. During an interview and record review with the director of nurses on (MONTH) 28, (YEAR), at 11:15 a.m., an inquiry was made regarding the documentation of the left heel DTI on the Comprehensive Resident assessment dated (MONTH) 30, (YEAR), and the lack of continuous assessment and/or treatment orders. She stated the facility monitored the area for any changes. However, she was not able to locate documented evidence of the physician being notified of the left heel. The facility policy and procedure titled Pressure Sore Management dated (MONTH) 1992, indicated if pressure sore(s) are present the documentation of findings will be entered in the nursing progress notes, care plan, weekly pressure sore report and pressure sore management record and the physician will be contacted for appropriate treatment.

Based on interview, and record review, the facility failed to ensure a resident with history of aggressive behavior did not physically abuse one of 11 sampled residents by failing to respond timely, and to provide adequate supervision during and after the incident. (7 and 9) This deficient practice resulted in Resident 7 being scratched on the face and the arms, which caused her to be fearful and be afraid. Findings: During an initial tour on July 19, 2016 at 2 p.m., a Licensed Vocational Nurse (LVN 4) stated Resident 9 was transferred out because she got in to a fight with her roommate (Resident 7). According to the admission record Resident 7 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a standardized resident assessment and care screening ) dated April 7, 2016 indicated Resident 7 had no impairments with her daily-decision making, required supervision (oversight and encouragement) for activity of daily living and was totally dependent on staff for ambulation. According to the admission face sheet, Resident 9 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED].), and anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The resident required a gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach), and had dysphagia (a language disorder that affects a person's ability to communicate). A review of the Resident 9's psychiatric re-evaluation dated May 17, 2016 report indicated the resident was irritable, labile (rapid shifts in outward emotional expressions) and combative (ready or eager to fight). According to a progress note dated July 16, 2016 indicate Resident 9 was very alert and educated, but was resistant to being assisted. The physician's orders [REDACTED]. [MEDICATION NAME] 25 milligram (mg) three times a day for [MEDICAL CONDITION] manifested for combativeness, [MEDICATION NAME] 5 mg per milliter (ml) liquid (give 5 ml) for depression manifested by sadness and isolative behavior, Klonopin 0.25 mg through the GT. A review of the licensed personnel progress note dated July 2, 2016 for 11-7 p.m., shift indicated Resident 9 was alert, agitated, refusing care, combative towards staff, non-compliant with medication, restless, and had uncontrollable behavior. A review of the licensed personnel progress note dated July 2, 2016 at 7 a.m., indicated LVN 4 received Resident 9 agitated, combative with staff, and she was trying to get up on the bed. LVN 4 documented she informed the primary physician. The physician's orders [REDACTED]. The order also indicated to transfer the resident to a General Acute Care Hospital (GACH). During an interview with Resident 7 on July 15, 2016 at 8:30 a.m., the resident stated her roommate (Resident 9) would get upset when she called staff to assist the resident when she was agitation, or looked like she was going to get out of bed. Resident 7 stated on July 1, 2016 around 10:30 p.m., during the 3 to 11 p.m., shift she noticed Resident 9 trying to climb out of her bed, so she placed the call light on. Resident 9 then used her bedside table to get to her, by grabbing the edge of her bed. Resident 7 stated she took her backscratcher and banged on the bedrails at the same time screaming for help, but no one came. Resident 7 stated Resident 9 scratched her face and arms. Resident 7 stated after the attack, CNA 6 came in and asked what happen to her face. CNA 6 left to get help. Resident 7 stated she was scared and pleaded with CNA 6 not to leave her alone with Resident 9, but CNA 6 left her alone in the room. Resident 7 stated she was afraid of Resident 9 knocking her set (Television) over to the floor. Resident 7 stated she believed Resident 9's feeding tube prevented her from getting to her television. Resident 7 stated it took 4 employees (LVN 5, CNA 6, CNA 7, and CNA 8) to tie Resident 9 with the sheet while Resident 9 was fighting them. Resident 7 stated CNA 7 knew the resident was aggressive but still left her in the room all night with Resident 9. Resident 7 stated even the CNA's say Resident 9 was strong. On July 15, 2016 at 8:30 a.m., Resident 7 further stated after Resident 9 attacking her, she asked the staff for a phone so the police could be called. The resident stated no one brought me a phone. Resident 7 stated Resident 9 was so aggressive that at times the staff would tie her and her hands with a sheet to hold her down. Resident 7 stated she was fearful. Resident 7 stated that thin (sheet) was not going to hold Resident 9 away from her. Resident 7 stated during the incident she asked the facility to call the police. A review of the records failed to indicate the facility ever contacted the police department about the physical abuse. According to the physician's orders [REDACTED]. The order indicated to clean left side of the resident's face and left forearm with normal saline, pat dry, apply [MEDICATION NAME] (antibiotic) ointment, and leave it open to air for 14 days. During an interview with LVN 4 on July 26, 2016 at 11:20 a.m., stated Resident 7 had fresh scratches on her face and arms, so she reported the incident between Resident 7 and 9 to the Registered Nurse (RN 2). RN 2 works every other weekend. LVN 4 was asked if she consider the incident as abuse, she stated I'm not sure because it was resident to resident, as far as she knew resident to resident was not considered abuse. During an interview with the DON on July 26, 2016 at 11:40 a.m., she stated the incident between Resident 7 and Resident 9 was not considered abuse. The DON stated because Resident 9 was [MEDICAL CONDITION] and Resident 7 had [MEDICAL CONDITION] (refers to an abnormal condition of the mind described as involving a loss of contact with reality). The DON stated the facility's inter-disciplinary team (IDT), which included the Dietary, Social Service Director (SSD), and Activity director, all agreed it was not abuse. The DON stated CNA 6 reported Resident 7 had scratches, and on July 1, 2016 LVN 5 reported the resident was claiming she was scratched by her roommate. During an interview with Director of Staff Development (DSD) on July 26, 2016 at 12:15 p.m., stated it was reported to her that Resident 7 tried to shoo away Resident 9 with her back scratcher, but could not remember who told her. The DSD stated the CNA's found Resident 9 at the foot of Resident 7's bed. DSD stated the incident between Resident 7 and Resident 9 was considered abuse. DSD was responsible for direct staff training about the components on abuse. During an interview with CNA 8 on July 26, 2016 at 4:45 p.m., stated on the day of the incident she heard CNA 6 screaming for help, but did not really remember that night, because she was in a rush trying to get back to her station (station 2). CNA 8 stated LVN 5 knew what happen. CNA 8 stated Resident 7 showed her the scratch on her face, and saw Resident 9 on the floor. During interview with CNA 6 on July 26, 2016 at 4:45 p.m., on the day of the incident he heard Resident 7 screaming, and found the resident with scratches on her face. CNA 6 was asked why he left Resident 7 alone with Resident 9, he stated he had to go get help, and the resident could have hurt him too. CNA 6 stated he never thought Resident 9 would get up and attack Resident 7. CNA 6 stated CNA 8 and CNA 7 helped put Resident 9 back to bed, using a restraint but was not sure. A review of an undated facility's policy indicated to provide a safe environment for residents. Each resident has the right to be free from verbal, sexual, physical, mental and financial abuse, neglect or mistreatment, corporal punishment and involuntary seclusion.