Every finding on record at Park Avenue Healthcare & Wellness Center

Based on observation, interview, and record review, the facility failed to ensure eight of eight sampled residents (Resident 228, 159, 191, 19, 117, 40, 205, and 221), were treated with dignity when: A. Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 failed to knock on Resident 228 and Resident 159's door prior to entering the residents' shared room. B. The Housekeeping (HK) and CNA 2 failed to knock on Resident 191, 19 and 117's door prior to entering the residents' shared room. C. CNA 4 and Registered Nurse (RN) 2 failed to draw (fully close) Resident 40's privacy curtains completely around Resident 40's bed while changing Resident 40's soiled diaper.D. Resident 221 and Resident 205 were not provided with adequate information when the facility notified Resident 221 and Resident 205 about a room change.This deficient practice could potentially result in Residents 228, 159, 191, 19, 117, and 40 feeling bothered, startled, invaded and humiliated, and the potential to negatively impact the residents' psychosocial [the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment]) well-being. The deficient practice resulted in Resident 205 feeling scared and Resident 221 feeling bugged, annoyed, and frustrated about notification of the room change. Additionally, the deficient practice had the potential to affect Residents 205 and 221's psychosocial well-being. Findings:A. During a review of Resident 228's Face Sheet (FS - admission record), the FS indicated Resident 228 was admitted to the facility on [DATE] with multiple diagnoses including sepsis (a life-threatening blood infection), unspecified organism, and type 2 diabetes mellitus (DM II - adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing) with other specified complication.During a review of Resident 228's Physician/PA/NP Progress Note (PN), dated 7/27/2026 and timed at 3:25 PM, the PN indicated Resident 228 was A Ox3 (a person is alert and oriented to person, time, and place) and decision capacity was present.During a review of Resident 228's Minimum Data Set (MDS - a resident assessment tool), dated 7/29/2026, the MDS indicated Resident 228's cognitive skills (ability to think and process information) for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 228 was mostly dependent (helper does all of the effort) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 159's FS, the FS indicated Resident 159 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke - loss of blood flow to a part of the brain) affecting right dominant side, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), recurrent, mild.During a review of Resident 159's MDS, dated [DATE], the MDS indicated Resident 159's cognitive skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 159 was dependent with ADL.During a review of Resident 159's History of Present Illness (H&P), dated 7/18/2026, the H&P indicated Resident 159 was nonverbal at baseline due to a prior CVA (cerebrovascular accident - stroke) with aphasia (full loss of language).During an observation on 8/3/2026 at 9:49 AM in Station 1, multiple staff (unidentified) were entering multiple resident rooms without knocking on the doors.During an observation on 8/3/2026 at 10:04 AM, CNA 1 and LVN 1 entered Resident 228 and Resident 159's shared room without knocking on the door.During an interview on 8/3/2026 at 10:09 AM with LVN 1 and CNA 1, LVN 1 stated knocking prior to entering resident (in general) rooms was important to make the resident aware of staff entering and for patient privacy. CNA 1 stated knocking prior to entering resident rooms was important because maybe somebody is peeing.B. During a review of Resident 191's FS, the FS indicated Resident 191 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), unspecified, and unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic (relating to or affected with a psychosis - a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) disturbance, mood disturbance, and anxiety (intense, excessive, and persistent worry and fear about everyday situations).During a review of Resident 191's H&P, dated 1/29/2026, the H&P indicated Resident 191 had the capacity to understand make decisions.During a review of Resident 191's MDS, dated [DATE], the MDS indicated Resident 191's cognitive skills for daily decision making were intact. The MDS indicated Resident 191 was dependent on ADL.During a review of Resident 19's FS, the FS indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including COPD, unspecified, and bipolar disorder (mood swings from one extreme to another), unspecified.During a review of Resident 19's H&P, dated 5/21/2026, the H&P indicated Resident 19 had the capacity to understand and make decisions.During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 19 required substantial/maximal assistance (helper does more than half the effort) to supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) with ADL.During a review of Resident 117's FS, the FS indicated, Resident 117 was admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, unspecified, and anxiety disorder, unspecified.During a review of Resident 117's MDS, dated [DATE], the MDS indicated Resident 117's cognitive skills for daily decision making were severely impaired. The MDS indicated, Resident 117 was mostly dependent with ADL.During a review of Resident 117's H&P, dated 5/14/2026, the H&P indicated Resident 117 did not have the capacity to understand and make decisions.During a concurrent observation and interview on 8/3/2026 at 12:29 PM with the HK and CNA 2, the HK and CNA 2 entered Residents 191, 19 and 17's shared room together without knocking. The HK stated, it was ok to enter the room without knocking if the door was open and only knock when the door was closed. The HK stated, knocking prior to entering was important because residents could be getting changed (cleaned up) and for privacy reasons. CNA 2 stated, knocking on the door prior to entering was important for privacy and for courtesy.C. During a review of Resident 40's FS, the FS indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including quadriplegia (paralysis from the neck down), unspecified, and schizophrenia (a mental illness that is characterized by disturbances in thought), unspecified.During a review of Resident 40's H&P, dated 3/24/2026, the H&P indicated, Resident 40 had the capacity to understand and make decisions.During a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 40's cognitive skills for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated, Resident 40 was dependent to requiring substantial/maximal assistance with ADL.During a concurrent observation and interview on 8/3/2026 at 2:47 PM with CNA 4 and RN 2, CNA 4 and RN 2 were changing Resident 40's soiled diaper with Resident 40's privacy curtains drawn not fully drawn on both sides of Resident 40's bed and Resident 40's private area was exposed. RN 2 stated Resident 40's privacy curtains were not fully closed and it was important to close fully to provide privacy [to Resident 40]. CNA 4 stated Resident 40's privacy curtains were not closed all the way and it was important to close fully for privacy, privacy is very important.During an interview on 8/6/2026 at 9:02 AM with the Assistant Director of Nursing (ADON), the ADON stated, knocking or at least verbalizing prior to entering a resident's room was important for dignity purposes.During a review of the facility's policies and procedures (P&P) titled, Resident Rights, date revised 1/1/2012, the P&P indicated, employees were to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. During a review of the P&P titled, Resident Rights - Quality of Life, date revised March 2017, the P&P indicated, facility staff knocked and requested permission before entering resident's room. The P&P indicated, facility staff promoted, maintained, and protected resident privacy, including bodily privacy, when assisting with personal care and assisting residents as needed.D. During a review of Resident 221's FS, the FS indicated Resident 221 was admitted to the facility on [DATE] with multiple diagnoses including displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing (follow-up care for a broken right hip bone where the pieces moved apart, the skin did not break open, and the bone is healing normally), and unspecified fracture of shaft of humerus (a broken upper-arm bone), subsequent encounter for fracture with routing healing.During a review of Resident 221's H&P, dated 6/26/2026, the H&P indicated Resident 221 had the capacity to make medical decisions.During a review of Resident 221's MDS, dated [DATE], the MDS indicated Resident 221's cognitive skills for daily decision making were intact.During a review of Resident 221's Census List (CL), date range 1/26/2026 to 5/6/2026, the CL indicated Resident 221 had three room locations (changes) since admission.During a review of Resident 205's FS, the FS indicated Resident 205 was admitted to the facility on [DATE] with multiple diagnoses including COPD, and anxiety disorder.During a review of Resident 205's H&P, dated 5/12/2026, the H&P indicated Resident 205 had the capacity to understand and make decisions.During a review of Resident 205's MDS, dated [DATE], the MDS indicated Resident 205's cognitive skills for daily decision making were intact.During an interview on 8/3/2026 at 10:27 AM with Resident 221, Resident 221 stated, Resident 221 had been moved to different rooms four times since Resident 221's admission to the facility.During an interview on 8/5/2026 at 8:42 AM with Resident 221, Resident 221 stated, Resident 221 and Resident 205 were notified of a room change probably beginning of July [2026] by two staff (unidentified). Resident 221 stated the staff did not provide a reason for the move they didn't really give any explanation and Resident 221 stated Resident 221 felt bugged (being annoyed or frustrated) about the room change notification because Resident 221 had already been moved multiple times.During an interview on 8/5/2026 at 9:07 AM with Resident 205, Resident 205 stated, staff did not provide an explanation why Resident 221 and Resident 205 would be moved to a different room. Resident 205 stated, Resident 205 got scared like why? Resident 205 stated, Resident 205 and Resident 221 were happy at the current room and there was no reason for us to be moved. Resident 205 stated, Resident 205 got scared because Resident 205 did not know where Resident 205 would be moved to and who Resident 205's roommate would be in the new room.During a concurrent interview and record review on 8/5/2026 at 9:54 AM with the Social Services Director (SSD), Resident 221's medical records were reviewed. The SSD stated the Social Services Department was responsible for initiating room changes or the licensed nurses (in general) in the absence of a Social Services staff. The SSD stated the form Room Change Notification (RCN), was completed when a resident (in general) was moved to another room. The SSD stated, since Resident 221's admission on [DATE], Resident 221 was previously moved rooms on 1/31/2026 and on 2/2/2026. The SSD stated, there was no documentation indicating the reason or explanation provided to Resident 221's room change on 2/2/2026. The SSD stated, providing residents information for a room change was important since residents needed to be informed for their well-being, for the residents to be prepared and residents could feel depressed having to adjust to a new room when residents were used to the current room, and was a resident's right if residents did not want a room change.During an interview on 8/6/2026 at 8:12 AM with the SSD and the Social Services Assistant (SSA), the SSD stated the RCN was completed right away only if the resident agreed to move. The SSA stated, the SSA and the Administrator (ADM) notified Resident 221 and Resident 205 about a room change during the week of 7/20/2026. The SSA stated, the SSA told Resident 221 and Resident 205 the reason for the move was I only told them it was a room accommodation and the SSA did not explain what a room accommodation meant. The SSA could not provide an explanation why Resident 221 and Resident 205 were selected to be moved to another room. The SSA stated, there was no documentation indicating the reason Residents 221 and 205 were selected for a room change because the move did not actually happen. The SSA stated, providing adequate information about a room change (or plan of a room change) was important because the residents were already adjusted to their room and were comfortable.During an interview on 8/6/2026 at 9:02 AM with the ADON, the ADON stated, room accommodation as the reason for a room change was not enough information to provide to the residents. The ADON stated, staff should educate, discuss and elaborate the reason about the plan to move (change room) the residents because this is their home.During a review of the facility's P&P titled, Resident Rights, date revised 1/1/2012, the P&P indicated, employees were to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. The P&P indicated state and federal laws guaranteed certain basic rights to all residents of the facility that included but not limited to, a resident's right to be informed about what rights and responsibilities he or she has.During a review of the facility's P&P titled, Room and Roommate Change, effective date 6/9/2026, the P&P indicated prior to changing a room or roommate assignment, the resident/resident's representative, and the resident's new roommate would be provided timely notice. The P&P indicated the notice of a room change or roommate assignment would be completed and provided to the resident/resident representative.

Based on observation, interview, and record review, the facility failed to provide services to four of five sampled residents (Resident 18,199, 1, and 14) with limited range of motion ([ROM] full movement potential of a joint).A. For Resident 18, the facility failed to:- Provide Resident 18 with passive range of motion (PROM, moving a joint through its full capacity with the help of an outside force such as a physical therapist, Restorative Nurse Assistant [RNA, nurse assistants with extra training to help residents regain or maintain mobility, strength, and independence in activities of daily living], or a mechanical device, while the person keeps the resident's muscles completely relaxed) exercises to both arms and legs on 8/4/2026 and 8/5/2026 in accordance with the physician's order, dated 7/17/2026 and 7/18/2026. - Apply Resident 18's left elbow splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) and both hand splints on 8/4/2026 and 8/5/2026 in accordance with the physician's order, dated 7/17/2026. Additionally, on 8/6/2026, Certified Nursing Assistant (CNA) 9 applied Resident 18's elbow splint on the right elbow instead of the left elbow.B. For Resident 199, the facility failed to provide RNA services and ensure hand rolls (soft roll positioned in the palm of the hand and fastened with a strap) were applied to Resident 199 on 8/3/2026, 8/4/2026 and 8/5/2026 and in accordance with the physician's order, dated 11/20/2025.C. For Resident 1, the facility failed to maintain complete and accurate clinical records to demonstrate physician-ordered RNA services were provided to Resident 1. D. For Resident 14, the facility failed to provide Resident 14 with passive range of motion (PROM, moving a joint through its full capacity with the help of an outside force such as a physical therapist, RNA, or a mechanical device, while the person keeps the resident's muscles completely relaxed) exercises, failed to apply the right elbow splint, and the right-hand splint from 7/8/2025 to 7/31/2025 in accordance with the Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Discharge Summary recommendations, dated 7/7/2026. These failures had the potential for Resident 18, 199, 1, and 14 to experience a decline in range of motion (ROM, how far a person can move a joint or muscle in various directions) to both arms and legs including the worsening of contractures (stiffening/shortening at any joint that reduces the joint's range of motion), which could affect the provision of care during activities of daily living ([ADLs] basic tasks that individuals perform to maintain their daily lives and independence). Cross reference F725 and F842.Findings: A. During a review of Resident 18's Facesheet (FS, admission record), the FS indicated the facility admitted Resident 18 on 1/23/2024 with diagnoses that included anoxic brain damage (type of acquired brain injury that occurs when cells in the brain do not receive enough oxygen [a colorless gas essential to living organisms]), dependence on respirator (ventilator, a medical machine that moves air in and out of the lungs when the resident cannot breathe well on their own). During a review of Resident 18's care plan (CP), initiated 1/27/2024, the CP indicated Resident 18 had limited physical mobility related to contractures and disease process. The CP indicated Resident 18 was dependent (helper does all of the effort, the resident does none of the effort to complete the activity) on staff for activities of daily living needs. The CP's interventions indicated to provide Restorative Nurse Assistant (RNA, nurse assistants with extra training to help residents regain or maintain mobility, strength, and independence in activities of daily living) in accordance with the physician's order. During a review of Resident 18's Minimum Data Set (MDS – a resident assessment tool) dated 6/8/2026, the MDS indicated Resident 18's cognitive (the ability to think and process information) skills for daily decision making were severely impaired. The MDS indicated Resident 18 was dependent with all activities of daily living, rolling left and right and with tub/shower transfers. During a review of Resident 18's Order Summary Report (OSR), dated active as of 8/6/2026, the OSR indicated a physician's order for RNA: 1.RNA to provide passive range of motion (PROM, moving a joint through its full capacity with the help of an outside force such as a physical therapist, RNA, or a mechanical device, while the person keeps the resident's muscles completely relaxed) to the left and right lower extremities (legs) 5 times a week or as tolerated, order date 7/18/2026. 2.RNA to provide PROM to the left and right upper extremities (arms) 5 times a week or as tolerated, order date 7/18/2026. 3.RNA to apply a left elbow splint 4-6 hours per day, 5 times a week or as tolerated Monday to Friday, order date 7/17/2026. 4.RNA to apply left and right hand splints, 4-6 hours per day, 5 times a week or as tolerated Monday to Friday, order date 7/17/2026. During multiple observations on 8/4/2026 at 7:51 AM, 9:08 AM, 12:19 PM, 2:43 PM, and at 4:22 PM, Resident 18 was lying in bed with Resident 18's left elbow bent and hand aimed toward the resident's chest. At 9:08 AM and 12:19 PM, Resident 18 was lying in bed with the left and right wrists bent inward. At 4:22 PM, Resident 18 was lying in bed, the left wrist was bent inward, the left elbow was bent and the left hand aimed toward the chest, Resident 18's right hand fingers were curled toward the palm of the hand and the right elbow was bent with the right hand aimed toward the waist. CNA 9 did not provide ROM services to Resident 18, no splints were applied to the left elbow or the right and left hands. During an observation on 8/5/2026 in the SAU from 7:19 AM to 3:00 PM, CNA 9 turned, repositioned, and provided incontinent (involuntary loss of bladder [hollow muscular balloon-like organ that stores urine] or bowel control) care to Resident 18 during the following times; at 8:05 AM, from 10:19 AM to 10:51 AM, and from 1:10 PM to 1:18 PM. CNA 9 did not provide RNA services and no splints were applied to Resident 18's left elbow or the right and left hands. During an interview on 8/5/2026 at 3:35 PM, CNA 9 stated CNA 9 did not have time to provide ROM exercises or RNA services to CNA 9's assigned residents including Resident 18 on 8/4/2026, and 8/5/2026. CNA 9 stated, aside from being assigned to provide RNA services, CNA 9 needed to complete CNA tasks for all of CNA 9's assigned residents. CNA 9 stated that CNAs were instructed [by facility administration] to complete RNA tasks in addition to their regular CNA assignments during their shift. During an interview on 8/6/2026 at 11:56 AM with CNA 9, CNA 9 stated the SAUC had informed CNA 9 that when CNA's were repositioning, changing resident clothes, and showering the residents, CNA's were to provide RNA/ROM services. CNA 9 stated CNA 9 did not perform ROM exercises the correct way because the exercises take time, CNA 9 stated for the upper extremities, ROM exercises included moving the hands, the elbows, the shoulders up and down, in and out, bending and extending each body part and CNA 9 needed to repeat the exercises ten times. During an interview on 8/6/2026 at 1:02 PM, the SAUC stated CNA's were providing care, turning, repositioning, assisting residents with transfers, and were providing showers. The SAUC stated CNA's were also providing RNA services to the residents in the SAU. The SAUC stated if the residents with orders for RNA services were not provided ROM, applications of splints and rolls, and mobility exercises, the residents had the potential to decline in their ROM and mobility. During a review of the facility's RNA documentation date printed 8/6/2026 at 1:12 PM, the documentation indicated CNA 9 provided PROM to Resident 18's left and right upper extremities (arms), the left and right lower extremities (legs), applied splints to the left and right hands, and applied splints to the left elbow on 8/4/2026. The documentation indicated CNA 9 provided PROM to the right lower extremity and to the left and right upper extremities, to the left lower extremity, applied splints to the left and right hands on 8/5/2026. During an interview on 8/6/2026 at 5:06 PM with Registered Nurse (RN) 3, RN 3 stated RN 3 reminded the CNA's when asked how RN 3 monitored care such as ROM and application of splints. RN 3 was asked how RN 3 ensured ROM and application of rolls and splints were provided, RN 3 stated RN 3 reminded the CNA's to document when tasks were completed. During an interview on 8/7/2026 at 11:05 AM, CNA 9 stated CNA 9 documented CNA 9 provided PROM and applied splints because CNA 9 was called on 8/6/2026 and asked to document that CNA 9 provided RNA services and applied splints to CNA 9's assigned residents including to Resident 18 on 8/4/2026 and 8/5/2026. CNA 9 stated CNA 9 did not provide RNA services and did not apply splints to Resident 18 because CNA 9 did not have time due to CNA 9's other CNA tasks. During an interview on 8/7/2026 at 12:19 PM with the DON, the DON stated providing basic nursing services such as baths, showers, and grooming was different from providing RNA services. The CNAs in the SAU had informed the DON during a meeting, the CNAs were unable to provide RNA services. During that meeting, the CNA's were informed they were to continue to provide RNA services and no additional concerns were reported to the DON since that meeting. The DON stated if RNA services were not provided, residents could decline, contractures could develop or worsen, and the resident's circulation, skin integrity, comfort and positioning could get affected. During a review of Resident 18's Physical Therapy (PT, profession aimed in restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment (PTE), dated 8/6/2026, the PTE indicated Resident 18 had impaired ROM in the left and right lower extremities, the left and right hip, and the knee and ankle. During a review of Resident 18's Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment (OTE), dated 8/6/2026, the OTE indicated Resident 18 had impaired ROM in the left and right shoulder, wrist, and hand. During a review of Resident 18's OSR, dated active as of 8/6/2026, the OSR indicated a physician's order for RNA services, to apply a left elbow splint 4-6 hours per day 5 times a week or as tolerated Monday to Friday, order dated 7/17/2026. During an interview on 8/6/2026 at 10:00 AM with the SAUC, the SAUC stated CNA 9 applied the elbow splint to Resident 18 and the SAUC assisted with the application. During an observation on 8/6/2026 at 10:02 AM inside Resident 18's room, Resident 18 was lying in bed, Resident 18 had a splint on Resident 18's right elbow. During an interview on 8/6/2026 at 11:56 AM with CNA 9, CNA 9 stated the SAUC went to Resident 18's room with CNA 9 and CNA 9 applied the splint to Resident 18. CNA 9 did not answer when asked why the splint was placed on Resident 18's right elbow. CNA 9 stated CNA 9 applied the splint on Resident 18's left elbow last week. B. During a review of Resident 199's FS, the FS indicated the facility originally admitted Resident 199 on 6/2/2015 and recently admitted on [DATE] with diagnoses including respiratory failure (serious condition that develops when the lungs cannot get oxygen into the blood), attention to tracheostomy (a surgical opening in the neck leading directly into the windpipe to help a person get air into the lungs when they cannot breathe normally through their mouth or nose), attention to gastrostomy (a medical procedure that creates an opening from the outside of the abdomen directly into the stomach, allows for the placement of a feeding tube), quadriplegia (paralysis from the neck down, including arms and legs), and contractures (permanent, shortening of muscles, causing rigid, stiff joints and reduced movement) to both shoulders, both knees, and multiple (unspecified) muscle sites. During a review of Resident Minimum Data Set (MDS- a resident assessment tool), dated 7/7/2026, the MDS indicated Resident 18's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 199 had ROM limitations in both arms and legs and was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers was required to complete the activity) for oral hygiene, toileting hygiene, showering/bathing, dressing, and rolling to either side while lying in bed. During a review of 199's OSR, dated active as of 8/6/2026, the OSR indicated the following RNA orders; 1. RNA to provide PROM exercises to the left and right upper extremities daily 5 times per week or as tolerated Monday to Friday, dated 11/20/2025. 2. RNA to apply roll (a hand support designed to keep fingers from curling tightly into the palm, preventing fingernails from injuring the skin, absorb moisture, and gently encourage joint extension) to the left and right hands, 4-6 hours per day, 5 times per week or as tolerated Monday to Friday, dated 11/20/2025. During multiple observations on 8/4/2026 at 7:56 AM, 10:05 AM, 12:17 PM, 2:40 PM and at 4:24 PM, at 10:05 AM, Resident 119's left elbow was bent and the left hand was aimed toward Resident 119's chest. CNA 9's interactions with Resident 199, CNA 9 did not provide PROM/RNA services to Resident 199's upper extremities and did not apply a roll to Resident 199's left or right hands. During a review of the facility's RNA documentation, dated August 2026, the documentation was left blank on 8/3/2026 and on 8/4/2026. During multiple observations on 8/5/2026 at 1:40 PM, 2:27 PM, and from 2:39 to 2:48 PM, during CNA 9's interactions with Resident 199, CNA 9 did not provide PROM/RNA services to Resident 199's upper extremities and did not apply a roll to Resident 199's left or right hands. During an interview on 8/5/2026 at 3:35 PM, CNA 9 stated CNA 9 did not have time to perform ROM/RNA exercises or apply splints/rolls to CNA 9's assigned residents including Resident 119 on 8/3/2026, 8/4/2026, and 8/5/2026. During an interview on 8/6/2026 at 11:56 AM with CNA 9, CNA 9 stated the SAUC had informed CNA 9 that when CNAs were repositioning, changing resident clothes, and showering the residents, CNAs were to provide RNA services. CNA 9 stated CNA 9 could not perform ROM exercises the correct way because the exercises took time. CNA 9 stated for the upper extremity, ROM included moving the hands, the elbows, the shoulders up and down, in and out, bending and extending and each one needed to be repeated ten times. During a review of the facility's Policy and Procedure (P&P), titled Performing Range of Motion Exercises, dated 12/22/2025, the P&P indicated to perform ROM as prescribed. 2. Neck - Flexion, extension, lateral bending, rotation (only if not contraindicated). 3. Shoulder - Flexion, extension, abduction, adduction, internal/external rotation. 4. Elbow - Flexion, extension. 5. Wrist - Flexion, extension, rotation. 6. Fingers - Flexion, extension, abduction. 7. Hip - Flexion, extension, abduction, adduction, internal/external rotation. 8. Knee - Flexion, extension. 9. Ankle - Dorsiflexion, plantarflexion, rotation. 10. Toes- Flexion, extension The P&P indicated the facility will provide Range of Motion (ROM) exercises per order from the provider, occupational and/or Physical Therapist. The purpose would be to To maintain or increase Range of Motion (ROM) of joint or prevent a decline. To prevent or reduce contractures and joint stiffness. To maintain, improve, or prevent decline in muscle strength and flexibility. To increase or preserve the functional use of the involved extremities to support daily activities. To promote circulation, reduce discomfort associated with immobility, and enhance overall mobility. During a review of the P&P titled Restorative Nursing Program Guidelines dated 5/26/2026, the P&P indicated Restorative Nursing Program may include passive of active range of motion exercises, transfer training, ambulating.orthotics or brace application. C. During a review of Resident 1's FS, the FS indicated the facility admitted Resident 1 on 4/1/2026, with diagnoses including traumatic brain injury (damage to the brain caused by an external physical force, such as a sharp blow, bump, or a jolt to the head, or an object piercing the skull), muscle weakness, and lack of coordination. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 was dependent on activities of daily living and was dependent on mobility. During a record review of Resident 1's OSR, dated 7/16/2026, the OSR indicated Resident 1 had physician orders for (RNA) services, as follows: RNA for (PROM) left lower extremity (LLE): once daily, five times per week, or as tolerated. RNA for (PROM) right lower extremity (RLE): once daily, five times per week, or as tolerated. RNA to perform (PROM) exercises to left upper extremity (LUE): five times per week, or as tolerated. RNA to perform (PROM) exercise to right upper extremity (RUE): five times per week, or as tolerated. During a record review of Resident 1's Order Listing Report (OLR), dated 7/22/2026, the OLR indicated Resident 1's physician orders for (RNA) services were discontinued on 7/22/2026, as follows: RNA for (PROM) (LLE): once daily, five times per week, or as tolerated. RNA for (PROM) (RLE): once daily, five times per week, or as tolerated. RNA to perform (PROM) exercises to (LUE): five times per week, or as tolerated. RNA to perform (PROM) exercise to (RUE): five times per week, or as tolerated. During a record review of Resident 1's (RNA) Schedule for July 2026, there was no documentation indicating Resident 1 received the physician-ordered (PROM) RNA services from 7/16/2026 through 7/22/2026. During an interview on 8/3/2026 at 10:05 AM, with the Family Member (FM), the FM stated the FM visited Resident 1, her husband, regularly and often and the FM observed Resident 1's RNA services were not being provided routinely. The FM stated this was concerning because the services were important to maintain Resident 1's mobility and functional abilities and to prevent further decline. During an interview and concurrent record review on 8/5/2026 at 1:05 PM, Resident 1's OSR, OLR, and the July 2026 (RNA) schedule were reviewed with Registered Nurse (RN) 3. RN 3 stated there was no documentation that the physician-ordered RNA services was provided from 7/16/2026 through 7/22/2026. RN 3 stated if services were not documented, they were considered not done. RN 3 stated it was important to document RNA services to demonstrate the services were provided as ordered. During an interview and concurrent record review on 8/5/2026 at 2:20 PM, Resident 1's OSR, OLR, and the July 2026 (RNA) schedule were reviewed with the DON. The DON stated newly graduated RNs sometimes failed to document the appropriate flowsheets for the RNAs to document the services were provided. The DON stated she believed the RNA services were provided; however, acknowledged there was no documentation demonstrating that the physician-ordered RNA services were provided from 7/16/2026 through 7/22/2026. The DON stated without documentation, the services were considered not provided to Resident 1. The DON stated documentation was necessary to demonstrate that physician-ordered care was provided. During a review of the facility's P&P titled Performing Range of Motion Exercises, dated 12/22/2025, the P&P indicated to document type of ROM performed (active, assisted, passive), joints exercised, resident participation and tolerance, any pain, limitations, or changes noted. The P&P indicated to document: type of ROM performed, resident participation and tolerance, any pain, limitations or changes noted. During a review of the facility's P&P titled, Documentation, revision date 1/1/2012, the P&P's purpose indicated to ensure that resident progress in the restorative nursing program is documented accurately and timely. The P&P's policy indicated treatment provided by RNAs will be documented on a daily basis and there will be at least weekly documentation of progress, response to treatment and functional status of each resident in the Restorative Nursing Program. In addition, the P&P indicated the RNA will document and communicate any significant resident problems or changes to the charge nurse promptly. The P&P indicated the licensed nurse's weekly summary in the medical record should reflect the resident's involvement in the restorative nursing program. The P&P indicated weekly RNA charting: the RNA will document: the treatment provided (ambulation, ROM, feeding, ADL training) and the specific distance or repetitions. D. During a review of Resident 14's FS, the Face Sheet indicated the facility originally admitted Resident 14 on 2/15/2024 and admitted on [DATE] with diagnoses including spastic quadriplegic cerebral palsy (abnormal brain development or damage causing muscle stiffness, tightness, and poor motor control in all four limbs, torso, neck, and face), attention to tracheostomy (hole made through the front of the neck and into the windpipe (trachea) to allow air into the lungs), attention to gastrostomy tube (surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), muscle spasm (sudden, forceful muscle contraction), and epilepsy (brain disorder characterized by recurring, unprovoked seizures). During a review of Resident 14's Physical Therapy ([PT] profession aimed in restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 6/20/2025, the PT Evaluation indicated Resident 14 had ROM limitations in both knees. The PT Evaluation also indicated Resident 14 did not have any contractures to both legs. During a review of Resident 14's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 6/25/2025, the OT Evaluation indicated Resident 14 had ROM impairments in both shoulders, the right elbow, both wrists, and both hands. During a review of Resident 14's PT Discharge summary, dated [DATE], the PT Discharge Summary recommendations indicated Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) for PROM exercises to both legs, five times per week as tolerated. During a review of Resident 14's physician's orders, dated 7/3/2025 and discontinued on 8/4/2025, the physician's orders indicated for RNA to provide PROM exercises to both legs, five times per week, as tolerated. During a review of Resident 14's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated RNA for PROM exercises to both arms, five times per week, and application of the right elbow splint and both hand splints for four to six hours per day, five times per week or as tolerated. During a review of Resident 14's physician's orders, the physician's orders did not include RNA to provide Resident 14 with PROM exercises to both arms and apply the right elbow splint and both hands splints in accordance with the OT Discharge recommendations. During a review of Resident 14's Census List (record of hospitalizations, room changes, and payer source changes), the Census List indicated Resident 14 was discharged to the hospital on 7/31/2025 and returned to the facility on 8/7/2025. The Census List also indicated Resident 14 was discharged to the hospital on 9/4/2025 and returned to the facility on 9/9/2025. The Census List indicated Resident 14 has resided at the facility since 9/9/2025. During a review of Resident 14's MDS, dated [DATE], 2/13/2026, and 5/11/2026, the MDS indicated Resident 14 had did not have speech, rarely/never expressed needs and wants, rarely/never understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 14 had ROM limitations in both arms and legs and was dependent for oral hygiene, toileting hygiene, showering/bathing, dressing, and rolling to either side while lying in bed. During a review of the Order Listing Report for residents receiving RNA services, dated 8/6/2026 at 7:45 a.m., the Order Listing Report did not include Resident 14. During an observation on 8/6/2026 at 9:50 a.m. in Resident 14's room, Resident 14 was lying in bed with the head rotated to the left side. Both of Resident 14's elbows were observed in a flexed position and the fingers in both hands were bent into a fist. Both of Resident 14's hips were rotated to the left and both knees were in a slightly bent position. During a concurrent interview and record review on 8/6/2026 at 11:19 a.m. with the Director of Rehabilitation (DOR), Resident 14's PT Discharge summary, dated [DATE], and OT Discharge summary, dated [DATE], were reviewed. The DOR stated Resident 14's PT Discharge Summary recommendations indicated RNA for PROM exercises to both legs. The DOR stated Resident 14's OT Discharge Summary recommendations indicated RNA for PROM exercises to both arms and application of the right elbow splint and both hand splints. During an interview on 8/6/2026 at 1:03 p.m. with RN 5, RN 5 stated Resident 14 was unable to talk and was dependent on staff for mobility. RN 5 stated Resident 14 could experience a decline in ROM without the provision of splints and ROM exercises. During a concurrent interview and record review on 8/6/2026 at 2:31 p.m. with RN 5, Resident 14's PT Discharge summary, dated [DATE], and OT Discharge summary, dated [DATE], physician's orders for RNA, dated 7/3/2025, and current physician's orders were reviewed. RN 5 stated Resident 14 did not have physician's orders for RNA to provide PROM to both arms after discharged from OT on 7/7/2025. RN 5 stated Resident 14's physician's order, dated 7/3/2025, for RNA to provide PROM to both legs was discontinued on 8/4/2025 due to Resident 14's hospitalization on 7/31/2025. RN 5 stated Resident 14 has not received RNA for application of splints and PROM to both arms and legs since readmission on [DATE]. During concurrent interview and record review on 8/7/2026 at 9:00 a.m. with the DOR, Resident 14's RNA tasks were reviewed. The DOR stated the Director of Staff Development (DSD) discontinued Resident 14's RNA tasks for PROM to both arms and application of both hand splints on 7/11/2025. During a concurrent interview and record review on 8/7/2026 at 10:03 a.m. with the DSD, Resident 14's OT Discharge summary, dated [DATE], physician's orders, and RNA tasks were reviewed. The DSD stated the RNAs could not provide any services without a physician's order. The DSD stated Resident 14's RNA task for PROM exercises to both arms and application of both hand splints were discontinued on 7/11/2025 because Resident 14 did not have physician's orders to provide these RNA tasks. The DSD stated a physician's order for RNA was not entered in Resident 14's medical record in accordance with the OT Discharge Summary recommendations to provide PROM to both arms and apply the right elbow splint and both hand splints. The DSD stated Resident 14 did not receive PROM to both arms and application of the right elbow splint and both hand splints from OT discharge on [DATE] to 7/31/2025 when Resident 14 went to the hospital. The DSD stated Resident 14 could have experienced ROM decline, development of contractures, and placed the resident at increased risk for development of pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) without RNA services to provide splints and ROM. During an interview on 8/7/2026 at 11:58 a.m. with the DON, the DON stated the general process for the resident to receive RNA services included the therapists (PT and OT) entering the physician's order for RNA in the resident's medical record after discharge from therapy. The DON stated the licensed nurses were supposed to confirm the RNA order with the resident's physician and then create the RNA task and care plan for the resident. The DON stated Resident 14's physician's order for RNA to provide PROM exercises to both arms and application of the right elbow and both hand splints were not entered in Resident 14's medical record, which prevented the process to initiate these RNA services after Resident 14's discharge from OT. During a review of the facility's P&P titled, Performing Range of Motion Exercises, effective 12/22/2025, the P&P indicated the facility will provide ROM exercises per order from the provider, OT, and/or PT. The P&P indicated the purpose of performing ROM exercises included to maintain or increase ROM or prevent decline and to prevent or reduce contractures and joint stiffness.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services for two of two sampled residents (Resident 5 and Resident81), when: a. Resident 5, who had a clinically justified indwelling catheter (a medical device that drains urine from your bladder [hollow muscular balloon-like organ that stores urine] into a bag outside your body), was not assessed or monitored closely for the facility to recognize changes in Resident 5's urine and the physician was not notified in accordance with Resident 5's CP, initiated 5/16/2025, and the physician's order, dated 6/12/2026.b. Resident 81, who was incontinent (involuntary loss of bladder [hollow muscular balloon-like organ that stores urine] or bowel control) of bowel, had multiple episodes of large foul-smelling diarrhea (loose, watery bowel movements [stool/poop]). The facility failed to assess Resident 81, notify Resident 81's physician, and hold the administration of laxatives (medications used to treat constipation [problem with passing stool or having hard dry stool]) as indicated in Resident 81's Order Summary Report (OSR), dated active as of 8/3/2026. The deficient practice had the potential to result in the recurrence of a urinary tract infection (UTI - an infection [the invasion and growth of germs in the body] in the bladder/urinary tract) and serious complications to Resident 5. The deficient practice resulted in a malodorous odor in Resident 81's shared room and the adjacent hallway and the potential to result in Resident 81 developing severe dehydration (a condition caused by the loss of too much fluid from the body), electrolyte imbalances (when certain vital mineral levels in your blood get too high or too low), an infection (the invasion and growth of germs in the body), and a physical decline to Resident 81. Cross Reference F656 and F757 Findings:a. During a review of Resident 5's Face Sheet (FS, admission Record), the FS indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including neuromuscular dysfunction of bladder (a loss of bladder [hollow muscular balloon-like organ that stores urine] control caused by damage to the brain), unspecified, and personal history of UTI.During a review of Resident 5's care plan (CP), initiated 5/16/2025, the CP indicated Resident 5 was at risk for UTIs. The CP's interventions indicated to evaluate urine characteristics and notify the physician of urine cloudiness and deepening of urine color.During a review of Resident 5's History and Physical Examination (H&P), dated 12/18/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 5 was dependent on ADL.During a review of Resident 5's OSR, dated active as of 8/4/2026, the OSR indicated an order, dated 6/12/2026 to assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment (a buildup or solid particles, mineral crystals, mucus, or cellular debris that forms in the urine and collects inside a drainage bag), blood, odor, and amount of urine output every shift and Foley catheter (F/C, a thin, flexible plastic tube inserted into the bladder to drain urine) care to be provided every shift.During a concurrent observation and interview on 8/4/2026 at 8:44 AM with Licensed Vocational Nurse (LVN) 3, Resident 5's F/C was draining to gravity into a collection bag inside a dignity bag (a discreet opaque pouch that slips over a medical urine drainage bag to hide collected urine from public view). LVN 3 stated Resident 5's urine had thick sediments and was light brown and cloudy in color. LVN 3 milked (a technique used to clear obstructions within a catheter tubing and encourage urine flow) Resident 5's F/C and the F/C continued to drain cloudy light brown urine with sediments. LVN 3 stated it was the facility's process for Certified Nursing Assistants (CNA, in general) to empty the drainage bags and the treatment nurses observed the catheter tubing for leaking and for sediments. LVN 3 stated monitoring Resident 5's urine was important to prevent UTIs.During an interview on 8/6/2026 at 9:02 AM with the Assistant Administrator (ADON), the ADON stated observing and monitoring F/C urinary output for odor, color, sediments, and urine consistency was important to note any changes in the urine that could indicate infections, UTIs, and hydration status. The ADON stated cloudy urine or sediments in the urine could indicate a UTI. During a review of the facility's P&P titled, Indwelling Catheter, effective date 8/19/2026, the P&P indicated the residents would be periodically assessed for the need for continued catheter use and/or any complications associated with catheter use. b. During a review of Resident 81's FS, the FS indicated Resident 81 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM II - adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), and encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 81's Physician/PA/NP Progress Note (PN), dated 6/16/2026, timed at 12:28 PM, the PN indicated Resident 81was alert and oriented x 4 (a person is awake and correctly knows who they are, location, the time, and the situation) and decision capacity was present.During a review of Resident 81's Minimum Data Set (MDS- a resident assessment tool), dated 6/17/2026, the MDS indicated Resident 81's cognitive skills (ability to think and process information) for daily decision making were severely impaired. The MDS indicated Resident 81 was dependent (helper does all of the effort) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) including toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). The MDS indicated Resident 81 was always incontinent of bowel movements.During a review of Resident 81's OSR, active orders as of 8/3/2026, the OSR indicated physician orders that included the following laxative medications: Dulcolax Suppository (Bisacodyl), 10 mg (milligrams - metric unit of measurement), insert 1 suppository rectally every 24 hours as needed (prn) for constipation every 3rd day if Milk of Magnesia is ineffective, dated 6/13/2026. Fleet Enema (Sodium Phosphates), 7-19 gm (grams - unit of measurement for mass or weight)/118 ml (milliliter - a metric unit of volume), insert 1 application rectally every 24 hours as needed for constipation every 4th day if Dulcolax suppository ineffective, dated 6/13/2026.Milk of Magnesia (MOM) Suspension 400 mg/5 ml (Magnesium Hydroxide), give 30 ml via G-tube (soft flexible tube surgically inserted directly into the stomach through a small opening in the abdomen, used to deliver liquid nutrition, hydration, and medications for people who cannot eat or swallow safely) every 24 hours as needed for constipation give every 3rd day if no bowel movement, dated 6/13/2026.ClearLax oral powder 17 gm /scoop (Polyethylene Glycol 3350), give 1 scoop enterally (giving food, liquid, or medicine directly into the stomach or intestines) in the morning for bowel management, mix with 4-8 ounces (oz - a unit of weight) of water, hold for loose stools, dated 6/17/2026.Docusate Sodium Liquid 50 mg/ml, give 10 ml by mouth one time a day for bowel management, hold for loose stool, dated 7/8/2026.Lactulose Solution 10 gm/15 ml, give 30 ml via G-Tube one time a day for bowel management, 5 gm/7.5 ml solution, hold for loose stool, dated 7/14/2026.During a review of Resident 81's Bowel Elimination (BE), dated 6/2026, 7/2026, and 8/2026, the BE indicated, Resident 81 had multiple episodes of loose [stools]/diarrhea.During a review of Resident 81's Medication Administration Record (MAR), dated 7/1/2026 - 7/31/2026, the MAR indicated, Resident 10 was administered the following laxative medications daily at 9:00 AM:ClearLax oral powder 17 gm /scoop (Polyethylene Glycol) 1 scoop enterally.Docusate Sodium Liquid 50 mg/ml, give 10 ml by mouth.Lactulose Solution 10 gm/15 ml, give 30 ml via G-Tube.During a review of Resident 81's MAR, dated 8/1/2026 - 8/31/2026, the MAR indicated Resident 10 was administered with the following laxative medications daily at 9:00 AM until 8/3/2026:ClearLax oral powder 17 gm /scoop (Polyethylene Glycol) 1 scoop enterallyDocusate Sodium Liquid 50 mg/ml, give 10 ml by mouthLactulose Solution 10 gm/15 ml, give 30 ml via G-Tube. During an observation on 8/3/2026 at 8:28 AM, Station 1 south side hallway had a malodorous odor.During an observation on 8/3/2026 at 9:49 AM, Station 1 south side hallway had a malodorous odor.During an interview on 8/3/2026 at 10:41 AM with Resident 81's Emergency Contact (EC), the EC stated, staff did not change Resident 81 right away when Resident 81 had a bowel movement and the EC could smell Resident 81's stool from the outside Resident 81's shared room, is that my mom?During an observation on 8/3/2026 at 11:17 AM, Station 1 south side hallway had a malodorous odor.During an observation on 8/4/2026 at 7:45 AM with CNA 3 and CNA 6, Resident 81 was in bed. Resident 81's diaper was soiled with large runny brown colored foul-smelling diarrhea spilling out of Resident 81's diaper.During an interview on 8/4/2026 at 8:00 AM with CNA 6, CNA 6 stated, Resident 81 had diarrhea for a week and a half because Resident 81 was on antibiotics (a powerful medicine used to treat infections caused by bacteria).During an interview on 8/5/2026 at 1:41 PM with CNA 1, CNA 1 stated Resident 81 was dependent and required diaper changes and Resident 81 was having a lot of smell too much, smell bad, diarrhea the last 3 days. CNA 1 stated the multiple diarrhea episodes were reported to the nurse (unidentified).During a concurrent interview and record review on 8/5/2026 at 1:59 PM with LVN 4, Resident 81's medical record including physician's orders, MAR dated 7/2026 and 8/2026 and the BEs were reviewed. LVN 4 stated LVN 4 was aware of Resident 81's foul smelling diarrhea and noticed the diarrhea when LVN 4 provided treatment to Resident 81. LVN 4 stated Resident 81 had orders for Dulcolax suppository prn, Fleet enema prn, MOM prn, ClearLax routine, Docusate Sodium daily, Lactulose daily. LVN 4 stated the BEs indicated, Resident 81 was having loose [stools]/diarrhea and staff should not have administered the laxatives, hold off bowel management meds. LVN 4 stated there was no documentation indicating Resident 81's physician was notified of Resident 81's multiple diarrhea episodes or indicating a change of condition (CoC, an alteration in a resident's physical health that differs from their previous baseline) and assessment was completed. LVN 4 stated implementing interventions such as notifying the physician and completing an assessment was important to prevent dehydration and the development of UTIs to Resident 81. LVN 4 stated Resident 81's physician was not notified and notifying Resident 81's physician was important because the physician would have written orders to send Resident 81's stool for C. diff (Clostridioides difficile - a highly contagious bacterial infection that causes diarrhea and inflammation of the colon) testing, laboratory (blood work), and ordered Imodium (anti-diarrhea medication). During an interview on 8/6/2026 at 9:02 AM with the Assistant Director of Nursing (ADON), the ADON stated, Resident 81's bowel management medications should have been held, and the physician should have been notified.During a review of the facility's policies and procedures (P&P) titled, Change in Condition, effective date 8/25/2022, the P&P indicated the Licensed Nurse would assess the change in condition and determine what nursing interventions were appropriate. The P&P indicated documentation pertaining to a change in condition in the resident's condition would be maintained in the resident's medical record.During a review of the facility's P&P titled, Bowel and Bladder Continence Assessment and Management, effective date 11/14/2025, the P&P indicated the facility was to provide residents who were incontinent of bowel and/or bladder appropriate treatment and services to minimize urinary tract infections and to restore as much bowel and/or bladder function as possible, to prevent skin breakdown and irritation, and improve resident quality of life.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for three of 3 sampled residents (Residents 14, 18, and 199). a. For Resident 199, the facility failed to:1. Complete documentation to determine Resident 199's need for Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation upon readmission (on 10/29/2025) in accordance with the physician's order, dated 10/29/2025. 2. Complete documentation for Resident 199's quarterly Rehabilitation ([Rehab] therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) Rounding and Screening (process to identify residents with potential functional changes and allow those residents to receive therapy services if functional declines or improvements are present and skilled services are required) in accordance with the facility's policy and procedure (P&P) titled, Rehab Rounding and Screening, revised 8/28/2025 and effective 11/11/2025. b. For Resident 18, the facility failed to accurately document the provision of Restorative Nursing Assistant (RNA) services on 8/4/2026 and 8/5/2026 when Resident 18 did not receive passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) exercises and application of splints to the left elbow and both hands. c. For Resident 14, the facility failed to1. Complete quarterly Rehab Rounding and Screening in accordance with the facility's P&P titled, Rehab Rounding and Screening, revised 8/28/2025 and effective 11/11/2025. 2. Complete documentation for turning and repositioning. These failures resulted in inaccurate and incomplete medical records for the provision of Resident 18's RNA services and screening for changes in Resident 14 and 199's functional status, which placed the residents at increased risk for developing a decline in ROM (movement of a joint through the range of motion) and further development of contractures (stiffening/shortening at any joint that reduces the joint's range of motion). These failures also resulted in incomplete medical records for Resident 14's turning and repositioning, which placed the residents at increased risk for developing pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). Cross reference F688, F725.Findings: a. During a review of Resident 199's Face Sheet (FS), the FS indicated the facility originally admitted Resident 199 on 6/2/2015 and recently admitted on [DATE] with diagnoses including respiratory failure (serious condition that develops when the lungs cannot get oxygen into the blood), attention to tracheostomy (hole made through the front of the neck and into the windpipe (trachea) to allow air into the lungs), attention to gastrostomy (surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), quadriplegia (paralysis from the neck down, including arms and legs), and contractures to both shoulders, both knees, and multiple (unspecified) muscle sites. During a review of Resident 199's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 10/30/2025, the MDS indicated Resident 199 had ROM limitations in both arms and legs and was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for oral hygiene, toileting hygiene, showering/bathing, dressing, and rolling to either side while lying in bed. 1. During a review of Resident 199's physician's orders (PO), dated 10/29/2025, the physician's orders indicated Resident 199 may have PT/Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) evaluation and treatment if indicated. During a review of Resident 199's OT Evaluation and Plan of Treatment, dated 10/31/2025, the OT Evaluation indicated Resident 199 had (unspecified) ROM limitations with contractures in in both shoulders, elbows, and hands. The OT Evaluation indicated Resident 199 had hand rolls (soft roll positioned in the palm of the hand and fastened with a strap) for both hands. During a review of Resident 199's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated recommendations for the RNA to provide passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) exercises and apply both hand rolls for four to six hours, five days per week. During a review of Resident 199's PO, dated 11/20/2025, the physician's orders indicated for the RNA to apply Resident 199's left-hand and right-hand rolls, four to six hours per day, five times per week, as tolerated. During an observation on 8/6/2026 at 9:40 a.m. in Resident 199's room, Resident 199 was lying in bed with the head turned toward the right side. Both of Resident 199's elbows were observed in a flexed (bent) position and the fingers in both hands were bent into a fist over a hand roll. Both of Resident 199's hips were observed rotated toward the right side with both hips and knees bent. During a concurrent interview and record review on 8/7/2026 at 9:37 a.m. with the Director of Rehabilitation (DOR), Resident 199's PO, dated 10/29/2025, for PT/OT evaluation and treatment if indicated, MDS assessments, and medical records were reviewed. The DOR stated Resident 199 did not receive a PT Evaluation upon admission (on 10/29/2025) because it was not indicated. The DOR stated Resident 199's medical record did not include documentation indicating Resident 199 did not require a PT Evaluation upon admission. 2. During a review of the facility's P&P titled, Rehab Rounding and Screening, revised 8/28/2025 and effective 11/11/2025, the P&P indicated screening was a hands-off process, and information should be gathered using resident observation/interview, chart review/nursing notes, interdisciplinary team (IDT) interviews, reports, and IDT meetings. The P&P also indicated Screening forms will be placed in the resident's medical records. During a review of Resident 199's MDS, dated [DATE], 4/20/2026, and 7/7/2026, the MDS indicated Resident 199 did not have speech, rarely/never expressed needs and wants, rarely/never understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 199 had ROM limitations in both arms and legs and was dependent for oral hygiene, toileting hygiene, showering/bathing, dressing, and rolling to either side while lying in bed. During an interview on 8/6/2026 at 8:09 a.m. with the DOR, the DOR stated the Rehab Screening process (in general) occurred quarterly to determine declines in mobility, ROM, and speech. During an observation on 8/6/2026 at 9:40 a.m. in Resident 199's room, Resident 199 was lying in bed with the head turned toward the right side. Both of Resident 199's elbows were observed in a flexed (bent) position and the fingers in both hands were bent into a fist over a hand roll. Both of Resident 199's hips were observed rotated toward the right side with both hips and knees bent. During an interview on 8/6/2026 at 1:03 p.m. with Registered Nurse (RN) 5, RN 5 stated Resident 199 was unable to talk and was dependent on staff for mobility. RN 5 stated Resident 199 could experience a decline in ROM without the application of splints and provision of ROM exercises. During a concurrent interview and record review on 8/6/2026 at 1:36 p.m. with RN 5, Resident 199's physician's orders for RNA were reviewed. RN 5 stated Resident 199 had physician's orders, dated 6/4/2025, for the RNA to provide PROM to both legs which were discontinued on 10/28/2025 due to Resident 199's hospitalization. RN 5 stated Resident 199 was admitted to the facility on [DATE]. RN 5 stated Resident 199 has not received RNA for PROM to both legs since admission on [DATE] (over nine months). RN 5 stated Resident 199 could experience a decline in ROM and development of contractures in both legs without PROM exercises. During an interview on 8/6/2026 at 4:44 p.m. with the DOR, the DOR stated the Rehab Screens (in general) were visual, hands-off screens of each resident in accordance with the resident's quarterly MDS assessment. During an interview on 8/7/2026 at 8:50 a.m. with the DOR, the DOR stated the residents' medical records (in general) did not include documentation of each resident's visual, quarterly Rehab Screen unless there was a need for an evaluation. During a concurrent interview and record review on 8/7/2026 at 9:37 a.m. with the DOR, Resident 199's MDS assessments and medical records (in general) were reviewed. The DOR stated Resident 199's medical record did not include a quarterly Rehab Screen on 10/30/2025, 1/23/2026, 4/20/2026, and 7/7/2026 in accordance with Resident 199's MDS calendar. During a concurrent interview and record review on 8/7/2026 at 11:58 a.m. with the Director of Nursing (DON), the DON reviewed the facility's P&P titled, Rehab Rounding and Screening. The DON stated the purpose of documentation (in general) included evidence that care was provided to the residents. The DON stated the Rehab Screening form should be in the residents' medical records in accordance with the facility's P&P to provide documentation that the Rehab Screen was provided. The DON stated the facility would not know how to address a resident's ROM limitations (in general) if the resident's medical record did not include documentation of the Rehab Screen. c1. During a review of Resident 14's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 14 on 2/15/2024 and admitted on [DATE] with diagnoses including spastic quadriplegic cerebral palsy (abnormal brain development or damage causing muscle stiffness, tightness, and poor motor control in all four limbs, torso, neck, and face), attention to tracheostomy, attention to gastrostomy, muscle spasm (sudden, forceful muscle contraction), and epilepsy (brain disorder characterized by recurring, unprovoked seizures). During a review of Resident 14's PO, dated 7/3/2025, the PO included RNA to provide PROM exercises to both legs, five times per week, as tolerated. Further review of Resident 14's PO, dated 8/4/2025, indicated to discontinue RNA for PROM to both legs due to Resident 14's hospitalization. During a review of Resident 14's Census List (record of hospitalizations, room changes, and payer source changes), the Census List indicated Resident 14 was discharged to the hospital on 7/31/2025 and returned to the facility on 8/7/2025. The Census List also indicated Resident 14 was discharged to the hospital on 9/4/2025 and returned to the facility on 9/9/2025. The Census List indicated Resident 14 has resided at the facility since 9/9/2025. During a review of the facility's P&P titled, Rehab Rounding and Screening, revised 8/28/2025 and effective 11/11/2025, the P&P indicated screening was a hands-off process, and information should be gathered using resident observation/interview, chart review/nursing notes, interdisciplinary team (IDT) interviews, reports, and IDT meetings. The P&P also indicated Screening forms will be placed in the resident's medical records. During a review of Resident 14's MDS, dated [DATE], 2/13/2026, and 5/11/2026, the MDS indicated Resident 14 had did not have speech, rarely/never expressed needs and wants, rarely/never understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 14 had ROM limitations in both arms and legs and was dependent on staff for oral hygiene, toileting hygiene, showering/bathing, dressing, and rolling to either side while lying in bed. During a review of the Order Listing Report for residents receiving RNA services, dated 8/6/2026 at 7:45 a.m., the Order Listing Report did not include Resident 14. During an interview on 8/6/2026 at 8:09 a.m. with the DOR, the DOR stated the Rehab Screening process (in general) occurred quarterly to determine declines in mobility, ROM, and speech. During an observation on 8/6/2026 at 9:50 a.m. in Resident 14's room, Resident 14 was lying in bed with the head rotated to the left side. Both of Resident 14's elbows were observed in a flexed position and the fingers in both hands were bent into a fist. Both of Resident 14's hips were rotated to the left and both knees were in a slightly bent position. During a concurrent interview and record review on 8/6/2026 at 11:19 a.m. with the DOR, Resident 14's PT Discharge summary, dated [DATE], and OT Discharge summary, dated [DATE], were reviewed. The DOR stated Resident 14's PT Discharge Summary recommendations indicated RNA for PROM exercises to both legs. The DOR stated Resident 14's OT Discharge Summary recommendations indicated RNA for PROM exercises to both arms and application of the right elbow splint and both hand splints. During an interview on 8/6/2026 at 1:03 p.m. with RN 5, RN 5 stated Resident 14 was unable to talk and was dependent on staff for mobility. RN 5 stated Resident 14 could experience a decline in ROM without the provision of ROM exercises. During a concurrent interview and record review on 8/6/2026 at 2:31 p.m. with RN 5, Resident 14's PT Discharge summary, dated [DATE], and OT Discharge summary, dated [DATE], physician's orders for RNA, dated 7/3/2025, and current physician's orders were reviewed. RN 5 stated Resident 14 did not have physician's orders for RNA to provide PROM to both arms after discharged from OT on 7/7/2025. RN 5 stated Resident 14's PO, dated 7/3/2025, for RNA to provide PROM to both legs was discontinued on 8/4/2025 due to Resident 14's hospitalization. RN 5 stated Resident 14 has not received RNA for PROM to both arms and legs since 9/9/2025. RN 5 stated Resident 14 could have a decline in ROM and can develop contractures without ROM exercises to both arms and legs. During an interview on 8/6/2026 at 4:44 p.m. with the DOR, the DOR stated the Rehab Screens (in general) were visual, hands-off screens of each resident in accordance with the resident's quarterly MDS assessment. The DOR stated Resident 14's medical record did not include documentation for the quarterly Rehab Screen. During an interview on 8/7/2026 at 8:50 a.m. with the DOR, the DOR stated the residents' medical records (in general) did not include documentation of each resident's visual, quarterly Rehab Screen unless there was a need for an evaluation. During a concurrent interview and record review on 8/7/2026 at 9:00 a.m. with the DOR, Resident 14's MDS assessments and medical records (in general) were reviewed. The DOR stated Resident 14's medical records did not include the Rehab Screen for mobility and functional decline upon Resident 14's readmission to the facility on 9/9/2025. The DOR stated Resident 14's medical records did not include a quarterly Rehab Screen on 11/17/2025, 2/13/2026, and 5/11/2026 in accordance with Resident 14's MDS calendar. During a concurrent interview and record review on 8/7/2026 at 11:58 a.m. with the DON, the DON reviewed the facility's P&P titled, Rehab Rounding and Screening. The DON stated the purpose of documentation (in general) included evidence that care was provided to the residents. The DON stated the Rehab Screening form should be in the residents' medical records in accordance with the facility's P&P to provide documentation that the Rehab Screen was provided. The DON stated the facility would not know how to address a resident's ROM limitations (in general) if the resident's medical record did not include documentation of the Rehab Screen. b. During a review of Resident 18's FS, the FS indicated the facility admitted Resident 18 on 1/23/2024, with diagnoses that included anoxic brain damage (type of acquired brain injury that occurs when cells in the brain do not receive enough oxygen), dependence on respirator (ventilator – a machine that breathes for you if you cannot breathe on your own). During a review of Resident 18's Care Plan (CP) titled, The resident has limited physical mobility related to contractures, disease process.resident is dependent on staff for Activities of Daily Living needs, initiated on 1/27/2024. The CP's interventions indicated to provide RNA services in accordance with the physician's order. During a review of Resident 18's MDS dated [DATE], the MDS indicated Resident 18 rarely/never understands verbal content and rarely/never able to express ideas and wants. The MDS indicated Resident 18 was dependent on all activities of daily living, rolling left and right and with tub/shower transfers. During a review of Resident 18's Order Summary Report (OSR), the OSR indicated a current order for the following Restorative Nursing Assistance; RNA to provide PROM to left (L) and right (R) lower extremities, 5 times a week or as tolerated, order dated 7/18/2026. RNA to provide PROM to L and R upper extremities, 5 times a week or as tolerated, order dated 7/17/2026. RNA to apply a L elbow splint 4-6 hours per day, 5 times a week or as tolerated on Monday to Friday, order dated 7/17/2026. RNA to apply the L and R hand splint 4-6 hours per day, 5 times a week or as tolerated on Monday to Friday, order dated 7/17/2026. During multiple observations on 8/4/2026 during the following times, there was no range of motion exercises observed, and Resident 18 did not have a splint applied to both the L and R hand and no splint applied to the L elbow; At 7:51 AM, Resident 18 was lying in bed with the L arm bent at the elbow area towards the chest. At 9:08 AM, Resident 18 was lying in bed with the L and R wrists bent inward, the R leg was bent towards the knee. At 12:19 PM, Resident 18 was lying in bed with the L and R wrists bent inward, the right leg bent. At 2:43 PM, Resident 18 was lying in bed, facing Resident 18's R side. There was a folded sheet placed under Resident 18's L side and a folded sheet under the R arm. At 4:22 PM, Resident 18 was lying in bed, L wrist was bent inward, the L elbow was bent towards the chest, the R fingers curled towards the palm and the right elbow was bent towards the waist. During multiple observations on 8/5/2026 during the following times; Certified Nursing Assistant 9 (CNA 9) did not provide PROM to Resident 18's both upper and lower extremities, CNA 9 did not apply hand splints to both L and R hands and CNA 9 did not apply a splint to the L elbow. At 8:05 AM, CNA 9 and an unidentified CNA went inside Resident 18's room to turn and reposition Resident 18. At 10:19 to 10:51 AM, Licensed Vocational Nurse (LVN) 8 and CNA 9 turned Resident 18 to Resident 18's R side in preparation for wound care. Treatment Nurse (TN) 1 came to take over the wound care to the Ischium pressure ulcer. CNA 9 stayed with Resident 18 during the wound care. At 1:10 PM to 1:18 PM, CNA 9 turned and repositioned Resident 18. During an interview on 8/5/2026 at 3:35 PM, CNA 9 stated CNA 9 did not have time to perform ROM exercises and to apply splints to CNA 9's assigned residents including Resident 18 on 8/5/2026 and 8/6/2026. CNA 9 stated CNA needed to complete CNA tasks for all his assigned residents During a review of RNA documentation printed on 8/6/2026 at 1:12 PM, the RNA documentation indicated CNA 9 documented CNA 9 provided PROM to the L and R upper extremities, the L and R lower extremities, applied splints to the L and R hand, and applied splints to Resident 18's L elbow on 8/4/2026. The documentation indicated CNA 9 provided PROM to the R lower extremity and to the L and R upper extremity on 8/5/2026. During an interview on 8/7/2026 at 11:05 AM, CNA 9 stated that CNA 9 documented that CNA 9 provided PROM and applied splints because CNA 9 was called on 8/6/2026 and asked to document that CNA 9 provided ROM and applied splints to CNA 9's assigned residents on 8/4/2026 and 8/5/2026. CNA 9 stated CNA 9 did not provide the exercises and did not apply the splints because CNA 9 did not have the time on top of CNA 9's other CNA tasks. c2. During a review of Resident 14's FS, the FS indicated the facility originally admitted Resident 14 on 2/15/2024 and admitted on [DATE] with diagnoses including spastic quadriplegic cerebral palsy (abnormal brain development or damage causing muscle stiffness, tightness, and poor motor control in all four limbs, torso, neck, and face), attention to tracheostomy, attention to gastrostomy, muscle spasm (sudden, forceful muscle contraction), and epilepsy (brain disorder characterized by recurring, unprovoked seizures). During a review of Resident 14's MDS, the MDS indicated Resident 14 rarely/never understands verbal content and rarely/never able to express ideas and wants. The MDS indicated Resident 14 was dependent on all activities of daily living, rolling left and right and with tub/shower transfers. During multiple observations on 8/5/2026 at the following times; CNA 9 turned and repositioned Resident 14 at 12:43 PM during a diaper change. At 8:05 AM, CNA 9 inside Resident 18's room for turning and repositioning. At 10:19 AM to 10:50 AM, CNA 9 inside Resident 18's room, At 10:52 AM to 11:00 AM, CNA was inside room [ROOM NUMBER]. At 11:05 AM to 11:14 AM, CNA 9 was charting at the Nurse's station. At 11:15 AM, CNA 9 was inside room [ROOM NUMBER] A. At 11:34 AM, CNA 9 turned and repositioned a resident inside room [ROOM NUMBER] C. At 12:25 to 12:40 CNA 9 checked delivered lunch trays and checked residents eating lunch. At 12:43 PM, CNA 9 changed Resident 14's adult incontinence brief, the adult incontinence brief was 100% saturated, there was a large loose stool. At 12:51 PM, CNA 9 changed the adult incontinence brief for a resident inside room [ROOM NUMBER] B. At 12:57 PM, CNA 9 walked to room [ROOM NUMBER] to assist a resident. At 1:18 PM, CNA 9 was inside Resident 18's room for turning and repositioning. At 1:20 PM, CNA 9 reposition a resident inside room [ROOM NUMBER] A. At 1:40 PM, CNA 9 changed Resident 199's incontinent pad. 08/5/2026 2:27 PM to 2:48 PM, CNA 9 transferred and showered Resident 199. During an interview on 8/5/2026 at 3:25 PM, CNA 9 stated CNA 9 had only repositioned Resident 14 once because CNA 9 did not want Resident 14 to be in pain, Resident 14 would cry when being moved and would start yelling. CNA 9 stated CNA 9 checked Resident 14's adult incontinence brief at 9:00 or 10:00 AM and Resident 14 was dry. CNA 9 stated CNA 9 left Resident 14 in the same position because that is the only way Resident 14 stayed in bed. During a review of Resident 14's Documentation Survey Report for the task titled, Turn and Reposition every 2 hours and as needed, CNA 9 documented CNA 9 turned and repositioned Resident 14 at 8AM, 10 AM, 12 noon and at 2 PM. During an interview on 8/6/2026 at 5:06 PM with Registered Nurse 3 (RN 3). RN 3 stated RN 3 reminded the CNAs to document when task was completed when asked how RN 3 ensured turning and repositioning was completed. During an interview on 8/7/2026 at 12:40 PM with the Director of Nursing (DON), the DON stated documentation of care provided needed to be accurate, the staff needed to document what actually happened and the actual care provided. During a review of the facility's Policy and Procedure titled, Medical Records Manual – General, dated 3/25/2026, the P&P indicated the facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of two sampled residents (Residents 114 and 84). a. Resident 114's call light was above the resident's head, clipped to the side of the resident's mattress.b. Resident 84 call light was hanging off the top of the bed, in between the bed's siderail and resident's mattress. These deficient practices had the potential to result in the delay of treatment/services for Residents 114 and 84, affecting the residents' quality of care.a. During a review Resident 114's Face Sheet (FS), the FS indicated Resident 114 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (weakness or inability to move on one side of the body) affecting left dominant side, dementia (a long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and lack of coordination. During a review of Resident 114's Care Plan (CP) titled Resident was high risk for falls/injury/fracture related to poor safety awareness and severe cognitive impairment revised on 4/27/2026, the CP intervention indicated to keep Resident 114's call light within reach. During a review of Resident 114's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 5/5/2026, the MDS indicated Resident 114 had severe cognitive impairment (loss of intellectual capacity, memory, reasoning) and needed substantial assistance (helper does more than half the effort) with eating, oral and toilet hygrine, upper and lower body dressing, and sit to lying position. During a review of Resident 114's CP titled Resident was a high risk for falls/recurrent falls and fall-related injury due to Brief Interview for Mental Status (BIMS, a short, standard test used in long-term care facilities to check a person's memory, awareness, and thinking skills), score of 3 (severe cognitive impairment), revised on 8/3/2026, the CP intervention indicated to maintain Resident 114's call light within reach. During an observation on 8/3/2026 at 10:19 am, Resident 114 was in bed. Resident 114's call light was pinned on the upper right side of the mattress, above the resident's head, not within Resident 114's reach. During an observation and concurrent interview with Registered Nurse 4 (RN 4) on 8/3/2026 at 10:30 am, RN 4 stated the call lights should be within the residents' reach needed for the resident to ask for assistance and to prevent falls. b. During a review of Resident 84's FS, the FS indicated Resident 84 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis affecting left non dominant side and type 2 diabetes mellitus (elevated blood sugar levels in the blood stream). During a review of Resident 84's MDS dated [DATE], the MDS indicated Resident 84 had moderate cognitive impairment and needed substantial assistance with bathing, sitting to lying and lying to sitting on side of the bed. During a review of Resident 84's CP titled Resident had Activities of Daily Living (ADL) self-care performance deficit related to hemiplegia/hemiparesis affecting left non-dominant side, impaired balance, limited mobility, impaired cognition, revised on 6/12/2026, the CP intervention indicated to encourage the resident to use the bell to call for assistance. During a review of Resident 84's CP titled Potential for injury, related to use of bilateral upper side rail used as enabler for bed mobility, turning and repositioning, revised on 7/14/2026, the CP intervention indicated to keep the resident's call light within reach. During an observation and concurrent interview with Certified Nurse Assistant 5 (CNA 5) on 8/3/2026 at 1:13 pm, inside Resident 84's room, the resident's call light was hanging off the bed, to the left side of the resident, behind the head of the bed, in between the bed's side rail and mattress. The call light was not within Resident 84's reach. CNA 5 stated Resident 84's call light should be within reach to ensure the resident could call for assistance if/when help was needed. During an interview with the Assistant Director of Nursing (ADON) on 8/6/2026 at 9:02 am, the ADON stated call lights should always be within (the resident's) reach, to call for assistance if the residents needed help. During a review of the facility's Policy and Procedure (P&P) titled Communication - Call System, revised on 8/24/24, the P&P indicated the call alert device will be placed within the resident's reach. During a review of the facility's P&P titled Communication - Call System, revised on 8/29/24, the P&P indicated the facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting/bathing facilities. The purpose was to ensure that residents have a means of contacting facility staff for assistance.

Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for two of two sampled residents (Resident 157 and Resident 196) by failing to:a. Ensure Resident 157's ambient room temperature was between 71 to 81 degrees Fahrenheit ( F - temperature scale) on 8/3/2026. b. Ensure a comfortable sound level was provided for Resident 196 on 8/3/2026.This deficient practice resulted in Resident 157 feeling hot and uncomfortable and Resident 196 feeling scared due to Resident 196's environment being too noisy. Additionally, the deficient practice had the potential to affect Residents 157 and 196's psychosocial well-being. Findings: a. During a review of Resident 157's Face Sheet (FS, admission record), the FS indicated Resident 157 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and lack of coordination.During a review of Resident 157's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 6/25/2026, the MDS indicated Resident 157's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 157 required maximal assistance (helper does more than half the effort) with toileting hygiene and moderate assistance (helper does less than half the effort) with lower and upper body dressing and when going from sitting to standing.During an observation, on 8/3/2026 at 2:33 PM, Resident 157's room felt hot.During an observation and concurrent interview on 8/3/2026 at 2:34 PM with Resident 157 inside the resident's room, Resident 157 was lying in bed, and a thin bed sheet was covering the resident. Resident 157 was fanning himself with his hand and stated, I'm trying to catch some air, its hot in here.During an observation and concurrent interview on 8/3/2026 at 2:37 PM inside Resident 157's room with the Maintenance Technician (MT), the MT took Resident 157's room temperature with the facility's digital thermometer. The following temperatures were obtained by the MT:Wall with the window facing the courtyard = 85 degrees F.Wall above Resident 157's head = 86 degrees F.Entrance door wall = 87 degrees F.The MT stated room temperatures should be 75 degrees F or lower. The MT stated the air-conditioning vents were closed and Resident 157's room felt warmer than the adjacent hallway.During an interview on 8/5/2026 at 1:54 PM with the Director of Nursing (DON), the DON stated temperatures in resident rooms should be comfortable and within the regulated ranges to help the resident's healing process.During a review of the facility 's manual titled, Temperatures May 2026 - August 2026 logs - by Direct Supply, the manual's test and log air temperatures indicated all buildings are required to maintain an ambient temperature throughout resident and patient areas in a temperature range of 71 to 81 degrees F .During a review of the facility's policy and procedure (P&P) titled Resident Rooms and Environment, revised 1/1/2012, the P&P indicated to provide residents with a safe, clean, comfortable and homelike environment. The P&P indicated facility staff aim to create a personalized, home-like atmosphere, paying close attention to comfortable temperatures.b. During a review of Resident 196's FS, the FS indicated Resident 196 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder (a feeling of worry, nervousness, or unease) and psychosis (a mental health problem that causes people to perceive or interpret things differently from those around them).During a review of Resident 196's History and Physical (H&P), dated 4/18/2026, the H&P indicated Resident 196 was alert. During a review of Resident 196's MDS, dated [DATE], the MDS indicated Resident 196 was cognitively (the ability to think and process information) intact, had clear speech, and had the ability to understand and be understood by others. The MDS indicated Resident 196 needed maximal assistance (helper does more than half the effort) with oral and personal hygiene, dressing, and when going from lying to a sitting position.During an observation and interview on 8/3/2026 at 11:27 AM, inside Resident 196's room, Resident 196's was in bed (located closest to the door). Resident 196's roommate (bed located directly next to Resident 196) was singing in a tone well above speaking voice. Resident 196 stated I want to move rooms; my roommate sings and yells all night. I feel like I am hooked up to her. During the same observation, Spanish music was heard coming from the hallway directly outside Resident 196's room. Resident 196 stated that music blasting, that is always on too! Between the singing in here and the noise out there, it's just too noisy. I feel scared cause I don't have any privacy.During an interview on 8/5/2026 at 7:59 AM with Certified Nurse Assistant (CNA) 2, CNA 2 stated, in the past (no date recall), Resident 196 had complained about the noise level inside and outside of the resident's room. CNA 2 stated CNA 2 had informed Licensed Vocational Nurse (LVN) 12 about Resident 196's concerns regarding noise levels. CNA 2 stated resident rooms should be a place of quiet and for resting.During an interview on 8/5/2026 at 8:11 AM with LVN 12, LVN 12 stated LVN 12 was aware of Resident 196's concerns about the noise level inside and outside Resident 196's room and LVN 12 did not document or inform any other staff. LVN 12 stated peace and quiet were important because Resident 196 needed to rest and should enjoy the room for healing.During a review of the facility's policy and procedure (P&P), titled Resident Rooms and Environment, revised on 1/1/2012, the P&P indicated to provide residents with a safe, clean, comfortable, and homelike environment. The P&P indicated facility staff aim to create a personalized, home-like atmosphere, paying close attention to comfortable noise levels.

Based on observation, interview, and record review, the facility failed to intervene and prevent an incident of physical abuse for one of one sampled resident (Resident 173) on 8/6/2026 when Resident 173 entered Resident 41's room and Resident 41 forcibly removed Resident 173 from Resident 41's room.The deficient practice resulted in Resident 41 and Resident 173 falling to the floor due to Resident 41 forcibly grabbing Resident 173's forearm. Additionally, there was a potential for injury and physical harm to Resident 173 and Resident 41.Findings: a. During a review of Resident 41's Face Sheet (FS, admission record), the FS indicated Resident 41 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including aphasia (a brain based language disorder that impairs speaking, understanding, reading, and writing) following unspecified cerebrovascular disease (all conditions that affect the blood vessels and blood supply of the brain), dementia (a gradual decline in mental ability usually caused by a brain disease), and impulse disorder (mental health condition involving a repeated inability to resist harmful urges or aggressive impulses).During a review of Resident 41's History and Physical (H&P), dated 5/10/2026, the H&P indicated Resident 41 had a history of agitation and noncompliance. During a review of Resident 41's Minimum Data Set (MDS- a resident assessment tool), dated 6/1/2026, the MDS indicated Resident 41's cognition (ability to understand and process information) was severely impaired and Resident 41 needed setup or clean-up assistance (helper sets up or cleans up, resident activity) for personal and toileting hygiene. The MDS indicated Resident 41 did not have disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject).b. During a review of Resident 173's FS, the FS indicated Resident 173 was admitted to the facility 6/4/2022 and readmitted on [DATE] with multiple diagnoses including metabolic encephalopathy (loss or change in brain function due to an underlying condition), dementia, and age-related cataract (vision impairing disease characterized by gradual progressive clouding and thickening of the lens of the eye resulting in blurry vision).During a review of Resident 173's Care Plan (CP), initiated 4/5/2026, the CP's focus indicated Resident 173 entered other resident rooms. The CP's interventions indicated to reorient and redirect Resident 173 as needed to room and calmly guide Resident 173 to activity or quiet area without arguing, maintaining a consistent calm presence for the resident. The CP's goal indicated to prevent altercations with other residents, ensure safety, reduce anxiety, and prevent Resident 173 from wandering.During a review of Resident 173's MDS, dated [DATE], the MDS indicated Resident 173's cognition was severely impaired and required partial/ moderate assistance (helper does less than half the effort) for bathing and toileting hygiene.During an interview on 8/6/2026 at 9 AM with Licensed Vocational Nurse (LVN) 10, LVN 10 stated we (the facility) always had at least one Certified Nurse Assistant (CNA) and one activities staff member in the activities/dining room for safety of the residents.During an observation on 8/6/2026 at 11:57 AM in the facility's locked dementia unit, Resident 41 and Resident 173 were observed face to face in the doorway of Resident 41's room. Resident 41 was facing Resident 173 and used both hands to grab Resident 173's forearm while shouting You can't come over here. I told you to stay away! Resident 41 walked backwards while grabbing Resident 173's forearm and forcibly removing Resident 173 from Resident 41's doorway, Residents 41 and 173 fell to the floor.During an interview on 8/6/2026 at 1:33 PM with the Administrator (ADM), the ADM stated the ADM was informed that Resident 173 had entered Resident 41's room by mistake and Resident 41 was the aggressor and told Resident 173 to get out of Resident 41's room. The ADM stated the Activities Assistant (AA) saw one of the residents leave the dining room and asked another staff member for help [LVN 10] because the AA could not leave the dining room.During an interview on 8/6/2026 at 2:10 PM with Resident 41, Resident 41 stated Resident 173 was always in Resident 41's room and that this time they were going to fight. Resident 41 stated Resident 41 knocked down Resident 173 and both residents fell. Resident 41 stated Resident 173 was always in Resident 41's room and Resident 41 was done with it, and meant to hurt Resident 173.During an interview on 8/6/2026 at 2:24 PM with CNA 12, CNA 12 stated staff (in general) were supposed to be in the hallways monitoring residents who entered other residents' rooms. CNA 12 stated Resident 173 was confused and liked to take walks around the unit and sometimes wandered into other resident rooms.During an interview on 8/6/2026 at 2:30 PM with LVN 10, LVN 10 stated LVN 10 heard the AA call for help and then observed Resident 41 coming out of the dining room walking toward Resident 41's room. LVN 10 stated LVN 10 assumed Resident 173 was inside Resident 41's room and yelled out to Resident 41 to wait and stop. LVN 10 stated Resident 41 was territorial over the room and Resident 173 was a resident that staff (general) tried to watch more closely and redirect due to being very confused. During an interview on 8/6/2026 at 2:46 PM with the AA, the AA stated the incident occurred during lunch time after coffee had been passed to the residents in the dining room. The AA stated a CNA (unidentified) was in the dining room with the AA to pass coffee and the CNA left the room to remove the coffee cart and prepare lunch. The AA stated that during the time the CNA left, the AA observed Resident 173 leave the dining room and the AA attempted to redirect Resident 173 back into the dining room. The AA stated the AA was unable to follow Resident 173 because the AA was the only staff member in the dining room left to monitor residents. The AA stated the AA then called LVN 10 for assistance with Resident 173. The AA stated the AA did not witness the incident between Resident 41 and 173 due to monitoring the residents in the dining room and stated the incident between Resident 41 and 173 could have been prevented.During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Management, dated effective 6/12/2024, the P&P indicated physical abuse is defined as, but not limited to, hitting, slapping, punching, and/or kicking. It also includes corporal punishment which is physical punishment used to correct and/or control behavior. The P&P further indicated under 4. Prevention: d. The facility identifies, corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur.

Based on interview and record review, the facility failed to define specific behavioral manifestations related to the use of valproic acid (a mood stabilizing medication) and fluoxetine (an antidepressant medication) in one of five residents sampled for unnecessary medications (Resident 125).These deficient practices had the potential for Resident 125 to be prescribed psychotropic medications for longer, or at a higher dose than is necessary possibly leading to a decline in her quality of life. Findings:During a review of Resident 125's Face Sheet (a summary page that provides key details about a resident), dated 5/27/2026, the Face Sheet indicated that Resident 125 was admitted to the facility on [DATE] with diagnoses including: impulse disorder, obsessive-compulsive disorder (OCD - a mental health condition that involves a cycle of unwanted thoughts (obsessions) and actions (compulsions), autistic disorder (challenges with social skills, repetitive behaviors, speech and nonverbal communication) and depression (a mental illness characterized by depressed mood, insomnia, and lack of energy or interest in usually enjoyable activities).A review of Resident 125's Order Summary Report (a summary of all current physician orders), dated 8/5/2026 indicated Resident 125's attending physician prescribed valproic acid 500 milligrams (mg - a unit of measure for mass) to take by mouth two times a day for mood disorder manifested by poor impulse control and fluoxetine HCl 20mg to take one tablet by mouth one time a day for OCD manifested by repetitive compulsive behaviors.During an interview on 08/05/2026 at 10:42 AM with the Director of Nursing (DON), the DON stated the behaviors for Resident 125's use of valproic acid and fluoxetine are not specific and cannot be objectively monitored. The DON stated that without specific behavioral manifestations linked to the use of psychotropic medications, there is a risk that Resident 125 may be on psychotropic medications longer, or at a higher dose than is necessary to manage her behaviors possibly leading to a decline in her quality of life. During a review of the facility's policy and procedure (P&P) titled, Behavior/Psychoactive Drug Management, dated 3/24/2024, the P&P indicated that any order for psychoactive medications must include a specific behavior manifestation.

Based on interview and record review, the facility failed to accurately complete the minimum data set (MDS - a comprehensive resident assessment tool) assessment Section I (active diagnoses), dated 6/20/2026, by failing to include diagnoses of impulse disorder (group of behavioral conditions that make it difficult to control actions or reactions) and obsessive-compulsive disorder (OCD - a mental health condition that involves a cycle of unwanted thoughts (obsessions) and actions (compulsions)) for one of five residents sampled Residents (Resident 125) for unnecessary medications.This deficient practice had the potential to increase the risk that Resident 125 may not have received care planning and treatment according to Resident 125's needs and possibly leading to a decline in the resident's overall health and well-being. Findings:During a review of Resident 125's Face Sheet (a summary page that provides key details about a resident), dated 5/27/2026, the Face Sheet indicated that Resident 125 was admitted to the facility on [DATE] with diagnoses including: impulse disorder, OCD, autistic disorder (challenges with social skills, repetitive behaviors, speech and nonverbal communication) and depression (a mental illness characterized by depressed mood, insomnia, and lack of energy or interest in usually enjoyable activities).A review of Resident 125's care plan related to the use of aripiprazole and fluoxetine HCl, last revised 6/9/26, indicated Resident 125 was using aripiprazole for inability to resist overwhelming urges and fluoxetine for OCD with repetitive behaviors related to depression.During a review of Resident 125's MDS assessment Section I dated 6/20/2026, the MDS indicated that Resident 125 did not have a diagnosis of impulse control disorder or OCD.A review of Resident 125's MDS assessment Section I, dated 6/20/26, indicated Resident 125 did not have a diagnosis of impulse control or OCD. A review of Resident 125's MDS assessment Section N (medications), dated 6/20/2026, indicated Resident 125 was taking an antipsychotic (aripiprazole), and an antidepressant (fluoxetine) during seven out of seven days in the look back period. A review of Resident 125's Order Summary Report (a summary of all current physician orders), dated 8/5/2026 indicated Resident 125's attending physician prescribed aripiprazole 5 milligrams (mg - a unit of measure for mass) to take one tablet by mouth one time a day for impulse control disorder manifested by throwing self on the floor and fluoxetine HCl 20mg to take one tablet by mouth one time a day for OCD manifested by repetitive compulsive behaviors.During an interview on 08/05/2026 at 10:42 AM with the Director of Nursing (DON), the DON stated the diagnoses for impulse control disorder and obsessive-compulsive disorder are missing from the MDS assessment dated [DATE] Section I. The DON stated the resident assessment must be accurate to ensure that resident specific interventions are care-planned for the resident. The DON stated failing to include relevant diagnoses on the MDS assessments could lead to the resident receiving suboptimal care due to lack of care planned resident-specific interventions possibly leading to a decline in her quality of life. During a review of the facility's policy and procedure (P&P) titled, RAI Process, dated 10/4/2016, the P&P indicated that the facility will provide resident-assessments that accurately depict and identify resident-specific issues and objectives as required.

Based on interview and record review, the facility failed to ensure the preadmission screening and annual resident review (PASARR) assessment screening were complete to determine the facility's ability to provide the special needs services for one of 4 sampled residents (Resident 11).This deficient practice placed Resident 11 at risk of not receiving necessary care and services according to Resident 11's needs.Findings:During a review of Resident 11's face sheet (FS), the FS indicated the resident was originally admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that include unspecified mood [affective] disorder (a mental health condition that causes long-lasting, extreme changes in a person's emotional state), unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic disturbance (a mental state where a person loses touch with reality), mood disturbance, and anxiety, cognitive (the ability to think and process information) communication deficit, unspecified depression, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), recurrent, severe with psychotic symptoms.During a review of Resident 11's History and Physical (H&P), dated 4/16/2026, the H&P indicated, Resident 11 has the ability to make needs known, family making medical decisions.During a review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/10/2026, the MDS indicated the resident is able to make self-understood and has the ability to understand others.During a review of Resident 11's PASRR Level II Evaluation dated 6/14/2026, the PASRR indicated a Serious Mental Illness (SMI) Level II Mental Health Evaluation was not scheduled for the following reason: facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening.During a concurrent interview and record review on 8/5/2026 at 11:21 AM with Minimum Data Set Nurse (MDSN), Resident 11's Notice of Attempted Evaluation, dated 6/14/2026 was reviewed. The Notice of Attempted Evaluation, indicated Serious Mental Illness (SMI) Level II Mental Health Evaluation was not scheduled for the following reason: facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening. The MDSN stated, On the PASRR website the Level II letter stated unable to complete the Level II for serious mental illness. Facility staff were not responsive. Two or more separate attempts of communication within 24 hours of level I screening. Completed on 6/14/2026.During an interview on 8/5/2026 on 11:21 AM with the MDSN, the MDSN stated, The Level II was not completed - PASRR people called on the weekend and if the MDSN was not in the facility and able to help them, they can't complete their evaluation. The MDSN stated the MDSN needs to go on the PASRR website and look up/check the information. The MDSN stated after a couple of days from completing the PASSAR, the letter is downloaded and placed in the MISC (miscellaneous) tab on PCC (PointClickCare, a cloud-based software system used by nursing homes and senior care centers). The MDSN stated Level II letter had the information regarding if the resident's placement into the Skilled Nursing Facility (SNF) is correct or if the resident needs additional [mental health] services.During a review of the facility's policy and procedure (P&P) titled, admission Screening Resident Review (PASRR), dated 6/12/2024, the P&P indicated, 5. The facility MDS Coordinator will be responsible for accessing and ensure updates to the PASRR are completed per MDS guidelines (e.g. Significant Change of Status MDS).During a review of the facility's P&P titled, Pre-admission Screening Level II Resident Review (PASRR Level II), dated 6/12/2024, the P&P indicated, 1. The facility will log onto the PASRR portal daily to check for Level II determinations and evaluators reports.

Based on interview and record review, the facility failed to ensure one of eight sampled resident's (Resident 10's) Preadmission Screening and Resident Review Level 1 (PASRR I - a preliminary assessment to determine whether a person might have severe mental illness [SMI] or intellectual disability [ID/DD/RD]) was completed accurately for submission. This deficient practice resulted in Resident 10's PASRR Level I was negative for SMI and PASRR Level II (assessment for individuals who test positive at PASRR Level I are then evaluated in depth) was not completed for Resident 10 which potentially result in Resident 10 not receiving the necessary and appropriate psychiatric (relating to the medical treatment, study, or care of mental health and mental illness) treatment and services at the facility. Findings: During a review of Resident 10's Face Sheet (FS - admission record), the FS indicated, Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), single episode, unspecified. During a review of Resident 10's History of Present Illness (H&P), dated 5/14/2026, the H&P indicated, Resident 10 was admitted to a hospital on 5/6/2026 on a 5150 hold (an emergency legal rule that lets police or health workers take a person to a hospital against their will for a mental health check) under psychiatric service for psychosis. The H&P indicated, Resident 10 had been awake, responsive, and cooperative with questioning. The H&P indicated, Resident 10 had a psychotic disorder/psychosis. During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 6/5/2026, the MDS indicated, Resident 10's cognitive skills (ability to think and process information) for daily decision making were intact (decisions consistent/reasonable). The MDS indicated, Resident 10 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) to setup or clean-up assistance (helper sets up or cleans up) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 10's Order Summary Review (OSR), active orders as of 8/5/2026, the OSR indicated, an order on 7/18/2026 for Mirtazapine (a prescription medicine used to treat major depression) oral tablet 15 mg (milligrams - metric unit of measurement, used for medication dosage and/or amount), give 1 tablet by mouth at bedtime for depression. During a concurrent interview and record review on 8/5/2026 at 10:45 AM with the Minimum Data Set Nurse (MDSN), Resident 10's medical records including the admission record, physician orders and the PASRR Level 1 Screening dated 9/18/2025 were reviewed. The MDSN stated Resident 10's PASRR Level I Screening dated 9/18/2025 was completed since Resident 10 had a significant change in condition. The PASSR Level 1 Screening indicated, the answer was No to the question Does the Individual have a serious diagnosed mental disorder such as Depressive Disorder.? The MDSN stated Resident 10 was diagnosed with depression on 4/29/2025 and had a physician order for Mirtazapine. The MDSN stated the MDSN filled out the PASSR Level 1 Screening, and the PASSR Level 1 was not accurate. The MDSN stated the answer should have been a Yes to the question Does the Individual have a serious diagnosed mental disorder such as Depressive Disorder.? The MDSN stated, submitting Resident 10's PASRR Level 1 Screening accurately was important to possibly trigger a PASRR Level II and if the facility was an appropriate placement for Resident 10 for special needed services. During an interview on 8/6/2026 at 9:02 AM with the Assistant Director of Nursing (ADON), the ADON stated, completing the PASSR Level I Screening accurately was important so a PASRR Level II would not be missed or conducted and for the staff to be aware if the facility was an appropriate placement for the resident. During a review of the facility's policy and procedure (P&P) titled, admission Screening Resident Review (PASRR), effective date 6/12/2024, the P&P indicated, the facility MDS Coordinator would be responsible for accessing and ensuring updates to the PASRR were completed.

Based on observation, interview, and record review, the facility failed to develop individualized, person-centered comprehensive care plans (CP) for three of three sampled residents (Resident 3, Resident 14, and Resident 81) by failing to:a. Ensure a CP that addressed a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition that can develop after experiencing or witnessing a traumatic event) was developed for Resident 3.b. Ensure a CP that addressed Resident 14's intolerance to certain positions with interventions including positioning options was developed for Resident 14.c. Ensure a CP that addressed multiple episodes of diarrhea was developed for Resident 81.This deficient practice had the potential to result in unmet individualized needs and the potential to negatively affect the delivery of necessary care and services to Resident 3, Resident 14, Resident 81.Cross Reference F690 and F686 Findings: a. During a review of Resident 3's Face Sheet (FS, admission record), the FS indicated the facility admitted Resident 3 on 3/2/2026, with diagnoses including PTSD, schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder (a feeling of excessive worry, nervousness, or fear that can make a person feel tense, uneasy or overwhelmed). During a review of Resident 3's Progress Notes (PN), dated 3/4/2026, the PN indicated Resident 3 was educated on good sleep hygiene, was provided supportive psychotherapy focusing on emotional regulation, coping strategies, and reduction of PTSD symptoms. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 3's cognition (the ability to think and process information) was intact. The MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with mobility. The MDS indicated Resident 3 had an active diagnosis of PTSD. During an interview and concurrent record review on 8/5/2026 at 1:05 PM, Resident 3's MDS, Section I – Active Diagnoses, progress notes, and CPs were reviewed with Registered Nurse (RN) 3, RN 3 stated Resident 3 had an active diagnosis of PTSD and stated Resident 3 did not have an individualized CP that addressed PTSD. RN 3 stated PTSD resulted from a traumatic event, such as a war veteran experiencing combat. RN 3 stated early recognition of Resident 3's specific trauma, needs, and potential triggers was important to develop an individualized, person-centered CP with interventions tailored to the resident's specific trauma. RN 3 stated that individualized interventions would provide staff with guidance to appropriately address and care for Resident 3's PTSD-related needs. During a review of the facility's policy and procedure (P&P) titled Person-Centered Care Planning, revision date 4/24/2026, the P&P indicated: 1.Trauma Informed Care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. 2.The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the comprehensive assessment. The comprehensive assessment plan must describe the following: The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. b. During a review of Resident 14's FS, the FS indicated the facility originally admitted Resident 14 on 2/15/2024 and readmitted the resident on 8/22/2025 with diagnoses including spastic quadriplegic cerebral palsy (abnormal brain development or damage causing muscle stiffness, tightness, and poor motor control in all four limbs, torso, neck, and face), attention to tracheostomy (a surgical opening in the neck leading directly into the windpipe to help a person get air into the lungs when they cannot breathe normally through their mouth or nose), attention to gastrostomy (a medical procedure that creates an opening from the outside of the abdomen directly into the stomach, allows for the placement of a feeding tube), muscle spasm (sudden, forceful muscle contraction), and epilepsy (brain disorder characterized by recurring, unprovoked seizures). During a concurrent review of Resident 14's CP, initiated 2/16/2024, target date 11/1/2026, the CP indicated Resident 14 had the potential for impaired skin integrity, the CP did not indicate specific interventions regarding positioning options for Resident 14. During a review of Resident 14's CP, dated 2/20/2024, with a target date of 11/1/2026, the CP indicated Resident 14 had the potential for the development of pressure ulcers (pressure injuries [PI], lesion/wound caused by unrelieved pressure usually over a bony prominence that results in damage of underlying tissue). The CP did not indicate specific interventions regarding positioning options for Resident 14. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14's cognitive skills for daily decision making were severely impaired. The MDS indicated rarely/never understood verbal content and rarely/never was able to express ideas and wants. The MDS indicated Resident 18 was dependent with all activities of daily living, rolling left and right, and with tub/shower transfers. During observations on 8/4/2026 at the following times, At 8:02 AM Resident 14 was lying in bed, Resident 14's head was turned to toward Resident 14's left shoulder and the right elbow was bent. At 10:24 AM, Resident 14 was lying in bed with Resident 14's head turned toward the left and both elbows were bent. At 12:21 PM, Resident 14 was lying in bed Resident 14's head turned toward the left and both elbows were bent. At 2:45 PM, Resident 14 was lying in bed with Resident 14's head turned toward the left. At 4:26 PM, Resident 14 was lying in bed Resident 14's head turned toward the left. During an observation on 8/5/2026 at 12:43 PM, Certified Nursing Assistant (CNA) 9 turned and repositioned Resident 14 on Resident 14's back at 12:43 PM during an adult brief change. CNA 9 stated after the repositioning, Resident 14's head remained turned toward Resident 14's left side. During an interview on 8/5/2026 at 3:25 PM, CNA 9 stated CNA 9 was caring for Resident 14 and CNA 9 had only repositioned Resident 14 once today because CNA 9 did not want Resident 14 to be in pain. CNA 9 stated Resident 14 cried when Resident 14 was repositioned and started yelling. CNA 9 stated there was no guidance or direction provided to CNA 9 from the nurses (in general) on how to turn and reposition Resident 14. CNA 9 stated, [CNA9's repositioning approach to Resident 14] was mainly CNA 9's idea or plan. During a concurrent record review and interview on 8/6/2026 at 3:41 PM, with Treatment Nurse (TN) 1, Resident 14's CPs were reviewed with TN 1. TN 1 stated interventions in the CPs did not address Resident 14's turning and repositioning needs specific to Resident 14's anatomy and Resident 14's comfort. TN 1 stated there was no CP that addressed Resident 14's intolerance to certain positions with interventions including positioning options in Resident 14's medical record. During a concurrent record review and interview on 8/6/2026 at 4:32 PM, with the Subacute Unit Coordinator (SAUC), Resident 14's CP, dated 2/20/2024, was reviewed. The CP indicated Resident 14 had the potential for further PI development. The SAUC stated Resident 14's anatomy limited Resident 14's positioning. The SAUC stated Resident 14 did not tolerate different positions. The SAUC stated the CP included an intervention to turn and reposition Resident 14 at least every two hours, but the CP did not address Resident 14's intolerance to certain positions or include interventions for positioning options. The SAUC stated Resident 14's CP was not individualized to address Resident 14's position limitations while in bed, specify what positioning devices staff could use, or what positions Resident 14 could tolerate. During a review of the facility's P&P titled Person-Centered Care Planning revision date 4/24/2026, the P&P indicated a Person-centered care plan means that the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. The P&P indicated person-centered care includes making an effort to understand what is important to each resident with regard to daily routines and preferred activities. c. During a review of Resident 81's FS, the FS indicated Resident 81 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM II – adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), and encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 81's Physician/PA/NP PN, dated 6/16/2026, timed at 12:28 PM, the PN indicated Resident 81was alert and oriented x 4 (a person is awake and correctly knows who they are, where they are, the time, and the situation) and decision capacity was present. During a review of Resident 81's MDS, dated [DATE], the MDS indicated, Resident 81's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 81 was dependent (helper does all of the effort) with ADL including toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). The MDS indicated Resident 81 was always incontinent (lack of control) of bowel movements. During a review of Resident 81's Bowel Elimination (BE), dated 6/2026, 7/2026, and 8/2026, the BEs indicated, Resident 81 had multiple episodes of loose/diarrhea. During an observation on 8/3/2026 at 8:28 AM, Station 1 south side hallway had a malodorous odor. During an observation on 8/3/2026 at 9:49 AM, Station 1 south side hallway had a malodorous odor. During an interview on 8/3/2026 at 10:41 AM with Resident 81's Emergency Contact (EC), the EC stated, Resident 81 had a bowel movement and the EC could smell Resident 81's stool from the outside of Resident 81's shared room, is that my mom? During an observation on 8/3/2026 at 11:17 AM, Station 1 south side hallway had a malodorous odor. During a concurrent observation and interview on 8/4/2026 at 7:40 AM with Resident 7, Resident 7 was sitting up in a wheelchair at the doorway of Resident 81 and Resident 7's shared room. Station 1 south side hallway and the shared room had a malodorous odor. Resident 7 was upset and stated, am pissed [angry or annoyed] and complained about the smell. Resident 7 stated, the smell had been here since, it wasn't even 7:00 [AM] yet. During an observation on 8/4/2026 at 7:45 AM with CNA 3 and CNA 6, Resident 81 was in bed. Resident 81's diaper was soiled with large runny brown colored foul-smelling diarrhea spilling out of Resident 81's diaper. During an interview on 8/4/2026 at 8:00 AM with CNA 6, CNA 6 stated, Resident 81 had diarrhea for a week and a half because Resident 81 was on antibiotics (a powerful medicine used to treat infections caused by bacteria). During an interview on 8/5/2026 at 1:41 PM with CNA 1, CNA 1 stated Resident 81 was dependent and required diaper changes and Resident 81 was having a lot of smell too much, smell bad, diarrhea the last 3 days. During a concurrent interview and record review on 8/5/2026 at 1:59 PM with Licensed Vocational Nurse (LVN) 4, Resident 81's BEs were reviewed. LVN 4 stated LVN 4 was aware of Resident 81's foul smelling diarrhea and noticed the diarrhea when LVN 4 provided treatment to Resident 81. LVN 4 stated implementing interventions such as notifying Resident 81's physician, conducting a change in condition, and creating a CP was important. During an interview on 8/6/2026 at 9:02 AM with the Assistant Director of Nursing (ADON), the ADON stated creating a CP was important since a CP had a goal and interventions that guided staff for the resident's (in general) problem. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, effective date 9/7/2023, the P&P indicated, the facility would provide person-centered, comprehensive, and interdisciplinary care that reflected best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to revise care plans (CP) for two of two sampled residents (Resident 14 and 199) who had limited range of motion (ROM, full movement potential of a joint) by failing to:a. Accurately revise Resident 14's CP for interventions related to activities of daily living ([ADLs] basic tasks that individuals perform to maintain their daily lives and independence) after each Minimum Data Set (MDS- a resident assessment tool), dated 11/17/2025, 2/13/2026, and 5/11/2026.b. Accurately revise Resident 199's CP interventions related to both arm contractures (stiffening/shortening at any joint that reduces the joint's range of motion) after each MDS, dated [DATE], 1/23/2025, 4/20/2026, and 7/7/2026.This failure resulted in inaccurate interventions to address Resident 14 and 199's ROM limitations which had the potential to affect the resident's provision of care.Findings:a. During a review of Resident 14's Face Sheet (FS, admission record), the FS indicated the facility originally admitted Resident 14 on 2/15/2024 and readmitted on [DATE] with diagnoses including spastic quadriplegic cerebral palsy (abnormal brain development or damage causing muscle stiffness, tightness, and poor motor control in all four limbs, torso, neck, and face), attention to tracheostomy (hole made through the front of the neck and into the windpipe (trachea) to allow air into the lungs), attention to gastrostomy tube (surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), muscle spasm (sudden, forceful muscle contraction), and epilepsy (brain disorder characterized by recurring, unprovoked seizures).During a review of Resident 14's CP titled, The resident has an ADL self-care performance deficit, initiated 6/17/2024, the CP's interventions, initiated 7/11/2025, included Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) for passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both legs, five times per week or as tolerated.During a review of Resident 14's MDS, dated [DATE], 2/13/2026, and 5/11/2026, the MDS indicated Resident 14 had did not have speech, rarely/never expressed needs and wants, rarely/never understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 14 had ROM limitations in both arms and legs and was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for oral hygiene, toileting hygiene, showering/bathing, dressing, and rolling to either side while lying in bed. During a review of the Order Listing Report for residents receiving RNA services, dated 8/6/2026, timed at 7:45 a.m., the Order Listing Report did not include Resident 14. During an observation on 8/6/2026 at 9:50 a.m. in Resident 14's room, Resident 14 was lying in bed with the head rotated to the left side. Both of Resident 14's elbows were observed in a flexed (bent) position and the fingers in both hands were bent into a fist. Both of Resident 14's hips were rotated to the left and both knees were in a slightly bent position. During a concurrent interview and record review on 8/6/2026 at 2:31 p.m. with Registered Nurse 5 (RN 5), Resident 14's current physician's orders were reviewed. RN 5 stated Resident 14 had not received RNA services since readmission. During an interview on 8/7/2026 at 10:39 a.m. with the MDS Nurse (MDSN), MDSN stated the MDS (in general) was an assessment to determine any decline or changes in a resident. The MDSN stated the MDS assessments (in general) also generated resident-centered CPs for the provision of a resident's care.During a concurrent interview and record review on 8/7/2026 at 10:59 a.m. with the MDSN, Resident 14's MDS assessments, dated 11/17/2025, 2/13/2026, and 5/11/2026, and CPs for ADLs were reviewed. The MDSN stated Resident 14's MDS assessments indicated Resident 14 had ROM impairments to both arms and legs and was not receiving RNA services. The MDSN stated Resident 14's CP revision for the MDS, dated [DATE], was completed on 11/23/2025. The MDSN stated Resident 14's CP revision for the MDS, dated [DATE], was completed on 2/14/2026. The MDSN stated Resident 14's CP revision for the MDS, dated [DATE], was completed on 5/12/2026. The MDSN reviewed Resident 14's CPs for ADLs which indicated interventions to provide RNA for PROM to both legs. The MDSN stated Resident 14's CP interventions were not accurate. During an interview on 8/7/2026 at 11:58 a.m. with the Director of Nursing (DON), the DON stated inaccurate CP (in general) interventions may prevent the provision of appropriate care to the resident.b. During a review of Resident 199's FS, the FS indicated the facility originally admitted Resident 199 on 6/2/2015 and readmitted the resident on 10/29/2025 with diagnoses including respiratory failure (serious condition that develops when the lungs cannot get oxygen into the blood), attention to tracheostomy (a surgical opening in the neck leading directly into the windpipe to help a person get air into the lungs when they cannot breathe normally through their mouth or nose), attention to gastrostomy (a medical procedure that creates an opening from the outside of the abdomen directly into the stomach, allows for the placement of a feeding tube), quadriplegia (paralysis from the neck down, including arms and legs), and contractures to both shoulders, both knees, and multiple (unspecified) muscle sites. During a review of Resident 199's CP titled, severe contractures to BUE (both arms), rigid (stiff) muscle tone to BUE, initiated 5/31/2023, the CP's interventions, initiated 6/5/2022, included ordering both knee splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for contracture management. During a review of Resident 199's MDS, dated [DATE], the MDS indicated Resident 199 had ROM limitations in both arms and legs and was dependent for oral hygiene, toileting hygiene, showering/bathing, dressing, and rolling to either side while lying in bed. During a review of Resident 199's Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 10/31/2025, the OT Evaluation indicated Resident 199 had (unspecified) ROM limitations with contractures in both shoulders, elbows, and hands. The OT Evaluation indicated Resident 199 had hand rolls (soft roll positioned in the palm of the hand and fastened with a strap) for both hands. During a review of Resident 199 OT Discharge summary, dated [DATE], the OT Discharge Summary indicated recommendations for the RNA to provide PROM exercises and apply both hand rolls for four to six hours, five days per week.During a review of Resident 199's physician's orders, dated 11/20/2025, the physician's orders indicated for the RNA to apply Resident 199's left-hand and right-hand rolls, four to six hours per day, five times per week, as tolerated. During a review of Resident 199's MDS, dated [DATE], 4/20/2026, and 7/7/2026, the MDS indicated Resident 199 did not have speech, rarely/never expressed needs and wants, rarely/never understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 199 had ROM limitations in both arms and legs and was dependent for oral hygiene, toileting hygiene, showering/bathing, dressing, and rolling to either side while lying in bed. During an observation on 8/6/2026 at 9:40 a.m. in Resident 199's room, Resident 199 was lying in bed with the head turned toward the right side. Both of Resident 199's elbows were observed in a flexed (bent) position and the fingers in both hands were bent into a fist over a hand roll. Both of Resident 199's hips were observed rotated toward the right side with both hips and knees bent. During a review of Resident 14's CP titled, Resident is on the RNA Program and is at risk for contractures, decreased ROM, decline in mobility/ADLs, initiated 7/11/2025 and revised 8/6/2026, the CP's interventions, initiated 8/6/2026, included RNA to provide PROM to both arms, five times per week as tolerated, and apply both hand rolls four to six hours per day, five times per week as tolerated. During a concurrent interview and record review on 8/7/2026 at 10:39 a.m. with the MDSN, Resident 199's CP for severe contracture to both arms, initiated 5/31/2023, the CP for RNA program, initiated 7/11/2025, and MDS assessments, dated 10/30/2025, 1/23/2025, 4/20/2026, and 7/7/2026, were reviewed. The MDSN stated the MDS (in general) was an assessment to determine any decline or changes in a resident. The MDSN stated MDS assessments (in general) also generated resident-centered CPs for the provision of a resident's care. The MDSN stated Resident 199's CP revision for the MDS, dated [DATE], was completed on 11/4/2025. The MDSN stated Resident 199's CP revision for the MDS, dated [DATE], was completed on 1/24/2025. The MDSN stated Resident 199's CP revision for MDS, dated [DATE], was completed on 4/23/2026. The MDSN stated Resident 199's CP revision for MDS, dated [DATE], was completed on 7/9/2026. The MDSN stated Resident 199's CP for severe contractures to both arms, initiated 5/31/2023, had an inaccurate intervention of ordering both knee splints. The MDSN stated Resident 199's CP intervention for both knee splints should have been discontinued. The MDSN stated Resident 199's CP for RNA, initiated 7/11/2025, did not include the provision of Resident 199's PROM to both arms and application of both hand rolls until yesterday [8/6/2026]. The MDSN stated Resident 199's CP interventions for the RNA program should have been updated during the quarterly reviews. The MDSN stated inaccurate CPs were not resident-centered. During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, revised 4/24/2025 and effective 5/22/2025, the P&P indicated care plan interventions included actions, treatments, procedures, or activities designed to meet an objective. The P&P also indicated the comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Based on observation, interview and record review, the facility failed to ensure one of one sampled resident's (Resident 160), peripheral intravenous (IV - into or within a vein) Heplock (H/L - a medical device catheter placed in a vein to administer medication or fluid into the bloodstream) was labeled and dated in accordance with the facility's policy and procedure (P&P), titled Catheter Insertion and Care. This deficient practice could potentially result in the healthcare staff being unable to verify when the H/L IV was placed or due for a change and could increase the risk of complications from an old H/L access including infiltration (when IV fluid leaks into tissue because of improper catheter placement or dislodgement), phlebitis (inflammation of a vein) and bloodstream infection (the invasion and growth of germs in the body) that could potentially compromise Resident 160's safety.Findings: During a review of Resident 160's Face Sheet (FS), the FS indicated, Resident 160 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), unspecified, and unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic (relating to or affected with a psychosis - a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) disturbance, mood disturbance, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 160's History and Physical Examination (H&P), dated 3/17/2026, the H&P indicated Resident 160 did not have the capacity to understand make decisions. During a review of Resident 160's Minimum Data Set (MDS - a resident assessment tool), dated 7/20/2026, the MDS indicated, Resident 160's cognitive skills (ability to think and process information) for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated, Resident 160 was dependent (helper does all of the effort) to requiring setup or clean-up assistance (helper sets up or cleans up) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 160's Order Summary Report (OSR), active orders as of 8/3/2026, the OSR indicated an order on 7/29/2026 to check IV site dressing and monitor for signs or symptoms of infection at site every shift. During a concurrent observation and interview on 8/3/2026 at 11:31 AM with Registered Nurse (RN) 1, Resident 160 was asleep in bed. Resident 160 had a pink colored ACE bandage wrap (a brand of elasticized long bandage) around Resident 160's left hand. Underneath the ACE bandage wrap was an inserted H/L IV with an unlabeled/undated dressing (a protective or supportive covering) on. RN 1 stated, Resident 160 was on IV antibiotic (a powerful medicine used to treat infections caused by bacteria) and labeling the H/L IV dressing and changing the H/L IV every forty-eight (48) hours were important to prevent infection and issues with the site (H/L IV). During an interview on 8/6/2026 at 9:02 AM with the Assistant Director of Nursing (ADON), the ADON stated, flushing the H/L IV daily and changing the H/L IV dressing as needed and dating and initialing the dressing were important for staff to know when the dressing was last changed, we want patient safety. During a review of the facility's P&P titled, Catheter Insertion and Care, effective date July 2013, the P&P indicated, label on dressing should include date and time of dressing placement, initials, gauge size, and length of catheter.

Based on observation, interview and record review, the facility failed to ensure care and services were provided to prevent the development of pressure ulcers (PU- localized damage to the skin and/or underlying soft tissue as a result of intense and/or prolonged pressure. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful) for one of three residents (Resident 14) when the facility failed to;1. Ensure Resident 14 was turned and repositioned every 2 hours by ensuring Nursing Assistants (CNAs) were given clear interventions or directions on how to turn and reposition Resident 14 who had limitations to repositioning in bed due to contractures.2. Ensure licensed nurses monitored CNAs on Resident 14's turning and repositioning in accordance with Resident 14's care plan. These deficient practices resulted in Resident 14 developing a dark discoloration on Resident 14's left ear.Findings:During a review of Resident 14's Face sheet (FS), the FS indicated the facility originally admitted Resident 14 on 2/15/2024 and readmitted the resident on 8/22/2025 with diagnoses including spastic quadriplegic cerebral palsy (abnormal brain development or damage causing muscle stiffness, tightness, and poor motor control in all four limbs, torso, neck, and face), attention to tracheostomy (a surgical opening in the neck leading directly into the windpipe to help a person get air into the lungs when they cannot breathe normally through their mouth or nose), attention to gastrostomy (a medical procedure that creates an opening from the outside of the abdomen directly into the stomach, allows for the placement of a feeding tube), muscle spasm (sudden, forceful muscle contraction), and epilepsy (brain disorder characterized by recurring, unprovoked seizures). During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool) dated 5/11/2026, the MDS indicated Resident 14's cognitive skills for daily decision making were severely impaired. The MDS indicated rarely/never understood verbal content and rarely/never was able to express ideas and wants. The MDS indicated Resident 18 was dependent with all activities of daily living, rolling left and right, and with tub/shower transfers. During observations of Resident 14 on 8/4/2026 at the following times:At 8:02 AM Resident 14 was lying in bed, Resident 14's head was turned toward Resident 14's left shoulder and the right elbow was bent.At 10:24 AM, Resident 14 was lying in bed with Resident 14's head turned toward the left and both elbows were bent.At 12:21 PM, Resident 14 was lying in bed Resident 14's head turned toward the left and both elbows were bent.At 2:45 PM, Resident 14 was lying in bed with Resident 14's head turned toward the left.At 4:26 PM, Resident 14 was lying in bed Resident 14's head turned toward the left. During an observation of Resident 14 on 8/5/2026 at 12:43 PM, Certified Nursing Assistant (CNA) 9 turned and repositioned Resident 14 on Resident 14's back during an adult incontinence brief change. CNA 9 stated after the repositioning, Resident 14's head remained turned toward Resident 14's left side. The Subacute Unit Coordinator (SAUC) was called to assess Resident 14 and the SAUC stated the tip of Resident 14 left ear was blanchable and the upper part of the left ear with discolored area remained dark red in color. During an interview on 8/5/2026 at 3:25 PM, CNA 9 stated CNA 9 was caring for Resident 14 and CNA 9 had only repositioned Resident 14 once today because CNA 9 did not want Resident 14 to be in pain. CNA 9 stated Resident 14 cried when Resident 14 repositioned and started yelling. CNA 9 stated there was no guidance or direction provided to CNA 9 from the licensed nurses (in general) on how to turn and reposition Resident 14. CNA 9 stated, CNA 9's repositioning approach to Resident 14 was mainly CNA 9's idea or plan. During a review of the document titled, Change in Condition, dated 8/5/2026 at 1:24 PM, the COC indicated there was discoloration to Resident 14's left ear. The COC indicated the discoloration to Resident 14's left ear was started 8/5/2026. During a concurrent observation and interview on 8/6/2026 at 3:41 PM, with Treatment Nurse (TN) 1. Resident 14 was lying in bed, with the head turned towards the left shoulder. TN 1 stated Resident 14's position would put Resident 14's left ear directly on the bed and there was no offloading of Resident 14's left ear. TN 1 stated there would be a risk for the pressure injury to worsen and the injury to open into a pressure ulcer. During a concurrent record review and interview on 8/6/2026 at 4:32 PM, with the SAUC, Resident 14's CP, dated 2/20/2024, was reviewed. The CP indicated Resident 14 had the potential for further PI development. The SAUC stated Resident 14's anatomy limited Resident 14's positioning. The SAUC stated Resident 14 did not tolerate different positions. The SAUC stated the CP included an intervention to turn and reposition Resident 14 at least every two hours, but the CP did not address Resident 14's intolerance to certain positions or include interventions for positioning options. The SAUC stated Resident 14's CP did not address Resident 14's position limitations while Resident 14 was lying in bed to specify what positioning devices staff could use, or what positions Resident 14 could tolerate. The SAUC stated the left ear discoloration could worsen into a pressure ulcer. During an interview on 8/6/2026 at 5:06 PM with Registered Nurse (RN) 3, RN 3 stated RN 3 verbally reminded the CNAs to turn and reposition Resident 14 to ensure the turning and repositioning were completed. During a review of the RN Supervisor Job Description, undated, the Job Description indicated the RN Supervisor would make resident rounds to ensure appropriate care is being rendered, identifying and making corrections as necessary. The RN Supervisor would assist in the supervision and direction of nursing personnel. During an interview on 8/7/2026 at 12:19 PM, the Director of Nursing (DON) stated the task of the Supervisor and the SAUC would be to monitor and report to the DON when there are any issues with the provision of care to the residents in the subacute unit. During a review of the facility's Policy and Procedure (P&P) titled, Pressure Injury Prevention, dated 7/31/2024, the P&P indicated to implement interventions identified in the plan of care which may include, but are not limited to.turn and reposition.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 206), who was receiving enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) received appropriate care and services to prevent potential complications by failing to properly store and cap/cover the feeding tube connector tip when the tube feeding was not connected to Resident 206.This deficient practice could potentially result in contamination of the tube feeding leading to bacterial (microscopic, single celled living organism some can cause disease) growth, an infection (the invasion and growth of germs in the body), and severe to Resident 206. Findings:During a review of Resident 206's Face Sheet (FS, admission record), the FS indicated Resident 206 was admitted to the facility 6/30/2026 with multiple diagnoses including dysphagia (difficulty swallowing) following nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status.During a review of Resident 206's Minimum Data Set (MDS - a resident assessment tool), dated 7/2/2026, the MDS indicated Resident 206's cognitive skills (ability to think and process information) for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 206 was dependent (helper does all of the effort) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 206's History and Physical Examination (H&P), dated 7/31/2026, the H&P indicated Resident 206 did not have the capacity to understand make decisions.During a review of Resident 206's Order Summary Report (OSR), active orders as of 8/3/2026, the OSR indicated a physician's order, dated 7/30/2026 for enteral feeding, two times a day, Jevity 1.5 (a high calorie liquid nutrition that is given to residents via tube feeding) at sixty (60) milliliters/hr (ml, a metric unit of volume per hour) via pump x (times) twenty (20) hours.via (GT - gastrostomy tube, soft flexible tube surgically inserted directly into the stomach through a small opening in the abdomen, used to deliver liquid nutrition, hydration, and medications for people who cannot eat or swallow safely) for indication/dx (diagnosis) of poor intake, on at 1400 [2:00 PM], off at 1000 [10:00 AM] or until the dose was met.During a review of Resident 206's care plan (CP), initiated 7/31/2026, the CP indicated Resident 206 was dependent with tube feeding r/t [related to] dysphagia, swallowing problem. The CP indicated one of the goals was for Resident 206 to remain free of side effects or complications related to tube feeding.During a review of Resident 206's Medication Administration Record (MAR), dated 8/1/2026 - 8/31/2026, the MAR indicated Resident 206 received tube feeding daily, on at 1400 (2:00 PM) and off at 1000 [AM].During a concurrent observation and interview on 8/3/2026 at 1:03 PM with Licensed Vocational Nurse (LVN) 2, Resident 206 was awake in bed but was unable to cummunicate. Resident 206's Jevity 1.5 calorie tube feeding dated 8/3/2026, timed at 6:00 AM with 800 ml left in the bottle, was on top of the tube feeding pump located at the bedside on Resident 206's left side. The tube feeding tubing was hanging down from the feeding pump with the tubing connector tip open to air, not capped or covered, and was a foot or less from the floor. LVN 2 stated Resident 206's tube feeding tubing was hanging and the tip should be covered. LVN 2 stated it was important to keep the tubing covered to not get the feeding contaminated since the tube feeding was going to be connected to Resident 206 and for infection control.During an interview on 8/6/2026 at 9:02 AM with the Assistant Director of Nursing (ADON), the ADON stated, tube feeding tubing should be covered or capped when not connected to a resident to prevent negative outcomes like infection or GI [gastrointestinal - digestive tract] upset, and for infection control.During a review of the facility's policy and procedure (P&P) titled, Enteral Tube Management: Nasogastric Tube, Gastrostomy Tube, and Jejunostomy Tube effective date 10/10/2023, the P&P indicated, the facility's policy was to maintain patency and safety of enteral tubes before initiating enteral feeding, hydration, and medication administration.

Based on observation, interview, and record review, the facility failed to provide respiratory (relating to breathing) care and services for two of nine sampled residents (Resident 18 and Resident 160) when the facility failed to:1. Ensure the emergency equipment was completed and placed at Resident 18's bedside as part of the Tracheostomy (opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube [trach tube] through it to provide an airway and to remove secretions from the lungs. The person with a tracheotomy breathes through the tracheostomy tube [trach tube] rather than through the nose and mouth) Care for residents with a tracheostomy. These deficient practices had the potential for Resident 18 not being able to keep an open airway in case of emergent removal of the trach tube. Findings: During a review of Resident 18's Face Sheet (FS, summary of a resident's information), the FS indicated the facility admitted Resident 18 on 1/23/2024, with diagnoses that included anoxic brain damage (type of acquired brain injury that occurs when cells in the brain do not receive enough oxygen), dependence on respirator (ventilator - a machine that breathes for you if you cannot breathe on your own), tracheostomy. During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 6/8/2026, the MDS indicated Resident 18 rarely/never understands verbal content and rarely/never able to express ideas and wants. The MDS indicated Resident 18 was dependent on all activities of daily living, rolling left and right and with tub/shower transfers. During an observation on 8/5/2026 at 7:19 AM inside Resident 18's room, Resident 18 was lying in bed with a trach tube (short for tracheostomy tube, a curved plastic or metal tube placed into a surgically make hole in the windpipe [trachea] to help a person breathe when that person normal airway is blocked or bypassed), type 1 size 8 labeled on the face plate (flange - extends from either side of the trach tube and rest on the neck) of the tracheostomy tube. Respiratory Therapist (RT) 1 checked Resident 18's emergency equipment. There was a trach tube Type 1 size 7, and a manual resuscitator. During an interview on 8/5/2026 at 7:25 AM, RT 1 stated for the emergency equipment at the bedside, a spare tracheostomy tube of the same size which is a trach tube Type 1 size 8 and a smaller size, trach tube Type 1 size 7 and an Ambu Bag (short for Artificial Manual Breathing Unit, also called a bag-valve-mask or [BVM] is a handheld medical tool. It is used to push air into a patient's lungs when the patient could not breathe well or could not breathe at all) needed to be at the bedside. RT 1 stated a smaller size trach tube is important to ensure an open airway if the original size tube (trach tube size 8) will not fit due to swelling of the airway tract. RT 1 stated the use of the smaller size trach tube may cause a leak and inadequate ventilation. RT 1 stated a trach tube of the same size needed to be at the bedside to be used first to keep the airway open. During an interview on 8/5/2026 at 1:10 PM with the Subacute Coordinator (SAUC), the SAUC stated the same sized trach tube, a one size smaller trach tube, and an Ambu Bag are the emergency equipment that needed to be kept at the bedside for all residents [including Resident 10] who is dependent on the tracheostomy for breathing. During a review of the facility's Policy and Procedure (P&P) titled, Tracheostomy Care, dated 10/31/2025, the P&P indicated to validate that emergency replacement tracheostomy tubes are available at bedside, one tracheostomy tube the same size and type the resident is using, one tracheostomy tube one size smaller than what the resident is currently using. Validate that an emergency manual resuscitator is at the bedside.

Based on interview and record review, the facility failed to provide trauma-informed care for one (1) of 1 sample resident (Resident 3) by not ensuring that the resident received adequate care and services to address Resident 3's Post-Traumatic Stress Disorder (PTSD-a mental health condition that can develop after someone has experienced a deeply disturbing or frightening event).This resulted in inadequate attention to Resident 3's specific trauma-related needs.Findings:During a review of Resident 3's Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility admitted Resident 3 on 3/2/2026, with diagnoses including PTSD, schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder (a feeling of excessive worry, nervousness, or fear that can make a person feel tense, uneasy or overwhelmed).During a review of Resident 3's Progress Notes (PN), dated 3/4/2026, the PN from the Nurse Practitioner (NP) indicated that Resident 3 was educated on good sleep hygiene was provided supportive psychotherapy focusing on emotional regulation, coping strategies, and reduction of PTSD symptoms.During a review of Resident 3's Trauma Informed Care Screen (TICS), dated 3/5/2026, the (TICS) indicated that Resident 3 had not experienced a traumatic event.During a review of Resident 3's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 6/2/2026, the MDS indicated Resident 3's cognition (the ability to think and process information) was intact. The MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with mobility. The MDS indicated Resident 3 had an active diagnosis of PTSD.During an interview and concurrent record review on 8/5/2026 at 1:05 PM, Resident 3's (MDS), Section I - Active Diagnoses, (PN), and (TICS) were reviewed with Registered Nurse (RN) 3, RN 3 acknowledged Resident 3 had an active diagnosis of PTSD and that the NP's (PN) documented supportive psychotherapy focusing on emotional regulation, coping strategies, and reduction of PTSD symptoms. RN 3 stated the (TICS) indicated Resident 3 had not experienced a traumatic event, which was inconsistent with the documented active PTSD diagnosis and the NP's (PN). RN 3 stated that the interdisciplinary team (IDT, a group of healthcare staff from different areas who work together to plan and provide a resident's care) should have followed up on the discrepancy and made reasonable efforts to identify the resident's trauma history through the resident, responsible party, primary care provider (PCP), or NP. RN 3 stated identifying the Resident 3's trauma history and potential triggers was necessary to develop individualized trauma-informed interventions, guide staff in appropriately addressing the resident's needs, and prevent potential triggers and re-traumatization.During an interview and concurrent record review on 8/7/2026 at 11:45 AM, Resident 3's (TICS), and the NP's (PN) were reviewed with the Social Services Assistant (SSA). The SSA acknowledged the (TICS) was completed but stated she was unaware of the NP's progress notes addressing PTSD symptoms and Resident 3's active PTSD diagnosis. The SSA stated that additional follow-up should have been conducted to identify the residents' trauma history and potential triggers. The SSA acknowledged that if the information could not be obtained from the resident himself, the facility should have followed up with the responsible party and/or the NP. The SSA stated that identifying Resident 3's trauma history and potential triggers was necessary to develop individualized trauma-informed interventions and minimize the risk of triggering or re-traumatizing the resident.During a review of the facility's policy and procedure (P&P) titled, P-NP147 Trauma Informed Care - Screening, Training, and Care Integration Program, dated 3/21/2025, the P&P indicated:That the facility will ensure residents who are trauma survivors receive culturally competent, trauma informed care; account for resident experience and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.To address the health, safety, welfare, dignity, and respect for residents with mental and psychosocial disorders as well as residents with a history of trauma and/or post-traumatic stress disorder.

Based on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff to provide restorative services (treatments and care designed to repair, rebuild, or bring a resident back to their original normal function and health such as physical, occupational, speech therapy, and range of motion [ROM, structured physical therapy or caregiving interventions designed to measure preserve or improve the degree of movement around a body joint] exercises) to meet resident's plan of care for two of 20 sampled residents (Resident 18 and Resident 199) in the sub-acute unit (SAU, a transitional health care department that provides goal-oriented, specialized medical and rehabilitative care for residents who are stable enough to leave an acute care hospital but are too fragile to recover safely at home).This deficient practice resulted in Certified Nursing Assistants (CNA's, in general) not providing restorative services in the SAU on 8/4/2026 and 8/5/2026 for Residents 18 and 199 and had the potential for the residents to develop contractures (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) or worsening of contractures leading to discomfort, pain, and physical declines.Cross Reference F688Findings:a. During a review of Resident 18's Facesheet (FS, admission record), the FS indicated the facility admitted Resident 18 on 1/23/2024 with diagnoses that included anoxic brain damage (type of acquired brain injury that occurs when cells in the brain do not receive enough oxygen [a colorless gas essential to living organisms]), dependence on respirator (ventilator, a medical machine that moves air in and out of the lungs when the resident cannot breathe well on their own).During a review of Resident 18's care plan (CP), initiated 1/27/2024, the CP indicated Resident 18 had limited physical mobility related to contractures and disease process. The CP indicated Resident 18 was dependent (helper does all of the effort, the resident does none of the effort to complete the activity) on staff for activities of daily living needs. The CP's interventions indicated to provide Restorative Nurse Assistant (RNA, nurse assistants with extra training to help residents regain or maintain mobility, strength, and independence in activities of daily living) in accordance with the physician's order.During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 6/8/2026, the MDS indicated Resident 18's cognitive (the ability to think and process information) skills for daily decision making were severely impaired. The MDS indicated Resident 18 was dependent with all activities of daily living, rolling left and right and with tub/shower transfers.During a review of Resident 18's Order Summary Report (OSR), dated active as of 8/6/2026, the OSR indicated a physician's order for RNA:1.RNA to provide passive range of motion (PROM, moving a joint through its full capacity with the help of an outside force such as a physical therapist, RNA, or a mechanical device, while the person keeps the resident's muscles completely relaxed) to the left and right lower extremities (legs) 5 times a week or as tolerated, order date 7/18/2026.2.RNA to provide PROM to the left and right upper extremities (arms) 5 times a week or as tolerated, order date 7/18/2026.3.RNA to apply a left elbow splint 4-6 hours per day, 5 times a week or as tolerated Monday to Friday, order date 7/17/2026.4.RNA to apply left and right hand splints, 4-6 hours per day, 5 times a week or as tolerated Monday to Friday, order date 7/17/2026.During multiple observations on 8/4/2026 at 7:51 AM, 9:08 AM, 12:19 PM, and at 2:43 PM and at 4:22 PM, CNA 9 did not provide ROM services to Resident 18, no splints were applied to the left elbow or the right and left hands.During an observation on 8/5/2026 in the SAU from 7:19 AM to 3:00 PM, CNA 9 turned, repositioned, and provided incontinent (involuntary loss of bladder [hollow muscular balloon-like organ that stores urine] or bowel control) care to Resident 18 during the following times; at 8:05 AM, from 10:19 AM to 10:51 AM, and from 1:10 PM to 1:18 PM. CNA 9 did not provide RNA services and no splints were applied to Resident 18's left elbow or the right and left hands.b. During a review of Resident 199's FS, the FS indicated the facility admitted Resident 199 on 6/2/2015 and readmitted the resident 10/29/2025 with diagnoses that included cerebral palsy (disorders that affect a person's ability to move and maintain balance and posture) and contractures.During a review of Resident 199's CP, initiated on 7/11/2025, the CP indicated Resident 199 was in the RNA Program and was at risk for contractures, decreased ROM, decline in mobility/ADLs, and musculoskeletal complications. The CP indicated interventions to assist Resident 199 in performing movements/tasks.During a review of Resident 199's MDS, dated [DATE], the MDS indicated Resident 18's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 18 was dependent with all activities of daily living, rolling left and right, and with tub/shower transfers.During a review of 199's OSR, dated active as of 8/6/2026, the OSR indicated the following RNA orders;1. RNA to provide PROM exercises to the left and right upper extremities daily 5 times per week or as tolerated Monday to Friday, dated 11/20/2025.2. RNA to apply roll (a hand support designed to keep fingers from curling tightly into the palm, preventing fingernails from injuring the skin, absorb moisture, and gently encourage joint extension) to the left and right hands, 4-6 hours per day, 5 times per week or as tolerated Monday to Friday, dated 11/20/2025.During multiple observations on 8/4/2026 at 7:56 AM, 10:05 AM, 12:17 PM, 2:40 PM and at 4:24 PM, CNA 9 did not provide ROM services to Resident 199's upper extremities and did not apply a roll to Resident 199's left or right hands.During an observation on 8/5/2026 at 7:19 AM to 3:00 PM in the SAU, CNA 9 turned, repositioned, and provided incontinent care to Resident 199. At 2:27 PM, CNA 9 provided a shower to Resident 199. CNA 9 did not provide ROM services to Resident 199's upper extremities and did not apply a roll to Resident 199's left or right hands.During an interview on 8/5/2026 at 3:35 PM, CNA 9 stated CNA 9 did not have time to provide ROM exercises or services to CNA 9's assigned residents including Resident 18 and Resident 199 on 8/4/2026, and 8/5/2026. CNA 9 stated, aside from being assigned to provide RNA services, CNA 9 needed to complete CNA tasks for all of CNA 9's assigned residents. CNA 9 stated the facility's Director of Nursing (DON), Administration (ADM), the Director of Rehabilitation (DOR) and the SAU Coordinator (SAUC) added RNA services to CNA tasks starting July 2026 and the day shift (7:00 to 3:00 PM) CNA's met with the DON, ADM, and SAUC to discuss a concern regarding the new assignment. CNA 9 stated that CNAs were instructed to complete RNA tasks in addition to their regular CNA assignments during their shift.During an interview on 8/6/2026 at 8:45 AM, RNA 1 stated CNA's in the SAU working the day shift were responsible for providing ROM and applying splints from Monday to Friday if ordered 5 days a week.During an interview on 8/6/2026 at 9:02 AM, CNA 8 stated day shift CNA's were instructed to provide RNA services to the residents in the SAU starting July 1, 2026. CNA 8 stated CNA's in the SAU could be assigned a maximum of 10 residents [SAU residents are a heavier load, to ensure delivery of quality of care], CNA's only have a 7 hours [deducting staff lunch and breaks] to perform both CNA and RNA tasks.During an interview on 8/6/2026 at 1:02 PM, the SAUC stated CNA's were providing care, turning, repositioning, assisting residents with transfers, and were providing showers. The SAUC stated CNA's were also providing RNA services to the residents in the SAU. The SAUC stated if the residents with orders for RNA services were not provided ROM, applications of splints and rolls, and mobility exercises, the residents had the potential to decline in their ROM and mobility.During an interview on 8/6/2026 at 5:06 PM with Registered Nurse (RN) 3, RN 3 stated RN 3 reminded the CNA's when asked how RN 3 monitored care such as ROM and application of splints. RN 3 was asked how RN 3 ensured ROM and application of rolls and splints were provided, RN 3 stated RN 3 reminded the CNA's to document when tasks were completed.During an interview on 8/7/2026 at 11:21 AM, CNA 10 stated the residents in the SAU were not alert, were totally dependent on staff, and required total care. CNA 10 stated CNA 10 tried to provide RNA services but the time CNA 10 had available was not enough to provide these services. CNA 10 stated providing RNA services took at least 4 minutes for each part of the extremity and one extremity had different parts such as the fingers, wrist, elbow, shoulder and the whole arm. CNA 10 stated the SAUC informed the CNA's, when changing the residents' incontinent pad, changing the clothes, providing showers, CNAs were to provide RNA services. CNA 10 stated there was no facility staff monitoring that care such as RNA services were provided. CNA 10 stated RNA services required time and the tasks for CNA's required time so it was difficult for the CNA's to provide RNA services. CNA 10 stated when RNA services were not provided, residents could develop contractures or contractures could get worse.During an interview on 8/7/2026 at 12:19 PM, the DON stated the CNA's in the SAU had a workload ratio of one CNA to 10 residents. The DON stated the CNA's had a meeting with the facility's management 2 weeks before today regarding the CNA's concern about CNA's providing RNA services in the SAU but there was no concern reported to the DON since the meeting. The DON stated resident care should be provided according to the plan of care and any issues with the provision of care should be reported to the DON.During a review of the facility's Subacute CNA Daily Assignment Sheet, dated 8/4/2026 and 8/5/2026, the assignment indicated CNA 9 had 9 assigned residents in the SAU on 8/4/2026 and 8 assigned residents in the SAU on 8/5/2026. Based on a review of the facility's Order Listing Report, dated August 2026, the report indicated six of CNA's assigned residents required RNA services 8/4/2026 and on 8/5/2026.During a review of the facility's Policy and Procedure (P&P), titled Restorative Nursing Program, effective date 1/30/2026, the P&P's purpose indicated the program is aimed at promoting physical mobility, functional independence, cognitive engagement, and overall quality of life.During a review of the facility's P&P titled Subacute Nursing Staffing and Competency Requirements, effective date 3/25/2026, the P&P indicated it is the policy of the facility to provide nursing care to residents in accordance with their plan of care which promotes each resident's physical, mental, and psychosocial health.

Based on observation, interview, and record review, the facility failed to maintain accountability of one dose of a controlled substance (medications with a high risk for abuse or diversion [any use other than that intended by the prescriber]) on the controlled substance accountability record affecting Resident 197 in one of five inspected medication carts (Station 1 Cart 3).This deficient practice had the potential for Resident 197 to be given controlled substance medication more often than prescribed due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings:During a concurrent observation and interview on 8/4/2026 at 11:47AM with Licensed Vocational Nurse (LVN) 6, the Drug Control Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication) of Station 1 Cart 3 indicated there were 20 doses left of hydrocodone/acetaminophen (a medication used to treat pain) 10/325 milligrams (mg - a unit of measure for mass) however, the medication card contained 19 doses. LVN 6 stated she administered Resident 197's missing dose of hydrocodone/acetaminophen earlier today around 10 AM but failed to sign the Drug Control Record at that time. LVN 6 stated the Drug Control Record needs to be signed immediately after the dose is removed to maintain accountability of the controlled medication, prevent diversion, and ensure that Resident 197 does not receive the medication more often than prescribed. LVN 6 stated that if Resident 197 receives hydrocodone/acetaminophen too often, it could lead to medical complications possibly requiring hospitalization. During a review of the facility's policy and procedure (P&P) titled, Controlled Substance Storage, dated 06/2026, the P&P indicated that pertinent information about the resident and the controlled substance the resident is receiving is to be completed on the accountability form upon dispensing of a controlled substance.

Based on observation, interview, and record review, the facility failed to ensure Resident 9 did not physically assault (occurs when a person uses physical violence and causes injury to another person's body) two of six sampled residents (Resident 7 and Resident 8). On 3/31/2025, Resident 9 hit Resident 7 multiple times on Resident 7's face with Resident 9's closed fist and pulled Resident 8's necklace and held Resident 8's neck. As a result, on 3/31/2025 Resident 7 sustained a facial (face) contusion (bruising or skin discoloration), a closed head injury (head injury that does not break through the skull and occurs when the head gets hit hard), swelling and discoloration to Resident 7's left cheek, discoloration to the left and right eyelids, and bleeding from inside Resident 7's mouth. Resident 7 experienced sudden facial pain rated six out of 10 pain (moderately strong pain that interferes with normal daily activities) on a pain scale from 0 to 10 (0 means no pain, and 10 means the worst possible pain felt). The facility transferred Resident 7 to General Acute Care Hospital (GACH) 1 for further evaluation due to facial and a head injury. Additionally, Resident 8 sustained redness on the left side of the Resident 8's neck. Cross Reference: F689 Findings: a. During a review of Resident 7's Admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included dementia (a group of symptoms affecting memory, thinking, and social abilities), Schizophrenia (a serious mental health condition that affects how people think, feel, and behave) and psychosis (abnormal condition of the mind that involves a loss of contact with reality). During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 3/11/2025, the MDS indicated Resident 7's cognition (ability to think and process information) was severely impaired. The MDS indicated Resident 7 used a wheelchair for mobility. During a review of Resident 7's Change in Condition Evaluation (COC, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains), dated 3/31/2025, timed at 8:40 AM, the COC indicated (on 3/31/2025) at 6:30 AM, Resident 7 was sitting in the hallway on Resident 7's wheelchair saying, P--a (offensive language in Spanish) repeatedly and was swinging Resident 7's doll. The COC indicated the doll touched another resident (Resident 9). The COC indicated Resident 9 reacted and made physical contact with Resident 7's face by using a closed fist. The COC indicated Resident 7 had swelling and discoloration on Resident 7's left cheek, left and right eyelids, and Resident 7 was bleeding inside Resident 7's mouth. The COC indicated Resident 7 complained of sudden pain rated six out of 10. During a review of Resident 7's Physician's Order (PO), dated 3/31/2025, the PO indicated to apply an ice pack to Resident 7's face prn (as needed). During a review of Resident 7's Transfer Form (TF) dated 3/31/2025, timed at 1:34 PM, the TF indicated the facility transferred Resident 7 to GACH 1 for further evaluation for facial injury and a CT (computed tomography scan, a medical imaging technique used to obtain detailed internal images of the body) scan of Resident 7's face. The TF indicated Resident 7 was administered Acetaminophen (pain medication) 325 milligrams (mg, unit of measurement) for facial pain on 3/31/2025 at 10:30 AM. During a review of Resident 7's GACH 1 record, titled, Emergency Department Note Physician (ENP), dated 3/31/2025, the ENP indicated Resident 7's chief complaint was bruising and mouth pain (unrated) to Resident 7's face and head after Resident 9 assaulted Resident 7 at the facility. The ENP indicated Resident 7 reported mouth pain (unrated) due to Resident 7 being punched in the face several times (by Resident 9). The ENP indicated Resident 7 had bilateral (left and right side) facial contusions, and a closed head injury. During an observation of Resident 7's face and concurrent interview with Resident 7, on 4/16/2025 at 8:15 AM, Resident 7 had light gray discoloration around both eyes. Resident 7 stated a guy (Resident 9) with two hands, hit me on the face, Boom, Boom, in my eyes. Resident 7 raised Resident 7's left and right fists and punched the air. Resident 7 stated, I was bleeding in the mouth. Resident 7 stated, It hurt. b. During a review of Resident 8's AR, the AR indicated the facility admitted Resident 8 on 11/5/2021, with diagnoses that included dementia and bipolar disorder (a mental disorder with periods of depression [serious illness that negatively affects how one feels, thinks and acts] and periods of elevated mood). During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8's cognition was severely impaired. During a review of Resident 8's COC, dated 3/31/2025, timed at 7:37 AM, the COC indicated, (on 3/31/2025) at 6:33 AM, Resident 8 was standing in the hallway close to the nurse's station. The COC indicated another resident [Resident 9] came from behind and pulled Resident 8's shirt and necklace, causing Resident 8's necklace to break, and held Resident 8 around Resident 8's neck. The COC indicated Resident 8 had redness on Resident 8's left side of the neck and first aid was applied (no specific treatment indicated). c. During a review of Resident 9's AR, the AR indicated the facility admitted Resident 9 on 2/4/2025, with diagnoses that included dementia and bipolar disorder. During a review of Resident 9's MDS dated [DATE], the MDS indicated Resident 9's cognition was severely impaired. The MDS indicated Resident 9 used a walker and had no impairment to both lower and upper extremities. During a review of Resident 9's COC, dated 3/31/2025, timed at 6:30 AM, the COC indicated Resident 9 had a resident-to-resident altercation (fight between two residents) and Resident 9 made physical contact, using closed fists, with another resident's [Resident 7] face. During a review of Resident 9's Progress Notes (PN), dated 4/1/2025, timed at 9:57 AM, the PNs indicated on 3/31/2025 at 6:30 AM, Resident 9 had an altercation with two residents (Resident 7 and Resident 8). During a review of Resident 9's PO, dated 3/31/2025, the PO indicated to transfer Resident 9 to GACH 1 for evaluation of aggressive behavior (act aimed at harming a person or animal or damaging physical property) manifested by hitting other residents. During a review of Resident 9's TF dated 3/31/2025, timed at 7:58 AM, the TF indicated Resident 9 was transferred to GACH 1 for behavioral symptoms that included agitation (unpleasant state of extreme arousal) and psychosis. During a review of Resident 9's GACH 1's ENP, dated 3/31/2025, the ENP indicated Resident 9 was at risk for danger to others. The ENP indicated Resident 9 reported, she [Resident 7] was asking for it and I [Resident 9] was trying to kill her [Resident 7]. During an interview on 4/15/2025 at 5:17 PM, the Director of Nursing (DON) stated abuse was defined as intentional harm to another person (physically, verbally, or mentally). The DON stated, It was not ok for Resident 9 to pull Resident 8's necklace or hold Resident 8 around the neck. The DON stated, Resident 9 used a closed fist and harmed Resident 7 more than once. The DON stated Resident 9's actions were willful, and This was abuse. During an interview on 4/16/2025 at 9:20 AM, Licensed Vocational Nurse (LVN) 6 stated on 3/31/2025, Resident 9 was walking by Resident 7 when Resident 7 was swinging Resident 7's doll. LVN 6 stated, Resident 7's doll hit Resident 9 and Resident 9 reacted by hitting Resident 7 with a closed fist three to four times on Resident 7's face. LVN 6 stated Resident 7's mouth was bleeding, and Resident 7 had swelling around the eyebrows, cheeks, and lips. LVN 6 stated within a minute after Resident 9 hit Resident 7, Resident 9 wheeled himself close to Resident 8, pulled Resident 8's shirt from behind and held Resident 8's neck. During a review of the facility's Policy and Procedure (P&P) titled, Safety of Residents, dated 1/1/2012, the P&P indicated the purpose of the policy was to provide a safe environment for residents and facility staff. During a review of the facility's P&P titled Abuse - Prevention, Screening & Training Program, dated July 2018, the P&P indicated, Abuse was defined as willful, deliberate infliction of injury .with resulting physical harm, pain or mental anguish.

Based on interview and record review, the facility failed to prevent and control the spread of Influenza (flu, highly contagious, sometimes deadly respiratory infection [the invasion and growth of germs in the lungs and the airway, caused by the influenza virus) for 7 of 15 sampled residents (Residents 1, 2, 3, 4, 5, 6 and 7) during the current flu season (from 10/1/2024 to 3/31/2025) in according to the facility's policy and procedure (P&P) titled, Influenza Prevention and Control, by failing to: 1. Ensure Infection Preventionists (IPs, a healthcare professional who specializes in preventing the spread of infections in healthcare settings) 1 and 2 provided information/education regarding the benefits, risks, and the potential side effects (injuries resulting from medication use including physical and mental harm, or loss of function) of the flu vaccine (an injection administered to lower the risk of contracting the flu) and providing an opportunity to decline (choosing not to accept the influenza vaccine) or accept the vaccine for Residents 1, 2, 3, 4, 5 and 6) and/or their responsible parties (RP) for the flu season that began on 10/1/2024. 2. Ensure IP 1, and IP 2 administered the flu vaccine to Resident 7 after Resident 7 consented to receive the flu vaccine on 12/18/2024. 3. Ensure the facility had a system in place to track Residents 1, 2, 3, 4, 5, 6 and 7's flu vaccination status for the current flu season. As a result of these failures, Residents 1, 2, 3, 4, 5, and 6 were not offered the flu vaccine, and Resident 7 was consented for the flu vaccine (on 12/18/2024) but did not receive the vaccine after consenting to receive the flu vaccine. Residents 1, 2, 3, 4, 5, 6, and 7 being diagnosed with the flu and the residents had respiratory symptoms (symptoms that affect the lungs and or the airways). Residents 1, 2, 3, 4, 6, and 7 were hospitalized due to sepsis (a serious condition in which the body responds improperly to an infection) and/or pneumonia (PNA, an infection that inflames the air sacs in one or both lungs and may cause a buildup of fluid or pus that can be life-threatening). These failures also had the potential to place Residents 1, 2, 3, 4, 5, 6, and 7 at risk for respiratory illness complications that could lead to serious injuries, harm, and or death. On 1/15/2025 at 7:09 pm, while at the facility, the surveyors called an Immediate Jeopardy [IJ, a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to offer/administer flu vaccines for Residents 1, 2, 3, 4, 5, 6 and 7. The facility also failed to have a system in place to track resident vaccination status for Residents 1, 2, 3, 4, 5, 6 and 7 as indicated in Title 42, the Federal Code of Regulation (CFR) S483.80(d)(1) Influenza. On 1/16/2025, the facility submitted an IJ Removal Plan (IJRP, plan that includes interventions to immediately correct the deficient practices). While onsite at the facility, the surveyors verified the IJ situation (failure to offer/administer flu vaccines) was no longer present and confirmed the facility's implementation of the IJRP through observations, interviews, and record review. The IJ was removed on 1/16/2025 at 6:53 pm, in the presence of the ADM, the DON, and the Assistant Director of Nursing (ADON). The acceptable IJRP included the following immediate actions: 1. On 1/15/2025, IP 1 and IP 2 were immediately placed on administrative suspension, pending investigation. 2. On 1/15/2025, The ADM promoted a Licensed Vocational Nurse (LVN) to be the interim (temporary) IP (IP 3). IP 3 had received the Infection Prevention Training for Skilled Nursing Facilities, as well as worked as an Infection Prevention & Control Nurse at another facility. Effective immediately, the DON will be responsible for the oversight of the Infection Prevention & Control Program for compliance by conducting weekly compliance audits and verification. 3. On 1/15/2025, the following actions were immediately completed for Residents 1, 2, 3, 4, 5, and 6 related to influenza vaccine offering and administration: a. Resident 1: On 1/15/2025, the influenza vaccine was offered to Resident 1's RP (RP 1) who consented to receive the flu vaccine. Resident 1 received the flu vaccine on 1/15/2025. b. Resident 2: On 1/15/2025, at 10:26 pm, the DON contacted Resident 2's PR (RP 2) to verify Resident 2's influenza vaccination status and left a voice message. On 01/16/2025 at 8:57 am, the ADON called RP 2 and received a declination for the seasonal Influenza vaccine. c. Resident 3: On 1/15/2025, the influenza vaccine was consented by Resident 3's representative the interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward resident goals) Resident 3 received the flu vaccine on 1/15/2025. d. Resident 4: On 1/15/2025, the influenza vaccine was offered to Resident 4, who consented to receive the flu vaccine. Resident 4 received the flu vaccine on 1/15/2025. e. Resident 5: On 1/15/2025, the influenza vaccine was consented by the RP 5 (IDT) as the resident's representative. Resident 5 physically did not allow the nurses to administer the seasonal Influenza vaccine. On 1/15/2025, Resident 5's attending physician was notified. f. Resident 6: On 1/16/2025, the influenza vaccine was offered to Resident 6's RP (RP 6) who consented to receive the flu vaccine. Resident 6 received the flu vaccine on 1/16/2025. 4. Resident 7 remained hospitalized as of 1/15/2025. 5. On 01/15/2025, the ADM, the DON, and the Medical Director conducted a Quality Assurance Performance and Improvement (QAPI, a process that aims to improve the quality of healthcare and safety of patients/residents) meeting to discuss Infection Prevention and Control concerns related to influenza vaccination including screening, offering, tracking, and monitoring of influenza vaccine status. 6. On 1/15/2025, the DON, and ADON conducted an audit of current residents and revalidated the consents for influenza immunizations. The DON and ADON initiated verification of influenza vaccine declinations. 7. On 1/15/2025, the ADM and DON initiated an in-service education to the licensed nurses (all licensed nurses) regarding the P&Ps for Influenza Prevention and Control. 8. On 01/15/2025, the ADM contacted the Pharmacy Representative to reserve 50 doses of the seasonal Influenza vaccine, which was delivered on 1/15/2025. Cross Reference F842 Findings: a. During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/25/2022 with diagnoses that included immunodeficiency (decreased ability of the body to fight infections and other diseases), and personal history of COVID -19 (Coronavirus -19, highly contagious virus that can affect lungs and airways and spreads form person to person). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/9/2024, the MDS indicated Resident 1's cognition (ability to think and process information) was severely impaired. The MDS indicated Resident 1/RP 1 was offered and declined the flu vaccine (on 10/20/2023). The MDS indicated Resident 1 did not receive the flu vaccine while at the facility. During a review of Resident 1's eINTERACT/Change in Condition Evaluation (CIC, a change in the resident's health or functioning that requires further assessment and intervention) form, dated 12/27/2024, timed at 3:25 pm, the CIC indicated Resident 1 was noted with increased fatigue (extreme tiredness) and slept more than usual. During a review of Resident 1's Progress Notes (PN), dated 12/27/2024, timed at 10:50 pm, the PN indicated Resident 1 was being monitored for increased fatigue and fever. During a review of Resident 1's Order Summary Report (OSR), dated 12/28/2024, the OSR indicated for Resident 1 to be transferred to General Acute Care Hospital (GACH) 1 for evaluation and treatment. During a review of Resident 1's CIC, dated 12/28/2024, timed at 2:54 pm, the CIC indicated Resident 1 had episodes of vomiting and Resident 1's oxygen saturation [O2 sats, the percentage (%) of hemoglobin (a red protein responsible for transporting oxygen) in the blood] dropped (% was not indicated). The CIC indicated Resident 1 was put on 02 via nasal cannula (NC, a small plastic tube which fits into the person's nostrils for providing supplemental oxygen). The CIC indicated Resident 1 was sent to GACH 1. During a review of Resident 1's GACH 1 H&P, dated 12/28/2024, timed at 6:20 am, the H&P indicated Resident 1 was brought to GACH 1's Emergency Department (ED) for fever and hypoxia (a condition where the body's tissues do not receive enough oxygen). The H&P indicated Resident 1 was febrile (also known as fever), tachycardic [heart rate faster that 100 beats per minute (BPM)], and sepsis. Resident 1 received intravenous [IV, a soft, flexible tube placed inside a vein (a blood vessel that carries blood to the heart from the tissues and organs in the body) to administer fluids and medication directly to the bloodstream] fluids and antibiotic (medicine used to treat bacterial infections) per sepsis protocol (a set of guidelines followed by healthcare providers to treat sepsis). The H&P indicated, Resident 1's laboratory results (findings from a medical test) indicated, Influenza A (one of three types of viruses that cause the illness called influenza was detected). During a telephone interview on 1/15/2025 at 10:32 am with RP 1, RP 1 stated RP 1 would not decline the flu vaccine for Resident 1. b. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 4/16/2024 with diagnoses that included unspecified immunodeficiency, and type 2 diabetes mellitus [DM2, a chronic (long standing) disease that occurs when the body does not produce enough insulin (a hormone that regulates the amount of glucose/sugar in the blood)]. During a review of Resident 2's H&P, dated 12/20/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's CIC, dated 12/26/2024, timed at 6:34 pm, the CIC indicated Resident 2 had a O2 Sat of 79 % (normal level of oxygen saturation level (measure of how much oxygen is traveling through your body in your red blood cells) is between 95% and 100%) and a fever of 102.1 degrees Fahrenheit [ F, unit of temperature (a normal body temperature is generally considered to be 98.6 F)]. The CIC indicated Resident 2's primary care provider recommended for Resident 2 to be transferred to GACH 2 via emergency services by calling 911 (a phone number used to contact emergency services). During a review of Resident 2's GACH 2 H&P, dated 12/27/2024, timed at 3:06 pm, the H&P indicated Resident 2 tested positive for Influenza A (contagious viral infection that can have life-threatening complications if left untreated) and had a fever secondary to the flu and PNA. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate impaired cognition. The MDS indicated Resident 2/RP 2 was offered and declined the flu vaccine (on 10/20/2023). c. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included DM2, immunodeficiency, personal history of COVID - 19, and PNA. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderate impaired cognition. The MDS indicated, Resident 3 received the flu vaccine in the facility on 11/29/2023. During a review of Resident 3's CIC, dated 12/30/2024, timed at 9:03 am, the CIC indicated Resident 3 was noted with increased weakness and poor oral (PO, by mouth/orally) intake. The CIC indicated Resident 3's physician ordered to send Resident 3 to GACH 3 for further evaluation. During a review of Resident 3's OSR, dated 12/30/2024, the OSR indicated to transfer Resident 3 to GACH 3 for further evaluation. During a review of Resident 3's GACH 3 H&P, dated 12/31/2024, timed at 12 pm, the H&P indicated Resident 3 presented to GACH 3's ED with failure to thrive (FTF, a decline caused by chronic diseases and functional impairments which could cause weight loss, decreased appetite, poor nutrition, and inactivity). The H&P indicated Resident 1 was currently on Levofloxacin (medication used to treat infections) 250 milligrams, (mg, unit of measurement) IV, every 24 (Q 24) hours. During a review of Resident 3's GACH 3 Discharge Summary (DS) dated 1/5/2025, timed at 10:17 am, the DS indicated Resident 3 was admitted with multiple diagnoses including, Influenza A and PNA. The DS indicated the hospital problem list included hypoxia (absence of enough oxygen in the tissues to sustain body functions) likely due to PNA. The DS indicated to continue droplet (mucus and/or saliva spray from coughing, sneezing, or talking) isolation (separation of residents who have an infection from residents who do not have infections) and starting Tamiflu (medication used to treat the flu). During a review of Resident 3's PN, dated 1/5/2025, timed at 4:55 pm, the PN indicated Resident 3 was readmitted from GACH 3 with Influenza A and was currently on droplet precautions (Droplet precautions are necessary when a patient infected with a pathogen, such as influenza, is within three to six feet of the patient). d. During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (a type of heart disease that occurs when plaque builds up inside the arteries) of native coronary artery (major blood vessels in the body supply blood to the heart) without angina pectoris (chest pain), and immunodeficiency. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had moderately impaired cognition. The MDS indicated Resident 4/RP 4 was offered the flu vaccine and declined (on 11/8/2023). During a review of Resident 4's CIC, dated 12/25/2024, at 9:21 pm, the CIC indicated Resident 4 had a fever of 102.3 F, O2 sats of 83 % on room air (no supplemental oxygen), and was tachycardic (fast/increased heart rate) at 117 beats per minute, (BPM, a normal resting heartbeat/heartrate should be between 60 to 100 BPM). The CIC indicated Resident 4's attending physician recommended to transfer Resident 4 to GACH 1 via emergency services by calling 911 for further evaluation. During a review of Resident 4's GACH 1 Emergency Department Physician Note (EDPN), dated 12/26/2024, timed at 12:18 am, the EDPN indicated Resident 4 presented to the ED with shortness of breath (the feeling of not being able to breathe deeply enough or getting enough air into your lungs), productive cough [a type of cough that produces mucus (phlegm or sputum)], and fevers of 103 F for two days. The EDPN indicated Resident 4 needed to be admitted to GACH 1 for treatment of Influenza A, PNA, and sepsis. e. During a review of Resident 5's AR, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning), and personal history of COVID-19. During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had moderate impaired cognition. The MDS indicated Resident 5 was offered and declined the flu vaccine and Resident 5 did not receive the flu vaccine in the facility. During a review of Resident 5's CIC, dated 1/6/2025, timed at 1:58 pm, the CIC indicated Resident 5 was positive for Influenza A and had a non-productive cough (dry cough). The CIC indicated Resident 5's physician was notified, and the physician ordered Tamiflu, 75 mg, twice a day (BID) for five days. f. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 9/22/2023 with diagnoses that included unspecified respiratory failure (a serious condition that makes it difficult to breathe), unspecified dementia, and DM2. During a review of Resident 6's H&P, dated 9/27/2024, the H&P indicated Resident 6 did not have the capacity to understand and make decisions due to a diagnosis of dementia. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had severe impaired cognition. The MDS indicated Resident 6 was offered and declined the flu vaccine. During a review of Resident 6's CIC dated 1/5/2025, timed at 11:09 am, the CIC indicated Resident 6 could not swallow, had a productive (wet- full of mucus or phlegm) cough, and Resident 6's O2 Sat was at 87 % when on room air. The CIC indicated Resident 6 was transferred to the ED for further evaluation. During a review of Resident 6's GACH 1 H&P, dated 1/5/2025, the H&P indicated Resident 6 was exposed to Influenza at the facility, and presented with upper respiratory symptoms, short of breath, acute (sudden) respiratory failure, and tested positive for Influenza A. The H&P indicated a chest X-ray (imaging study that takes pictures of bones and soft tissues) showed pulmonary infiltrate (PNA). During a review of Resident 6's CDII dated 1/9/2025, the CDII indicated Resident 6 verbally declined the flu vaccine due to not feeling well. The CDII indicated IP 1signed Resident 6's IP form. During a review of Resident 6's PN, dated 1/14/2025, timed at 10:51 pm, the PN indicated IP 1, spoke with resident regarding influenza vaccine. Resident is self-responsible and verbally declined . The PN indicated IP 1 was the author of the note. During a concurrent interview and record review on 1/15/2025 at 11:39 am, with IP 1, Resident 6's MDS, dated [DATE] was reviewed, the MDS indicated Resident 6 had severe impaired cognition. IP 1 stated Resident 6 declined the flu vaccine. IP 1 stated, It was not safe to offer Resident 6 the flu vaccine because Resident 6 could not understand the risks and benefits of the flu vaccine. g. During a review of Resident 7's AR, the AR indicated, Resident 7 was admitted to the facility on [DATE] with multiple diagnoses including DM2 without complications, immunodeficiency, and heart failure (a lifelong condition in which the heart muscle could not pump enough blood to meet the body's needs for blood and oxygen). During a review of Resident 7's H&P, dated 12/17/2024, the H&P indicated, Resident 7 could make needs known but could not make medical decisions. During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognition was moderately impaired. The MDS indicated Resident 7 was offered and declined the flu vaccine and Resident 7 did not receive the flu vaccine at the facility. During a review of Resident 7's CIC, dated 1/11/2025, timed at 7:11 am, the CIC indicated a CNA (unidentified) reported Resident 7 complained Resident 7 could not breath. The CIC indicated Resident 7's O2 sats were at 78 % while Resident 7 was on 2 liters (L, unit of volume) of O2 via NC. The CIC indicated Resident 7's oxygen delivery rate was increased to 4 L. During a review of Resident 7's OSR, dated 1/11/2025, the OSR indicated to send Resident 7 to GACH 1 due to altered level of consciousness (ALOC, which is a state where someone is less awake, alert, or aware of their surroundings) and O2 desaturations (a drop in blood oxygen levels). During a review of Resident 7's GACH 1 H&P, dated 1/11/2025, timed at 6:57 pm, and signed on 1/12/2025 at 12:57 am, the H&P indicated Resident 7 presented to ED with reports of acute (sudden and severe) onset shortness of breath, hypoxia, and cough. The H&P indicated, Resident 7 was afebrile, hypoxic (low levels of oxygen in the body's tissues), and tachypneic (rapid, shallow breathing). The H&P indicated, Resident 7's workup (process of obtaining all necessary data for diagnosing and treating a patient) revealed pneumonia and Resident 7 was positive for influenza. The H&P's assessment/plan indicated, Resident 7 was in septic shock (severe drop in blood pressure caused by an infection) and the plan was to admit Resident 7 to the ICU (Intensive Care Unit - a department of a hospital in which patients who are?dangerously?ill are kept under constant observation) and continue administration of IV antibiotics and bronchodilators (medication used to widen the airways to make breathing easier). During a review of Resident 7's GACH 1 Critical Care/Pulmonologist (doctor who specializes in lung conditions) Consultation Notes (CN), dated 1/11/2025, signed at 12:58 pm, the CN indicated, Resident 7 was in severe sepsis and acute hypoxic with respiratory failure 2/2 (secondary to) pneumonia. The CN indicated Resident 7 was ill-appearing, frail, moderate distress, awake but not alert on HFNC (HiFlow Nasal Cannula - a type of non-invasive device for providing supplemental oxygen) and to monitor closely for intubation (a procedure involving a tube placed inside your trachea, also called the windpipe, through the mouth or nose and attached to a machine that helps you breathe). The CN indicated, to continue empiric (medical treatment initiated without definitive knowledge of the underlying cause or pathogen) antibiotics and start Tamiflu. During a review of Resident 7's GACH 1 Infectious Disease (doctor who specializes in the diagnosis and treatment of illnesses and infections) CN, dated 1/12/2025, timed at 1:41 pm, the CN indicated, Resident 7 was in septic shock, likely secondary to Influenza A and pneumonia likely secondary to Influenza A. During a concurrent interview and record review of Resident 7's CDII form on 1/14/2025 at 5:08 pm, with IP 1, IP 1 stated Resident 7's RP consented for Resident 7 to receive the flu vaccine on 12/18/2024. IP 1 stated the flu vaccine was not administered to Resident 7. IP 1 stated Resident 7 should have been offered the flu vaccine upon admission on 12/16/2024. During a concurrent interview and record review on 1/14/2025 at 5:08 pm, with IP 1, the facility's line list (a table that summarizes key information about each case during an outbreak (OB, two or more linked cases of the same illness) for the influenza was reviewed. The line listing was incomplete with missing information for Residents 1, 2, 3, 4, 5, 6, and 7. IP 1 stated the flu season started on 10/1/2024 until 3/31/2025. IP 1 stated staff (licensed nurses) began offering the flu vaccine as early as late September and began administering the flu vaccine to residents as early as 10/1/2024. IP 1 stated (in general) the flu vaccine should be administered within three days, after a resident or RP consented to receive the flu vaccine. IP 1 stated it was important to offer the flu vaccine at the beginning of each flu season to prevent residents from getting sick from the flu, or for the symptoms to be minimized. IP 1 stated the IPs (IPs 1 and 2) were not following the process and were not appropriately tracking residents' flu vaccine status because the facility was not organized. IP 1 stated IP 1 did not have an answer to why the facility was not following the facility's process for vaccinating residents. IP 1 and IP 2 stated the flu OB line list provided was not up to date (incomplete). IP 1 stated all residents were more susceptible to catching the flu because the IPs did not know what residents were vaccinated and what residents were not vaccinated. During an interview on 1/15/2025 at 4:21 pm, with the DON, the DON stated the process for obtaining flu vaccine consents was for admitting nurses to offer and obtain the consent or declination form from either the resident or their RPs. The DON stated all licensed nurses were responsible for conducting flu vaccine status screening upon a residents' admission. The DON stated, It was important to screen residents to protect them from the flu and prevent the development of an infection. The DON stated the IPs were supposed to follow up on any newly admitted residents and screen all residents in August to offer and obtain consents for the flu season that started on 10/1/2024. The DON stated a flu vaccine tracking system was important because it allowed for the facility to keep track of all residents' flu vaccination status. The DON stated when there was no tracking system or log in place, residents who were medically eligible to receive the flu vaccine would not be offered the vaccine because of the facility's disorganization [lack of tracking]. During a review of the facility's undated Centers for Disease Control and Prevention Vaccine Information Statements (CDC VIS), the CDC VIS indicated people [AGE] years and older, and people with certain health conditions such as heart disease, cancer, diabetes, or a weakened immune system were at greater risk of flu complications. The CDC VIS indicated flu could cause fever and chills, sore throat, muscle aches, fatigue, cough, headache, and runny or stuffy nose. The CDC VIS indicated flu vaccine prevented millions of illnesses and flu-related visits to the doctor each year. During a review of the facility's P&P titled, Influenza Prevention and Control revised 9/10/2020, the P&P indicated to prevent and control the spread of influenza in the facility, the facility would follow infection prevention and control policies and procedures to minimize the risk of residents acquiring, transmitting or experiencing complications from influenza. The P&P indicated the CDC considered the flu season to be between October 1st and March 31st. The P&P indicated residents were to be offered the influenza immunization every year during flu season, unless medically contraindicated, or the resident had already been immunized during the current flu season. The P&P indicated the resident's medical record would include documentation that indicated, at a minimum, the resident or the resident's representative was provided education regarding the risk and benefits and potential side effects of the influenza vaccination and whether the resident received the influenza vaccine, could not receive the vaccine due to a medical contraindication or refused the vaccine. P&P indicated the vaccine type, dose, route, and nurse administering the vaccine would be documented on the medication administration record. The P&P indicated the vaccine lot number would be recorded on the immunization log.

Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 1 and 6) were free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by failing to: 1. Protect Resident 1 and Resident 6 from physical abuse when Resident 2 physically assaulted (the illegal act of causing physical harm or unwanted physical contact to another person) Resident 1 and Resident 6 on 2/3/2024 at 6:45 a.m. 2. Ensure Licensed Vocational Nurse (LVN) 2 notified the Director of Nursing (DON) of Resident 2's aggressive behavior on 2/2/2024 in accordance with the facility's policy and procedure (P&P) titled, Resident-To-Resident Altercations. As a result, on 2/3/2024 at 6:45 a.m., Resident 2 hit Resident 1 and 6 while under the care of the facility. Resident 1 sustained swelling (enlargement of a body part) and contusion (bruising or skin discoloration) on Resident 1's right eye, face, left cheek with slight (small amount) bleeding from Resident 1's mouth, and hematoma (a collection of blood outside of blood vessels) on Resident 1's left scalp (the skin covering the head). Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 2/3/2024 at 7:34 a.m. for further evaluation and care. Resident 6 sustained an abrasion (a superficial rub or wearing off from the skin) on Resident 6's right eye and discoloration on the left side of Resident 6's face. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 1's and Resident 6's severely impaired cognition (ability to think and process information), an individual subjected to physical abuse would have suffered physical pain and psychological (mental or emotional) effects including feelings of fear, embarrassment, humiliation, and emotional distress. Findings: 1. During a review of Resident 1's Admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE] with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 1's History and Physical Examination (H&P), dated 2/27/2023, 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 care screening tool), dated 12/1/2023, the MDS indicated, Resident 1 had severely impaired cognitive skills. The MDS indicated, Resident 1 required supervision or touch assistance (helper provided verbal cues and/or touching/steadying and/or guard assistance) from staff for eating, dressing, and personal hygiene. During a review of Resident 1's eINTERACT Change in Condition Evaluation (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains), dated 2/3/2024, timed at 7:06 a.m., the COC indicated, (on 2/3/2024) at 6:45 a.m., LVN 1 found Resident 1 on the floor (in Resident 1's room) with slight blood on Resident 1's mouth and a swollen (enlarged) right eye. The COC indicated, Resident 1 had a physical altercation (a dispute between individuals in which one or more persons sustain bodily injury) with Resident 2, who was Resident 1's roommate. The COC indicated, Registered Nurse (RN) 1 assessed Resident 1 and immediately called 911 (emergency services) to send Resident 1 to the GACH 1 per Resident 1's Physician's (Physician 1's) order. During a review of Resident 1's Progress Notes, dated 2/3/2024, timed at 8:19 a.m., the Progress Notes indicated, on 2/3/2024 at 6:45 a.m., Resident 2 hit Resident 1 on Resident 1's face. The Progress Notes indicated, the facility called 911 and Resident 1 was transferred to GACH 1. During a review of Resident 1's GACH 1 Emergency Department Note Physician (ED Note), dated 2/3/2024, timed at 12:41 p.m., the ED Note indicated, Resident 1 presented to GACH 1's emergency roiagnom on [DATE] at 7:34 a.m. with complaint of (c/o) face pain (unrated) and facial trauma status post (s/p, condition after) assault by roommate (Resident 2). The ED Note indicated, Resident 1 had bruising over Resident 1's right eyelid and face and bleeding from Resident 1's mouth. The ED Note indicated, Resident 1 would be admitted to GACH 1 for further evaluation. During a review of Resident 1's GACH 1 Computed Tomography (CT scan, a diagnostic imaging exam), of the head report, dated 2/3/2024, timed at 9:20 a.m., the CT scan report indicated, Resident 1 had swelling and contusion on Resident 1's left cheek and hematoma on Resident 1's left scalp. During a review of Resident 1's GACH 1 Infectious Disease Physician (a doctor who specialized in illnesses caused by harmful organisms that get into the body) Consultation Notes, dated 2/4/2024, timed at 8:02 p.m., the Consultation Notes indicated, Resident 1's face was still swollen and had periorbital edema (swelling around the eyes). The Consultation Notes indicated, Resident 1 was on intravenous (IV, within a vein) antimicrobials (agent that kills microorganisms or stops their growth) for streptococcus bacteremia (infection caused by bacteria in the blood). 2. During a review of Resident 6's AR, the AR indicated, the facility admitted Resident 6 to the facility on [DATE] with diagnoses that included dementia, anxiety disorder (a mental health condition characterized by persistent and excessive worry that interferes with one's daily activities), and lack of coordination (not able to move different parts of the body together well or easily). During a review of Resident 6's MDS, dated [DATE], the MDS indicated, Resident 6 had severely impaired cognitive skills. The MDS indicated, Resident 6 required supervision or touch assistance from staff for toileting hygiene, dressing, and personal hygiene. During a review of Resident 6's COC, dated 2/3/2024, timed at 8:46 a.m., the COC indicated, (on 2/3/2024) at 6:45 a.m., LVN 1 heard Resident 6 yelling for help from Resident 6's room. The COC indicated, LVN 1 entered Resident 6's room and found Resident 6 yelling that Resident 2 (Resident 6 and Resident 1's roommate) hurt Resident 6. The COC indicated, Resident 6 was immediately assisted out of Resident 6's room and gently separated from Resident 2. The COC indicated, Resident 6 had an abrasion on Resident 6's right eye and discoloration on the left side of Resident 6's face. 3. During a review of Resident 2's AR, the AR indicated, the facility admitted Resident 2 to the facility on [DATE] with diagnoses that included paranoid (where a person feels distrustful and suspicious of other people) schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and anxiety disorder. During a review of Resident 2's H&P, dated 1/24/2024, the H&P indicated, Resident 2 can make needs known but cannot make medical decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated, Resident 2 had severely impaired cognitive skills. The MDS indicated, Resident 2 required partial/moderate assistance (helper did less than half the effort) from staff for toileting hygiene, dressing, and personal hygiene. During a review of Resident 2's COC, dated 2/3/2024, timed at 8:08 a.m., the COC indicated, on 2/3/2024 at 6:30 a.m., Resident 2 came out of Resident 2's room and requested to smoke a cigarette. The COC indicated, LVN 1 informed Resident 2 that it was not time for a smoke-break. The COC indicated, Resident 2 started displaying behaviors towards LVN 1 by swinging Resident 2's arms towards LVN 1 and touching LVN 1. The COC indicated, LVN 1 redirected Resident 2 back to Resident 2's room and offered Resident 2 snacks and juice. The COC indicated, after Resident 2 ate the snacks, LVN 1 informed Resident 2 that he could smoke after breakfast. The COC indicated, Resident 2 stayed calm in Resident 2's room. The COC indicated, (on 2/3/2024) at 6:45 a.m., LVN 1 and other staff (unidentified) heard Resident 6 (Resident 1 and Resident 2's roommate) calling for help and LVN 1 and other staff (unidentified) immediately ran into Resident 6, Resident 1, and Resident 2's room. The COC indicated, LVN 1 found Resident 2 with blood on his hands and Resident 1 on the floor with slight blood on Resident 1's face. The COC indicated no documentation regarding Resident 6's condition. During a review of Resident 2's Progress Notes, dated 2/3/2024, timed at 2:47 p.m., the Progress Notes indicated, the facility transferred Resident 2 to GACH 2 at 12:40 p.m. (on 2/3/2024) due to an increase in aggressive behavior. The Progress Notes indicated, Resident 2's right hand was swollen. During a telephone interview on 2/6/2024 at 10:25 a.m. with LVN 1, LVN 1 stated on 2/3/2024, at around 6:30 a.m. (could not remember exact time), Resident 2 asked LVN 1 for a cigarette. LVN 1 stated LVN 1 told Resident 2 that smoking time was after breakfast then Resident 2 became upset. LVN 1 stated Resident 2 started swinging at LVN 1 and tapped LVN 1's shoulder. LVN 1 stated LVN 1 gave Resident 2 a snack (could not remember) then Resident 2 calmed down. LVN 1 stated after Resident 2 ate the snack, Resident 2 went back to Resident 2's room and laid down in Resident 2's bed. LVN 1 stated about 5 minutes later, LVN 1 heard Resident 6 screaming from Resident 6, Resident 2, and Resident 1's room (roommates). LVN 1 stated when LVN 1 entered Resident 6's room, LVN 1 saw Resident 6 trying to get out of Resident 6's bed. LVN 1 stated LVN 1 saw Resident 1 on the floor with swelling on Resident 1's (right) eye and blood near Resident 1's mouth. LVN 1 stated LVN 1 saw Resident 2 standing by Resident 1's bedside with blood on Resident 2's hands. LVN 1 stated the facility called 911 because of Resident 1's injuries. LVN 1 stated Resident 6 claimed Resident 2 tried to hurt Resident 1 and Resident 6. LVN 1 stated Resident 6 had abrasion on Resident 6's right eye and discoloration on the left side of Resident 6's face. During a concurrent observation and interview on 2/6/2024 at 11:21 a.m. with Resident 6, in Resident 6's room, Resident 6 had a purple line under Resident 6's left eye and a purple spot on the bridge of Resident 6's nose. Resident 6 pointed to Resident 2's bed and stated Resident 2 started to act up and started to touch Resident 6. Resident 6 stated Resident 2 was fighting everybody (unable to identify). Resident 6 stated Resident 2 pounded on this guy and pointed to Resident 1's bed. During a concurrent observation and interview on 2/6/2024 at 3:15 p.m. with GACH 1's RN 2, in Resident 1's room at GACH 1, Resident 1 was lying in Resident 1's bed with Resident 1's eyes shut. Resident 1's lips and bilateral (affecting both sides) eyelids were swollen. The left side of Resident 1's face was dark purple. GACH 1's RN 2 stated Resident 1's eyelids were swollen shut. GACH 1 RN 1 stated Resident 1 had an admission diagnosis of s/p assault. During a concurrent interview and record review on 2/7/2024 at 7:33 a.m. with LVN 2, Resident 2's Care Plan titled, The Resident Is Refusing Medications and Being Physically Aggressive with Staff, initiated on 2/2/2024, was reviewed. LVN 2 stated LVN 2 created the Care Plan because Resident 2 got aggressive with staff on 2/2/2024. LVN 2 stated Resident 2's demeanor (outward behavior) was aggressive, and that Resident 2 would get up in our (staff in general) face like he (Resident 2) was trying to intimidate us (staff in general). LVN 2 stated LVN 2 did not notify the Director of Nursing (DON) when Resident 2 was aggressive with staff (on 2/2/2024). LVN 2 stated LVN 2 should have notified the DON of Resident 2's aggression so the DON could have considered providing one-to-one (1:1, one staff supervised one resident) supervision (provide continuous observation for an individual patient for a period of time during acute physical or mental illness) for Resident 2. During an interview on 2/7/2024, at 8:20 a.m. with the DON, the DON stated LVN 2 did not notify the DON of Resident 2's aggressive behavior on 2/2/2024. The DON stated LVN 2 needed to notify the DON about Resident 2's aggression so the DON could transfer Resident 2 for an evaluation or placed Resident 2 on 1:1 supervision. The DON stated residents (in general) who have any kind of aggressive behaviors could escalate to becoming physically aggressive. During a concurrent interview and record review on 2/7/2024, at 8:27 a.m. with the Director of Staff Development (DSD) 1, the P&P titled, Resident-To-Resident Altercations, revised on 11/1/2015, was reviewed. The P&P indicated, the facility acted promptly and conscientiously (in a thorough and responsible way) to prevent and address altercations between residents. The P&P indicated, facility's staff observed residents for aggressive or inappropriate behavior toward other residents, family members, visitors, or facility staff. The P&P indicated, any occurrences of such behavior are promptly reported to the Charge Nurse, the Director of Nursing Services, and the Administrator. DSD 1 stated staff must report aggressive behaviors of residents (all residents) to the DON per the facility's P&P. DSD 1 stated the DON needed to be notified, even if there was no physical altercation with the aggressive behavior. During a review of the facility's P&P titled, Reporting Abuse, revised on 1/8/2014, the P&P indicated, the facility will ensure that the residents have the right to be free from verbal, sexual, physical, and mental abuse.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 10) received cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue) treatments including radiation (treatment of using beams of intense energy to kill cancer cells) treatment planning and oncology (study, treatment, and prevention of tumors) follow-up appointments as ordered by Resident 10's Medical Doctor (MD) 3/Radiation Oncologist 1 [a medical practitioner qualified to diagnose and treat tumors (a solid mass of tissue that forms when abnormal cells group together)] and failed to follow the facility's policy and procedure (P&P) titled, Referrals to Outside Services, by failing to: 1. Ensure Registered Nurse 7 (RN 7) kept Resident 10's oncology (the study and treatment of tumors) follow-up appointment with MD 5/Radiation Oncologist 2, at General Acute Care Hospital (GACH) 2, on 3/16/2023. 2. Ensure RN 7 followed up with Resident 10's Case Manager (CM) and the Social Services Director (SSD) to arrange transportation for Resident 10's oncology appointment with MD 3, at GACH 3, on 3/21/2023 for radiation treatment plan. 3. Ensure RN 5 kept Resident 10's transportation for a scheduled radiation follow-up appointment of the neck on 3/23/2023 with MD 5 at GACH 2. 4. Ensure RN 5 or RN 7 requested the SSD to arrange transportation for Resident 10's oncology consultation appointment on 4/5/2023 with MD 3 at GACH 3. 5. Ensure RN 5 kept Resident 10's oncology consultation appointment on 4/26/2023 at GACH 4 with MD 4/Hematology (study of blood disorder) Oncologist. These failures resulted in Resident 10 missing oncology follow-up appointments on 3/16/2023, 4/5/2023, 4/26/2023, and the radiation treatment plan appointments on 3/21/2023 and 3/23/2023. Resident 10 did not receive treatments for oropharynx (mouth/throat) and tonsil (lymphoid tissue in the throat) cancer which led to worsening of Resident 10's cancer and the cancer metastasized (spread) to Resident 10's lungs. Cross Reference: F778 Findings: a. During a review of Resident 10's Initial Evaluation with MD 3 at GACH 3, dated 12/28/2022, the Initial Evaluation indicated, on 10/31/2022, the result of Resident 10's chest computer tomography (CT, type of imaging test) indicated, No acute findings in the chest. During a review of Resident 10's Admission Record, the Admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of oropharynx and tonsillar cancer, and lymph (small lumps of tissue that contain white blood cells and fight infection) node cancer of the head, neck, and face. Resident 10 required the use of a tracheostomy (incision made in the windpipe to provide an air passageway). During a review of Resident 10's phone order, dated 3/10/2023, at 5:03 pm, the phone order indicated Resident 10 had a follow-up oncology appointment with MD 5, on 3/16/2023, at 10:30 am, at GACH 2. During a review of Resident 10's Progress Note, dated 3/10/2023, at 5:34 pm, the Progress Note indicated RN 7 wrote MD 5's office called to inform that Resident 10 had a follow-up appointment with MD 5 on 3/16/2023, at 10:30 am. During a review of Resident 10's phone order, dated 3/10/2023 at 6:05 pm, the phone order indicated Resident 10's follow-up appointment with MD 5, on 3/16/2023, at GACH 2, was cancelled without an indicated reason. During a review of Resident 10's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 9/7/2023, the MDS indicated Resident 10 had moderately impaired cognition (ability to think, reason, and function). Resident 10 required extensive assistance (resident involved activity, staff provide weight-bearing support) with bed mobility, dressing, toilet use, and personal hygiene. Resident 10 was totally dependent (full staff performance every time) with eating, and activities that did not occur included transfers, walking, and locomotion. During an interview on 9/15/2023 at 12:10 pm, with the Social Services Director (SSD), the SSD stated RN 7 did not instruct the SSD to schedule Resident 10's transportation for the appointment on 3/16/2023. During a concurrent interview and record review, on 9/15/2023, at 3:50 pm, with RN 7, Resident 10's telephone order, dated 3/10/2023 was reviewed. The order indicated, Resident 10's oncology follow-up appointment was cancelled. RN 7 stated Resident 10's oncology appointment on 3/16/2023 was cancelled due to insurance issues related to transportation. b. During a review of Resident 10's phone order, dated 3/15/2023, at 11:42 am, the phone order indicated Resident 10 had a follow-up oncology appointment with MD 3, on 3/21/2023, at 2:30 pm, at GACH 3. During a review of Resident 10's phone order, dated 3/15/2023, at 11:53 am, the phone order indicated Resident 10's follow appointment with MD 3 on 3/21/2023, at GACH 3 was cancelled. During a review of Resident 10's GACH 3 Nursing Note, dated 3/17/2023, at 12:34 pm, the Nursing Note indicated Radiation Medicine Staff (RMS) 1 called and instructed RN 7 to keep the re-evaluation appointment scheduled dated 3/21/2023. The note indicated the RMS 1 had a treatment plan for Resident 10. The note indicated RN 7 told RMS 1 that Resident 10's insurance did not cover the transportation cost for Resident 10's appointments. The note indicated RN 7 advised RMS 1 to speak with the facility's CM on Monday, 3/20/2023 (the next business day). During a review of Resident 10's GACH 3 Nursing Note, dated 3/20/2023, at 1:05 pm, the Nursing Note indicated RMS 1 left a message for facility's CM requesting a callback. During a review of Resident 10's GACH 3 Nursing Note, dated 3/27/2023, at 1:23 pm, the Nursing Note indicated another RMS (RMS 2) called the facility's CM, and left a voicemail requesting for a callback. The note indicated RMS 2 requested Resident 10 to return to the oncology follow-up appointment before the radiation treatment began. During an interview on 9/15/2023, at 12:10 pm, with the facility's SSD, the SSD stated both GACH 2 and GACH 3 were not located in the same county as the facility. The SSD stated RN 7 did not instruct the SSD to schedule Resident 10's transportation for the appointment on 3/21/2023. c. During a review of Resident 10's Facility Transportation Request Form (TRF), dated 3/10/2023, the TRF indicated the Social Services Assistant (SSA) cancelled the transportation as requested by RN 5, on 3/23/2023, at 2:15 pm for radiation of the neck with MD 5 at GACH 2. During a review of Resident 10's phone order, dated 3/15/2023, at 11:35 am, the phone order indicated Resident 10 had a follow-up appointment on 3/23/2023 at 2:15 pm, with MD 5, at GACH 2. During a review of Resident 10's Progress Note, dated 3/15/2023, at 11:53 am, the Progress Note indicated LVN 6 wrote, Resident 10 had two radiation follow-up appointments (One at GACH 3 and one at GACH 2). The note indicated Resident 10 needed a radiation follow-up appointment at GACH 2 with MD 5 on 3/23/2023 at 2:15 pm. During a review of Resident 10's Progress Note, dated 3/21/2023, at 5:09 pm, the Progress Note indicated RN 5 wrote, RN 5 called GACH 2 Oncology Department, left a message to cancel Resident 10's appointment on 3/23/2023 due to transportation/insurance issue. During a concurrent interview and record review, on 9/15/2023, at 12:10 pm, with the SSD, Resident 10's Progress Notes, dated 3/21/2023 was reviewed. The note indicated, RN 5 cancelled Resident 10's radiation follow-up appointment on 3/23/2023. The SSD stated, RN 5 instructed the SSD to cancel Resident 10's appointment dated 3/23/2023, at 2:25 pm. The SSD stated, RN 5 did not tell the SSD the reason why RN 5 cancelled the appointment. The SSD stated Resident 10's insurance did not cover transportation costs for Resident 10's oncology follow-up appointments and radiation planning appointments. The SSD stated nursing staff did not inform the SSD there was a transportation issue or that Resident 10 missed the radiation oncology appointments due to transportation issues. On 9/15/2023, at 5:11 pm and 5:47 pm, two telephone interviews were attempted, RN 5 was not available to be interviewed. d. During a review of Resident 10's phone order, dated 3/7/2023, at 4:11 pm, the phone order indicated Resident 10 had an oncology consult appointment on 4/5/2023, at 11:30 am, at GACH 3. During a review of Resident 10's Progress Note, dated 3/7/2023, at 4:30 pm, the Progress Note indicated Resident 10 had an oncology appointment scheduled for 4/5/2023 at 11:30 am. During an interview with the SSD, on 9/15/2023 12:10 pm, the SSD stated RN 5 and RN 7 did not request the SSD to set up the transportation for Resident 10 oncology consultation appointment on 4/5/2023. During an interview with RN 7 on 9/15/2023, at 3:50 pm, RN 7 stated Resident 10's appointment on 4/5/2023 was not scheduled in the facility's unofficial calendar used for residents with outside appointments. During an interview with the Assistant Administrator (Asst. Admin), on 9/15/2023, at 6:24 pm, the Assist. Admin stated Resident 10's appointments needed to be followed through as ordered by the physicians. e. During a review of Resident 10's phone order, dated 4/20/2023, at 4:52 pm, the phone order indicated Resident 10 was scheduled for an oncology follow-up appointment with MD 4 on 4/26/2023, at 2 pm. During a review of Resident 10's Progress Note, dated 4/20/2023, at 12:04 pm, the Progress Note indicated the SSA scheduled transportation for oncology follow-up appointment on 4/26/2023 at 2 pm. During a review of Resident 10's phone order, dated 4/25/2023, at 5:49 pm, the phone order indicated Resident 10's oncology follow-up appointment with MD 4 scheduled on 4/26/2023 at 2 pm was cancelled due to Resident 10 was not a candidate for cancer treatment. During a review of Resident 10's Progress Note, dated 4/25/2023, at 5:53 pm, the Progress Note indicated RN 5 instructed the SSD to cancel Resident 10's transportation for an appointment with MD 4 on 4/26/2023. The note indicated Resident 10 was not a candidate for cancer treatment. During a review of Resident 10's Head and Neck Cancer Center Follow-Up Note at GACH 3, dated 6/27/2023, the follow-up note indicated Resident 10, May have not started radiation therapy, or started and stopped shortly after. During a review of Resident 10's Established Patient Exam (EPE), from GACH 3, dated 7/18/2023, the EPE indicated, MD 3 reviewed Resident 10's CT chest result and Resident 10's CT chest showed numerous bilateral pulmonary (lung) nodules (small swelling or aggregation of abnormal cells in the body) concerning for metastatic disease (cancer that spreads from where it started to a distant part of the body). The EPE indicated MD 3 was concerned of the newly diagnosed lung nodules due to metastatic disease. During a concurrent interview and a record review on 9/15/2023, at 3:50 pm, with RN 7, Resident 10's Progress Notes, dated 4/25/2023 was reviewed. The note indicated RN 5 cancelled Resident 10's oncology consultation appointment on 4/26/2023, RN 7 stated RN 5 cancelled the appointment for 4/26/2023 due to a misunderstanding of Resident 10's cancer treatment. RN7 stated Resident 10 was not a candidate for chemotherapy (a drug treatment that uses powerful chemicals to kill fast-growing cells int eh body) but Resident 10 was a candidate to receive radiation therapy/treatment (a treatment using ionizing radiation, or to kill or control the growth of cancer cells). RN 7 stated RN 7 did not know about Resident 10's radiation treatment schedules. RN 7 stated radiation treatment schedule needed to be followed strictly so Resident 10's health could improve. On 9/15/2023, at 5:11 pm and 5:47 pm, two telephone interviews were attempted, RN 5 was not available to be interviewed. During an interview on 9/15/2023 at 6:24 pm, with the Asst. Admin, the Assist. Admin stated it was not the facility's practice to cancel appointments or not send Resident 10 to the resident's appointments due to GACH 2 and GACH 3 were too far. The Assist. Admin stated RN 5 and RN 7 could not cancel Resident 10's appointments. The Assist. Admin stated it was out of a nurse's scope of practice to cancel an appointment without understanding the larger treatment picture. The Assist. Admin stated, Nurses are not doctors. The Assist. Admin stated Resident 10 missing oncology appointments could be very dangerous for Resident 10's health. During an interview on 9/19/2023, at 4:41 pm, with MD 3, MD 3 stated Resident 10 could not come to the appointment scheduled on 3/21/2023 due to the cost of transportation. MD 3 stated his staff (unidentified) spoke to RN 5 on 4/25/2023 and were again told that Resident 10's appointments were being cancelled due to transportation issues. MD 3 stated the facility cancelled Resident 10's appointments at GACH 2 on 3/16/2023 and 3/23/2023, GACH 3 on 3/21/2023, 4/5/2023, and GACH 4 on 4/26/2023. MD 3 stated Resident 10 had only been to one CT simulation (pictures/images of the body to prepare for radiation therapy/treatment) appointment since Resident 10 was admitted to the facility. MD 3 stated MD 3 and MD 4 (Hematology Oncologist at GACH 4) discussed that Resident 10 was not a candidate for chemotherapy but was a candidate for radiation therapy. MD 3 stated it was MD 3's professional opinion that Resident 10's cancer worsened by metastasizing (spreading) to Resident 10's lungs because the facility did not follow Resident 10's cancer treatment schedules. MD 3 stated Resident 10 required radiation treatments and follow-up oncology appointments to treat Resident 10's cancer. MD 3 stated when Resident 10 first started with Resident 10's cancer treatment, Resident 10 did not have lung metastases (cancerous tumors that start somewhere else in the body and spread to the lungs). During a review of the facility's P&P titled, Referrals to Outside Services, revised 12/1/2013, the P&P indicated the facility will provide residents with outside services as required by physician's orders or the care plans. The P&P indicated the SSD coordinated the referral of residents to outside agencies/programs to fulfill the resident needs for services not offered by the facility. The P&P indicated for clinical services; a nursing designee would assist the SSD in locating a provider. The P&P indicated referrals for medical services were only made pursuant to an Attending Physician's order, and the SSD or his/her designee will coordinate with nursing staff to ensure that the order and referral to outside provider was documented in the resident's medical record.

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was provided necessary behavioral health care and services for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Resident 1 who exhibited aggressive behavior from alcohol intoxication (also known as alcohol poisoning, described as drunkenness or negative behavior and physical effects caused by a recent consumption of alcohol) was monitored and supervised from walking out of the facility and coming back intoxicated (A disturbance in behavior or mental function during or after alcohol consumption). 2. Resident 1's aggressive behavior and mental status was being monitored and supervised to prevent the resident from hitting another resident (Resident 2) after Resident 1 came back to the facility intoxicated on 4/5/2022. 3. Resident 1 was evaluated by a psychiatrist (a medical doctor who specializes in mental health, including substance use disorders. Psychiatrists are qualified to assess both the mental and physical aspects of psychological problems) when a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Resident 1 was monitored and supervised when the resident violated the out on pass order (an inpatient who is ordered by the physician to go out to the community temporarily from a period of time) that was placed on hold due to the resident consuming alcohol. The resident signed out of the facility on 3/13/2022, 4/2/2022, 4/5/2022 to go to the store. 5. Resident 1's behavior was continually monitored to prevent him from hitting Resident 2 and causing Residents 3 and 4 to feel threatened when Resident 1 returned to the facility intoxicated. These deficient practices had the potential to result in the likelihood that Resident 1 would continue to be intoxicated with alcohol and be verbally and physically aggressive that could lead to fear, and possible injury to other residents if not be treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/7/2022 at 8:31 PM, 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) was identified in the presence of the facility's Administrator (ADM), Director of Nursing (DON) and Social Service Designee (SSD) regarding the facility's failure to provide supervision and monitoring to Resident 1 who violated the facility's policy and procedure on out on pass and returned to the facility intoxicated, verbally and physically abusive towards others. On 4/8/22 at 5:52 PM, the IJ was removed after the ADM submitted an acceptable removal plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the removal plan while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM. The acceptable removal plan was as follows: 1. On 4/7/2022, the Licensed Nurse contacted Resident l's attending physician as Resident 1 exceeded the 2-hour timeframe for out on pass and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . - Completion Date: 4/7/2022 2. On 4/7/202, Resident 1 returned to the facility, was assessed by a Licensed Nurse, and was moved to a different room between 10:30PM to 12AM. 3. On 4/7/2022, the Licensed Nurse contacted Resident l's attending physician and received an order to discontinue out on pass privileges until psychiatrist evaluates him and deems him safe to go out on pass. 4. On 4/7/2022, the Administrator contacted the Psychiatrist and arranged for Psychiatry Evaluation for Resident 1 on 4/8/2022. 5. On 4/7/2022, the DON initiated an in - service education to the staff regarding the policy and procedures related to Out on Pass, Discharge Against Medical Advice, Resident to Resident Altercation, and assessment of residents upon returning from out on pass. This in - service education will be completed by 4/15/2022. Any Licensed Nurses and Certified Nursing Assistants (CNAs) on call or on leave will receive the education upon return to work, and newly hired Licensed Nurses and CNAs will receive training during their orientation period. 6. On 4/7/2022, Resident 2 was assessed by a Licensed Nurse to ensure feeling of safety in the facility. 7. On 4/7/2022, Assistant Administrator and DSD conducted room rounds to ensure that Resident 1 did not have any alcoholic beverages in the room. 8. On 4/7/2022, the Interdisciplinary Team (IDT, a group of diverse health care professionals from different fields), met with the resident to offer alternatives to alcohol cessation, discussed risks and benefits. 9. On 4/7/2022, at 8PM, one on one supervision (the resident's clinical status is unstable enough to require a nurse or doctor to be present and observing/treating them at all times) supervision was initiated for Resident 1. Cross Reference F600 Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 4/27/2018 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .), [CONDITION(S)] (excessive use of alcohol) and hematemesis (coughing up blood). A review of Resident 1's plan of care, dated 11/8/2021 indicated the resident had a behavioral problem with history of cursing, yelling at staff and had short temper (easily angered). Interventions included for the resident to have fewer episodes of cursing at the staff was for the facility to encourage the resident to ventilate feelings (to express openly). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/29/2022, indicated the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident 1 was assessed having limitations on one side of the lower extremity which placed resident at risk for injury. A review of Resident 1's physician order, dated 3/9/2022, indicated to place a hold on Resident 1's out on pass order due the resident consuming alcohol while out on pass. A review of Resident 1's physician order, dated 3/26/22, indicated to transfer Resident 1 to the hospital for medical clearance and psychiatric (the field of medicine that diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's clinical record indicated no psychiatric evaluation was conducted as ordered by the physician or no follow up was made for the resident to receive psychiatric evaluation or treatment from 3/26/2022 to 4/7/2022. A review of the Release of Responsibility While Out On Pass and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's plan of care, dated 3/29/2022, indicated Resident 1 was at risk for decreased psychosocial wellbeing, emotional/mental distress, ineffective coping skills, and difficulty adjusting to placement in the facility due to resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . To ensure the resident accept staff support and interventions, the facility would do the following: a. Assess resident's coping skills and support system. b. Will be evaluated by psychologist and psychiatrist as needed. c. Provided support visits weekly and as needed to monitor psychosocial wellbeing. A review of Resident 1's Psychologist Notes, dated 4/1/2022 indicated the justification for the continued treatment was due to ongoing mental health symptoms and decline from baseline. The notes indicated the psychiatrist recommended for the resident to continue to work on, decreasing anger outburst and maintain sobriety (absence of alcohol or other substance use). A review of Resident 1's IDT Note, dated 4/6/2022, timed at 2:35 PM, indicated IDT met with Resident 1 regarding having an altercation with another resident (Resident 2). The note indicated IDT attempted to invite Resident 1 to the care plan meeting and Resident 1 declined, yelling and cursing man why the f . are you guys making it a big deal. He should have not been in [MEDICATION(S)]. The note indicated IDT would respect Resident 1's wishes and would discuss interventions that the staff and Resident 1 can practice avoiding another altercation. The note indicated the staff would monitor Resident 1 for any aggression and to remind Resident 1 that violence was prohibited at the facility and provide a safe environment to Resident 1. A review of Resident 1's clinical record had no documented evidence that the resident's aggressive behavior was consistently monitored every shift. A review of Resident 1's Psychiatrist report, dated 4/8/2022, indicated Resident 1 appeared somewhat paranoid (is the feeling that you're being threatened in some way), with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The report indicated the psychiatrist plan of care indicated to transfer Resident 1 to an inpatient psychiatric unit due to resident was unstable, and to place him on a 5150 hold (a Welfare and Institutions Code, which allows a person with a mental illness to be involuntarily detained for a 72-hour psychiatric hospitalization ) due to being Danger to Others (DTO). A review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2' MDS, dated [DATE], indicated Resident 2 had no cognitive impairment requiring assistance (resident involved in activity and staff provide weigh bearing support) with one-person physical assist on walking and transfers. A review of Resident 3's Admission Record indicated the facility admitted the resident on 3/10/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MDS, dated [DATE] indicated the resident had no cognitive impairments and required extensive assistance with one-person physical assistance on bed mobility and toilet use. A review of Resident 4's Admission Record indicated the facility admitted the resident on 11/21/2020 and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS, a standardized assessment and care planning tool) dated 2/17/22 indicated the resident had moderate cognitive impairments. During an observation on 4/7/2022 at 1:40 PM, in the presence of the AIT (Administrator in Training) Resident 1 was observed sitting in the wheelchair in the front lobby getting ready to leave the facility. The resident was observed with a skin cut on the right elbow covered with dried blood. Resident 1 was asked about his right elbow and the resident replied, I fell off the wheelchair the other day. The resident refused to elaborate further regarding the alleged incident. Resident 1 was asked about the altercation related to Resident 2. Resident 1 replied, I do not know what you are talking about, I did not hit anyone or had a fight with anyone. Resident 1 stated, No one mess with me you do not know what I have been to, I will walk over you before you walk all over me. Resident 1 refused to discuss the alleged altercation between Residents 1 and 2. Resident 1 then proceeded to leave the facility and the AIT informed Resident 1 not to drink while he was out on pass. During a concurrent interview the AIT stated, Resident 1 went out on pass alone and sometimes returned to the facility intoxicated. During an interview with the Certified Nursing Assistant (CNA 1) on 4/7/2022 at 2 PM, she stated on 4/5/2022, she heard screaming from Resident 1 and Resident 2's room and witnessed Resident 1 hit and push Resident 2 to his bed while repeatedly screaming at Resident 2 telling him, I am not doing anything to you F you F . you. CNA 1 stated Resident 2 did not fight back and was separated from Resident 1 who smelled like alcohol and looked like he had been drinking alcohol when the incident occurred. CNA 1 stated Resident 1 often left the facility alone and returns to the facility smelling like alcohol, drunk and very aggressive towards other residents and staff when intoxicated. CNA 1 stated Resident 1 was not monitored and supervised closely when he is drunk. During an interview on 4/7/2022 at 2:56 PM, Resident 2 stated that on 4/5/2022, Resident 1 rushed him to get out of the restroom because he wanted to use the restroom. Resident 2 stated, Resident 1 who smelled like alcohol and was drunk, repeatedly pushed him, hit him on the chest, cursed and yelled at him with profanity and told him, F you F you then pushed him towards the bed. Resident 2 stated he did not feel safe to be in the same room as Resident 1 who was often drunk and repeatedly threatened to throw him out on the street and beat him up and kill him. Resident 2 explained Resident 1 often goes out of the facility and returned drunk fighting with staff and residents. During an interview on 4/7/2022 at 4:14 PM, the Licensed Vocational Nurse (LVN 1) stated Resident 1 often left the facility out on pass and came back drunk. LVN 1 stated Resident 1 did not comply with the out on pass policy of the facility and returned to the facility at any time he wanted, often drunk and aggressive towards others. During an interview and concurrent record review of Resident 1's clinical record with Administrator (ADM) on 4/7/2022 at 4:29 PM, ADM stated Resident 1 was noncompliant with the facility's policy and procedure of out on pass and often left the facility and returned back to the facility sometimes drunk and aggressive towards others. The ADM stated on 3/10/2022 she witnessed Resident 1 being aggressive and angry towards others when he was not allowed to go out on pass. ADM stated since Resident 1 was alert, oriented and was self-responsible, he had legal right to go out on pass. The ADM stated there was no documentation that the IDT meeting was conducted to determine if Resident 1 may go out on pass safely. The ADM stated Resident 1 went out on pass without supervision and did not sign in or out when leaving or returning to the facility, puts the resident at risk for fall, accident, and injury. During a record review of the Release of Responsibility While Out on Pass, and concurrent interview with the ADON (Assistant Director of Nursing) on 4/7/2022 at 4:44 PM, indicated on 7/31/2021, 3/13/22, 4/2/22, and 4/6/22, Resident 1 left the facility to go to the store without documentation of when the resident returned to the facility. The ADON stated, the facility's staff were supposed to document when residents left the facility and document when they returned to ensure the residents returned safely. During an interview and review of Resident 1's clinical record on 4/7/2022 at 4:48 PM, the Social Service Designee (DSD) stated Resident 1 was noncompliant with care and the last few months Resident 1 had been going out on pass even against the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the following progress notes in Resident 1's clinical record indicated the following: a. On 2/14/2022, timed at 15:07 PM, Resident 1 was found with an alcohol bottle in room at bedside. The SSD and ADM was informed. Resident 1 with aggressive behavior towards CNA and charge nurse and punched CNA on the face and attempted to hit the charge nurse. Police was called and report done. b. On 3/9/2022, timed at 4:24 PM, Resident 1 the (Nurse Practitioner) NP wrote an order to allow Resident 1 to go out on pass to go to the store for 1-2 hours, resident left at 10:35 AM and returned at 12:30 PM. Resident 1 returned to the facility and looked like he had been consuming alcohol. When Resident 1 was asked if he had been consuming alcohol, the resident replied, Do you think I am stupid to tell you if I had any alcohol, what kind of stupid question is that. Resident 1 disrespected the staff and called her names Do not F with me you know how I roll, do not F . with me you know I take care of business. c. On 3/10/2022, timed at 2:01 PM, Resident 1 with unsteady gait and with strong odor of alcohol went to the nursing station and yelling and cursing at the staff. Resident 1 was asked if he had consumed alcohol? Resident 1 replied You cannot prove that, come on prove it to me. I can have you fired. Resident 1 continued to harass charge nurse. Resident 1 approached the staff and stated he wanted to go to the store, when Resident 1 was informed he had no order for out on pass the resident continued to be aggressive and violent towards the staffs and stated, Well I went out yesterday. The NP was called ordered not to out on pass and to be given a 30-day discharge notice to the resident. NP was made aware that Resident 1 was homeless. d. On 3/17/2022, timed at 2:52 PM housekeeping found three empty bottles of alcohol in the trash can, DON and ADM aware. Resident 1 found ordering alcohol through online order but did not go through. e. On 3/26/2022, timed at 12:35 PM, Resident 1 was ordered by the NP to go to the acute care hospital and resident refused and stated there was nothing wrong with him. f. On 4/1/2022, timed at 2:32 PM, SSD and Ombudsman met with Resident 1 to review 30 days discharge plan. Resident 1 was adamant and preferred having his own independent living situation, which was out of the Resident 1's price range. Resident 1 informed SSD to call the Social Security office and go with him so that they can get me more money. g. On 4/6/2022 at 4:46 PM, SSD visited Resident 1 to talk to the resident about the altercation with another resident. Resident 1 did not want to speak to the SSD. During an interview and concurrent record review of Resident 1's medical record, on 4/7/2022 at 4:39 PM, the SSD stated on 3/26/2022 the physician ordered Resident 1 to go to the acute hospital for medical and psychiatric evaluation, but the resident refused. The SSD stated there was no monitoring of Resident 1's behavior or follow up referral to a psychiatrist when Resident 1 continued to have aggressive behavior towards others. The SSD stated Resident 1 was evaluated by a psychologist (A psychologist is a person who specializes in the study of mind and behavior or in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The SSD stated Resident 1 was not referred or evaluated by the psychiatrist because Resident 1 was not taking any psychiatric medications. During an interview on 4/7/22 at 5:10 PM, the ADM stated, Resident 1 had not returned to the facility, and they have not searched for the resident. The ADM stated she was not aware that the NP ordered Resident 1 not to go out on pass on 3/9/22. During an interview on 4/7/2022 at 5:35 PM, Resident 3 was observed lying in bed. In an interview Resident 3 stated his new roommate Resident 1 kept him awake all night because he was talking and drinking. Resident 3 stated he was afraid Resident 1 will hit and hurt him when he gets drunk just like what he did to his previous roommate (Resident 2). During an interview on 4/7/2022 at 7:14 PM, the ADON stated there was no change of condition report, monitoring of behavior or supervision when Resident 1 returned to the facility with alcohol intoxication. The ADON stated there was no documentation of the monitoring of Resident 1's whereabouts when he was out on pass. The ADON stated, it was important to monitor Resident 1 because, He is aggressive and a possibility that he might hurt or punch staff, or other residents. The ADON stated, when Resident 1 went out on pass, facility staff were supposed to assess for the resident before the resident left and returned to the facility after being out on pass. The ADON stated, there was no documented evidence that Resident 1 was assessed for mental status, behavior, mental alertness and mobility prior to or when he returned to the facility. During a telephone interview on 4/7/2022 at 7:33 PM, Nurse Practitioner (NP) stated she witnessed when Resident 1 returned to the facility intoxicated on 3/25/2022, and the resident was demanding towards facility staff. NP stated the resident would hide his alcohol or come back already drunk and with unusual behavior when returning to the facility. The NP stated she did not remove the hold for the out on pass order for Resident 1 because of the continued noncompliance with not drinking alcohol. The NP stated she should have referred Resident 1 to the psychiatrist because the resident was noncompliant with alcohol use, has a behavior disorder and is a danger to others. During an interview on 4/7/2022 at 7:45 PM the ADM stated Resident 1 returned to facility. During an observation on 4/7/2022 at 7:55 PM, Resident 1 was observed sitting in the wheelchair in his room. During an interview Resident 1 had slurred speech, was irritable and refused to be interviewed. Resident 1 stated he used his wheelchair to return back to the facility. During an observation and concurrent interview on 4/7/2022 at 8:19 PM, Resident 4 was observed sitting in the wheelchair across from Resident 1's room. Resident 4 questioned why Resident 1 was allowed to go out, get alcohol and get drunk. Resident 4 stated when Resident 1 was drunk, the resident was very loud, aggressive, physically, and verbally abusive towards others. Resident 4 stated she felt threatened when Resident 1 returned to the facility drunk because he had no control of his mouth and cursed at everyone. On 4/7/22 at 8:51 PM, the ADON informed the surveyors that Resident 1 was in his room, and he just lost balance and fell on the floor, but he was able to get up from the floor at 8 PM today. During an interview with the Medical Doctor (MD 1) on 4/7/2022 at 9:47 PM, MD 1 stated he wrote an order to allow Resident 1 to go out on pass. MD 1 stated the resident could make decisions and the facility was not a jail. MD 1 stated, We cannot stop him from going out. MD 1 stated, We are working on his psychiatrist consult sooner. MD 1 was unable to recall if Resident 1 was referred to a psychiatrist to treat the Resident 1's behavior. During an interview on 4/8/2202 5:40 PM, CNA 2 stated he witnessed Resident 1 always drunk and brought alcohol to the facility. CNA 2 stated a month ago he found Resident 1 with a bottle of alcohol in his hand after the resident fell on the floor while he was drunk. CNA 2 stated Resident 1 became angry and tried to choke him. CNA 2 stated Resident 1 was not monitored or supervised when he returns to the facility intoxicated. CNA 2 stated he observed the resident yelling at his roommate (Resident 2) and others on many occasions and informed the ADM and the DON multiple times. A review of the facility's policy and procedure, titled Out on Pass dated 1/11/2016, indicated, the facility will make reasonable effort to ensure the resident safety and uphold resident rights. If the nursing staffs believe the out on pass order conflicts with the resident's plan of care or jeopardizes the resident's health and safety, the nursing staff will hold the out on pass order until the physician/psychiatrist can determine the resident can safely leave the facility. Prior to the resident leaving out on pass the licensed nurse will assess the resident's physical and mental status and will be reassessed when he/she returns to the facility to determine the resident's condition. The licensed nurse will document the time the resident left the facility, the destination when out on pass, contact phone number and expected time of return. A review of the facility's policy and procedure, dated 12/1/13, titled Resident Drug and [CONDITION(S)] indicated, the facility will provide safe and drug free environment for residents while at the facility by implementing the following: a. The facility has zero tolerance policy for the use of alcohol in the facility or on the ground of the facility without the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] b. The residents whose medical record provides a history of [CONDITION(S)] may be seen by a psychiatrist, as indicated, who will address current behavioral management issues. c. The IDT will review the care plan after it is developed and as needed thereafter. d. If the resident violates the policy, the resident may be asked to submit to drug screening test for the presence of any illegal substances in their body. If the drug screening is positive, the resident will be discharged to a more appropriate setting according to the facility discharge procedures. A review of the facility's policy and procedure, dated 1/16/2020, titled Behavioral Management indicated, residents who displays a mental disorder, psychosocial adjustment difficulties (e.g., crying, yelling, hitting, etc.) or has a history of trauma and/or post-traumatic stress disorder, will receive appropriate treatment to address the problem or attain the highest practicable mental and psychosocial wellbeing. Efforts will be made by the Interdisciplinary Team (IDT) to implement non-pharmacological interventions to alleviate behavior symptoms before initiating any psychoactive medications. The facility will utilize the IDT assessment process to identify additional resources if the resident does not respond to standard interventions and/or medications and consider psychiatric or psychological consultation if appropriate.

Based on observation, interview, and record review, the facility failed to remain free of pests by not having an effective pest control for 192 of 192 sampled residents (Residents 1-192) who are residing in the facility consuming food, receiving fluids, and used tableware from the kitchen, by failing to: 1. Eradicate (destroy/kill) a cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen. 2. Eliminate harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices [narrow openings]) on the walls, floors, and different surfaces in the kitchen. These deficient practices placed the 192 sampled residents at risk of vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches, mosquitos, ticks, and fleas) and had the potential for the 192 sampled residents to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that can lead to life threatening complications and death. On 2/2/2022, at 1:20 p.m., the State Survey Agency (SSA) received notification from the Los Angeles County (LAC) Department of Public Health (DPH) Environmental Health (EH) District Surveillance and Enforcement (DSE) Branch (department responsible for ensuring food provided for human consumption is safe and free of contamination) reported a cockroach infestation in the facility's kitchen. At 1:15 p.m., Registered Environmental Health Specialist 1 (REHS 1 - a county health inspector who inspects various food facilities to determine compliance with State and local food codes) closed the kitchen. During the kitchen observation, the following were observed: 1. At 3:04 p.m., three live adult cockroaches were observed under the handwashing sink, walking on the tankless hot water heater. 2. At 3:08 p.m., one live adult cockroach and live nymph (an adolescent cockroach) were observed under a scraping sink, walking on the wall. 3. At 3:11 p.m., one live adult cockroach was observed under the garbage disposal, walking on the wall. On 2/2/2022, at 5:08 p.m., the SSA called an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents), in the presence of the facility's Administrator and was notified of the findings. On 2/7/2022, at 11:12 a.m., five days after identifying the IJ, the SSA removed the IJ in the presence of the Administrator after confirming on-site that implemented the acceptable plan of action (POA, action to correct the deficient practices) as follows: 1. Pest control service was conducted by the pest control company on 2/2/2022, 2/3/2022, and 2/5/2022. The pest control company will conduct weekly inspections for one month, then monthly thereafter and provide results to the Administrator for resolution, as warranted. 2. The facility conducted in-service training to all staff, including the dietary staff on 2/2/2022 and 2/3/2022 to report any pests or penetrations in the kitchen for immediate corrective action. 3. The licensed nursing staff conducted assessments of the 192 residents on 2/2/2022 and 2/3/2022 for any presence of gastrointestinal (GI) symptoms, such as abdominal pain, nausea, vomiting, and diarrhea/loose stools. None of the residents had any symptoms. Findings: A review of the facility's census report, dated 2/1/2022, indicated there were 192 residents residing in the facility. A review of the Retail Food Official Inspection Report, dated 2/2/2022, indicated REHS 1 observed the following: 1. Six live adult cockroaches harboring between the wall and the two-compartment food preparation sink back splash. 2. Two live adult cockroaches harboring between the potable water valve and the wall, under the two-compartment food preparation sink. 3. Five live nymphs harboring between the wall and a drainpipe entering the wall, located under the drainboard attached to the automatic ware washing machine. 4. Two live adult cockroaches harboring behind a bracket, that is holding up a drainage line, and that is attached to the wall, under the drainboard to the automatic ware washing machine. 5. Two live adult cockroaches crawling on the wall, under the drainboard that is attached to the automatic ware washing machine. 6. Two live adult cockroaches harboring between the wall and the 3-compartment utensil sink drainpipe. 7. One live adult cockroach harboring within a corrugated electrical line attached to the wall, beneath the drainboard, that is attached to the automatic ware washing machine. 8. Four live adult cockroaches harboring on the side of the hot water heater, located below the handwash sink in the kitchen. On 2/2/2022, at 2:55 p.m., a complaint investigation was conducted regarding allegations of cockroaches observed in the kitchen. Administrator was informed of the visit. On 2/2/2022, at 3 p.m., during an interview, REHS 1 stated he arrived at the facility on 2/2/2022, at 11:45 a.m., and proceeded to conduct a routine inspection of the kitchen. Between 11:50 a.m. and 1 p.m., he saw 26 live German cockroaches (small species of cockroach that can access food items and carry serious diseases. These cockroaches also spread different forms of gastroenteritis [food poisoning, dysentery, diarrhea, and other illnesses], plus they carry several allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma) of various stages of development throughout the kitchen. On 2/2/2022, at 3:04 p.m., during an observation of the kitchen with REHS 1. three live adult German cockroaches were observed under the handwashing sink, walking on the tankless hot water heater. At 3:08 p.m., one live adult cockroach and live nymph (an adolescent cockroach) were observed under a scraping sink (sink where excess food are removed from table/potware), walking on the wall. At 3:11 p.m., one live adult cockroach was observed under the garbage disposal, walking on the wall. On 2/2/2022, at 3:40 p.m., during an interview, Dietary Supervisor (DS) stated she had been informed by dietary staff when she started working at the facility in 10/2021 that there were cockroaches in the kitchen. DS stated she was also informed the pest control company serviced (application of treatment) the facility on a weekly basis. On 2/2/2022, at 4:55 p.m., REHS 1 posted a County Food Closure sign on the kitchen door and informed the Administrator the sign should not be removed until the EH DSE officially reopens the kitchen. A review of the Pest Control Service Report dated 11/16/2021, 12/29/2021, and 1/27/2021, indicated a pest control service was conducted at the facility. All three service reports indicated the pest control technician applied treatment in the kitchen and each of these times, the technician observed cockroach activities. A review of the facility's Pest Control policy, dated 1/1/2012, indicated the facility would maintain an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. It also indicated the pest control service provider will carry out any pest control actions needed to rid the facility and its grounds of any environmental pests. A review of the 2017 U.S. Food and Drug Administration Food Code 6-202.15 indicated insects and rodents are vectors of disease-causing microorganisms (living thing that is too small to be seen with the naked eye) which may be transmitted to humans by contamination of food and food contact surfaces. Food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings; closed, tight fitting windows and solid self-closing tight fitting doors. A review of the 2017 U.S. Food and Drug Administration Food Code 4-402.11 indicated the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic (disease-causing) microorganisms that are transmissible through food. A review of the Centers for Disease Control and Prevention (CDC) Guidelines for Environmental Infection Control in Health Care Facilities, updated on 7/23/2019, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). A review of the undated article from the County of Los Angeles, Department of Public Health, Effective Management of Cockroach Infestation (retrieved on 12/30/2021, from http://publichealth.lacounty.gov/eh/docs/specialized/vector_management/cockroachmgmt.pdf indicated cockroaches may become pests in any structure that has food preparation or storage areas. The article indicated cockroaches contaminate food and kitchen utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high numbers. Cockroaches that live outdoors could come into contact with human excrement (waste matter/feces) in sewers or with animal fecal matter and had the potential to transmit bacteria that cause food poisoning if they enter the structures.

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who was assessed at risk for falls, (move downward, typically rapidly and freely without control, from a higher to a lower level) was evaluated for rehabilitation services (improve skills and functioning for daily living that has been lost or impaired) after a change in condition that occurred on 4/1/21 and was adequately supervised while lying in bed to prevent the resident from falling out of bed on 4/3/2021. On 4/3/2021 at 9:25 am, while Certified Nursing Assistant 1 (CNA 1) was changing Resident 1's adult brief, CNA 1 left the resident unwatched on the bed while reaching for the resident's adult brief. These deficient practices resulted to Resident 1's fall on 4/3/2021. Resident 1 suffered a head trauma (any damage to the scalp, skull or brain caused by injury) and sustained a two-centimeter (cm, a metric unit of length) laceration (a deep cut) to the left eyebrow and was transferred to a General Acute Hospital 1 (GACH 1) on 4/3/2021 at 12 pm where the resident received five sutures (a stitch or row of stitches holding together the edges of a wound) to the left eyebrow. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 8/25/2020 with diagnoses of generalized muscle weakness, [CONDITION(S)] (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), [CONDITION(S)] (lung condition that causes shortness of breath), and [CONDITION(S)] (mental disorder characterized by abnormal social behavior and failure to understand what is real). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 1/14/2021, indicated Resident 1 was moderately impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making and required a one person extensive assistance for bed mobility and transfer. The MDS indicated Resident 1 was total dependent (needs full staff assistance) for dressing, toilet use, personal hygiene, and bathing with one person to assist. A review of Resident 1's Morse Fall Risk Assessment (method of assessing a patient's likelihood of falling), dated 1/14/2021, indicated Resident 1 was assessed at being high risk for falls. A review of Resident 1's untitled care plan dated 1/14/2021, indicated Resident 1 was at risk for fall and the interventions included for the nursing staff to complete a fall risk evaluation upon admission, quarterly, with significant changes and as needed, refer for rehabilitation consultation, and orient resident to environment each time changes were made. A review of Resident 1's Situation- Background- Assessment- Recommendation (SBAR, provides a framework for communication between members of the health care team about a resident's condition), dated 4/1/2021, and timed at 1:57 pm, indicated Resident 1 had change of condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains.), a decrease in functional mobility and developed new contracture. A review of Resident 1's clinical record from 4/1/21-4/3/21 indicated no documented evidence a rehabilitation consultation was conducted for the resident in accordance with the resident's care plan intervention or that the resident was re-evaluated for fall risk to provide physical therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function), consultation after Resident 1 had a decline in functional ability (move independently and safely to participate in the activities of daily living), and development of new contractures (deformity and joint stiffness). A review of Resident 1's Progress Notes dated 4/3/2021, and timed at 12:03 pm, indicated that on 4/3/2021, at 9:25 am, CNA (unidentified) was providing care to Resident 1 on the resident's bed. The notes indicated the CNA (unidentified) reached for an adult brief and Resident 1 slid to the floor and sustained a laceration on the resident's left eyebrow. The notes indicated the facility transferred the resident to GACH 1 at on 4/3/2021, at 12pm. A review of Resident 1's GACH 1 Emergency Department Physician Note, dated 4/3/2021, and timed at 4:49 pm, indicated Resident 1 sustained a traumatic (refers to physical injuries of sudden onset and severity which require immediate medical attention) fall after the resident was being turned over in bed and the railing (barrier made of rails) was down. The notes indicated Resident 1 suffered a head trauma and sustained a two cm laceration over the left lateral (side) aspect of the eyebrow and the resident received five sutures. A review of Resident 1's Care Conference Summary (CCS), dated 4/5/2021, and timed at 11am, indicated Resident 1 slid off the resident's bed on 4/3/2021 (no time identified) while CNA1 was providing care. CCS indicated Resident 1 was on a low air loss mattress (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air), which was made of slippery material. During an observation and interview with licensed vocational nurse 3 (LVN 3) on 4/14/2021 at 11:52 am, Resident 1 was observed inside the resident's room with a white gauze (bandage) on the left eyebrow. LVN 3 stated Resident 1 fell on [DATE] from the bed, sustained a laceration, and had sutures. During an interview on 4/14/2021 at 2:29 pm, LVN 2 stated on 4/3/2021 at 9:25 am, LVN 2 was giving medications to Resident 1's roommate when she heard a loud thump coming from Resident 1's bed. LVN 2 stated CNA 1 called for her help and when she went to help CNA 1, she saw Resident 1 on the floor. LVN 2 observed the Resident 1 bleeding from the left side of the head near eyebrows. During a concurrent record review and interview on 4/14/2021 at 4:14 pm with MDS nurse, she stated Resident 1's Summary of Physician Orders did not indicate any order for rehabilitation consultation referral from when Resident 1 had a COC on 4/1/2021 until the fall incident on 4/3/2021. MDS Nurse stated Resident 1 required a one person assistance for bed mobility and toilet use according to the MDS on 1/14/2021. MDS nurse stated Resident 1 needed two people assist with Activities of Daily Living (ADL, people's daily self-care activities including changing of adult briefs) after the resident fell on [DATE]. MDS nurse stated there were no updates on the resident's care plan on 4/1/2021 after determination of Resident 1's COC. During a telephone interview on 5/26/2021 at 11:30 am, the facility's Director of Nursing (DON) stated according to the facility's Fall Management Program policy, a licensed nurse (any) would conduct a new fall risk evaluation upon identification of a significant COC. DON stated the policy indicated the licensed nurse (any) would update the resident's fall risk status, update and document the interventions in the resident's care plan. DON stated the fall risk assessment was not completed for Resident 1 due to the decline in mobility and development of new contractures on 4/1/2021. DON stated it was important to complete a new fall risk evaluation after Resident 1's COC was noted to determine how much ADL assistance needed and to update the care plan with interventions to prevent fall. During a telephone interview on 6/2/2021 at 1:51 pm, DON stated Resident 1's care plan dated 1/14/2021 indicated Resident 1 was at risk for fall and the interventions were to refer for rehabilitation consultation. DON stated there was no documented evidence of a rehabilitation consultation referral from when Resident 1 had the COC on 4/1/2021 to the incident of fall on 4/3/2021. DON stated, it was important to have a timely rehabilitation consultation referral to ensure resident receive the necessary treatment and prevent harm and further decline. During a telephone interview on 6/3/2021 at 9:56 am, Nurse Practitioner (NP, a nurse qualified to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe treatment plans) stated she gave an order for rehabilitation consultation for Resident 1 on 4/1/2021 after receiving a notification of Resident 1's COC. NP stated it was important for the rehabilitation consultation to be done as ordered to prevent further decline and injury to Resident 1. NP stated the rehabilitation consultation could have prevented Resident 1's fall. During a concurrent record review and telephone interview on 6/4/2021 at 9:01 am, Rehabilitation Department Director (RDD) stated Resident 1's physician order summary did not indicate a rehabilitation consultation order on 4/1/2021 or on 4/2/2021. RDD stated the rehabilitation department was not made aware of any rehabilitation consultation ordered for Resident 1 on 4/1/2021, after the resident's change in condition. RDD stated it was important to make sure residents' received proper rehabilitation consultation and interventions to help residents improve their functional ability, avoid decline and prevent injury. During a telephone interview on 6/25/2021 at 2:44 pm, CNA 1 stated on 4/3/2021, at 9:25 am, she was providing care and she reached out to get an adult brief when Resident slip off the bed and she called for help. A review of the facility's policy titled, Fall Management Program, revised 3/13/2021, indicated a licensed nurse would conduct a new fall risk evaluation quarterly, annually, upon identification of a significant COC, post fall and as needed. The policy indicated the IDT would initiate, review, and update the Resident's fall risk status and care plan at the following intervals quarterly, annually, upon identification of a significant COC, post fall and as needed.

Based on observation, interview, and record review, the facility failed to put measures in place to ensure safety and supervise residents who were diagnosed with dementia (a decline in mental ability severe enough to interfere with daily life) from wandering out, placing residents who reside in the locked unit (locked, secured, or alarmed units) at risk from elopement (occurs when a resident leaves the premises or a safe area without authorization) by failing to: 1. Ensure Resident 138 who was diagnosed with dementia and assessed as a high risk for elopement by the facility, did not walk out of the facility's locked unit unsupervised. 2. Implement Resident 138's plan of care who had a history of walking out of the facility, by placing a monitoring device (continuously keeps track) on the resident to monitor the resident's whereabouts. 3. Ensure CNA (Certified Nursing Assistant 2 [CNA 2]), was able to identify Resident 138, who walked out of the facility unsupervised, was a current resident residing in the facility. On 5/18/2021 at 1 pm, Resident 138 was observed walking alone outside on a main street approximately 0.2 miles (1056 feet) away from the facility. Resident 138 was unable to state name or place of residence. The resident was not wearing an identification band (ID bands, used to confirm the resident's identity or a monitoring device to track the resident's whereabouts). 4. Ensure Resident 459, who was diagnosed with dementia and was assessed by the facility as a high risk for elopement, did not walk out of the facility toward the parking lot unsupervised on 5/18/2021 at 3:12 pm. These deficient practices caused Resident 138 and Resident 459 to leave the facility unsupervised and placed the residents at risk for serious injuries or death, and had the potential for the 28 remaining residents in the locked unit to elope. On 5/18/2021 at 7:24 pm, during a recertification survey, the Department of Public Health called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), in regards to Resident 138 and Resident 459's unsupervised elopement, in the presence of the Administrator (ADM) and Director of Nursing (DON). On 5/21/2021 at 9:37 am, the Department of Public Health removed the IJ while onsite after the surveyors verified the facility implemented the Plan of Action (POA, a detailed plan to address findings), given by the ADM which included: a. On 5/18/2021 between 1:05 pm to 1:10 pm, the Elopement Code (to alert of a resident elopement) was activated and the nursing staff immediately assisted Resident 138 back to the facility. b. On 5/18/2021 at 1:15 pm, Resident 138 was assisted back to the locked unit and a head to toe assessment was done immediately on by a Charge Nurse. There was no injury or skin discoloration noted. c. On 5/18/2021 at approximately 1:25 pm, Maintenance Supervisor along with Environmental Consultant checked all interior and exterior exit doors to ensure proper function. No issues were identified. d. On 5/18/2021 at 2:15 pm, the ADM in-serviced the interdisciplinary team on the facility's policy and procedure titled, Wandering & Elopement, and Elopement Risk Reduction Approaches, the contents of the Elopement Binder, and location of Elopement binders. e. On 5/18/2021 at 3:10 pm, Resident 459 was assisted back to the unit and head to toe assessment was immediately done on by a Charge Nurse. There was no injury or skin discoloration noted. f. On 5/18/2021 at approximately 5 pm, staff were provided in-service by the ADM, DON, and Director of Staff Development (DSD) on the most recent high elopement risk residents list including where the elopement binders could be located. g. On 5/18/21 at 5 pm, the DSD in-serviced staff on the locked unit exit door. h. On 5/18/2021 at approximately 8:30 pm, Administrator (ADM) and DON posted signage on all exit and hallway doors (stations 2, 3, and 4) reminding staff to ensure all doors were shut closed when exiting and entering. i. On 5/18/21 at 9 pm, staff were in-serviced by DSD & Registered Nurse (RN), Nurse Consultant to monitor Residents 138 and Resident 459 every 30 minutes to ensure the residents did not exit the facility. j. On 5/18/21 at approximately 3:30 pm, the Admissions Coordinator checked the 35 residents in station 3 for the precision soft guard wrist identification (ID bands, used to confirm the resident's identity). k. On 5/18/21 at approximately 8:30 pm, the DON and Licensed Nurses conducted elopement risk assessments for the 181 residents in house to identify residents who were at high risk for elopement. Forty-two residents were identified to be at high risk of elopement. l. On 5/19/21 at approximately 11:30 am, Nurse Consultants checked the 179 residents in the facility for the precision soft guard wrist ID bands. Findings: A review of Resident 138's Face Sheet (admission record) indicated the facility admitted Resident 138 on 4/9/2021, with diagnoses of dementia and [CONDITION(S)] disorder (a mental illness that affects moods and thoughts, characterized by loss of contact with reality and the environment, abnormal social behavior and failure to understand what is real). A review of Resident 138's Elopement Risk Tool dated 4/9/2021, indicated Resident 138 was at risk for elopement. A review of Resident 138's Department Notes dated 4/10/2021 timed at 1:42 pm, indicated Resident 138 was confused and tried to exit the door (unspecified door). The resident stated she wanted to go home. A review of Resident 138's History and Physical dated 4/11/2021, indicated Resident 138 did not have the capacity to understand and make decisions. A review of Resident 138's Department Notes dated 4/11/2021, and timed at 9:53 am, indicated a late entry from 4/10/2021, at 10 am, indicated Resident 138 was restless. The resident ran out of the facility and stood in the middle of the street. The notes indicated the staff brought the resident back to the facility. There was no evidence the facility that interventions were provided for the resident to prevent walking out of the facility from 4/11/2021 to 4/15/2021. A review of Resident 138's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 4/16/2021, indicated Resident 138 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making, with short and long term memory problems. The MDS indicated Resident 138 was assessed requiring supervision with walking. A review of Resident 138's Care Plan titled Wandering: Unsafe situations, dated 4/16/2021, indicated to place a monitoring device on Resident 138 that sounded alarms when resident left the building. The care plan indicated to designate staff (unspecified) to account for the resident's whereabouts throughout the day, monitor, and document target behaviors. The care plan indicated to note which exits Resident 138 favored for elopement from the facility, and to alert staff. The care plan indicated if Resident 138 wandered away from the unit, staff were to stay with the resident, converse and gently persuade to walk back to designated area with the resident. A review of Resident 138's Physician's Telephone Orders dated 4/23/2021, at 1:30 pm, indicated an order to move the resident to the locked unit of the facility due to the resident being an elopement risk. A review of Resident 138's Department Notes dated 4/23/2021, and at 2:45 pm, indicated Resident 138 was not in her room and the resident was out of the facility's premises and was brought back by staff (unidentified). A review of Resident 138's medical record indicated no documented evidence of a care plan for the resident's monitoring device or a monitoring system of the resident's whereabouts as indicated on the resident's wandering care plan from 4/16/21-5/18/21. During an observation on 5/18/2021 at 1 pm, two surveyors observed Resident 138 walking alone outside on a main street approximately 0.2 miles from the facility. The surveyors intervened and attempted to speak to the resident. The resident was unable to identify name or place of location. On 5/18/21, at 1:14pm an observation and interview, in the street, the facility's Director of Social Services (SSD) arrived to walk with Resident 138 back to the facility. Resident 138 recognized SSD, and stated, She is my friend and I know she will make sure I am safe. While walking back to the facility's premises with Resident 138, the SSD confirmed Resident 138 was not wearing a monitoring device and did not have an ID band. During an interview on 5/18/2021 at 1:36 pm, Certified Nursing Assistant 2 (CNA 2) stated she observed Resident 138 in the facility's parking lot on 5/18/2021 before 1 pm. CNA 2 stated she asked Resident 138 if she was a resident of the facility but Resident 138 waved at her and left. CNA 2 stated did not know Resident 138 was a resident from the facility and did not know the resident was at risk for elopement. CNA 2 stated she should have called for help immediately but that she did not call for help. During an interview on 5/18/21 at1:48 pm, Licensed Vocational Nurse 4 (LVN 4) stated he worked in the locked unit and stated he was the only licensed nurse working in the unit. It was impossible to monitor all the residents including Resident 138 in the locked unit. LVN 4 stated that he did not check if all the residents, including Resident 138 wore an ID band on 5/18/2021 because he was busy administering medications to all 29 residents in the locked unit. LVN 4 stated he did not know who was responsible for checking if residents wore an ID band. LVN 4 stated on 5/18/2021 before 1 pm, he did not have time to monitor the exit doors. LVN 4 stated that staff in Station 3 did not know Resident 138 had eloped until the facility called a code green, which was a code that a resident had eloped from the facility. During an interview on 5/18/021 at 2:46 pm, CNA 3 stated that on 5/18/2021 during lunch time (before 1pm), medical records staff 1 (MR 1) asked her to open the emergency door located in the locked unit for her. CNA 3 stated the emergency door was not to be used as an entrance, and should be used for emergencies only but because MR 1 asked her to open the door for her, she opened it and let her in. CNA 3 stated that there was no alarm on that door, once a code was entered, this emergency door lead to the parking lot. During an interview on 5/20/2021 at 3:08 pm, DON stated the locked unit was a secured unit to prevent the 29 residents from getting out of the unit unsupervised and prevent them from getting injured outside the facility. DON stated residents in the locked unit such as Resident 138, required close supervision to ensure that they did not injured themselves and ensure their safety. A review of Resident 459's Face Sheet indicated the facility admitted Resident 459 on 5/6/2021 with diagnoses of dementia and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 459's Department Notes dated 5/6/2021 indicated the resident was at risk for wandering and had exhibited elopement tendency during the resident's stay at the facility. During observation on 5/18/2021 at 3:12 pm in the facility's yellow zone (area where residents with symptomatic or suspected with Corona Virus 19 [COVID-19], a respiratory illness that can spread from person to person] are placed for quarantine) Resident 459 was observed walking down the hallway leaving the yellow zone through the entrance/exit door of the facility and walking toward the back parking lot of the facility. There were no staff seen with the resident as the resident exited the building. A surveyor observed the resident leaving the yellow zone walking towards the parking lot. The surveyor intervened and alerted the staff to the incident. Two staff (unidentified) responded after being told by the surveyor that the resident had walked out of the building who was heading towards the back-parking lot. During an interview on 5/18/2021 at 3:18 pm, LVN 1 stated Resident 459 had the tendency to elope requiring a one-to-one supervision (supervise at all times). LVN 1 stated Resident 459 attempted to elope the facility three or four times on 5/18/2021. LVN 1 stated she did not notice Resident 459 eloped through the exit door in the yellow zone because it did not alarm and stated staff (unidentified) forgot to enter the code on the way out so it didn't alarm when the resident walked out. During an interview on 5/18/21 at 3:20 pm LVN 7 stated she did not see the resident walk out of the yellow zone until the surveyor informed her the resident eloped the facility. During an observation on 5/18/2021 at 6:15 pm and an interview LVN 1 stated Resident 459 did not have an ID band. A review of the facility's policy and procedure titled Elopement Risk Reduction Approaches, with a revised date of November 2012, indicated to establish a resident identification file and to accompany wandering residents on their journeys when supervision was required to ensure safety or encourage a meaningful alternate activity. A review of the Facility's Policy and Procedures titled: Wandering and Elopement, with a revised date of July 2017, indicated that if facility staff observed a resident leaving the premises without having followed proper procedures, the staff could try to prevent the departure in a courteous manner, get help from other facility staff in the immediate vicinity, if necessary; if the resident exited the facility despite efforts to stop the resident, a staff member would accompany or follow the resident to ensure the resident's safety until assistance arrived. A review of the Facility's Policy and Procedures titled: Elopement Risk Reduction Approaches, with a revised date of November 2012, indicated to ensure the residents were monitored and remain safe, account for each resident on a regular basis, establish a resident identification file with recent photographs and former addresses, plan to provide searches with a description of clothing worn and other relevant information. The policy indicated the facility staff needed to know the consequences of unsafe wandering, the protocols to follow to minimize successful exiting and the procedures to follow when a resident is lost.

Based on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus 19 disease, a severe respiratory illness caused by virus and spread from person to person) in accordance to the local Public Health guidelines, facility's policy, and Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) for 22 of 22 sampled residents by failing to: 1. Ensure 131 staff members, that work directly with the residents, were fit tested for the correct N95 facemasks (masks used to filter respiratory protective device designed to achieve a close facial fit and efficient filtration of airborne particles) and provided the appropriate size of N95 facemasks as required by the Occupational Safety and Health Administration (OSHA) Respiratory Protection standard (29 CFR 1910.134) and California Department of Public Health All Facilities Letter 20-74 (CDPH AFL 20-74, letter that send to facilities to provide guidance regarding new or amended requirement or recommendation). 2. Obtain COVID test results for 16 newly admitted residents (Residents 10, 11,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25) and retest residents who previously tested negative for COVID 19 upon being admitted to the facility. 3. Ensure two residents (Residents 4 and 5), who were receiving [MEDICAL TREATMENT] (treatment to filter wastes and water from the blood when the kidneys failed) outside of the facility, were placed in the Yellow Zone (area where residents under investigation for COVID-19 are allocated) and not cohorted (grouped together) with the residents in the Green Zone (area where residents tested negative for COVID-19 are allocated). 4. Ensure Receptionist 1 (R 1) screened Transportation Team Members 1, 2, and 3 (TTMs 1, 2 and 3, specially trained medical technicians certified to provide transportation services) who entered the facility to transport Resident 4 for [MEDICAL TREATMENT], for signs and symptoms of COVID-19 (fever, chills, cough, shortness of breath, new loss of taste or smell, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, or not feeling well) and possible exposure of COVID-19. 5. Designate a full time Infection Prevention Nurse (IPN, a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) to monitor, prevent, and control the spread of COVID-19 in the facility while the main Infection Prevention Nurse (IPN 1) was off work from 12/21/2020 to 1/4/2021. 6. Ensure the Administrator submitted the COVID-19 test results for all residents and staff with the line listing (a list of suspected and confirmed COVID-19 cases) to the local Public Health Nurse 1 (PHN 1). 7. Ensure the Administrator informed Respiratory Therapist 1 (RT 1) and Registered Nurse 1 (RN 1) of their positive COVID-19 test results immediately so they could start to self-quarantine (the method of slowing the spread of COVID-19 by staying at home and away for other people). These deficient practices had the potential to spread COVID-19 from Residents 4, 5, 10, 11,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25 to other residents and staff in the facility and could lead to severe respiratory illness, hospitalization , and/or death. On 1/9/2021 at 6:59 pm, 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) was identified in the presence of the facility's Administrator (ADM), Assistant Director of Nursing (ADON), Infection Control Preventionist (ICP) and the Director of Staff Development (DSD) regarding the facility's staff failure to implement interventions to prevent the spread of COVID-19 infection that threatened the health and safety of the residents and staff. On 1/13/2021 at 6:20 pm, the IJ was lifted after the Director of Nursing (DON) and Registered Nurse Consultant (RNC) submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyors verified and confirmed the implementations of the POA while onsite by observation, interview, and record review. The IJ was removed in the presence of the DON, ADON, and RNC. The acceptable POA as follows: 1. On 1/12/2021, a total of 85 employees have been fit tested for N95 face masks. All non-nursing staff and department managers will be fit tested by 1/19/2021. 2. On 1/9/2021, 17 newly admitted residents were tested for COVID-19 with the rapid test (COVID test that provide the result on the same day). 3. On 1/10/2021, Residents 4 and 5 were placed in the Yellow Zone. 4. On 1/10/2021, the administrator provided in-service regarding COVID-19 Visitor Screening Guidelines to R 1 and R 2. 5. On 1/4/2021, the Designated IPN (IPN 2) started working but began self-quarantine on 1/8/2021 for 14 days. On 1/11/21, the Interim Certified Infection Prevention Nurse (IPN 3) started working full time. 6. On 1/9/2021, the Administrator submitted the COVID-19 test results for all residents and staff and an updated line listing to PHN 1. On 1/12/2021, the Administrator provided a revised line listing to PHN 1. 7. On 1/10/2021, the DSD reported COVID-19 test results to RT 1 and RN 1. Findings: 1. During an observation of the Yellow Zone on 1/9/2021 at 1:45 pm, the ADON was wearing a loose fitting N95 facemask. The ADON kept touching and adjusting the mask to raise it and fit the bridge of her nose. A concurrent interview was conducted with the ADON, and she stated she was never fit tested for N95 facemask. She stated the facemask was too large for her face. During an observation of the Yellow Zone on 1/9/2021 at 2 pm, the DSD was wearing a loose-fitting N95 facemask. The DSD repeatedly adjusted the mask to fit the sides of her face. A concurrent interview was conducted with the DSD; she stated there were a total of 246 direct and non-direct care staff in the facility. The DSD stated most of the staff wore N95 facemasks that were not fit tested for the correct size and model. The DSD stated she was a member of the Infection Control Committee (a group of facility staff responsible in controlling the infection in the facility), and during the meeting the committee members did not discuss about N95 fit testing. The DSD stated she was not aware of the need to fit test staff members for the correct N95 facemasks during the facility's COVID-19 outbreak that started on 11/23/20. During an interview on 1/9/2021 at 2:19 pm, the DSD stated it was important to have all staff members tested for an N95 facemasks to protect themselves and the residents from COVID-19. During an observation of the facility's Sub-Acute Unit (a unit in the facility that provide care for residents who were on ventilators (a machine that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently) or with [MEDICAL CONDITION] (a tube inserted to the neck used to deliver oxygen) that required frequent suctioning) on 1/9/2021 at 3:14 pm, Respiratory Therapist 3 (RT 3) was wearing a white Honeywell N95 mask. A concurrent interview was conducted; RT 3 stated he was fitted with a round N95 mask in July 2020, and not the one worn during the observation. During an observation of the Sub-Acute Unit on 1/9/2021 at 4:10 pm, RN 3 was wearing a loose-fitting face mask. A concurrent interview was conducted; RN 3 stated she worked in the subacute unit and was taking care of ventilator dependent residents that required frequent suctioning, but she had not been fit tested for the N95 facemask or been asked to be fit tested . During a telephone interview on 1/11/2021 at 11:39 am, the Administrator stated she was hired at the facility on 12/14/2020. The Administrator stated she was part of the Infection Control Committee, but she was not aware that facility had not completed the fit testing as required by OSHA and CDPH AFL 20-74. A review of the CDPH AFL 20-74, dated 9/22/2020, indicated N95 facemasks were recommended for healthcare workers who worked with COVID positive residents, COVID suspected residents (residents with COVID symptoms who are waiting for COVID test results) and COVID exposed residents (newly admitted residents and residents who received [MEDICAL TREATMENT] outside of the facility). A review of the local Department of Public Health's Health Officer Order for Control of COVID-19, dated 11/24/2020 and the OSHA Respiratory Protection standard (29 CFR 1910.134), indicated for healthcare workers to have an initial respirator fit test to identify the right model, style, and size for each worker. A fit test confirmed that a respirator correctly fits for the users. Additionally, tight-fitting respirators, including N95s, require a user seal check to ensure the best fit possible. 2. During an observation of the Yellow Zone, Green Zone, and the Sub-Acute unit on 1/8/2021 at 3:30 pm, there were 170 residents in the facility. During a review of the facility's Detailed Admission/Discharge Report, dated 12/31/2020, and a concurrent interview with the DSD on 1/9/2021 at 12:31 pm, she stated 16 residents (Residents 10, 11,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25) were admitted to the facility from 11/24/2020 to 12/31/2020. The DSD stated there was no documentation or record indicated these 16 newly admitted residents were screened and tested for COVID-19. The DSD stated she overlooked the need to screen and assess the newly admitted and readmitted residents for COVID-19. The DSD stated she did not check if the residents were tested for COVID-19 prior to admission to the facility. The DSD stated she did not know the residents' results of the COVID-19 test were or if the residents needed COVID-19 testing upon admission. The DSD stated she would call the hospitals and review the hospitals' records for the COVID-19 status of theses residents. During a review of the facility's transfer records and a concurrent interview on 1/10/2021 at 9:30 am, the DSD explained on 1/9/21 she obtained the COVID-19 test results from the facilities where residents were admitted from which indicated as follows: 1. Resident 10 was admitted to the facility on [DATE] and tested negative for COVID-19 on 12/9/2020 (22 days prior to admission). 2. Resident 11 was admitted on [DATE] and tested negative for COVID-19 on 12/27/2020 (2 days prior to admission) 3. Resident 12 was admitted on [DATE] and tested negative for COVID-19 on 12/29/2020 (1 day prior to admission). 4. Resident 13 was admitted on [DATE] and tested negative for COVID-19 on 12/21/2020 (9 days prior to admission). 5. Resident 14 was admitted on [DATE] and tested negative for COVID-19 on 12/2/2020 (28 days prior to admission). 6. Resident 15 was admitted on [DATE] and tested negative for COVID-19 on 12/26/2020 (5 days prior to admission). 7. Resident 16 was admitted on [DATE] and tested negative for COVID-19 test on 12/11/2020 (18 days prior to admission). 8. Resident 17 was admitted on [DATE] and tested negative for COVID-19 on 11/27/2020 (3 days prior to admission) 9. Resident 18 was admitted on [DATE] and tested negative for COVID-19 on 11/19/2020 (5 days prior to admission). 10. Resident 19 was admitted on [DATE] and tested negative for COVID-19 on 10/20/2020 (4 days prior to admission). 11. Resident 20 was admitted on [DATE] and tested negative for COVID-19 on 12/27/2020 (2 days prior to admission). 12. Resident 21 was admitted on [DATE] and there was no data indicated the resident was tested for COVID-19. Resident 21 was tested for COVID-19 at the facility on 11/27/2020 (3 days after admission). 13. Resident 22 was admitted on [DATE] and tested negative for COVID-19 on 12/5/2020 (25 days prior to admission). 14. Resident 23 was admitted on [DATE] and tested negative for COVID-19 on 12/3/2020 (27 days prior to admission). 15. Resident 24 was admitted on [DATE] and tested negative for COVID-19 on 12/28/2020 (1 day prior to admission). 16. Resident 25 was admitted on [DATE] and tested negative for COVID-19 on 12/30/2020 (1 day prior to admission). During a telephone interview on 1/10/2021 at 11:33 am, the Administrator stated she did not know the DSD did not have the COVID-19 test results for the newly admitted residents. The ADM stated the residents should have been tested for the COVID-19 if the results of the COVID-19 were negative prior to admittance to the facility. A review of the facility's COVID-19 Mitigation Plan, dated 11/16/2020, indicated if the resident had not been tested within 72 hours for COVID-19 prior to admission or readmission from the hospital, other healthcare facility or home, the resident will be tested for COVID-19 upon admission or readmission. The MP indicated on the fourteenth day, the resident will be retested for COVID-19 again, and if the results come back negative, the residents can be released from quarantine (Yellow Zone). 3a. A review of Resident 4's face sheet (admission record) indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's Physician Orders, dated 12/4/2019, indicated for the resident to receive [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday at an off-site [MEDICAL TREATMENT] center. During an observation of Resident 4's room with the ADON on 1/9/2021 at 4:01 pm, TTMs 1, 2, and 3 were transporting Resident 4 back to the resident's room. Resident 4's room did not have postings/signages on the entry door marking the area as a section of the Yellow Zone. There was no alcohol base hand sanitizer (ABHS) or Personal Protective Equipment (PPE, facemasks, gowns and gloves that worn to minimize exposure to hazards that cause serious workplace injuries and illness) at the front entrance of the room. A concurrent interview was conducted; the ADON stated Resident 4 was returning from an off-site [MEDICAL TREATMENT] center. Resident 4 shared the room with two other residents (Residents 8 and 9). The ADON stated Resident 4 was not in the Yellow Zone and Residents 8 and 9 were not receiving [MEDICAL TREATMENT] and were not newly admitted to the facility. The ADON stated Residents 4's, 7's and 8's room was in the Green Zone. b. A review of Resident 5's face sheet indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 5's Physician Orders, dated 2/29/2020, indicated the resident was to receive [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday at an off-site [MEDICAL TREATMENT] center. During an observation on 1/9/2021 at 4:05 pm, with the ADON and the DSD, Resident 5 was lying in bed resting. Resident 5's room did not have postings/signages on the entry door marking the area as a section of the Yellow Zone. Residents 6 and 7 were in the same room with Resident 5. A concurrent interview was conducted; the DSD stated Residents 8 and 9 were not receiving [MEDICAL TREATMENT] and were not newly admitted to the facility. The DSD stated Residents 5's, 6's and 7's room was in the Green Zone. During an interview with the DSD and the DON on 1/9/2021 at 4:10 pm, the DSD and the DON stated they were not aware of the local Department of Public Health guideline indicating the residents, who were regularly receiving [MEDICAL TREATMENT], were to be cohorted (grouped) in the Yellow Zone. A review of the facility's COVID-19 Mitigation Plan, dated 11/16/2020, indicated residents who undergo regular [MEDICAL TREATMENT] treatments outside of the facility should be cohorted in the quarantine area (Yellow Zone) together. A review of the local Department of Public health guideline at http://publichealth.lacounty.gov/acd/nCorona2019/B73COVID/SNF/index.htm, updated 12/30/2020, indicated Yellow Cohort/ Yellow Zone/Mixed quarantine & symptomatic cohort is for residents who had close contacts to a known COVID-19 case, newly admitted or readmitted residents, residents who frequently leave the facility for medical appointments ([MEDICAL TREATMENT] residents) and Residents who have symptoms of COVID-19 pending test results including atypical symptoms. 4. A review of Resident 4's face sheet indicated Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's Physician Orders, dated 12/4/2019, indicated for the resident to receive [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday at an off-site [MEDICAL TREATMENT] center. During an observation of the facility's lobby on 1/9/2021 at 3:58 pm, TTMs 1, 2 and 3 were transporting Resident 4 in a gurney, through the facility's lobby, went past the screening desk by the Administrative Manager (AM), and walked directly to Resident 4's room without being screened for signs and symptoms of COVID-19 such as fever, chills, cough, shortness of breath, new loss of taste or smell, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, or unwell feeling. During an interview, on 1/9/2021 at 4:03 pm, TTM 3 stated it was his third time entering the facility today. A review of the facility's screening log, titled Visitor COVID-19 Screening, dated 1/920/2021, indicated three TTMs entered the facility but did not indicate their names or titles of the ambulance staff. In the temperature column, three temperatures were documented; however, no names were listed as to whom the temperatures belonged to. In the COVID-19 screening questions 1 single N was noted for all three TTMs. During an interview and concurrent review of the Visitor COVID-19 Screening log, TTMs 1, 2 and 3 stated on 1/9/2021 at 4:10 pm, they did not fill in the questionnaire. TTMs 1, 2 and 3 stated their names were not listed in the visitors' sign-in sheet and could not remember which temperature reading belonged to them. During an interview and a review of the Visitor COVID-19 Screening log on 1/9/2021 at 4:15 pm, the AM stated the essential visitors such as transportation team members should be screened every time, they enter the facility. The AM stated the visitors log should be individualized; the name, titles and temperature readings as well as the visitors' Covid-19 screening questions needed to be entered in the log and screened for safety reasons. The AM further stated completed screenings were important to determine who has Covid-19 symptoms and who can enter the facility for the protection of the residents and staff. During a telephone interview on 1/9/2021 at 6:42 pm, the Administrator stated every person needed to be screened upon entry into the facility. A review of the facility's COVID 19 Mitigation Plan, dated 11/16/2020, indicated all visitors, regardless of reason for the visit, shall be screened for fever and symptoms of COVID-19. A log will be provided for contact tracing for visitors that include name, contact information, who they are visiting, and the location of the facility visited. Visitors will be informed and must report to the facility if they develop respiratory symptoms or test positive for COVID-19 within 14 days after visiting the facility. A review of the facility's policy, titled Visitation During the COVID-19 Pandemic, dated on 10/28/2020, indicated all visitors must sign-in on a log including name, date, contact information, and who they visited. The sign-in log will be maintained by the facility. 5. A review of the facility's staffing schedule dated from 12/1/2020 to 1/4/2021 indicated no IPN designee was assigned in the facility while IPN 1 was on self-quarantined from 12/21/2020 to 1/4/2021. During an interview on 1/8/2020 at 3:30 pm, IPN 1 stated the facility's COVID 19 outbreak began on 11/23/2020. The IPN stated she was off work from 12/21/2020 to 1/4/2021 and there was no IPN designated to perform the IPN duties while she was off. During an observation on 1/9/2021 at 9:30 am, there was no IPN on duty in the facility. A concurrent interview was conducted, and the DSD stated the newly hired IPN (IPN 2) was on self-quarantined from 1/8/2021 and there was no designated IPN in the facility. During a review of the facility's line listing with the DSD on 1/9/2021 at 12:20 p.m., the line listing indicated the following: a. COVID-19 test results for 246 employees and the 170 residents did not indicate the test date. b. 16 newly admitted residents did not have the latest COVID-19 test results and these residents were not tested for COVID-19 upon admission. c. No information indicated interventions to mitigate COVID-19 since the facility had an outbreak on 11/23/2020. d. No records to indicate how the staff and the residents were informed of their COVID-19 test results. A concurrent interview was conducted, the DSD stated IPN 1 was the person in charge of updating the line listing. The DSD stated when IPN 1 was off, the line listing was completed by the Administrator. The DSD stated she also helped complete some of the responsibilities of the IPN 1 but she was also performing her responsibilities as a DSD. During an interview on 1/12/2021 at 4:30 pm, the Administrator stated she was a certified IP (Infection Preventionist) and assumed the infection control responsibilities of the IPN while newly hired IPN 2 was off work, but she was unable to do the job of a full-time because she had to complete the administrator responsibilities. The ADM stated she did not assign an IPN designee while IPN 1 was off from 12/21/2020 to 1/4/2021 or when IPN 2 also required isolation on 1/7/21 because she was going to get help from the DSD and DON. The ADM stated she also required to be on isolation from 1/8/21 to present and could not be in the facility to lead the infection control responsibilities in the facilities, which were overwhelming. During an interview with the Administrator on 11/13/2020 at 3:45 pm, regarding the Infection Control Committee's measures to mitigate the COVID-19 outbreak, and the absence of the IPN, the ADM replied, she had not met with the team since she began working at the facility on 12/14/2020 because she had been busy with her other administrative responsibilities. A review of the facility's COVID-19 Mitigation Plan, dated 11/16/2020, indicated the facility will have a full time Infection Preventionist designated to monitor and improve infection control practices based on public health advisories (local, state and federal). The Infection Control Preventionist shall spend adequate time in the facility focused on activities dedicated to infection control such as screening and documenting every individual entering the facility for COVID 19 per CDC guidelines, monitoring test results to guide residents placement, observing changes in staff assignments, infection control measures and maintaining a line listing of all COVID-19 infections. 6. A review of the facility's COVID-19 Outbreak report dated 11/23/2020 indicated there were two residents and 2 staff members, who had tested positive for COVID-19. A review of the facility's COVID-19 test results for residents and staff, dated 11/24/2020, 11/30/2020, 12/2/2020, 12/14/2020, and 12/15/2020 did not indicate the dates the COVID 19 test were conducted, and the COVID test results of all staffs and residents as required by the local Public Health Department. During an interview on 1/9/2021 at 2:20 pm, the ADON stated it was difficult to trace the COVID-19 results from staff, who obtained their COVID-19 tests outside of the facility which was why the line listing was inaccurate. During an interview on 1/13/2021 at 4:13 pm, the Administrator stated she tried her best to update the line listing as much as possible, but she did not have access to the line listing from IPN 1 to compare its accuracy. The Administrator stated she did not reach out to the IPN to clarify concerns with the line listings. During an interview on 1/15/2021 at 2 pm, PHN 1 stated he received the facility's line listing regarding the residents and staff that tested for COVID-19, but the listings provided were inaccurate. A review of the local Department of Public health guideline at http://publichealth.lacounty.gov/acd/Corona2019/B73COVID/SNF/index.htm, updated 12/30/2020, indicated for response testing, if a single positive COVID-19 case is identified among either staff or residents, the SNF must conduct comprehensive testing of all residents and staff to identify potential asymptomatic infections. All residents should be tested on ce weekly and all staff should be tested at the same frequency as routine staff testing. If testing capacity is limited, testing may be prioritized for the residents and staff in the same area (nursing station, floor) as the COVID-19 positive individual. Any close contacts and exposed residents of confirmed COVID-19 cases will need to be quarantined accordingly in the Yellow Cohort. All residents and staff who test negative will need to be included in response testing until there are at least 2 weeks with no additional infections identified. After 2 weeks of negative testing for residents, the facility could restart routine testing for residents as outlined below, in consultation with local Public Health 7. During an interview with RN 1 on 1/9/2021 at 10:41 am, she stated a weekly COVID-19 testing was done at the facility, but the Administrator, Assistant ADON, and the DSD did not inform her or other staff of the test results. RN 1 stated, she assumed her test result was negative and that was why she was not informed. During an interview on 1/9/2021 at 11:30 pm, RT 1 stated the facility performs weekly COVID-19 test to all staff, but she did not receive the test result from the ADON, the DSD or the IPN who assist with the COVID-19 testing. During an interview on 1/9/2021 at 2:30 pm, the ADON stated she does not have access to the line listing of the COVID-19 test results of the residents and staff. The ADON explained there was no systematic method of who, when, and how soon should the staff and residents be informed of the COVID-19 test results to immediately determine if there was an outbreak in the facility. A review of the facility's COVID-19 Mitigation Plan, dated 11/16/2020, indicated the facility will work with the local Public Health Department to develop plan for regular testing residents and staff. The MP indicated the plan of regular testing should meet the time requirement of reporting results within 48 hours of the samples being collected. Test results will be used to identify outbreak and control transmission.

Based on interview and record review, the facility failed to provide quality nursing care (nursing care that result in desirable outcome and are consistent with current profession knowledge) to one of three sampled residents (Resident 1) by failing to: 1. Ensure Registered Nurse 1 (RN 1) call a second Physician (MD 2) to obtain an admission order for Resident 1 when the resident's Primary Care Physician (MD 1) told her that he was really sick and gave her a verbal order to find another physician to take over the care for Resident 1. 2. Ensure a registered nurse (in general) was available in the Sub-Acute Unit (a unit in the facility that provide care for residents who were on ventilators (a machine that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently) or with [MEDICAL CONDITION] (a tube inserted to the neck used to deliver oxygen) that required frequent suctioning) to assess and provide interventions when Resident 1 had episodes of restlessness (inability to rest or relax) while pointing at the ventilator (a machine that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a person who is physically unable to breathe, or breathing insufficiently), and continuously pressing the call light (device used by the resident to signal his or her need for assistance from professional staff). 3. Ensure RN 1 as well as Respiratory Therapists 1 and 4 (RTs 1 and 4) were able to communicate with Resident 1 in the resident's native language (Cantonese, a Chinese dialect). RN 1, RTs 1 and 4 tried to orient the resident to the facility and calm him down in English, but the resident could not understand. 4. RT 1 failed to implement the facility's policy and procedure, titled [MEDICAL CONDITION] Change, to emergently intervene and reinsert the [MEDICAL CONDITION] of Resident 1 that accidentally dislodged (moved or forced out of a desired position). These deficient practices had the potential to result in Resident 1's [MEDICAL CONDITION] being dislodged; RT 1 was unable to reinsert the tracheotomy tube back in the tracheotomy, and the resident could not breathe. On [DATE], the paramedics arrived and pronounced the resident expired in the facility at 9:23 am. On [DATE] at 9:59 pm, 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) was identified in the presence of the facility's Administrator (ADM), Assistant Director of Nursing (ADON), Infection Control Preventionist (ICP), and Director of Staff Development (DSD) regarding the facility's staff failure to provide quality of nursing care in preventing the [MEDICAL CONDITION] dislodgment. On [DATE] at 6:20 pm, the Department lifted the IJ after the DON and Registered Nurse Consultant (RNC) submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyors verified and confirmed the implementations of the POA while onsite by observation, interview and record review. The IJ was removed in the presence of the DON, ADON and RNC. The acceptable POA was as follows: 1. RN Supervisor (RNS) would report any abnormal finding related to the ventilator and tracheotomy to the residents' physicians. 2. On [DATE], RT 1 conducted room rounds in the Sub-Acute Unit and assessed 18 residents for any indication of respiratory distress including need for suctioning (removing saliva by using suction). The Administrator would check daily staffing in the Sub-Acute Unit for RN coverage for all shifts before the next scheduled day. 3. On [DATE], RN 2 and Licensed Vocational Nurse 8 (LVN 8) and Social Service Designee 2 (SSD 2) conducted random room rounds to ensure that a communication board was available for residents who need it. The Communication Preference List was revised and updated on [DATE]. 4. On [DATE], DSD and the Quality Assurance Nurse Consultant (QANC) started providing in-services to licensed nurses and respiratory therapists on the Policy titled, [MEDICAL CONDITION] Care, and [MEDICAL CONDITION] Suctioning,. On [DATE] the Contracted RT Consultant (CRTC) started providing in services on Tracheotomy Safety, Dislodgement and Decannulation (the process whereby a [MEDICAL CONDITION] is removed once the resident no longer needs it). The in-services to all license nurses and RT's would be completed by [DATE]. Findings: 1. A review of Resident 1's Nurses Notes from the General Acute Care Hospital (GACH), dated [DATE] at 6:06 pm, indicated the resident was alert, was able to follow commands, was anxious, and required frequent suctioning (oral/mouth and [MEDICAL CONDITION]/trach). The notes indicated Resident 1 had a right neck abscess (a collection of pus from an infection in spaces between the structures of the neck) with moderate/large purulent discharge (thick and milky discharge from a wound). On [DATE] at 5 pm, Resident 1 was placed back on a ventilator. The notes indicated Resident 1 was going to be placed in the Sub-Acute Unit. A review of Resident 1's Face Sheet (admission record) indicated the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. During an interview on [DATE] at 11:36 am, RN 1 stated that on [DATE] at 9:15 pm, she called MD 1 to inform him that Resident 1 was admitted to the facility. RN 1 stated MD 1 gave her a verbal order to find another MD to take over the care of Resident 1 due to MD 1 being ill. RN 1 stated she left the facility without calling a second MD to take over the care for Resident 1. RN 1 stated she did not write a verbal order to call another physician to take over the care for Resident 1 and she did not endorse the task to night shift Licensed Vocational Nurse 7 (LVN 7). A review of RN 1's Declaration Statement, dated [DATE] and timed 3:12 pm, indicated on [DATE] at 9:15 pm, MD 1 requested her to call another physician to take over the care for Resident 1 due to he was ill. RN 1's statement indicated she did not endorse MD 1's request to LVN 7. RN 1 wrote, I am sorry about that. RN 1's statement indicated that on [DATE] at 7:15 am (approximately 10 hours after MD 1 requested RN 1 to contact another physician) RN 1 informed the DON of MD 1's request. During an interview and concurrent record review of Resident 1's clinical record, conducted with the ADON, on [DATE] at 12:00 pm, indicated no documented evidence of that RN 1 contacted another physician regarding Resident 1's admission to the facility when MD 1 informed RN 1 that he could not take care of the resident because he was ill. A review of the facility's policy and procedure, titled 'Sub Acute 24 hours Communication Log, revised on [DATE], indicated when the Licensed Nurses (in general) received telephone orders, they must document the time and date of the calls and write the order down with a black ball point pen. A review of the facility's policy and procedure, titled Admission and Orientation of Residents, revised in [DATE], indicated the facility would accept and retain only the residents for whom they could provide adequate care and have an Attending Physician orders for such care. 2. A review of Resident 1's Nurses Notes dated [DATE] and timed 8:53 pm, indicated Resident 1 arrived at the facility with a [MEDICAL CONDITION] and was dependent on a ventilator. A review of the facility's Daily Census Report, dated [DATE], indicated the facility did not have a registered nurse (in general) during the night shift from 9:00 pm to 7:15 am, for the Sub-Acute Unit. A review of RN 1's Current Pay Period (time sheet) indicated on [DATE], RN 1 ended her shift and left the facility at 9:02 pm. A review of Resident 1's Nurses Notes, dated [DATE] and timed 11:55 pm, indicated LVN 7 entered late notes for Resident 1 dated [DATE], untimed. The notes indicated Resident 1 arrived at the facility (untimed). The notes indicated the resident was able to follow commands but restlessness and anxious. The notes did not indicate what interventions were provided for the resident to help him calm down. During an interview on [DATE] at 6 pm, RN 2 stated there was no RN Supervisor (in general) on [DATE] night shift to assess the residents in the Sub Acute Unit. RN 2 stated there should RN present in the sub-acute unit 24 hours a day, 7 days a week. RN 2 stated the role of an RN Supervisor was to check on residents on ventilators for shortness of breath, secure connections, alarms, and to constantly assess residents on their medical status and intervene if needed. During an interview on [DATE] at 6:22 p.m. the ADON stated, when a resident on a ventilator or with [MEDICAL CONDITION] is observed agitated, restless and anxious, the resident should be assessed for respiratory status such as shortness of breath, labored breathing, decreased oxygenation, quality of lung sounds and check the alarm for the connections or increased secretion in case the resident need suctioning. During a concurrent record review on [DATE] at 6 :25 p.m., the ADON stated there was no documented evidence the resident was assessed for the respiratory status, including oxygen blood level when During a telephone interview on [DATE] at 9:46 am, LVN 7 stated on [DATE] at 8:30 pm, she informed RN 1 that Resident 1 was anxious, restless, moving his hands, legs and body in bed. LNV 7 stated she reported to RN 1 that Resident 1 didn't seem stable. LVN 7 stated RN 1 left the facility at 9 pm. LVN 7 stated during the night, the Sub-Acute Unit did not have a register nurse on duty to assess the residents. LVN 7 stated if there was a registered nurse at the unit, she would have notified him/her of Residents 1' restlessness but there was no registered nurse present. LVN 7 stated on [DATE], the Sub-Acute unit was short staffed, and she was concerned that a registered nurse was not scheduled for the night shift. During an interview on [DATE] at 1:18 pm, and concurrent review of the Daily Staffing Sign in Sheet, dated [DATE], the DSD stated she was aware that a registered nurse was not scheduled on [DATE] for the 7 pm to 7:30 am shift. The DSD stated authorization from the Administrator was needed prior to calling the Registry staff (staff from contract agencies that work at the facility as needed). The DSD stated she did not inform the Administrator that a registered nurse was needed in the Sub-Acute Unit during the night shift and did not obtain an authorization to call registry staffing. During an interview on [DATE] at 11:36 am, RN 1 stated Resident 1 arrived at the facility on [DATE] at 7:50 pm. The resident was moving around in his bed, pointing at his [MEDICAL CONDITION] and the ventilator machine attempting to communicate by mouthing his words. RN 1 stated Resident 1 was really anxious, and trying to say something, but she was unable to understand him. RN 1 stated on [DATE] prior to ending her shift, she did not inform MD 1 or MD 2 of Resident 1's anxiety, constant moving around in bed and continuously pointing at his [MEDICAL CONDITION] and then at the ventilator. RN 1 stated she did not provide assess the causes (reasons) of Resident 1's anxiety and provide nursing interventions to calm or relax the resident. RN 1 stated it was important to ensure proper assessment, continuity of care, and resident safety. A record review of RN 1's Declaration Statement dated [DATE], indicated RN 1 informed the DON and the Administrator that there was no RN scheduled for the Sub-Acute Unit on [DATE] during the night shift. RN 1's Statement indicated that on [DATE] at 5 pm, the DSD asked her to stay until 11 pm but she declined. The Statement indicated RN 1 reminded the DON of Resident 1 (new admission), who was expected to arrive at the facility after 7 pm, and there was no RN scheduled for the night shift. A review of the policy and procedure, dated [DATE], titled Nursing Department-Staffing, Scheduling and Postings, indicated the facility will ensure adequate numbers of nursing personnel to meet the resident's needs. The facility is licensed for 100 beds or more beds will have at least one RN awake and on duty in the facility during the day and night. 3. During an interview on [DATE] at 4:25 pm, LVN 2 stated that on [DATE] at 8 am, during her rounds, Resident 1 was mouthing words in Chinese. LVN 2 stated she was unable to understand Resident 1. During an interview on [DATE] at 4:28 pm, RN 2, RT 3, and LVN 2 stated they were unaware of the language translator services offered by the facility and the Language Line Solutions - Quick Reference Guide, that was posted at the Nurses Stations this morning ([DATE]) by the Social Services Assistant (SSA). During an observation and concurrent interview on [DATE] at 4:30 pm, at the sub-acute nurse stations a posting titled Language Line Solutions - Quick Reference Guide was observed. During a interview, SSA stated that she posted the Language Line Solutions - Quick Reference Guide, earlier that morning ([DATE]) and stated there were no cordless phones or iPads at any nurses stations at the facility. SSA stated she was unsure of how the staff would use the translator line for bed bound (unable to leave ones bed) residents with-out cordless phones or iPads. The SSA stated that a portable phone was needed to use the telephone translating services. During a telephone interview on [DATE] at 5:40 pm, Resident 1's Family Member (FM 1) stated that the resident only spoke Cantonese. During an interview on [DATE] at 8:30 pm, the Administrator stated the staff would use the telephone interpreter, and call the residents' family, or use a communication board. The Administrator stated there were no cordless phone at the Nurses Stations. During a telephone interview on [DATE] at 9:46 am, LVN 1 stated it was difficult to communicate with Resident 1, who was a new admission and only spoke Chinese dialect. LVN 1 stated Resident 1 would attempt to speak or make a noise, but LVN 1 was unable to understand resident's need. LVN 1 stated throughout the night, Resident 1 was restless, would often push his call light, and was moving his right arm and legs, and was pointing to his neck and the suction machine. LVN 1 stated it was difficult to communicate with Resident 1 due to language barrier and did not make other attempts to communicate with the resident. During an interview on [DATE] at 11:36 am, RN 1 stated Resident 1 arrived at the facility on [DATE] at 7:50 p.m., and was moving around in his bed, pointing at his [MEDICAL CONDITION] and the ventilator machine attempting to communicate by mouthing his words. RN 1 stated Resident 1 was really anxious, and trying to say something, but she was unable to understand him. RN 1 stated, Resident 1 was nodding and she assumed the resident could understand English and she did not know if anyone in the facility could speak Chinese dialect. During an interview on [DATE] at 11:38 a.m., RN 1 stated on [DATE] at (unknown time) RN 1 called FM 1 to inform him of the resident's arrival to the facility. RN 1 stated FM 1 requested to speak with Resident 1 on FaceTime (a face-to-face conversation with over the internet). RN 1 explained the facility did not have a communication tool to allow the resident to communicate via Face Time. RN 1 stated she did not attempt to use other tools to allow the resident to communicate with the family. During an interview on [DATE] at 11:36 am, RN 1 stated on [DATE] prior to ending her shift, she did not inform MD 1 or MD 2 of Resident 1's anxiety, constant moving around in bed and continuously pointing at his [MEDICAL CONDITION] and then at the ventilator. RN 1 stated she did not provide assess the causes (reasons) of Resident 1's anxiety and provide nursing interventions to calm or relax the resident. RN 1 stated it was important to ensure proper assessment, continuity of care, and resident safety. During an interview on [DATE] at 12:37 pm, RT 1 stated on [DATE] at 8 pm, Resident 1 was admitted to the facility on a ventilator, awake, mouthing words, moving his right hand, and pointing at his mouth then at the suction machine. RT 1 stated the resident was speaking another language and she was unable to understand the resident. RT 1 stated she continued to orient Resident 1 to the facility in English. RT 1 stated Resident 1 was attempting to speak and communicate, pointing at things but she could not understand what the resident was trying to convey. RT 1 stated she was never in-serviced on language barriers and was un-aware if a translator line was available. During a telephone interview on [DATE] at 3:21 pm, RT 5 stated that on [DATE] at 7:50 pm, Resident 1 arrived at the facility on a ventilator, agitated, anxious, moving around, and attempting to say something. RT 5 stated he could not understand what Resident 1 was trying to say. RT 5 stated, I could not understand him at all. A review of the facility's policy and procedure, titled Admission and Orientation of Residents, revised in ,[DATE], indicated to introduce self and staff to the resident upon arrival to the unit. The policy indicated in case of a language or hearing barrier; staff would contact a translator. A review of the facility's policy and procedure, titled Communication, revised on [DATE], indicated for staff to provide activities to improve or maintain the resident's self-performance in functional communication skills or to assist the resident in using residual communication skills and adaptive devices. 4. A review of Resident 1's care plan titled Ventilator Alarm, dated [DATE], indicated the goal was to ensure the resident received care to prevent pulling out the [MEDICAL CONDITION] leading to respiratory distress. The approached interventions were to assess Resident 1 when the ventilator alarm would go off for any signs of respiratory distress and to ensure proper placement of [MEDICAL CONDITION] and circuit connections. A review of Resident 1's care plan, titled Respiratory Care, dated [DATE], indicated goals were for the resident to maintain a patent airway and reduce incidences of accidental extubation (the removal of a tube) or decannulation. The approached interventions were to check and secure [MEDICAL CONDITION] tie (bands that go around the neck to ensure the [MEDICAL CONDITION] is in place) and to replace [MEDICAL CONDITION] with a [MEDICAL CONDITION] bedside if accidental decannulation occurs. A review of Resident 1's Physician Order, dated [DATE], untimed, received from the Medical Records Assistant (MRA) on [DATE] at 1:32 pm indicated to change inner cannula (fits inside the tracheal tube and acts as a liner) daily and as needed, and a ventilator on a stand-by and use T-BAR with oxygen concentrator as tolerated. A review of the Respiratory Therapy Progress Notes, dated [DATE] and [DATE], did not have a documented evidence the cause of the Resident 1's ventilator low alarm and if interventions were provided to stop the alarm. A review of Resident 1's Respiratory Therapy Progress Notes, dated [DATE], timed 8 am, indicated RT 1 was called to Resident 1's room regarding resident manipulating ventilator ballard ( a tube connected to the [MEDICAL CONDITION] use to suction mucus from the trachea) she placed the resident back on the ventilator as resident requested and ensure the ballard was securely re-connected. RT 1 indicated Resident 1 attempted to disconnect the ventilator and refused to be connected. RT 1 indicate Resident 1 was place on a TBAR via concentrator. RT 1 indicated that 8:50 am, Resident 1's [MEDICAL CONDITION] was dislodged, and RT 1 called RN 1. A review of Resident 1's Nurses Notes dated [DATE], and timed 10:55 am, indicated that at 7:15 am, Resident 1 was very anxious, holding his disconnected ventilator ballard in his hand. The notes indicated RN 1 attempted to connect Resident 1's ballard to the oxygen concentrator, but the resident wants vent back on, and RN 1 called RT 1 to the bedside. The notes indicated at 8 am, Resident 1 was manipulating his ballard and was reconnected to the ventilator, but the resident During an interview with the ADON and review of Resident 1's Nurses Notes and Physician Order on [DATE] at 12 pm, the Nurses Notes and Physician Orders did not indicate evidences of admission orders [REDACTED]. A review of RT 1's Declaration Statement dated [DATE], indicated on [DATE] at 6 am, RT 1 removed Resident 1 from the ventilator and placed on T-Bar with oxygen via concentrator. The Statement indicated a few minutes later, Resident 1 was pointing and RT 1 reconnected the resident back on the ventilator. Resident 1 was observed moving his fingers back and forth, manipulating his Ventilator Ballard and RT 1 re-connected Resident 1 back on T-BAR. The statement indicated RT 1 continued to deflate (release air) the resident's cuff (a balloon attached around the outside of the tube) and checked for the resident's oxygen saturation level (a measure of how much oxygen the blood is carrying). The statement indicated at 8:30 am, RT 1 noticed Resident 1's [MEDICAL CONDITION] was dislodged. RT 1 attempted to reinsert Resident 1's [MEDICAL CONDITION] but was unsuccessful due to resistance (fight against/oppose) at the [MEDICAL CONDITION] site . RT 1 called for help; a rapid response (a team of health professionals who provide emergency care) was initiated and 911 (calls for emergency assistance) was called. and covered Resident 1's stoma (A temporary or permanent surgical opening into the neck). A review of RT 1's Declaration Statement dated [DATE] indicated Resident 1's [MEDICAL CONDITION] was found dislodged at 8:30 am, and the Respiratory Therapy Progress Notes, dated [DATE], indicated Resident 1's [MEDICAL CONDITION] was found dislodged at 8:50 am, In a concurrent interview, RT 1 stated there was inconsistency in the record because she does not recall the exact time that Resident 1's [MEDICAL CONDITION] was found dislodged, and the exact time the resident needed respiratory assistance and when CPR was conducted because there was no CPR record completed. During a telephone interview on [DATE] at 3:21 pm, RT 5 stated that on [DATE] at 7:50 pm, Resident 1 arrived at the facility on a ventilator, agitated, anxious, moving around. RT 5 stated Resident 1's ventilator alarm kept on alarming, on and off during the night and showed low-pressure alarm (the pressure in the ventilator circuit has dropped and are usually caused by a leak or disconnect). RT 5 stated on [DATE] at 5:30 am, he called RT 1 to notify her that Resident 1 had a problem with low pressure alarm as he placed Resident 1 on a T-bar with the oxygen concentrator (a device that concentrates the oxygen from a gas supply to supply an oxygen). RT 5 stated he did not inform a doctor or asked the RT 1 for assistance before 5:30 am to determine the cause of the low pressure alarm. RT stated the low pressure alarm wound stop for a little while after the resident was suctioned. During an interview on [DATE] at 11:36 am, RN 1 stated on [DATE] at 7:15 am, Resident 1's ventilator ballard was disconnected and the resident pointing at the ventilator machine. RN 1 stated she reconnected Resident 1's ventilator ballard and called RT 1 to the residents bedside. RN 1 stated at 8:15 am, the resident connected to an oxygen concentrator, trying to manipulate his ventilator ballard as if his neck was itchy; pointing at his neck then to the ventilator machine and was fighting the ventilator and having difficulty breathing. The notes indicated at 8:50 am, Resident 1 started to desaturate (decrease oxygen concentration in the blood), 911 (emergency services) was called, and the resident had no pulse. The facility started Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure done when breathing or heartbeat has stopped). The notes indicated that at 8:55 am, the paramedics came to the facility and took over the CPR. The notes indicated the paramedics pronounced Resident 1's time of death at 9:23 am. During an interview on [DATE] at 12:37 pm, RT 1 stated Resident 1's [MEDICAL CONDITION] was dislodged and did not use the obturator (is a thin, curved piece of hard plastic or rubber that is inserted into the [MEDICAL CONDITION] to help with placing the tube into the trachea), because she could not reach the obturator on the right side of the bed. RT 1 explained she had a hard time reinserting the [MEDICAL CONDITION] without the obturator and she felt resistance she was delivering the oxygen via ambu-bag ( a hand held device used to deliver oxygen to patients who are not breathing). During an interview on [DATE] at 11:49 a.m., RT 1 stated, she was not trained how to reinsert a [MEDICAL CONDITION] when the [MEDICAL CONDITION] was accidentally dislodged until [DATE]. RT 1 stated she learned on [DATE] that she had to use the obturator to guide the [MEDICAL CONDITION] into the trachea (windpipe) to effectively deliver oxygen and guide the [MEDICAL CONDITION] in place. During an interview on [DATE] at 1:49 pm, RT 1 stated she was never trained for emergency decannulation until [DATE]. During a telephone interview on [DATE] at 9:56 am, MD 2 stated he was not informed of Resident 1's admission. MD 2 stated he received two calls on [DATE] (could not remember the exact time). MD 2 stated the first call was to let him know that Resident 1's [MEDICAL CONDITION] was dislodged and a staff (unidentified) could not put it back, and the second call was when the resident had expired. A review of Resident 1's paramedic report, titled Prehospital Care Report, dated [DATE], indicated on [DATE] the paramedics arrived at the facility at 8:54 am and pronounced the resident time of death at 9:23 am. A review of the facility's undated policy and procedure, titled [MEDICAL CONDITION] Change, indicated [MEDICAL CONDITION] may also be replaced as needed for accidental extubation, cuff failure, size or style change, or obstruction of the airway. The policy indicated a minimum of two licensed nurses and/or respiratory therapist are required for the procedure as follows: 1. Disconnection of the blow by aerosol (a fine spray) or the ventilator circulatory and bagging (first aid to blow air in a person's mouth) the resident on oxygen. 2. Remove the ties of the old tube and deflate the cuff, repeat [MEDICAL CONDITION] suction, hyper-oxygenate (deliver an excess supply of oxygen) the resident. 3. Evaluate indwelling [MEDICAL CONDITION] (tube placed into the trachea (windpipe)) for ease of movement within the stoma. 4. Position the resident and the bed until [MEDICAL CONDITION] moves [MEDICATION NAME] with in the stoma. 5. Don on sterile gloves. 6. Remove inner cannula (fits inside the trachea tube and acts as a liner) or the new tube and insert the obturator. 7. Lubricate the tube well. 8. Remove the [MEDICAL CONDITION] clean glove with a downward pulling motion (do not attempt insertion if resident is coughing). 9. In the event you are unable to insert a tube of the same size as the one removed, immediately follow the last step with a tub one size smaller. 10. Remove the obturator and have the assistant hold the tube in place. 11. Inflate the cuff (a balloon attached around the outside of the [MEDICAL CONDITION]), if applicable, and HOLD [MEDICAL CONDITION] in place. 12. Bag the resident and assess bilateral breath sounds, bilateral and equal chest expansion. 13. Cuff leakage (air escaping form mouth or heard with auscultation) above the clavicle (collar bone). 14. Assess resident's neck and upper chest regions for signs of subcutaneous [MEDICAL CONDITION]. 15. If tube is not in place deflate cuff and [MEDICAL CONDITION] and repeat the steps. 16. Post (after) second attempt [MEDICAL CONDITION] still not in place cover stoma and start rescue breathing with bag mask (hand held device to provide air) until resident is stable. 17. If unable to [MEDICAL CONDITION] upon third attempt active the 911 system and continue rescue breathing). 18. Document respiratory status before and after procedure.

Based on observation, interview, and record review, the facility failed to ensure 10 of 30 sampled residents (Residents 1, 2, 4, 5, 6, 7, 9, 10, 11 and 12), who were positive for Coronavirus 19 (COVID-19, a mild to severe respiratory illness caused by virus that spread from person to person) were safe and appropriate to transfer (move to another facility) to a designated COVID - 19 skilled nursing sister facility (Facility 2). The facility failed to: 1. Notify the Ombudsman and California department of Public Health (CDPH, the Department), before Residents 1, 2, 4, 5, 6, 7, 9, 10, 11 and 12, were transferred as indicated in the facility Mitigation Plan. 2. Obtain a physician's order to transfer Resident 1 and Resident 4 prior to the transfer as indicated in the facility's physician order policy. 3. Provide assessment and complete an assessment record for the condition of Residents 1, 2, 4, 5, 6, 7, 9, 10, 11 and 12 prior to the transfers as indicated in the facility's transfer policy. 4. Notify the residents' responsible party before Resident 2 and Resident 10 was transferred as indicated in the facility's transfer policy. 5. Provide and complete an inventory list (an itemize list of a resident's personal belonging) prior to discharge for Residents 1, 2, 4, 5, 6, 7, 9, 10, 11 and 12 as indicated in the facility personal property policy. 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) situation was called on 8/13/20 at 3:45 p.m., in the presence of the facility Administrator and Infection Preventionist (IP, a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) nurse. The facility Administrator and IP nurse were informed of the facility's failure to have systems in place to ensure safe and appropriate discharges, insufficient preparation and orientation to the receiving facility, a physician order and documentation by the physician that the discharge was necessary, and effective transition of care. These deficient practices resulted in Resident 7's condition upon transfer was not assessed and had to be rerouted from being transferred to Facility 2 to the general acute care hospital (GACH), on 8/11/20. Resident 4's Primary Physician was not aware of the transfer. The responsible parties of Resident 2 and 10 were not given a choice on whether they agree to transfer Resident 2 and 10. Residents 1, 2, 4, 5, 6, 7, 9, 10, 11 and 12 health status were not endorsed to Facility 2 due to the facility staff neglecting to complete the residents' discharge assessments, and the residents' inventory (a complete list and accounting of a resident's belongings upon transfer) of personal belongings. On 8/17/20, the facility submitted an acceptable plan of action (POA), and the survey team verified the implementation of the POA by observation, interview, and record review and confirmed the removal of the immediate jeopardy on 8/17/20 at 3:35 p.m. in the presence of the facility administrator, facility IP, and acting DON. The facility's acceptable POA was as follows: 1. The DSD will continue to provide in-service to licensed nurse regards to the followings: a. Resident's assessment and obtaining vital signs (comprising of a blood pressure, pulse rate, body temperature, and respiration; used as a measure of health or physical condition) prior to transfer, b. Physician notification of change of condition and obtaining physician order for [REDACTED].>c. Family/resident's representative notification of changes in resident condition including transfer and d. Completing inventory upon discharge. 2. Transferring to other Covid-19 Skilled Nursing Facilities will be on hold immediately until the facility notifies, communicates and collaborate with CDPH and Public Health Department. 3. The OSHPD approved barrier needed to expand the red zone (COVID -19 area). Acting DON and/ or RN supervisor will check for completion of assessment, notification to physician and family prior to transferring, obtaining physician order for [REDACTED]. 4. Medical record director will audit resident's transfer within 72 hours for completion of assessment including vital signs, notification to physician and family, obtaining physician order for [REDACTED].>5. Administrator and/ or DON will review daily during morning meeting (Monday thru Friday) regards to completing of assessment including vital signs, notification to physician and family, obtaining order for transfer to other facility prior to transferring and completion of inventory upon discharge. 6. Any negative patterns or trends of resident's transfer process will be reported to Quality Assessment and Assurance (QAA) Committee by the administrator and/or DON monthly x three months and quarterly thereafter. Findings: During an interview, on 8/11/20 at 12:20 p.m., the IP stated the facility had a census of 150 residents. The IP stated the facility had 55 COVID - 19 positive residents, 27 suspected (believe to be) COVID - 19 residents, and 68 residents Non COVID - 19 residents. On 8/11/20 between 12:12 p.m. to 4:36 p.m., during the facility tour, the residents from the facility's green zone (Non-COVID - 19 area), residents from the facility's yellow zone (suspected COVID-19 area), and residents from the facility's red zone (COVID -19 area) were observed in the designated zones. Prior to entering the red zone, PPE supplies observed with signage indicating, Red Zone, outside of the locked unit. During an interview on 8/11/20 at 12:20 p.m., the Administrator (ADM) and the IP stated 22 residents were transferred to Facility 2, on 8/10/20. The ADM stated the red zone (facility's designated COVID - 19 positive care area) was at capacity (the area had no more available bed in the red zone). The IP stated the facility did not notify the public health nurse (PHN) or California department of Public Health (CDPH) prior to transferring the residents to their sister facility. During an interview on 8/11/20 at 2:57 p.m., the Social Service Director (SSD) stated notifying the families and residents regarding the transfers. The SSD stated a fax was sent to the Ombudsman (OMB) at the time of the transfers. SSD stated they were having difficulties faxing the transfers and they also sent an email to the OMB. The SSD stated the OMB was unable to open the email regarding the transfers. During an interview on 8/12/20 at 11:07a.m., in the presence of the ADM, the IP stated the facility transferred eight residents (Resident 1, 2, 4, 5, 6, 7, and 8) to Facility 2, on 8/11/20. The IP stated Facility 2 had the capability to care for the newly positive COVID-19 residents. The IP stated the family members did not want the residents to be transferred. The IP stated the medical director was not notified of the transfers, and the facility corporation has plans to transfer an additional 13 residents from the red zone. During an interview, on 8/12/20 at 3:50 p.m., the OMB stated they were receiving faxes, on 8/11/20, regarding transfers of COVID - 19 positive residents from the facility to Facility 2. The OMB called the facility and spoke with the Social Service Director, who confirmed the transfer of multiple residents, and stated there were no further plans to transfer additional residents. The following day, on 8/12/20, the OMB received additional faxes reporting transfers of COVID positive residents from the facility to Facility 2. The OMB stated they were receiving complaints from family members of the residents who were transferred and the inability to gain updates on the status of the transferred residents. a. A review of Resident 1's undated Face Sheet (admission record) indicated Resident 1 was admitted to the facility, on 10/4/18 with [DIAGNOSES REDACTED]. A review of Resident 1's Initial History and Physical (H&P), dated 10/23/19, indicated Resident 1 had the capacity to make needs known, but not make medical decisions. A review of Resident 1's entire medical record indicated no physician's order for transfer to Facility 2, no nursing assessment at transfer, no proposed notice of transfer or discharge, and no property inventory list of belonging prior to transfer, on 8/11/20. During an interview and concurrent record review of Resident 1's entire medical records, on 8/12/20 at 3:50 p.m., the Director of Staff Development (DSD) stated Resident 1 did not have a physician order for [REDACTED]. b. A review of Resident 2's undated Face Sheet indicated Resident 2 was admitted to the facility, on 10/11/18, with [DIAGNOSES REDACTED]. A review of Resident 2's history and physical examination [REDACTED]. A review of Resident 2's Minimum Data Set (MDS, a resident assessment and care-screening tool) dated 7/1/20 indicated the resident was severely impaired in cognitive skills (the ability to make decisions) and required extensive assistance with transfers and was total dependent for personal hygiene. During an interview and concurrent record review of Resident 2's entire medical record, on 8/12/20 at 3:50 p.m., the Director of Staff Development (DSD) stated Resident 2 did not have a physician order for [REDACTED].>nursing assessment on transfer or inventory of belonging at transfer. The DSD validated the documents were not present in Resident 2's entire medical records. During a telephone interview on 8/13/20 at 1:08 p.m., Resident 2's Family Member (FM 1) stated, on 8/11/20, the facility called him (unidentified date and time) to let him know they had already transferred Resident 2 to another facility. FM 1 stated he had no choice and was concerned regarding the sudden transfer. and the facility did not give him the opportunity to choose whether he agreed or disagreed with the transfer. FM 1 stated Resident 2 was not able to make her own decisions and was confused. During an interview and concurrent record review of Resident 2's entire medical record on 8/14/20 at 3:41 p.m., RN 2 stated Resident 2's medical record did not contain evidence of a nursing assessment or any other documentation including physician orders regarding the resident's transfer on 8/11/20. RN 2 stated Resident 2's entire medical record did not contain any information regarding the resident's condition before the transfer. RN 2 stated the nurses were supposed to ensure to have a physician orders, nursing assessments, family notification before the facility transferred the resident for safety reasons according to the facility's policy and procedure. c. A review of Resident 4's undated Face Sheet indicated an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 4's Initial H&P, dated 7/25/20, indicated Resident 4 did not have the capacity to understand and make decisions. During an interview and concurrent record review of Resident 4's entire medical record, on 8/13/20 at 11:10 a.m., the Director of Staff Development (DSD) verified Resident 4's entire medical record had no physician's order for transfer to the SNF, no nursing assessment at transfer, no proposed notice of transfer or discharge and no discharge inventory list. no nurse's assessment or inventory of belonging on transfer to designated COVID - 19 skilled nursing sister facility. During an interview on 8/12/20 at 12 p.m., Resident 4's Responsible Party (RP) stated a concern with the transfer of Resident 4 to Facility 2. The RP stated the Social Worker (SW) told her that it was protocol. The RP stated that if the transfer was not mandatory, she would not have agreed to the transfer of Resident 4 to Facility 2. During an interview on 8/14/20 at 1:14 p.m., the Primary Physician for Resident 4, stated he was not notified of Resident 4's transfer to Facility 2. The primary Physician stated he needed to be notified to know where the resident was going because Resident 4 was his responsibility, because follow up care needed to be coordinated. The primary Physician stated that there should be a physician orders at transfer and that it is unsafe for the resident if the Primary Physician was not notified. d. A review of Resident 5's undated Face Sheet indicated an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 5's H&P, dated 7/21/20, indicate Resident 5 did not have the capacity to understand or make decisions. During an interview and concurrent record review of Resident 5's entire medical record, on 8/13/20 at 11:10 a.m., the Director of Staff Development (DSD), verified Resident 5's entire medical record had no nursing assessment at transfer, no proposed on transfer to designated COVID - 19 skilled nursing sister facility. e. A review of Resident 6's undated Face Sheet indicated a readmission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 6's H&P dated 2/11/20, indicated Resident 6 did not have the capacity to understand or make decisions. During an interview and concurrent record review of Resident 6's entire medical record, on 8/13/20 at 11:10 a.m., the Director of Staff Development (DSD) verified Resident 6's entire medical record had no nursing assessment at transfer, no proposed notice of transfer or discharge and no discharge inventory list on transfer to designated COVID - 19 skilled nursing sister facility on 8/10/20. During an interview on 8/13/20 at 8:10 a.m., Licensed Vocational Nurse 1 (LVN 1) stated when transferring a resident to another skilled nursing facility, the resident's physician and family were to be notified, and a fax was sent to the OMB. LVN 1 stated that a resident's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) were assessed at transfers, and the vital signs documented on the nurse's note. LVN 1 stated the resident's family member was notified regarding the transfer to another skilled nursing facility. LVN 1 stated if the RP refuses, the refusal was documented and reported to Social Services, the Director of Nurse (DON), and Administrator. LVN 1 stated the transfer to Facility 2 will not be carried out when refusals were encountered. During an interview on 8/13/20 at 8:55 a.m., LVN 2 stated on transfers, assessment of the resident was to be done to ensure the resident was stable. LVN 2 stated a transfer notice, a physician order, a notification of the family and the vital signs were to be obtained and documented on the nurses note to indicate how the resident was at the time of transfer. f. A review of Resident 7's undated Face Sheet indicated the facility admitted the resident on 5/11/20 and readmitted him, on 6/16/20, with [DIAGNOSES REDACTED]. A review of Resident 7's history and physical examination [REDACTED]. A review of resident 7's General Acute Care Hospital (GACH) emergency room Report dated 8/11/20 and timed at 10:53 p.m., indicated the resident tested positive for COVID-19, on 8/7/20. Upon arrival of Resident 7 at Facility 2 (receiving facility), the nursing staff assessed Resident 7 and noted him with dried blood to his left ear and altered mental status (a change of level of awareness) and asked EMTs to transfer the resident to the GACH. The report indicated the LVN (unidentified, nursing staff from Facility 2) did not know Resident 7's baseline medical condition. The report indicated Resident 7's lip smacking could be due to [MEDICAL CONDITION] (a sudden, uncontrolled electrical disturbance in the brain), and the GACH admitted the resident for further evaluation, on 8/11/20. During an interview and concurrent review of Resident 7's entire medical record on 8/12/20 at 3:50 p.m., the Director of Staff Development stated Resident 7 did not have a physician order for [REDACTED].>no nursing assessment on transfer or inventory of belonging at transfer. The DSD validated the documents were not present in Resident 7's entire medical records. During an interview on 8/13/20 at 8:26 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 7's RP was aware that the resident was being transferred Facility 2. LVN 1 stated Resident 7's RP did not want Resident 7 to go to Facility 2. During a review of Resident 7's entire medical record and an interview on 8/14/20 at 11:41 a.m., Registered Nurse 2 (RN 2) stated Resident 7's entire medical record did not contain evidence of a nursing assessment or any other documentation including physician orders regarding his transfer on 8/11/20. RN 2 stated Resident 7's entire medical record did not contain any information regarding the resident's condition before the transfer. RN 2 stated Resident 7's FM 2 told her (unknown date) he did not want the facility to transfer the resident to another skilled nursing facility (SNF). RN 2 stated FM 2 was very upset and told her the ambulance took the resident to a general acute care hospital (GACH) instead because he had a change of condition on 8/11/20. During a telephone interview on 8/14/20 at 2:50 p.m., Licensed Vocational Nurse 5 (LVN 5) stated he was assigned to Resident 7 on 8/11/20. LVN 5 stated he was overwhelmed with all the residents' transfers and there was no Registered Nurse in the red zone (an area where residents who test positive for COVID-19 are confined) on 8/11/20 to assist with transfer assessments. LVN 5 stated he remembered checking Resident 7 before the transporters transferred the resident but he could not find the resident's medical record and he did not document his condition before the transporters transferred the resident. LVN 5 stated he was overwhelmed. g. A review of Resident 9's undated Face Sheet indicated a readmission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 9's H&P dated 2/11/20, indicated Resident 9 did not have the capacity to understand or make decisions. During an interview and concurrent record review of Resident 9's entire medical record, on 8/13/20 at 11:10 a.m., the Director of Staff Development (DSD) verified Resident 9's entire medical record had no nursing assessment, no proposed notice of transfer or discharge, and no discharge inventory list on transfer to designated COVID - 19 skilled nursing sister facility on 8/10/20. h. A review of Resident 10's undated Face Sheet indicated a readmission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 10's initial H&P, dated 1/1/20, indicated Resident 10 did not have the capacity to understand and make decisions. During an interview and concurrent record review of Resident 10's entire medical record, on 8/13/20 at 11:10 a.m., the Director of Staff Development (DSD) verified Resident 10's entire medical record had no nursing assessment at transfer and no discharge inventory list on transfer to designated COVID - 19 skilled nursing sister facility on 8/11/20. During an interview, on 8/14/20 at 11:53 a.m., Resident 10's RP stated the facility contacted her regarding Resident 10's transfer to Facility 2. The RP stated she was not given a choice. The RP had preferred for Resident 10 to remain in the facility and not transfer Resident 10 to Facility 2. During an interview on 8/13/20 at 7:30 a.m., the IP stated 2 residents (Resident 11 and Resident 12), were transferred to Facility 2. i. A review of Resident 11's undated Face Sheet indicated Resident 11 was admitted to the facility, on 3/26/19, with [DIAGNOSES REDACTED]. A review Resident 11's Initial H&P, dated 3/29/19, indicated Resident 11 did not have the capacity to understand or make decisions. A review of Resident 11's entire medical record indicated no nursing assessment at transfer, no notice of proposed transfer or discharge to the SNF, and no discharge inventory list. During an interview and concurrent review of Resident 11's entire medical record, on 8/13/20 at 9:34 a.m., LVN 3 stated when residents were transferred out of the facility, physician's order must be obtained, with a medication list, property inventory list, a notice of proposed transfer or discharge and vital signs must be documented in nurse's notes to indicate if the resident was stable at the time of transfer. LVN 3 could not locate these records in Resident 11's chart. j. A review of Resident 12's undated Face Sheet indicated an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 12's Initial H&P, dated 8/5/19, indicated the capacity to understand and make decisions. A review of Resident 12's entire medical record indicated no nursing assessment at transfer and no discharge inventory list. During an interview and concurrent record review of Resident 12's entire medical record, on 8/14/20 at 3:41 p.m., RN 2 verified Resident 12's entire medical record had no nurse's assessment or inventory of belonging on transfer to Facility 2, on 8/12/20. During an interview, on 8/13/20 at 10:31 a.m., the ADM stated he did not agree or disagree with the residents' transfers. The ADM stated the transfers were directed by the corporate office to transfer the residents. The ADM stated the facility had staffing issues and stated the other facilities were more experienced to care for the residents who were confirmed positive for Coronavirus 19. During an interview on 8/13/20 at 11:19 a.m., the IP stated the staff did not transfer the residents as indicated in the facility's Discharge and Transfer of Residents policy and procedure. The IP stated the staff did not have enough time to conduct nursing assessments, did not have time to notify all the residents' family members and responsible party. The IP stated the discharge documentations for the transferred residents were not completed prior to the discharge. IP nurse stated the transfers were rushed and unsafe. IP nurse stated the residents who were transferred out to different facilities were already in the red zone. The IP state she could not understand the reason of the transfers and that they had staffs (LVN and CNA) available to care for them in the facility. IP nurse stated the facility did not transfer the residents' belongings with the residents. During an interview on 8/13/20 at 2:51 p.m., the facility's DSD stated she helped to transfer 10 to 15 residents (not identified). The DSD stated she did not assess and did not complete the documentation for several of the residents (not identified). The DSD stated some of the residents (not identified) were missing physician orders and family notifications. The DSD stated the transfers were like an evacuation mode. The DSD stated it was important to assess the residents before they were transfer out and ensure the facility had physician orders prior to the transfers for the residents' safety. During an interview, on 8/14/20 at 9:30 a.m., the IP verified Resident 9 and Resident 10 were transferred Facility 2, on 8/13/20. During an interview, on 8/14/20 at 9:44 a.m., the ADM stated that he was unaware of the transfer of Resident 9 and Resident 10 to Facility 2 on 8/13/20. During an interview on 8/14/20 at 10:04 a.m., RN 2 stated nursing assessments must be done on the residents, when they were to be transferred, a notice of proposed transfers must be obtained, and on transfer. RN2 stated the notice of proposed transfers must be sent to the Ombudsman via fax and placed back into the residents' medical record. The RN stated that a nursing assessment must be done to ensure the condition of the resident was stable. RN 2 stated a physician order was required prior to any transfer or discharge to ensure safety, assume the liability, and responsibility of the resident. During a telephone interview on 8/14/20 at 10:26 a.m. LVN 4 stated she assisted the facility to transfer the residents (Residents 1, 2, 4, 5, 6, 7, 11 and 12), on 8/11/20. LVN 4 stated some of the residents (Resident 10 and Resident 12) did not want to go to Facility 2. LVN 4 stated the facility did not give the residents a choice. During a telephone interview on 8/14/20 at 10:43 a.m., LVN 1 stated the residents who were transferred did not have physician orders, family notifications, and no assessments. LVN 1 stated the transfers did not make any sense because the residents were already in the red zone. LVN 1 stated the residents' (Residents 1, 2, 4, 5, 6, 7, 9, 10, 11 and 12) belongings were still in the facility and were not transferred with the residents. During a telephone interview on 8/14/20 at 11:03 a.m., the facility's Medical Director (MD 1) stated he was aware of the residents who were transferred to a designated Covid-19 SNF. MD1 further stated that the expectations from the facility staff (RN and LVN) was to assess the residents and ensure they are stable for transfer, and to assess the condition of the resident, and to take precautions by conducting a full assessment. MD 1 stated the nurses were supposed to assess the residents' overall conditions before the transfers. MD 1 stated the nurses were also supposed to ensure that the primary physician ordered the transfers, and to verify if the family members or the responsible parties agreed with the transfers. During an interview on 8/14/20 at 3:38 p.m., RN 1 stated all licensed nursing (RN and LVN) were responsible for assessment on admission, transfers, and discharges. RN 1 stated it was necessary to ensure the assessment were done and verified to ensure the safety and proper transfer or discharge of the residents. RN 1 stated a physician order, notice of transfer of transfer and discharge, and assessments were required for any transfers or discharge to obtain baseline status and continued safe transfer. RN 1 stated if any of the documents were missing, non-emergent transfers to the SNF will be halted until necessary documents were obtained. A review of the facility's COVID - 19 Mitigation Plan, revised date 5/29/20, indicated when relocating resident after baseline testing, all transfer must first be cleared by the local health department (Ombudsman, Public Health Department, and CDPH). A review of the facility's Discharge and Transfer of Residents policy and procedure, revised date of 2/2018, indicated prior to discharging a resident, nursing staff/IDT would prepare Discharge Summary/Post Discharge Plan on Care and would document the summary in the resident's medical record including the resident's medical status measurements. The policy indicated when a resident was discharged , nursing staff must document a written statement of the reason of the discharge, date and time, and condition of the resident upon discharge. The written document also included, condition and [DIAGNOSES REDACTED]. representative, except in emergency situation. The policy and procedure indicated the medical record would contain documentation from the resident's Attending Physician regarding the residents' discharge plan of care if the resident's needs could not be met in the facility. The policy indicated that at the time of the discharge, the facility staff would prepare a resident's property inventory list. A review of the facility's Personal Property policy and procedure, revised date, 7/14/17, indicate if a resident was transferred and expected to return to the facility, the resident's CNA will inventory the resident's property at the time of transfer. A review of the facility's Physician Orders policy and procedure (P&P), revised on 1/1/12, indicated to verify physician orders were complete, accurate and clarified. The P&P indicated orders will include a description complete enough to ensure clarity of the physician's plan of care. Documentation pertaining to physician orders will be maintained in the resident's medical record.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent the presence of cockroaches (small insects that cause spread of bacterial infection) in the facility's kitchen. This deficient practice placed the 211 residents out of 211 residents at risk of vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches, mosquitos, ticks, and fleas). On 11/26/19, at 4:15 p.m. and at 5:20 p.m., respectively, the surveyor and the Registered Environmentalist Health Specialist (REHS - performs inspections of various facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections) observed live cockroaches in the facility's kitchen. On 11/26/19, at 7:20 p.m., an Immediate Jeopardy (IJ-as situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident) was declared and the facility's administrator and the director of nursing were notified of the findings. On 11/27/19 at 3:00 p.m., the IJ was removed in the presence of the administrator after the facility submitted an acceptable plan of action as follows: 1. The increase of pest control service from once a month to every week until the infestation was resolved. 2. An in-service that included the proper kitchen sanitation and monitoring signs of infestation to be done by a dietary consultant. 3. The Maintenance Director or designee will inspect the kitchen area weekly and as needed for any entry points where the pest may penetrate. 4. Infection Control Preventionist will inspect the kitchen and facility surroundings weekly to identify infection control issues and report any negative findings immediately to the administrator. 5. The kitchen staff will focus on cleaning floor mats, drains and walls to get rid of any food debris that may attract pests. 6. Housekeeping to clean residents' rooms daily and will put more focus on bed side tables and corners. Findings: A review of the facility's census report, dated 11/26/19, indicated there were 211 residents residing in the facility. On 11/26/19, at 4:38 p.m., the district office's supervisor received a report from a REHS. The REHS reported during the kitchen inspection on 11/26/19, at 4:15 p.m., the REHS found seven cockroaches under the mechanical wash ware sink area (dish washing area) and one dead cockroach at the food preparation sink. The REHS also reported the facility had closed the kitchen at 4:30 p.m. A review of the report titled, Retail Food Official Inspection Report, for the facility by the RHES, indicated on 11/26/19 inspection date, the RHES found a total of seven live German cockroaches and one dead German cockroach (German cockroaches are known to carry disease-producing organisms, such as bacteria, protozoans, [MEDICAL CONDITION]. These cockroaches also spread different forms of gastroenteritis (food poisoning, dysentery, diarrhea, and other illnesses), plus they carry a number of allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma). A review of article from the Department of Public Health, County of Los Angeles titled, Effective management of cockroach infestation (retrieved 12/6/19 at publichealth.lacounty.gov/eh/docs/specializedvencor_managment) indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated 7/2019, (retrieved 12/10/19 at https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html) indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). On 11/26/19, at 5:20 p.m., during an observation, the surveyor and the REHS conducted an inspection of the facility's kitchen. Both the surveyor and the REHS observed five live roaches underneath the kitchen dishwashing area. On 11/26/19, at 5:30 p.m., during an interview, the Dietary Supervisor (DS) stated a pest control company comes to the facility every 1st of Thursday of the month and applies treatment (pesticides - any substance used to kill, repel, or control pests). DS stated the pest control company usually comes at night around 9 p.m. when there was no one in the kitchen. On 11/26/19, at 5:40 p.m., during an interview, the surveyor and the REHS informed the DS and the dietitian regarding the five live cockroaches and showed them the areas where the cockroaches were seen. The DS stated the pest control company serviceman will come to apply treatment, this same night. On 11/26/19, at 6 p.m., during an interview, the DS stated the pest control serviceman had been at the facility, a few days earlier, on 11/7/19, and applied a treatment. On 11/26/19, at 7 p.m., a review of the pest control company work order, dated 11/7/19, indicated the pest control company provided treatments, on 11/7/19, night service between 9 p.m. and 9:30 p.m. The target pest were ant, roach, and spider (ANT, RCH, and SP). On 11/27/19, at 10 a.m., during a follow-up observation inspection of the kitchen with the administrator and maintenance supervisor and concurrent interview, the maintenance supervisor stated some open gaps around the pipes were found on the walls located underneath the dish washing areas. The administrator stated the maintenance supervisor would cover all the gaps and other areas where roaches could possibly get in. A review of the facility's policy for Pest Control, revised date 1/1/12, indicated the facility maintains an ongoing pest control program to ensure the building and grounds were kept free of insects, rodents, and other pests. The Administrator arranges for a pest control company to visit and inspect the facility once year. The pest control company will carry out inspection, evaluation, submit, and carry out actions needed to rid the facility and its grounds of any environmental pests.

Based on interview and record review, the skilled nursing facility failed to ensure six of six sampled residents (Resident 16, 23, 26, 27, 28, and 36) had sufficient improvement in their health status and were safe and appropriate to transfer to a lower level of care. The skilled nursing administrator, the corporate office vice president and an independent living staff member, randomly selected ambulatory residents for discharge to the independent living facility (a housing arrangement for those who can live independently within a community setting). The skilled nursing administrator, a corporate office vice president, and the independent living staff, either individually or jointly, discharged Residents 23, 26, and 36 and attempted to discharge Residents 16, 27, and 28 to an independent living facility, without discharge planning, physician's documentation that the residents health sufficiently improved and the discharge was necessary, or ensuring the independent living facility could meet the resident's needs. These deficient practices resulted in Resident 23 eloping (leaving without permission) from the independent living facility, upsetting Resident's 28 responsible party/family due to the possibility of discharge, sending Resident 36 to an independent living facility without his medications or instructions on how to check his blood sugar levels, making Resident 16 fearful of being homeless, and forcing Residents 16 and 27 to sign discharge papers they did not understand. Findings: 1. A review of Resident 23's Face Sheet (admission record) indicated an admission to the skilled nursing facility on 10/12/15, and a readmission on 12/15/18. The resident's [DIAGNOSES REDACTED]. A review of Resident 23's Minimum Data Set (MDS - standard assessment and care-planning tool), dated 3/31/19, indicated the resident had severely impaired cognition (mental action of acquiring knowledge and understanding). Resident 23 required supervision with walking, locomotion on and off the unit (how resident moved between locations), bed mobility, transferring to and from surfaces (such as the bed or wheelchair), and eating. Resident 23 also required limited assistance (a resident involved in activity, staff provide guided maneuvering) with dressing, toilet use, and personal hygiene. A review of Resident 23's history and physical examination [REDACTED]. A review of Resident 23's Elopement Risk Assessment, dated 3/31/19, indicated the resident was a high risk for elopement. A review of Resident 23's Plan of Care, dated 2/10/19, indicated the resident was at risk for wandering (to move or walk aimlessly) and elopement related to his cognitive status. The approach was to provide the resident's safety in a secured unit (a specialized unit for residents who suffer from dementia or memory impairment). A review of Resident 23's Licensed Personnel Weekly Progress Notes, dated 5/7/19 at 2 p.m., indicated Registered Nurse 1 (RN 1) received a call (time not indicated) from the Administrator to transfer Resident 23 to an independent living facility. RN 1 notified Resident 23's attending physician, Physician 1, but Physician 1 did not agree with the transfer. The Administrator spoke with Physician 1 (exact time not indicated) and the physician agreed to transfer the resident to an independent living facility. RN 1 called (exact time not indicated) five telephone numbers listed on the resident's face sheet, but was unable to contact the resident's responsible party (RP 1) or a family member. Per the Administrator, the Social Services Director 1 (SSD 1) already spoke with RP 1. On 5/7/19, at 3:29 p.m., a staff member from the independent living facility transported Resident 23, from the skilled nursing, to the independent living facility. A review of Resident 23's Physician and Telephone Orders, dated 5/7/19 at 2 p.m., signed by Licensed Vocational Nurse 3 (LVN 3) indicated to discharge the resident to an independent living facility, with visits provided by a Home Health Agency (HHA- an agency providing nursing services). The physician had not sign the discharge telephone order. A review of Resident 23's Physician Discharge Summary indicated on 5/7/19, the skilled nursing facility staff discharged the resident to an independent living facility. The status of the resident's condition and the physician's signature were blank on the discharge form. A review of Resident 23's Discharge Summary/Post Discharge Plan of Care, dated 5/7/19, indicated there were no post-discharge plans for the independent living facility or home health agency to follow. The discharge form did not include any special instructions about the resident's care and treatment. A review of Resident 23's Notice of Proposed Transfer and Discharge form, dated 5/7/19, indicated the resident health had improved sufficiently and he no longer required skilled nursing services. Neither the skilled nursing facility representative nor the resident/resident's responsible party (RP 1) signed the proposed transfer discharge form. A review of a Police Report, dated 5/9/19 at 12:40 p.m., indicated they found Resident 23 in a shopping center parking lot, attempting to get into a vehicle. Resident 23 knew his name and date of birth. When asked where he was, he answered here. It was determined that Resident 23 had an altered mental status (disruption how your brain work and changes your behavior), was taken to a general acute care hospital (GACH), and placed in the care of an Adult Protective Services (APS) staff. A review of the GACH social worker's progress notes, dated 5/9/19, indicated the Social Worker 1 (SW 1) searched for Resident 23's family members and made contact with RP 1 at 8:05 p.m. RP 1 stated they informed her that Resident 23 transferred from the skilled nursing facility to a board and care (non-medical custodial care that may assist with daily activities like bathing, eating and toileting) Alzheimer's facility, on 5/7/19. RP 1 stated the skilled nursing facility told her that Resident 23 would be going to a locked facility for those with [MEDICAL CONDITION]. RP 1 stated the skilled nursing facility did not provide her with the address and telephone number of the independent living facility. When SW 1 called and spoke with a staff member at the independent living facility, the staff member stated Resident 23 did not reside in a locked housing facility or a locked board and care Alzheimer's unit, but resided in an independent living facility. A review of Resident 23's GACH social worker's progress notes, dated 5/9/19, indicated SW 1 spoke with the House Supervisor at the independent living facility. The House Supervisor stated the independent living facility provides a room and meals. The residents in the independent living facility are able to perform their own ADLs; are alert and oriented to person, place, time, and situation; and are able to take their own medications. The House Supervisor stated she did not know that Resident 23 had [MEDICAL CONDITION] and was unable to live independently. On 5/10/19 at 11:37 a.m., Resident 23 transferred back to the skilled nursing facility, under the care of Physician 1, at RP 1's request. On 5/23/19 at 10:45 a.m., during an interview, Physician 1 stated he received a call from the skilled nursing facility about the need to discharge Resident 23 to an independent living facility. Physician 1 stated he was totally against the discharge and he refused to give the order. Physician 1 stated he did not evaluate Resident 23 to see if he was a candidate for a lower level of care. Physician 1 stated for the resident's safety, he would never discharge him to a lower level of care. Physician 1 added he never wrote or gave an order to discharge Resident 23 to an independent living facility. On 5/23/19 at 1:30 p.m., during an interview, SSD 1, from the skilled nursing facility, stated because Resident 23 has dementia and could wander away from the independent living facility, he should never been discharged . On 5/23/19 at 2 p.m., during an interview, LVN 3 stated a social services staff member informed her they would be notifying RP 1 about Resident 23's discharge (on 5/7/19). LVN 3 stated RN 1 told her to write Resident 23's discharge order. LVN 3 stated she assumed RN 1 called Physician 1 to obtain the discharge order. LVN 3 stated to help RN 1, she wrote the discharge order and considered it as teamwork. On 5/23/19 at 2:15 p.m., during an interview, Social Services Designee 2 (SSD 2) stated the skilled nursing administrator, corporate office vice president, and a representative from the independent living facility came to the facility (on 5/7/19). They went to the nursing station and selected ambulatory residents for discharge. SSD 2 stated the skilled nursing facility staff chose Resident 23 because he could walk. SSD 2 stated she called RP 1, on 5/7/19, to notify her about Resident 23's discharge to the independent living facility and told her the independent living would supervise the resident. SSD 2 stated she did not know Physician 1 had not given the discharge order when she notified RP 1. On 5/28/19 at 1:40 p.m., during an interview, RN 1 stated she called Physician 1 to get an order to discharge Resident 23 to an independent living facility. RN 1 stated Physician 1 did not give the discharge order, so she notified the Administrator. RN 1 stated the Administrator later told her on 5/7/19 (no time indicated), that Physician 1 gave the order to discharge Resident 23 to the independent living facility. On 6/13/19 at 8:45 a.m., during an interview and a concurrent record review, the Director of Nursing (DON) stated there no assessment prior to Resident 23's transfer to the independent living facility. The DON stated Resident 23's discharge should not have happened. 2. A review of Resident 28's Face Sheet indicated an admission to the skilled nursing facility on 12/18/18 and a readmission on 4/9/19 with [DIAGNOSES REDACTED]. A review of Resident 28's MDS, dated [DATE], indicated the resident had severe impairment in cognition. The MDS indicated Resident 28 required supervision with walking, locomotion on and off the unit, bed mobility, and transfers; required limited assistance with personal hygiene; and required extensive assistance (resident involved in activity; staff provide weight-bearing support) with dressing and toilet use. A review of Resident 28's history and physical examination [REDACTED]. A review of Resident's 28's Plan of Care, dated 4/10/19, indicated the resident was at risk for wandering or elopement related to his cognitive status and the approach was to provide the resident safety in a secured unit. A review of Resident 28's Licensed Personnel Weekly Progress Notes, dated 5/7/19 at 2 p.m., indicated RN 1 received a call from the skilled nursing facility Administrator to transfer Resident 28 to an independent living facility. A review Resident 28's Physician and Telephone Orders, dated 5/7/19, indicate the skilled nursing facility may transfer the resident to an independent living facility with home health services. On 5/23/19 at 2:15 p.m., during an interview, SSD 2 stated after the skilled nursing staff chose Resident 23 for discharge (on 5/7/19), the Administrator informed a (unidentified) staff member to call Resident 28's family and let the family know about the discharge. SSD 2 stated RP 2 called, crying and was very upset because she did not want Resident 28 to leave the skilled nursing facility. SSD 2 stated she told the Administrator that Resident 28's responsible party was upset and did not agree to the discharge. SSD 2 stated RP 2 came to the skilled nursing facility and brought Resident 28's proof of insurance to show that the benefits had not run out. Resident 28's discharge did not take place. 3. A review of Resident 26's Face Sheet indicated an admission to the skilled nursing facility on 8/29/18 and a readmission on 2/24/19. Resident 26's [DIAGNOSES REDACTED]. Resident 26 was self-responsible (made decision for themselves). A review of Resident 26's history and physical examination [REDACTED]. A review of Resident 26's MDS, dated [DATE], indicated the resident had moderately impaired cognition (decisions poor; cues/supervision required). Resident 26 required limited assistance from staff with walking, locomotion on and off the unit, and eating; and required limited assistance with bed mobility, transferring, dressing, toilet use, and personal hygiene. A review of Resident 26's Social Work Progress Notes form, dated 5/7/19 (no time specified), indicated Social Service Designee 3 (SSD 3) spoke with the resident regarding her discharge to a lower level of care and the resident agreed. SSD 3 informed Resident 26's family member about the proposed discharge. The family member agreed, but voiced her concerns about the provisions of care in an independent living facility. SSD 3 wrote that per the independent living facility staff, the resident would receive home health services. The skilled nursing facility staff discharged Resident 26, to the lower level of care, with home health services. A review of Physician and Telephone Orders, dated 5/7/19, indicated to discharge Resident 26 to an independent living facility with home health services. A review of Resident 26's Notice of Proposed Transfer and Discharge, dated 5/7/19 and signed by the resident, indicated the resident's health had improved and the discharge was appropriate because she no longer required skilled nursing services. 4. A review of Resident 36's Face Sheet indicated an admission to the skilled nursing facility on 3/5/19. The resident's [DIAGNOSES REDACTED]. Resident 36 had a responsible party, but there was no contact information listed on the face sheet. A review of Resident 36's Physician Orders, dated 3/5/19, indicated to check the resident's blood sugar level before meals (QAC) and before bedtime (QHS). The resident was to receive regular insulin (a medication to improve blood sugar control and starts to work within 30 minutes from injection) per sliding scale (the resident is given a predetermine dose of insulin depending on his/her blood sugar level). A review of Resident 36's Elopement Risk Assessment, dated 3/5/19, 3/7/19, and 4/10/19, indicated a high risk for potential elopement. On 3/7/19, Resident 36 attempted to leave the facility and verbalized his desire to go home. A review of the Resident 36's care plan, dated 3/6/19, indicated the resident was a risk for wandering and elopement related to his cognitive status. The approach was to provide safety in the secured unit. A review of Resident 36's history and physical examination [REDACTED]. A review of Resident 36's MDS, dated [DATE], indicated that the resident's cognition was intact. Resident 36 required extensive assistance with walking, bed mobility, transfers, dressing, and toilet use. Resident 36 used a walker for mobility. A review of Resident 36's Notice of Proposed Transfer and Discharge, dated 5/9/19, did not indicate the reason for discharge. The proposed discharge notice form did not have a signature of the resident or the resident's representative. A review of Resident 36's Physician and Telephone Orders, dated 5/9/19 (untimed), indicated an order to discharge Resident 36 to an independent living facility with home health services. Another physician order, dated 5/9/19, indicated to discontinue the home health services. A review of Resident 36's Licensed Personnel Weekly Progress Notes, dated 5/9/19 at 5:30 p.m., indicated a staff member from the home health agency went to the facility to transport Resident 36 to the independent living facility. After the staff from the home health agency spoke with Resident 36, she took the resident's belongings, and brought him to the car. The staff member from the home health agency did not inform the charge nurse that she was taking Resident 36 to the independent living facility and left behind the resident's medications. The charge nurse called the home health agency and left a voice message about the resident's medications. The charge nurse also called Resident 36's responsible party. On 7/5/19 at 3:50 p.m., during an interview, LVN 9 stated SSD 1 and SSD 3 informed her about Resident 36's discharge from the skilled nursing facility. LVN 9 stated the owner of the home health agency took Resident 36's belongings to the car. LVN 9 stated the resident was alert and oriented, and walked by holding on to the side rails. LVN 9 stated the resident's gait (manner of walking) was not steady. LVN 9 stated, Honestly, I did not notify the family. I assume the family was aware because it was fast. 5. A review of Resident 16's Face Sheet indicated the resident's admission to the facility on [DATE] and a readmission on 9/10/18 with diagnoses, which included squamous cell [MEDICAL CONDITION] left lower limb ([MEDICAL CONDITION]), diabetes mellitus, difficulty in walking, and muscle weakness. Resident 16 was self-responsible. A review of Resident 16's history and physical examination [REDACTED]. A review of Resident 16's MDS, dated [DATE], indicated the resident could understand others and make decisions. Resident 16 required supervision with walking, locomotion on and off the unit, and eating; and required limited assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. On 5/9/19 at 10 a.m. during an interview, Resident 16 stated he had a meeting, on 5/7/19, with the skilled nursing facility's corporate office vice president. Resident 16 stated, the corporate office vice president told him he had to leave the facility on Friday (5/10/19) by 5 p.m. Resident 16 showed a paper that the corporate office vice president gave him and stated it cost $9,000 for him to stay in the skilled nursing facility. Resident 16 stated the corporate office vice president threatened me and informed him that if he did not sign the paper, they would remove him from the facility and put him out on the street. Resident 16 stated the corporate office vice president forced him to sign the papers, but he did not know what he was signing. Resident 16 stated the facility did not give him a notice of proposed discharge. Resident 16 also stated, I did not want to be homeless. A review of the facility's census, dated 7/4/19, indicated Resident 16 was still in the skilled nursing facility. 6. A review of Resident 27's Face Sheet indicated an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 27 was self-responsible. A review of Resident 27's MDS, dated [DATE], indicated the resident understood others and could make decisions. The MDS indicated Resident 27 did not walk and used a wheelchair for mobility; needed supervision with locomotion on and off the unit; and required extensive assistance with bed mobility, transfers, dressing, toilet, and personal hygiene. A review of Resident 27's Social Work Progress Notes, dated 5/9/19, indicated the skilled nursing facility's administrator-in-training (AIT) told Resident 27 to leave the facility by 5/10/19 and not to come back. The notes indicated Resident 27 stated he could not leave and no one could pack his belongings without his permission. On 5/9/18 at 9 a.m. during an interview, Resident 27 stated he had a meeting on 5/7/19 with a corporate office vice president, an independent living staff member and SSD 1. The corporate office vice president informed him that he needed to find a place on Friday (5/10/19) by 5 p.m. Resident 27 stated the corporate office vice president showed him a paper and told him it cost $18,000 a month for him to stay at the skilled nursing facility. Resident 27 stated if he did not leave the facility, they would call the police and report the resident for trespassing. Resident 27 stated he felt pressured and threatened, and he did not know what to do. A review of the facility's policy and procedure titled, Discharge and Transfer of Residents, revised on 2/18, indicated the facility was to ensure that discharge planning is complete and appropriate and that necessary information is communicated to the continuing care provider. Discharge planning will begin on the resident's admission to the facility. The attending Physician will review the resident's progress and determine a possible discharge date . The medical record will contain documentation from the resident's Attending Physician regarding the residents discharge plan of care if the resident is discharge because 1. It is necessary for the resident's welfare and the resident's needs cannot be met in the facility. 2. The resident's health has improved and he/or she no longer needs the facility's services. On 7/5/19 at 7:20 p.m., the Department of Public Health informed the skilled nursing facility administrator (ADM 2) about the Immediate Jeopardy (IJ) situation at the skilled nursing facility. The IJ included the facility's failure to have systems in place to ensure safe and appropriate discharges, insufficient preparation and orientation to the receiving facility, and effective transition of care. In addition, the residents did not meet the requirements for discharge to a lower level of care, which included documentation of the discharge planning, the service available by the receiving facility, a physician order [REDACTED]. During an onsite visit, on 7/8/19 at 6:25 p.m., the Department of Public Health verified and confirmed the immediate jeopardy was removed after ADM 2 presented an acceptable plan of correction. The plan of correction included: 1. The Governing Body suspending the skilled nursing facility's corporate office vice president on 7/6/19 and will not allow the independent living facility staff to enter the facility. 2. The ADM 2, DON, Medical Director/Attending Physician, and the Interdisciplinary Team (IDT - a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) members will approve the resident's discharge to a lower level of care. 3. In-services given by the vice president of Behavioral Health regarding compliance with safe and appropriate discharge process. On 7/8/19 at 4:56 p.m., during an interview and a concurrent record review, the DON stated Resident 16's medical record did not contain progress notes from his primary physician regarding discharge plans. The DON stated Resident 16 was involved with his care and requested assistance from the social worker to find a place of his choice. The DON stated the corporate vice president's process of asking Resident 16 to leave the facility was inappropriate. On 7/8/19 at 5:15 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 23's medical record to support the discharge to an independent living facility. The DON stated Physician 1 did not give an order to discharge Resident 23. The DON stated there was no IDT meeting regarding Resident 23's discharge plans. The DON stated Resident 23 is at risk for elopement and requires supervision in a secured environment. On 7/8/19 at 5:20 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 26's medical record to support the discharge to a lower level of care. The DON stated Resident 26's medical record did not have progress notes from the primary physician regarding plans for discharge. On 7/8/19 at 5:25 p.m., during an interview and a concurrent record review, the DON stated Resident 27 discharge to a lower level of care did not take place. The DON stated the corporate vice president's process of asking Resident 27 to leave the facility was inappropriate. The DON stated there was no IDT meeting conducted and no physician progress notes [REDACTED]. On 7/8/19 at 5:28 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 28's medical record to support the discharge to an independent living facility. The DON stated there was no IDT meeting conducted and no physician progress notes [REDACTED]. The DON stated Resident 28 was not a candidate for discharge to a lower level of care. Resident 28 required a supervised and secured environment for safety due to his risk of wandering. The DON stated the former administrator's processes of discharging Resident 28 was inappropriate and not based on the resident needs. On 7/8/19 at 5:30 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 36's medical record to support the discharge to a lower level of care. The DON stated there was no IDT meeting conducted and there was no physician progress notes [REDACTED]. The DON stated the corporate vice president and the former administrator planned and decided Resident 36's discharge.

Based on interview and record review, the facility failed to notify five of six sampled residents (Resident 16, 23, 27, 28, and 36) or resident's responsible party, in writing, about the residents proposed transfer and discharge to a lower level of care, as soon as possible, before the transfer and discharge; provide the contact information, such as address and telephone number, of the receiving facility; document the discussion of the discharge planning; and provide accurate information about the level of care from the receiving facility. The skilled nursing administrator, the corporate office vice president and an independent living staff member, randomly selected ambulatory residents for discharge to the independent living facility (a housing arrangement for those who can live independently within a community setting). For Resident 23, the skilled nursing facility informed the resident's responsible party (RP 1) that the resident was transferred to a secured home (a residence that is made safe) for residents with Alzheimer's dementia (a progressive disease that destroys memory and other important mental functions) and the skilled nursing facility did not provide RP 1 with the name and address of independent living facility. For Resident 28, the skilled nursing facility informed the resident's responsible party (RP 2), of the resident's discharge, prior to the discharge to an independent living facility on 5/7/19, the day of the discharge. Resident 28's responsible party was crying and upset and went to the facility to show proof that the resident's insurance benefit had not ran out. For Resident 36, a home health agency staff member transported the resident on 5/9/19 to an independent living facility without notifying the charge nurse, leaving behind the resident's medications. For Resident 16 and 27, the corporate office vice president met the residents on Tuesday (5/7/19) and informed them that they had to leave by Friday, 5/10/19, at 5 p.m., because it cost the resident's $9,000 and $18,000 a month respectively, for them to stay in the skilled nursing facility. The Director of Nurses (DON) stated the skilled nursing facility did not give a written notice of discharge prior to discharging the residents. These deficient practices resulted in Resident 23 eloping (leaving without permission) from the independent living facility, upsetting Resident's 28 responsible party/family due to the possibility of discharge, sending Resident 36 to an independent living facility without his medications or instructions on how to check his blood sugar levels, making Resident 16 fearful of being homeless, and forcing Residents 16 and 27 to sign discharge papers they did not understand. Findings: 1. A review of Resident 23's Face Sheet (admission record) indicated an admission to the skilled nursing facility on 10/12/15, and a readmission on 12/15/18. The resident's [DIAGNOSES REDACTED]. A review of Resident 23's Minimum Data Set (MDS - standard assessment and care-planning tool), dated 3/31/19, indicated the resident had severely impaired cognition (mental action of acquiring knowledge and understanding). Resident 23 required supervision with walking, locomotion on and off the unit (how resident moved between locations), bed mobility, transferring to and from surfaces (such as the bed or wheelchair), and eating. Resident 23 also required limited assistance (a resident involved in activity, staff provide guided maneuvering) with dressing, toilet use, and personal hygiene. A review of Resident 23's history and physical examination [REDACTED]. A review of Resident 23's Elopement Risk Assessment, dated 3/31/19, indicated the resident was a high risk for elopement. A review of Resident 23's Plan of Care, dated 2/10/19, indicated the resident was at risk for wandering (to move or walk aimlessly) and elopement related to his cognitive status. The approach was to provide the resident's safety in a secured unit (a specialized unit for residents who suffer from dementia or memory impairment). A review of Resident 23's Licensed Personnel Weekly Progress Notes, dated 5/7/19 at 2 p.m., indicated Registered Nurse 1 (RN 1) received a call (time not indicated) from the Administrator to transfer Resident 23 to an independent living facility. RN 1 notified Resident 23's attending physician, Physician 1, but Physician 1 did not agree with the transfer. The Administrator spoke with Physician 1 (exact time not indicated) and the physician agreed to transfer the resident to an independent living facility. RN 1 called (exact time not indicated) five telephone numbers listed on the resident's face sheet, but was unable to contact RP 1 or a family member. Per the Administrator, the Social Services Director 1 (SSD 1) already spoke with RP 1. On 5/7/19, at 3:29 p.m., a staff member from the independent living facility transported Resident 23, from the skilled nursing, to the independent living facility. A review of Resident 23's Physician and Telephone Orders, dated 5/7/19 at 2 p.m., signed by Licensed Vocational Nurse 3 (LVN 3) indicated to discharge the resident to an independent living facility, with visits provided by a Home Health Agency (HHA- an agency providing nursing services). The physician had not sign the discharge telephone order. A review of Resident 23's Notice of Proposed Transfer and Discharge form, dated 5/7/19, indicated the resident health had improved sufficiently and he no longer required skilled nursing services. Neither the skilled nursing facility representative nor the resident/resident's responsible party (RP 1) signed the proposed transfer discharge form. A review of a Police Report, dated 5/9/19 at 12:40 p.m., indicated they found Resident 23 in a shopping center parking lot, attempting to get into a vehicle. Resident 23 knew his name and date of birth. When asked where he was, he answered here. It was determined that Resident 23 had an altered mental status (disruption how your brain work and changes your behavior), was taken to a general acute care hospital (GACH), and placed in the care of an Adult Protective Services (APS) staff. A review of the GACH social worker's progress notes, dated 5/9/19, indicated the Social Worker 1 (SW 1) searched for Resident 23's family members and made contact with RP 1 at 8:05 p.m. RP 1 stated they informed her that Resident 23 transferred from the skilled nursing facility to a board and care (non-medical custodial care that may assist with daily activities like bathing, eating and toileting) Alzheimer's facility, on 5/7/19. RP 1 stated the skilled nursing facility told her that Resident 23 would be going to a locked facility for those with [MEDICAL CONDITION]. RP 1 stated the skilled nursing facility did not provide her with the address and telephone number of the independent living facility. When SW 1 called and spoke with a staff member at the independent living facility, the staff member stated Resident 23 did not reside in a locked housing facility or a locked board and care Alzheimer's unit, but resided in an independent living facility. A review of Resident 23's GACH social worker's progress notes, dated 5/9/19, indicated SW 1 spoke with the House Supervisor at the independent living facility. The House Supervisor stated the independent living facility provides a room and meals. The residents in the independent living facility are able to perform their own ADLs; are alert and oriented to person, place, time, and situation; and are able to take their own medications. The House Supervisor stated she did not know that Resident 23 had [MEDICAL CONDITION] and was unable to live independently. On 5/10/19 at 11:37 a.m., Resident 23 transferred back to the skilled nursing facility, under the care of Physician 1, at RP 1's request. On 5/23/19 at 10:45 a.m., during an interview, Physician 1 stated he received a call from the skilled nursing facility about the need to discharge Resident 23 to an independent living facility. Physician 1 stated he was totally against the discharge and he refused to give the order. Physician 1 stated he did not evaluate Resident 23 to see if he was a candidate for a lower level of care. Physician 1 stated for the resident's safety, he would never discharge him to a lower level of care. Physician 1 added he never wrote or gave an order to discharge Resident 23 to an independent living facility. On 5/23/19 at 1:30 p.m., during an interview, SSD 1, from the skilled nursing facility, stated because Resident 23 has dementia and could wander away from the independent living facility, he should never been discharged . On 5/23/19 at 2 p.m., during an interview, LVN 3 stated a social services staff member informed her they would be notifying RP 1 about Resident 23's discharge (on 5/7/19). LVN 3 stated RN 1 told her to write Resident 23's discharge order. LVN 3 stated she assumed RN 1 called Physician 1 to obtain the discharge order. LVN 3 stated to help RN 1, she wrote the discharge order and considered it as teamwork. On 5/23/19 at 2:15 p.m., during an interview, Social Services Designee 2 (SSD 2) stated the skilled nursing administrator, corporate office vice president, and a representative from the independent living facility came to the facility (on 5/7/19). They went to the nursing station and selected ambulatory residents for discharge. SSD 2 stated Resident 23 was selected for discharge because he could walk. SSD 2 stated she called RP 1, on 5/7/19, to notify her about Resident 23's discharge to the independent living facility and told her the independent living facility staff would supervise the resident. SSD 2 stated she did not know Physician 1 had not given the discharge order when she notified RP 1. On 5/28/19 at 1:40 p.m., during an interview, RN 1 stated she called Physician 1 to get an order to discharge Resident 23 to an independent living facility. RN 1 stated Physician 1 did not give the discharge order, so she notified the Administrator. RN 1 stated the Administrator later told her on 5/7/19 (no time indicated), that Physician 1 gave the order to discharge Resident 23 to the independent living facility. 2. A review of Resident 28's Face Sheet indicated an admission to the skilled nursing facility on 12/18/18 and a readmission on 4/9/19 with [DIAGNOSES REDACTED]. A review of Resident 28's MDS, dated [DATE], indicated the resident had severe impairment in cognition. The MDS indicated Resident 28 required supervision with walking, locomotion on and off the unit, bed mobility, and transfers; required limited assistance with personal hygiene; and required extensive assistance (resident involved in activity; staff provide weight-bearing support) with dressing and toilet use. A review of Resident 28's history and physical examination [REDACTED]. A review of Resident's 28's Plan of Care, dated 4/10/19, indicated the resident was at risk for wandering or elopement related to his cognitive status and the approach was to provide the resident safety in a secured unit. A review of Resident 28's Licensed Personnel Weekly Progress Notes, dated 5/7/19 at 2 p.m., indicated RN 1 received a call from the skilled nursing facility Administrator to transfer Resident 28 to an independent living facility. A review Resident 28's Physician and Telephone Orders, dated 5/7/19, indicate the skilled nursing facility may transfer the resident to an independent living facility with home health services. On 5/23/19 at 2:15 p.m., during an interview, SSD 2 stated after Resident 23 was selected for discharge (on 5/7/19), the Administrator informed a (unidentified) staff member to call Resident 28's family and let the family know about the discharge. SSD 2 stated RP 2 called, crying and was very upset because she did not want Resident 28 to leave the skilled nursing facility. SSD 2 stated she told the Administrator that RP 2 was upset and did not agree to the discharge. SSD 2 stated RP 2 came to the skilled nursing facility and brought Resident 28's proof of insurance to show that the benefits had not run out. Resident 28's discharge did not take place. On 6/13/19 at 10:30 a.m., during an interview and concurrent record review of Resident 28's medical record, the Director of Nursing (DON) stated that there was no written notice of discharge given to Resident 28 and RP 2. On 6/13/19 at 3:45 p.m., during an interview, RP 2 stated someone called from the facility telling her they were going to transfer Resident 28 to another place. RP 2 stated she was not in agreement with the proposed transfer/discharge and she informed the facility not to discharge the resident. RP 2 stated the facility did not give her a written notice of proposed transfer/discharge. 3. A review of Resident 36's Face Sheet indicated an admission to the skilled nursing facility on 3/5/19. The resident's [DIAGNOSES REDACTED]. Resident 36 had a responsible party, but there was no contact information listed on the face sheet. A review of Resident 36's Physician Orders, dated 3/5/19, indicated to check the resident's blood sugar level before meals (QAC) and before bedtime (QHS). The resident was to receive regular insulin (a medication to improve blood sugar control and starts to work within 30 minutes from injection) per sliding scale (the resident is given a predetermine dose of insulin depending on his/her blood sugar level). A review of Resident 36's Elopement Risk Assessment, dated 3/5/19, 3/7/19, and 4/10/19, indicated a high risk for potential elopement. On 3/7/19, Resident 36 attempted to leave the facility and verbalized his desire to go home. A review of the Resident 36's care plan, dated 3/6/19, indicated the resident was a risk for wandering and elopement related to his cognitive status. The approach was to provide safety in the secured unit. A review of Resident 36's history and physical examination [REDACTED]. A review of Resident 36's MDS, dated [DATE], indicated that the resident's cognition was intact. Resident 36 required extensive assistance with walking, bed mobility, transfers, dressing, and toilet use. Resident 36 used a walker for mobility. A review of Resident 36's Notice of Proposed Transfer and Discharge, dated 5/9/19, did not indicate the reason for discharge. The proposed discharge notice form did not have a signature of the resident or the resident's representative. A review of Resident 36's Physician and Telephone Orders, dated 5/9/19 (untimed), indicated an order to discharge Resident 36 to an independent living facility with home health services. Another physician order, dated 5/19/19, indicated to discontinue the home health services. A review of Resident 36's Licensed Personnel Weekly Progress Notes, dated 5/9/19 at 5:30 p.m., indicated a staff member from the home health agency went to the facility to transport Resident 36 to the independent living facility. After the staff from the home health agency spoke with Resident 36, she took the resident's belongings, and brought him to the car. The staff member from the home health agency did not inform the charge nurse that she was taking Resident 36 to the independent living facility and left behind the resident's medications. The charge nurse called the home health agency and left a voice message about the resident's medications. The charge nurse also called Resident 36's responsible party. On 7/5/19 at 3:50 p.m., during an interview, LVN 9 stated SSD 1 and Social Service Designee 3 (SSD 3) informed her about Resident 36's discharge from the skilled nursing facility. LVN 9 stated the owner of the home health agency took Resident 36's belongings to the car. LVN 9 stated the resident was alert and oriented, and walked by holding on to the side rails. LVN 9 stated the resident's gait (manner of walking) was not steady. LVN 9 stated, Honestly, I did not notify the family. I assume the family was aware because it was fast. 4. A review of Resident 16's Face Sheet indicated the resident's admission to the facility on [DATE] and a readmission on 9/10/18 with diagnoses, which included squamous cell [MEDICAL CONDITION] left lower limb ([MEDICAL CONDITION]), diabetes mellitus, difficulty in walking, and muscle weakness. Resident 16 was self-responsible. A review of Resident 16's history and physical examination [REDACTED]. A review of Resident 16's MDS, dated [DATE], indicated the resident could understand others and make decisions. Resident 16 required supervision with walking, locomotion on and off the unit, and eating; and required limited assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. On 5/9/19 at 10 a.m. during an interview, Resident 16 stated he had a meeting, on 5/7/19, with the skilled nursing facility's corporate office vice president. Resident 16 stated, the corporate office vice president told him he had to leave the facility on Friday (5/10/19) by 5 p.m. Resident 16 showed a paper that the corporate office vice president gave him and stated it cost $9,000 for him to stay in the skilled nursing facility. Resident 16 stated the corporate office vice president threatened me and informed him that if he did not sign the paper, they would remove him from the facility and put him out on the street. Resident 16 stated the corporate office vice president forced him to sign the papers, but he did not know what he was signing. Resident 16 stated the facility did not give him a notice of proposed discharge. Resident 16 also stated, I did not want to be homeless. On 6/13/19 at 8:45 a.m., during an interview, the DON stated that there was no written notice of discharge given to Resident 16 and Resident 16's proposed discharge was inappropriate. A review of the facility's census, dated 7/4/19, indicated Resident 16 was still in the facility. 5. A review of Resident 27's Face Sheet indicated an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 27 was self-responsible. A review of Resident 27's MDS, dated [DATE], indicated the resident understood others and could make decisions. The MDS indicated Resident 27 did not walk and used a wheelchair for mobility; needed supervision with locomotion on and off the unit; and required extensive assistance with bed mobility, transfers, dressing, toilet, and personal hygiene. A review of Resident 27's Social Work Progress Notes, dated 5/9/19, indicated the skilled nursing facility's administrator-in-training (AIT) told Resident 27 to leave the facility by 5/10/19 and not to come back. The notes indicated Resident 27 stated he could not leave and no one could pack his belongings without his permission. On 5/9/18 at 9 a.m. during an interview, Resident 27 stated he had a meeting on 5/7/19 with a corporate office vice president, an independent living staff member and SSD 1. The corporate office vice president informed him that he needed to find a place on Friday (5/10/19) by 5 p.m. Resident 27 stated the corporate office vice president showed him a paper and told him it cost $18,000 a month for him to stay at the skilled nursing facility. Resident 27 stated if he did not leave the facility, they would call the police and report the resident for trespassing. Resident 27 stated he felt pressured and threatened, and he did not know what to do. On 5/9/19 at 9:30 a.m., during an interview, SSD 1 stated the corporate office vice president threatened Resident 27 to leave the facility during the meeting on 5/7/19. On 6/13/19 at 8:45 a.m., during an interview, the DON stated the skilled nursing facility did not give a written notice of discharge to Resident 27 and Resident 27's proposed discharge was inappropriate. A review of the facility's policy and procedure titled, Transfer/Discharge, revised on 10/2017, indicated that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility. When possible, the facility should provide at least 30 days' notice before the resident is transfer or discharged . If less than 30 days, the notice may be made as soon as practicable. The Notice of Proposed Transfer and Discharge will be signed by the resident. If the resident does not have the capacity or ability to sign, the responsible party may sign the document. If the responsible party is not available to sign, contact should be made by phone and documented on the Notice of Proposed Transfer and Discharge form. A copy of the Notice of Proposed Transfer and Discharge will then be sent by certified mail to obtain the signature of the responsible party. The certified mail receipt will be attached to the chart copy of the notice and retained until the signed copy is returned. Completion by fax is also acceptable. On 7/5/19 at 7:20 p.m., the Department of Public Health informed the skilled nursing facility administrator (ADM 2) about the Immediate Jeopardy (IJ) situation at the skilled nursing facility. The IJ included the facility's failure to have systems in place to ensure safe and appropriate discharges, insufficient preparation and orientation to the receiving facility, and effective transition of care. In addition, the residents did not meet the requirements for discharge to a lower level of care, which included documentation of the discharge planning, the service available by the receiving facility, a physician order [REDACTED]. During an onsite visit, on 7/8/19 at 6:25 p.m., the Department of Public Health verified and confirmed the immediate jeopardy was removed after ADM 2 presented an acceptable plan of correction. The plan of correction included: 1. The Governing Body suspending the skilled nursing facility's corporate office vice president on 7/6/19. 2. All staff members including the ADM 2, DON, Medical Director/Attending Physician will participate the completing the discharge planning for all residents. 3. In-services given by the vice president of Behavioral Health regarding compliance with safe and appropriate discharge process. 4. The ADM 2 and DON will review the notices of discharge for completeness. On 7/8/19 at 4:56 p.m., during an interview, the DON stated the corporate office vice president process of asking Resident 16 to leave the facility was inappropriate. On 7/8/19 at 5:15 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 23's medical record to support the discharge to an independent living facility. The DON stated Physician 1 did not give an order to discharge Resident 23. The DON stated there was no IDT meeting regarding Resident 23's discharge plans. The DON stated Resident 23 is at risk for elopement and requires supervision in a secured environment. On 7/8/19 at 5:28 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 28's medical record to support the discharge to an independent living facility. The DON stated there was no IDT meeting conducted and no physician progress notes [REDACTED]. The DON stated Resident 28 was not a candidate for discharge to a lower level of care. Resident 28 required a supervised and secured environment for safety due to his risk of wandering. The DON stated the former administrator's processes of discharging Resident 28 was inappropriate and not based on the resident needs. On 7/8/19 at 5:30 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 36's medical record to support the discharge to a lower level of care. The DON stated there was no IDT meeting conducted and there was no physician progress notes [REDACTED]. The DON stated the corporate vice president and the former administrator planned and decided Resident 36's discharge.

Based on interview and record review, the facility failed to prepare and orient four of six sampled residents (Resident 23, 26, 28, and 36) to a lower level of care (a level of care that promotes independence) provide accurate information to the residents/responsible party about the services offered by the lower level of care, and document the preparation and orientation to the residents/responsibility party. The skilled nursing administrator, a corporate office vice president and an independent living staff member, randomly selected residents (Resident 23, 26, 28, and 36), who were able to walk, for discharge to the independent living facility (a housing arrangement for those who can live independently within a community setting) on the same day. The skilled nursing administrator, a corporate office vice president, and the independent living staff, either individually or jointly, discharged Resident 23, 26, and 36, and attempted to discharge Resident 28. These deficient practices resulted in Resident 23 eloping (leaving without permission) from the independent living facility, upsetting Resident's 28 responsible party/family due to the possibility of discharge, sending Resident 36 to an independent living facility without his medications or instructions on how to check his blood sugar levels. These deficient practice had the potential for other ambulatory residents to be discharged inappropriately and involuntarily to a lower level of care. Findings: 1. A review of Resident 23's Face Sheet (admission record) indicated an admission to the skilled nursing facility on 10/12/15, and a readmission on 12/15/18. The resident's [DIAGNOSES REDACTED]. A review of Resident 23's Minimum Data Set (MDS - standard assessment and care-planning tool), dated 3/31/19, indicated the resident had severely impaired cognition (mental action of acquiring knowledge and understanding). Resident 23 required supervision with walking, locomotion on and off the unit (how resident moved between locations), bed mobility, transferring to and from surfaces (such as the bed or wheelchair), and eating. Resident 23 also required limited assistance (a resident involved in activity, staff provide guided maneuvering) with dressing, toilet use, and personal hygiene. A review of Resident 23's history and physical examination [REDACTED]. A review of Resident 23's Elopement Risk Assessment, dated 3/31/19, indicated the resident was a high risk for elopement. A review of Resident 23's Plan of Care, dated 2/10/19, indicated the resident was at risk for wandering (to move or walk aimlessly) and elopement related to his cognitive status. The approach was to provide the resident's safety in a secured unit (a specialized unit for residents who suffer from dementia or memory impairment). A review of Resident 23's Licensed Personnel Weekly Progress Notes, dated 5/7/19 at 2 p.m., indicated Registered Nurse 1 (RN 1) received a call (time not indicated) from the Administrator to transfer Resident 23 to an independent living facility. RN 1 notified Resident 23's attending physician, Physician 1, but Physician 1 did not agree with the transfer. The Administrator spoke with Physician 1 (exact time not indicated) and the physician agreed to transfer the resident to an independent living facility. RN 1 called (exact time not indicated) five telephone numbers listed on the resident's face sheet, but was unable to contact the resident's responsible party (RP 1) or a family member. Per the Licensed Personnel Weekly Progress Notes, the Administrator, the Social Services Director 1 (SSD 1) already spoke with RP 1 (date and time not indicated). On 5/7/19, at 3:29 p.m., a staff member from the independent living facility transported Resident 23, from the skilled nursing, to the independent living facility. A review of Resident 23's Physician and Telephone Orders, dated 5/7/19 at 2 p.m., signed by Licensed Vocational Nurse 3 (LVN 3) indicated to discharge the resident to an independent living facility, with visits provided by a Home Health Agency (HHA- an agency that provides services such as nursing, rehabilitation, social worker, etc. at a person's residence). The physician had not signed the discharge telephone order. A review of a Police Report, dated 5/9/19 at 12:40 p.m., indicated they found Resident 23 in a shopping center parking lot, attempting to get into a vehicle. Resident 23 knew his name and date of birth. When asked where he was, he answered here. It was determined that Resident 23 had an altered mental status (disruption how your brain work and changes your behavior), was taken to a general acute care hospital (GACH), and placed in the care of an Adult Protective Services (APS) staff. A review of the GACH social worker's progress notes, dated 5/9/19, indicated the Social Worker 1 (SW 1) searched for Resident 23's family members and made contact with RP 1 on 5/9/19 at 8:05 p.m. RP 1 stated the skilled nursing facility informed her that Resident 23 transferred from the skilled nursing facility to a board and care (non-medical custodial care that may assist with daily activities like bathing, eating and toileting) Alzheimer's facility, on 5/7/19. RP 1 stated the skilled nursing facility told her that Resident 23 would be going to a locked facility for those with [MEDICAL CONDITION]. RP 1 stated the skilled nursing facility did not provide her with the address and telephone number of the independent living facility. When SW 1 called and spoke with a staff member at the independent living facility, the staff member stated Resident 23 did not reside in a locked housing facility or a locked board and care Alzheimer's unit, but resided in an independent living facility. A review of Resident 23's GACH social worker's progress notes, dated 5/9/19, indicated SW 1 spoke with the House Supervisor at the independent living facility. SW 1 spoke with the House Supervisor who stated the independent living facility provides a room and meals. The residents in the independent living facility are able to perform their own ADLs; are alert and oriented to person, place, time, and situation; and are able to take their own medications. The House Supervisor stated she did not know that Resident 23 had [MEDICAL CONDITION] and was unable to live independently. On 5/10/19 at 11:37 a.m., Resident 23 transferred back to the skilled nursing facility, under the care of Physician 1, at RP 1's request. On 5/23/19 at 10:45 a.m., during an interview, Physician 1 stated he received a call from the skilled nursing facility about the need to discharge Resident 23 to an independent living facility. Physician 1 stated he was totally against the discharge and he refused to give the order. Physician 1 stated he did not evaluate Resident 23 to see if he was a candidate for a lower level of care. Physician 1 stated for the resident's safety, he would never discharge him to a lower level of care. Physician 1 added he never wrote or gave an order to discharge Resident 23 to an independent living facility. On 5/23/19 at 1:30 p.m., during an interview, SSD 1, from the skilled nursing facility, stated because Resident 23 has dementia and could wander away from the independent living facility, he should never been discharged . On 5/23/19 at 2 p.m., during an interview, LVN 3 stated a social services staff member informed her they would be notifying RP 1 about Resident 23's discharge (on 5/7/19). LVN 3 stated RN 1 told her to write Resident 23's discharge order. LVN 3 stated she assumed RN 1 called Physician 1 to obtain the discharge order. LVN 3 stated to help RN 1, she wrote the discharge order and considered it as teamwork. On 5/23/19 at 2:15 p.m., during an interview, Social Services Designee 2 (SSD 2) stated the skilled nursing administrator, corporate office vice president, and a representative from the independent living facility came to the facility (on 5/7/19). They went to the nursing station and selected ambulatory residents for discharge. SSD 2 stated Resident 23 was selected because he could walk. SSD 2 stated she called RP 1, on 5/7/19, to notify her about Resident 23's discharge to the independent living facility and told her the independent living facility staff would supervise the resident. SSD 2 stated she did not know Physician 1 had not given the discharge order when she notified RP 1. On 5/28/19 at 1:40 p.m., during an interview, RN 1 stated she called Physician 1 to get an order to discharge Resident 23 to an independent living facility. RN 1 stated Physician 1 did not give the discharge order, so she notified the Administrator. RN 1 stated the Administrator later told her on 5/7/19 (no time indicated), that Physician 1 gave the order to discharge Resident 23 to the independent living facility. On 6/13/19 at 8:45 a.m., during an interview and a concurrent record review, the Director of Nursing (DON) stated there was no discharge assessment prior to Resident 23's transfer to the independent living facility. The DON stated Resident 23's discharge should not have happened. 2. A review of Resident 28's Face Sheet indicated an admission to the skilled nursing facility on 12/18/18 and a readmission on 4/9/19 with [DIAGNOSES REDACTED]. A review of Resident 28's MDS, dated [DATE], indicated the resident had severe impairment in cognition. The MDS indicated Resident 28 required supervision with walking, locomotion on and off the unit, bed mobility, and transfers; required limited assistance with personal hygiene; and required extensive assistance (resident involved in activity; staff provide weight-bearing support) with dressing and toilet use. A review of Resident 28's history and physical examination [REDACTED]. A review of Resident's 28's Plan of Care, dated 4/10/19, indicated the resident was at risk for wandering or elopement related to his cognitive status and the approach was to provide the resident safety in a secured unit. A review of Resident 28's Licensed Personnel Weekly Progress Notes, dated 5/7/19 at 2 p.m., indicated RN 1 received a call from the skilled nursing facility Administrator to transfer Resident 28 to an independent living facility. A review of Resident 28's Physician and Telephone Orders, dated 5/7/19, indicated the skilled nursing facility may transfer the resident to an independent living facility with home health services. On 5/23/19 at 2:15 p.m., during an interview, SSD 2 stated after the skilled nursing staff chose Resident 23 for discharge (on 5/7/19), the Administrator informed a (unidentified) staff member to call Resident 28's family and let the family know about the discharge. SSD 2 stated RP 2 called, crying and was very upset because she did not want Resident 28 to leave the skilled nursing facility. SSD 2 stated she told the Administrator that Resident 28's responsible party was upset and did not agree to the discharge. SSD 2 stated RP 2 came to the skilled nursing facility and brought Resident 28's proof of insurance to show that the benefits had not run out. Resident 28's discharge did not take place. On 6/13/19 at 3.45 p.m., during an interview, Resident 28's responsible party (RP 2) stated someone called from the skilled nursing facility informing her the skilled nursing facility was transferring the resident to another place. RP 2 stated she did not agree with the transfer and told the skilled nursing facility not to discharge the resident. 3. A review of Resident 26's Face Sheet indicated an admission to the skilled nursing facility on 8/29/18 and a readmission on 2/24/19. Resident 26's [DIAGNOSES REDACTED]. Resident 26 was self-responsible (made decision for themselves). A review of Resident 26's history and physical examination [REDACTED]. A review of Resident 26's MDS, dated [DATE], indicated the resident had moderately impaired cognition (decisions poor; cues/supervision required). Resident 26 required limited assistance from staff with walking, locomotion on and off the unit, and eating; and required limited assistance with bed mobility, transferring, dressing, toilet use, and personal hygiene. A review of Resident 26's Social Work Progress Notes form, dated 5/7/19 (no time specified), indicated Social Service Designee 3 (SSD 3) spoke with the resident regarding her discharge to a lower level of care and the resident agreed. SSD 3 informed Resident 26's family member about the proposed discharge. The family member agreed, but voiced her concerns about the provisions of care in an independent living facility. SSD 3 wrote that per the independent living facility staff, the resident would receive home health services. The skilled nursing facility staff discharged Resident 26, to the lower level of care, with home health services. A review of Physician and Telephone Orders, dated 5/7/19, indicated to discharge Resident 26 to an independent living facility with home health services. 4. A review of Resident 36's Face Sheet indicated an admission to the skilled nursing facility on 3/5/19. The resident's [DIAGNOSES REDACTED]. Resident 36 had a responsible party, but there was no contact information listed on the face sheet. A review of Resident 36's Physician Orders, dated 3/5/19, indicated to check the resident's blood sugar level before meals (QAC) and before bedtime (QHS). The resident was to receive regular insulin (a medication to improve blood sugar control and starts to work within 30 minutes from injection) per sliding scale (the resident is given a predetermine dose of insulin depending on his/her blood sugar level). A review of Resident 36's Elopement Risk Assessment, dated 3/5/19, 3/7/19, and 4/10/19, indicated a high risk for potential elopement. On 3/7/19, Resident 36 attempted to leave the facility and verbalized his desire to go home. A review of the Resident 36's care plan, dated 3/6/19, indicated the resident was a risk for wandering and elopement related to his cognitive status. The approach was to provide safety in the secured unit. A review of Resident 36's history and physical examination [REDACTED]. A review of Resident 36's MDS, dated [DATE], indicated that the resident's cognition was intact. Resident 36 required extensive assistance with walking, bed mobility, transfers, dressing, and toilet use. Resident 36 used a walker for mobility. A review of Resident 36's Physician and Telephone Orders, dated 5/9/19 (untimed), indicated an order to discharge Resident 36 to an independent living facility with home health services. Another physician order, dated 5/9/19, indicated to discontinue the home health services. A review of Resident 36's Licensed Personnel Weekly Progress Notes, dated 5/9/19 at 5:30 p.m., indicated a staff member from the home health agency went to the facility to transport Resident 36 to the independent living facility. After the staff from the home health agency spoke with Resident 36, she took the resident's belongings, and brought him to the car. The staff member from the home health agency did not inform the charge nurse that she was taking Resident 36 to the independent living facility and left behind the resident's medications. The charge nurse called the home health agency and left a voice message about the resident's medications. The charge nurse also called Resident 36's responsible party. On 7/5/19 at 3:50 p.m., during an interview, LVN 9 stated SSD 1 and SSD 3 informed her about Resident 36's discharge from the skilled nursing facility. LVN 9 stated the owner of the home health agency took Resident 36's belongings to the car. LVN 9 stated the resident was alert and oriented, and walked by holding on to the side rails. LVN 9 stated the resident's gait (manner of walking) was not steady. A review of the facility's policy and procedure titled, Discharge and Transfer of Residents, revised on 2/2018, indicated to ensure that discharge planning is complete and appropriate and that necessary information is communicated to the continuing care provider. Discharge planning will begin on the resident's admission to the facility. A review of the facility's policy and procedure titled, Transfer and Discharge, revised on 10/2017, indicated preparation for and assistance with discharge planning will be documented in the medical records. The Social Services Staff will orient the resident to the impending discharge. The Social Service Staff may coordinate a care conference to discuss discharge needs, plan, and teaching, and will involve the Interdisciplinary Team (IDT - a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) members as appropriate. On 7/5/19 at 7:20 p.m., the Department of Public Health informed the skilled nursing facility administrator (ADM 2) about the Immediate Jeopardy (IJ) situation at the skilled nursing facility. The IJ included the facility's failure to have systems in place to ensure safe and appropriate discharges, insufficient preparation and orientation to the receiving facility, and effective transition of care. In addition, the residents (Resident 23, 26, 28, and 36) did not meet the requirements for discharge to a lower level of care, which included documentation of the discharge planning, the service available by the receiving facility, a physician order [REDACTED]. During an onsite visit, on 7/8/19 at 6:25 p.m., the Department of Public Health verified and confirmed the immediate jeopardy was removed after ADM 2 presented an acceptable plan of correction. The plan of correction included: 1. The Governing Body suspending the skilled nursing facility's corporate office vice president on 7/6/19 and will not allow the independent living facility staff to enter the facility. 2. The ADM 2, DON, Medical Director/Attending Physician, and the Interdisciplinary Team (IDT - a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) members will approve the resident's discharge to a lower level of care. 3. In-services given by the vice president of Behavioral Health regarding compliance with safe and appropriate discharge process. 4. The Social Services Director/Designee will follow-up on residents discharged to a lower level of care to ensure no issues/concerns have arisen. Within 3-5 days and prior to the 30th day of discharge, the Medical Director will review these discharges for issues/concerns. On 7/8/19 at 5:15 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 23's medical record to support the discharge to an independent living facility. The DON stated Physician 1 did not give an order to discharge Resident 23. The DON stated there was no IDT meeting regarding Resident 23's discharge plans. The DON stated Resident 23 is at risk for elopement and requires supervision in a secured environment. On 7/8/19 at 5:20 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 26's medical record to support the discharge to a lower level of care. The DON stated Resident 26's medical record did not have progress notes from the primary physician regarding plans for discharge. The DON stated Resident 26's discharge to a lower level of care was not planned. On 7/8/19 at 5:28 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 28's medical record to support the discharge to an independent living facility. The DON stated there was no IDT meeting conducted and no physician progress notes [REDACTED]. The DON stated Resident 28 was not a candidate for discharge to a lower level of care. Resident 28 required a supervised and secured environment for safety due to his risk of wandering. The DON stated the former administrator's processes of discharging Resident 28 was inappropriate and not based on the resident needs. On 7/8/19 at 5:30 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 36's medical record to support the discharge to a lower level of care. The DON stated there was no IDT meeting conducted and there was no physician progress notes [REDACTED]. The DON stated the corporate vice president and the former administrator planned and decided Resident 36's discharge.

Based on interview and record review the facility failed to conduct an Interdisciplinary Team (IDT - a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) meeting to discuss and develop a safe and appropriate discharge plan, with the involvement of the resident and the resident's responsible party; inform the resident/resident responsible party of the final discharge plan; provide effective transition to the lower level of care facility; document referrals to a home health agency; and document that the residents discharge needs and plans were evaluated for six of six sampled residents (Resident 16, 23, 26, 27, 28, and 36). The skilled nursing administrator, the corporate office vice president and an independent living staff member, randomly selected ambulatory residents, Residents 23, 26, and 36 and attempted to discharge Residents 16, 27, and 28 to an independent living facility (a housing arrangement for those who can live independently within a community setting), without discharge planning to discuss the resident's discharge needs, physician documentation that the discharge was necessary; and ensuring the independent living facility met the needs of the residents. These deficient practices resulted in Resident 23 eloping (leaving without permission) from the independent living facility, upsetting Resident 28's responsible party/family due to the possibility of discharge, sending Resident 36 to an independent living facility without his medications or instructions on how to check his blood sugar levels, making Resident 16 fearful of being homeless, and forcing Residents 16 and 27 to sign discharge papers they did not understand. This deficient practice had the potential for the independent living facility not meeting the needs of Resident 26 and other ambulatory residents to be discharged inappropriately, involuntarily and to experience anxiety. Findings: 1. A review of Resident 23's Face Sheet (admission record) indicated an admission to the skilled nursing facility on 10/12/15, and a readmission on 12/15/18. The resident's [DIAGNOSES REDACTED]. A review of Resident 23's Minimum Data Set (MDS - standard assessment and care-planning tool), dated 3/31/19, indicated the resident had severely impaired cognition (mental action of acquiring knowledge and understanding). Resident 23 required supervision with walking, locomotion on and off the unit (how resident moved between locations), bed mobility, transferring to and from surfaces (such as the bed or wheelchair), and eating. Resident 23 also required limited assistance (a resident involved in activity, staff provide guided maneuvering) with dressing, toilet use, and personal hygiene. A review of Resident 23's history and physical examination [REDACTED]. A review of Resident 23's Elopement Risk Assessment, dated 3/31/19, indicated the resident was a high risk for elopement. A review of Resident 23's Plan of Care, dated 2/10/19, indicated the resident was at risk for wandering (to move or walk aimlessly) and elopement related to his cognitive status. The approach was to provide the resident's safety in a secured unit (a specialized unit for residents who suffer from dementia or memory impairment). A review of Resident 23's Licensed Personnel Weekly Progress Notes, dated 5/7/19 at 2 p.m., indicated Registered Nurse 1 (RN 1) received a call (time not indicated) from the Administrator to transfer Resident 23 to an independent living facility. RN 1 notified Resident 23's attending physician, Physician 1, but Physician 1 did not agree with the transfer. The Administrator spoke with Physician 1 (exact time not indicated) and the physician agreed to transfer the resident to an independent living facility. RN 1 called (exact time not indicated) five telephone numbers listed on the resident's face sheet, but was unable to contact RP 1 or a family member. Per the Administrator, the Social Services Director 1 (SSD 1) already spoke with Responsible Party (RP 1). On 5/7/19, at 3:29 p.m., a staff member from the independent living facility transported Resident 23, from the skilled nursing, to the independent living facility. A review of Resident 23's Physician and Telephone Orders, dated 5/7/19 at 2 p.m., signed by Licensed Vocational Nurse 3 (LVN 3) indicated to discharge the resident to an independent living facility, with visits provided by a Home Health Agency (HHA- an agency providing nursing services). The physician had not sign the discharge telephone order. A review of Resident 23's Physician Discharge Summary indicated on 5/7/19, the skilled nursing facility staff discharged the resident to an independent living facility. The status of the resident's condition and the physician's signature were blank on the discharge form. A review of Resident 23's Discharge Summary/Post Discharge Plan of Care, dated 5/7/19, indicated there were no post-discharge plans for the independent living facility or home health agency to follow. The discharge form did not include any special instructions about the resident's care and treatment. A review of a Police Report, dated 5/9/19 at 12:40 p.m., indicated they found Resident 23 in a shopping center parking lot, attempting to get into a vehicle. Resident 23 knew his name and date of birth. When asked where he was, he answered here. It was determined that Resident 23 had an altered mental status (disruption how your brain work and changes your behavior), was taken to a general acute care hospital (GACH), and placed in the care of an Adult Protective Services (APS) staff. A review of the GACH social worker's progress notes, dated 5/9/19, indicated the Social Worker 1 (SW 1) searched for Resident 23's family members and made contact with RP 1 at 8:05 p.m. RP 1 stated they informed her that Resident 23 transferred from the skilled nursing facility to a board and care (non-medical custodial care that may assist with daily activities like bathing, eating and toileting) Alzheimer's facility, on 5/7/19. RP 1 stated the skilled nursing facility told her that Resident 23 would be going to a locked facility for those with [MEDICAL CONDITION]. RP 1 stated the skilled nursing facility did not provide her with the address and telephone number of the independent living facility. When SW 1 called and spoke with a staff member at the independent living facility, the staff member stated Resident 23 did not reside in a locked housing facility or a locked board and care Alzheimer's unit, but resided in an independent living facility. A review of Resident 23's GACH social worker's progress notes, dated 5/9/19, indicated SW 1 spoke with the House Supervisor at the independent living facility. The House Supervisor stated the independent living facility provides a room and meals. The residents in the independent living facility are able to perform their own ADLs; are alert and oriented to person, place, time, and situation; and are able to take their own medications. The House Supervisor stated she did not know that Resident 23 had [MEDICAL CONDITION] and was unable to live independently. On 5/10/19 at 11:37 a.m., Resident 23 transferred back to the skilled nursing facility, under the care of Physician 1, at RP 1's request. On 5/23/19 at 10:45 a.m., during an interview, Physician 1 stated he received a call from the skilled nursing facility about the need to discharge Resident 23 to an independent living facility. Physician 1 stated he was totally against the discharge and he refused to give the order. Physician 1 stated he did not evaluate Resident 23 to see if he was a candidate for a lower level of care. Physician 1 stated for the resident's safety, he would never discharge him to a lower level of care. Physician 1 added he never wrote or gave an order to discharge Resident 23 to an independent living facility. On 5/23/19 at 1:30 p.m., during an interview, SSD 1, from the skilled nursing facility, stated because Resident 23 has dementia and could wander away from the independent living facility, he should never been discharged . On 5/23/19 at 2 p.m., during an interview, LVN 3 stated a social services staff member informed her they would be notifying RP 1 about Resident 23's discharge (on 5/7/19). LVN 3 stated RN 1 told her to write Resident 23's discharge order. LVN 3 stated she assumed RN 1 called Physician 1 to obtain the discharge order. LVN 3 stated to help RN 1, she wrote the discharge order and considered it as teamwork. On 5/23/19 at 2:15 p.m., during an interview, Social Services Designee 2 (SSD 2) stated the skilled nursing administrator, corporate office vice president, and a representative from the independent living facility came to the facility (on 5/7/19). They went to the nursing station and selected ambulatory residents for discharge. SSD 2 stated Resident 23 was selected for discharge because he could walk. SSD 2 stated she called RP 1, on 5/7/19, to notify her about Resident 23's discharge to the independent living facility and told her the independent living facility staff would supervise the resident. SSD 2 stated she did not know Physician 1 had not given the discharge order when she notified RP 1. On 5/28/19 at 1:40 p.m., during an interview, RN 1 stated she called Physician 1 to get an order to discharge Resident 23 to an independent living facility. RN 1 stated Physician 1 did not give the discharge order, so she notified the Administrator. RN 1 stated the Administrator later told her on 5/7/19 (no time indicated), that Physician 1 gave the order to discharge Resident 23 to the independent living facility. On 6/13/19 at 8:30 a.m., the SSD 2 stated that the process for discharge planning included the social worker meeting with the resident or the family on admission to discuss discharge plans. SSD 2 stated an IDT meeting should also be conducted before the actual discharge of the resident to ensure safety. On 6/13/19 at 8:45 a.m., during an interview and a concurrent record review, the Director of Nursing (DON) stated there no assessment prior to Resident 23's transfer to the independent living facility. The DON stated Resident 23's discharge should not have happened. 2. A review of Resident 28's Face Sheet indicated an admission to the skilled nursing facility on 12/18/18 and a readmission on 4/9/19 with [DIAGNOSES REDACTED]. A review of Resident 28's MDS, dated [DATE], indicated the resident had severe impairment in cognition. The MDS indicated Resident 28 required supervision with walking, locomotion on and off the unit, bed mobility, and transfers; required limited assistance with personal hygiene; and required extensive assistance (resident involved in activity; staff provide weight-bearing support) with dressing and toilet use. A review of Resident 28's history and physical examination [REDACTED]. A review of Resident's 28's Plan of Care, dated 4/10/19, indicated the resident was at risk for wandering or elopement related to his cognitive status and the approach was to provide the resident safety in a secured unit. A review of Resident 28's Licensed Personnel Weekly Progress Notes, dated 5/7/19 at 2 p.m., indicated RN 1 received a call from the skilled nursing facility Administrator to transfer Resident 28 to an independent living facility. A review Resident 28's Physician and Telephone Orders, dated 5/7/19, indicate the skilled nursing facility may transfer the resident to an independent living facility with home health services. On 5/23/19 at 2:15 p.m., during an interview, SSD 2 stated after Resident 23 was selected for discharge (on 5/7/19), the Administrator informed a (unidentified) staff member to call Resident 28's family and let the family know about the discharge. SSD 2 stated RP 2 called, crying and was very upset because she did not want Resident 28 to leave the skilled nursing facility. SSD 2 stated she told the Administrator that RP 2 was upset and did not agree to the discharge. SSD 2 stated RP 2 came to the skilled nursing facility and brought Resident 28's proof of insurance to show that the benefits had not run out. Resident 28's discharge did not take place. On 6/13/19 at 3.45 p.m., during an interview, Resident 28's responsible party (RP 2) stated someone called from the skilled nursing facility informing her the skilled nursing facility was transferring the resident to another place. RP 2 stated did not agree with the transfer and told the skilled nursing facility not to discharge the resident. 3. A review of Resident 36's Face Sheet indicated an admission to the skilled nursing facility on 3/5/19. The resident's [DIAGNOSES REDACTED]. Resident 36 had a responsible party, but there was no contact information listed on the face sheet. A review of Resident 36's Physician Orders, dated 3/5/19, indicated to check the resident's blood sugar level before meals (QAC) and before bedtime (QHS). The resident was to receive regular insulin (a medication to improve blood sugar control and starts to work within 30 minutes from injection) per sliding scale (the resident is given a predetermine dose of insulin depending on his/her blood sugar level). A review of Resident 36's Elopement Risk Assessment, dated 3/5/19, 3/7/19, and 4/10/19, indicated a high risk for potential elopement. On 3/7/19, Resident 36 attempted to leave the facility and verbalized his desire to go home. A review of the Resident 36's care plan, dated 3/6/19, indicated the resident was a risk for wandering and elopement related to his cognitive status. The approach was to provide safety in the secured unit. A review of Resident 36's history and physical examination [REDACTED]. A review of Resident 36's MDS, dated [DATE], indicated that the resident's cognition was intact. Resident 36 required extensive assistance with walking, bed mobility, transfers, dressing, and toilet use. Resident 36 used a walker for mobility. A review of Resident 36's Physician and Telephone Orders, dated 5/9/19 (untimed), indicated an order to discharge Resident 36 to an independent living facility with home health services. Another physician order, dated 5/19/19, indicated to discontinue the home health services. A review of Resident 36's Licensed Personnel Weekly Progress Notes, dated 5/9/19 at 5:30 p.m., indicated a staff member from the home health agency went to the facility to transport Resident 36 to the independent living facility. After the staff from the home health agency spoke with Resident 36, she took the resident's belongings, and brought him to the car. The staff member from the home health agency did not inform the charge nurse that she was taking Resident 36 to the independent living facility and left behind the resident's medications. The charge nurse called the home health agency and left a voice message about the resident's medications. The charge nurse also called Resident 36's responsible party. On 6/12/19 at 7:45 a.m., during an interview, the DON stated the representative from the independent living facility came to the facility on [DATE] to pick-up Resident 36 and transfer the resident to an independent living facility. The DON stated Resident 36 had only been in the open unit for two weeks when the facility discharged him to a lower level of care; he previously came from a secured unit. On 6/13/19 at 8:30 a.m., during an interview, SSD 2 stated that the facility did not conduct an IDT meeting before discharging Residents 36 because the Administrator and the corporate office vice president wanted to remove the resident from the facility immediately. On 7/5/19 at 3:50 p.m., during an interview, LVN 9 stated SSD 1 and Social Service Designee 3 (SSD 3) informed her about Resident 36's discharge from the skilled nursing facility. LVN 9 stated the owner of the home health agency took Resident 36's belongings to the car. LVN 9 stated the resident was alert and oriented, and walked by holding on to the side rails. LVN 9 stated the resident's gait (manner of walking) was not steady. LVN 9 stated, Honestly, I did not notify the family. I assume the family was aware because it was fast. 4. A review of Resident 16's Face Sheet indicated the resident's admission to the facility on [DATE] and a readmission on 9/10/18 with diagnoses, which included squamous cell [MEDICAL CONDITION] left lower limb ([MEDICAL CONDITION]), diabetes mellitus, difficulty in walking, and muscle weakness. Resident 16 was self-responsible. A review of Resident 16's history and physical examination [REDACTED]. A review of Resident 16's MDS, dated [DATE], indicated the resident could understand others and make decisions. Resident 16 required supervision with walking, locomotion on and off the unit, and eating; and required limited assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. On 5/9/19 at 10 a.m. during an interview, Resident 16 stated he had a meeting, on 5/7/19, with the skilled nursing facility's corporate office vice president. Resident 16 stated, the corporate office vice president told him he had to leave the facility on Friday (5/10/19) by 5 p.m. Resident 16 showed a paper that the corporate office vice president gave him and stated it cost $9,000 for him to stay in the skilled nursing facility. Resident 16 stated the corporate office vice president threatened me and informed him that if he did not sign the paper, they would remove him from the facility and put him out on the street. Resident 16 stated the corporate office vice president forced him to sign the papers, but he did not know what he was signing. Resident 16 stated the facility did not give him a notice of proposed discharge. Resident 16 also stated, I did not want to be homeless. A review of the facility's census, dated 7/4/19, indicated Resident 16 was still in the skilled nursing facility. 5. A review of Resident 27's Face Sheet indicated an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 27 was self-responsible. A review of Resident 27's MDS, dated [DATE], indicated the resident understood others and could make decisions. The MDS indicated Resident 27 did not walk and used a wheelchair for mobility; needed supervision with locomotion on and off the unit; and required extensive assistance with bed mobility, transfers, dressing, toilet, and personal hygiene. A review of Resident 27's Social Work Progress Notes, dated 5/9/19, indicated the skilled nursing facility's administrator-in-training (AIT) told Resident 27 to leave the facility by 5/10/19 and not to come back. The notes indicated Resident 27 stated he could not leave and no one could pack his belongings without his permission. On 5/9/18 at 9 a.m. during an interview, Resident 27 stated he had a meeting on 5/7/19 with a corporate office vice president, an independent living staff member and SSD 1. The corporate office vice president informed him that he needed to find a place on Friday (5/10/19) by 5 p.m. Resident 27 stated the corporate office vice president showed him a paper and told him it cost $18,000 a month for him to stay at the skilled nursing facility. Resident 27 stated if he did not leave the facility, they would call the police and report the resident for trespassing. Resident 27 stated he felt pressured and threatened, and he did not know what to do. 6. A review of Resident 26's Face Sheet indicated an admission to the skilled nursing facility on 8/29/18 and a readmission on 2/24/19. Resident 26's [DIAGNOSES REDACTED]. Resident 26 was self-responsible (made decision for themselves). A review of Resident 26's history and physical examination [REDACTED]. A review of Resident 26's MDS, dated [DATE], indicated the resident had moderately impaired cognition (decisions poor; cues/supervision required). Resident 26 required limited assistance from staff with walking, locomotion on and off the unit, and eating; and required limited assistance with bed mobility, transferring, dressing, toilet use, and personal hygiene. A review of Resident 26's Social Work Progress Notes form, dated 5/7/19 (no time specified), indicated SSD 3 spoke with the resident regarding her discharge to a lower level of care and the resident agreed. SSD 3 informed Resident 26's family member about the proposed discharge. The family member agreed, but voiced her concerns about the provisions of care in an independent living facility. SSD 3 wrote that per the independent living facility staff, the resident would receive home health services. The skilled nursing facility staff discharged Resident 26, to the lower level of care, with home health services. A review of Physician and Telephone Orders, dated 5/7/19, indicated to discharge Resident 26 to an independent living facility with home health services. On 6/12/19 at 7:45 a.m., during an interview, the DON stated representative from the independent living facility came to the facility on [DATE], picked-up Resident 26, and transferred her to an independent living facility. On 6/13/19 at 8:30 a.m., during an interview, SSD 2 stated that the facility did not conduct an IDT meeting before discharging Residents 26 because the Administrator and the corporate office vice president wanted to remove the resident from the facility immediately. A review of the facility's policy titled Transfer and Discharge, version 2.0, revised in (MONTH) (YEAR), indicated that if the IDT and the attending physician determine that the resident may be appropriate for discharge, Social Services Staff will coordinate the discussion of discharge with IDT, the resident, and the responsible party. A review of the facility's policy and procedure titled, Discharge and Transfer of Residents, revised on 2/18, indicated to ensure that discharge planning is complete and appropriate and that necessary information is communicated to the continuing care provider. Discharge planning will begin on the resident's admission to the facility. The attending Physician will review the resident's progress and determine a possible discharge date with information from the IDT. The medical record will contain documentation from the resident's Attending Physician regarding the residents discharge plan of care if the resident is discharge because: 1. it is necessary for the resident's welfare and the resident's needs cannot be met in the facility. 2. The resident's health has improved and he/or she no longer needs the facility's services. On 7/5/19 at 7:20 p.m., the Department of Public Health informed the skilled nursing facility administrator (ADM 2) about the Immediate Jeopardy (IJ) situation at the skilled nursing facility. The IJ included the facility's failure to have systems in place to ensure safe and appropriate discharges, insufficient preparation and orientation to the receiving facility, and effective transition of care. In addition, the residents did not meet the requirements for discharge to a lower level of care, which included documentation of the discharge planning, the service available by the receiving facility, a physician order [REDACTED]. During an onsite visit, on 7/8/19 at 6:25 p.m., the Department of Public Health verified and confirmed the immediate jeopardy was removed after ADM 2 presented an acceptable plan of correction. The plan of correction included: 1. The Governing Body suspending the skilled nursing facility's corporate office vice president on 7/6/19 and will not allow the independent living facility staff to enter the facility. 2. The ADM 2, DON, Medical Director/Attending Physician, and the Interdisciplinary Team (IDT - a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) members will approve the resident's discharge to a lower level of care. 3. In-services given by the vice president of Behavioral Health regarding compliance with safe and appropriate discharge process, which include a thorough assessment by the IDT team and physician approval. 4. The Social Services Director/Designee will follow-up on residents discharged to a lower level of care to ensure no issues/concerns have arisen. Within 3-5 days and prior to the 30 day of discharge, the Medical Director will review these discharges for issues/concerns. On 7/8/19 at 4:56 p.m., during an interview and a concurrent record review, the DON stated Resident 16's medical record did not contain progress notes from his primary physician regarding discharge plans. The DON stated Resident 16 was involved with his care and requested assistance from the social worker to find a place of his choice. The DON stated the corporate vice president's process of asking Resident 16 to leave the facility was inappropriate. On 7/8/19 at 5:15 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 23's medical record to support the discharge to an independent living facility. The DON stated Physician 1 did not give an order to discharge Resident 23. The DON stated there was no IDT meeting regarding Resident 23's discharge plans. The DON stated Resident 23 is at risk for elopement and requires supervision in a secured environment. On 7/8/19 at 5:20 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 26's medical record to support the discharge to a lower level of care. The DON stated Resident 26's medical record did not have progress notes from the primary physician regarding plans for discharge. On 7/8/19 at 5:25 p.m., during an interview and a concurrent record review, the DON stated Resident 27 discharge to a lower level of care did not take place. The DON stated the corporate vice president's process of asking Resident 27 to leave the facility was inappropriate. The DON stated there was no IDT meeting conducted and no physician progress notes [REDACTED]. On 7/8/19 at 5:28 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 28's medical record to support the discharge to an independent living facility. The DON stated there was no IDT meeting conducted and no physician progress notes [REDACTED]. The DON stated Resident 28 was not a candidate for discharge to a lower level of care. Resident 28 required a supervised and secured environment for safety due to his risk of wandering. The DON stated the former administrator's processes of discharging Resident 28 was inappropriate and not based on the resident needs. On 7/8/19 at 5:30 p.m., during an interview and a concurrent record review, the DON stated there was no documentation in Resident 36's medical record to support the discharge to a lower level of care. The DON stated there was no IDT meeting conducted and there was no physician progress notes [REDACTED]. The DON stated the corporate vice president and the former administrator planned and decided Resident 36's discharge.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to prevent pressure ulcer development (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or/friction) and worsening of existing pressure ulcer and the inaccurate pressure ulcer assessment for two of two sample residents with pressure ulcers (Resident 1 and 138) in a total resident sample of 40. 1. For Resident 138 the facility failed to: a. Relieve the pressure from Resident 138's heels when in bed and wheelchair. b. Implement the Care Plan to turn and reposition the resident in bed every two hours. c. Revise the plan of care to avoid positioning the resident on the pressure ulcer. d. Follow the staff in-service training to prevent skin breakdown and or blister on lower extremities by keeping the resident's feet elevated and floated. e. Avoid the use of plastic backed diaper that will block the airflow and may potentially trap heat and moisture against the resident's skin. f. Notify Resident 138's physician of the resident's low [MEDICATION NAME] level (indicative that the body has begun to breakdown muscle to compensate for an inadequate intake of protein. In individuals with pressure ulcer, protein is important to help the body heal the wounds). 2. For Resident 1 the facility failed to accurately assess Resident 1's pressure ulcers. These failures resulted in: 1. Resident 138's developing avoidable, unstageable pressure ulcers (full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (soft moist dead tissue, which can be yellow, tan, gray, green or brown) and or eschar (thick, leathery dead tissue which can be, tan, brown or black) in the wound bed) to: - Both heels - The left fifth metatarsal area (the long bone on the outside of the foot which connects to the little toe). Worsening of Resident 138's Stage IV pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed and undermining (destruction of tissue extending under the skin edges so that the pressure ulcer is large at its base than at the skin surface) may be present.) to the: - Sacrococcyx area (sacral (a triangular shaped bone at the bottom of the spine) coccyx (tailbone)) - Right ischium (the bottom area of the ischium) 2. Inaccurate assessment of Resident 1's pressure ulcer which may lead to improper treatment orders and delay in healing. Findings: A review of the Resident Admission assessment dated [DATE], indicated that Resident 138's [DIAGNOSES REDACTED]. The Resident Admission Assessment also indicated that Resident 138 was admitted with the following: 1. No pressure ulcer to both heels and left fifth metatarsal area. 2. Sacrococcyx Stage IV pressure ulcer which measured 5.0 centimeter (cm) (2.5 cm = 1 inch) in length (L), by 4.0 cm in width (W), and 0.2 cm in depth. 3. Right ischium Stage IV pressure ulcer which measured 9.0 cm (L), by 7.0 cm (W), and 2.0 cm in depth. A review of the Braden Scale for Predicting Pressure Sore Risk (a nursing tool which uses a scoring system to evaluate a resident's risk of developing a pressure ulcer) indicated Resident 138 scored 13 on [DATE] and [DATE]. A total score of ,[DATE] indicates moderate risk for pressure ulcer. A review of the Minimum Data Set (MDS-a standardized assessment and care planning tool) dated [DATE], indicated Resident 138 was assessed with [REDACTED]. thin, clean tube used to drain from the bladder when you cannot urinate). A review of Resident 138's Alteration Skin Integrity care plans dated [DATE] for the saccrococcyx and right ischium Stage IV pressure ulcers interventions included: 1. Keep resident clean/dry. 2. Assist in turning at least every two hours and as needed. 3. Low air loss mattress (a mattress used for pressure ulcer management that that has tiny holes in the top of the mattress in which air continually blows out which reduces the skin interface pressure with the mattress and wicks away moisture which aids in keeping the resident dry) as indicated. 4. Re-assess nutritional needs of resident. A review of the Change in Condition assessment dated [DATE], indicated Resident 138 was assessed as having blood blisters to his right heel, left heel and left lateral malleolus (outer ankle area). A review of Resident 138's Alteration Skin Integrity care plans dated [DATE] for the right heel fluid blister, left heel deep tissue injury, and lateral malleolus blood blister interventions included: 1. Keep resident clean/dry. 2. Assist in turning at least every two hours and as needed. 3. Low air loss mattress as indicated. 4. Re-assess nutritional needs of resident. A review of Resident 138's Wound Doctor assessment dated [DATE] indicated that Resident 138 had the following unstageable pressure ulcers: 1. Right heel 2.0 cm (L) by 2.0 cm (W) with firm eschar. 2. Left heel 4.0 cm (L) by 3.0 cm (W) with firm eschar. 3. Left fifth metatarsal 3.0 cm (L) by 2.0 cm (W). A review of Resident 138's Alteration Skin Integrity care plans dated [DATE] for the right and left heel unstageable pressure ulcer and left fifth metatarsal unstageable pressure ulcer interventions included: 1. Keep resident clean/dry. 2. Assist in turning at least every two hours and as needed. 3. Low air loss mattress as indicated. 4. Re-assess nutritional needs of resident. During multiple observations, Resident 138 was lying on his back on a low air loss mattress (a mattress used for pressure ulcer management that that has tiny holes in the top of the mattress in which air continually blows out which reduces the skin interface pressure with the mattress and wicks away moisture which aids in keeping the resident dry) both the right and left heels were observed resting directly on either a pillow or mattress on the following dates: 1. [DATE] at 2:45 p.m., both heels were resting directly on the pillow. 2. [DATE] at 8:10 a.m., 9 a.m., 10:17 a.m., both heels were resting directly on the pillow. 3. [DATE] at 8:37 a.m., 9:35 a.m., 3:30 p.m., both heels were resting directly on the pillow 4. [DATE] at 8:10 a.m., 9:15 a.m., 10:15 a.m., 2:20 p.m., both heels were resting directly on the mattress. On [DATE] at 11:10 a.m., 12:30 p.m., 1:35 p.m., and 2:38 p.m. Resident 138's was observed in a wheelchair with both his right and left heels resting directly on a pillow placed on the wheelchair footrest. During Resident 138's treatment observation on [DATE] at 9:35 a.m., Resident 138 was alert and coherent while in bed. He was wearing a plastic backed diaper. His [MEDICAL CONDITION] bag had small amount of stool. His supra pubic catheter was connected to the urine collection bag which contained a moderate amount of yellow colored urine. The Treatment Nurse (TN 1) assessed Resident 138's pressure ulcers as follows: 1. Sacrococcyx Stage IV pressure ulcer- 5.5 cm (L) by 6.0 cm (W) and 3.0 cm depth with undermining of 2.0 cm at 12 o'clock position (as if a clock was placed on the wound, 12 o'clock position would be toward the head), 2.0 cm at 1 o'clock, 1.0 cm at 6 o'clock and 0.5 cm at 8 o'clock. The wound bed (base of the wound) and periwound (the tissue surrounding the wound itself) was red in color. On admission [DATE], the sacrococcyx pressure ulcer was assessed to be 5.0 cm (L) by 4.0 cm (W) and 0.2 cm in depth with no undermining. 2. Right ischium Stage IV pressure ulcer - 8 cm (L) by 4.5 cm (W) 1.5 cm depth with undermining of 0.8 cm at 1 o'clock, 2 cm at 5 o'clock and 0.1 cm at 8 o'clock. The wound bed had moderate amount of yellow green colored slough. The periwound was red in color. On admission [DATE], the right ischium pressure ulcer was assessed to be 9 cm (L) by 7 cm by 2 cm with no undermining. 3. Right heel - unstageable (UTD) pressure ulcer - 0.5 cm (L) by 0.5 cm (W) no depth, no undermining. The wound bed had 100 percent yellow green colored slough tissue. Not present on admission. 4. Left heel - unstageable pressure ulcer - 3.5 cm (L) by 2.8 cm (W) by 0.5 cm depth, no undermining. The wound bed had moderate amount of yellow green colored slough. Not present on admission. 5. Left fifth metatarsal - unstageable pressure ulcer - 1.5 cm (L) by 0.8 cm (W) no depth, no undermining. The wound bed had 100 percent yellow green colored slough. Not present on admission. During an interview on [DATE] at 9:58 a.m., Resident 138 stated the certified nursing assistants (CNAs) on all shifts did not turn and reposition him for pressure relief every two hours while he was in bed. He stated he was paralyzed from the waist down due to a spinal cord injury. Resident 138 stated that he needed assistance from the staff for pressure relief of his rear end and feet. Resident 138 stated that he did not refuse to be turned and repositioned in bed. During an interview on [DATE] at 2:45 p.m., with CNA 10, she stated the facility had turning and repositioning schedule every two hours. CNA 10 stated she did not turn and reposition Resident 138 in bed because he already had a special bed (low air loss mattress) to heal his pressure ulcers and prevent further skin breakdown. CNA 10 stated she was aware Resident 138 had pressure ulcer to his right heel and left heel. CNA 10 stated she did not float (do not come in contact with any surface) the resident's heels because she was busy taking care of another resident. CNA 10 stated the pressure ulcer will get worse due to pressure when the resident's heels are not floated on a pillow and when the resident was lying directly on the pressure ulcer. CNA 10 stated she was not informed by any staff that Resident 138 should not wear a plastic backed diaper when on low air loss mattress. During record review and concurrent interview on [DATE] at 3:20 p.m., TN 1 stated she was responsible in reviewing and revising Resident 138's Care Plan pressure ulcer when the interventions were not effective to heal the wound. TN 1 stated the Care Plan was not revised to avoid positioning the resident directly on the pressure ulcer because she thought turning and repositioning the resident every two hours was enough. TN 1 stated she forgot to revise the Care Plan to float Resident 138's heels on pillow when his pressure ulcer had progressed to unstageable pressure ulcer on [DATE]. TN 1 stated the CNAs were told not to apply a diaper because the resident was on low air loss mattress and his pressure ulcer will not heal due to moisture being retained by the diaper (the air being blown out from the mattress was blocked by the diaper, preventing the air to reach the resident and keeping him dry). During record review and concurrent interview on [DATE] at 3:55 p.m., the Director of Staff Development (DSD) stated the previous DSD had resigned on [DATE]. DSD stated she started as the new DSD of the facility on [DATE]. DSD disclosed the in-service training log from (YEAR) through (YEAR), indicated only one in-service training was given to the staff regarding prevention of pressure ulcer which was on [DATE]. The in-service meeting minutes dated [DATE], indicated all staff were made aware regarding the cause of blisters/ pressure ulcers. Staff were taught to keep the resident's lower extremities elevated and floated and to reposition the resident every two hours in bed. The in-service training dated [DATE], did not have an attachment lesson plan as to what specific learning objectives and course content was discussed to the staff. There was no documented evidence staff were given an in-service training to avoid positioning a resident on pressure ulcer and to not apply plastic backed incontinent pad to the resident on low air loss mattress. DSD stated facility had turning and repositioning schedule every two hours but did not have a written or visual monitoring system to ensure a resident with pressure is not lying directly on pressure ulcer. On [DATE] at 9:54 a.m., the medical record of Resident 138 was reviewed with the Registered Nurse Supervisor (RN 1). The Physician order [REDACTED]. RN 1 contacted the laboratory (8 days later) and the result was faxed to the facility on [DATE] at 9:58 a.m. The laboratory result dated [DATE], indicated Resident 138's pre-[MEDICATION NAME] level was 5 mg/dl (milligrams/deciliter) (normal range ,[DATE] mg/dl) and [MEDICATION NAME] level (a type of protein in the body, needed for growth and repair of body tissues) was 1.8 g/dl (normal range 3XXX,[DATE].7 g/dl). The RN 1 stated it is the responsibility of the licensed staff to follow up with the physician who ordered the labs and to immediately notify the physician of the abnormal result. However, this was not done. During record review and concurrent interview on [DATE] at 10:30 a.m., the Director of Nursing (DON) stated he started working at the facility on [DATE]. The DON stated that he was aware Resident 138 had developed pressure ulcers to his right heel, left heel and left fifth metatarsal. DON stated he was supposed to give an in-service training to make sure staff knows how to take care of a resident with pressure ulcer such as turning and repositioning and to offload (take pressure off) the heels but failed to do so. DON stated Resident 138 developed blister to his heels because he can't move his legs due to paralysis. DON stated Resident 138 should not be lying directly on the pressure ulcer because it will not heal. DON confirmed the facility had no visual or monitoring system if the staff were properly turning and repositioning the resident with pressure ulcer every two hours in bed. A review of the facility's undated policy and procedure for Laboratory-Critical Values indicated The facility will have critical laboratory values immediately reported to the resident's Attending Physician. Critical laboratory values (also referred to as panic values) are those that, if left untreated, could be life threatening or could place the resident at serious risk. The licensed nurse will immediately call the Attending Physician with the results. A review of Medical Surgical Nursing Ninth Edition pages ,[DATE], Prevention remains the best treatment for [REDACTED]. Never position directly on the pressure sore. A review of AHCPR (Agency for Health Care Policy and Research) guidelines for pressure ulcer treatment indicated When using support surfaces that increase airflow across the patient's skin (such as air fluidized beds and low air loss beds), patient should not wear adult incontinence briefs, because these briefs obstructs airflow to the skin. http://trim/ahrqguidelines. b. A review of the of the Admission Face Sheet indicated Resident 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a standardized assessment and care planning tool) dated [DATE], indicated Resident 1 was severely impaired with cognitive skills for daily decision making and was totally dependent with all activities of daily living such as bed mobility, transfer, locomotion, dressing, toileting, personal hygiene, and bathing. Resident 1 was also incontinent of both bowel and bladder. Resident was determined as at risk of developing pressure ulcer (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction). A review of Resident 1's Braden scale (tool to predict pressure ulcer risk), dated [DATE] indicated a score of 10 (score of 12 or less represents high risk). Further review of the form indicated risk factors included very limited perception (responds only to painful stimuli), skin was often moist, bedfast (confined to bed), on tube feeding (tube inserted into the stomach for feeding and administration of medications), and required moderate to maximum assistance in moving. On [DATE] at 9:44 a.m., during interview, Certified Nurse Assistant (CNA 11) stated Resident 1 was total care for all activities of daily living (ADL). CNA 11 also stated Resident 1 does not have a pressure ulcer, but was being repositioned every two hours on the right side, left side, and on his back. CNA 11 stated Resident 1 was incontinent of bowel and bladder. On [DATE] at 11:40 at a.m., during the treatment observation and interview with Licensed Vocational Nurse (LVN 6), she stated that Resident 1 has an excoriation (a scratch or abrasion of the skin) on the right and left buttock which could be due to incontinence. LVN 6 stated Resident 1's right buttock was intact two days ago when she did the treatment. On [DATE] at 11:46 a.m., during concurrent observation and interview with LVN 6 and Registered Nurse (RN 1), RN 1 assessed Resident 1 and stated the assessment of excoriations to the right and buttock was not accurate. RN 1 assessed Resident 1 to have a Stage I (intact skin with non-blanchable (remains a red color even when pressure is applied) redness of a localized area, usually over a bony prominence) pressure ulcer on the left buttock and Stage II (a partial-thickness loss of skin presenting as a shallow open ulcer with a red-pink wound bed) pressure ulcer on the right buttock. RN 1 stated she will notify the physician to obtain treatment orders for the pressure ulcers. RN 1 stated that Resident 1 being totally dependent for bed mobility and incontinence for bowel were factors to the development of the right and left buttock pressure ulcers. A review of a facility form titled, Weekly Pressure Injury/Ulcer Progress Report, dated [DATE] after RN 1 assessed Resident 1, indicated that Resident 1 had the following: 1. Stage II pressure ulcer with a measurement of 0.2 centimeters (cm) in length, a width of 0.2 cm. and a depth of 0.1 cm 2. Left buttock redness with a measurement of 2.0 cm in length and a width of 0.8 cm. A review of Resident 1's care plan titled, Altered Skin Integrity Related to Excoriation on the Left and Right Buttock, dated [DATE], indicated staff interventions included were to monitor skin site daily for any signs and symptoms of infection, assess site daily and call physician if treatment is ineffective, and provide treatment as ordered. A review of the facility's policy and procedure (P&P) titled, Pressure Ulcer Management, revised [DATE], stipulated that upon admission, the facility will perform a skin assessment of each resident that includes checking for the presence of pressure ulcers or proneness to their development. It also indicated that a resident who has a pressure ulcer will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing.

Based on interview and record review, the facility failed to ensure that one of three sample residents (Resident 1) was catheterized (insertion of a flexible tube into the urinary system to obtain a urine sample) in accordance with the facility's policies and professional standards. The facility failed to ensure that: 1. There was a valid physician's orders [REDACTED]. 2. Resident 1's physician was notified of the unsuccessful catheterization attempt due to resistance when inserting the catheter. 3. There was a valid physician's orders [REDACTED]. These deficient practices resulted in injury to Resident 1's urethra (part of the urinary system that drains the urine from the urinary bladder (part of the urinary system that collects the urine from the kidneys) to outside the body) and bleeding from Resident 1's penis. Findings: A review of Resident 1's admission face sheet indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and care planning tool, dated [DATE] indicated Resident 1 had severely impaired cognitive skills for decision making, required total dependence with toilet use, bathing, always incontinent (lost of control) of bowel and bladder. A review of Resident 1's Change in Condition Assessment dated [DATE] indicated Resident 1 had a fever of 101.2 degrees Fahrenheit (F), blood pressure of ,[DATE], and pulse of 98 beats per minute. Resident 1's physician ordered a chest x-ray (photograph to look inside the chest), CBC (complete blood count, a blood test used to evaluate overall health), Chem 7 (group of blood tests that provides information about the body's metabolism) and an UA (urine analysis) with a C&S (culture and sensitivity, a test to determine the type of bacteria that may have caused the infection and indicates what antibiotics would be effective to treat the infection). On [DATE], a review of Resident 1's Physician Telephone Orders dated [DATE] indicated the following orders: 1. Chest X-ray 2. CBC, Chem 7, UA C&S 3. Sputum C&S 4. May straight cath (catheterize) to obtain urine The Physician telephone order was not signed by any physician. During an interview with Licensed Vocational Nurse (LVN) 1 on [DATE] at 3:05 p.m., LVN 1 stated that Resident 1 was noted with fever at the end of the shift. LVN 1 also stated that he called the attending physician and ordered the following: 1. CBC 2. Chem 7 3. Chest X-ray 4. UA C & S 5. Sputum C & S 6. May straight catheterize patient to obtain urine During an interview with Registered Nurse (RN) 1 on [DATE] at 2:20 p.m., RN 1 stated that he performed the first straight catheterization to Resident 1 on [DATE] around ,[DATE] a.m. but was unable to collect urine due to resistance when he inserted the catheter half-way into Resident 1's penis. RN 1 stated that he did not inform Resident 1's physician that he encountered resistance and was not able to obtain the urine sample. RN 1 stated that the order did not indicate to catheterize Resident 1 only once. RN 1 stated on his own discretion, he attempted a second catheterization at 11:30 a.m. RN 1 stated that he again encountered resistance during his second catheterization and no urine was obtained. RN 1 stated when he withdrew the catheter some clotted blood came out from the tip of Resident 1's penis. RN 1 stated 10 minutes after his second catheterization attempt Certified Nurse Assistant (CNA) 1 informed him that Resident 1 was bleeding from his penis. RN 1 stated that when he went to check Resident 1, he found Resident 1's bed sheet was soaked with a large amount of blood around Resident 1's buttocks area. During an interview with CNA 1 on [DATE] at 2:55 p.m., CNA 1 stated she cleaned up Resident 1. However, blood continued to flow out from Resident 1's penis. A review of Resident 1's, Change in Condition Assessment dated [DATE] indicated Resident 1 had no urine output at this time, was bleeding from penile area, assessed to have blood coming out of urethra, notified physician and received order to send Resident 1 to General Acute Care Hospital (GACH). A review of Resident 1's, Physician Telephone Orders, dated [DATE] indicated to transfer Resident 1 to the GACH for evaluation d/t (due to) urethral bleeding s/p (status [REDACTED]. During an interview with the Director of Nursing (DON) on [DATE] at 3:20 p.m., the DON stated that RN 1 should have called Resident 1's physician regarding the outcome of the first catheterization. The DON stated that if the physician order [REDACTED]. During a concurrent telephone interview and record review with Resident 1's physician on [DATE] at 4:00 p.m. in the presence of the DON, Resident 1's telephone order dated [DATE] was reviewed with the physician. Resident 1's physician stated: 1. He gave orders for the following: CBC, Chem 7, Chest X-ray, UA C & S and Sputum C & S. 2. He did not give an order to catheterize Resident 1. 3. He was not informed that there was resistance during the first catheterization attempt. 4. He did not order the second catheterization and was not informed that Resident 1 had been catheterized twice. Resident 1's physician stated that he ordered Resident 1 to be transferred to the GACH when he was informed that Resident 1 was bleeding due to the catheterization. On [DATE] at 4:00 p.m., a second record review of Resident 1's clinical record was conducted with the Assistant Director of Nursing. Resident 1's Physician telephone order dated [DATE] was still not signed by Resident 1's physician. (Title 22, California Code of Regulations, section (c) Verbal orders for drugs and treatments shall be signed by the prescriber within five days.) On [DATE], at 3:00 p.m. an in-person interview was conducted with Resident 1's physician. Resident 1's physician again stated that he did not give an order to catheterize Resident 1. Resident 1's physician provided a signed declaration that he did not order Resident 1 to be catheterized. A review of Resident 1's GACH, Emergency Department Report, dated [DATE] indicated Resident 1 had [MEDICAL CONDITION] (abnormally low blood pressure (BP)), Resident 1 was brought in with persistent urethral bleeding after straight cath (catheterized) today. Resident 1's vital signs were: Temperature 98.2 degrees F, BP of ,[DATE] (prior BP ,[DATE]) and pulse of 115 (prior pulse 98), was actively bleeding from tip of penis. Review of GACH notes titled, Death Summary, dated [DATE] indicated Resident 1 expired in the early morning of [DATE] with final [DIAGNOSES REDACTED]. by feeling tired, weak or short of breath). A review of Resident 1's Certificate of Death dated [DATE] signed by Resident 1's attending physician indicated that Resident 1's immediate cause of death was cardiopulmonary arrest (absence of heart and lung function) and underlying cause was [MEDICAL CONDITIONS] (blockage of the blood vessels of the heart). A review of the facility's policy and procedure titled Catheter Insertion dated [DATE] indicated that one of the purposes of catheterization is to obtain specimen for [DIAGNOSES REDACTED].>A review of the facility's policy and procedure titled Physician Orders dated [DATE] indicated that the purpose is to ensure that all physician orders [REDACTED]. Orders will include a description complete enough to ensure clarity of the physician's plan of care. According to Cooper and Gosnell, authors of Foundations of Nursing 7th edition copyrighted 2015: Report any unusual findings immediately for straight catheterization which includes no urine output and inability to insert catheter (If it is not possible to advance the catheter, report immediately to the physician).

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent accidents for three of three residents (Resident 8, 16, and 25) with falls in a total sample of 30 residents. a. For Resident 8, the facility failed to: (1) Follow the Minimum Data Set assessment (MDS-a standardized assessment and care planning tool) to provide Resident 8 with two person physical support during transfer. (2) Follow the staff in-service training for the proper removal of sling when the resident was transferred to bed using a mechanical lift (an assistive device to transfer the resident between a bed and a chair). (3) Implement safety precautions when transferring a resident using a mechanical lift as indicated in the Operator's Instruction Manual. (4) Revise the plan of care to prevent the resident from falling during a transfer. These failures resulted in a fractured fifth rib after Resident 8 had a fall from the bed. b. For resident 16, the facility failed to revise the plan of care to include alternative measures or other assistive device after it was known that Resident 16 removes her pad alarm and turns it off when she attempts to get up from bed or wheelchair unassissted to use the toilet. As a result, Resident 16 had a repeat fall and sustained a distal right femoral shaft (the long, straight part of the thigh bone) fracture. c. For Resident 25, there was no pad or tab alarm applied to Resident 25 who had a physician order [REDACTED]. As a result, Resident 25 had an unattended fall in Resident 25's room. d. Additionally, there were two TVs that were not secured down. LVN 2 stated all the TVs should be secure to prevent accidents. Findings: a. A review of the admission record (Face Sheet) indicated Resident 8 was a [AGE] year old male who was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the initial and quarterly Fall Risk Evaluation (a nursing tool which uses a scoring system to evaluate resident's risk of fall), dated 6/27/16 and 10/4/16, indicated Resident 8 scored 16. The Fall Risk Evaluation indicated a total score of 16 or above represented a high risk for fall. A review of the initial and quarterly Minimum Data Set assessment dated [DATE], 10/4/16 and 1/3/17, indicated Resident 8 had short term memory recall ability, required total dependence (full staff performance every time during entire seven day period) in bed mobility with one person physical assist and total dependence in transfer with two persons physical assist. A review of the Licensed Personnel Weekly Progress Notes indicated on 1/20/17 at 4:30 a.m., CNA 3 (Certified Nursing Assistant) had reported to the licensed staff that Resident 8 slid off from his bed when she pulled the wet bed sheet. The licensed staff found the resident lying on his back on the floor next to his bed. The resident sustained [REDACTED]. The physician was notified of the fall incident on 1/20/17. The physician's treatment order on 1/20/17, indicated resident's abrasion to his right lower back was to be cleansed with Normal Saline (sterile mixture of salt and water) and to apply triple antibiotic ointment (combination of antibiotic medicines used as a first aid to prevent infections in minor cuts, scrapes, or burns on the skin) once a day for 14 days. The resident did not complain of pain, until 1/21/17 at 7:30 a.m., to his right side of head, right shoulder, right side of ribs, and right hip. The physician was made aware of the resident's complain of pain on 1/21/17, and ordered X-ray (a test that produces images of the bone structures inside the body) of the above pain locations. A review of the X-ray report, dated 1/22/17, indicated Resident 8 had a fractured right fifth rib with minimal displacement. The report also indicated the resident had osteopenia (bone density (amount of bone mineral in bone tissue) that is lower than normal peak but not low enough to be classified as osteoporosis (weak and brittle bone)). A review of the Physician order [REDACTED]. 1. On 1/22/17, apply chest binder and schedule orthopedic consult. 2. On 1/23/17, Tramadol (pain reliever) 50 milligram (mg) by mouth twice a day routinely for pain management. 3. On 1/24/17, apply chest binder only when the resident goes to dialysis center. 4. On 2/18/17, Tramadol 50 mg by mouth whenever necessary for moderate to severe pain. 4. On 2/27/17, no additional appointment and treatment for [REDACTED]. During an interview on 3/8/17 at 9:26 a.m., Resident 8 was observed lying in bed. He was alert and Spanish speaking. Evaluator 2 acted as an interpreter for Resident 8. Resident 8 stated he had a fractured rib to his right side after he fell from the bed approximately two months ago. Resident 8 stated that a female CNA (CNA3) took him to the shower room by herself using a mechanical lift. CNA 3 told him that he is too heavy and could not transfer him by herself. CNA 3 did not ask for another staff to assist Resident 8 during transfer using the mechanical lift. After the shower, CNA 3 transferred him to the edge of his bed. CNA 3 turned his body towards the right side (facing the CNA), pulled out the wet sheet and sling underneath his body too hard, and he fell hitting the right side of his head and the right side of his shoulder on the floor. Resident 8 further stated sometimes he was unable to sleep due to pain from his fractured right rib which was radiating (spreading to) to his left leg. During an interview on 3/8/17 at 3:40 p.m., CNA3 stated she was not the regular caregiver of Resident 8. She had no permanent assignment and floats around mostly for Nurse Station 2. CNA 3 stated she put back Resident 8 to his bed after shower using a mechanical lift. CNA 3 transferred the resident by herself without asking for assistance from another staff. CNA 3 turned the resident's body to his right side at the edge of bed while she was trying to pull out the wet sheet and the sling underneath when the resident slid off the bed. The resident fell to the floor on the right side of his body. CNA 3 stated she was aware Resident 8 needed two persons physical assist in transfer because the resident was heavy. CNA 3 stated, I thought I could transfer him and remove the wet sheet and sling by myself. CNA 3 stated removal of the wet sheet and sling should be done by two staff for Resident 8 to prevent him from rolling down the bed. CNA 3 stated she used the EZ Way Smart Lift (mechanical lift) to transfer Resident 8. CNA 3 stated the fall incident happened in the afternoon of January 2017. During an interview on 3/9/17 at 3:20 p.m., the Staff Developer stated Resident 8 was assessed as totally dependent in bed mobility and transfer. The resident was heavy and required two persons physical assist in transfer. She stated CNA3 attended the in-service about the use of the EZ Way Smart Lift on 12/16/16. She in-serviced all the CNAs regarding proper removal of the sling for a resident who required two persons physical assist during a transfer in bed. She stated the resident was to be rolled to one side and the CNA will tuck in the sling underneath the resident. The CNA on the back of the resident will tuck half of the sling underneath the resident while the other CNA in front will hold the resident's body for support then the resident will be log rolled to the opposite direction to pull the rest of the sling out. The Staff Developer stated CNA 3 did not follow the in-service training for the proper removal of the sling for Resident 8 who required two persons physical assist in transfer to prevent fall from bed. A review of the Competency Checklist for the use of EZ Way Smart lift dated 12/16/16, indicated CNA 3's signature that she had the proper training for the sling removal during transfer of a resident in bed. A review of the EZ Way Smart brochure safety notes indicated The EZ Way Smart Lift was designed to be operated safely by one caregiver. However, depending on the situation, facility policy, and the patient's condition, two caregivers may be necessary. On 3/10/17 at 3:30 p.m., the medical record of Resident 8 was reviewed with the DON (Director of Nursing) and MDS 3 (Minimum Data Set Nurse). The Plan of Care dated 6/27/16, indicated Resident 8 had self-care deficit and required assistance in transfer related to general weakness, dementia and dialysis. The Plan of Care interventions indicated to transfer Resident 8 with one to two persons physical assist. The MDS assessment dated [DATE], 10/4/16 and 1/3/17, indicated Resident 8 needed two persons physical assist due to total dependence in transfer. The Plan of Care was not revised to reflect two persons physical assistance was needed for Resident 8 during transfer. MDS 3 stated the Plan of Care was not revised because it was overlooked. b. A review of the facility's fall incident log (list of residents who had incident/s of fall) for 2/2016 to 2/2017 indicated a total of 72 falls in the facility for a year. For Resident 16, the fall incident log indicated Resident 16 had an unattended fall in the bathroom (in Resident 16's room), on 2/24/16 during the 7:00 a.m. to 3:00 p.m. shift, which required transfer to the general acute care hospital (GACH, a health facility with an organized medical staff that provides 24-hour inpatient care, including the following basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services). A review of Resident 16's face sheet (a document that gives a resident's information at a quick glance), indicated Resident 16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 12/24/15, indicated Resident 16 required one person extensive assistance from staff (one staff providing weight-bearing support) with toilet use (how resident uses the toilet room, commode, bedpan and transfer on/off toilet). The MDS indicated Resident 16 had incidents of falls on 10/13/15, 10/18/15, and 2/24/16. A review of Resident 16's medical record indicated Resident 16 had a fall on 10/13/15, and on 10/18/15, at 11:30 a.m., physician ordered to apply a pad alarm when Resident 16 was on her bed or wheelchair. A review of Resident 16's care plan for fall, dated 9/17/15, indicated the care plan was revised after the first fall on 10/13/15 and included the intervention to call for assistance due to Resident 16's desires to be independent with her activities of daily living beyond her abilities, and a pad alarm while in bed or on wheelchair. After the physician order [REDACTED]. to go back to bed and sat down on the floor. On 12/24/15, the care plan for fall was revised due to episodes of the Resident 16 removing and turning off the pad alarm from the bed and wheelchair. The intervention included to educate Resident 16 regarding the risk of removing and turning the pad alarm off. Upon further review, an IDT conference report was done on 12/24/15 for the episodes of removing the pad alarm. The IDT report indicated Resident 16 stated that during the day she is able to feel when she needs to use the bathroom. The report indicated IDT decided not to proceed with bowel and bladder retraining program due to cognitive and functional impairment. The recomendation was to educate Resident 16 regarding the risk and benefits of using the pad alarm, and to ask for staff assistance due to needing extensive assistance by nursing staff for toileting and transfer and being at high risk for falls with history of falls in the past while trying to transfer without assistance. There was no other intervention or alternative device listed, to alert the staff when Resident 16 gets up from wheelchair or bed to use the toilet, to prevent her from falling. A review of the licensed personnel weekly progress notes, dated 2/24/16, at 2:00 p.m., indicated Resident 16 had another fall while attempting to use the toilet unassisted. The weekly progress notes indicated the certified nursing assistant (CNA 2) informed the charge nurse she found Resident 16 on the floor of the resident's bathroom when she returned after she went out of the room to obtain towels for Resident 16's roommate. A review of an incident and accident record for the fall on 2/24/16, indicated the charge nurse was informed by CNA 2 that Resident 16 was found on the floor when she returned to the room after leaving the room to obtain towels. The incident and accident record further indicated the charge nurse verified the pad alarm was in place on Resident 16's bed. A review of the IDT report, dated 2/25/16, indicated Resident 16 has history of falls due to wanting to be independent with her activities of daily living (ADL, resident's daily activities such as eating, bathing, dressing, toileting, and transferring or walking), and not calling for assistance despite the education and reminder to call for assistance. The report further indicated the pad alarm was at the bedside and not on the wheelchair. A physician order, dated 2/24/16, indicated a stat (need to be completed within two hours from order time) order for an X-ray of the right femur (bone in the thigh), knee, and tibia/fibula (bones of the lower leg) due to pain. The X-ray result, dated 2/24/16, indicated a recent right femur fracture. On 2/24/16, at 4:20 p.m., Resident 16 was ordered Toradol (anti-inflammatory medication that combats inflammation and pain) 30 milligrams (mg) for severe pain to the leg. Resident 16 was transferred to the GACH the same day. A review of the GACH history and physical, dated 2/24/16 indicated Resident 16 sustained a distal right femoral shaft (the long, straight part of the thigh bone) fracture from a mechanical fall (means resident slipped, tripped or lost balance). Resident 16 had a surgical intervention with an open treatment of [REDACTED]. During an interview with Resident 16, on 3/9/17, at 1:46 p.m., she was sitting calmly on her wheelchair next to her bed. Resident 16 was alert with disorientation to time. When asked if she recalls the fall in the bathroom, she stated yes. Resident 16 stated it happen a long time ago because she was calling for assistance to use the bathroom but no one assisted her. Resident 16 further stated she fell when she stood up and thinks the floor was wet. After the fall Resident 16 stated she had lots of pain and has not been able to walk since. During an interview with CNA 2, on 3/13/17, at 8:04 a.m., when asked about the fall for Resident 16 on 2/24/16, she stated she left Resident 16's room to obtain some towels and when she returned she found Resident 16 sitting on the bathroom floor. CNA 2 further stated she did not hear any alarm and verified Resident 16 had history of turning off the alarm. During an interview with the director of nursing (DON) and assistant DON, on 3/13/17, at 12:16 p.m., they reviewed Resident 16's medical record and verified the three falls including the fall on 2/24/16 which resulted to a fracture. When asked if the fall could have been prevented, the DON stated yes because the facility was aware Resident 16 has dementia and had the behavior of removing the pad alarm. The DON further stated the facility could have prevented the fall by revising the plan of care with other alternative interventions. c. During an observation, on 3/13/17, at 9:15 a.m., Resident 25 was on her wheelchair outside the shower room. There was no pad or tab alarm applied to Resident 25. A review of the facility's fall incident log for 2/2017, indicated Resident 25 had an unattended fall in Resident 25's room on 2/4/16, during the 7:00 a.m. to 3:00 p.m. shift. A review of Resident 25's face sheet, indicated Resident 25 was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. A review of Resident 25's Minimum Data Set (MDS/a standardize assessment tool) dated 1/19/17, indicated Resident 25 required limited assist with ambulation on hallway. During an interview with the director of nursing, on 3/13/17, at 9:37 a.m., she reviewed Resident 25's medical record and verified the physician order [REDACTED]. d. During an observation and interview, on 3/7/17 at 1:30 p.m., with licensed vocation nurse (LVN 2) there were two TVs that were not secured down. LVN 2 stated all the TVs should be secure to prevent accidents. In a record review of the facility's policy and procedure titled, Television Sets, dated 01/2012 indicated if the Administrator or designee approves the TV set, maintenance staff will assist the resident in installing the TV set in the resident's room. Admissions staff will note the presence and date of installation of the TV set in the resident's personal inventory record.