Every finding on record at Pine Ridge Care Center

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by another resident, when Resident 6 yelled and cursed at one of four residents sampled for abuse (Resident 7) after they became roommates on 12/10/25.This failure caused Resident 7 to be upset and angry and had the potential to negatively impact her psychosocial well-being.Findings:A review of Resident 7's admission record indicated she was last admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), unspecified dementia (progressive state of decline in mental abilities) and generalized anxiety (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 7's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/28/2026, indicated Resident 7 had severe cognitive impairment (a decline in mental abilities such as memory, reasoning, language, and judgment).A review of Resident 6's admission record indicated she was last admitted to the facility on [DATE] and had a diagnosis of anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest).A review of Resident 6's MDS, dated [DATE], indicated Resident 6 had severe cognitive impairment.A review of Resident 6's medical record revealed: A social service progress note (documentation of a resident's clinical status, response to treatment, and care updates), dated 12/10/2025 at 12:41 p.m., indicated, Resident [6] moved. to room [ROOM NUMBER]B for compatibility as she will have a Spanish speaking roommate.A nursing progress note, dated 12/11/25 at 1:49 p.m., indicated, . Resident is not adjusting to room change well. Roommate [Resident 7] was in dining room for most of AM [day shift from approximately 7 a.m. to 3 p.m.] shift to separate residents.A nursing progress note, dated 12/11/25 at 10:51 p.m., indicated, . Resident is not adjusting to room change well. Resident is yelling at staff and roommate.A nursing progress note, dated 12/12/25 at 1:42 a.m., indicated, .resident noted shouting, 'WHO LET THIS WOMAN IN MY HOUSE'.Not adjusting to roommate well.A nursing progress note, dated 12/12/25 at 2:30 p.m., indicated, Monitoring for s/sx [signs and symptoms] of emotional distress d/t [due to] room adjustment. currently agitated.resident noted [sic] continuously shouted at roommate and staff. resident is not adjusting to room change or roommate well.A Change of Condition (a significant, often sudden, deviation from a patient's or resident's established baseline in physical, mental, or functional health) note, subtitled Narrative Notes, dated 1/9/26 at 11:21 p.m., indicated, Monitoring for increase of yelling and verbal aggression.resident continue [sic] to yell towards staff and roommate.During an observation on 2/10/26 at 11:22 a.m., Resident 7 was out of her room and Resident 6 was in her bed. A certified nursing assistant (CNA D) went into the room and Resident 6 yelled (in English), This is my house. Resident 6's yelling was very loud and she continued to yell, Call the police.During an interview a on 2/10/26 at 11:30 a.m., CNA D stated Resident 6 did not want a roommate and she thought her room at the facility was her house. CNA D stated Resident 6 and Resident 7 fought all the time. CNA D stated the staff closed their room's door to the hall because they upset and disturbed other residents.During an observation on 2/10/26 at 11:36 a.m., Resident 6 was still yelling in her room.During a concurrent observation and interview on 2/10/26 at 11:45 p.m., Confidential Family Member X (CFM X) and Confidential Family Member Y (CFM Y) were sitting with Resident 7 in the hall near nurse station #2 while she ate lunch. Resident 7 was not conversive and continued to eat her lunch.During an interview on 2/10/26 at 12:40 p.m., CFM X and CFM Y stated Resident 7 had been roommates with Resident 6 but Resident 6 did not want anyone in the room with her and said offensive words directed at Resident 7. CFM X and CFM Y stated Resident 7 was angry and upset when her roommate swore at her.During an interview on 2/10/26 at 2:10 p.m., Licensed Nurse C (LN C) stated Resident 6 and Resident 7 had been roommates but she did not like to put Resident 7 in her room because the roommates would [NAME]. LN C stated Resident 6 was angry and swore at Resident 7 in Spanish and used very ugly and hateful words. She stated she directed these words at Resident 7 calling her, Son of a b- - - -. LN C stated Resident 6 had said, Get this b- - - - out of my house. During an interview on 2/10/26 at 4:15 p.m., CNA F stated Resident 6 was, really confused and agitated. He stated when Resident 7 returned to her room, Resident 6 would get agitated.During an interview on 2/11/26 at 10:45 a.m., CNA E stated Resident 6 thinks her room is her house and she does not want anyone in her house. He stated staff move Resident 7 out of the room during the day because the roommates fight.During an interview on 2/11/26 at 12 p.m., LN G stated Resident 6 sometimes used curse words when she got triggered, and her screaming was loud. LN G stated examples of verbal abuse could include someone cursing you, calling you names and yelling at you; she stated if that caused emotional distress, it would be verbal abuse.During a follow-up interview on 2/11/26 at 3:15 p.m., LN C was asked if the interactions between Resident 6 and Resident 7 were abusive. LN C stated they might be abusive if emotional distress was an outcome.During a concurrent interview and record review on 2/11/26 at 4 p.m., the Director of Nursing (DON) reviewed Resident 6's electronic medical record and multiple nursing progress notes. The DON confirmed Resident 6 and Resident 7 had become roommates on 12/10/2025. The DON reviewed the monitoring that occurred during the initial 72-hours period following the room change on 12/10/25, when Residents 6 and 7 became roommates. The DON stated the terms b- - - - and stupid, or other ugly words, would be considered abusive if they upset the recipient.During an interview, on 2/11/26 at 5 p.m., the Administrator stated staff had reported that Resident 6 was yelling but did not report the exact words utilized. The administrator stated he would want to know if residents were name-calling each other and saying, Get the b - - - - out of [the] room or Get stupid out of the room. He stated he would have investigated the issue because if the terms were directed toward Resident 7, it was potential verbal abuse.During a review of the facility's policy titled, Abuse, Neglect and Exploitation Prohibition, subtitled, Definitions, (undated), indicated, . Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents. within their hearing distance regardless of their age, ability to comprehend, or disability. Under subtitle, Prevention the policy indicated, . 2. Company supervisors will immediately correct and intervene in reported or identified situations in which abuse. is at risk for occurring.

Based on interview and record review, the facility failed to ensure one of seven sampled resident's (Resident 6) Minimum Data Set (MDS, a federally mandated resident assessment tool) accurately reflected the resident's condition when Resident 6 was assessed as having no verbal behaviors impacting other people.This failure placed Resident 6 at risk for inadequate care planning.Findings:A review of Resident 6's admission record indicated she was last admitted to the facility on [DATE] and had diagnoses of 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) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest).A review of Resident 6's MDS, dated [DATE], indicated Resident 6 had severe cognitive impairment (a decline in mental abilities such as memory, reasoning, language, and judgment). Section E of the MDS indicated Resident 6 had no verbal behavior symptoms (like screaming and cursing at others) directed toward other people.A review of Resident 6's Change of Condition (a significant, often sudden, deviation from a patient's or resident's established baseline in physical, mental, or functional health) note, subtitled Narrative Notes, dated 1/9/26 at 11:21 p.m., indicated, Monitoring for increase of yelling and verbal aggression toward staff, resident continue [sic] to yell towards staff and roommate.Review of Resident 6's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 1/1/26 through 1/31/26 indicated, Antianxiety Lorazepam (medication used to decrease anxiety): Manifested by constant yelling causing exhaustion to self. Monitor behavior. q [every] shift.During an interview on 2/10/26 at 2:10 p.m., Licensed Nurse C (LN C) stated she spoke Spanish; she stated Resident 6 cursed at Resident 7 in Spanish and used very ugly, hateful words directed at Resident 7.During a concurrent interview and record review on 2/12/26 at 1 p.m., LN H stated he was the MDS nurse and he used various sources of data for his resident assessments including observations and review of the electronic MAR and nursing progress notes (documentation of a resident's clinical status, response to treatment, and care updates). LN H reviewed Section E of Resident 6's MDS, dated [DATE], and confirmed it indicated she had no verbal behaviors symptoms (including screaming) directed toward other people. LN H reviewed Resident 6's January 2026 MAR and confirmed she was being monitored for yelling that caused her to become exhausted; he confirmed the MAR indicated she had multiple episodes of yelling incidents. LN H stated yelling to exhaustion could meet the criteria of behaviors affecting others. LN H stated he did not know why he didn't catch that and added, he probably just missed it.Review of facility policy titled, Resident Assessment Instrument (RAI) Process (undated) indicated, The facility shall complete the RAI. using standardized tools (MDS 3.0.) . All assessments shall be: Completed accurately. Used to guide individualized, resident-centered care planning and quality outcomes.

Based on observation, interview, and record review, the facility failed to treat one resident (Resident 1) with respect and dignity when Resident 1's personal motorized wheelchair was taken from her after she had difficulty returning to the facility after an outing to see a movie.This failure caused the resident to lose her independence and subjected her to the discomfort of a facility wheelchair that was not appropriate for her medical conditions.Findings:A review of Resident 1's admission record indicated admission to the facility on [DATE] with relevant diagnoses of Multiple Sclerosis (MS - a disease that causes breakdown of the protective covering of nerves. MS can cause numbness, weakness, trouble walking, vision changes and other symptoms), Contractures of right and left knee (chronic loss of joint mobility caused by structural changes in non-bony tissue, including muscles and tendons), and Kyphosis (an excessive forward rounding of the upper back).A review of Resident 1's Brief Interview for Mental Status (BIMS- an assessment tool which facilities use to screen and identify memory, orientation, and judgement status of the resident) score of 15 indicated Resident 1 had no cognitive impairment (thinking, learning, and memory skills were fully functioning).During an interview on 1/7/26 at 4:16 p.m., Resident 1 stated she was very mobile until two weeks ago. Resident 1 stated the past two weeks had been a particularly rocky time in her life. Resident 1 explained she had gone to a movie using her motorized wheelchair by way of a specialized public transportation service, but the transportation company never arrived to take her back to the facility. Resident 1 stated she called the facility and was instructed to call 911. She was transported to the hospital with the emergency services and then back to the facility the next morning. Resident 1 stated upon her return to the facility the Administrator (ADM) informed her she was grounded.During a concurrent observation and interview on 1/8/26 at 2:48 p.m., Resident 1 was observed sitting in her bed tilted slightly to the side with cushions used to prop her up. Resident 1 stated she had her own motorized wheelchair which came with her to the facility, but she did not know where her wheelchair was. Resident 1 also stated she had asked about the location of her personal wheelchair, and no one would tell her where it was. Resident 1 stated she wanted her personal wheelchair as the facility wheelchair she was given as a replacement was very uncomfortable.During an interview on 1/8/26 at 4:15 p.m., the ADM stated Resident 1's personal motorized wheelchair was in the facility. The ADM acknowledged he told Resident 1 she could not have her motorized wheelchair, and Resident 1 was provided with a manual wheelchair to use instead. The ADM stated Resident 1 left the facility in the evening using her own transport service and was unable to get back to the facility. The ADM was unable to arrange transport back to the facility due to the late hour so Resident 1 was transported to a local hospital via emergency services. Resident 1 returned to the facility the following morning. The ADM stated the Interdisciplinary Team (IDT - a coordinated group of healthcare professionals from different clinical and support disciplines who work together to plan, deliver, and evaluate patient care) met and the Medical Doctor (MD) agreed to revoke Resident 1's ability to leave the facility on a pass. The ADM stated Resident 1 left the facility a second time using her motorized wheelchair and specialized public transportation service and was unable to get back to the facility. Resident 1 called 911, was transported to a local hospital, and returned to the facility the following morning. The ADM stated the only option he had to keep Resident 1 safe had been to deny her access to her motorized wheelchair.During an interview on 1/9/25 at 9:14 a.m., Resident 1 stated the manual wheelchair she had been given by the facility was very uncomfortable because of her MS and scoliosis (a condition where the spine curves abnormally to the side). Resident 1 stated she had been in the manual wheelchair and her arm got stuck behind the wheelchair and it took a long time for staff to help her. Resident 1 also stated she had edema (a collection of fluid) in her legs, and she had been unable to elevate her legs in the manual wheelchair to alleviate the edema.A review of the facility's policy and procedure titled, Resident Rights, undated, indicated The Company protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination. prior to or upon admission, a representative of the admitting office will provide the resident with a written copy of resident rights.A review of a document which was included in Resident 1's admission packet to the facility included an outline of resident's specific rights and indicated, the resident has the right to use and retain personal possessions.unless to do so would infringe upon the rights or health and safety of other residents.

Based on interview and record review, the facility failed to ensure the Consulting Pharmacist conducted a monthly Medication Regimen Review (MRR- the process by which a Consultant Pharmacist reviews medication used for a patient and identifies medications that may no longer be necessary or may be more appropriate in a lower dose) for a census of 81 residents. This failure decreased the facility's potential to ensure residents were not administered unnecessary medications that can cause serious side effects or adverse consequences.Findings:During a review of the MRR facility binder on 12/4/25 at 9:21 a.m., the Consulting Pharmacist's October 2025 MRR report was not observed in the MRR.During an interview with the Director of Nursing (DON) on 12/5/25 at 11:30, a copy of the October 2025 MRR report was requested and was not received prior to the survey team exiting the facility. The DON stated she did not have a copy of the Consultant Pharmacist's October 2025 MRR because the Consultant Pharmacist was out on paternity leave during that month.On 12/10/25 the DON emailed the surveyor a copy of the October 2025 MRR report. According to the report, the Consultant Pharmacist reviewed a total of 67 resident medication lists and had zero recommendations.A review of the facility's policy and procedure titled, Medication Monitoring Medication Regimen Review and Reporting, dated 2007, indicated, The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist utilizing a variety of sources including medication administration records (MAR), prescriber's orders, progress notes, nurse's notes, and Resident Assessment Instrument (RAI), Minimum Data Set (MDS), laboratory and diagnostic test results, behavior monitoring information and information from the nursing care center staff and other health professionals involved in the resident's care.A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format to nurses, physicians, and the care planning team within 48 hours of MRR completion.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food service safety for a census of 83 when:1. One cook did not cover his beard while working around food in the kitchen;2. Prepared sandwiches were unlabeled and undated in Refrigerator 1 and an open bag of chicken breasts was unlabeled and undated in Freezer 1;3. Two seasoning containers were past their use-by dates;4. Sealed cardboard boxes labeled Mashed Potatoes, received 11/26/25, were found directly on the floor in dry storage area on 12/2/25; and5. A manual can opener had missing metal on the tip of the blade. These failures had the potential to contribute to the spread of foodborne illnesses among a vulnerable resident population.Findings:1. During the initial kitchen tour on 12/2/25 at 9:49 a.m., [NAME] 1 (CK 1) was observed in the kitchen prep area without a beard restraint or face mask. CK 1 had a full-face beard extending from ear to ear, covering half of the cheeks, jawline, and chin, with dense facial hair approximately 0.25 inches in length. During an interview on 12/2/25 at 10:10 a.m., the Dietary Manager (DM) stated the facility did not have any beard restraints available for staff use.During a review of the facility's policy and procedure (P&P) titled, Food Handling Practices, undated, indicated staff must use proper food handling techniques and practice personal hygiene, including restraining hair.During a review of the U.S. Food and Drug Administration's (FDA) Food Code, 2022 version, section 2-402.11 indicated, food workers must wear hair restraints, including beard restraints, to keep hair away from food and equipment.2. During the initial kitchen tour on 12/2/25 at 9:47 a.m., approximately 21 cheese sandwiches in Refrigerator # 1 were observed to be undated and unlabeled. During an interview on 12/2/25 at 9:49 a.m. with the Dietary Aide (DA) and CK 1, the DA stated she did not know when they were made and CK 1 stated they were made yesterday. During the initial kitchen tour on 12/2/25 at 9:53 a.m., an open plastic bag of chicken breasts was found in Freezer #1 without a label or date.During an interview on 12/3/25 at 9:58 a.m., with the Registered Dietitian (RD) and DM, the RD and DM both said foods must be labeled and dated, and that having unlabeled foods-especially raw chicken-was not acceptable because it increases the risk of residents getting sick.Review of the FDA Food Code (2022) section 3-501.17 indicated, opened or prepared food must be labeled with the date it was opened or prepared and discarded by the proper date.3. During the initial kitchen tour on 12/2/25 at 9:57 a.m., a container of sage and another unlabeled container of dried green herbs were found with use-by dates of 11/27/25.During an interview on 12/3/25 at 10:08 a.m., with the DM and RD, the DM and RD confirmed there had been expired herbs available for use in the kitchen. The DM stated it was important to use items by their use by dates and added, If items are not fresh it can pose potential sickness, nausea, upset stomach can occur for the residents.Review of the FDA Food Code (2022) section 3-501.17 indicated, food establishments must not use items beyond the manufacturer's intended use-by date to maintain quality and prevent safety risks.4. During the initial kitchen tour on 12/2/25 at 9:59 a.m., boxes labeled Mashed Potatoes, received 11/26/25, were found directly on the floor in the dry storage area. During an interview on 12/3/25 at 10:08 a.m., the DM stated food may be contaminated if kept on the floor because the floor is not sanitary. During a review of the facility's P&P titled, Receiving Foods, undated, indicated, food items should be placed in appropriate storage areas as quickly as possible.5. During an observation of the kitchen on 12/4/25 at 10:20 a.m., the can opener was observed with metal having worn off the tip of the blade and food build-up above the tip.During an interview on 12/4/25 at 10:23 a.m., the DM agreed the blade looked worn and could pose a possible infection control problem.Review of the FDA Food Code (2022) section 4-501.11 indicated, can-opener blades must be sharp to prevent metal fragments from breaking off into food.Review of the FDA Food Code (2022) section 4-202.15 indicated, can openers that become pitted or unable to be cleaned must be replaced because they can no longer be properly sanitized.

Based on interview and record review, the facility staff failed to inform and offer written information regarding Advance Directives (AD-a legal document which specifies healthcare wishes and appoints someone to make decisions in cases of an inability to communicate with the healthcare team) to 9 residents (Residents 45, 2, 67, 76, 6, 73, 16, 53, and 84) out of a census of 83 residents when there was no documented evidence of written or verbal information was communicated to each resident regarding the formulation and execution of an AD upon admission or thereafter as legally mandated.This failure decreased the facility's potential to provide care consistent with residents' wishes should they become incapacitated.Findings:A review of Resident 45's Physician Orders for Life-Sustaining Treatment (POLST- a form which indicates residents' preferences for life sustaining treatment in the event of a medical emergency), dated [DATE], indicated Resident 45 had no AD on file.A review of Resident 45's Electronic Medical Record (EMR) indicated no documented evidence that facility staff informed or offered Resident 45 or his Responsible Party (RP- an individual or entity legally accountable for specific financial, legal, and health care obligations) information regarding an AD.A review of Resident 2's POLST, dated [DATE], indicated he had no AD on file.A review of Resident 2's EMR indicated no documented evidence that facility staff informed or offered Resident 2 or his RP information regarding an AD.A review of Resident 67's POLST, dated [DATE], indicated Resident 67 elected for staff not to conduct cardiopulmonary resuscitation (CPR) which made Resident 67's CPR status as Do Not Resuscitate (DNR)- medical orders directing healthcare providers not to provide any life sustaining treatment). A review of Section D (information regarding AD status) of this POLST was left blank.A review of Resident 67's Electronic Medical Record (EMR) indicated no documented evidence that facility staff informed or offered Resident 67 or his RP information regarding an AD.A review of Resident 76's POLST, dated [DATE], indicated Resident 76's CPR status was DNR. A review of Section D of this POLST was left blank.A review of Resident 76's EMR indicated no documented evidence that facility staff informed or offered Resident 76 or his RP information regarding an AD.A review of Resident 6's POLST, dated [DATE], indicated he had no AD on file.A review of Resident 6's EMR indicated no documented evidence that facility staff informed or offered Resident 6 or his RP information regarding an AD.A review of Resident 73's POLST, dated [DATE], indicated he had no AD on file.A review of Resident 73's EMR indicated no documented evidence that facility staff informed or offered Resident 73 or his RP information regarding an AD.A review of Resident 16's POLST, dated [DATE], indicated Resident 16 elected to receive CPR and full treatment interventions if she was found without a pulse and not breathing. A review of Section D of this POLST was blank.A review of Resident 16's EMR indicated no documented evidence that facility staff informed or offered Resident 16 or his RP information regarding an AD.A review of Resident 53's POLST, dated [DATE], indicated Resident 53's CPR status was DNR. A review of Section D of this POLST was blank.A review of Resident 53's EMR indicated no documented evidence that facility staff informed or offered Resident 53 or his RP information regarding an AD.A review of Resident 84's EMR on [DATE] at 3:29 p.m., indicated he had no AD or POLST on file and no documented evidence that facility staff informed or offered Resident 84 or his RP information regarding an AD.During an interview on [DATE] at 9:08 a.m., the Director of Nursing (DON) stated AD and POLST were not the same. The DON stated a POLST was an order from the physician for life sustaining treatment, and an AD was a document which described measures for treatment the residents preferred when they are unable to make decisions for themselves. The DON further stated the Social Services Director (SSD) should have a conversation with the residents regarding ADs upon admission and the conversation should be documented in the residents' EMR.During an interview on [DATE] at 9:15 a.m., the SSD stated she offered ADs to the residents and families when they arrived. The SSD stated she often gave them a blank AD form to fill out if they want to move forward with establishing an AD. The SSD stated, I do not document these conversations. because many times it's an emotional issue to talk about death or incapacitation [for the resident and family].A review of a blank POLST form indicated, POLST does not replace the Advance Directive. When available review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conflicts.It is recommended that POLST be reviewed periodically. Review is recommended when.The patient is transferred from one care setting.to another, or.There is a substantial change in the patient's health status, or.The patient's treatment preferences change.A review of the facility's policy titled Advance Directives, undated , indicated, The resident has the right to accept or refuse medical or surgical treatment and to formulate an Advance Directive in accordance with state and federal law.Upon admission, the Company will provide a resident or the resident's representative with written information regarding the Company's policy on Advance Directives and a copy of this policy.If a resident has not executed an Advance Directive and the resident has capacity to make health care decisions, the social services department should contact the resident to determine whether the resident wishes to make an Advance Directive .If a resident.does not have capacity to do so at the time of admission, then the Company must follow state law to determine who has authority to make health care decisions on behalf of the resident.The Company must document in a prominent part of the resident's clinical record whether the resident has issued an Advance Directive.

Based on interviews and record reviews, the Interdisciplinary Team (IDT, a group of professionals from different fields who work closely and collaboratively to coordinate care to achieve resident goals) failed to meet as a complete team to provide quarterly care conferences for four residents (Resident 5, Resident 76, Resident 67, and Resident 3) of 21 sampled residents.This failure resulted in a lack of oversight to determine whether resident goals were achieved and what revisions needed to be made to assist the residents to achieve their goals.Findings:A review of Resident 5's face sheet indicated admission to the facility on 6/20/25 with a diagnosis of Cerebral Infarction due to unspecified occlusion or stenosis of left middle cerebral artery (also known as an ischemic stroke, happens when a blood clot blocks an artery supplying the brain, cutting off oxygen and nutrients, causing brain cells to die), Unspecified dementia (a person has dementia symptoms (memory loss, confusion, personality changes), but the specific cause or type isn't clear, Hemiplegia unspecified affecting right dominant side (paralysis affecting one side of the body), and Aphasia (a language disorder from brain damage (often stroke) that affects speaking, understanding, reading, and writing, but not intelligence. A review of Resident 5's Minimum Data Set (MDS, an assessment tool) dated 9/24/25 indicated Resident 5 had a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 2 which indicated severe cognitive impairment.A review of Resident 5's physician progress notes dated 10/14/25 indicated, [Resident 5] does not have capacity to make health care decisions. A review of Resident 5's care plans on 12/2/25 indicated care plans initiated between 6/20/25 and 9/30/25 had not been revised.A review of Resident 76's face sheet indicated admission to the facility on 8/30/22 with a diagnoses of Adult Failure to Thrive (a state of significant physical and functional decline in older adults), Community Acquired Pneumonia (a lung infection contracted outside of the facility) and Severe Protein Calorie Malnutrition (a condition resulting from insufficient absorption of protein and energy leading to physical decline and increased risk of infection). A review of Resident 76's IDT Care Conference notes indicated Resident 76 had care conferences (meetings where the interdisciplinary team meets to discuss, develop or revise the comprehensive plan of care with the resident and/or resident representative) on 6/13/23 and 9/14/23. There was no documented evidence that care conferences were held for 4th quarter of 2022, 1st quarter of 2023, 4th quarter of 2023, all quarters of 2024 and all quarters of 2025 to date. A review of Resident 67's face sheet indicated admission to the facility on 2/4/25 with diagnoses of hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following a cerebral infarction (stroke) affecting right dominant side, repeated falls and post-traumatic stress disorder (a mental health disorder that can develop after experiencing or witnessing a life threatening or shocking traumatic event). A review of Resident 67's IDT Care Conference notes indicated Resident 67 had care conferences on 2/17/25 and 5/8/25. There was no documented evidence of care conferences being held for the 3rd and 4th quarter to date. A review of Resident 3's face sheet indicated admission to the facility on 7/14/25 with a diagnosis of vascular dementia (a decline in thinking skills caused by conditions that damage blood vessels and reduce blood flow to the brain, leading to problems with memory, planning, judgment and mood). A review of Resident 3's IDT Care Conference notes indicated Resident 3 had a care conference on 7/18/25. There was no documented evidence of care conferences being held for the 3rd and 4th quarter to date.During an interview on 12/4/25 at 11:02 a.m., the Social Services Director (SSD) stated she was behind [with care conferences] on long term people about a month or two across the board. The SSD acknowledged IDT care conferences should occur at least every quarter and the purpose of them is to review the plan of care with the resident and/or resident representative and assess if it needed to be revised, and to see if the resident had any new goals. During a concurrent interview and record review on 12/4/25 at 4:04 p.m., the MDS Coordinator (MDS 1) stated IDT meetings are conducted quarterly and usually consisted of the Social Worker, the MDS Coordinator, and other team members when available. The residents and family are invited with family attending on the telephone. During a review of Resident 5's medical record, MDS 1 confirmed there was no documented evidence of care conferences or IDT meeting notes located in Resident 5's medical records. During a review of the facility's operations policy and procedure titled, Care Plan Conference undated, indicated, The comprehensive plan of care must.Be developed by an [IDT] that includes the attending physician, a registered nurse, and other appropriate staff as determined by the resident's needs; Be periodically reviewed and revised by the [IDT] as changes in the resident's care and treatment occur; Reflect participation of the resident, the resident's family, or the resident's legal representative.Re-evaluate and modify care plans.as necessary to reflect changes in care, service, and treatment; quarterly, annually.Ensure that care plan evaluation includes the following.The status of progress toward goal achievement is documented in the [IDT] Progress Notes as part of the resident's medical record. Participants date and sign the care plan evaluation.

Based on observations, interviews, and record review, the facility failed to serve food that was palatable, attractive, and appetizing for 6 residents (Resident 51, Resident 63, Resident 70, Resident 75, Resident 89, and Resident 90) of 21 sampled residents when they complained the food was terrible and dissatisfying.This failure decreased the facility's potential to prevent unplanned weight loss and could negatively affect the health and well-being of the affected residents.Findings:During an interview on 12/2/25 at 10:50 a.m., Resident 89 stated, The food is horrible; I'm on a pureed diet. [It] Seems nutritious, but they don't tell you what you are eating. I get a green dish, a gray dish, an orange dish.During an interview on 12/2/25 at 10:57 a.m., Resident 63 complained the meat was sometimes too hard to chew.During an interview on 12/2/25 at 11:48 a.m., Resident 75 stated, [The] Food is awful.During an interview on 12/2/25 at 2:41 p.m., Resident 70 stated, [The] Food here is best described as pathetic.During an interview on 12/3/25 at 8:38 a.m., Resident 90 stated, Food was so-so. The pureed diet had lumps and was not very tasty.During an observation on 12/3/25 at 1:15 p.m., the Department sampled a test tray of the facility's lunch service, which included Herb Baked Fish, Bowtie Pasta, Broccoli with Cheese Sauce, and a Wheat Roll. Both regular and pureed diet trays were evaluated. The regular tray was noted to be bland, and the cheese sauce on the broccoli lacked detectable flavor. The pureed tray was observed to be unappetizing in appearance, lacking in taste, and the pasta had a gummy texture, which adhered to the roof of the mouth during sampling.During an interview on 12/3/25 at 4:49 p.m., Resident 90 stated, Lunch was not good. The pureed food had no taste and was gummy in texture.During a Resident Council meeting on 12/4/25 at 11:25 a.m., attendees stated meat was often overcooked, baked chicken was like jerky, and the pizza was like cardboard. During an interview on 12/4/25 at 12:34 p.m. with Resident 51, Resident 51 described the lunch as, Absolutely forgettable, and commented that kitchen staff should learn how to cook.During an interview on 12/4/25 at 2:20 p.m., the Registered Dietitian (RD) stated palatability was a concern as it could reduce intake and cause unplanned weight loss for the residents. During an interview on 12/5/25 at 11:21 a.m., Resident 89 reiterated their dissatisfaction with the food, stating, Still hate the food.A review of the facility's undated policy and procedure (P&P) titled, Food Handling Practices indicated, The objectives of good food preparation are to.Serve foods which are attractive, palatable, and in the form best tolerated/accepted by residents .

Based on observation, interview, and record review, the facility failed to provide drinks consistent with resident preferences for six residents (Residents 21, 29, 33, 43, 69, and 74) of 16 sampled residents when hot beverage service was unavailable for over two weeks.This failure caused the residents to feel unhappy and dissatisfied with the dietary services provided.Findings:A review of Resident 21's admission record indicated admission to the facility on 2/7/18 and the resident was the responsible party (RP - person responsible for making decisions for the resident).A review of Resident 69's admission record indicated admission to the facility on 8/26/21 and resident was the RP.A review of Resident 29's admission record indicated admission to the facility on 7/26/22 and spouse was the RP.A review of Resident 43's admission record indicated admission to the facility on 7/29/23 and resident was the RP.A review of Resident 74's admission record indicated admission to the facility on 4/19/24 and a non-related person was the RP.A review of Resident 33's admission record indicated admission to the facility on 6/13/24 and resident was the RP.During a concurrent observation and interview in Resident 74's room on 12/3/25 at 8:08 a.m. Resident 74 was awake and alert. Resident 74 stated the facility had not served any coffee in about two weeks. Resident 74 stated it was a problem.During an interview in Resident 33's room on 12/3/25 at 8:10 a.m., Resident 33 stated the facility had not had coffee for three weeks. Resident 33 stated it was a problem. Resident 33 also stated he drank coffee every day when he was at home.During an interview in Resident 43's room on 12/3/25 at 8:20 a.m., Resident 43 stated he had not had coffee in a while. Resident 43 stated it was a problem that he had not had coffee.During an interview in Resident 29's room on 12/3/25 at 8:25 a.m., Resident 29 confirmed he also had not had any coffee in a while, and it was a problem for him. Resident 29 stated it had been two weeks, and he liked to drink coffee.During an interview Resident 21's room on 12/3/25 at 9:02 a.m., Resident 21 stated her only issue with food service was she had not been served coffee. Resident 21 stated she wanted to have coffee, and it was a problem for her.During an interview in Resident 69's room on 12/4/25 at 11 a.m., Resident 69 stated the tap water was a good temperature for her except it was not hot enough to make a cup of tea. Resident 69 stated she has not had access to hot water to make tea for several weeks. She also stated she was unhappy that she could not make hot tea as that was one of her preferred beverages, especially during the winter.During an interview on 12/5/25 at 9:30 a.m. the Dietary Manager (DM) stated the facility coffee maker broke down sometime before Thanksgiving (11/27/25). The company representative for the coffee supplier took away the old machine and installed a temporary machine. The temporary machine made one pot of coffee and had a hot water spigot for tea and hot cocoa. The company representative did not check the temperature of the coffee or the water used for tea and cocoa before he left the facility. The DM stated the Administrator (ADM) decided the machine could be used for the daily coffee social (a social event in the dining room where the residents had been served coffee, tea, or cocoa according to their individual preferences). During the coffee social the Activities Director noticed the temperature of the water and coffee was too hot to serve and she notified the ADM. The ADM notified staff that the temporary coffee machine would not be used to provide hot beverages for any of the residents. The DM asked the company representative to return to the facility to adjust the water temperature of the temporary machine, but the representative did not return. The DM stated when she walked around the facility residents had repeatedly asked her about getting coffee served and they had stated they were not happy they did not get any coffee. The DM confirmed she would be very unhappy if she had not had access to coffee or tea. During a concurrent observation and interview on 12/5/25 at 10:14 a.m. in the ADM's office, there were two large containers of coffee with cups and condiments on the ADM's desk. The ADM stated he brought in coffee every week as a treat for his staff. The AMD also stated the lack of coffee or other hot beverages did not affect the quality of life for the residents. He stated he had not allowed staff to serve the residents any hot beverages during coffee social as the temporary coffee machine produced coffee and water that was scalding hot. The ADM stated residents enjoyed attending the coffee social where they had coffee, tea, and hot chocolate, but that had not been an option since the coffee machine broke sometime before Thanksgiving. The ADM stated residents had asked him repeatedly when they would be served coffee. A review of a facility document titled, [Company Name] Healthcare Fall/Winter 2025, Week 1, House Diet indicated coffee or tea was on the menu for every breakfast, lunch, and dinner. A review of the menu for Week 2 also indicated coffee or tea was on the menu for every breakfast, lunch and dinner.A review of the facility's policy titled, Resident Food Preferences, undated, indicated, Individual food preferences will be assessed upon admission and communicated to the Interdisciplinary Team [a group of professionals from different areas of the facility who work together to provide comprehensive patient centered care].

Based on interview and record review, the facility failed to ensure a safe discharge for one resident (Resident 100) of four sampled residents when Resident 100 required assistance with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and was discharged to an Independent Living Facility (ILF) that did not provide assistance.This failure decreased the facility's potential to ensure the Resident 100's continuity of care needs was met upon discharge into the community.Findings:A review of Resident 100's resident face sheet indicated admission to the facility on 7/18/25 with diagnoses of Sepsis (life threatening infection) and Infection and inflammatory reaction (a body's response to harmful stimuli such as infection or injury) due to an internal left hip prosthesis (an artificial implant to replace damaged hip joint).A review of Resident 100's care plan, dated 7/18/25, indicated Resident 100 wished to return to the community upon discharge. Resident 100's goal was to return to the community safely. To assist Resident 100 achieve this goal, facility staff were expected to identify a safe place for Resident 100 to go to after discharge from the facility; provide information and assistance with community resources that Resident 100 could use; and call Resident 100 within 24 to 72 hours after discharge from the facility to conduct a welfare check.A review of Physical Therapy notes tiled PT Discharge Summary, dated 11/24/25 indicated, Discharge Location = [Resident 100] discharged to Group Home. Assistance/ Support to be Provided = AM [morning] assistance/ caregiver available, PM [evening] assistance/caregiver available.A review of Resident 100's progress notes indicated the following regarding his discharge planning: A note dated 11/4/25 at 4:56 p.m. indicated, [Resident 100] uses a wheelchair to aid him in ambulation. Resident [100] is able to walk using a FWW [front wheeled walker] with contact guard assist [when a caregiver uses a light touch, often with one or two hands, to help someone with balance and stability during a movement (like walking or transferring) to provide safety presence].he is.assisted with meals as staff needs to set up. [Resident 100] needs one-person physical assist with bathing. A note dated 11/20/25 at 6:50 p.m. indicated, [Resident 100] has agreed to be discharged to an [ILF]. [Elder Care Advisor (ECA)] will meet [Resident 100] tomorrow afternoon. A note dated 12/2/25 at 7:26 p.m. indicated, [Resident 100] was discharged today to an.[ILF].He uses a wheelchair and FWW to aid him with ambulation as he is still non full weight bearing related to hip surgery.A review of Resident 100's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 12/2/25, indicated a Brief Interview for Mental Status (BIMS, and assessment tool use by facilities to screen and identify memory, orientation, and judgment status of the resident) score of 15 of 15 which indicated no cognitive impairment. A review of Resident 100's functional abilities in this MDS indicated Resident 100 required supervision or touching assistance with showering/bathing self; tub/shower transfers; walking 10 feet, walking 50 feet with two turns, walking 100 feet, walking 10 feet on uneven surfaces, 1 step or curb, 4 steps, 12 steps and picking up an object.During an interview on 12/4/25 at 11:24 a.m., the SSD stated Resident 100 used a wheelchair and could not walk long distances. The SSD stated both the ILF and the ECA from an assisted living locator company told her the ILF would provide help for Resident 100 while he resided there. The SSD stated the assisted living locator company found the ILF for her and she believed them. The SSD further stated, It was a bad choice.During an interview on 12/4/25 at 11:59 a.m., the Administer (ADM) stated he was heavily involved in Resident 100's discharge as Resident 100 owed a great deal of money to the facility. The ADM acknowledged the assisted living locator company helped the SSD to find placement for Resident 100.During an interview on 12/4/25 at 2:10 p.m., the ECA from the assisted living locator company acknowledged her role was to provide assistance to healthcare facilities to find placement for residents who needed assisted living. The ECA stated she introduced the manager of the ILF to the SSD but knew ILFs would not take individuals who were not completely independent. The ECA stated ILFs were Room and Board facilities which provided lodging, not Board and Care which provided assistance with daily needs. The ECA denied telling the SSD the ILF would provide ongoing assistance to Resident 100.During an interview on 12/5/25 at 10:12 a.m., the Manager (MGR) of the ILF stated when Resident 100 arrived to the facility on [DATE], he was caught off guard when Resident 100 told him he could not walk. The medical transport van dropped him off at the end of the driveway, when both Resident 100 and the MGR realized Resident 100 could not stay at the facility. The MGR stated the ILF was not wheelchair accessible, nor was the bathroom. One of the residents at the ILF offered to carry Resident 100 upstairs to his room and bathroom until a different location could be found for Resident 100. The MGR stated, Obviously, this was not sustainable. I would not have accepted him if I knew he couldn't walk. He spent one night here. He left on the morning of 12/3/25 to the hospital, complaining of chest pain. The MGR stated he attempted to call the SSD and the ECA but could not reach either one of them.In an interview on 12/5/25 at 12:52 p.m., Resident 100 stated he had asked the SSD if the facility they were sending him to would be able to assist him and the SSD stated they would. Resident 100 stated he agreed to the discharge because he trusted the SSD. Resident 100 stated when he arrived to the ILF, the staff told him they would not be able to provide the assistance he needed. Resident 100 stated he was unable to cook and needed assistance setting up his food so he did not eat between the time he was discharged from the facility until he arrived to the hospital.A review of facility policy titled Transfer and Discharge, undated, indicated In determining the.discharge location for a resident, the decision to.discharge to a particular location will be determined by the needs, choices and best interests of that resident.

Based on observation, interview, and record review, nursing staff failed to develop a care plan for one resident (Resident 53) when there was no care for Resident 53's use of oxygen therapy. This failure decreased the facility's potential to meet Resident 53's needs, as well as cause a decline in Resident 53's physical health and emotional well-being.Findings:A review of Resident 53's face sheet indicated admission to the facility on 8/23/25 with a diagnosis that included Chronic Obstructive Pulmonary Disease (COPD, a progressive lung condition making it hard to breathe, encompassing chronic bronchitis (inflamed airways, mucus) and emphysema (damaged air sacs), Pleural Effusion (the buildup of excess fluid in the pleural space, the area between your lungs and chest wall), and Atelectasis (the partial or complete collapse of a lung or a lobe, occurring when tiny air sacs (alveoli) deflate, preventing proper oxygen exchange.A review of Resident 53's physician order report indicated Resident 53 had an order to receive supplemental oxygen at 2-3 liters per minute (LPM) and licensed nurses were expected to check Resident 53's pulse at least once during every shift starting on 9/18/25. A review of Resident 53's care plans dated 9/18/25 to 9/25/25 did not include a care plan for oxygen therapy. During an initial observation on 12/2/25 at 10:30 a.m., Resident 53 was sitting up in bed awake and alert. Resident 53 was wearing a nasal canula and her oxygen concentrator was set at 2 liters (L, a unit of measurement) of humidified oxygen.During an interview on 12/4/25 at 4 p.m., Licensed Nurse 6 (LN 6) confirmed there was no care plan for Resident 53's oxygen therapy.During a review of the facility's undated policy and procedure titled, Care Plan Essentials (CPE) indicated, By providing a centralized care summary, resident care experiences will improve, as the nursing staff will have important care and safety data related to individualized care and treatment of the resident.CPE includes the following resident-specific information.Respiratory.The Licensed Nurse will update the CPE information during shift-to-shift reporting/endorsement.The Licensed Nurses.will utilize the CPE during shift-to-shift reporting and may update when indicated.The Ambassador assigned to the resident may also update the CPE.The company's Director of Staff Development/Designee will review for the accuracy of information in CPE during the morning meeting. When an update in any section is indicated, a new CPE will be initiated.

Based on observation, interview and record review, facility staff failed to provide communication services to one resident (Resident 8) out of 21 sampled residents when translation services were not used to communicate with Resident 8 whose primary language was Mandarin.This failure decreased the facility's potential to prevent a decline in Resident 8's ability to perform Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and a decline in ensuring Resident 8 received necessary care and services.Findings:A review of Resident 8's face sheet indicated admission to the facility on [DATE] with diagnoses of Tubulo-Interstitial Nephritis (a type of kidney disease which involves damage to the small tubes and surrounding tissue in the kidney) and Malignant Neoplasm of the Breast (breast cancer). A further review of this face sheet indicated Resident 8's preferred language was Chinese, but no specific dialect of Chinese was documented.During an observation in Resident 8's room on 12/2/25 at 2:39 p.m., Resident 8 was lying in bed gesturing toward the wall and pointing at her bedside table. Resident 8 would not speak, just grunted as she pointed to the bedside table. During a phone interview on 12/4/25 at 7:55 a.m., Resident 8's Responsible Party (RP, an individual or entity legally accountable for specific financial, legal, and health care obligations) stated Resident 8 spoke very little English, and Mandarin Chinese was her preferred language. The RP stated Resident 8 has become frustrated with her limited ability to communicate with the staff. The RP stated at times, Resident 8 wanted to talk to staff about her inability to sleep because of her roommate, or about her current level of pain.During an interview on 12/5/25 at 8:55 a.m., Licensed Nurse 5 (LN 5) stated he was frequently assigned as Resident 8's nurse. LN 5 stated he attempted to communicate with her non-verbally, but stated, It's kind of hard sometimes. LN 5 stated he sometimes used a translation application on his personal cell phone, but admitted he was unsure of Resident 8's dialect of Chinese. LN 5 further stated he was unsure if the facility offered translation services to their residents. LN 5 stated it was important for residents and staff to understand each other for resident safety.During an interview on 12/5/25 at 9:01 a.m., LN 4 stated she used the translation application on her phone to work with her residents who did not speak English, including Resident 8. LN 4 stated she was unsure of Resident 8's dialect. LN 4 stated she was unaware of any translation services provided by the facility.During a concurrent interview and document review on 12/5/25 at 10:06 a.m., the Administrator (ADM) motioned toward the translation services flyer posted in the kitchen hallway. The ADM stated translation services were reviewed and encouraged during staff orientation. A review of the facility's translation service invoices between April 2025 and November 2025 indicated Mandarin Chinese translation service was used twice on 4/13/25 for a total of 9 minutes.A review of the facility's policy titled Communication with Persons with Limited English Proficiency, undated, indicated, [The facility] will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits. [The facility] will conduct a regular review of the language access needs of our patient population.[The facility] shall promptly identify the language and communication needs of the LEP person. If necessary, staff will use a language identification card or posters to determine the language.The administrator is responsible for.obtaining an outside interpreter if a bilingual staff or staff interpreter is not available.Translators are available 24 hours per day via [translator services].

Based on interview and record review, facility staff failed to ensure one resident (Resident 67) of 21 sampled residents was screened for a need for trauma-informed care when upon admission. This failure decreased the facility's potential to provide culturally competent care that minimized triggers or further traumatized Resident 67.Findings:A review of Resident 67's face sheet indicated admission to the facility on 2/4/25 with diagnoses of hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following a cerebral infarction (stroke) affecting right dominant side and post-traumatic stress disorder (a mental health disorder that can develop after experiencing or witnessing a life threatening or shocking traumatic event).A review of Resident 67's care plans indicated the following:-A care plan dated 2/4/25 indicated Resident 67 had behavioral problems with verbal outbursts. Resident 67's goal for this behavior was to be diverted into a productive and meaningful activity. To reach this goal, staff were directed to remove [Resident 67] from triggering environment to a calm and quite [sic] place with supervision.-A care plan dated 3/31/25 indicated Resident 67 was agitated and verbalized anxiety. Resident 67's goal was to have decreased episodes of anxiety. To reach this goal, staff were directed to identify and attempt to remove anxiety triggers.During a concurrent observation and interview in Resident 67's room on 12/2/25 at 2:52 p.m., Resident 67 was observed pacing about his room with a seated walker (a wheeled mobility aids with a built-in seat and often a backrest). Resident 67 stated, I don't feel safe here. Resident 67 further stated he was feeling threatened by the resident across the patio and wished he had a gun to protect himself.During an interview on 12/4/25 at 10:13 a.m., Licensed Nurse 2 (LN 2) stated she was often assigned to care for Resident 67. LN 2 stated she was unsure what triggered Resident 67's behavior. LN 2 spoke of an incident which occurred earlier that morning where a resident was loudly singing which caused Resident 67 to slam his door and scream. LN 2 stated another time, Resident 67 became so frightened, he approached LN 2 and told her he was being followed by another resident and to make him stop.During an interview on 12/4/25 at 11:02 a.m., the Social Services Director (SSD) stated residents who experienced trauma should have a care plan initiated right away for the best care. The SSD stated the facility used a Trauma Informed Care screening form upon admission. The questions and content of this form would reveal traumatic events that occurred in the resident's life, which would help formulate the care plan for trigger mitigation or elimination. The SSD confirmed Trauma Informed Care screening was not completed for Resident 67 but understood how it would have benefitted him. A review of the facility's policy titled Trauma Informed Care, undated, indicated, Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers.Nursing staff and Social Services staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. The designated staff will conduct the Trauma Informed Care (TIC) assessment tool within seven (7) days of admission to identify any history of trauma and any current event or diagnosis of trauma, including possible signs/symptoms through interviews of resident/patient, and if available, interviews of resident/patient-representative(s), significant other(s), and family member(s). Medical records review will also be conducted by the designated staff to identify any history of trauma, any current diagnosis and/or signs/symptoms of trauma.

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was clean and in a usable state for one resident (Resident 76) out of 21 sampled residents when the rented oxygen concentrator in Resident 76's room had visible dust and debris in the vents and needed a filter change.This failure decreased the facility's potential to prevent bacteria and debris directly enter Resident 76's lungs, placing her at risk for infection.Findings:A review of Resident 76's face sheet indicated admission to the facility on 8/30/22 with diagnoses of Community Acquired Pneumonia (a lung infection contracted outside of the facility) and Adult Failure to Thrive (a state of significant physical and functional decline in older adults).A review of Resident 76's physician orders, dated 10/28/25, indicated, Oxygen 2-4 L [liters, a unit of measure] via nasal canula [flexible device used to deliver oxygen through the nose] for saturation [the amount of oxygen carried in your blood as a percentage of the maximum it could carry] < [less than] 90%.During an observation on 12/2/25, at 11:06 a.m., in Resident 76's room, an oxygen concentrator (a medical device that pulls air from the surrounding environment, filters out impurities and delivers medical-grade oxygen to residents with a respiratory condition) was seen against the wall near Resident 76's bed. The oxygen concentrator was noted to have visible debris on the front of the machine. The filter used to clean and purify the air was black and needed to be changed. The vents near the filter had accumulated dust build up.During an interview on 12/5/25 at 8:19 a.m., the Director of Nursing (DON) stated the oxygen concentrators were rented from a local company and the facility's maintenance department was responsible for daily checks of the equipment. During an interview on 12/5/25 at 8:21 a.m., the Maintenance Director (MNT) stated the oxygen concentrators were checked daily by housekeeping. The MNT acknowledged the oxygen concentrator in Resident 76's room was not clean and in a usable condition. The MNT stated that because the equipment was rented, he was not sure of the process for checking for functionality and cleanliness, further adding the rental company made weekly visits to check on the state of the equipment. During an interview on 12/5/25 9:25 a.m., the Infection Preventionist (IP) stated using a dusty oxygen concentrator with a dirty filter placed the resident at risk. The IP stated the oxygen concentrator could blow particles from the dust and debris found on the concentrator into the residents' lungs and could cause an infection or illness. She further stated filters on the oxygen concentrators should be changed weekly.During an interview on 12/5/25 at 8:48 a.m., the Administrator (ADM) stated the facility was responsible for maintaining cleanliness of the equipment and has not been following their own policy.A review of the facility's policy titled Cleaning Respiratory Equipment, undated, indicated, The Company provides and maintains clean respiratory equipment. Wipe down all.concentrators.clean oxygen concentrator filters weekly.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from abuse when Resident 2 struck her on the left cheek.This failure had the potential to result in serious physical harm to Resident 1.Findings:A review of Resident 1's admission record indicated she was admitted in 5/19 with the diagnosis of cognitive impairment (persistent function deficits that can impact a person's ability to think, learn and remember).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/16/25, indicated she had severe cognitive impairment.A review of Resident 1's nursing note, dated 8/13/25 and written by Licensed Nurse 1 (LN 1), indicated a staff person had reported to him she had witnessed Resident 1 being struck in the left cheek by Resident 2.A review of Resident 2's admission record indicated he was admitted in 8/20 with the diagnosis of dementia (a progressive state of decline in mental abilities).A review of Resident 2's MDS, dated [DATE], indicated he had severe cognitive impairment.A review of Resident 2's nursing note, dated 8/13/25 and written by LN 1, indicated a staff person had reported to him she had witnessed Resident 2 strike Resident 1 in the left cheek.During an interview on 9/8/25 at 11:56 a.m. with Activities Assistant 1 (AA 1), AA 1 stated she had been in the dining room on 8/13/25 and witnessed Resident 2 strike Resident 1 in her left cheek as he wheeled himself past her in his wheelchair. AA 1 stated Resident 1's cheek was a little red but she had not cried out in pain.During an interview on 9/8/25 at 12:39 p.m. with the Social Services Director (SSD), the SSD stated she was aware of the incident that had occurred between Resident 1 and Resident 2 on 8/13/25. The SSD agreed Resident 1 had suffered abuse by Resident 2 and confirmed it was the facility's responsibility to keep all residents safe.During an interview on 9/8/25 at 1:24 p.m. with LN 1, LN 1 stated he assessed Resident 1 on 8/13/25 after she had been struck by Resident 2 and her left cheek was slightly reddened after the incident but there were no complaints of pain.During a review of the facility's policy titled, Abuse Prevention Program, undated, the policy stipulated, Our residents have the right to be free from abuse.This includes physical abuse.

Based on interviews and record reviews, the facility failed to immediately notify the responsible party (RP, a person who is designated in making decisions about health care and financial matters) for one out of two residents (Resident 1), when Resident 1's RP was not notified until 4/20/25 that Resident 1 fell on 4/18/25 and 4/19/25.This failure was a violation of residents' rights. Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the residents) indicated Resident 1 was admitted to the facility in April of 2025 with a RP listed and a note that indicated, .[phone] number corrected to [xxx-xxx-1966] from [xxx-xxx-9518] on 4/20/25.A review of Resident 1's Nursing Progress note, dated 4/18/25 at 4:26 a.m., indicated, .[Resident 1] is found sitting on the floor next to his bed. [Resident 1] stated, ‘.I just fell on my butt.'.Called RP.no answer.A review of Resident 1's Nursing Progress, dated 4/19/24 at 4:40 p.m., indicated, . [Resident 1] was sitting in his w/c [wheelchair] . resident was trying to turn his w/c around when he slid down from his w/c, landed [on] his bottom [buttocks].RP.left 3x [three times] voice mail, no return call noted.A review of Resident 1's Nursing Progress note, dated 4/20/25 at 11:15 a.m., indicated, .spoke with [Resident 1's RP] .during course of conversation, brought up to [RP] .writer called her at [phone number xxx-xxx-9518] and left a voicemail to call facility back; per [RP] she did not receive the voicemail. We then checked the face sheet. The contact number that is in the face sheet [xxx-xxx-9518], according to [RP] is not the number that she is using but it's [xxx-xxx-1966]. This may be the reason why she did not receive the call.During an interview on 8/4/25 at 3:44 p.m., Licensed Nurse (LN) B stated a fall was considered a change of condition (COC, a noticeable alteration in a patient's health status, either positive or negative) and should be reported to the resident's RP and the resident's physician. LN B stated fall incidents should be reported to RP immediately or at least before the end of shift. LN B stated the facility was responsible to ensure the correct contact information is listed on the resident's face sheet to be able to notify the RP for a fall. LN B stated not notifying the RP of a COC was a violation of residents' rights.During a concurrent interview and record review on 8/4/25 at 4:34 p.m. with LN A, Resident 1's face sheet was reviewed. LN A verified there was a note on Resident 1's face sheet indicating on 4/20/25, the day of Resident 1's discharge, the RP's contact number was changed to the correct contact number [xxx-xxx-1966]. LN A stated the facility was responsible for ensuring the RP's contact number on residents' files were accurate. LN A verified that due to the wrong contact number on the face sheet, the RP was not made aware of Resident 1's fall incidents on 4/18/25 or 4/19/25 timely. LN A stated it was important that RPs were aware of COC such as falls.During a telephone interview on 8/5/27 at 1:57 p.m., the Director of Nursing (DON) verified Resident 1's RP contact number listed on Resident 1's face sheet was incorrect and that was the reason why Resident 1's RP was not notified of the fall incidents on 4/18/25 and 4/19/25. The DON confirmed Resident 1's RP was only made aware of the falls on 4/20/25 when the RP was picking Resident 1 for discharge. The DON stated it was the facility's responsibility to ensure the contact information on the face sheet was correct.A review of the facility's policy and procedure (P&P) titled, Changes in Resident's Condition, undated, indicated, . the resident and/or resident representative [RP] (if resident has no capacity to make health care decisions or resident may have requested the Licensed Nurse to contact a family member during a change of condition),.[RP] and physician are notified by [LN]/Company Designee when there is. an accident involving resident.and has the potential for requiring physician intervention.

Based on interviews and record reviews, the facility failed to ensure a summary of the baseline care plan (BCP, a document created within 48 hours of a resident's admission to a nursing home, outlining the initial care needed to ensure residents' safety and well-being, focusing on basic needs and resident-specific information) was provided for one resident out of two sampled residents (Resident 1), when there was no documentation indicating Resident 1's responsible party (RP, a person who is designated in making decisions about health care and financial matters) was provided the BCP summary. This failure has the potential to decrease the RP's ability to be informed about Resident 1's care and services.Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the residents) indicated Resident 1 was admitted to the facility in April of 2025 with a RP listed.A review of Resident 1's BCP, dated 4/14/25, did not indicate a copy of the summary of the BCP was provided to Resident 1's RP.During a concurrent interview and record review on 8/4/25 at 4:34 p.m. with Licensed Nurse (LN) A, Resident 1's BCP, dated 4/14/25, was reviewed. LN A stated a BCP was important because it provided a map for the residents' safe care. LN A stated it was important to provide a resident's RP with a summary of the BCP so they can ensure the facility will provide quality care the resident requires. LN A stated there was no indication a summary of Resident 1's BCP was provided to Resident 1's RP.During a telephone interview on 8/5/25 at 1:57 p.m., the Director of Nursing (DON) verified she had looked into Resident 1's BCP dated 4/14/25 and acknowledged there was no indication a copy of the BCP summary, dated 4/14/25, was provided to the RP. The DON stated, if it was not documented, then it did not happen.A review of the facility's policy and procedure (P&P) titled Baseline Care Planning, undated, the P&P indicated, .a baseline plan of care to meet the resident's immediate needs shall be developed for each residents within 48 hours of admission. the resident and their [RP] will be provided a summary of the [BCP].Documentation In Electronic Health Record (EHR) .may use the paper form and will be uploaded in EHR.

Based on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was provided an environment free of accident hazards and received adequate supervision to prevent accidents, when Resident 1 fell from a wheelchair (WC) provided by the facility. This failure could result in the increased risk of accidents.Findings:A review of Resident 1s face sheet (front page of the chart that contains a summary of basic information about the residents) indicated an admission date of 4/2025 with a diagnosis of Alzheimer's Disease (AD, a disease characterized by a progressive decline in mental abilities) and Anxiety (fear, worry).A review of the Fall care plan (CP, a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed), dated 4/14/25 , did not indicate Resident 1 used a WC.A review of Resident 1's Nursing Progress Note, dated 4/14/25 at 11:00 a.m., indicated, .[Resident 1] ambulatory [walking] with cane, fall risk.Hx [history] of falls (1 fall per month) .prone to wandering behavior, 1:1 [a situation where a single healthcare professional provides care or observation to a single patient] redirection advised.A review of Physical Therapy (PT, a healthcare profession that focuses on improving and restoring physical function and mobility) evaluation and plan of treatment, dated 4/15/25, indicated Resident 1 did not use a wheelchair and there was no recommendation from the PT that Resident 1 was safe to use the WC.A review of Resident 1's Nursing Progress Note, dated 4/19/24 at 4:40 p.m., indicated, . [Resident 1] was sitting in his w/c [wheelchair] . resident was trying to turn his w/c around when he slid down from his w/c, landed [on] his bottom [buttocks].A review of Resident 1's electronic health records produced no documentation that Resident 1 had a WC assessment (an evaluation to determine a person's specific needs for a wheelchair and related equipment).During a concurrent interview and record review, on 8/4/25 at 4:34 p.m., with Licensed Nurse (LN) A, Resident 1's electronic health records were reviewed. LN A verified the progress note dated 4/14/25 at 11:00 a.m. indicated Resident 1 walked with cane. LN A verified Resident 1's Nursing Progress Note, dated 4/19/25 at 4:40 p.m., indicated Resident 1 fell while he was on a WC. LN A stated Resident 1 should not be placed on a wheelchair since there was no evaluation done that Resident 1 needed or was safe to use a WC.During a telephone interview on 8/8/25 at 10:07 a.m., the Director of Nursing (DON) verified on 4/19/25 Resident 1 slid from a WC and landed on his buttocks. The DON verified there was no care plan to indicate Resident 1 should be using a WC. The DON verified Resident 1 was seen by PT with no note or assessment to indicate Resident 1 was safe to use the WC.A review of the facility's policy and procedure (P&P) titled Fall Management, undated, the P&P indicated, .based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to reduce the risk of the resident falling .

Based on interview and record review, the facility failed to report to the Department an injury of unknown source (an injury which was not observed, cannot be explained by the resident, and is suspicious because of the extent or location) for one of four sampled residents (Resident 1) when Resident 1 sustained a broken left arm. The facility was aware of Resident 1's injury on 7/6/25, but did not report it to the Department until 7/8/25.This failure resulted in a delay in the Department's investigation into Resident 1' s injury and its cause, putting Resident 1 at risk for additional harm. A review of Resident 1's Resident Face Sheet, printed 7/16/25, indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a progressive brain disorder that gradually impairs memory, thinking, and language skills, eventually affecting a person's ability to carry out daily tasks), epilepsy (defined by recurrent seizures, which are sudden, temporary disruptions of normal brain activity), and hemiparesis (a condition characterized by weakness on one side of the body) following cerebral infarction (a condition where brain tissue dies due to a lack of blood supply) affecting the left side of the body.During a review of Resident 1's Minimum Data Set (MDS-an assessment and care planning tool), Section B (describing hearing, speech and vision ability), dated 6/13/25, it indicated Resident 1 could not speak or communicate in any way that could be understood by others. During a review of Resident 1's MDS Section C (describing abilities relating to the mental process involved in knowing, learning, and understanding things), dated 6/13/25, it indicated Resident 1's ability to make decisions was severely impaired, and Resident 1 had short and long-term memory deficits.During a review of Resident 1's Resident Progress Notes, dated 7/5/25 at 9:54 p.m., it indicated resident was noted with facial grimace, moaning and almost crying upon repositioning left arm.resident with behavior of grabbing and pulling with right hand. N.O. (new order) from [MD]-Xray of LT (left) wrist 3 view; LT hand 3 view; LT forearm; noted and carried out.During a review of Resident 1's Radiology Report, dated 7/6/25, it indicated Resident 1 had the following , Forearm.Left, Results: Severely comminuted fracture (where the bone is broken into three or more pieces) of the distal radial (near the wrist joint) and ulnar metaphysis (the ulna is one of the two bones in your forearm, located on the pinky side. The metaphysis is the area between the diaphysis (shaft) and the epiphysis (end) of the bone). Radial fracture shows complete lack of apposition and alignment (apposition refers to the degree of contact between bone fragments at the fracture site, while alignment describes the overall position and orientation of the bone fragments). Ulnar fracture shows angulation (describes the degree to which the broken bone fragments are misaligned, forming an angle with each other).During a review of Resident 1's Resident Progress Notes, dated 7/6/25 at 1:30 p.m., it shows the time/date the facility became aware of Resident 1's left forearm fracture.A review of CDPH (California Department of Public Health) Incident/Intake Report for intake number CA00971772 (for incident date 7/6/25) indicated the facility reported this incident to CDPH on 7/8/25 at 5:40 p.m., via telephone voicemail message.During a concurrent interview and record review on 7/16/25 at 2:00 p.m. with Resident 1's primary care provider (PCP) and the Director of Nursing (DON), Resident 1's radiology results and recent skin assessments were reviewed. The DON agreed on multiple occasions Resident 1 was noted to have unexplained skin discoloration, redness, or other abnormal marks on her arms, face, trunk, thighs, and hands. The PCP stated it would be hard to determine exactly where or how Resident 1's broken arm occurred. The PCP further stated although Resident 1's medical conditions and medications may contribute to brittle bones and spontaneous fractures, he agreed a comminuted fracture is usually connected to falls, car accidents or other high-impact blows.During an interview with the facility's Administrator (ADM) on 7/16/25 at 3:30 p.m., the ADM stated he did not believe that this incident was required to be reported within two hours because abuse was not suspected. The ADM did not give any indication of how abuse could be ruled out for such a serious unexplained injury before a preliminary investigation was conducted. A review of facility policy and procedure titled Abuse Investigation and Reporting (undated), indicated: Reporting:1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Company Administrator, or his/her designee, to the following persons or agencies: a) The State licensing certification agency responsible for surveying/licensing the facility; b) The local/state Ombudsman (works independently as an intermediary to provide individuals with a confidential avenue to address complaints and resolve issues); c) The Resident's Representative (Sponsor) of Record; d) Adult Protective Services (where state law provides jurisdiction in long-term care); e) Law enforcement officials; f) The Resident's Attending Physician; and g) The Company Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown sources and misappropriation of resident property) will be reported immediately but not later than: a) Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b) Twenty-four (24) hour if the alleged violation does not involve abuse AND has not resulted in bodily injury.

Based on interview and record review the facility failed to: 1. Ensure nursing staff were able to correctly state the facility ' s policy on how and when to perform Cardiopulmonary Resuscitation (CPR - an emergency procedure that combines chest compressions (the action of pushing hard and fast on the chest while performing CPR) and rescue breathing to restart a person ' s heartbeat and breathing) and Basic Life Support (BLS- a set of life-saving procedures performed on someone if/when their heart stops beating or the person has difficulty breathing until advanced medical help arrive) when four nursing staff (Certified Nursing Assistant A (CNA A), Licensed Nurse C (LN C), LN D, and LN G) of six nursing staff incorrectly stated the facility ' s policy; 2. Immediately perform CPR on one resident (Resident 1) of three sampled residents on [DATE] when she was found in bed not breathing and without a heartbeat; 3. Ensure an Automated External Defibrillator (AED- a portable medical device used to deliver an electric shock to a person experiencing an abnormal heart rhythm) was present for LNs to use as part of the CPR/BLS) procedure; and, 4. Ensure one LN of four LNs were currently certified to perform CPR/BLS for one resident (Resident 1) of three sampled residents when Resident 1 was found unresponsive, without a heartbeat and not breathing in her room. This failure decreased the facility ' s potential to provide successful resuscitation (to revive from unconsciousness or apparent death) efforts to Resident 1 and other residents who were identified as a Full Code (the resident ' s choice to receive all emergency treatment including CPR to resuscitate and maintain life). Findings: 1. A review of Resident 1 ' s Face Sheet (a summary of basic information about the resident) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of multiple fractures (broken bones), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypokalemia (a low level of potassium (an important mineral) in the blood), hypertension (HTN-high blood pressure), and atherosclerotic heart disease (a narrowing of the vessels in the heart, causing obstruction of blood flow). A review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) signed by Resident 1 ' s Representative and dated [DATE], indicated Resident 1 selected, Attempt Resuscitation/CPR. During an interview on [DATE] at 10:20 a.m., CNA A stated the facility trained CNAs on CPR. During an interview on [DATE] at 10:50 a.m., LN C stated if a resident was found unresponsive by a CNA, the CNA is expected to go to one of the nurses ' stations to alert an LN. An LN then would assess the resident. If the resident was unresponsive, the LN would call another LN to stay with the resident while the other LN checked the resident ' s POLST in the paper chart or in the EHR. If the resident was Full Code, an LN was expected to call 911 (a phone number used to call emergency services) and make an overhead announcement on the paging system to activate the Rapid Response Team (RRT- a designated group of nurses who respond to assist residents whose condition requires an immediate response). LN C stated the rapid response would be activated after the POLST was checked. LN C also stated the time CPR was provided mattered because if oxygen (a gas essential for human life) did not get to the brain quickly brain cells died . During an interview on [DATE] at 11:12 a.m., LN D stated if a CNA reported an unresponsive resident, the LN was expected to assess the resident and instruct the CNA to call for help. LN D stated help was summoned by using a call light in the resident ' s room so someone at the nurses ' station would respond. LN D stated she was unsure if the facility had a paging system and did not really know how to call for help. LN D stated she printed a daily census (a list of residents residing in the facility each calendar day) and wrote the code status of the residents she was assigned to. LN D confirmed she did not have the census on her person and kept it at the nurses ' station. LN D stated the time CPR was started was important because brain cells were affected by a lack of oxygen. During an interview on [DATE] at 2:12 p.m., the Director of Staff Development (DSD) stated CNAs were instructed to report to an LN when a resident was found unresponsive. The DSD stated CNAs did not provide CPR in the facility; only licensed staff (nurses who have the legal authority to practice nursing within a specific scope of practice as granted by a state or regulatory department) provided CPR. During an interview and record review on [DATE] at 10:47 a.m., the Director of Nursing (DON) stated she expected LNs to have residents ' code statuses easily accessible. The DON confirmed the RRT was made up of four people which included the Unit Manager (a nurse who supervises and manages staff in a specific unit) and the charge nurses from each of the three nurse ' s stations. The DON also stated there were phones in the hallways for staff to use to make an overhead Rapid Response announcement so everyone could hear it. During an interview on [DATE] at 4:28 p.m., LN G stated CNAs were CPR certified and could assist with CPR. A review of an undated facility policy titled, Emergency Procedure - Cardiopulmonary Resuscitation indicated, .General Guidelines .The chances of surviving SCA [Sudden Cardiac Arrest - when a person ' s heart stops] may be increased if CPR is initiated immediately upon collapse . If an individual .is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR .Instruct a staff member to activate the .[Rapid Response] code and call 911 .Verify or instruct a staff member to verify the DNR or code status .Initiate the .BLS sequence of events . When the AED arrives, assess for need and follow AED protocol as indicated. 2. A review of Resident 1 ' s progress note documented by Resident 1 ' s assigned LN (LN E) dated [DATE] at 9:40 p.m. indicated, During med [medication] pass; the [Resident 1] was observed eye closed with no chest rise and fall. Attempts to call the resident by her name three times yielded no response. Upon checking the resident ' s pulse, found it to be pulseless. The resident ' s skin was noted to be warm to touch; This writer promptly informed other LN ' s to verify the resident code status. Once the complete code status was confirmed, I commenced [started] CPR. Another nurse promptly dispatched 911. Subsequently, another nurse retrieved the crash cart [a wheeled container which stored equipment used in emergency resuscitations]. A review of Resident 1 ' s progress note documented by the UM of Resident 1 ' s nurse ' s station dated [DATE] at 9:43 p.m. indicated, This writer informed to help asses [Resident 1]. Resident is warm to touch. No chest rise and fall noted. Pupillary reflex [the automatic change in the size of a person ' s pupils, which are the openings in the center of the eye, in response to light] checked and bilaterally [both eyes] unreactive to light and accommodation. A review of Resident 1 ' s progress note dated [DATE] at 10:57 p.m. indicated, Paramedics terminated CPR. Death pronounced at 10:55 p.m. During an interview on [DATE] at 3:55 p.m., LN F stated on the evening of [DATE] she heard shouting and went to Resident 1 ' s room. LN F called 911. LN F stated she did not know why LN H had not called 911 or why LN H had left Resident 1 ' s room and later returned. During a concurrent interview and record review on [DATE] at 10:42 a.m., the DON confirmed a document titled, .County EMS [Emergency Medical Services] Field Determination of Death indicated emergency personnel from the local Fire Department arrived on the scene at 10:25 p.m. on [DATE]. During a concurrent interview and review of Resident 1 ' s progress note on [DATE] at 10:47 a.m., the DON stated she expected CPR should be done immediately and LNs should have code statuses easily accessible. The DON confirmed Resident 1 ' s nurse progress notes dated [DATE], indicated at 9:40 p.m. LN E found Resident 1 unresponsive, not breathing, without a pulse and other LNs were asked to verify Resident 1 ' s code status prior to starting CPR. The DON also confirmed Resident ' s progress note dated [DATE] indicated at 9:43 p.m. LN G went to Resident 1 ' s room and checked Resident 1 ' s skin temperature, apical pulse (a pulse point on a chest at the bottom tip of the heart), respiratory status, and pupillary response. After LN G confirmed Resident 1 did not have a pulse, was not breathing, and Resident 1 ' s code status was confirmed, LN E then started CPR. The DON stated LNs had residents ' code status written on the daily census and was in the EHR system on the medication cart. The DON stated she was unaware if the RRT used the paging system when Resident 1 required CPR on [DATE]. During an interview on [DATE] at 2:08 p.m., LN H stated on the evening of [DATE] he was documenting on resident charts at the nurse ' s station when LN E walked to the nurse ' s station and said he needed help. LN H did not recall who checked Resident 1 ' s code status. LN H stated he finished typing his documentation and went to Resident 1 ' s room. LN H stated he saw LN E was performing chest compressions on Resident 1. LN H stated LN F called 911. LN H took over chest compressions on Resident 1 while the EMS dispatcher coached the team over the phone. During an interview on [DATE] at 4:28 p.m., LN G confirmed she was the UM on the evening of [DATE]. LN G stated LN E came to the nurse ' s station and requested an assessment of Resident 1. LN G got her stethoscope (a medical instrument used for listening to a person ' s heart and/or breathing) and pen light (a small flashlight). LN G stated Resident 1 was in her bed and warm to the touch. LN G stated she listened to Resident 1 ' s apical pulse and four quadrants of her lungs and heard no heartbeat or breath sounds. LN G also stated Resident 1 ' s pupils were fixed (not reacting/moving) to light and dilated (enlarged). LN G told LN E to make sure Resident 1 was a full code and then LN G ran out of the room to get the crash cart. LN G then paged all nurses to go to Resident 1 ' s room. LN G stated LN E started chest compressions and she used the Ambu bag. LN H entered the room and then left. LN F came to the room and was told to call 911. LN H later returned to Resident 1 ' s room and assisted with chest compressions. LN G confirmed there was a paging system at the nurse ' s station. LN G stated the paging system was used for emergencies after 9 p.m. LN G stated the RRT team members were expected to respond to the RRT overhead announcement. A review of an email and records received from the facility Administrator (ADM) on [DATE] at 12:18 p.m. indicated: - A Medication Administration Record dated [DATE] at 9:54 p.m., LN E had passed medication to a resident in another room which did not align with the LN E ' s progress note documented on [DATE] at 9:40 p.m. which indicated LN E discovered Resident 1 unresponsive and promptly initiated CPR. - According to a screen shot of a phone log, LN H called the DON at 10:10 p.m. on [DATE]. - According to a screen shot of a phone log, a call was placed to 911 was placed at 10:11 p.m. on [DATE]. - According to a screen shot of a phone log, a call was made to the DON a second time to notify her Resident 1 was found unresponsive, CPR was initiated, and 911 had been called at 10:11 p.m. A review of an undated facility policy titled, Emergency Procedure - Cardiopulmonary Resuscitation indicated, .If an individual .is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR . If the resident ' s DNR [DNR- a medical order instructing healthcare providers not to perform CPR or other life-saving measures if a person ' s heart or breathing stop] status is unclear, CPR to be initiated until it is determined that there is a DNR or a physician ' s order not to administer CPR . Instruct a staff member to activate the .[Rapid Response] code and call 911 . A review of the 2020 American Heart Association ' s Adult Basic Life Support [BLS] Algorithm for Healthcare Providers indicated, .Look for no breathing .and check pulse (simultaneously). Is pulse definitely felt within 10 seconds? .[If] No breathing .pulse not felt .By this time in all scenarios, emergency response system or backup is activated, and AED [automatic external defibrillator] and emergency equipment are retrieved or someone is retrieving them .Start CPR .Use AED as soon as it is available .AED arrives. Check rhythm. Shockable rhythm [the pattern or timing of the heart beats]? Yes, shockable .Give 1 shock [an electric shock to a person experiencing an abnormal heart rhythm]. Resume CPR immediately . 3. During a concurrent interview and policy review on [DATE] at 10:47 a.m., the DON confirmed the facility policy, Emergency Procedure - Cardiopulmonary Resuscitation indicated, .Instruct a staff member to retrieve the automatic external defibrillator [AED]. The DON stated the facility did not have an AED to be used to provide BLS to a resident who needed it. During an interview on [DATE] at 3:30 p.m., the Medical Director (MD) stated he expected nursing staff to follow the CPR policy. The MD also stated the use of an AED was expected as part of the BLS process. A review of an undated facility policy titled, Emergency Procedure - Cardiopulmonary Resuscitation indicated, Purpose .Personnel have completed training on the initiation of .CPR and .BLS, including defibrillation for victims of .SCA. Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival . Maintain equipment and supplies necessary for CPR/BLS in the facility at all times .Initiate the .BLS sequence of events . When the AED arrives, assess for need and follow AED protocol as indicated. 4. A review of an email received from the DON on [DATE] at 12:31 p.m. indicated, .Hereto attached are the CPR certs [certification] for [LN H], [LN G], and [LN E]. [LN F ' s] is expired. But she [LN F] did not perform CPR that day [[DATE] on Resident 1]. A review of an undated facility policy titled, Emergency Procedure - Cardiopulmonary Resuscitation indicated, Purpose .Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation for victims of sudden cardiac arrest. CPR/BLS certifications are required for the Registered Nurses, Licensed Vocational Nurses .Preparation for [CPR] .Obtain and/or maintain American Red Cross or American Heart Association .certification in .BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel .

Based on interview and record review, the facility failed to supervise and assist two of two residents with generalized muscle weakness and requiring assistance with personal care (Residents 1 and 2) to prevent accidents. For Resident 1, the facility failed to supervise and assist the resident while using the commode (a portable toilet chair with a removable basin placed next to the bed of residents with mobility deficits to facilitate toileting). This failure resulted in Resident 1 getting up unassisted from the commode and falling forward face down on the floor, causing a neck fracture (broken bone) requiring hospitalization and surgical repair. For Resident 2, the facility failed to supervise and assist the resident while attempting to get out of the bed to use the commode. This failure resulted in Resident 2 falling and braking her right arm while trying to get up from her bed unassisted. Findings: RESIDENT 1 A review of Resident 1 ' s Face Sheet indicated she was admitted to the facility on [DATE], and had diagnoses including heart failure (when the heart does not pump enough blood), muscle weakness, falls, obesity, need for assistance with personal care, dementia (A group of thinking and social symptoms that interferes with daily functioning), and psychosis (a mental health disorder causing the person to see and hear things others do not and have false beliefs about external reality). A review of Resident 1 ' s care plans indicated fall prevention care plan titled Falls dated 2/3/21, containing interventions including: (1) address identified risk factors from fall risk assessment; (2) provide assistance as identified in transfer and mobility; and (3) establish patient ' s physical function and capabilities and provide measure/approaches to assist patient. A review of Resident 1 ' s Fall Risk assessment dated [DATE], indicated a score of 14 (scores of 10 or higher represents the resident was at HIGH RISK for falls). The Fall Risk Assessment indicated Resident 1 was FORGETFUL, REQUIRES REGULAR ASSIST[ANCE] for mobility during toileting, had GAIT (a person ' s manner of walking)/BALANCE PROBLEM, and took medications known to increase the risk for falls such as antipsychotics (a type of medication primarily used to manage psychosis) and diuretics (a diuretic is any substance that promotes the increased production of urine thereby ridding the body of excess water and salt. Diuretics are often used to treat high blood pressure and/or heart problems.) A review of Resident 1 ' s Minimum Data Set (MDS) (a comprehensive, standardized resident assessment tool) dated 2/10/23 indicated the following: - Resident 1 had a BIMs (Brief Interview for Mental Status - the cognitive assessment of the MDS) score of 9 (Scores of 8-12 indicate impaired cognition); - Resident 1 was not independent and needed staff assistance for activities of daily living including toilet use and personal hygiene; - Resident 1 was not steady, only able to stabilize with staff assistance during moving from seated to standing position, walking, turning around, moving on and off the toilet and during surface-to-surface transfers (transfers between bed and chair or wheelchair); - Resident 1 used a walker as a mobility device; - Resident 1 was receiving antipsychotic (to treat psychosis) and diuretic (to treat blood pressure) medications (antipsychotics and diuretics can cause dizziness and increase the risk of falls); and, - Resident 1 was occasionally incontinent (loss of control) of bowel and bladder. A review of Resident 1 ' s SBAR-FALL (SBAR is an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) record dated 3/12/23 indicated Resident 1 suffered a fall in her room on 3/12/23, as follows: During safety rounds Charge Nurse heard the resident yell Help Charge Nurse immediately went to Resident ' s room. Resident noted sitting on the floor, upon asking resident what happened resident verbalized I lost my balance and fell . A review of Resident 1 ' s care plans indicated a second fall prevention care plan, also titled Falls, created on 3/12/23. This care plan restated the fall prevention interventions found in the first Falls care plan dated 2/3/21. A review of IDT (Interdisciplinary Team) note dated 3/28/23 indicated the facility had reviewed Resident 1 ' s fall of 3/12/23 and decided not to implement new fall prevention interventions and to continue with the current fall plan of care interventions of low bed (bed and/or mattress close to the floor), encourage resident to use walker and monitor the resident. A review of Resident 1 ' s Fall Risk assessment dated [DATE] indicated a score of 16. The Fall Risk Assessment indicated Resident 1 was FORGETFUL, REQUIRES REGULAR ASSIST[ANCE] for mobility during toileting, had GAIT/BALANCE PROBLEM, had previous falls, and took medications known to increase the risk for falls such as antipsychotics and diuretics. A review of Resident 1 ' s MDS assessment dated [DATE] indicated the following: - Resident 1 had a BIMs score of, now, 8; - Resident 1 was not independent and needed staff assistance for activities of daily living including toilet use and personal hygiene; - Resident 1 was not steady, only able to stabilize with staff assistance during moving from seated to standing position, walking, turning around, moving on and off toilet and during surface-to-surface transfers (transfers between bed and chair or wheelchair; - Resident 1 used a walker as a mobility device; - Resident 1 was receiving antipsychotic (to treat psychosis) and diuretics (to treat blood pressure) medications (antipsychotics and diuretics can cause dizziness and increase the risk of falls); and - Resident 1 was occasionally incontinent of bowel and bladder. A review of Progress Note dated 5/17/23, at 3:27 p.m., written by Licensed Nurse A, indicated: During safety rounds, Resident [1] is seen on her commode. A review of Progress Note dated 5/17/23, three minutes later, at 3:30 p.m., also written by Licensed Nurse A, indicated: During endorsement [when nurses pass on the care of residents to the oncoming shift] 2LNs [Licensed Nurses] heard a silent muffled sound. 2LNs immediately when to the resident [Resident 1]. Resident [1] is found face forward on the floor. Resident stated, I felt dizzy and fell face forward. Resident is unable to move upper and lower extremities (upper extremities: arms; lower extremities: legs). Resident is noted with 6/10 [6 on a 0-10 scale] generalized pain . A review of Progress Note dated 5/17/23, at 3:43 p.m., indicated Paramedics arrived. Resident sent to [hospital]. A review of Resident 1 ' s SBAR-FALL record dated 5/18/23 indicated Resident 1 suffered an unwitnessed fall on 5/17/23 resulting in injury and transfer to the hospital. A review of Progress Note dated 5/18/23, at 2:22 a.m., indicated Resident [1] currently in the Operating Room to have surgery . A review of Progress Note dated 5/18/23, at 2:38 a.m., indicated .they will be putting a rod on [Resident 1] ' s neck . A review of Progress Note dated 5/18/23, at 1:24 p.m., indicated . [Resident 1] had C1-C2 laminectomy (a neck/spine surgery) . A review of Progress Note dated 5/18/23, at 2:08 p.m., indicated Resident 1 remained hospitalized in the Intensive Care Unit. During an interview on 5/19/23, at 12:59 p.m., Confidential Witness stated the facility allowed Resident 1 to use the commode and get up unassisted. Confidential Witness further stated Resident 1 had complained earlier in the day on 5/17/23, prior to her fall, of feeling dizzy. During an interview and record review on 7/7/23, at 1:35 p.m., Nursing Supervisor B confirmed Resident 1 fell on [DATE] at 3:30 p.m. and injured her neck. Nursing Supervisor B stated on the day of fall, 5/17/23, Resident 1 was observed seated in the commode in her room before she was found on the floor face down, as indicated by the Licensed Nurse A ' s note dated 5/17/23 at 3:27 p.m. Nursing Supervisor B stated it appeared [Resident 1] got up from the commode by herself and fell forward. RESIDENT 2 A review of Resident 2 ' s Face Sheet indicated she was originally admitted to the facility on [DATE] with diagnoses including repeated falls, history of multiple, frequent falls, muscle wasting, muscle weakness, difficulty in walking, need for assistance with personal care, and stroke. A review of Resident 2 ' s care plans indicated a fall prevention care plan titled Falls dated 4/8/19 containing interventions which included: (1) address identified risk factors from fall risk assessment; (2) provide assistance as identified in transfer and mobility; and (3) establish patient ' s physical function and capabilities and provide measure/approaches to assist patient. A review of Resident 2 ' s Falls care plan was updated on 11/4/20, 12/20/20 and 2/10/21 with interventions including: (4) toileting schedule (assist to the bedside commode) at night shift between 2 a.m. and 7 a.m. when awake; (5) staff member to stay by the door by turns between 1 a.m. and 7 a.m.; and (6) Falling Star Program (a set interventions to prevent resident falls). A review of Resident 2 ' s Minimum Data Set (MDS) (a comprehensive, standardized resident assessment tool) dated 1/14/23 indicated the following: - Resident 2 had a BIMs (Brief Interview for Mental Status - the cognitive assessment of the MDS) score of 3 (Scores of 0-7 indicate severe impaired cognition); - Resident 2 was not independent and needed staff assistance for activities of daily living including toilet use and personal hygiene; - Resident 2 was not steady, only able to stabilize with staff assistance during moving from seated to standing position, walking, turning around, moving on and off the toilet and during surface-to-surface transfers (transfers between bed and chair or wheelchair); - Resident 2 used a wheelchair as a mobility device; - Resident 2 was occasionally incontinent (loss of control) of bowel and bladder. A review of Resident 2 ' s Fall Risk assessment dated [DATE] indicated Resident 2 had fall risk factors including disorientation (confusion, forgetfulness) and that Resident 2 required regular assistance with elimination (toileting). A review of Resident 2 ' s MDS assessment dated [DATE] indicated the following: - Resident 2 had a BIMs score of 3; - Resident 2 was not independent and needed staff assistance for activities of daily living including toilet use and personal hygiene; - Resident 2 was not steady, only able to stabilize with staff assistance during moving from seated to standing position, walking, turning around, moving on and off toilet and during surface-to-surface transfers (transfers between bed and chair or wheelchair; - Resident 2 used a wheelchair as a mobility device; and - Resident 2 was occasionally incontinent of bowel and bladder. A review of Progress Note dated 5/12/23, at 10:30 p.m., written by Licensed Nurse B, indicated: While safety rounds is being done, resident was found sitting on the floor . Patient complained of pain in the right shoulder . Right arm noted with abrasion . A review of Resident 2 ' s SBAR-FALL (SBAR is an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) record dated 5/13/23, 12:45 a.m., indicated Resident 2 suffered an unwitnessed fall in her room on 5/12/23, at 10:30 p.m. and that an x-ray of Resident 2 ' s right shoulder was ordered. A review of Progress Note dated 5/13/23, at 10:14 a.m., indicated the facility received the results of Resident 2 ' s x-ray which revealed a humeral neck fracture (broken arm). During an observation and interview on 7/10/23, at 3:10 p.m., Resident 2 was in her room visiting with a family member. The family member stated Resident 2 was very confused and forgetful, had muscle weakness and needed staff assistance to transfer out of bed, used a commode next to her bed for bowel and bladder elimination and used a wheelchair for locomotion. The family member stated Resident 2 had a long history of falls and was admitted to the facility because of falls at home. During an interview on 7/10/23, at 3:35 p.m., Licensed Nurse B, who found Resident 2 on the floor on 5/12/23, the date of the fall, stated Resident 2 she was trying to go to the commode. Licensed Nurse B stated Resident 2 most likely fell while attempting to transfer from bed to the commode unassisted. During an interview on 7/10/23, at 4 p.m., the Nursing Supervisor stated Resident 2 had dementia, muscle weakness, was incontinent and needed staff assistance to transfer to the commode. The Nursing Supervisor stated Resident 2 was very good at using the call light to alert staff she needed to use the commode but sometimes forgot to do it. During an interview on 7/12/23, at 10:13 a.m., the Director of Nursing (DON) was asked what new interventions had been implemented to prevent further falls for Resident 2. The DON stated the facility had increased supervision of Resident 2 and implemented a toileting program where staff checked Resident 2 every two hours to see if Resident 2 needed to use the commode and assist her. A review of facility policy and procedure titled, Fall Management, undated, indicated: Based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes and try to reduce the risk of the resident falling and try to minimize complications from falling. A fall prevention program will be developed for each resident that will provide staff with creative functional strategies to minimize the risk of falls and undue injuries from such incidents . Resident conditions that may contribute to the risk of falls include . delirium (a serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings) or other cognitive impairment; lower extremity weakness, medication side effects; functional impairments; and incontinence. Medical factors that contribute to the risk of fall include: .heart failure; neurological disorders; and balance and gait disorders. The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for fall and establish a resident-centered falls prevention plan based on relevant assessment information. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of fall for each resident at risk or a with a history of falls. A review of facility policy and procedure titled, Safety Supervision of Residents, undated, indicated: Resident safety and supervision and assistance to prevent accidents are Company-wide priorities. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs .

Based on observations, interviews, and record reviews, the facility failed to ensure the safety of one resident, Resident 1, when she was not provided adequate supervision and assistance with transfer and mobility, based on her plan of care to prevent falls and plan of care related to visual deficit (a lack or deficiency in vision). This failure had resulted in a fall with fracture (broken bone) to Resident 1 that caused her to be in severe pain and required a surgical procedure to repair the affected hip. Findings: A review of Resident 1's Progress Notes, dated 4/23/23, at 7:50 p.m., authored by Licensed Vocational Nurse A (LVN A), indicated, Resident was heard yelling for help; LN (Licensed Nurse) and other staff immediately went to the resident (Resident 1) and seen (sic) her lying down on her left side outside room [ROOM NUMBER]. Upon assessment done by 3 LN's; Skin is intact, but resident (Resident 1) is moaning and crying. Upon further assessment, resident (Resident 1) remains alert and verbally responsive .Confused as baseline. Unable to obtain more information regarding how she fell as it was unwitnessed . LN's (Licensed Nurses) asked resident (Resident 1) to move her upper extremities, she was able to move her bilateral arms with no pain or discomfort, but when asked to move her lower extremities, patient's (Resident 1's) crying intensified and was trying to hold her left thigh. Other LN's present called PA (Physician's Assistant) to report the incident and got an order to send the patient (Resident 1) out to the ED (Emergency Department) for further eval (evaluation). 911 called; spoke to dispatcher while with the patient. A review of Resident 1's Hospital Medicine H&P (History and Physical) Note, dated 4/23/23, at 10:33 p.m., the HPI (History of Present Illness) indicated, An elderly female who is a resident of a SNF (Skilled Nursing Facility) due to advanced Dementia had an unwitnessed ground level fall in the hallway of the facility with immediate onset of left hip pain. She (Resident 1) was brought in by ambulance to ER (emergency room ) where imaging studies revealed left hip fracture .At baseline she is alert and oriented 4 (for) herself, here she is not able to provide any history other than stating that her leg hurts. She has no recollection of the events and cannot provide any information. A concurrent observation and interview with Resident 1 on 5/10/23, at 10:20 a.m., was assisted by Certified Nursing Assistant B (CNA B) to do translations, as Resident 1 was Spanish speaking only. Resident 1 was observed lying in bed, on her left side, and her lower extremities were covered with a blue blanket. When CNA B asked her in Spanish how she was doing, Resident 1 responded in Spanish which CNA B translated that Resident 1 stated she was fine but was having pain, observed holding on to her left lower leg. When Resident 1 was asked to describe the fall incident, Resident 1 stated in Spanish that she was trying to get out of bed and fell . Resident 1 stated that she was not using her walker when she fell . This surveyor and CNA B, both observed that Resident 1's walker was not in her current room. When CNA B asked Resident 1 where was her walker, she stated that it was stolen from her, and that her daughter bought that walker for her. During a concurrent observation and interview on 5/10/23, at 12:50 p.m., with CNA C, when he was asked what was Resident 1 doing prior to the incident, CNA C stated that he saw Resident 1 in the dining room after dinner together with five or six other residents and they were watching T.V. CNA C showed where Resident was seated while she was watching T.V. and the kind of chair that she was seated on, which was a regular dining room chair. CNA C then took this surveyor to the location where Resident 1 fell in the hallway in front of room [ROOM NUMBER]. The distance from where Resident 1 was seated at the dining room to where she fell was approximately 35-40 feet. CNA C stated that he was alerted to the location of the fall when he responded to a call from one of the licensed nurses. CNA C stated that LVN A and five other staff had already responded to the incident when he came to help. During an interview on 5/10/22, at 1:35 p.m., with LVN A, he stated at around 7 p.m. on 4/23/23, Resident 1 was finished with her dinner and was watching T.V in the dining room (across from the nurse's station) with three other residents. Shortly thereafter, LVN A stated that he was charting at the nurse's station when he heard somebody yelling and the CNA's close to the area of yelling responded and got there before he did. LVN A stated that it was probably CNA D or another female aide who responded to the incident. LVN A stated he saw Resident 1 lying on the floor on her left side and was yelling in pain. LVN A stated that he had Resident 1 stay where she was and let the EMTs (Emergency Medical Technicians) take her to the ED. LVN A stated that he did not see Resident 1's walker at the location of the fall and stated, definitely, [Resident 1] was not using her walker when she fell . LVN A stated that there was no staff in the dining room with the residents before the resident (Resident 1) fell . LVN A stated that Resident 1 had to use a walker for stability. During an interview on 5/10/23, at 2:15 p.m., with CNA D, she stated she was in room [ROOM NUMBER] doing patient care when she heard a big scream and found Resident 1 lying on the floor, on her left side and screaming in pain while holding her thigh. CNA D stated that Resident 1 was found close to her former room [ROOM NUMBER]. CNA D stated that Resident 1 usually used her walker but the day she fell , she was not using a walker. CNA D stated that Resident 1 would sometimes forget to use a walker and would grab on the handrails for balance. CNA D stated she did not know if Resident 1 left her walker in her room or in the dining room. CNA D stated that residents who are alert can be left in the dining room without supervision. A review of Resident 1's MDS (Minimum Data Set- is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 4/21/23, the MDS indicated on Section B (Hearing, Speech, and Vision), Resident 1's vision was assessed to be moderately impaired (limited vision; not able to see newspaper headlines but can identify objects). On Section C (Cognitive Patterns), Resident 1 received a BIMS (Brief Interview for Mental Status) score of 3, indicating that her cognition (Cognition is the mental process involved in knowing, learning, and understanding things) was severely impaired. The MDS indicated on Section G (Functional Status), the mobility devices that Resident 1 normally used were a walker and wheelchair. Also under Section G, for Transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position, excludes to/from bath/toilet), it indicated that Resident 1 needed extensive assistance (resident involved in activity, staff provide weight bearing support) during transfers with one staff providing physical assistance. Under Walk in Corridor (how resident walks in corridor or unit), it indicated Resident 1 needed Supervision (oversight, encouragement or cueing). A review of Resident 1's Care Plan for falls, dated 7/20/2017, indicated that Resident 1 was at risk for falls, the goal for this care plan indicated, Resident 1 will be free of falls, and one of the interventions to prevent falls indicated, Increased staff supervision with intensity based on resident need. A review of Resident 1's Care Plan for falls, initiated on 9/19/18, indicated that Resident 1 was at risk for falls due to: Wandering (Wandering occurs when a person with dementia roams around and becomes lost or confused about their location); Fall Risk Assessment Score (10 and above high risk). The care plan indicated the last two fall assessment scores prior to the fall with injury on 4/23/23, were as follows: 1/7/23: Score 16 (high risk), 4/11/23, Score 12 (high risk). The goal for the care plan for falls indicated, Decrease resident's risk of fall and injury with interventions. One of the interventions to prevent falls indicated, Encourage/remind resident to ask for help when needed if able. Provide assistance as identified in transfer and mobility. A review of Resident 1's Care Plan for visual deficit due to cataracts (A condition in which the lens of the eye becomes cloudy. Symptoms include blurred, cloudy, or double vision; sensitivity to light; and difficulty seeing at night) initiated on 3/1/20, had a goal that indicated, Resident's risk for functional decline due to visual deficit will be minimized with interventions. One of the interventions on this care plan indicated, Assist with transfer, mobility, and ADL (Activities of Daily Living) as needed and keep call lights within reach. During an interview on 5/10/23, at 3:10 p.m., with the Director of Nursing (DON), the DON stated that residents can stay in the dining room after dinner with no staff supervision but with visual checking done by a staff every 30 minutes. The DON stated that there was no assigned staff to do visual checks but whoever was available would do the visual checks of the residents in the dining room. When the DON was asked if there was a policy and procedure on how to do visual checks and how often were the visual checks of the residents in the dining room conducted, she stated that there was no policy or procedure on doing visual checks at the dining room if the residents decided to stay to watch T.V. after dinner. The DON stated that there were no documentation or logs to show that the visual checks were being done by staff. When the DON was asked about Resident 1's wandering behavior, she stated that Resident 1 had been seen trying to exit from the facility's front door. During an interview on 5/15/23, at 2:30 p.m., with Resident 1's daughter, she stated that she was the daughter who visited Resident 1 on 4/23/23, day of the fall with injury. Resident 1's daughter stated that she was surprised to see Resident 1 in the dining room because she rarely went out of her room. She stated Resident 1 was already in the dining room when she came to visit. She stated she visited Resident 1 for two hours and Resident 1 did not have a walker with her in the dining room. Resident 1's daughter stated that Resident 1's personal four-wheeled walker was broken and the facility was not able to fix it, but provided Resident 1 with a facility-owned walker. A review of a facility policy and procedure P&P titled, Fall Management, undated, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to reduce the risk of the resident falling and to try to minimize complications from falling. Under procedure, the P&P indicated, Any resident admitted will have a potential for a fall and/or injuries care plan initiated by the Licensed Nurse within twenty-four (24) hours of admission. This care plan will be modified, as needed with the baseline Care Plan, admission MDS-CAA (Care Area Assessment), and subsequent care plans. Care plans will address any risk factors such as previous history of falls in the past 180 days with or without injury history of wandering, poor safety awareness, use of psychotropic medications, and a current clinical condition of dizziness or irregular heart rate/rhythm, TIA's (Transient Ischemic Attacks), CVA's (Cerebrovascular Accidents), and/or postural hypotension. Under fall risk factors, the P&P indicated, Resident conditions that may contribute to the risk of falls include Visual Deficits.

Based on observation, interview, and record review, the facility failed to ensure residents remained free from abuse when: 1) a. Five of five staff (Unlicensed Staff A, Unlicensed Staff H, Unlicensed Staff I, Administrative Staff G, and Maintenance Staff F) observed on a one-to-one (a clinical assignment used to ensure the safety of residents who have or have the potential to exhibit unsafe behaviors when not attended by staff) assignment did not consistently implement the one-to-one assignment to supervise Resident 1 after the facility learned of Resident 1's sexual abuse of Resident 2. b. Facility staff did not document consistently in the clinical record during one-to-one assignment. These failures provided Resident 1 the opportunity to potentially abuse Resident 2 again, or other residents in the facility. Due to the facility's failure to consistently implement one-to-one supervision of Resident 1, the Administrator and Director of Nurses were verbally notified of an Immediate Jeopardy situation on 7/31/19, at 5:08 p.m. The Administrator and Director of Nurses were informed of the observations and interviews with staff and staff's inconsistent practice. On 7/31/19, at 9:45 p.m., the facility presented and implemented a corrective plan of action, including but not limited to: Competency training for all staff assigned to one-to-one assignments, consistent implementation and documentation for one-to-one assignments, and a process to audit the training and documentation for one-to-one assignments. Removal of the Immediate Jeopardy occurred in the presence of the Administrator, Director of Nurses (DON), Regional Vice President of Operations (RVPO), and Regional Director of Clinical Operations (RDCO) on 8/1/19, at 4:16 p.m., after observations, interviews and record reviews confirmed staff members tasked with a one-to-one assignment had been trained consistently and implemented one-to-one assignments consistently. 2) The facility did not investigate or care plan one resident's (Resident 1) behavior of wandering into other residents' rooms before 7/29/19, or provide supervision to Resident 1 after staff observed the behavior. This resulted in Resident 1's sexual abuse of another resident (Resident 2). 3) The facility did not implement its Abuse & Neglect Prohibition policy, when the facility learned of a sexual abuse allegation against one resident (Resident 4) but did not investigate the allegation or make the facility's abuse coordinator aware of the allegation for three days. This failure provided Resident 4 the opportunity to potentially abuse facility residents. 4) The facility did not care plan to manage one resident's (Resident 4) sexual behavior toward facility residents of the opposite sex. This failure did not meet Resident 4's sexual expression and psychosocial needs, and did not ensure the environment of care was safe and free from abuse when six residents (Resident 5, 6, 8, 9, 10, and 11) vocalized concerns for safety and anger based on alleged unwanted sexual contacts by Resident 4 or observing Resident 4's behaviors. Findings: 1. During an observation inside Resident 1's room on 7/30/19, at 1:50 p.m., Unlicensed Staff A was standing near a chair placed in a corner of the room close to Resident 1's bedside. Resident 1 was resting in the bed with the lights dimmed. Resident 1 appeared asleep. A review of Resident 1's Face Sheet (a document in the medical record containing basic medical and socioeconomic data) indicated Resident 1 had a medical history of [REDACTED]. A review of Resident 1's most current MDS (Minimum Data Set, an assessment tool) indicated Resident 1 achieved a summary score of 7 on a brief interview for mental status (BIMS) from 5/7/19, indicating severe cognitive impairment (impairment indicating severe decline of mental function). Resident 1's MDS indicated the resident required supervision with most activities of daily living and could ambulate without an assistive device. During an interview on 7/30/19, at 3:00 p.m., Resident 1 stated he recalled the sexual abuse incident with Resident 2. Resident 1 stated It was quite entertaining for me. Resident 1 stated he recalled fondling and feeling Resident 2's penis and stated It was entertaining and very exciting. A review of Resident 2's Face Sheet indicated Resident 2 had a medical history of [REDACTED]. A review of Resident 2's most current MDS indicated Resident 2 achieved a summary score of 10 on a BIMS from 5/13/19, indicating moderate cognitive impairment (impairment of the mind, between one's expected mental decline with age and severe decline of mental function). Resident 2's MDS also indicated the resident used a wheelchair to move about the facility and was dependent on at least two staff for assistance when repositioning in bed. During an observation inside Resident 2's room on 7/30/19, at 3:10 p.m., Resident 2 was quietly lying in bed. A wheelchair was positioned at Resident 2's bedside. Resident 2 was awake and alert. During an interview on 7/30/19, at 3:30 p.m., Resident 2 stated he recalled Resident 1 touching Resident 2's penis and underneath his brief. Resident 2 stated Resident 1's touching was unwanted. Resident 2 stated 30 minutes passed between when Unlicensed Staff B separated Residents 1 and 2, and when Licensed Staff C visited Resident 2 to assess the resident following the incident. During an interview on 7/30/19, at 1:08 p.m., the Administrator stated on the morning of 7/29/19, at 8:45 a.m., Unlicensed Staff B came to me and reported seeing Resident 1 sexually abusing Resident 2. the Administrator stated Unlicensed Staff B observed Resident 1 standing over Resident 2, handling Resident 2's genitalia. The Administrator stated she was the facility's abuse coordinator. The Administrator stated Unlicensed Staff B reported the observation to the Administrator immediately after Unlicensed Staff B reported to the charge nurse. During an interview on 7/30/19, at 1:35 p.m., Unlicensed Staff B stated she observed Resident 1 abuse Resident 2 on the morning of 7/29/19, at 8:45 a.m. Unlicensed Staff B stated she was assigned to Resident 2's care that morning. She stated when she entered Resident 2's room to get some diapers for a resident in another room, she noticed Resident 2 waving for attention. Unlicensed Staff B stated she walked toward Resident 2 and found Resident 1 at Resident 2's bedside. Unlicensed Staff B stated Resident 1's hand was inside Resident 2's gown and blankets, and Resident 1's hand was moving up-and-down at or around Resident 2's genitals. Unlicensed Staff B stated she separated Residents 1 and 2 and notified the charge nurse. Unlicensed Staff B stated she did not recall what the charge nurse initially told her; however, sometime later, the charge nurse (Licensed Staff C) told me to finish (morning hygiene), and then tell the administrator about the incident. Unlicensed Staff B stated after informing Licensed Staff C of the incident, she completed her prior task, washed her hands, and then initiated morning hygiene with Resident 2. Unlicensed Staff B stated she knew Resident 1 had touched Resident 2's penis and genitals because Resident 2's penis was outside the resident's brief when she performed Resident 2's morning hygiene. During an interview on 7/30/19, at 1:50 p.m., Unlicensed Staff A stated his shift assignment required supervision of (Resident 1). Unlicensed Staff A stated he was assigned to observe Resident 1 for sexual contact. Unlicensed Staff A stated he would report all observations of sexual-contact behavior by Resident 1 during his shift that day. During an interview on 7/30/19, at 2:00 p.m., Licensed Staff C stated she was Resident 2's nurse at the time of the abuse incident involving Residents 1 and 2. Licensed Staff C stated she was not near the location of the incident when Unlicensed Staff B notified her. Licensed Staff C stated she was in the middle of med pass, but stopped med pass upon learning of the incident to assess Resident 2. Licensed Staff C stated Resident 2 exhibited no signs of distress or emotional concern, and nodded in affirmation when asked, Are you OK? Licensed Staff C stated she physically assessed the resident around 9:05 a.m., about the time she informed Unlicensed Staff B to notify the administrator about the abuse. During an interview on 7/30/19, at 2:35 p.m., Licensed Staff D stated she was Resident 1's nurse at the time of the abuse. Licensed Staff D stated Licensed Staff C notified her of the incident. Licensed Staff D could not recall the time when she was notified. Licensed Staff D stated she could not recall what she was doing when she was notified. Licensed Staff D stated she assessed Resident 1 upon learning of his behavior toward Resident 2. Licensed Staff D stated Resident 1 did not remember touching anybody or being in Resident 1's room. Licensed Staff D stated the facility instituted one-to-one monitoring for Resident 1 afterward. Licensed Staff D stated she created a new care plan to meet Resident 1's need for supervision. During an observation on 7/31/19, at 8:20 a.m., Resident 1 was seated in the lobby with a staff member, Maintenance Staff F, seated nearby. During a concurrent observation and interview on 7/31/19, at 8:30 a.m., Maintenance Staff F was seated alongside Resident 1. Maintenance Staff F stated his shift assignment was one-to-one with Resident 1. Maintenance Staff F stated he did not know the duties for his assignment and stated I don't know. Maintenance Staff F stated he was required to ensure the safety of (Resident 1). Maintenance Staff F stated Administrative Staff G trained him. Maintenance Staff F stated this was the second time he received a one-to-one assignment to ensure resident safety. During an observation on 7/31/19, at 9:00 a.m., Maintenance Staff F was seated next to Resident 1 in the lobby. Maintenance Staff F stood and walked over to the lobby reception desk. Maintenance Staff F helped the receptionist with her desk. Resident 1 remained seated. Maintenance Staff F focused his attention on the desk and its drawer, spoke with the receptionist, and turned his back to Resident 1. Maintenance Staff F returned to the chair beside Resident 1 holding a desk drawer. Seated next to Resident 1, Maintenance Staff F worked on the desk drawer with his hands. Maintenance Staff F identified another staff member entering the facility's lobby. Maintenance Staff F stood and walked ten feet away to speak with the staff member, leaving Resident 1 and the drawer unattended. Resident 1 remained seated. After the conversation ended, Maintenance Staff F returned to the seat beside Resident 1 and recommenced fixing the drawer. During an interview on 7/31/19, at 9:50 a.m., the DON stated the facility maintained neither a policy on one-to-one assignments, nor a policy defining the supervision required for a one-to-one assignment. The DON stated the facility maintained guidelines for monitoring residents. The DON stated the facility's Director of Staff Development (DSD) was responsible for training staff on those guidelines. During an interview on 7/31/19, at 9:55 a.m., the Director of Staff Development stated the facility did not provide a formal training on one-to-one assignments or supervision to non-clinical staff. The DSD stated non-clinical staff did not receive a copy of the facility's guidelines for monitoring residents. The DSD stated non-clinical staff received a verbal training from charge nurses and were informed to speak to the nurses if they have any questions. The DSD stated a one-to-one assignment required constant observation of the assigned resident, in a close proximity to the resident. During a concurrent interview and record review on 7/31/19, at 10:30 a.m., the Director of Staff Development reviewed the facility's in-service records from (YEAR) and 2019. The DSD stated the facility retained evidence of one training for its clinical staff on the topic of one-to-one monitoring. An In-Service Training Report, dated 3/12/2019, indicated the facility trained its licensed nurses (no unlicensed staff, nursing or otherwise) on (One-to-one) Monitoring, however, the report did not describe what information the facility used to train its staff or what information the facility used to deem its staff competent. During an observation on 7/31/19, at 10:52 a.m., Maintenance Staff F was seated next to Resident 1 in the lobby. During an interview and observation on 7/31/19, at 11:20 a.m., Administrative Staff G sat next to Resident 1 in the activities room. Administrative Staff G stated she had a one-to-one with Resident 1. Administrative Staff G stated she was not required to document in any record for the one-to-one assignment. During an interview on 7/31/19, at 11:25 a.m., Licensed Staff Z stated Maintenance Staff F and Administrative Staff G had a one-to-one assignment for Resident 1 for parts of the day. Licensed Staff Z stated the staff assigned as one-to-one with Resident 1 did not have to document in the clinical record. Licensed Staff Z stated the staff assigned had to provide a verbal report, after (their) shift, to Resident 1's nurse or the unit manager. Licensed Staff Z stated she checked visually, every hour, to ensure the assigned staff member was with Resident 1. Licensed Staff Z stated one-to-one monitoring required the facility to closely monitor the indicated resident, whatever they are doing, and the charge nurse must document in the progress notes. During a concurrent interview and record review on 7/31/19, at 1:30 p.m., the Director of Nurses stated she expected staff with a one-to-one assignment to watch the patient and only that patient, with no other assignment. The DON stated staff with a one-to-one assignment must be physically present and keep the patient in vision. The DON stated she ensured a one-to-one assignment was implemented appropriately by checking the documentation of staff assigned to the one-to-one assignment. During a concurrent interview and record review on 7/31/19, at 2:30 p.m., Administrative Staff G reviewed a form titled, (One-to-one Monitoring) Documentation. Administrative Staff G stated the form was the documentation for Resident 1's one-to-one monitoring, for 7/31/19. Administrative Staff G stated she began to complete the form, including the portions indicated for Maintenance Staff F's completion. The form indicated no date. The form indicated no initials next to each entry made. The form indicated it should be completed by a C.N.[NAME], or certified nurse assistant. The form indicated staff entered information about Resident 1's activity, every 30 minutes, between (8:00 a.m.) and (2:30 p.m.) The form indicated no documentation before 8:00 a.m., on 7/31/19. Administrative Staff G verified the form was incomplete and documentation was missing. During a concurrent interview and record review on 7/31/19, at 2:45 p.m., Unlicensed Staff I reviewed the facility's staffing assignment sheet for 7/29/19. Unlicensed Staff I confirmed she had a one-to-one assignment with Resident 1 on 7/29/19. Unlicensed Staff I stated she was assigned to Resident 1 because the resident's fall risk. Unlicensed Staff I stated she did not recall other risks prompting the one-to-one assignment. Unlicensed Staff I stated her one-to-one assignment with Resident 1 did not require documentation. During an observation on 7/31/19, at 3:20 p.m., Unlicensed Staff H was standing against a wall in the lobby near where Resident 1 was seated. Another resident called out for Unlicensed Staff H's attention. Unlicensed Staff H walked away from Resident 1, over to the other resident and took a package from the other resident's hands. With the package, Unlicensed Staff H walked behind the nursing station and into a room, and closed the door behind her. Unlicensed Staff H opened the door and walked out of the room, and returned to the spot where she stood against the wall near Resident 1. Unlicensed Staff H did not ask any other staff to supervise Resident 1 while facilitating the other resident's request. During an interview on 7/31/19, at 3:20 p.m., Unlicensed Staff H stated her assignment for the shift was one-to-one with Resident 1. Unlicensed Staff H stated she had left Resident 1's side to put away another patient's food. Unlicensed Staff H stated she knew Resident 1 would not leave if she left the lobby and returned, Because (Resident 1) stays. During a review of the clinical record for Resident 1, the Resident Progress Notes, dated 7/29/19, at 8:45 a.m., indicated Licensed Staff D initiated visual checks for Resident 1 q 15 mins, or every 15 minutes, after the facility learned of Resident 1's sexual abuse of Resident 2. During a review of the clinical record for Resident 1, the Care Plan, dated 7/29/19, no time, indicated the facility implemented (one-to-one monitoring) for Resident 1 for at least 72 hours after the incident. During a review of the clinical record for Resident 1, Resident 15 Minutes Visual Check forms, dated 7/29/19 and 7/30/19, no times, indicated no entry to indicate staff performed a Visual Check of Resident 1 during the 7/29/19 AM Shift, between 11:00 a.m. and 2:45 p.m., on 7/29/19, or during the 7/30/19 N[NAME] Shift, between 11:00 p.m. and 2:30 a.m., 3:00 a.m. and 4:45 a.m., and 5:15 a.m. and 6:45 a.m. During a review of the clinical record for Resident 1, the Every 30 minutes Safety Watch form, dated 7/31/19, no time, indicated facility staff initiated a Safety Watch to record the activity of Resident 1, on 7/31/19, every thirty minutes between 6:30 a.m. and 1:30 p.m. The form did not indicate staff performed a safety watch of Resident 1 before 6:30 a.m., or after 1:30 p.m. During a review of the clinical record for Resident 1, the (One-to-one) Monitoring Documentation form, no date, no time, did not indicate the date when the facility implemented one-to-one monitoring for Resident 1. The form indicated the facility began implementing one-to-one monitoring at (8:00 a.m.) The form indicated the facility did not implement one-to-one monitoring between 12:00 a.m. and 8:00 a.m. The facility guideline titled Guidelines in Monitoring of Residents, dated 05/2013, indicated it was used for safety, generally. The guidelines indicated only the facility's Interdisciplinary Team (IDT) may institute one-to-one monitoring. The guidelines did not define one-to-one monitoring. The guidelines did not indicate the duties for one-to-one monitoring. The guidelines indicated one-on-one monitoring required more supervision than close supervision, which required resident relocation to areas monitored by staff. The guidelines did not standardize the location where staff tasked with a one-to-one monitoring assignment could document. The guidelines indicated staff may utilize an hourly, or every 30 minutes, or every 15 minutes form for documentation and/or nurses' notes. The facility policy and procedure titled, Abuse & Neglect Prohibition, revised 10/2004, indicated the facility will protect residents from harm during the investigation. The policy indicated no suggested approach for ways the facility would monitor, if appropriate, residents exhibiting abusive behavior to protect other residents from harm. 2. During an interview on 7/30/19, at 1:08 p.m., Administrator stated on the morning of 7/29/19, at 8:45 a.m., Unlicensed Staff B came to me and reported seeing Resident 1 sexually abusing Resident 2. Administrator stated Unlicensed Staff B observed Resident 1 standing over Resident 2, handling Resident 2's genitalia. Administrator stated she was the facility's abuse coordinator. Administrator stated Unlicensed Staff B reported the observation to Administrator immediately after Unlicensed Staff B reported to the charge nurse. During an interview on 7/30/19, at 1:45 p.m., Unlicensed Staff B stated she was assigned to care for the abused, Resident 2, at the time of the incident. Unlicensed Staff B stated she did not know Resident 1 posed a safety risk on the morning of the incident, 7/29/19. Unlicensed Staff B stated she did not pay attention to the safety risk posed by residents to which she was not assigned. Unlicensed Staff B stated: I have a habit to just get my report. I do my patient. She stated: I do not listen for safety concerns mentioned about other residents. During an interview on 7/30/19, at 2:00 p.m., Licensed Staff C stated she had no recollection of Resident 1's wandering behavior, but recalled Resident 1 would just walk and not go into rooms. During an interview on 7/30/19, at 2:35 p.m., Licensed Staff D stated she was aware of Resident 1's wandering behavior. Licensed Staff D stated Resident 1 goes in-and-out of his room, and was out of his room frequently. During an interview on 7/31/19, at 5:34 p.m., Social Service Director (SSD) stated she observed Resident 1 seated inside Resident 2's room at the bedside between 7/20/19 and 7/29/19. SSD stated she observed Resident 1 sitting on Resident 2's wheelchair and recalled Resident 2 did not want Resident 1 there. SSD stated she notified Licensed Staff [NAME] of her observation. SSD stated Resident 1 had a history of [REDACTED]. SSD stated Resident 1 wandered into Resident 2's room because that room had a sliding door. SSD stated Resident 1 liked sliding doors. SSD stated the facility moved Resident 1 in early (MONTH) into a room without a sliding door because of Resident 1's wandering and elopement risk. During an interview on 7/31/19, at 6:40 p.m., Resident 2 stated Resident 1 had been inside Resident 2's room days before the abuse. Resident 2 stated Resident 1 sat in Resident 2's wheelchair at the resident's bedside. Resident 2 stated the Social Services Director removed Resident 1 on that occasion. During an interview on 8/20/19, at 11:02 a.m., Licensed Staff D stated nursing supervised Resident 1's elopement and wandering behaviors prior to the 7/29/19 incident through general nursing rounds. Licensed Staff D stated nursing did not place Resident 1 on heightened supervision until the incident of abuse because Resident 1 was not going into other resident rooms. During a review of Resident 1's medical record, the Care Plan for Behavioral Symptoms, dated 4/23/18, indicated Resident 1 exhibited searching behaviors and had a history of [REDACTED]. During a review of Resident 1's medical record, the Progress Notes, dated 7/3/19, indicated Resident 1 needs to be in a room with no sliding door, because the resident has a behavior of wandering. During a review of Resident 1's medical record, no care plans indicated a plan to manage the potential for Resident 1's searching behavior to bring Resident 1 into other residents' rooms with a sliding door. The facility policy and procedure titled Resident Elopement, released 8/5/01, indicated the policy concerned residents attempting to leave the premises, or suspected of being missing . The policy did not indicate how the facility managed residents who wandered in the facility without leaving the premises or going missing. The facility maintained no policy and procedure to standardize a process for managing patients with a history of wandering (behaviors of repetitive walking or similar movement, which is inconsistent with boundaries, limits, or obstacles, and which expose a resident to harm). The facility guideline titled Guidelines in Monitoring of Residents, dated 05/2013, indicated it was used for safety, generally. The guidelines indicated only the facility's Interdisciplinary Team (IDT) may institute one-to-one monitoring. The guidelines indicated one-on-one monitoring required more supervision than close supervision, which required physical relocation of the resident to areas monitored by staff. The guidelines did not define one-to-one monitoring. The guidelines did not indicate the duties for one-to-one monitoring. 3. During an interview on 7/30/19, at 1:08 p.m., Administrator stated the facility Administrator was the facility's Abuse Coordinator. During an interview on 8/16/19, at 12:30 p.m., Administrator stated she was present in the facility on 8/2/19, when Resident 6 vocalized concern to a charge nurse about the behavior of a male resident in the facility. Administrator stated the facility moved Resident 6 to another room on 8/2/19, between 5:00 p.m. and 6:00 p.m., during the PM shift. A review of Resident 6's Face Sheet indicated Resident 6 had a medical history of [REDACTED]. A review of Resident 6's most current MDS (Minimum Data Set, an assessment tool) indicated Resident 6 achieved a summary score of 12 on a brief interview for mental status (BIMS) from 5/21/19, indicating moderately impaired cognitive ability (impairment of the mind, between one's expected mental decline with age and severe decline of mental function). During an observation and interview on 8/16/19, at 2:35 p.m., Resident 6 was seated in a common area alongside a mental health caseworker. Resident 6 stated about six weeks ago Resident 4 stood in Resident 4's doorway and made a sexual hand gesture in Resident 6's direction. Resident 6 stated the hand gesture comprised of Resident 4 sticking his index finger of one hand into a hole, created by the index finger and thumb of Resident 4's other hand. Resident 6 stated she was admitted to a room across the hallway from Resident 4 at the time. Resident 6 stated she witnessed this gesture while lying in bed and talking on the phone. Resident 6 stated the gesture made her feel really, really offended. Resident 6 stated she told Resident 4 to Stop that, after which Resident 4 turned closed Resident 4's door. Resident 6 stated Resident 6's door was open because someone who had been inside her room earlier had forgotten to close it. Resident 6 stated she was pretty big about keeping the door closed now. After the incident, Resident 6 stated the facility moved her to different hallway, away from Resident 4, on Resident 6's request. During an interview on 9/4/19, at 12:45 p.m., Family Member R stated Resident 6 informed Family Member R of an incident when a facility resident located across the hall from Resident 6 had made a sexual hand gesture toward Resident 6. Family Member R stated the facility had since moved (Resident 6) away from that resident and placed (Resident 6) somewhere else. Family Member R stated he believed Resident 6 was currently safe. Family Member R stated Resident 6 has episodes [MEDICAL CONDITION](a mental disorder characterized by excessive excitement), during which the resident vocalized issues that were nothing of concern. Family Member R stated when the resident exhibited mania, investigation is required to determine whether something is right or wrong. During a review of the clinical record for Resident 6, the Resident Progress Notes, dated 8/2/19, at 5:52 p.m., indicated Resident 6, (v)erbalized seeing someone in the room, constantly yelling. The nurse who documented the progress note redirected (Resident 6), but (Resident 6) insisted on moving room(s). Room change done. During a review of the clinical record for Resident 6, the Resident Progress Notes, dated 8/5/19, at 2:30 p.m., indicated (Resident 4) made a gesture with his hand to (Resident 6), and (Resident 6) was not offended and (could) not recall anything about the incident. The progress note indicated it was a Late Entry, entered into Resident 6's medical record on 08/09/2019, seven days after the incident and one day after the facility notified CDPH of the incident, on 8/8/19. During a review of the clinical record for Resident 6, the Care Plan, updated by MDS Coordinator on 8/19/19, at 12:25 p.m., indicated the facility planned to manage Resident 6's hallucination from 8/2/19. The care plan indicated on 8/2/19 Resident 6 insisted on seeing another person (male) in her room. The care plan indicated staff immediately checked at that moment but did not observe a male resident in Resident 6's room at that time. The care plan indicated the facility would take the several approach(es) to manage the residents psychiatric and behavioral health needs, including to identify issues that may trigger behavioral manifestations. The facility's Investigation Summary of the incident between Residents 4 and 6, dated 8/15/19, indicated the facility learned about Resident 4's behavior on or before 8/2/19, a Friday. On the same day, the facility facilitated a room change for Resident 6 because the resident desired to be away from a gesturing male resident. The report indicated on 8/2/19 Resident 6 initially reported a concern about the male resident to the charge nurse. The facility policy and procedure titled Abuse & Neglect Prohibition, revised (MONTH) 2004, indicated Each resident has the right to be free from . abuse . The policy indicated the definition of Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. The policy indicated the definition of Sexual abuse includes sexual harassment. The facility policy indicated facility supervisors will immediately correct and intervene in reported or identified situations in which abuse . is at risk for occurring. The policy indicated The facility will conduct an investigation of any alleged abuse . in accordance with state law. The policy indicated the facility will protect residents from harm during the investigation. The facility policy and procedure titled Abuse and Neglect Prohibition Policy and Procedure California Facility Addendum, revised 9/2018, indicated The facility Administrator or designee shall report incidents of 'alleged' or 'suspected' abuse to the Department of Health Services immediately, or within 24 hours. The policy addendum indicated The facility will investigate incidents of 'alleged' or 'suspected' abuse and report the results of all investigations to the facility Administrator or designee as soon as practically possible. The facility policy and procedure titled Abuse Investigation and Reporting, revised 5/28/19, indicated the facility Administrator played a paramount role during an abuse investigation, to lead the response and coordinate data collection and reporting after the investigation concludes. The facility policy and procedure titled Abuse Prevention Program, revised 5/28/19, indicated the facility will, identify and assess all possible incidents of abuse . (and) . Investigate and report any allegations of abuse within timeframes as required by federal requirements, contrary to an abuse policy noted earlier. The state of California has defined sexual harassment, to include a sexual gesture. (https://www.dfeh.ca.gov/resources/frequently-asked-questions/employment-faqs/sexual-harassment-faqs/). 4. A review of Resident 5's Face Sheet indicated Resident 5 had a medical history of [REDACTED]. function). A review of Resident 5's most current MDS (Minimum Data Set, an assessment tool) indicated Resident 5 achieved a summary score of 13 on a brief interview for mental status (BIMS) from 8/7/19, indicating intact cognitive ability. During an interview

Based on observation, interview, and record review, the facility failed to ensure 6 of 19 sampled residents (Resident 4, 5, 6, 7, 16, and 19), and 9 of 21 unsampled residents (Unsampled Residents 20, 21, 22, 23, 24, 27, 29, 34, & 39) were cared for in a respectful manner and in an environment that maintained and enhanced their dignity when: 1. Resident 6 and Unsampled Resident 20 were told to have bowel movements in bed and staff would return later to change them. This failure made residents feel upset and terrible. (Cross Reference 353) 2. Call bells were placed on residents' weak sides therefore making the call bell inaccessable when Residents 5, 6, and 16 and Unsampled Resident 29 needed to summon the nurse for necessary care needs and call bells were not answered timely. (Cross reference F323) 3. Feces was found in the showers when residents attempted to shower, and staff did not clean showers (shower Rooms 1B and 2A) after resident use (Unsampled Resident 34). This failure made the resident feel disgusted. (Cross reference F441) 4. Resident 27 was not provided the necessary staff assistance with opening a sugar packet, salt packet, and a milk carton, causing Resident 27 to struggle to open the sugar packet, and sugar went all over the tray missing the cereal bowl. (Cross reference F311 and F353) 5. Resident 16 was not provided the necessary staff assistance to feed Resident 16 the breakfast tray, which resulted in the meal being cold. (Cross reference F311 and F353) 6. Privacy curtains did not wrap around the residents bed area for 4 of 19 sampled residents (Residents 4, 5, 7, 16) and 5 of 21 Unsampled Residents 21, 22, 23, 24, and 39. These failures resulted in residents not having complete privacy during incontinence care, urinal use, dressing, and other activities of daily living. (Cross reference F460) Findings: 1. A. During an interview on 2/18/16 at 6:49 p.m., when asked about the timeliness of call response, Resident 6 stated he sometimes had to wait a long time. Resident 6 stated he had recently put his call light on at night because he had to have a bowel movement. Resident 6 stated he told the Certified Nursing Assistant (CNA), who responded to his call light, he couldn't hold it any longer, and needed assistance to the bathroom. Resident 6 stated the CNA responded by telling him she was too busy, she couldn't find a bedpan, he should just go in his bed, and she would return later to change him in bed. It made me feel very upset, because I didn't want to have to change my diaper, and I pride myself on being able to use the bathroom. Resident 6's Minimum Data Set (a resident assessment tool), comparing the last 3 quarters of assessments, dated 8/11/15, 11/11/15, and 2/11/16, indicated the following: a. Resident 6 was alert and oriented, without behaviors. b. Resident 6 had deteriorated, under the facility care, from occasional incontinent bowel to frequent incontinent bowel. During an interview on 2/19/16 at 7:42 a.m., when asked what the facility policy was about encouraging residents to be incontinent for the convenience of staff, Administrative Staff H stated, That would be a big issue on dignity. B. During an interview on 2/19/16 at 9 a.m., Unsampled Resident 20 stated she always knew when she was going to have a bowel movement, and would put on her call bell. Unsampled Resident 20 stated some CNAs didn't change her timely, or help, and she had been told, 'you go ahead, and do it in the bed, and we'll clean it up later.' When asked how that made her feel, Unsampled Resident 20 stated, Feels terrible, and my husband hates it. During a concurrent interview on 2/19/16 at 9 a.m., Unlicensed Staff NN stated some CNAs were lazy, and she had found Resident 20 dirty in her bed at change of shift. Unlicensed Staff NN stated Resident 20 was blind and did not ambulate, so she needed full assist to get up in a wheelchair and transferred to the bathroom. During an interview on 2/22/16 at 10:40 a.m., Unlicensed Staff VV stated it would not be appropriate to tell residents they could go in their beds and return to care for them later. Unlicensed Staff VV stated that the facility policy required staff to answer call bells within one to two minutes, and staff should do every 30 minute safety rounds. 2. During an observation on 2/16/16 at 3:34 p.m., Resident 5 sat up on the left side of his bed, facing the doorway. Resident 5's call bell was wrapped around the bedrail on the right side of the bed. Resident 5 stated, in interview, that he had rib pain. When asked if he he could reach his call bell, Resident 5 had to lie back down in bed, and log roll to his right in order to reach, and press the call light with his left hand. During a confidential group interview on 2/17/16 at 10 a.m., three of five residents stated issues with call lights not being answered timely, especially at night. One confidential resident stated, We don't push buttons, because no one's out there at night. Residents stated the facility had only two nurses at night time. One resident stated that when he had been in another room, he would wait 1.5 hours before getting assistance. During a meal observation on 2/18/16 at 8:13 a.m., Resident 6's call light was tied to the left bedrail. Resident 6 had left-sided paralysis, and could not reach with his left arm. Resident 16's hands were contracted and movement appeared limited. Resident 16's call bell was wrapped around the right bedrail. Resident 16 called out, Excuse me. Excuse me. During an interview on 2/18/16 at 8:55 a.m., Resident 16 stated his call bell was often out of reach. Resident 16 demonstrated that it was difficult to reach or grab things, but that he had more reach in his left arm, than his right. During an observation and interview on 2/18/16 at 6:49 p.m., Resident 6's call bell was tied to the left bedrail. When asked if it was within reach, Resident 6 stated the call bell was difficult to reach and was frequently placed on his weak side. During an interview on 2/19/16 at 7:42 a.m., Administrative Staff H stated call bells should be on the strong side, and CNAs should check residents frequently. When asked about response time to call lights, Administrative Staff H indicated a 30 minute wait would be too long, saying, You always have to think a call light is an emergency. During an interview on 2/18/16 at 12:13 p.m., Unlicensed Staff OO stated Resident 16 was a full assist, and fully dependent resident. Unlicensed Staff OO stated Resident 16 had more reach in is left hand, than his right. Unlicensed Staff OO stated call bells should be placed on residents' strong side. Unlicensed Staff OO stated she was sometimes so busy with bedbaths, that a call light might go off and she didn't know if they were answered. Unlicensed Staff OO stated other available staff were supposed to answer call lights when assigned staff were busy elsewhere. During an observation on 2/19/16 at 10:15 a.m., Resident 27's call bell dangled over the left side of the bed. During an observation on 2/22/16 at 8:15 a.m., Resident 31's call bell hung over the edge of the bed. When asked whether the call bell could be reached, Resident 31 replied that Resident 31 was unable to reach it and that it was frequently out of reach. A review of the facility's policy, Call Lights - Answering of, dated 6/2011, indicated staff will provide an environment that helps meet residents' needs by answering call lights timely, completing the task the resident requests, and ensuring the call light is placed within residents' reach. 3. During an initial tour on 2/16/16, at 10:58 a.m., shower 1B had a broken shower hook. The shower head rested on a shower chair. The shower chair had brown feces-looking material in a crevice of the chair. The plastic shower curtain had spots and stains. The handrail in the shower was sticky and had unidentified substance on it. During a concurrent interview on 2/16/16 at 10:58 a.m., Unsampled Resident 34 stated staff frequently stored hampers, for dirty linens, in the shower rooms, preventing him from taking a shower. Unsampled Resident 34 stated the shower chair was often poopy, uncovered garbage cans had dirty depends in them, and maintenance was disgusting. During an observation on 2/16/16 at 3:25 p.m., shower 1B had the following: A. A strong odor. B. Dried, dark feces-looking substance adhered to a handrail in the shower stall. C. Dried, dark feces-looking substance was caked between a crevice in the shower chair. D. Red stains, and brown spots, pock-marked the plastic shower curtain. E. The shower curtain had four unattached hooks, and sagged. During an observation on 2/16/16 at 3:28 p.m., shower 2A had a puddle of water near the entrance door, and an uncovered small garbage can, without a liner, had brown feces-looking remnants on the bottom and along one side. During an interview on 2/22/16 at 10:40 a.m., Unlicensed Staff VV stated housekeeping should clean showers between resident use. 4. During a breakfast observation on 2/18/16 at 8:17 a.m., Unsampled Resident 27 sat on the edge of her bed with her breakfast tray on the bedside table. Unsampled Resident 27 had deformed, arthritic looking hands. Unsampled Resident 27 opened a sugar packet, with difficulty, and attempted to pour the sugar on her breakfast cereal. Unsampled Resident 27 missed the bowl, and the majority of the sugar went on her tray. When asked if staff helped set up her meals, (unwrapped the butter, opened the sugar and salt packets, and opened her milk carton), Unsampled Resident 27 stated her usual CNA was not working that day. During an interview on 2/19/16 at 7:42 p.m., Administrative Staff H stated part of the facility's service to residents were to set up meals. 5. During a breakfast observation on 2/18/16 at 8:13 a.m., Resident 16's meal tray sat on a bedside table pushed against a wall. Resident 16 laid in bed and waited to be fed. When Unlicensed Staff OO returned to feed Resident 16, she did not ask him whether the temperature of the meal was adequate, and did not offer to reheat it. During an interview on 2/18/16 at 8:55 a.m., Resident 16 stated that hot food was cold, because meals were delivered and sat for awhile, before staff returned to feed him. Resident 16 stated staff did not offer to reheat it. During an interview on 2/18/16 at 12:13 p.m., Unlicensed Staff OO stated she fed two residents during mealtimes. The facility's policy, Assisting the Resident to Eat, dated 3/2000, under the subheading, Procedure, number six, indicated staff removed food covers, and arranged food, and made sure consistency and temperature of foods and fluids were appropriate. 6. During an initial tour on 2/16/16, at 10:43 a.m., Unsampled Resident 39's privacy curtain was off the track, so that it did not provide full privacy when pulled. During an observation of medication administration on 2/17/16 at 8:41 a.m., Unsampled Resident 21's barrier curtain could only be pulled partially, preventing full privacy. During an observation at 9:17 a.m., Unsampled Resident 21 requested privacy to use his bedside urinal. Unsampled Resident 21's privacy curtain could only be pulled partially, so Unsampled Resident 21 got up and used the bathroom. During an observation on 2/17/16 at 12:03 p.m., Unsampled Resident 22's privacy curtain had several missing hooks and sagged. Unsampled Resident 22 indicated, via her laptop, she had asked maintenance, for several weeks, to fix her privacy curtain because it had missing hooks, and got tangled up. A review of the facility's policy, Resident Dignity & Personal Privacy, dated 12/18/2002, indicated the facility provides care for residents in a manner that enhances each resident's dignity, individuality, and right to personal privacy. During an observation on 2/19/16 at 3:45 p.m., Resident 16's lower extremities were exposed from hallway in public view when Unlicensed Staff AA was providing perineal care due to privacy curtain was not pulled to assure privacy. During concurrent observation and interview on 2/19/16 at 4:05 p.m., Unlicensed Staff AA stated she pulled the resident's privacy curtain to assure full visual privacy when she provided perineal care to residents. Unlicensed Staff AA stated she was unable to pull the privacy curtain hanging between Resident 16's bed and his roommate's bed to assure full visual privacy due to curtain was stuck. Unlicensed Staff AA demonstrated how the privacy curtain became stuck at a certain point on the track. Unlicensed Staff AA stated she should have notified housekeeping to fix the privacy curtain. Resident 16's privacy curtain did not wrap around to provide full visual privacy even if unstuck. During observations on 2/19/16 at 4:30 p.m., Residents' 4, 5, 7, 23, & 24 privacy curtains did not wrap around to assure full visual privacy. The facility policy, Resident Dignity and Personal Privacy, released date 12/18/2001, indicated residents' privacy should be maintained during all personal care or treatment procedures by closing door, drawn privacy curtain, or both.

Based on observation, interview, and document review, the facility failed to ensure that Resident 2 was provided safe care when hot water bottles reaching 186.9 Fahrenheit (F) were placed in Resident 2's bed by CNA C and Resident 2's family members. These failures had the potential to cause serious burns and infection to Resident 2. An immediate jeopardy was called on 12/16/15 at 12:19 p.m., regarding placement of hot water bottles in Resident 2's bed. Findings: A complaint was reported to the Department on 11/12/15 that Resident 2 had a burn. During an interview on 12/3/15 at 3:06 p.m., Licensed Nurse A stated that when she had learned about the blister on 11/12/15, it reminded Licensed Nurse A of the hot water bottles that were applied to the Resident 2's abdomen and always caused redness. Licensed Nurse A asked CNA B if she noticed hot water bottles on Resident 2's right leg. CNA B said the hot water bottles were put next to Resident 2's lower legs. During an interview on 12/4/15 at 4:18 p.m., CNA B stated that CNA B saw the hot water bottles next to Resident 2's legs. CNA B stated that CNA C fills the hot water bottles with water from the kitchen. During an observation and concurrent interview on 12/16/15 at 11:00 a.m., CNA C confirmed that she put hot water bottles at the foot of the bed. CNA C was asked to provide instructions or a nursing plan of care for placement of the hot water bottles. CNA C stated that the family had instructed her to put the hot water bottles in the bed but there was no specific instruction. CNA C could not provide a nursing plan of care for the hot water bottles. CNA C stated that the hot water bottles were not a treatment; they were for comfort. CNA C stated she does not provide treatments, she is not a nurse. CNA C stated that she used to apply the hot water bottles to the abdomen but now they are at the foot of the bed. CNA C was asked to show us where she got the water for the hot water bottles to fill them. CNA C went to the kitchen, pointed to an orange spigot on the coffee maker, a cook was getting water from the spigot, there was steam coming out of the water. Cook D was asked to measure the temperature of the water. The water temperature measured 186.9 (F). CNA C stated that she gets the water for the hot water bottles from that spigot used by the cook and the water occasionally splashes on her skin and she put her hands up to show us and stated that I do not get burned. During an observation, concurrent interview, and document review on 12/16/15 at 11:35 a.m., Licensed Nurse E, treatment nurse and Director of Nursing F were asked about the two hot water bottles at the foot of the bed. Licensed Nurse E and Director of Nursing F stated that they were unaware of the hot water bottles and that they did not know that the family was directing CNA C to put the hot water bottles on Resident 2 and the foot of the bed. Director of Nursing F was asked if there was a physician's order for the hot water bottles, Director of Nursing replied there is no physician order, I would have known. Director of Nursing was asked if there was a nursing care plan for the hot water bottles, she stated no. Director of Nursing was asked if there was a policy and procedure for hot water bottles, she replied no and stated that they do not use hot water bottles or warm compresses. Director of Nursing F was asked about the possible burn to Resident 2's right inner thigh, Director of Nursing F stated that it was not a burn, it was cellulitis, that was confirmed with the Acute Care Hospital's history and physical dated 11/11/15, which indicated that Resident 2 had mild cellulitis on the right medial (middle) thigh with a bullous (a large blister) formation. During an interview on 12/16/15 at 12:19 p.m., Administrator G, Licensed Nurse E, and Director of Nursing F were asked what they were going to do about the hot water bottles. Director of Nursing F stated that she would check with the son about the hot water bottles. An immediate jeopardy was declared on 12/16/15 at 12:19 p.m., regarding the hot water bottles in Resident 2's bed and the potential for serious burns as the hot water bottles were filled with water reaching 186.9 (F). The Immediate Jeopardy was abated on 12/16/15 at 3:56 p.m. The hot water bottles were immediately removed, the facility began a Plan of Action to inservice all staff regarding not using hot water bottles. CNA C was suspended pending an investigation, and there will be a meeting on 12/21/15 with the family regarding the use of hot water bottles.

Based on observation, interview, and record reviews the facility failed to provide and maintain adequate supervision to prevent accidents and assistance devices when the facility failed to: 1. Lower the bed and provide assistive devices to prevent accidents, when Resident 19 fell out of bed and sustained a cervical fracture of the second vertebrae. These failures resulted in Resident 19 was not sent to the hospital until 5 days later for an evaluation and stabilization of Resident 19's neck which was a delay in treatment. Resident 19 experienced pain and potential for paralysis of Resident 19's body. 2. Provide effective interventions for 3 of 25 sampled residents: b) Resident 29 had three falls where (R29) fell sustained laceration to the forehead and exhibited signs and symptoms of lethargy, nausea, and complained of a headache; c) Resident 31 had two falls where (R31) slipped on a wet floor and cut the back of R31's head open requiring 5 staples; and d) Resident 32 had two falls where (R32) fell cutting Resident 32's lip and R32 complained about pain in Resident 32's knees. 3. Provided a safe environment with adequate assessment and supervision for three residents who chose to smoke, (Residents 21, 34 and 35), which resulted in Resident 21 sustaining burns from cigarettes and the potential for burns and injury to Residents 34 and 35. 4. Prevent 2 of 25 sampled residents (Residents 12 and 13) from eloping from the facility, both residents had wanderguards (a device designed to alert staff with an alarm if the resident exits the building), when the wires of the wanderguard system were cut and the residents eloped undetected onto a heavily traveled road that could of resulted in injury and death. 5. Maintain the environment to prevent accidents when bed cranks protruded from the base of beds, at shin level which could cause injuries. Findings: 1. During an observation on the initial tour on 5/13/13 at 9:15 a.m., Resident 19 was observed wearing a hard plastic collar around his neck. A physician's orders [REDACTED]. An order, dated 3/7/13, also indicated that a licensed nurse was to check placement and function of the side rails during each shift. Resident 19's Treatment Administration Record (TAR) for April indicated documentation that the side rails were checked each shift that included the night shift of 4/1/13. During an interview on 5/16/13 at 1:20 p.m., Resident 19 stated he had broken his neck on Tuesday 4/2/13 at 2:30 a.m. Resident 19 stated, "No one here has a clue on how to help a patient with a broken neck." The resident stated he supported his own neck while CNAs put him back in bed, and asked, "Isn't it protocol to put on a neck brace? " Resident 19 stated that the CNAs usually move his bed to a position higher off the ground to provide care in the evening and forget to return it to a low position when done. The resident stated that the CNAs did not lower his bed or put the side rails back up and he fell out of the bed. Resident 19 stated, "Now I have to wear this neck brace for six months. This really sets my recovery way back. I came in for my knees." Resident 19 stated an x-ray was taken of his neck on Wednesday 4/3/13. Resident 19 stated he was told by facility staff that his physician would see him on Thursday 4/4/13, but Resident 19 stated he "never saw (the physician)." Resident 19's change of condition notes, dated 4/2/13 at 2:30 a.m., revealed that the resident was found down at bedside with arms folded to knees and complained of pain 7 out of 10 (on a scale where 0 indicates no pain and 10 indicates the worst pain). The note indicated that the resident was placed back in bed and his head supported with pillows. The note indicated an order for [REDACTED]. A note dated 4/2/13 at 5:30 a.m. indicated that Resident 19 was provided with education regarding "C-spine injury" (injury to the bones or portion of the spine that extends from the skull to the base of the neck). During an interview on 5/20/13 at 9:55 a.m., Licensed Nurse Z (LN Z) stated he found Resident 19 sitting on the floor on 4/2/13 at 2:30 a.m. The resident was alert and oriented, in a crouched position with his arms resting on his knees. LN Z stated that Resident 19 told him he awoke from a dream (on the floor). Resident 19 complained of pain in his neck. LN Z stated he assessed Resident 19 to confirm that the resident could move his arms and legs. LN Z stated Resident 19 supported his own neck while he was assisted back to bed. The Lippincott Manual of Nursing Practice, Ninth Edition, indicates that "Any person with a ...neck...injury should be suspected of having a potential spinal cord injury until proved otherwise" and that the spine should be immediately immobilized while performing the primary assessment (p. 1202). Nurse's Notes dated 4/6/13 at 2 p.m., revealed that "resident assessed for pain in neck. Resident able to move neck side to side very minimally. Able to nod up and down minimally with pain noted. Referred to MD." A subsequent note, dated 4/6/13 at 6 p.m., indicated that a physician order [REDACTED]. A Nurse's Note, dated 4/7/13 at 9 a.m., indicated that Resident 19 was picked up by ambulance for transport to the hospital. A Nurse's Note dated 4/7/13 at 11:30 a.m., reflected a call from one of Resident 19's physicians reporting that the resident would not return to the facility due to a "C-2 fracture," (a break in the second bone in the neck). A hospital admission note, dated 4/7/13, included imaging results documenting a CT scan that indicted fractures at C2 on both sides of the second bone in the neck. 2. b. During observation on 6/10/13 at 11:50 a.m., Resident 29's (R29) was observed in a regular bed (approximately 18'' from the floor to the top of the mattress) with a floor mat next to the bed, two alarm boxes attached to the bed side rail, and the call bell within Resident 29's reach. A star symbol was posted next to R 29's name outside the room, indicating that Resident 29 was at risk for falling. R29's admission information dated 4/22/11, indicated that the resident had a [DIAGNOSES REDACTED]. Risk meeting notes dated 7/18/12, revealed R29 had "episodes of ambulating unassisted and wandering around the facility holding onto hallway siderails which may have caused skin tear." (sic) Resident needs assistance with activities of daily living (ADLs), constant reorientation. First Fall A Change of Condition Note, dated 8/14(/12) at 8 p.m., reflected "resident fell , found by CNA (nursing assistant)...laceration on (right) forehead, "that measured one inch long and 0.1 inch wide. The same Change of Condition Note, in the section titled "Safety Interventions: (check all that apply " contains the symbol for zero, and no interventions are checked. The section titled Patient Education indicated that R29 was instructed in " safety precaution, use of call light, .... " A Physician's Progress Note, dated 8/15/12, indicated an "urgent, focused visit ...(due to) fall (with) trauma to (left) forehead. " The note indicates R29 was sleepy, lethargic and complaining of headache and nausea. The plan included obtaining an x-ray of R29's head. Second Fall A Change of Condition Note, dated 12/23/12 9:30 p.m., indicated R29 "tried to stand up from his (wheelchair) but slid (and) fell to the floor. " The note indicated R29 complained of pain in his right elbow and an x-ray was ordered. Safety interventions included a low bed, pressure pad alarm, and floor mat. Patient education included "use call light for assistance," and close monitoring. The change of condition note did not specify what "close monitoring" meant and R29 was observed on 6/10/13 at 11:50 a.m., in a regular bed. Staff encouraged R29 to use the call light. The fall care plan indicated that it was rewritten on 2/20/13. During concurrent interview, the MDS Coordinator stated that she reprints care plans and stamps them as rewritten when the quarterly MDS (Minimum Data Set, a resident assessment instrument) is done. The MDS Coordinator adds handwritten interventions carried forward from the previous care plan and did not consider that the interventions were ineffective. Third Fall A Change of Condition Note, dated 3/1/13 12:40 p.m., reflected that a CNA found R29 on the floor next to his bed, and that a skin tear on R29's right arm had reopened. The nurse's note dated 3/4/13 (no time) revealed that R29 has multiple falls with an unsteady gait. R29 reopened his skin tear from a previous falls. The intervention was that staff encouraged R29 to use the call light. There were no effective interventions for a resident who exhibited behaviors of getting out of bed unassisted to prevent further falls and injuries. R29's care plan dated 3/1/13 reflected his risk for falls/injury due to dementia, history of falls, use of psychoactive medications, and a history of wandering. R29' s fall risk was 13 (nine or higher indicates high risk). Interventions included pressure pad alarms (devices that make an alarm noise when weight is released from the pad) on R29's bed and wheelchair, a very low bed, and a floor mat next to the bed. During an observation on 6/10/13 at 11:50 a.m, R29 was observed in a regular bed. There were no effective interventions to prevent R29 from further falls and injuries. 2c. First Fall Resident 31's (R31) Change of Condition note dated 6/5/12 (day shift) revealed that a CNA found R31 on the floor (time illegible), and R31 stated she " fell while trying to sit on the chair. " The section titled Safety Interventions reflected a zero symbol, and no interventions were checked. R31's MDS, dated [DATE], reflected that R31 was not steady and only able to stabilize with staff assistance when moving from seated to standing, walking, turning around, moving on and off the toilet, and transferring between surfaces such as bed and chair or wheelchair. R31's MDS (Minimum Data Set, a resident assessment tool), dated 12/7/12, indicated that R31 had moderately impaired cognition, and was unstable during walking, turning, moving on and off the toilet, and moving from seated to standing position. R31 has a recent episode of fall and has dementia with poor safety awareness. The facility indicated that they would provide a safe environment that included that they would anticipate R31's needs, direct care staff would provide safety cues and they would refer to rehabilitation as needed. Second Fall During an interview on 6/10/13 at 11:35 a.m., Resident 31 stated that she fell two weeks ago and needed four stitches in the back of her head. R31 stated she slipped in the bathroom because the floor was wet after cleaning. The risk meeting notes confirmed on 1/11/13, that R31 had a history falls and had an unsteady gait. R31 slipped and fell in the bathroom. A Change of Condition note, dated 1/11/13, indicated a nursing assistant (CNA) notified licensed staff at 9 a.m. that R31 had fallen in the bathroom. R31 was sent to a local emergency room where a cut to the back of her head was repaired with five skin staples. A section of the note titled Safety Interventions reflected a zero symbol, and no effective interventions were checked. There was no consideration for adequate supervision to prevent accidents. The Fall Risk Data Collection reflected a score of 8 on 12/2/12; a score of 9 or above indicates high risk. R31 s score remained the same when her fall risk was reassessed on 3/2/13. An entry of zero was made on 3/2/13 in the section for recording falls in the past three months, even though R31 experienced a fall less than two months previously on 1/11/3. Correct documentation of the fall in the risk data collection would have raised R31's score to 10, high risk. 2 d. Resident admission record dated 4/8/13, indicated that Resident 32 (R32) had dementia, muscle weakness, and abnormal gait. First Fall A change of condition note, dated 4/15/13 at 11:30 p.m., indicated that R32 was found on the floor. R32 was bleeding from the inner surface of her lower lip and complaining of pain 5 out of 10 (zero indicating no pain, 10 the worst pain) in both of her knees. The physician was notified and ordered a pressure pad alarm for R32's bed and wheelchair. An initial fall assessment done 4/18/13, 10 days after admission, scored her risk as 19 (9 or above is high risk). R32's MDS (Minimum Data Set, a resident assessment instrument), dated 4/18/13, indicated the need for a falls care plan. The interventions on the plan of care indicated that she had a sensor pad and a low bed. R32 was to use the call light when needing assistance. A consulting physician saw R32 on 4/23/13 and documented that " she is very off balance ... " and had uneven coordination. Second Fall A change of condition note, dated 5/19/13, reflected that R32 was found sitting on the floor when staff responded to the sound of an alarm in her room at 5:15 p.m. R32 pointed to the right side of her face. The physician was notified and new orders given to provide the resident with a low low bed (lower than the typical hospital bed) and a floor mat for safety. A fall assessment scored R32 at 23. A falls care plan was initiated 5/19/13, the date of R32's second fall with injury. Interventions added 5/20/13 included alarms on R32's bed and wheelchair, a "low low bed" with a cushioning mat next to the bed. A change of condition note dated 5/20/13 indicates R32 was experiencing pain at 6 out of 10. A nurse practitioner evaluated R32 on 5/20/13 in the facility and ordered immediate x-rays of her right hand and right side of her face due to swelling and pain. During observation and concurrent interview on 6/12/13 at 9:17 a.m., Resident 32 was in a wheelchair in the corridor approximately 20 feet from her room, attended by CNA BB. A star symbol, indicating a risk for falls, was next to R32's name outside the door to her room. CNA BB stated he was taking the resident to an activity in the dining room. When asked what safety measures were in place for R32, CNA BB stated that she had an alarm for her wheelchair, but "it's in the room." CNA BB left R32 unattended while he walked to the nurse's station at the end of the hall. CNA BB returned with the alarm box portion of the pressure pad alarm system, and attached it to the pad on R32's wheel chair. During an interview and concurrent review of training documents, on 6/12/12 at 2 p.m., the Director of Staff Development, (DSD), stated the Certified Nurse Assistants, (CNAs), were provided training for Transfers and Mobility during their orientation to the facility and "as needed". The DSD stated the only annual training facility staff received was in the area of abuse prevention, reporting, and dementia care. The DSD stated she had done classes 6/8/13 for CNAs and Licensed Nurses regarding Transfers and Mobility, (after fall prevention and care had been identified as deficient practice by the survey team on 5/13/13). Review, of the lesson plan, indicated the course content included discussion of the "Fall Prevention Program". The course content did not include care plan interventions or revision of care plans for the Licensed Staff providing effective and adequate supervision to prevent accidents. 3. During an initial tour on 6/10/13 at noon, Resident 21 was sitting in an electric wheelchair in the outside smoking area, wearing a heavy cotton apron over her clothes. Resident 21 shook hands with the left hand, and was noted to have right facial droop, (indication of facial muscle weakness). Resident 21's right hand hung over the wheelchair armrest, when Resident 21 raised her right hand, an unlit partial cigarette was observed in the right hand. Resident 21 then used both hands to open the cigarette package on her lap, extracted a lighter, and lit the cigarette. Resident 21 responded appropriately to questions regarding length of stay and care in the facility. During the conversation, the Director of Nursing reached into Resident 21's lap and removed a cigarette butt. Two facility staff were present in the smoking area. The clinical record for Resident 21 was reviewed on 6/10/13 at 2:15 p.m. The resident admission record dated 7/30/02, indicated Resident 21 had [DIAGNOSES REDACTED]. Resident 21's Smoking Care Plan rewritten on 12/17/12, noted "Non-compliant with recommendation to keep smoking (materials) with nurses. The goals included:"Resident risk of injury to self and others will be minimized with interventions. The care plan included an undated handwritten note, for a smoking apron as an intervention. Another intervention dated 4/30/13, directed: Close monitoring during smoking hours", however "close monitoring" was not defined. A Nursing Care Plan for "Non-Compliant", rewritten 12/17/12, indicated Resident 21 was non-compliant 12/10/10, when she refused to "give smoking (materials) (secondary) to safety issues". An additional issue of non-compliance was in "using smoking apron". The goal of the care plan was the resident would understand the risk associated with being non-compliant. An, undated, handwritten intervention directed:"Provide adequate supervision ...smoking activity". The most recent Minimum Data Set, (MDS), a resident assessment tool, dated 3/13/13, indicated Resident 21 had limited motion in both upper and lower extremities, and required assistance with all activities of daily living. A Change of Condition Note, dated 4/29/13, indicated a CNA had noted fluid filled blisters on Resident 21's abdomen during daily care. A Licensed Nurse assessed and documented the blisters as follows: "...noted as fluid filled blisters. Abdomen site #1-1.5 X 1.8. Abdomen site #2- 2 X 3.5... Abdomen site #3-1 x 1.3. Abdomen site #4-1.8 x 1.8. L(eft) ant(erior) thigh -1 x 1." The Licensed Nurse wrote: "Resident verbalized it happened when she was smoking and refused to wear the smoking apron because its too heavy." The Licensed Nurse documented that the physician was notified and orders were obtained for the care of the blisters. The IDT (Interdisciplinary Team) risk meeting notes, dated 4/30/13, indicated the facility would provide different kinds of aprons for Resident 21 to try until an appropriate one was found to use as a protective device, and that Resident 21 would, "...have supervision during smoking sessions to ensure that resident is safe". There were no subsequent risk meeting notes that evaluated the effectiveness of the care plan. Smoking Nursing Plan of Care dated 4/30/13 noted "resident with episodes of refusing to wear smoking apron", a handwritten intervention, dated 4/30/13, indicated Resident 21 required close monitoring during smoking hours, the day after the burns were noted. During an observation and concurrent interview, on 6/11/13 at 10:35 a.m., Resident 21 had 4 four lesions on her abdomen that were small and covered with scabbed tissue. Multiple circular, dime-sized scarring was visible scattered over the entire abdomen. A fifth lesion, circular and covered with a yellow exudate, was present on the left lower abdomen. The Treatment Nurse stated the fifth lesion was new, he had not seen it before. The Treatment Nurse stated the previous anterior thigh blister was completely healed. Resident 21 stated that the lesions on her abdomen were burns from dropped cigarettes. During an interview on 6/11/13 at 10:35 a.m., Resident 21 stated when she dropped a cigarette she was able to recover it, however it took time to do so. Resident 21 stated the staff would help her if she dropped a cigarette, but the burns happened really quickly. When asked about wearing a smoking apron, Resident 21 stated in the past she had dropped cigarette(s), down the neck of an apron, the cigarette would get trapped between the apron and her body, a heavy apron made the burn even worse. The Safe Smoking assessment dated [DATE]-5/21/13, for Resident 21, was signed by the Interdisciplinary Team on 5/20-5/21/13. The Cognitive Assessment indicated Resident 21 was independent in decision making as she demonstrated reasonable, consistent and organized behaviors. Resident 21 was assessed as having impaired vision, she was not able to read regular print. Resident 21 was also found to demonstrate unsafe technique for putting out matches, (lighter), and disposing of ashes. The form directed if all answers were "Yes", the resident would be determined to be a safe smoker, however with one "No." Resident 21 was deemed to be an unsafe smoker that required supervision when smoking. The Safe Smoking Assessment directed if a resident was found to be an unsafe smoker, a care plan would be done "immediately" that included: Smoking Designation, Degree of supervision needed, Protective Device (if needed), where smoking materials will be stored, as well as observation for seizure activity if applicable. During a visit to the smoking area, on 6/11/13 at 11:35 p.m., Resident 21, wearing a cotton apron, manipulated the controls of her electric wheelchair with both hands as she readjusted her position, a lit cigarette dangled from her lips. The Medical Records Director sat at a picnic table, next to Resident 21's wheelchair, with a cell phone. The Medical Records Director did not look up as she manipulated the cell phone, as she also smoked. A second staff member, without a name tag, (later identified as a janitor), stood at the edge of the smoking area. The staff member stated he watched the residents smoke as he gestured toward the smoking area. The janitor was not observed watching the residents out in the smoking area. 3b. During a room visit, on 6/11/13 at 2:30 p.m., Resident 34 sat alone, in a wheelchair, the door to the room closed. When asked about the smoking program at the facility, Resident 34 stated she "...hated it, now they make me wear an apron!" Resident 34 stated she used to be able to go to the smoking area whenever she liked, now she could only go at scheduled times. Resident 34's clinical record was reviewed on 6/11/13 at 3:45 p.m. The Resident Admission Record indicated Resident 34 had a seizure disorder, (sudden violent involuntary muscle contractions of the head, neck, and torso), and kidney disease that required dialysis. The most recent MDS, dated [DATE], indicated Resident 34 required assistance with all activities of daily living due to generalized weakness, and was unsteady when ambulating. A Smoking Care Plan, dated 3/12/13, did not include Resident 34's required degree of supervision during smoking, where her smoking materials were stored, or direction for observation of potential seizure activity as directed in the Safe Smoking Assessment directions. The two Safe Smoking Assessments in Resident 34's clinical record revealed the following: A Safe Smoking assessment dated [DATE] indicated Resident 34 had a history of [REDACTED]. The assessment scored Resident 34 as an unsafe smoker and noted she was an unsafe smoker that required supervision. An Independent Smoker Contract dated 5/30/13, signed by both the resident and the Social Services Director, the contract listed the conditions that Resident 34 was required to meet to continue with independent smoker's privileges: smoking only in designated area, storage of smoking materials per facility policy, using ashtrays provided, and not sharing smoking materials with other residents. A Safe Smoking assessment dated [DATE], had identical findings as the previous assessment, however Resident 34 was designated as a safe smoker that required supervision. None of the documents noted that Resident 34 was required to wear an apron as a protective device. 3c. During a visit to the facility smoking area, on 6/12/13 at 10:35 a.m., Activity Aid M, (AA M), stood outside the exit door of the facility. Across the parking lot, two residents were sitting in the smoking area. AA M followed the surveyor across the parking lot to the smoking area. Resident 35 sat in a chair in the sun, smoking with the left hand in quick puffs, a long ash hung on the end of the cigarette. Clutched in the left hand was a second, unlit cigarette, a plastic cup rested in the resident's lap. Resident 35 answered most questions appropriately, some questions she did not answer. AA M walked with the surveyor across the parking area to the door to the facility. AA M, in response to questions, stated he was there to supervise the smoking area. When asked what that entailed, AA M stated he offered the residents a smoking apron, "They don't want one," as he gestured to the residents in the smoking area. AA M stated some residents let ashes fall on their body and they needed to have an apron, "Like (Resident 21)". The clinical record for Resident 35 was reviewed on 6/12/13 at 1:15 p.m. A History and Physical, dated 1/14/13, indicated Resident 35 had [DIAGNOSES REDACTED]. A psychiatric evaluation, done 2/20/13, indicated Resident 35 had altercations with other residents over cigarettes, and a behavior plan had been developed that included accompaniment by staff when she went to the smoking patio. The three Safe Smoking Assessments, dated 2/22/13, 4/13/13 and 5/21/13 indicated all three assessments scored Resident 35 as an unsafe smoker due to difficulty in decision making, impaired vision, inability to use safe technique to put out matches and dispose of ashes, and inability understand smoking could only occur in designated smoking areas. All assessments determined that Resident 35 required constant supervision when smoking. Resident 35's smoking care plan, rewritten 4/30/13, did not include Resident 35's smoking designation as an unsafe smoker, or the degree of supervision required; constant supervision, as directed in the Safe Smoking Assessment directions. During an interview, on 6/11/13 at 10:10 a.m., Director of Nursing D, (DON D), stated the facility staff had recently reassessed all the resident smokers for ability to smoke independently or required supervision to smoke. The last week in May the facility implemented what DON D called a "new" procedure for residents who wished to smoke. The procedure included the removal of all smoking materials from residents' keeping, resident access to the smoking area limited to certain scheduled times, and supervision of the smoking area by facility staff when any resident was present. DON D stated facility staff that smoked would accompany residents to the smoking area for supervision. DON D stated they were monitoring the situation and adjustments to the new procedure would be made as needed. There was not a written document that deliniated the "new" procedure. During an interview, on 6/11/13 at 2:45, DON D stated she planned an inservice for the staff regarding supervision of the smoking residents. DON D stated that presently the Director of Staff Development (DSD), was providing individual instruction regarding their responsibilities during smoking supervision to each CNA assigned to the smoking area. The facility policy titled "Smoking", last revised 10/10, indicated that each resident wishing to smoke would be assessed with [REDACTED]. The completed assessment would be reviewed by the facility Interdisciplinary Team (ID), who would then decide if the resident was a safe smoker and how much supervision the resident required. The policy specified a care plan would be developed based on the determination of ID and reviewed at the next Risk Meeting to assure it was still reflective of the resident's current status. 4a. Resident 12's record was reviewed on 5/16/13 at 2 p.m. Resident 12 was readmitted to the facility on [DATE], two weeks after leaving the facility without notifying staff. Admission [DIAGNOSES REDACTED]. An elopement risk review form, dated 2/25/13, noted elopement attempts within the last 30 days and a history of leaving the facility against facility advice from the first admission, as well as a history of substance abuse. An elopement care plan dated 2/26/13 noted risk for elopement due to poor safety awareness and included a wanderguard bracelet alarm to prevent wandering outside the facility. Risk meeting notes dated 4/5/13 at 2 p.m., Resident 12 could not be located for Resident 12's care conference. Staff searched the facility and the surrounding area and could not locate Resident 12. The local police were notified at 3:25 p.m. Resident 12 returned to the facility at 4:30 p.m. The Risk Meeting Notes, dated 4/5/13, noted that upon questioning, Resident 12 stated that he drove his car and walked around. 4b. Resident 13 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. An elopement risk assessment dated [DATE], noted elopement attempts within the last 30 days, wandering with no purpose, searching behaviors and wanting to go home, and that Resident 13 was at risk for elopement. An elopement care plan was initiated on 12/16/12 which included a wanderguard bracelet. Resident 13 used a walker, due to severe deconditioning and muscle weakness. The nursing notes dated 4/23/13 at 6:30 p.m., revealed that Resident 13 could not be found. The risk meeting notes, (not dated) noted that staff searched the facility and could not locate Resident 13 so a search was conducted outside the facility. Resident 13 was found nearby at the corner of the liquor store. Resident 13 was placed on close monitoring and the wanderguard was assessed for functioning. Intervention included monitoring Resident 13 with close visual checks for 72 hours. Clinical record notes did not indicate that the Wanderguard was in working order. physician progress notes [REDACTED]." During an interview on 5/17/13 at 10:30 a.m., when asked about Resident 12 and 13's elopements that wore wanderguard bracelets during the time of the elopements, the Director of Nursing D (DON) stated that there were usually staff at the nursing station and the reception desk by the front door. Staff were questioned and they did not know how Resident 12 and 13 left undetected. The DON D also stated that the wanderguard bracelet and the door alarm were checked when Resident 12 returned and both were in working order and that Resident 12 had stated that he left through the front door. When asked if the current system had been evaluated, the DON replied no. When asked to clarify close monitoring, the DON D stated that they did not have a policy, but she would provide the process later. Close monitoring included staff documenting Resident 13's whereabouts every 15 minutes. During an interview on 5/20/13 at 11 a.m., Receptionist AA stated that a list of residents with wanderguards was located at the reception desk, and that receptionist duties included watching the front door and alerting staff if a Resident left the facility and the door alarm sounded. If an alarm sounded, a visual check of the outside was required to see why the alarm sounded and notification of nursing staff if needed to bring a resident back inside. Receptionist AA also stated that there were times when the reception desk was not manned due to other job duties such as delivering the portable phone to residents, sending out fax documents and leaves for breaks and lunch. During concurrent observation and interview on 5/16/13 at 8:45 a.m., Maintenance Staff S stated he checks the door on his workdays Monday through Friday. Maintenance Staff S provided testing logs, titled Signaling Device Test Checklist for April and May. He stated that a "3" in the check box un

Based on interview and record review, the facility failed to treat a urinary tract infection when licensed nurse failed to obtain timely treatment for [REDACTED]. These failures resulted in a delay in treatment for 4 days when Resident 2 experienced lower abdominal pain, pain on urination and low back pain. Findings: During an interview on 5/16/13 at 3:30 p.m., a responsible party for Resident 2 stated the resident had history of frequent urinary tract infections (UTIs). The responsible party further stated that Resident 2 developed a urinary tract infection in April 2013 which was initially identified on 4/30/2013, and the specific germs causing the infection were identified on 5/2/13. The responsible party stated Resident 2 received no treatment for [REDACTED]. Resident 2's record revealed a urine test done on 4/30/13 that showed many bacteria, an increased number of white blood cells (cells that fight infection), and positive leukocyte esterase (a protein released into the urine by white blood cells). A notation on the lab results sheet indicates that these results were faxed to the resident's physician on 4/30/13 at 7 p.m. The nurses notes indicate that facility staff was awaiting a reply from the physician. The nurses notes, including a section titled "UTI (signs/symptoms)", reflected the following: Resident 2 had lower back pain, decreased appetite, and painful urinationon 4/29/13; lower back pain and painful urination on 4/30/13; lower back pain, painful urination, and decreased appetite on 5/1/13; lower back pain, decreased appetite, and painful urination on 5/2/13. The record revealed that two specific organisms were identified in Resident 2's urine on 5/2/13, Citrobacter freundii (C. freundii) and Providencia stuartii (P. stuartii). A notation on the lab results sheet indicates that it was faxed to Resident 2's physician on 5/2/13 at 4 p.m. Nurses notes reveal that the results were again faxed to Resident 2's physician three times on 5/3/13 and a text message was also sent to the physician with no reply. The nurses notes indicate "Unable to contact MD at this time" on 5/3/13 at 4 p.m. A personal document dated 5/4/13 provided by a responsible party for Resident 2 indicates the responsible party was told by facility staff on 5/3/13 at 4 p.m., that the laboratory results were sent to Resident 2's physician on the morning of 5/2/13 and the facility was awaiting treatment orders from the physician. The responsible party stated that she told facility staff of her intent to report the facility to the state (survey agency). The responsible party took Resident 2 out of the facility on pass at 5 p.m. on 5/3/13. At 5:20 p.m., the responsible party was contacted by the facility and told to return Resident 2 to the facility so she could be sent to the hospital by ambulance in accordance with physician orders. The personal document indicates that the responsible party called the office of Resident 2's physician and insisted on a return call, after being advised by the facility that the physician wanted Resident 2 seen at the hospital. The responsible party received a return call from the physician. The responsible party was told by the physician, "If we don't like his care and if we don't agree with his treatment plan we can go to another facility."

The facility violated the regulation by failing to provide adequate supervision to prevent an elopement from the facility when Resident 1 left the facility, in his car and drove away undetected on 12/15/12. Resident 1 was found by the police down a ravine following a car accident, where he had been ejected from the car and was clinging to a tree. The police estimated that Resident 1 had been clinging to the tree for five hours before a hiker heard Resident 1's cries for help. These failures resulted in Resident 1 sustained left hand fracture that was displaced and required surgical pinning on 12/15/12. Resident 1 continued, after 12/15/12, to go outside the building unsupervised. Review of the clinical record conducted on 12/27/12 revealed the following: A facility report dated 12/17/12 revealed that Resident 1 was admitted to the skilled nursing facility for rehabilitation and nursing services on 11/6/12, following an acute hospital stay with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS-an assessment tool) revealed that Resident 1 was able to understand and be understood. During an interview, on 1/10/13 at 9 a.m., the psychologist who had been following Resident 1, stated that he had reported to the facility on [DATE] that Resident 1 had a history of [REDACTED]. During an interview, on 12/27/12 at 9:30 a.m., Administrative Staff A stated that Resident 1 had been missing on 12/13/12, for three hours, and when he returned to the facility stated he had left to get clothes from home. This was when it was discovered that Resident 1 had a car and he refused to hand over the keys. Administrative Staff A stated that she did not know where Resident 1's car was at that time. A Non Compliant Care Plan, dated 12/13/12, revealed Resident 1 was non compliant with following the facility protocol of signing in and out for a pass and refused to turn in his car keys. The facility instituted an every 15 minute visual check on Resident 1's whereabouts. A physician order, dated 12/14/12, discontinued Resident 1's pass privilege due to non compliance with signing in or out of the facility. During an observation and interview, on 12/27/12 at 1 p.m., Resident 1's left hand was bandaged, the right hand and arm had multiple bruises and skin tears. Resident 1 stated that on 12/15/12, that he was tired of being in the facility, so used his cane to walk to his car, which was parked in the facility parking lot, and left at about 11 a.m., he drove to his old apartment and then went out to lunch. He then stated he wanted to drive out to the beach. Resident 1 did not recall going off the road, but does remember that he was ejected from the car and was pinned to a tree. Resident 1 stated that it was raining and he was extremely cold and that it took hours for a hiker to pass by and provide help. Resident 1 stated that the rescue team had to cut down several trees down the side of the ravine to be able to reach him, put him in a basket type stretcher, and haul him up to the road. Nurses notes, dated 12/15/12, revealed that Resident 1 was not in his room for the 12:15 p.m. visual check. This was an hour and 15 minutes after Resident 1 had left. The facility and facility perimeter were searched. At 1:20 p.m. Licensed Nurse (LN) C called Resident 1's contacts and called Resident 1's cell phone but it went to voice mail, at that time LN C noticed that Resident 1 had signed out on a pass at 12:05 p.m. At 2:50 p.m., 2 1/2 hours later, the facility administrator, the Director of Nurses and the police were notified. At 3:38 p.m., the police arrived at the facility. During an interview, on 12/27/12 at 11:15 p.m., LN C reviewed the sequence of events on 12/15/12. LN C stated that the police were notified around 2:45 p.m. When asked to clarify the procedure for how soon to notify the police of a missing resident, LN C responded immediately. When asked why this was not reported to the police immediately, LN C stated " I didn't want to call them and have him (Resident 1) show up, so I wanted to make sure he was really gone, I didn't want to look stupid." The police Incident Report, Case # SR 12-9677, dated 12/15/12, revealed that the date and time reported was: 12/15/12 at 1607 (4:07 p.m.), approximately four hours after Resident 1 was not found. The Police put out an All Points Bulletin (APB) for the missing elder. Police were later notified by the California Highway Patrol that they had located Resident 1 at a car crash scene. Resident 1 was down a ravine clinging to a tree after being ejected from the car during the crash. The CHP estimated that Resident 1 had been clinging to the tree for approximately five hours until a passerby found the crash. Resident 1 was transported to a local acute hospital. The local weather report revealed that the temperature for 12/15/12, was a high of 49 degrees and low of 40 degrees, with rain. The acute care hospital's discharge summary, dated 12/21/12, revealed that Resident 1 had been admitted on [DATE], following a car accident. Discharge [DIAGNOSES REDACTED]. During an interview, on 1/4/12 at 9:30 a.m., Administrative Staff A stated that the facility had not treated this as an elopement because Resident 1 had signed out on a pass that day. The facility policy titled "Resident on Pass", dated 4/15/01, revealed that "all residents leaving the facility must be signed out and have an appropriate 'out on pass' physician order [REDACTED]. During an interview , on 1/4/13 at 11:35 a.m., and a declaration signed on 1/9/13 at 10:00 a.m., Resident 1 stated that he had not signed out the last 2 times he left the facility and that was why he was in trouble. When the facility sign out record was presented for his review, Resident 1 stated that he had signed the first two entries, dated 12/5/12 and 12/8/12, but had not done the entries for 12/13/12 or 12/15/12; that it was not his handwriting, and that he had not asked staff to sign him out. During an interview, on 1/4/13 at 12:45 p.m., Administrative Staff A concurred that the last two entries on Resident 1's pass sign out sheet did not appear to be Resident 1's handwriting, and did not know who made the entries. An Elopement Risk Review form, dated 12/21/12, indicated that Resident 1 had eloped from the facility in the last 30 days and exhibited behaviors of "wanting to go home." The facility documented that Resident 1 was considered "at risk" for elopement. A physician order [REDACTED]." A wandering and elopement care plan, dated 12/23/12, included "at risk for wandering due to poor safety awareness, to place wanderguard on the resident (monitor function and placement every shift), check resident's whereabouts, redirect resident back to supervised areas, ...call MD for changes in resident's condition." A Non Compliant Care Plan dated 12/25/12, revealed that Resident 1 was non compliant with wearing the wanderguard, that it had been offered and refused three times, on 12/26/12, 12/27/12 and 1/3/13. Interventions included "monitor for untoward manifestations resulting from non compliant and provide intervention, ...inform family and MD." There were no effective interventions specified for staff to follow to prevent Resident 1 from eloping from the facility. The Interdisciplinary Team Risk meeting notes dated 12/30/12, included "placed on wanderguard for resident at risk for elopement. LN (licensed nurse) and other staff to check on resident from time to time. Will continue to monitor." The IDT note did not indicated specifically what "time to time" or what "continue to monitor" meant. There were no other effective interventions mentioned for staff to follow to provide adequate supervision to prevent accidents. During an observation and interview, on 1/4/13 at 11:05 a.m., and 11:35 a.m., Resident 1 was seated in a wheelchair with no visible wanderguard. When asked, Resident 1 stated that he refused the Wanderguard and had informed the staff that he was not a dog, so refused to wear it and that he had removed the first one. During an observation, on 1/4/13 at 12:35 p.m., Resident 1 was seated in his wheelchair, outside the facility, around the corner from the front door, on the driveway to the parking area to the back of the building, smoking. No staff were present. Resident 1 did not have a visible wanderguard. During an interview, on 1/4/13 at 12:40 p.m., when asked if the facility staff knew Resident 1's whereabouts at that time, both Administrative Staff A and B did not know. At 12:45 p.m., Resident 1 was observed at the front door of the facility, using his feet to propel the wheelchair back inside, with no staff present. During an interview, on 1/4/13 at 1 p.m., Administrative Staff A concurred that the physician should have been notified of the refusal for the wanderguard, and concurred that the driveway on the side of the building was not a safe place for Resident 1 to be alone, smoking. Administrative Staff A stated that the designated smoking area was in the back of the building, where staff could visually monitor the residents. Therefore, facility violated the regulation by failing to provide adequate supervision to prevent an elopement from the facility when Resident 1 left the facility, in his car and drove away undetected on 12/15/12. Resident 1 was found by the police down a ravine following a car accident, where he had been ejected from the car and was clinging to a tree. The police estimated that Resident 1 had been clinging to the tree for five hours before a hiker heard Resident 1's cries for help. These failures resulted in Resident 1 sustained left hand fracture that was displaced and required surgical pinning on 12/15/12. Resident 1 continued, after 12/15/12, to go outside the building unsupervised. This violation presented either imminent danger of death or serious harm would result or a substantial probability that death or serious physical harm would result.