Every finding on record at Pomona Vista Care Center

Based on interview and record review, the facility failed ensure one of one sampled resident (Resident 1) was free from physical abuse by failing ensure a direct line of observation was implemented in accordance with Resident 2's Care Plan Report (CPR), dated [DATE], indicating one-to-one (1:1, when a resident's physical, behavioral, or medical safety risks require continuous, dedicated observation and support from a single staff member) supervision on [DATE]. This deficient practice resulted in Resident 1 being forcefully punched in the chest by Resident 2 causing Resident 1 to experience fear. The deficient practice had the potential to result in physical injury and psychosocial harm to Resident 1 and well as other residents who may have come into contact with Resident 2.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE], with diagnoses including asthma (a condition in which your airways narrow and swell and may produce extra mucus), gastro-esophageal reflux disease (GERD - a long standing condition where stomach acid repeatedly flows back up into the tube connecting your mouth and stomach, irritating its lining), and depression (a serious mood disorder that causes a constant feeling of sadness and a loss of interest in things normally liked).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and with mobility.During a review of Resident 1's Change in Condition Evaluation (CCE), dated [DATE], the CCE indicated Resident 1 was holding her chest and claimed Resident 1 was hit in the chest by roommate [Resident 2]. The evaluation indicated skin check done, no redness, no bruises, and no discoloration to site.During a review of Resident 1's Progress Notes (PN), dated [DATE], the PN indicated that during a follow-up interview conducted by the Director of Nursing (DON) and the Social Service Director (SSD) with Resident 1, the PN indicated Resident 1 stated [on [DATE]] Resident 1 was sitting on her bed eating ice cream when Resident 1 noticed that someone was opening her privacy curtain. The PN indicated Resident 1 stated that Resident 1 got up and closed the curtain. The PN indicated Resident 1 then attempted to open the room door to exit [the room] and reported seeing [Resident 2] and a staff member outside the room. The PN indicated according to Resident 1, Resident 2 suddenly struck Resident 1 in the chest.During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on [DATE], with diagnoses including encephalopathy (general term for any disease, damage, or malfunction of the brain, altered brain function leading to altered mental state and confusion [lacks clarity and cannot think clearly]), dementia (a progressive state of decline in mental abilities), and impulse disorder (when a person has difficulty stopping themselves from doing something even when they know it may be inappropriate, harmful, or have negative consequences).During a review of Resident 2's CPR, initiated [DATE], the CPR indicated on [DATE], Resident 2 had an altercation with Resident 2's [previous] roommate [Resident 5]. The CPR indicated on [DATE], Resident 2 had a second altercation with Resident 5 when Resident 5 reported being pushed by Resident 2. The CPR indicated on [DATE], Resident 2 had an altercation with [Resident 1]. The CPR interventions/tasks, dated [DATE], indicated maintaining active 1:1 supervision continuously (happening without stopping or on an ongoing basis).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was severely impaired. The MDS indicated Resident 2 required setup or clean-up assistance (helper sets up or cleans up) with activities of daily living and Resident 2 was independent (resident completes the activity by themself) with mobility.During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on [DATE], with diagnoses including acute respiratory failure (ARF, a condition that occurs when the body's respiratory system can't supply enough oxygen to the blood and organs, or remove enough carbon dioxide [a colorless, odorless gas that's naturally present in the air, essentially a waste product that we breathe out when we exhale] from the body), chronic obstructive pulmonary disease (COPD, a long standing lung disease causing difficulty in breathing), and chronic kidney disease (CKD, a long standing condition where the kidneys are damaged and can't filter blood properly).During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognition was intact. The MDS indicated Resident 3 was independent (resident completes the activity by themself) with ADL and was independent with mobility.During an interview on [DATE] at 11:30 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated that while walking toward the south nurses' station, on [DATE], CNA 1 observed the door to Resident 1 and Resident 2's room (roommates) approximately halfway open. CNA 1 stated CNA 1 observed Resident 2 standing close in proximity to Resident 1 and the residents were facing one another inside the room near the doorway. CNA 1 stated Resident 2's Patient Sitter (the PS, staff assigned for 1:1 supervision), who was assigned to supervise Resident 2, was standing near the doorway but was facing away from Resident 1 and Resident 2's room and was not looking at Resident 2. CNA 1 stated CNA 1 knew Resident 2 could sometimes be unpredictable and Resident 1 preferred to be left alone. CNA 1 stated on [DATE], CNA 1 became concerned about the proximity of the residents to one another and CNA 1 alerted the PS that the residents were really close to each other because you never know what can happen.During an interview on [DATE] at 1:10 PM, Resident 1 stated a few days ago, at approximately 8:00 PM, Resident 1 was sitting on her bed eating ice cream when Resident 2 entered Resident 1's room, walked past her bed, closed her privacy curtain, and then closed the bedroom door as Resident 2 exited the room. Resident 1 stated Resident 2's assigned (the PS) staff member was standing near the doorway. Resident 1 stated Resident 1 opened the curtain and attempted to open the bedroom door, but the door would not open initially, and Resident 1 felt as if someone was holding the doorknob from the opposite side. Resident 1 stated, after waiting a few seconds, Resident 1 tried again and was able to open the door. Resident 1 stated Resident 2 then rushed into the room, looked at Resident 1 in a hostile manner, and forcefully punched Resident 1 directly in Resident 1's chest. Resident 1 stated Resident 1 immediately yelled for help and staff intervened. Resident 1 stated the incident occurred very quickly, and the PS was standing outside the room when the incident occurred. Resident 1 stated the PS was not observing Resident 2 directly or the PS would have intervened before Resident 2 was able to strike Resident 1. Resident 1 stated Resident 2 was Resident 1's roommate and Resident 1 did not know why Resident 2 struck Resident 1. Resident 1 stated the incident caused Resident 1 to feel frightened and scared. During an interview on [DATE] at 1:50 PM, with Resident 3, Resident 3 stated Resident 3 routinely took evening walks at approximately 8:00 PM almost daily. Resident 3 stated Resident 3 was walking past Resident 1 and Resident 2's room when Resident 3 witnessed Resident 2 forcefully punching Resident 1 directly in Resident 1's chest. Resident 3 stated Resident 1's bed was the first bed inside the room, the privacy curtain was open, and Resident 3 had a clear, unobstructed view of the incident from the hallway. Resident 3 stated the incident occurred very quickly, and Resident 3 could not recall which staff members were present. Resident 3 stated Resident 2 appeared aggressive and struck Resident 1 with force, giving Resident 3 the impression that Resident 2 knew what Resident 2 was doing. Resident 3 stated Resident 3 recalled Resident 1 calling out for help immediately after being struck.During a telephone interview on [DATE] at 11:44 AM, with the PS, the PS stated the PS was assigned to provide Resident 2 with 1:1 supervision when the alleged incident occurred on [DATE] at approximately 8:00 PM. The PS stated Resident 2 used the restroom located inside Resident 1 and Resident 2's room and, upon exiting, Resident 2 followed the PS toward the room's doorway. The PS stated the PS turned his back on Resident 2 while looking toward the unit hallway/south station. The PS stated the PS did not maintain direct observation of Resident 2. The PS stated he did not witness the alleged physical contact between Resident 1 and Resident 2 and observed Residents 1 and 2 were in close proximity after the incident. The PS stated turning his back on Resident 2 was a mistake and the PS should have remained positioned to continuously observe Resident 2 and should have followed behind Resident 2 (versus Resident 2 following the PS) after Resident 2 used the restroom. The PS stated this positioning would have maintained direct line of observation and allowed the PS to intervene, particularly given Resident 2's known behaviors and need for 1:1 supervision. During an interview on [DATE] at 12:15 PM, with the DON, the timeline of resident-to-resident altercations involving Resident 2 as the aggressor was discussed with the DON. The DON stated Resident 2 had a history of hitting other residents. The DON stated that for any resident assigned 1:1 supervision, the expectation is that the designated staff member (the PS) must maintain direct visual observation of the resident at all times. The DON stated staff were expected to remain with and visually monitor the residents and must obtain relief coverage before leaving for a break or for any other reason. The DON stated that for Resident 2, due to her history of altercations [with other residents], the purpose of 1:1 supervision included maintaining a safe distance between Resident 2 and other residents to allow staff to intervene before a situation escalated. The DON stated Resident 2 should be followed by the PS when ambulating rather than having Resident 2 follow behind the PS. The DON stated staff may provide Resident 2 appropriate personal space; however, they must maintain continuous visual observation of resident 2 and remain positioned to intervene if needed. The DON stated that if direct observation was not maintained, an incident could occur within a split second that could have potentially been prevented. The DON stated staff assigned to 1:1 supervision were instructed on these expectations. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, revision date [DATE], the P&P indicated it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The P&P's policy explanation and compliance guidelines indicated the facility will provide ongoing oversight and supervision of staff in order to assure its policies are implemented as written. The P&P's prevention of abuse, neglect and exploitation indicated the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The P&P indicated addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur.

Based on interview and record review, the facility failed to effectively implement care-planned interventions, for one of four sampled residents (Resident 2), in accordance with the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plans, and after a resident-to-resident altercation between Resident 1 and Resident 2 dated [DATE]. This deficient practice resulted in Resident 2 pushing Resident 1 on [DATE] and Resident 1 falling to the floor and hitting Resident 1's right knee. Additionally, there was a potential for physical decline to Resident 1.Cross Reference F689Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on [DATE], with diagnoses including encephalopathy (a serious health problem that affects brain function or structure), dementia (a progressive state of decline in mental abilities), and impulse disorder (a mental health condition where a person feels a very strong, sudden urge to do something, and they cannot stop themselves).During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 2's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and with mobility.During a review of Resident 1's AR, the AR indicated the facility admitted Resident 1 on [DATE], with diagnoses including diverticulosis (small bulging pouches or pockets in the wall of the large intestine [colon]), hypertension (HTN-high blood pressure), and gastro-esophageal reflux disease (acid reflux).During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with ADL and required supervision or touching assistance with mobility.During a review of Resident 2's Change in Condition Evaluation (CCE), dated [DATE], the CCE indicated Resident 2 had an altercation with Resident 1, resulting in a fall [to Resident 1].During a review of Resident 2's Care Plan Report (CPR), initiated [DATE], the CPR's goal indicated will prevent episode of altercations with other residents. The CPR's interventions, initiated/revised [DATE], indicated to anticipate [Resident 2's] needs, monitor (staff supervision) behavior and whereabouts, and staff would continue to closely monitor interactions between roommates and staff.During a review of Resident 1's Progress Note (PN), dated [DATE], the PN indicated that on [DATE], Resident 1 stated Resident 2 went to Resident 1's room, pushed her and Resident 1 fell to the floor, kneeling on the floor, and hitting Resident 1's right knee.During a concurrent interview and record review on [DATE] at 11:30 AM, Resident 2's CPR, initiated [DATE], was reviewed with the Licensed Vocational Nurse (LVN) 1, LVN 1, LVN 1 stated Resident 2's CPR indicated for staff to anticipate Resident 2's needs, monitor Resident 2's behavior and whereabouts, and closely monitor interactions between the residents and staff. LVN 1 stated no staff observed Resident 2 leaving Room A or observed Resident 2 travel toward Room C. LVN 1 stated the recurrence [of the incident] demonstrated care-planned interventions to monitor Resident 2's whereabouts and interactions were not implemented effectively.During an interview and concurrent record review on [DATE] at 12:30 PM, Resident 2's CPR, initiated [DATE], was reviewed with the Director of Nursing (DON), the DON stated the CPR indicated for staff to monitor Resident 2's behavior and whereabouts and closely monitor interactions between the residents and staff. The DON stated these interventions required communication and collaboration among CNAs and licensed nurses, and other staff. The DON stated no staff member observed Resident 2 leave Room A, travel through the facility hallways, or enter Room C. The DON stated the DON could not identify who was responsible for monitoring Resident 2 during that period. The DON stated this was problematic because the facility knew Resident 2 had recently pushed Resident 1 [on [DATE]). The DON stated Resident 2's unobserved return to Resident 1's room [on [DATE]] demonstrated [staff] supervision [of Resident 2] was not effectively implemented, allowing Resident 2 to regain access to Resident 1 and created the opportunity for the physical altercation to recur.During a review of the facility's P&P, titled, Comprehensive Care Plans, revised [DATE], the P&P indicated it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on interview and record review, the facility failed to provide adequate supervision to prevent a second resident to resident altercation from recurring for two of four sampled residents (Residents 1 and Resident 2) in accordance with the facility's Policy and Procedure (P&P) titled, Accidents and Supervision and as indicated in Resident 2's Care Plan Reports (CPR), dated [DATE].This deficient practice resulted in Resident 2 pushing Resident 1 and Resident 1 falling to the floor and hitting Resident 1's right knee on [DATE]. The deficient practice had the potential to result in serious injury, pain, and a physical decline to Resident 1.Cross Reference F656Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on [DATE], with diagnoses including encephalopathy (a serious health problem that affects brain function or structure), dementia (a progressive state of decline in mental abilities), and impulse disorder (a mental health condition where a person feels a very strong, sudden urge to do something, and they cannot stop themselves).During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 2's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and with mobility.During a review of Resident 1's AR, the AR indicated the facility admitted Resident 1 on [DATE], with diagnoses including diverticulosis (small bulging pouches or pockets in the wall of the large intestine [colon]), hypertension (HTN-high blood pressure), and gastro-esophageal reflux disease (acid reflux).During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with ADL and required supervision or touching assistance with mobility.During a review of Resident 2's Change in Condition Evaluation (CCE), dated [DATE], the CCE indicated Resident 2 had an altercation with another resident [Resident 1], resulting in a fall [to Resident 1].During a review of Resident 2's CPR, initiated [DATE], the CPR's goal indicated will prevent episode of altercations with other residents. The CPR's interventions, initiated/revised [DATE], indicated to anticipate [Resident 2's] needs, monitor (staff supervision) behavior and whereabouts, and staff would continue to closely monitor interactions between roommates and staff.During a review of Resident 2's Notification of Room/Bed/Roommate Change (NORBRC), dated [DATE], the NORBRC indicated Resident 2 was moved from Room C (shared room between Resident 1 and Resident 2) to Room A.During a review of Resident 1's Progress Note (PN), dated [DATE], the PN indicated Resident 1 stated [Resident 2] went to Resident 1's room, pushed her and Resident 1 fell to the floor, kneeling on the floor, and hitting Resident 1's right knee.During an interview on [DATE] at 10:00 AM, with Resident 1, Resident 1 stated that [on [DATE],] Resident 2 returned to Resident 1's room where they had previously roomed together and Resident 2 pushed Resident 1 resulting in Resident 1 falling [to the floor] onto her knee. Resident 1 stated Resident 2 traveled to Resident 1's room without staff (in general) noticing. Resident 1 stated if Resident 2 had been monitored [by staff], Resident 2 would not have reached Resident 1's room without staff intervention.During an interview on [DATE] at 11:00 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated CNA 1 was assigned to care for Resident 2 on [DATE]. CNA 1 stated resident monitoring was considered a collaborative responsibility among facility staff. CNA 1 stated CNA 1 had multiple assigned residents [on [DATE]] and CNA 1 could not continuously supervise and monitor Resident 2 while providing care [to other residents], answering call lights, and passing meal trays. CNA 1 stated CNA 1 believed the incident [dated [DATE]] occurred around lunchtime and stated CNA 1 was likely passing out meal trays [during the time of the incident]. CNA 1 stated CNA 1 did not see Resident 2 leave Room A or travel toward Room C. CNA 1 stated CNA 1 learned about the incident after staff had already responded. CNA 1 stated there was no resident-specific supervising/monitoring log or an established observation interval (a specific time segment used to measure behavior or events of a resident) for Resident 2 prior to the second incident between Resident 1 and Resident 2, dated [DATE]. CNA 1 stated CNA 1 could not identify who was monitoring Resident 2 while CNA 1 performed duties with other residents on [DATE].During a concurrent interview and record review on [DATE] at 11:30 AM, Resident 2's CPR, initiated [DATE], was reviewed with the Licensed Vocational Nurse (LVN) 1, LVN 1, LVN 1 stated the CPR indicated for staff to anticipate Resident 2's needs, monitor her behavior and whereabouts, and closely monitor interactions between the residents and staff. LVN 1 stated no staff observed Resident 2 leave Room A or observed Resident 2 travel toward nor enter Room C. LVN 1 stated Resident 1 stated Resident 2 entered her room and pushed Resident 1, causing her to fall onto her knee. LVN 1 stated effective staff communication and monitoring should have resulted in Resident 2 being identified and redirected [away from Room C] before Resident 2 reached Resident 1's room. LVN 1 stated the recurrence [of the incident] demonstrated that the care-planned interventions to monitor Resident 2's whereabouts and interactions were not implemented effectively.During an interview and concurrent record review on [DATE] at 12:30 PM, Resident 2's CPR, initiated [DATE], was reviewed with the Director of Nursing (DON), the DON stated the CPR indicated for staff to monitor Resident 2's behavior and whereabouts and closely monitor interactions between the residents and staff. The DON stated these interventions required communication and collaboration among CNAs, licensed nurses, the Registered Nurse (RN) supervisor (in general), rehabilitation staff, and other available staff. The DON stated no staff member observed Resident 2 leave Room A, travel through the facility hallways, or enter Room C. The DON stated the DON could not identify who was responsible for monitoring Resident 2 during that period. The DON stated this was problematic because the facility knew Resident 2 had recently pushed Resident 1 [on [DATE]) causing Resident 1 to fall. The DON stated Resident 2's unobserved return to Resident 1's room demonstrated [staff] supervision [of Resident 2] was not effectively implemented, allowing Resident 2 to regain access to Resident 1 and created the opportunity for the physical altercation to recur.During a review of the facility's Policy and Procedure (P&P) titled, Accidents and Supervision revision date [DATE], the P&P indicated: implementation of interventions using specific interventions to try to reduce a resident's risks from hazards in the environment. The P&P indicated the process includes: communicating the interventions to all relevant staff, assigning responsibility, and ensuring that the interventions are put into action. The P&P indicated monitoring is the process of evaluating the effectiveness of care plan interventions. The P&P indicated modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. The P&P indicated monitoring and modification processes include:a.Ensuring that interventions are implemented correctly and consistently.b.Evaluating the effectiveness of interventions.c.Modifying or replacing interventions as needed.d.Evaluating the effectiveness of new interventions.The P&P indicated supervision is an intervention and a means of mitigating accident risk and the facility will provide adequate supervision to prevent accidents. The P&P indicated Adequacy of supervision: defined by type and frequency, based on the individual resident's assessed needs and identified hazards in the resident environment

Based on observation, interview, and record review, the facility failed to ensure verbal complaints regarding moaning from a roommate was addressed and resolved promptly for one of one sampled resident (Resident 30).This deficient practice led to Resident 30 verbalizing being unable to sleep at night due to constant moaning. Findings:During a review of Resident 30's admission Record (AR), the AR indicated the facility admitted Resident 30 on 1/2/2025, with diagnoses that included acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the body's tissues) and severe protein-calorie malnutrition (an extreme deficiency of dietary energy and protein).During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 12/30/2025, the MDS indicated Resident 30 had intact cognition (ability to think, learn, and process information) and was independent with bed mobility such as rolling left and right, sit to lying, sit to stand.During an observation on 5/17/2026 at 12:10 PM, Resident 30's roommate (Resident 44) was assisted back to the room from activities by unidentified staff. Resident 30, who was lying in bed, asked why Resident 44 was already back in the room, Resident 30 stated Resident 30 was trying to get some sleep because Resident 30 was not able to sleep last night from the constant moaning.During an interview on 5/17/2026 at 3:22 PM, Resident 30 stated that Resident 30's roommate (Resident 44) was restless in bed, and there was a constant moaning or humming sound coming from Resident 44.During an interview on 5/17/2026 at 3:30 PM, Resident 30 stated that Resident 30 reported to the Certified Nursing Assistants (CNAs) and some of the licensed nurses assigned to Resident 30 that Resident 30 had a problem sleeping at night because of the roommate's constant moaning. Resident 30 stated that Resident 30 made the CNA's and nurses know for weeks. During an interview on 5/17/2026 at 5:18 PM, the Social Services Director (SSD) stated that Resident 30's roommate (Resident 44), had repetitive moaning as a behavior, but Resident 30 never mentioned this complaint to the SSD. The SSD stated that when a resident (in general) would complain to the staff, the staff could file the grievance on behalf of the complainant so the concern could be addressed.During a review of the facility's policy and procedure (P&P), titled Resident and Family Grievances, revised on 2/22/2023, the P&P indicated it is the policy of the facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Grievances may be voiced in the following forums:a. Verbal complaints to a staff member or Grievance Official.b. Written complaint to a staff member or Grievance Official.c. Written complaint to an outside party.d. Verbal complaint during resident or family council meetings.e. Via the company toll free Customer Service Line (if applicable).The P&P indicated the facility will make prompt efforts to resolve the grievance.

Based on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 23) was assessed prior to permitting self-administration of albuterol (a medication used to provide fast relief from symptoms such as wheezing, coughing, chest tightness, and shortness of breath) inhaler (handheld device that delivers medication in a measured dose while a person inhales) and did not ensure accurate documentation when Resident 23 self-administered .This deficient practice had the potential for Resident 23 to over-medicate and experience potential unwanted side effects (unintended consequences of medication/treatment).Findings:During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD, a progressive lung disease that damages airways and air sacs, making it hard to breathe), asthma (a chronic lung disease that causes the airways to become inflamed, swollen, and filled with extra mucus), and chronic respiratory failure (a condition that happens when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide from the body).During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/16/2026, the MDS indicated Resident 23 had intact cognition and used a manual wheelchair but required supervision or touching assistance to transfer from a bed to a chair.During a review of Resident 23's Order Summary Report (OSR) with active orders as of 5/17/2026, the OSR indicated a physician order for albuterol sulfate hydrofluoroalkane (HFA) inhalation aerosol solution (a liquid medication formulated to be converted into a fine mist or aerosol) with instructions to inhale two (2) puffs orally every four hours as needed for asthma/shortness of breathing/wheezing. May self-administer and keep at bedside with start date of 4/17/2026.During an observation on 5/17/2026 at 1:49 PM at the facility's outside patio, Resident 23 was observed removing an inhaler from Resident 23's jacket pocket and self-administering two doses of the inhaler.During an interview and observation on 5/17/2026 at 1:55 PM with Resident 23 in the activities room, Resident 23 stated that Resident 23 used inhalers for years and liked to keep it on hand just in case it was needed quickly. The box indicated the medication was Albuterol.During an interview on 5/17/2026 at 2:27 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated that Resident 23 requested to keep the inhaler on hand to be able to self-administer. LVN 3 stated LVN 3 would know if Resident 23 had used the inhaler by asking the resident at the end of the shift when and how many times it was used.During a review of Resident 23's Medication Administration Record (MAR) from 5/1/2026 to 5/31/2026, the MAR did not indicate Resident 23 had used the albuterol inhaler during the month of May 2026.During a concurrent observation and interview on 5/18/2026 at 11:33 AM with Resident 23, Resident 23's medication box containing albuterol inhaler was observed. The medication box indicated the albuterol inhaler had total of 200 metered dose inhalations. Resident 23 stated that the staff would not normally know when or how often Resident 23 used the inhaler and staff had not been asking Resident 23 when the inhaler was being used prior to 5/17/2026. Resident 23 stated the inhaler indicated how many doses were left by a counter on the inhaler but did not think the counter was accurate. The inhaler indicated 140 doses were left. Resident 23 stated the medication's box indicated that it should only be used every four hours as needed, but Resident 23 stated Resident 23 used it as often and whenever Resident 23 wanted. Resident 23 stated the medication could increase his blood pressure and heart rate. Resident 23 stated that Resident 23 is supposed to rinse their mouth after the medication administration, but Resident 23 does not want to and does not do so.During a review of Resident 23's Care Plan Report (CP, a form where one can summarize a person's health conditions, specific care needs, and current treatments) related to COPD and asthma and initiated on 1/13/2026, the CP's Interventions section indicated to give aerosol/inhalers or bronchodilators (a type of medication that makes breathing easier by relaxing the muscles in the lungs and widening the airways) as ordered. Monitor/document any side effects and effectiveness.During a review of Resident 23's Self-Administration of Medication (SAM), dated 5/17/2026, the SAM indicated Resident 23 could safely self-administer medication.During an interview on 5/18/2026 at 1:45 PM with the Director of Nursing (DON), the DON stated that it was the facility's protocol to obtain an order and perform an assessment prior to resident's self-administering medication. The DON stated the assessment had not been completed until 5/17/2026 because the nurse likely didn't know an assessment had to be completed. The DON stated it was important to perform an assessment prior to allowing the resident to self-administer because the resident may not know how to administer the medication, may over-medicate, and may not be able to verbalize adverse reactions (any unwanted undesirable and harmful effects of medications).During a review of the facility's policy and procedure (P&P), titled Resident Self-Administration of Medication, dated 12/19/2022, the P&P indicated a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The P&P indicated upon notification of the use of bedside medication by the resident, the medication nurse records self-administration on the MAR.

Based on interview and record review, the facility failed to ensure accurate documentation of the most recent Minimum Data Set (MDS - a federally mandated resident assessment tool) for two of two sampled residents (Resident 23 and Resident 1) by failing to: A. Ensure documentation of oxygen (a gas essential for life) therapy (an administration of supplemental oxygen) for Resident 23.B. Ensure documentation of use of anticonvulsant (a drug commonly used to prevent seizures [a sudden and uncontrolled electrical activity in the brain] or stabilize mood disorders) medication for Resident 1.This deficient practice had the potential for Resident 23 and Resident 1 not receiving treatment and/or services related to the oxygen therapy and anticonvulsant medication. Findings: A. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/28/2025, with diagnoses including acute respiratory failure (ARF - sudden inability to breathe adequately and maintain normal oxygen levels), bipolar disorder (a mental health condition causing episodes of mood changes, including depression and elevated or irritable moods), and chronic obstructive pulmonary disease (COPD, a progressive lung disease that damages airways and air sacs, making it hard to breathe). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognition (the ability to think and process information) was intact. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up) with activities of daily living (ADL - a term used in healthcare that refers to self-care activities) and required setup or clean-up assistance with mobility. Section N0415 – High Risk Drug Classes (Use and Indication) of the MDS indicated Resident 1 was not taking an anticonvulsant (a drug commonly used to prevent seizures or stabilize mood disorders) medication during the assessment period. During a review of Resident 1's Medication Administration Record (MAR), dated 4/2026 (4/1/2026 to 4/30/2026) and 5/2026 (5/1/2026 to 5/31/2026), the MAR indicated that Resident 1 received Carbamazepine (an anticonvulsant medication commonly used to prevent seizures or stabilize mood disorders) oral tablet, 200 milligrams (mg - a measurement used to show the amount or strength of medication), daily, for bipolar disorder. The MAR indicated that the medication was administered during the MDS assessment reference period. During a review Resident 1's Medication Review Report (MRR), dated 5/18/2026, the MRR indicated that Resident 1 had an active physician order for Carbamazepine, 200 mg, to give by mouth one time a day, initiated on 4/10/2026, with a start date of 4/11/2026, for bipolar disorder. The order was still active, and the resident was still being administered the medication at the time of review. During an interview and concurrent record review on 5/18/2026 at 4:26 PM, Resident 1's MDS, MAR, and MRR was reviewed with the MDS nurse (MDSN), the MDSN stated that accurate completion of the MDS was important to ensure the Resident 1's clinical status, medications, and care needs were correctly reflected in the medical record. The MDSN stated inaccurate coding of medications could affect care planning, reimbursement, and the facility's ability to accurately assess and monitor the resident's needs. The MDSN further stated that anticonvulsant medications administered during the assessment reference period should be accurately coded on the MDS according to the medication's pharmacological classification. B. During a review of Resident 23's AR, the AR indicated Resident 23 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD, a progressive lung disease that damages airways and air sacs, making it hard to breathe), asthma (a chronic lung disease that causes the airways to become inflamed, swollen, and filled with extra mucus), and chronic respiratory failure (a condition that happens when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide from the body). During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 had intact cognition and required supervision or touching assistance to transfer from a bed to a chair. The MDS did not indicate Resident 23 used oxygen therapy. During a review of Resident 23's Order Summary Report (OSR), dated with active orders as of 5/17/2026, the OSR indicated a physician order for oxygen at two liters per minute, may titrate (gradual adjustment of the dose) oxygen to three (3) liters per minute to maintain SPO2 (Saturation of Peripheral Oxygen – a measure of the percentage of hemoglobin in the red blood cells that is carrying oxygen from lungs to the rest of the body) greater or equal to 92 percent every shift for SOB (shortness of breath)/COPD with start date of 1/12/2026. During an observation on 5/17/2026 at 10:39 AM in Resident 23's room, Resident 23 was observed sitting up in bed while using oxygen at two liters per minute via nasal cannula (a device that delivers extra oxygen through a tube and into the nose). During an interview on 5/17/2026 at 2:27 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated that Resident 23 used oxygen via nasal cannula as needed but almost always uses it when out of bed. During an interview on 5/18/2026 at 10:46 AM with the MDSN, the MDSN stated that there was a discrepancy on the last completed MDS dated [DATE] and it was not marked that Resident 23 used oxygen. The MDSN stated that it was important for information on the MDS to be accurate to ensure Resident 23 received care related to oxygen use. During a review of the facility's policy and procedure (P&P), titled MDS 3.0 Completion, dated 12/19/2022, the P&P indicated: - Residents are assessed, using a comprehensive assessment process in order to identify care needs and to develop an interdisciplinary care plan. - All disciplines shall follow the guidelines in Chapter 3 of the current RAI manual for coding each assessment. - The facility has seven (7) days in which to encode the MDS data regarding the electronic completion of the MDS. - The assessment reference date is established as reference point for all staff participating in the assessment process. Although staff members may work on completing a resident's MDS on different days, establishment of the assessment reference date ensures the commonality of the assessment period.

Based on interview and record review, the facility failed to develop a comprehensive care plan (CP) that included specific and measurable interventions for two of two sampled residents (Resident 7 and Resident 11) who were at risk for falls.This deficient practice had the potential to result in unmet individualized needs for Residents 7 and 11 and had the potential to affect the residents' physical and psychosocial well-being. Findings:A. During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 10/24/2025, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to a ect a person's daily functioning) and epilepsy (a brain disorder in which a person has repeated seizures [a sudden, uncontrolled surge of electrical activity in the brain). During a review of Resident 7's Fall Risk-V4 assessment, dated 10/24/2025, the Fall Risk-V4 assessment indicated Resident 7 was At Risk for Falls. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 10/28/2025, the MDS indicated Resident 7 had severe cognitive impairment (ability to think and make decisions) and was dependent (helper does all of the effort) with bed mobility such as rolling left and right, sit to lying, and lying to sitting. During a concurrent record review and interview on 5/18/2026 at 8:58 AM with the Minimum Data Set Nurse (MDSN), the MDSN stated Resident 7's CP Report, initiated 11/4/2025, indicated Resident 7 was at risk for falls. The MDSN stated the CP's interventions indicated frequent visual checks. The MDSN stated frequent visual checks included the angel rounds (high-level, administrative check-ins performed once a day by managers or assigned staff), certified nursing assistant (CNA) rounds [a practice of visually checking the resident's well-being], and licensed nurses' rounds. The MDSN stated angel rounds were completed once a day for specific assigned rooms. The MDSN stated CNAs and licensed nurses conducted rounds frequently. The MDSN could not define the specific frequency of frequent visual checks and stated frequent visual checks were not measurable or specific for Resident 7. B. During a review of Resident 11's AR, the AR indicated the facility admitted Resident 11 on 11/5/2025 with diagnoses that included dementia and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 had severe cognitive impairement. The MDS indicated Resident 11 required substantial/maximal assistance (helper does more than half the effort) for sit to lying, sit to stand, chair/bed to chair transfer, toilet transfer, and when walking 10 feet. During a review of Resident 11's Fall Risk-V4 assessment, dated 11/5/2025, the Fall Risk-V4 assessment indicated Resident 11 was At Risk for Falls. During a concurrent record review and interview on 5/18/2026 at 9:20 AM, Resident 11's CP, initiated 12/4/2025, was reviewed with MDSN. The CP Report's focus indicated Resident 11 had an actual fall on 12/4/2025. The CP Report's interventions indicated frequent visual checks. The MDSN stated frequent visual checks included angel rounds, CNA rounds, and licensed nurse's rounds. The MDSN stated angel rounds were completed once a day for specific assigned rooms. The MDSN stated CNAs and licensed nurses conducted rounds frequently. The MDSN stated frequent visual checks were not measurable or specific for Resident 11. During an interview on 5/18/2026 at 5:38 PM with the Director of Nursing (DON), the DON stated measurable and specific interventions for falls will help to measure the effectiveness of the interventions. During a review of the facility's policy and procedure (P&P), titled Comprehensive Care Plan, dated 12/19/2022, the P&P indicated it is the policy of the facility to develop and implement a comprehensive person-centered CP for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The P&P indicated that the comprehensive CP will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The P&P indicated that the objectives will be utilized to monitor the resident's progress and alternative interventions will be documented, as needed.

Based on interview and record review, the facility failed to revise a care plan (CP, a form where one can summarize a person's health conditions, specific care needs, and current treatments) and develop individualized interventions accordingly after an actual fall incident on 5/14/2026 at 2:50 AM to prevent repeated fall incident on 5/14/2026 at 7:20 PM for one of one sampled resident (Resident 53).This deficient practice had the potential for facility staff to be unaware of new fall prevention interventions for Resident 53.Findings: During a review of Resident 53's admission Record (AR), the AR indicated Resident 53 was admitted to the facility on [DATE] with multiple diagnoses including metabolic encephalopathy (when the brain has trouble working because of a chemical or metabolic problems in the body), dementia (a gradual decline in mental ability usually caused by a brain disease), and overactive bladder (sudden urges to urinate that may be hard to control).During a review of Resident 53's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/31/2026, the MDS indicated Resident 53 had impaired cognition (ability to understand and process information), required substantial/ maximal assistance (helper does more than half the effort) for oral and personal hygiene and for transferring from bed to chair, and was dependent (helper does all of the effort) for toileting hygiene and toilet transfer.During a review of Resident 53's Fall Risk-V4 (FR) forms, dated 3/15/2026 at 10:08 AM, 5/14/2026 at 2:50 AM, and 5/14/2026 at 7:20 PM, the FR indicated Resident 53 was at risk for falls.During a review of Resident 53's Care Plan Report (CP) related to actual falls and initiated on 3/15/2026 for an unwitnessed fall, the CP indicated Resident 53 had an unwitnessed fall on 5/14/2026 at 2:50 AM and witnessed fall on 5/14/2026 at 7:20 PM. The CP indicated revision date of 5/18/2026. CP did not indicate specific revision or interventions after the fall incident on 5/14/2026 at 2:50 AM.During a concurrent interview and record review on 5/17/2026 at 5:03 PM with Licensed Vocational Nurse (LVN) 4, Resident 53's CP related to actual falls initiated on 3/15/2026, was reviewed. LVN 4 stated Resident 53 was a fall risk and when a resident has a fall at the facility, part of the facility's fall protocol is to update the resident's CP on how the fall took place and include interventions to prevent another fall. LVN 4 stated Resident 53's CP included the fall on 5/14/2026 at 7:20 PM but did not indicate Resident 53's fall on 5/14/2026 at 2:50 AM.During an interview on 5/18/2026 at 10:50 AM with the Director of Nursing (DON), the DON stated CP interventions needed to be modified if they're proven to be ineffective and staff need to check what interventions are appropriate. The DON stated staff would know the efficacy of the interventions to prevent falls if there were no falls noted after three months. The DON stated Resident 53 fell once on 3/15/2026 and twice on 5/14/2026. The DON stated the care plan related to actual falls did not include the unwitnessed fall on 5/14/2026 at 2:50 AM. The DON stated that the CP needed to include all falls to ensure interventions are individualized to Resident 53's fall situation so they could be implemented.During a review of the facility's policy and procedure (P&P), titled Fall Prevention Program, dated 12/19/2022, and revised on 4/20/2026, the P&P indicated when any resident experiences a fall, the facility will:e. Review the resident's care plan and update as indicated.

Based on interview and record review, the facility failed to ensure physician orders were followed for two of two sampled residents (Resident 10 and Resident 61) by failing to:A. Check Resident 10's Hemoglobin A1C (HgbA1C, a blood test that measures the average level of blood sugar levels over the past two to three months) on last Monday of March 2026.B. Check Resident 61's blood pressure (BP - is the amount of force blood uses to get through the arteries. Normal blood pressure reading for most adults is below 120/80 mm Hg) and heart rate (HR or PR refers to the number of times the heart beats per minute. The normal resting heart rate ranges from 60 to 100 beats per minute) prior administration of amlodipine (a medication used to treat high blood pressure and to prevent chest pain).These deficient practices had the potential to place Resident 61 at risk for the improper administration of amlodipine when clinical parameters indicated the medication should be held and Resident 10 at risk for uncontrolled blood sugar. Findings: A. During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including Type 2 Diabetes Mellitus (a condition in which the body cannot properly store or use glucose [sugar], the body's main source of energy), metabolic encephalopathy (a brain dysfunction caused by chemical imbalances in the body), and peripheral vascular disease (a condition where narrowed or blocked blood vessels restrict blood flow to the limbs, organs, or brain). During a review of Resident 10's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 3/31/2026, the MDS indicated Resident 10 had impaired cognition (ability to understand and process information) and required set up or clean-up assistance with eating and substantial/maximal assistance (helper does more than half the effort) with toileting hygiene. During a review of Resident 10's Medication Review Report (MRR), dated as of 5/18/2026, the MRR indicated a physician order to check HgbA1c on last Monday of September and March every year with the start date of 9/16/2025. During an interview on 5/18/2026 at 1:45 PM with the Director of Nursing (DON), the DON stated Resident 10's last HgbA1c result was from 9/2025. The DON stated checking the HgbA1c is important to be able to monitor Resident 10's blood sugar and if the HgbA1c is high, then Resident 10 might have consistently high blood sugar, and could experience more frequent urination, thirst, hunger or nerve pain. During a review of the facility's policy and procedure (P&P), titled Provision of Physician Ordered Services, revised on 5/15/2023, the P&P indicated the facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. B. During a review of Resident 61's AR, the AR indicated the facility admitted Resident 61 on 7/22/2024, with diagnoses that included severe protein calorie malnutrition (an extreme deficiency of dietary energy and protein) and functional quadriplegia (a complete inability to move due to severe disability or frailty caused by another condition without physical injury or damage to the spinal cord). During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61 rarely/never understands verbal content and rarely/never able to express ideas and wants. During a review of Resident 61's Medication Review Report (MRR), dated 4/1/2026 to 4/16/2026, the MRR indicated an order to administer amlodipine five milligrams (mg), one tablet, by mouth, one time a day for hypertension (high blood pressure) with an order date of 12/25/2025. The order indicated to hold if systolic blood pressure (SBP - the pressure when the heart actively beats) was below 100 or heart rate was (HR) less than 60. During a review of Resident 61's Medication Administration Record (MAR), dated 4/1/2026 to 4/30/2026, the MAR indicated amlodipine was administered from 4/1/2026 to 4/15/2026. The MAR indicated there was no BP or pulse documented on the MAR. During a review of Resident 61's Weights and Vitals Summary from 4/1/2026 to 4/16/2026, the blood pressure summary indicated there was no documented blood pressure from 4/1/2026 to 4/4/2026, from 4/7/2026 to 4/9/2026, and from 4/12/2026 to 4/15/2026 prior to hospitalization. During a review of Resident 61's Weights and Vitals Summary from 4/1/2026 to 4/16/2026, the pulse summary indicated no documented pulse from 4/13/2026 to 4/15/2026. During a review of Resident 61's Care Plan report (CP) for The resident has hypertension (HTN)/hyperlipidemia [HLD, a medical term for high levels of fats in the blood]), the Goal section indicated, The resident will remain free of complications related to hypertension. The CP indicated an intervention to observe blood pressure and or pulse monitoring parameters prior to medication administration. The CP indicated to monitor side effects such as orthostatic hypotension (a form of low blood pressure that happens when the person stands up), increased heart rate, and effectiveness. The CP indicated to monitor/document/report as needed any signs and symptoms of malignant hypertension (a life-threatening medical emergency characterized by a sudden, sever spike in blood pressure) including confusion, irritability, and seizure activity. During an interview on 5/18/2026 at 5:03 PM, Licensed Vocation Nurse 2 (LVN 2) stated on 4/16/2026, LVN 2 assessed Resident 61, Resident 61 was staring and mumbling, and the resident was transferred to the hospital for seizure like activity. LVN 2 stated LVN 2 checked Resident 61's vital signs during that change of condition. During an interview on 5/18/2026 at 5:35 PM, the Director of Nursing (DON) stated there was no documented evidence that the BP and PR was checked on 4/12/2026 to 4/15/2026. The DON stated the BP and PR was checked on 4/16/2026 when Resident 61 had a change of condition. The DON stated Resident 61's BP and HR needed to be checked prior to the administration of amlodipine in order to know if the administration parameters were met. The DON stated the BP and PR needed to be documented to indicate that there were checked. During a review of the facility's policy and procedure (P&P), titled Medication Administration, dated 12/19/2022, the P&P indicated to obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. During a review of the facility's P&P, titled Provision of Physician Ordered Services, revised on 5/15/2023, the P&P indicated medications will be administered following facility protocol, dosage guidelines, and documentation procedures.

Based on observation, interview, and record review, the facility failed to prevent falls (unintentionally coming to rest on the ground, floor, or other lower level) for one of three sampled residents (Resident 11), as evidenced by:Resident 11's was not provided assistance when walking from the dining room back to Resident 11's room on 12/4/2025.Resident 11 was not provided assistance when getting up from bed to the bathroom on 1/1/2026.This deficient practice resulted in Resident 11 falling on 12/4/2025 and on 1/1/2026 and had the potential to result in harm and health decline. Findings:During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 11/5/2025 with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality).During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool), dated 1/9/2026, the MDS indicated Resident 11 rarely/never understands verbal content and rarely/never able to express ideas and wants. The MDS indicated Resident 11 required substantial/maximal assistance (helper does more than half the effort) for sit to lying, sit to stand, chair/bed to chair transfer, toilet transfer, and when walking 10 feet.During a review of Resident 11's Fall Risk-V4 assessment, dated 11/5/2025, the Fall Risk assessment indicated Resident 11 was At Risk for Falls.a. During a review of Resident 11's SBAR Communication Form (SBAR - situation, background, assessment and recommendation, is a communication framework for sharing information with the team about the condition of a patient), dated 12/4/2025, the SBAR indicated Resident 11 was walking in the hallway, resident was stumbled and fell face down. The SBAR indicated Resident 11 sustained a cut above the left side of the upper lip.During a review of Resident 11's Care Plan Report (CP), initiated on 12/4/2025, the CP indicated Resident 11 had an actual fall on 12/4/2025. The CP indicated according to the Activity Staff (unidentified), Resident 11 was walking through the hallway, resident stumbled and took a fall face down. The CP indicated Resident 11 sustained a cut above the left side of the resident's upper lip. During an interview on 5/18/2026 at 11:40 AM, the Activity Assistant (AA) stated that the AA could not remember the exact date, but it was between 8:00 AM to 8:30 AM in December 2025 when Resident 11 fell. The AA stated that the AA saw residents walking out from the dining room due to dining room was being closed for cleaning. The AA stated residents were walking toward the AA and the AA witnessed Resident 11 was walking by herself, there was another resident in front of Resident 11, and then Resident 11's head disappeared from the AA's line of sight. The AA stated AA did not see how Resident 11 hit the ground but there was blood around.During a concurrent review of Resident 11's Physical Therapy Evaluation and Plan of Treatment (PTE/POT) notes, dated 11/7/2025, and interview on 5/18/2026 at 2:00 PM, the Physical Therapist (PT) stated that Resident 11 was initially evaluated by Physical Therapy on 11/7/2025, Resident 11 was able to walk 150 feet with partial/moderate assistance and requiring handheld assistance. The PT stated partial/moderate assistance would mean the resident would need help during ambulation. The PT stated Resident 11 had a balance deficit and decreased muscle strength. During a review of Resident 11's Physical Therapy Treatment Encounter Notes (PT/TEN), dated 12/4/2025, and interview on 5/18/2026 at 2:18 PM, the PT stated that Resident 11 walked 175 feet with handheld assistance of contact guard assistance which would mean Resident 11 needed assistance during ambulation.During an interview on 5/18/2026 at 5:42 PM, the Director of Nursing stated that when residents in general are provided with assistance during ambulation, we could lessen the severity of a fall, or we could prevent a fall.b. During a review of Resident 11's SBAR Communication Form, dated 1/1/2026, the SBAR indicated Resident 11's roommate called the assigned certified nursing assistant (CNA) and reported that Resident 11 fell in the bathroom and resident was transferred to the General Acute Care Hospital (GACH).During a review of Resident 11's PT/TEN, dated 12/30/2025, and interview on 5/18/2026 at 2:28 PM, the PT stated Resident 11 walked 225 feet with handheld assistance. The PT stated Resident 11 needed contact guard assistance with transfers due to balance deficit and required maximum cueing or redirection due to cognition.During an interview on 5/18/2026 at 5:42 PM, the Director of Nursing (DON) stated Resident 11 just walks and did not call for assistance when resident went to the bathroom. The DON stated that for residents with dementia, the facility needed to provide close supervision and activities, but the fall happened after breakfast early in the morning. The DON stated the staff found Resident 11 in the bathroom.During an observation on 5/18/2026 at 5:45 PM, the DON stated Resident 11 was not placed in a room closer to the Nurse's station because there was no room available. During a review of Resident 11's CP, titled At Risk for Fall, initiated on 11/5/2025, and related to episodes of pacing and being unaware of safety needs, the CP did not have interventions regarding the level of assistance Resident 11 needed during ambulation and during transfers as indicated on the PT/TEN report. During a review of Resident 11's CP, initiated on 12/4/2025, the CP indicated Resident 11 had an actual fall on 1/1/2026. The CP indicated Resident 11's roommate reported to the CNA that Resident 11 was sitting on the bathroom floor and had swelling, discoloration, and pain in the right knee/lower extremity. The CP indicated 911 (universal emergency telephone number in the United States) was activated to send Resident 11 to the GACH. During a review of the facility's policy and procedure (P&P), titled Fall Prevention Program, revised on 4/20/2026, the P&P indicated that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The P&P indicated to provide additional interventions as directed by the resident's assessment, including but not limited to increased frequency of rounds, scheduled ambulation or toileting assistance, therapy services referral . The P&P indicated At Risk Protocols included providing interventions that address unique risk factors measured by the risk assessment tools: medication, psychological, cognitive status, or recent change in functional status.

Based on observation, interview, and record review, the facility failed to ensure their medication error rate was not 5 percent or greater. Three medication errors were identified out of 29 opportunities and resulted in a medication error rate of 10.34 percent. The facility failed to ensure medications were administered in accordance with physician orders for two of six sampled residents (Resident 3 and Resident 5) by failing to:A. Ensure Resident 3's Omeprazole (medication used to reduce stomach acid and treat stomach irritation or reflux [backward flow of stomach acid into the esophagus [tube that connects the mouth to the stomach]) and Divalproex (medication used to treat seizures [episodes of abnormal brain activity] and mood disorders) medications were administered to swallow whole.B. Ensure Resident 5's Metformin (medication used to control blood sugar levels in diabetes [a persistent or long-lasting disease characterized by high blood sugar levels due to insufficient insulin [a hormone which regulates the amount of sugar in the blood] production]) was administered with food.These failures had the potential to result in ineffective therapeutic response and adverse medication reactions (injuries resulting from medication use including physical and mental harm, or loss of function), fluctuations in blood glucose levels, worsening of underlying medical conditions, and the potential for physical declines to Resident 3 and Resident 5. Findings: A. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 3/26/2025, and re-admitted the resident on 12/13/2025, with diagnoses including epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions [body muscles contract and relax rapidly and repeatedly, causing uncontrollable shaking and limb movements], associated with abnormal electrical activity in the brain), and encounter for attention to gastrostomy (G-tube, soft flexible tube surgically inserted directly into the stomach through a small opening in the abdomen, used to deliver liquid nutrition, hydration, and medications for people who cannot eat or swallow safely). During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 3's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 3 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL-term used in healthcare that refers to self-care activities) and with mobility. During a review of Resident 3's Medication Administration Record (MAR), dated 5/2026, the MAR indicated various medications were to be administered at 4:30 and 5 PM including: 1.Divalproex 125 milligrams (mg-a unit of medication measurement), give two capsules by mouth two times a day for seizure disorder, and to swallow whole do not crush or chew. 2.Omeprazole 40 mg, give one capsule by mouth two times a day for gastroesophageal reflux disease (GERD-acid reflux), and duodenal ulcer (sore in the small intestine), give before meals, swallow whole, and to not crush or chew. During a review of Resident 3's Order Summary Report (OSR), dated active as of 5/17/2026, the OSR included the following physician orders: Divalproex 125 mg, dated 4/1/2026, give 2 capsules by mouth two times a day for seizure disorder, the order indicated to swallow whole to not crush. The OSR indicated Omeprazole 40 mg, dated 4/1/2026, give one capsule by mouth two times a day for GERD/duodenal ulcer. The order indicated to swallow the capsule whole, and to not crush. During a medication pass (preparation and administration) observation on 5/17/2026 at 4:30 PM, Licensed Vocational Nurse (LVN) 2 prepared the following medications for Resident 3: Divalproex, Omeprazole, Lactulose (medication used to treat constipation or reduce ammonia [waste substance in blood] level), Namenda (medication used to treat memory loss and confusion), NovoLog (rapid-acting insulin [medication used to lower blood sugar]), Rifaximin (antibiotic used to reduce harmful bacteria in the intestines [bowels]), and Brimonidine Tartrate (eye medication used to lower eye pressure). LVN 2 removed the Omeprazole capsule from the bubble packaging (pre-packaged medications sealed in plastic bubbles), opened the capsule, and poured the contents into a medication cup. LVN 2 removed two Divalproex capsules from the bubble packaging and poured the contents into a separate medication cup. LVN 2 then prepared the remaining medications and administered each medication via G-tube. During an interview and concurrent record review on 5/17/2026 at 6:27 PM, Resident 3's OSR, dated 5/17/2026, was reviewed with LVN 2, LVN 2 stated the physician's orders for Resident 3's Divalproex and Omeprazole indicated the medications were to be swallowed whole and not to be crushed or chewed. LVN 2 stated she opened both capsules prior to the administration of the medications [and administered the contents of the capsule] via g-tube. LVN 2 stated that delayed release (medication coated to dissolve slowly instead of immediately) medications should not be opened unless specifically indicated by the physician or pharmacy as reflected in the physician's orders. LVN 2 stated altering the capsule may have affected how the medication was released and absorbed by the body, potentially reducing medication effectiveness or increasing the risk of adverse effects (AE, undesired harmful effect resulting from a medication). During an interview on 5/17/2026 at 6:46 PM, with the Director of Nursing (DON), the DON stated physician's orders are to be followed as written and should be properly followed when the order indicated medications are to be swallowed whole, not crushed or chewed. The DON stated delayed release or extended-release medications should not be altered unless specifically clarified and authorized by the prescribing physician or consulting pharmacist. The DON stated opening the capsules may alter the medication's intended release mechanism, potentially affecting absorption, decreasing therapeutic effectiveness, or increasing the risk for AEs. The DON stated nursing staff were expected to verify medication administration instructions prior to altering medications for G-tube administration. The DON stated these practices were essential to ensure resident safety and ensure medications were administered accurately according to the physician's orders. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration via Enteral Tube, revised 12/19/2022, the P&P indicated it is the policy of the facility to ensure the safe and effective administration of medications via enteral feeding tubes [G-tube] by utilizing best practice guidelines. The P&P indicated sublingual, enteric coated, or modified release medications will not be administered through the enteral tube [G-tube]. The P&P indicated pharmacy will be notified for more appropriate dosage form[s]. B. During a review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 12/16/2025, with diagnoses that included type 2 diabetes mellitus (DM, a disease that affects how the body uses glucose), and protein-calorie malnutrition. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had intact cognition and required supervision or touching assistance (helper provides verbal cues, steadying and/or contact guard assistance as resident completes the activity) with oral hygiene, and upper body dressing. During a review of Resident 5's Medication Review Report (MRR), dated 5/1/2026 to 5/31/2026, the MRR indicated a physician's order for Metformin Hydrochloride 500 mg, give one tablet by mouth three times a day for DM. The order indicated to administer Metformin with food. During an observation on 5/17/2026 4:32 PM, LVN 4 administered 500 mg of Metformin Hydrochloride to Resident 5 and did not provide or give food prior to the administration to Resident 5. During an interview on 5/17/2026 at 4:40 PM, LVN 4 stated Resident 5 usually had snacks at Resident 5's bedside. LVN 4 stated LVN did not remind or inform Resident 5 to take the medication [Metformin Hydrochloride] with food. LVN 4 stated taking Metformin with food as ordered [by the physician] prevented an upset stomach and a drop in blood sugar. During a review of the facility's P&P titled Medication Administration revised 12/19/2022, the P&P indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on observation, interview, and record review, the facility failed to post the nurse staffing data for one of three days (5/16/2026).This deficient practice failed to protect the rights of residents and their representatives to access nursing staffing data.Findings:During an observation on 5/16/2026 at 11:55 AM, there was a posted Census (the total number of residents staying in the building at that specific time) and Direct Care Service Hours Per Patient Day (the average number of hours a single resident receives hands-on care from the nursing staff in a 24-hour period), dated 5/15/2026. The data was posted near the Nursing Station close to the facility's entrance door.On 5/17/2026 at 11:01 AM, Licensed Vocational Nurse 1 (LVN 1)/Director of Staff Development (DSD) stated that posting the nursing hours was the LVN 1/DSD's responsibility and the Registered Nurse Supervisor (RNS) or charge nurses would be responsible for posting the nursing hours on the weekends. LVN 1/DSD stated the nursing hours would be posted before 10:00 AM and after the stand-up meeting everyday. The LVN1/DSD stated that the posting would show how many direct care staff were provided for residents care that day.On 5/17/2026 at 11:06 AM, LVN 1/DSD stated that LVN1/DSD did not know why the nursing hours were not posted on 5/16/2026. LVN 1/DSD stated that the nursing hours could have been posted on the other side but the area near the entrance would be the best place to post the nursing hours because it was more accessible.During a review of the facility's policy and procedure (P&P), titled Nurse Staffing Posting Information, revised on 3/10/2025, the P&P indicated it is the policy of the facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. The P&P indicated the facility will post the Nurse Staffing Sheet at the beginning of each shift. The P&P indicated the information posted will be.in a prominent place readily accessible to staff, residents and visitors.

Based on interview and record review, the facility failed to report an allegation of abuse for one of four sampled residents (Resident 1) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement in accordance with the facility's policy and procedure (P&P) titled, Abuse, Neglect, and Exploitation, dated 12/19/2022.This failure resulted in the delay of notification to the Department, the Ombudsman, and to the local law enforcement and had the potential to result in Resident 1 to be subjected to abuse while at the facility.(cross reference F580 and F656)Findings:a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (loss of blood flow to a part of the brain), and other abnormalities of gait and mobility (abnormal walking patterns, including limping, shuffling, dragging feet, or instability).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 2/2/2026, the H&P indicated that the resident had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/3/2026, the MDS indicated Resident 1 was mildly impaired in cognitive skills (ability to make daily decisions). The MDS indicated the resident required substantial/maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, showering/bathing self, lower body dressing, putting on/taking off footwear, and with moving around in bed. The MDS indicated Resident 1 was dependent on staff for transfers and walking.During a review of Resident 1's Progress Notes (PN), dated 3/3/2026 and timed at 2:57 PM, the PN indicated that the Social Services Director (SSD) requested psychology consultation for Resident 1 on 3/3/2026 because Resident 1 was having a hard time due to Resident 1's health challenges.b. During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (brain disease, damage, or malfunction caused by an illness or organs that are not working as well as they should), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 4's H&P, dated 2/21/2026, the H&P indicated that the resident did not have the capacity to understand and make decisions.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was severely impaired in cognitive skills. The MDS indicated Resident 4 required substantial/maximal assistance with oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and with transfers and walking.During a review of Resident 4's PN, dated 3/2/2026 and timed at 10:38 AM, the PN indicated that Resident 4 was throwing objects at staff, hitting head against wall, and grabbing other residents on 3/2/2026 at 9:45 AM and was sent to General Acute Hospital (GACH) 1 on 3/2/2026 at 10:30 AM for further evaluation.During a review of Resident 4's care plan (CP), initiated on 3/2/2026, the CP indicated Resident 4 was having a behavioral/psychotic episode by yelling out, throwing objects at staff, grabbing other residents and hitting head against wall.During a review of Resident 4's SBAR Communication Form (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/2/2026, the SBAR indicated that Resident 4 was agitated, yelling out, throwing objects at other people, and grabbing others and Resident 4 was sent out to the emergency room (ER- a specialized, 24/7 hospital unit designed to treat acute, life-threatening, or severe injuries and illnesses requiring immediate medical attention) for further evaluation.During an interview on 3/17/2026 at 10:46 AM with Resident 1, Resident 1 stated Resident 1 was scared when another resident (Resident 4) grabbed Resident 1's left arm in the hallway.During an interview on 3/17/2026 at 12:42 PM with Physical Therapy Assistant (PTA) 2, PTA 2 stated Resident 4 grabbed Resident 1's arm in the hallway which scared Resident 1 on 3/2/2026. PTA 2 stated the Social Services Director (SSD) witnessed the incident and Licensed Vocational Nurse (LVN) 1 and a registered nurse (unknown) checked on Resident 1. PTA 2 stated Resident 4 grabbing Resident 1's arm should have been reported as an allegation of physical abuse to the Department, the Ombudsman, and to local law enforcement within two hours.During an interview on 3/18/2026 at 2:08 PM with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 4 grabbed Resident 1's arm in the hallway on 3/2/2026. CNA 4 stated abuse or allegations of abuse must be reported to the charge nurse, the administrator and to the Director of Nursing (DON) right away.During a concurrent interview and record review on 3/17/2026 at 3:14 PM with the SSD, Resident 1's PN, dated 3/3/2026, was reviewed. SSD stated Resident 1 was shaking and tearing after Resident 1 was touched by Resident 4 in the hallway on 3/2/2026. SSD stated SSD requested psychology consultation for Resident 1 on 3/3/2026 due to Resident 1 having a hard time due to health challenges. The SSD stated that the SSD should report any abuse and allegation of abuse to the Department, the Ombudsman, and to local law enforcement within two hours.During an interview on 3/18/2026 at 11:42 AM with LVN 1, LVN 1 stated staff (in general) should report unwanted grabbing as physical abuse to the Department, the Ombudsman, and to local law enforcement within two hours.During an interview on 3/18/2026 at 12:35 PM with the DON, the DON stated the facility did not report the incident to the Department, the Ombudsman, and to local law enforcement regarding Resident 4 grabbing Resident 1's arm which scared Resident 1 in the hallway on 3/2/2026. The DON stated the facility should report any abuse and allegation of abuse to the Department, the Ombudsman, and to local law enforcement within two hours.During an interview on 3/18/2026 at 1:35 PM with the Administrator, the Administrator stated that the facility did not report the incident to the Department, the Ombudsman, and to local law enforcement regarding Resident 4 grabbing Resident 1's arm which scared Resident 1 in the hallway on 3/2/2026.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, and Exploitation, dated 12/19/2022, the P&P indicated that Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse,. The P&P indicated that the facility must ensure Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and record review, the facility failed to notify one of four sampled residents' (Resident 1's) physician that Resident 1 was scared after being grabbed by Resident 4 in the hallway on 3/2/2026.This failure had the potential for Resident 1 not to receive care and treatment to address Resident 1's physical and psychosocial health after an incident which could negatively affect Resident 1's health and wellbeing.(Cross Reference F609 and F656)Findings:a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (loss of blood flow to a part of the brain), and other abnormalities of gait and mobility (abnormal walking patterns, including limping, shuffling, dragging feet, or instability).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 2/2/2026, the H&P indicated that the resident had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/3/2026, the MDS indicated Resident 1 was mildly impaired in cognitive skills (ability to make daily decisions). The MDS indicated the resident required substantial/maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, showering/bathing self, lower body dressing, putting on/taking off footwear, and with moving around in bed. The MDS indicated Resident 1 was dependent on staff for transfers and walking.During a review of Resident 1's Progress Notes (PN), dated 3/3/2026 and timed at 2:57 PM, the PN indicated that the Social Services Director (SSD) requested psychology consultation for Resident 1 on 3/3/2026 because Resident 1 was having a hard time due to Resident 1's health challenges.b. During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (brain disease, damage, or malfunction caused by an illness or organs that are not working as well as they should), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 4's H&P, dated 2/21/2026, the H&P indicated that the resident did not have the capacity to understand and make decisions.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was severely impaired in cognitive skills. The MDS indicated Resident 4 required substantial/maximal assistance with oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and with transfers and walking.During a review of Resident 4's PN, dated 3/2/2026 and timed at 10:38 AM, the PN indicated that Resident 4 was throwing objects at staff, hitting head against wall, and grabbing other residents on 3/2/2026 at 9:45 AM and was sent to General Acute Hospital (GACH) 1 on 3/2/2026 at 10:30 AM for further evaluation.During a review of Resident 4's SBAR Communication (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/2/2026, the SBAR indicated that Resident 4 was agitated, yelling out, throwing objects at other people, and grabbing others.During an interview on 3/17/2026 at 10:46 AM with Resident 1, Resident 1 stated that Resident 1 was scared when another resident (Resident 4) grabbed Resident 1's left arm in the hallway.During an interview on 3/17/2026 at 12:42 PM with Physical Therapy Assistant (PTA) 2, PTA 2 stated Resident 4 grabbed Resident 1's arm in the hallway which scared Resident 1 on 3/2/2026. PTA 2 stated the Social Services Director (SSD) witnessed the incident and Licensed Vocational Nurse (LVN) 1 and a registered nurse (unknown) checked on Resident 1.During an interview on 3/18/2026 at 2:08 PM with the Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 4 grabbed Resident 1's arm in the hallway on 3/2/2026.During a concurrent interview and record review on 3/17/2026 at 3:14 PM with the SSD, Resident 1's PN, dated 3/3/2026, was reviewed. SSD stated Resident 1's doctor was not notified that Resident 1 was shaking and tearing after Resident 4 touched Resident 1 in the hallway on 3/2/2026. SSD stated SSD requested psychology consultation for Resident 1 on 3/3/2026 due to Resident 1 having a hard time due to health challenges. The SSD stated Resident 1's doctor should be notified whenever Resident 1's health condition had changed.During a concurrent interview and record review on 3/18/2026 at 11:42 AM with LVN 1, Resident 1's medical record was reviewed. LVN 1 stated that Resident 1's doctor was not notified and there were no progress notes or SBAR for Resident 1 after Resident 1's left upper arm was grabbed by Resident 4 on 3/2/2026. LVN 1 stated the resident's doctor should be notified whenever the resident had any change of condition.During a concurrent interview and record review on 3/18/2026 at 12:35 PM with the Director of Nursing (DON), Resident 1's medical record was reviewed. The DON stated there were no notes or SBAR regarding notifying Resident 1's doctor after Resident 1 was grabbed and scared by Resident 4 in the hallway on 3/2/2026. The DON stated that Resident 1's doctor was not made aware of the incident between Resident 1 and Resident 4 and that Resident 4 scared Resident 1 on 3/2/2026 when and after SSD requested a psychology consultation for Resident 1 on 3/3/2026. The DON stated that it was important to notify the physician and create an SBAR whenever residents had any change of condition and needed a psychology consultation.During a review of the facility's Policy and Procedure (P&P) titled, Notification of Changes, dated 12/19/2022, the P&P indicated, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include:1. Accidentsa. Resulting in injury.b. Potential to require physician intervention.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was provided with comfortable and homelike environment by failing to remove two boxes of canned soda, which did not belong to Resident 1, from Resident 1's nightstand.This deficient practice resulted in Resident 1 feeling upset and Resident 1's private privacy space being violated.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (loss of blood flow to a part of the brain), and other abnormalities of gait and mobility (abnormal walking patterns, including limping, shuffling, dragging feet, or instability).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 2/2/2026, the H&P indicated that the resident had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/3/2026, the MDS indicated Resident 1 was mildly impaired in cognitive skills (ability to make daily decisions). The MDS indicated the resident required substantial/maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, showering/bathing self, lower body dressing, putting on/taking off footwear, and with moving around in bed. The MDS indicated Resident 1 was dependent on staff for transfers and walking.During a concurrent observation and interview on 3/18/26 at 9:13 AM with Resident 1 in Resident 1's room, there were two boxes of canned soda in Resident 1's nightstand at bedside. Resident 1 stated that the canned soda was not Resident 1's and Resident 1 felt upset that someone violated Resident 1's private space.During a concurrent observation and interview on 3/18/26 at 9:22 AM with the Social Services Director (SSD) in Resident 1's room, there were two boxes of canned soda in Resident 1's nightstand at bedside. The SSD stated the nightstand was Resident 1's private space, and the facility should remove everything that did not belong to Resident 1 from the nightstand.During an interview on 3/18/2026 at 9:38 AM with the Infection Preventionist (IP), the IP stated the facility should not leave anything which did not belong to residents in resident's room including inside the nightstand and closet. The IP stated that the facility should remove things which did not belong to residents and ensure everything is clean in the residents' room.During an interview on 3/18/2026 at 12:35 PM with the Director of Nursing (DON), the DON stated the facility should not leave anything which did not belong to residents in residents' nightstand and closet. The DON stated it was residents' right to use the nightstand as their personal private space to place their own personal belongings.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/19/2022, the P&P indicated the facility should ensure the resident has a right to be treated with respect and dignity, including the right to retain and use personal possessions, including furnishings and clothing, as space permits. The P&P indicated that the facility should ensure the resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interview and record review, the facility failed to ensure a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) was developed and implemented for one of four sampled residents (Resident 1) to monitor Resident 1's physical and psychosocial well-being after Resident 1 was grabbed on the arm by Resident 4 on 3/2/2026 and Social Services Director (SSD) requested psychology consultation for Resident 1 on 3/3/2026.These deficient practices had the potential to place Resident 1 at risk of not receiving the individualized care services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.(cross reference F580 and F609)Findings:a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (loss of blood flow to a part of the brain), and other abnormalities of gait and mobility (abnormal walking patterns, including limping, shuffling, dragging feet, or instability).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 2/2/2026, the H&P indicated that the resident had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/3/2026, the MDS indicated Resident 1 was mildly impaired in cognitive skills (ability to make daily decisions). The MDS indicated the resident required substantial/maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, showering/bathing self, lower body dressing, putting on/taking off footwear, and with moving around in bed. The MDS indicated Resident 1 was dependent on staff for transfers and walking.During a review of Resident 1's Progress Notes (PN), dated 3/3/2026 and timed at 2:57 PM, the PN indicated that the Social Services Director (SSD) requested psychology consultation for Resident 1 on 3/3/2026 because Resident 1 was having a hard time due to Resident 1's health challenges.During a review of Resident 1's medical record, there was no care plan to address that Resident 1 was shaking and tearing after Resident 1 was touched by Resident 4 in the hallway on 3/2/2026 and Resident 1's need for a psychology consultation.b. During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (brain disease, damage, or malfunction caused by an illness or organs that are not working as well as they should), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 4's H&P, dated 2/21/2026, the H&P indicated that the resident did not have the capacity to understand and make decisions.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was severely impaired in cognitive skills. The MDS indicated Resident 4 required substantial/maximal assistance with oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and with transfers and walking.During a review of Resident 4's PN, dated 3/2/2026, the PN indicated that Resident 4 was throwing objects at staff, hitting head against wall, and grabbing other residents on 3/2/2026.During a review of Resident 4's care plan (CP), initiated on 3/2/2026, the CP indicated Resident 4 was having a behavioral/psychotic episode by yelling out, throwing objects at staff, grabbing other residents and hitting head against wall.During a review of Resident 4's SBAR Communication Form (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/2/2026, the SBAR indicated that Resident 4 was agitated, yelling out, throwing objects at other people, and grabbing others.During an interview on 3/17/2026 at 10:46 AM with Resident 1, Resident 1 stated that Resident 1 was scared when the other resident grabbed Resident 1's left arm in hallway.During an interview on 3/17/2026 at 12:42 PM with Physical Therapy Assistant (PTA) 2, PTA 2 stated Resident 4 grabbed Resident 1's arm in the hallway which scared Resident 1 on 3/2/2026.During an interview on 3/18/2026 at 2:08 PM with the Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 4 grabbed Resident 1's arm in the hallway on 3/2/2026.During a concurrent interview and record review on 3/17/2026 at 3:14 PM with the Social Service Director (SSD), Resident 1's medical record was reviewed. SSD stated the SSD was unable to find a care plan to address Resident 1 was shaking and tearing after Resident 1 was touched by Resident 4 in the hallway on 3/2/2026. SSD stated SSD requested psychology consultation for Resident 1 because Resident 1 was having a hard time due to health challenges on 3/3/2026 and there was no care plan for this psychology consultation request.During a concurrent interview and record review on 3/18/2026 at 11:42 AM with the Licensed Vocational Nurse (LVN) 1, Resident 1's medical record was reviewed. LVN 1 stated that there was no care plan for Resident 1 after Resident 1's left upper arm was grabbed by Resident 4 on 3/2/2026.During a concurrent interview and record review on 3/18/2026 at 12:35 PM with the Director of Nursing (DON), Resident 1's medical record was reviewed. The DON stated there was no care plan for Resident 1 after Resident 1 was grabbed and scared by Resident 4 in the hallway on 3/2/2026. The DON stated that there was no care plan for Resident 1 after SSD requested a psychology consultation due to health condition challenges. The DON stated that it was important to develop a care plan to monitor the residents' psychosocial well-being when the resident requested a psychology consultation.During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plans, dated 12/19/2022, the P&P indicated that the facility should develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The P&P indicated, The person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. The P&P indicated, The comprehensive care plan will describe, ., a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to provide respiratory care and services for two of two sampled residents (Resident 20 and Resident 41) when, a. Resident 20's oxygen [colorless, odorless gas] was not on continuously as indicated in Resident 20's care plan (CP). b. Resident 41's nebulizer mask and tubing was not changed in accordance with the facility's Policy and Procedure (P&P) titled, Oxygen Administration. These deficient practices had the potential to result in physical declines to Residents 20 and 41. Findings: a. During a review of Resident 20's Admission Record (AR), the AR indicated the facility admitted Resident 20 on 2/28/2025, with diagnoses that included acute (sudden) respiratory failure (when lungs cannot release enough oxygen into the blood, which prevents the organs from properly functioning. It also occurs if the lungs cannot remove carbon dioxide from the blood), chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow). During a review of Resident 20's CP titled, The resident has COPD, at risk for SOB [shortness of breath] initiated on 3/3/2025, the CP indicated to provide oxygen at 4 L (liters, unit of volume) per minute via nasal cannula ([NC] a device-lightweight flexible plastic tubing used to deliver supplemental oxygen, tubing ending is placed in the nostrils and is fitted over the patient's ears) continuously every shift for acute respiratory failure. During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool), dated 3/4/2025, the MDS indicated Resident 20 had moderate deficit in cognition (ability to understand and process information), Resident 20 was dependent on staff with toileting hygiene and required maximal assistance (helper does more than half the effort) with personal hygiene and rolling left and right bed mobility. During the following observations on 4/17/2025 at 8:21 AM, 9:44 AM, and at 10:39 AM, Resident 20's oxygen was off, the NC was not on Resident 20's nostrils and was on Resident 20's chin. During an interview on 4/17/2025 at 10:53 AM, the Director of Nursing (DON) stated the nurses, and the CNA assigned to Resident 20 needed to make rounds and check [to ensure oxygen delivery] Resident 20. During a review of the facility's P&P titled, Oxygen Administration revised 5/20/2024, the P&P indicated oxygen is administered under orders of a physician. The P&P indicated the resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: 1. The type of oxygen delivery system. 2. When to administer, such as continuous or intermittent and/or when to discontinue. b. During a review of Resident 41's AR, the AR indicated Resident 41 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis [complete or partial loss of muscle function] on one side of the body), hemiparesis following cerebral infarction (one sided weakness and paralysis after a stroke), and respiratory failure with hypoxia (occurs when a person doesn't have enough oxygen in the blood). During a review of Resident 41's MDS, dated [DATE], the MDS indicated Resident 41's cognition was severely impaired. During an observation on 4/15/2025 at 10:35 AM, Resident 41 was asleep in bed, the nebulizer mask tubing had a label indicating a date 3/23/2025. The tubing was hooked up to the nebulizer machine, with the nebulizer mask inside a clear, plastic bag dated 3/23/2025. During an interview on 4/16/2025 at 1:20 PM, Licensed Vocational Nurse 3 (LVN 3) stated the nurses administered the breathing treatments, the nebulizer mask and tubing dated 3/23/2025 were old and the masks and tubing needed to be changed weekly for infection control [purposes]. During an interview on 4/18/2025 at 11:10 AM, the Registered Nurse Supervisor (RN), the RN stated if the nebulizer mask was not changed per the facility's policy, there was a potential to not deliver the correct amount of nebulizer medication because the facility was using an old nebulizer mask and tubing. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration dated 5/20/2024, the P&P indicated to change the nebulizer tubing and delivery devices weekly and PRN [as needed], per manufacturer's recommendation or per facility policy and if they became soiled or contaminated.

Based on observation, interview, and record review, the facility failed to ensure 2 of 2 sampled residents (Resident 56 and Resident 41), who were fed by enteral feeding tubes (a tube inserted into the digestive system to deliver liquid nutrition when someone cannot eat or drink normally) received appropriate treatment by failure to: a. change the water flush bag for Resident 56 to follow the manufacturer's recommended time of a 24-hour use time. b. clarify a physician's order for oral (PO) medication administration for Resident 56, despite Resident 56 being documented as NPO (nothing by mouth) and receiving medications via gastrostomy-tube (G-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). c. change the water flush bag for Resident 41 to follow the manufacturer's recommended time of a 24-hour use time. These deficient practices had the potential for Resident 56 and Resident 41 to experience nausea and vomiting and failure increased the risk for aspiration (condition in which food, liquids, saliva, or vomit is breathed into the airways). Findings: a. During a review of Resident 56's Admission Record (AR), the AR indicated, Resident 56 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (brain disease that alters brain function or structure), protein-calorie malnutrition (a condition where there is a deficiency of both protein and calories in the diet, leading to serious health consequences), other abnormalities of gait and mobility (includes various conditions affecting a person's ability to walk and move), muscle weakness-generalized (a lack of strength in multiple muscle groups across the body ), dysphagia (difficulty swallowing), encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dementia (progressive state of decline in mental abilities), anxiety disorder (a mental health condition characterized by persistent and excessive worry or fear that can interfere with daily life and cause significant distress), and unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). During a review of Resident 56's History and Physical (H&P), dated 3/26/2025, the H&P indicated Resident 56 did not have the capacity to understand and make decisions. During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated Resident 56 was dependent on staff with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During an observation on 4/15/2025 at 04:32 PM in Resident 56's room, the water flush bag for Resident 56's tube feeding was observed with the date of 4/11/2025 written on the bag with black marker, and the tube feeding bag was dated 4/15/2025, timed 3:35 AM. During an interview with the Director of Nursing (DON) on 4/18/2025 at 2:02 PM, the DON stated the water flush bag for the feeding should be changed within 24 hours. The DON stated potential complications [from not changing the bag timely] included clogged tubing, patient discomfort or nausea, vomiting, and abdominal cramping if contaminated water reached the stomach and reduced nutrient/fluid delivery due to the potential of a compromised water bag. b. During a review of Resident 56's Order Summary Report (OSR), dated active as of 4/17/2025, the OSR included a physician's order (PO), dated 3/26/2025, the PO indicated Resident 56 was NPO (nothing by mouth). The OSR included the following POs for Resident 56 indicating: Quetiapine Fumarate oral tablet (Quetiapine Fumarate) Give 75 mg (milligrams, unit of measurement) by mouth two times a day for psychosis manifested by combativeness/aggression towards staff for no apparent reason, start date: 3/27/2025. During a medication administration observation with Licensed Vocational Nurse 2 (LVN 2) on 4/17/2025 at 08:45 AM in Resident 56's room, LVN 2 administered Quetiapine Fumarate (medication used to treat several kinds of mental health conditions including schizophrenia [a serious mental health condition that affects how people think, feel, and behave] and bipolar disorder [serious mental illness that causes unusual shifts in mood] oral tablet via G-tube to Resident 56. During an interview with the Director of Nursing (DON) on 4/18/2025 at 2:02 PM, the DON stated the nurse must clarify with the physician if Resident 56 was NPO or need to receive medications via G-Tube. The DON stated the route must be verified and clarified with the physician. The DON stated administering medications the wrong way can cause harm to the residents. The DON stated even if given via G-tube, if the order indicated PO (by mouth), the order needed clarification from the physician. 40913 c. During a review of Resident 41's AR, the AR indicated Resident 41 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis [complete or partial loss of muscle function] on one side of the body) and hemiparesis following cerebral infarction (one sided weakness and paralysis after a stroke), respiratory failure with hypoxia (occurs when you don't have enough oxygen in the blood). During a review of Resident 41's MDS, dated [DATE], the MDS indicated Resident 41's cognition was severely impaired. During an observation on 4/15/2025 at 10:37 AM, Resident 41 was asleep in bed, a 1-liter (unit of volume) bag of diabetisource (a formula used for tube feeding, TF) had a written date of 4/15/2025, timed at 3:49 AM, there was 800 ml (milliliters, unit of volume) left in the bag. The TF set up had a bag of water for water flush that had a written date of 4/10/2025, there was 500 ml left inside the water bag. Both bags were attached to the TF pump. During an interview with the DON on 4/18/2025 at 2:02 PM, the DON stated the water flush bag for the feeding should be changed within 24 hours. The DON stated potential complications [from not changing the bag timely] included clogged tubing, patient discomfort or nausea, vomiting, and abdominal cramping if contaminated water reached the stomach and reduced nutrient/fluid delivery due to the potential of a compromised water bag. During a review of the facility's policy and procedure (P&P) titled, Flushing a Feed Tube, revised 12/19/2022, the P&P indicated, Policy: It is the policy of this facility to ensure that staff providing care and services to the resident via a feeding tube are aware of, competent in and utilize facility protocols regarding feeding nutrition and care. Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice. During a review of the facility's P&P titled, Care and Treatment of Feeding Tubes, revised 12/19/2022, the P&P indicated, Policy: It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: Direction for staff on how to provide the following care will be provided: use of infection control precautions and related techniques to minimize the risk of contamination. During a review of the undated Cardinal Health's, Kangaroo OMNI Enteral Feed Pump Setup and Troubleshooting Guide, dated 2023, the guide indicated, Reusing feeding sets can impact feeding accuracy. Feeding sets are designed for single-patient use with a recommended 24 hour use time. Using the feeding set beyond the recommended 24 hours can impact the delivery accuracy of the pump by subjecting the silicone tubing to excessive or repeated strain. During a review of the facility's P&P titled, Medication Administration via Enteral Tube, revised 12/19/2022, the P&P indicated, Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines. Policy Explanation and Compliance Guidelines: Verify physician orders for medication and enteral tube flush amount.

Based on observation, interview, and record review, the facility failed to provide nursing care and services to prevent pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin and/or underlying soft tissue usually present over a bony prominence) for one of four sampled residents (Resident 42) when the facility failed to: a. Develop a care plan to address Resident 42's non-compliance to turning and repositioning. b. Ensure staff would follow the same system for turning and repositioning for Resident 42. c. Ensure proper communication of Resident 42's changes in skin condition. These deficient practices incresed the risk for Resident 42 to develop a deep tissue injury (DTI - Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue on the right malleolus. Findings: During a review of Resident 42's Admission Record (AR), the AR indicated Resident 42 was admitted to the facility 9/3/2024 with diagnoses that included unspecified dementia (a group of conditions, decline in mental ability, that interfere with daily activities), hyperlipidemia (having too many lipids [fats] in the blood), and psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). During a review of Resident 42's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/31/2025, the MDS indicated Resident 42 rarely/never understands verbal content and was rarely/never able to express ideas and wants. The MDS indicated Resident 42 was dependent with oral, toileting and personal hygiene and required maximal assistance with rolling left and right. The MDS indicated Resident 42 was at risk of developing pressure ulcers. During a review of Resident 42's Pressure Ulcer Risk Evaluation, dated 3/24/2025, the evaluation indicated a score of 13. The evaluation indicated Resident 42 had slightly limited sensory perception, constantly moist and had problem with friction and shear. During an observation on 04/17/2025 at 9:51 AM, CNA 3 and CNA 6 entered Resident 42's room to provide care. CNA 6 removed the resident gown and then the incotinence brief. CNA 6 wiped the perineal area with moistened towel and pat dry. When CNA 6 turned Resident 42 to face the Resident 42's right side, Resident 42's left hand held on to the left siderails. CNA 3 said, It's okay, I'm here. I'll hold your hand. Resident 42 slowly let go of the side rail and CNA 3 turned Resident 42 to the right side. CNA 3 stated Resident 42 was scared when being turned. When the CNAs were starting to turn Resident 42 to the left side, Resident 42 held the right siderails with both hands and after a minute of talking to Resident 42, CNA 3 was able to turn resident 42 to the the left side, there was a purple discoloration to the right lateral of Resident 42's foot. CNA 6 stated the discoloration was new and CNA 6 would notify the Treatment Nurse (TN). CNA 3 and CNA 6 assisted Resident 42 to lay on his back with no positioning pillow placed on either right or left side or under Resident 42's heels. During an interview on 4/17/2025 at 2:57 PM, CNA 6 stated CNA 6 did not turn and reposition Resident 42 because Resident 42 would refuse when being turned. CNA 6 stated, It's like this everyday. CNA 6 stated CNA 6 filled up the Skin Assessment Sheet and handed the sheet to the TN. CNA 6 stated CNA 6 did not verbally report the change in skin condition to the TN. During an interview on 4/17/2025 at 3:08 PM, the TN stated Resident 42 looked scared when being turned to the sides. The TN observed the behavior when TN helped change Resident 42's incontinence brief two weeks ago. The TN stated the TN did not report Resident 42's resistance to care to the Registered Nurse Supervisor. The TN stated Resident 42 did not have a pressure ulcer or injury. The TN stated the CNAs needed to turn and reposition the residents who were not ambulatory and had fragile skin. The TN stated there was no turning schedule as the CNAs turn and reposition the residents who needed assistance every 2 hours. During a concurrent Resident 42's skin observation and interview on 4/17/2025 at 3:27 PM to 3:35 PM with TN and the Registered Nurse Supervisor (RNS). Resident 42 was lying on his back with the ankles crossed and the heels were not offload. The TN and RNS stated the right ankle had a discoloration on the right malleolus. The TN and RNS stated the area of discoloration was blue and purple in color. The TN and RNS stated there was no extra pillow or positioning pillows on Resident 42's bed, closet or anywhere inside Resident 42's room. During an interview on 4/17/2025 at 3:37 PM, the RNS stated Resident 42 had a blue, purple discoloration on the right malleolus. The RNS stated Resident 42 had a DTI because it would be unknown what was underneath the skin discoloration. During an interview on 4/17/2025 at 3:41 PM, the RNS stated Resident 42 was not cooperative during admission and was not relaxed during turning. The RNS stated just like how the TN and RNS assured Resident 42 during turning, the staff just needed to talk more and reassure Resident 42 when turning and repositioning and give Resident 42 time to understand what is going on. Resident 42 has dementia, we need to give instructions clearly and inform Resident 42 what was going on and give time for Resident 42 to understand. During an interview on 4/17/2025 at 3:57 PM, the RNS stated the assigned CNA needed to have everything such as pillows ready when performing incontinence care and place a pillow to position Resident 42 to the left, right or on Resident 42's back and to offload Resident 42's heels. The RNS stated Resident 42's resistance to turning and repositioning was not a reason to leave Resident 42 on his back and not offloading the heels. During an interview on 4/17/2025 at 4:36 PM, CNA 8 stated Resident 42 needed assistance with turning and repositioning because Resident 42 could not move independently. CNA 8 stated the facility followed a turning schedule and CNA 8 showed the schedule on the back of CNA 8's badge. The schedule indicated at 6AM to 8 AM residents would be on the back, at 8AM -10 AM, residents would be facing the door, at 10 AM to 12 PM resident would be facing the window, at 12PM to 2PM, residents would be on the back and at 2PM - 4 PM, residents would be facing the door. CNA 8 stated the turning schedule was provided by the Director of Staff Development when CNA 8 started working at the facility a year ago. CNA 8 stated Resident 42 would refuse turning by holding the siderails during repositioning. CNA 8 stated the licensed nurses were aware of Resident 42's refusal to turn. During an interview on 4/17/2025 at 3:44 PM, the TN, the TN was not informed verbally that Resident 42 had a discolored area on the ankle. The TN stated the TN signed the Skin Assessment Sheet (SAS) but did not check and missed the skin report made by CNA 6. During an interview on 4/18/2025 at 8:28 AM, the Director of Nursing (DON) stated when residents (in general) would refuse turning and repositioning, the CNA's need to continue to offer because initially the residents would refuse, when the CNA's go back and offer to reposition again. The DON stated the licensed nurses need to develop a care plan to address the refusal to turning and repositioning to develop interventions to address the refusal to turn and reposition. During an interview on 4/18/2025 at 8:34 AM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 42 would have moments of refusing to turn and reposition approximately 3 out of 7 days in a week. Resident 42 would refuse turning and repositioning by holding on to the siderails. LVN 1 stated there was no turning schedule to follow but it was facility practice to turn and reposition the residents who needed assistance with turning and repositioning every 2 hours. When residents (in general) were not turned and repositioned, it could lead to the development of a pressure injury because of the pressure from the mattress to the bony prominences. During an interview on 4/18/25 at 9:10 AM, the DON stated interventions to the care plan when Resident 42 refused turning and repositioning, CNAs needed to attempt to turn and reposition Resident 42 three times. CNAs then needed to notify the charge nurse. The Charge Nurse once aware of the refusal needed to reach out to family members who might be able to talk to Resident 42. The DON stated the MDS Nurse needed to develop a care plan specific to the refusal to turn and reposition. During a concurrent review of Resident 42's plan of care and interview on 4/18/2025 at 9:25 AM, the DON stated there was no care plan developed to address Resident 42's refusal to turn and reposition. During a review of Resident 42's Change of Condition (COC) dated 4/18/2025, the COC indicated purplish discoloration (DTI) to the right lateral malleolus. During a review of the facility's Policy and Procedure (P&P) titled, Pressure Injury Prevention Guidelines, dated 11/27/2023, the P&P indicated interventions will be documented in the care plan and communicated to all relevant staff. The P&P indicated individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment and any pressure injury assessment. During a review of the facility's P&P titled, Pressure Injury Prevention and Management, dated 9/12/23, the P&P indicated interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications included resident non-compliance. During a review of the facility's P&P titled, Comprehensive Care Plans, dated 12/19/2022, the P&P indicated the comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, the resident and the resident representative .The P&P indicate the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative.

Based on observation, interview, and record review, the facility failed to develop comprehensive care plans (CP) for two of two sampled residents (Resident 42 and Resident 16) when, A. For Resident 42, a CP was not developed that addressed Resident 42's non-compliance to turning and repositioning. B. For Resident 16, a CP was not developed that addressed Resident 16's Post Traumatic Stress Disorder (PTSD, a mental health condition that can developed after experiencing or witnessing a traumatic event) diagnosis. This deficient practice had the potential to result in unmet individualized needs for Residents 42 and 16 and the potential to affect the resident's physical and psychosocial well-being. (Cross Reference F699) Findings: A. During a review of Resident 42's Admission Record (AR), the AR indicated Resident 42 was admitted to the facility 9/3/2024 with diagnoses that included unspecified dementia (a group of conditions, decline in mental ability, that interfere with daily activities), hyperlipidemia (having too many lipids [fats] in the blood), and psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool), dated 3/31/2025, the MDS indicated Resident 42's cognition (ability to understand and process information) was severely impaired. The MDS indicated Resident 42 was dependent with oral, toileting and personal hygiene and required maximal assistance with rolling left and right. During an observation on 04/17/2025 at 9:51 AM, CNA 3 and CNA 6 entered Resident 42's room to provide care. CNA 6 removed the resident's gown and adult brief. CNA 6 wiped the perineal (an area lower in the body located between the thighs) area with a moistened towel and patted dry. CNA 6 turned Resident 42 to face the right side, Resident 42's left hand held on to the left siderails. CNA 3 stated, It's okay, I'm here. I'll hold your hand. Resident 42 slowly let go of the side rail and CNA 3 turned Resident 42 to the right side. CNA 3 stated Resident 42 was scared when being turned. During an interview on 4/17/2025 at 2:57 PM, with CNA 6, CNA 6 stated CNA 6 did not turn or reposition Resident 42 because Resident 42 refused to be turned, It's like this every day. CNA 6 stated CNA 6 reported to the nurses occasionally and reported today to Licensed Vocational Nurse 1 (LVN 1) that Resident 42 refused to turn and reposition. CNA 6 stated LVN 1 stated, Okay. During an interview on 4/17/2025 at 3:08 PM, the Treatment Nurse (TN) stated Resident 42 looked scared when being turned to the sides. The TN stated the TN observed the behavior when the TN helped change Resident 42's adult briefs two weeks ago. During an interview on 4/18/2025 at 8:28 AM with the Director of Nursing (DON), the DON stated the licensed nurses needed to develop a CP that addressed the refusal to turn and reposition and develop interventions to address the refusal to turn and reposition. During an interview on 4/18/25 at 9:10 AM, the DON stated the MDS coordinator needed to develop a CP specific to address Resident 42's refusal to be turned and repositioned. During a concurrent review of Resident 42's CPs and interview on 4/18/2025 at 9:25 AM with the DON, the DON stated there was no CP developed to addressed Resident 42's refusal to turn and reposition. During a review of the facility's P&P titled Comprehensive Care Plans dated 12/19/2022, the P&P indicated the comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, the resident and the resident representative .The P&P indicate the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative 50016 B. During a review of Resident 16's AR, the AR indicated the facility admitted Resident 16 on 6/27/2024, with diagnosis including, PTSD, hypertension (HTN-high blood pressure), and peripheral vascular disease (PVD- a slow progressive narrowing of the vessels [blood flow] to the arms and legs). During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 had severe cognitive (the ability to think and process information) impairment. The MDS indicated Resident 16 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required substantial/maximal assistance with mobility. During an interview and a concurrent record review on 4/17/2025 at 12:35 PM, Resident 16's Care Plans were reviewed with the Director of Staff Development (DSD), the DSD stated Resident 16 did not have a CP for PTSD and the DSD was unaware Resident 16 had a PTSD diagnosis. The DSD stated the facility should have initiated an individualized, person-centered CP that addressed Resident 16's PTSD diagnosis. The DSD stated it was crucial for staff to know if a resident had PTSD, as it directly affected how staff approached care. The DSD stated PTSD could impact a resident's emotional and psychological well-being, and awareness of the diagnosis enabled staff to tailor their approach to the resident's specific needs. The DSD stated developing a PTSD CP ensured all members of the healthcare team were aligned with their approach and CPs outlined strategies for managing triggers, appropriate communication techniques, and ways to address behavioral concerns. The DSD stated CPs promoted consistent, compassionate, and mindful care delivery that supported the resident's mental health needs. During an interview on 4/18/2025 at 2:02 PM, with the Director of Nursing, the DON stated early identification of PTSD allowed for personalized care and strategies to prevent triggers. The DON stated developing a PTSD CP was essential to keep all staff aligned and address each resident's unique needs. The DON stated the facility should have initiated a PTSD CP for Resident 16 that included specific interventions, coping strategies, and trigger avoidance. During a review of the facility's P&P titled, Comprehensive Care Plans, revision date 12/19/2022, the P&P indicated it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that are identified in the resident's comprehensive assessment. The P&P indicated the following definition: Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. The P&P indicated policy explanation and compliance guidelines: a. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect if the trigger on the resident.

Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for one of five sampled residents (Resident 43) with rehabilitation (restoring function) and mobility concerns, by failing to: 1. Assist Resident 43 with ambulation (walking) for 200 feet with contact guard assistance (physical steadying assistance) in accordance with the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge recommendation on 11/10/22. 2. Report Resident 43's decline in mobility and increased need for physical assistance to the Rehabilitation Coordinator (RC). These deficient practices resulted in a significant decline in Resident 43's mobility from able to walk for 200 feet with contact guard assistance to requiring maximum assistance (50-75 percent [%] of physical assistance) for sit to stand transfers and maximum assistance of two people to walk 20 feet. Findings: A review of Resident 43's Admission Record indicated the facility admitted Resident 43 on 3/24/22 and readmitted the resident on 8/13/22, with diagnoses including hemiplegia and hemiparesis (weakness and paralysis to one side of the body) following other nontraumatic intracranial hemorrhage (bleeding in brain tissue) affecting the left non-dominant side, muscle weakness, difficulty walking, and dysphagia (difficulty swallowing). A review of Resident 43's PT Evaluation and Plan of Treatment, dated 3/25/22, indicated Resident 43 was independent with bed mobility, transfers, and walking without an assistive device (a device to assist a person to perform a task) prior to admission to the facility. The PT Evaluation and Plan of Treatment indicated Resident 43 required maximum assistance for bed mobility and transfers between surfaces. The PT Evaluation and Plan of Treatment indicated Resident 43 was unable to walk at the time of the PT Evaluation upon admission. The PT treatment plan for Resident 43 included exercises, neuromuscular (relating to nerves and muscles) reeducation and gait (manner of walking) training therapy, five times a week for four weeks. A review of Resident 43's PT Evaluation and Plan of Treatment, dated 7/6/22, indicated Resident 43 required moderate assistance for bed mobility, transfers, and walking 50 feet with the use of a hemi-walker (assistive device that allows a person to lean on one side while walking for support). The PT treatment plan for Resident 43 included exercises, neuromuscular reeducation, and gait training therapy, four times a week for four weeks. A review of Resident 43's PT Discharge Summary, dated 7/28/22, indicated Resident 43 required contact guard assistance for bed mobility and transfers. The PT Discharge Summary also indicated Resident 43 required minimum assistance with walking 175 feet using a hemi-walker. The PT discharge recommendations indicated for Resident 43 to use a hemi-walker for safe mobility and an ankle foot orthosis (AFO, brace to hold the foot and ankle in the correct position). The discharge reason indicated a change in Resident 43's payer source. A review of Resident 43's PT Evaluation and Plan of Treatment, dated 8/3/22, indicated Resident 43 required minimum assistance for bed mobility and transfers. The PT Evaluation and Plan of Treatment indicated Resident 43 required moderate assistance to walk 100 feet using a hemi-walker. The PT treatment plan for Resident 43 included exercises, neuromuscular reeducation, and gait training therapy, five times per week for four weeks. A review of the PT Discharge Summary, dated 8/10/22, indicated Resident 43 was discharged to the hospital. A review of Resident 43's Census List (record of hospitalization s, room changes, and payer source changes) indicated Resident 43 was discharged to the hospital on 8/10/22 and was readmitted back to the facility on [DATE]. A review of Resident 43's PT Evaluation and Plan of Treatment, dated 8/15/22, indicated Resident 43 had a decline in ambulation, mobility, and strength after Resident 43's hospitalization on [DATE]. The PT Evaluation indicated Resident 43 was totally dependent (more than 75% physical assistance) for bed mobility and transfers. The PT Evaluation did not assess Resident 43's ability to walk. The PT treatment plan for Resident 43 included exercises, neuromuscular reeducation, and gait training therapy, five times per week for four weeks. A review of Resident 43's PT Discharge Summary, dated 11/10/22, indicated Resident 43 required contact guard assistance for bed mobility, minimum assistance for transfers, and contact guard assistance to walk 200 feet using a hemi-walker. The discharge reason indicated Resident 43 achieved the highest practicable level (upmost functioning and wellbeing). The PT discharge recommendations included a Restorative Nursing Program [RNP, nursing program that uses restorative nursing aides (RNAs) to help residents maintain their function and joint mobility] with the use of an assistive device for safe mobility. A review of Resident 43's Restorative Nursing Program care plan, initiated on 11/10/22, indicated interventions for Resident 43 to walk 200 feet with a hemi-walker and contact guard assistance, every day, five times per week or as tolerated. The care plan interventions included to monitor Resident 43 for any changes (decline/improvements) and to refer to nursing and/or rehabilitation staff nurse with any change of condition. A review of Resident 43's Documentation Survey Report (record of nursing assistant tasks) for 11/2022 indicated RNA (unidentified) assisted Resident 43 in walking 200 feet using a hemi-walker with contact guard assistance on 11/11/22, 11/14/22 to 11/18/22, and 11/21/22 to 11/25/22. A review of Resident 43's Census List indicated Resident 43 was discharged to the hospital on 11/25/22 and readmitted back to the facility on [DATE]. A review of Resident 43's PT Evaluation and Plan of Treatment, dated 11/29/22, indicated Resident 43 was seen for an evaluation only. The PT Evaluation indicated Resident 43 required contact guard assistance for bed mobility, minimum assistance for transfers, and contact guard assistance for walking 200 feet. The PT Evaluation indicated Resident 43 was referred to RNP for ambulation. A review of Resident 43's Documentation Survey Report for 11/2022 indicated the RNA (unidentified) assisted Resident 43 in walking 200 feet using a hemi-walker with contact guard assistance on 11/30/22. A review of Resident 43's Documentation Survey Report for 12/2022 indicated Resident 43 received RNA services five times per week to walk 200 feet using a hemi-walker with contact guard assistance. A review of Resident 43's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 12/27/22, indicated Resident 43 had clear speech, clearly expressed ideas, and wants, clearly understood others, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 43 required extensive assistance (resident involved in activity while staff provide weight-bearing support) with bed mobility, transfers between surfaces, walking in room, walking in corridor, locomotion on unit (moving locations in room and nearby corridor, self-sufficient in wheelchair), locomotion off unit (other areas of the facility like the dining room and activity room), dressing, toileting, and personal hygiene. A review of Resident 43's Documentation Survey Report for 1/2023 and 2/2023 indicated Resident 43 received RNA services five times per week to walk 200 feet using a hemi-walker with contact guard assistance. A review of Resident 43's Documentation Survey Report for 3/2023 indicated Resident 43 received RNA services to walk 200 feet using a hemi-walker with contact guard assistance on 3/1/2/23, 3/2/23, 3/6/23, 3/7/23, and 3/8/23. A review of Resident 43's PT Evaluation and Plan of Treatment, dated 3/7/23, indicated Resident 43 was referred back to PT due to decreased mobility, decreased strength, limitation with ambulation, and increased need for assistance from others. The PT Evaluation indicated Resident 43 required maximum assistance for bed mobility and transfers. The PT Evaluation did not assess ambulation due to Resident 43's inability to walk. The PT treatment plan for Resident 43 included exercises, neuromuscular reeducation, therapeutic gait training therapy, and wheelchair management training, four times per week for four weeks. A review of Resident 43's Restorative Nursing Program care plan dated 3/8/23 indicated the RNP Program for walking 200 feet with a hemi-walker and contact guard assistance was resolved (discontinued) on 3/8/23. A review of Resident 43's MDS, dated [DATE], indicated Resident 43 transferred between surfaces only once or twice during the MDS assessment period. The MDS indicated Resident 43 did not walk in the room, did not walk in the corridor, did not participate in locomotion on unit, and did not participate in locomotion off unit during the MDS assessment period. During an observation and concurrent interview with Restorative Nursing Aide 1 (RNA 1) on 4/19/23 at 10:58 AM, RNA 1 stated RNA 1's job duties included the provision of RNA services and stocking the facility's central supply room. RNA 1 stated currently there were 21 residents in the facility requiring RNA services. RNA 1 observed and demonstrated the process of viewing each resident with RNA tasks and how to document RNA sessions on a computer screen mounted to the wall in the hallway. During a follow-up interview with RNA 1 on 4/19/23 at 2:39 PM, RNA 1 stated RNA 1 was the main RNA staff at the facility except on weekends. During an observation on 4/20/23 at 9:08 AM, Resident 43 sat up in a wheelchair to work with Physical Therapy Assistant 1 (PTA 1). Resident 43 was fully dressed and wore shoes. PTA 1 applied a sling to Resident 43's left arm and wheeled Resident 43 to the hallway. Resident 43's wheelchair was positioned with the facility's hallway railing on Resident 43's right side, which was Resident 43's stronger side. Resident 43 used the right arm to pull onto the railing to transfer from sitting to standing as PTA 1 stayed on Resident 43's left side. Resident 43 shifted Resident 43's body weight from the right leg to the left leg to practice stepping forward and backward with PTA 1's assistance. PTA 1 assisted Resident 43 to sit back in the wheelchair. PTA Student 1 (SPTA 1) stood in front of Resident 43 to assist PTA 1, who continued to be on Resident 43's left side, for the remainder of the PT treatment session. SPTA 1 and PTA 1 assisted Resident 43 in transferring from sitting in the wheelchair to standing. PTA 1 stated Resident 43 required maximum assistance to stand. PTA 1 physically moved Resident 43's left leg forward while the SPTA stood in front of Resident 43 while standing. Resident 43 then transferred Resident 43's body weight to the left leg to step forward with the right leg while holding on to the railing using the right arm. PTA 1 continued to physically lift and move Resident 43's left leg forward prior to Resident 43 stepping forward with the right leg in order to walk. Resident 43 walked with PTA 1 and SPTA 1's assistance for 10 feet. Resident 43 sat back down in the wheelchair and walked again another 10 feet with PTA and SPTA's physical assistance. During an interview with RNA1 on 4/20/23 at 9:49 AM, RNA 1 stated the Rehabilitation Coordinator (RC) and RNA 1 met weekly to discuss any concerns with residents receiving RNA services, including if any resident (in general) experienced a decline. RNA 1 stated the PT staff (unidentified) reviewed Resident 43's RNP program for ambulation prior to Resident 43's discharge from PT. RNA 1 did not remember PT's recommended distance to walk with Resident 43. RNA 1 stated sometimes the complete RNA task was not visible on the computer screen including the distance to walk with the resident. RNA 1 stated RNA 1 assisted Resident 43 to walk an average of 25 feet. RNA 1 stated the farthest distance Resident 43 walked with RNA 1 was 50 feet. A review of the facility's RNP Caseload Review (records of the weekly RC and RNA meetings) indicated RC and RNA 1 met on 11/25/22, 12/2/22, 12/9/22, 12/22/22, 12/30/22, 1/4/23, 1/25/23, 2/8/23, 2/15/23, 3/1/23, 3/8/23, 3/17/23, 3/20/23, and 3/29/23. The RNP Caseload Review records did not indicate any concerns for Resident 43. During an interview with Resident 43 on 4/20/23 at 1:25 PM, Resident 43 stated Resident 43 used to walk the whole length of the facility's hallway with one person's assistance while using a hemi-walker with PT. Resident 43 stated Resident 43 never walked a whole hallway with RNA 1, did not walk with RNA 1 consistently, and did not walk with RNA 1 five times a week. Resident 43 admitted to having a bad memory but stated Resident 43 would have remembered working with RNA1 if RNA 1 walked Resident 43 five days a week. During a follow-up interview with Resident 43 on 4/20/23 at 1:35 PM, Resident 43 stated feeling scared to lose the ability to walk. During a review of Resident 43's clinical record and interview with PTA1 on 4/20/23 at 1:55 PM, PTA 1 stated Resident 43 received PT services from 3/25/22 to 11/10/22. PTA 1 reviewed Resident 43's Treatment Encounter Note dated 11/9/22. PTA 1 stated Resident 43 required minimum assistance for sit to stand transfers, minimum assistance for transfers to the wheelchair, and contact guard assistance for walking, requiring verbal prompts and occasional physical assistance to walk. PTA 1 stated PTA 1 trained RNA 1 on Resident 43's RNP prior to discharge from PT on 11/10/22. PTA 1 stated RNA 1 was trained on the hemi-walker's placement and RNA 1's positioning to replicate the amount of assistance and distance Resident 43 achieved while walking with PT. PTA 1 stated PTA 1 expected RNA 1 to maintain Resident 43's mobility after working with PT, including assisting Resident 43 to walk from 125 to 200 feet using the hemi-walker. PTA 1 stated Resident 43 currently required maximum assistance for sit to stand transfers and maximum assistance of two people for walking. PTA 1 stated Resident 43 had obviously declined in mobility. During an observation, interview with RNA 1 and review of Documentation Survey Report for Resident 43 on 4/21/23 at 2:02 PM, RNA 1 stated Resident 43 walked 25 feet using a hemi-walker during RNA sessions (unidentified dates). RNA 1 stated Resident 43 walked a maximum distance of 50 feet using a hemi-walker from Resident 43's room to Nursing Station 1 (NS1). RNA 1 observed using a measuring tape to measure the distance from Resident 43's room to NS1 which measured 50 feet. RNA 1 did not remember PT's recommended distance to walk with Resident 43. RNA 1 stated Resident 43 required more assistance to walk since RNA 1 had difficulty holding onto Resident 43. RNA 1 stated Resident 43 walked 15 feet prior resuming PT on 3/2023. RNA 1 reviewed Resident 43's Documentation Survey Report from 11/2022 to 3/2023. RNA 1 stated RNA 1 never assisted Resident 43 to walk 200 feet. RNA 1 did not remember if Resident 43's decline in mobility and increase in physical assistance was reported to PT. RNA 1 stated Resident 43's decline should have been reported to PT for reassessment. During an interview with RC, PTA 1, and RNA 1 and review of Resident 43's clinical record on 4/21/23 at 2:42 PM, RC stated RNA was important to maintain a resident's mobility and to ensure the resident did not experience a decline in mobility. PTA 1 stated Resident 43's PT treatment session, prior to discharge on 11/10/22, included walking from the therapy room, down the entire hallway (approximately 100 feet), turning, and walking back to the rehabilitation gym (total of approximately 200 feet). PTA 1 stated Resident 43 walked an average of 175 feet with contact guard assistance using a hemi-walker. PTA 1 stated Resident 43 currently required maximum assistance for sit to stand transfers and maximum assistance of two people to walk a total of 20 feet. RC and PTA 1 stated Resident 43 experienced a significant decline in mobility from requiring contact guard assistance when discharged from PT to maximum assistance to currently walk with PT. The RC stated Resident 43's decline was not reported to PT. RC stated Resident 43's significant decline in mobility was avoidable since it was not reported to PT. During an interview with the Director of Nursing (DON) on 4/21/23 at 3:33 PM and record review of Resident 43's Documentation Survey Report for RNP ambulation program from 11/2022 to 3/2023, the DON stated Resident 43's Documentation Survey Report indicated RNA 1 completed the task of walking Resident 43, 200 feet using a hemi-walker with contact guard assistance. The DON stated, if RNA 1 did not actually assist Resident 43 with walking 200 feet, then Resident 43's Documentation Survey Report for RNP was inaccurate. The DON stated Resident 43 experienced a significant decline in mobility since Resident 43 went from walking 200 feet with contact guard assistance to walking 20 feet with maximum assistance of two people. The DON stated Resident 43's decline was preventable and should have been reported. During an interview on 4/21/23 at 4:01 PM, the facility's Therapy Regional Director stated the facility's policy to maintain a resident's mobility was included in the policy for Activities of Daily Living. A review of the facility's Policy and Procedure titled, Activities of Daily Living (ADLs), revised 9/2/22, indicated the facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services may consist of the following activities of daily living: (2). Transfer and Ambulation.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with the resident's plan of care, the facility's policies and procedures and professional standards of practice for two of 21 sampled residents (Resident 39 and 46). a. For Resident 39, the facility failed to: 1. Inform Resident 39's physician (MD 1) about Resident 39's diagnosis of Type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels), advocate (to promote and protect patient's rights, health, and safety) for Resident 39, and obtain the necessary orders to monitor and control Resident 39's blood sugar level. 2. Monitor, document, and report to MD 1 regarding Resident 39's signs and symptoms of hyperglycemia (an excess of glucose [sugar] in the bloodstream) such as increased thirst as indicated on Resident 39's plan of care. As a result, on 4/12/2023 at 10:30 am, Resident 39 had slurred speech (a symptom characterized by the poor pronunciation of words, mumbling, or a change in speed or rhythm) and an elevated blood sugar level of HI (blood glucose level more than 600 milligrams per deciliter [mg/dL, a unit of measurement], normal range = 99 mg/dL) and received 10 units of regular insulin (injectable medication used to manage diabetes mellitus and high blood sugar) subcutaneously (SQ, below the skin). On 4/12/2023 at 10:50 am, Resident 39 was transferred to General Acute Care Hospital 1 (GACH 1) via emergency services (911) for further evaluation and was found to have an elevated blood sugar over 700 mg/dL with significant hypernatremia (high concentration of sodium [salt] in the blood in people who do not drink enough water). Resident 39 was admitted to GACH 1's Intensive Care Unit (ICU, a unit with a specialized staff, equipment, and standards to handle severe, potentially life-threatening illness). b. For Resident 46, the facility failed to obtain weekly weights on 2/14/2023 and 2/21/2023 as ordered by the physician. This deficient practice had the potential for the staff to miss potential weight loss for Resident 46 and not provide the neccessary care and services. Findings: a. A review of Resident 39's Admission Records indicated the facility admitted Resident 39 on 8/3/2021, with diagnoses including Type 2 diabetes mellitus with hyperglycemia , gastrostomy tube (G-tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food and medications), and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when the heart does not pump enough blood for the body's needs). A review of Resident 39's History and Physical dated 8/3/2022, indicated Resident 39 did not have the capacity to understand and make decisions. A review of Resident 39's untitled Care Plan revised on 10/16/2022, indicated Resident 39 had increased potential for exacerbation (to become worse) of symptoms and complications related to Type 2 diabetes mellitus with hyperglycemia and long term (current) use of insulin. The goal indicated Resident 39 would be free from any signs and symptoms (s/sx) of hypoglycemia (low blood sugar), hyperglycemia, and complications related to diabetes. The nursing interventions included to monitor, document, and report as needed any s/sx of hyperglycemia such as increased thirst, dry skin, and weight loss, and any s/sx of hypoglycemia such as slurred speech. A review of Resident 39's Laboratory (a room equipped for research and testing) Results Report dated 2/6/2023, indicated Resident 39's blood glucose level was 293 mg/dL. A review of Resident 39's Licensed Progress Notes dated 2/6/2023, timed at 5:51 pm, indicated the licensed staff reported the lab results to MD 1 and MD 1 did not give any new orders. A review of Resident 39's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 3/14/2023, indicated Resident 39 had severely impaired cognitive skills (ability to think, understand, learn, and remember). The MDS indicated Resident 39 required extensive to total assistance with activities of daily living. The MDS indicated Resident 39 had an active diagnosis of diabetes mellitus but did not receive any insulin injection during the last seven days. A review of Resident 39's Medication Review Report from 4/1/2023 to 4/30/2023, indicated the following physician's orders: 1. Enteral (passing through the intestine via the mouth or through an artificial opening) feeding of Isosource 1.5 (complete nutrition formula with fiber for increased calorie needs and/or limited fluid tolerance) every evening shift via tube feeding (T/F) at 60 cubic centimeters (cc, measurement unit of volume) per hour (cc/hr) for 12 hours, start at 8 pm and off at 8 am, order dated 8/3/2021. 2. Nothing by mouth (NPO) diet, order dated 4/29/2022. A review of Resident 39's Licensed Progress Notes dated 4/12/2023 at 10:30 am, indicated Resident 39 had slurred speech and Resident 39's blood sugar reading indicated HI. The notes indicated Licensed Vocational Nurse 1 (LVN 1) notified MD 1, and MD 1 ordered to give regular insulin 10 units subcutaneously now. The notes indicated the LVN 1 administered 10 units of regular insulin to Resident 39 and called the paramedics (healthcare professionals who respond to emergency calls for medical help outside of a hospital). The notes indicated the paramedic brought Resident 39 to GACH 1. A review of Resident 39's Physician Order dated 4/12/2023 at 10:34 am, indicated to transfer Resident 39 to GACH 1's Emergency Department (ED) via 911 for further evaluation related to altered level of consciousness (ALOC, decreased wakefulness, awareness, or alertness), slurred speech, and hyperglycemia. A review of Resident 39's History and Physical Report from GACH 1, dated 4/12/2023, indicated Resident 39 presented with altered mental status with elevated blood sugar of over 700 with significant hypernatremia. The report indicated Resident 39 was started on an insulin drip (a method of delivering insulin directly into the bloodstream to lower blood sugar level) as a stroke (a life-threatening condition that happens when part of the brain doesn't receive enough blood flow to maintain its functions) due to confusion (declined in mental ability to think and make decisions). The report indicated GACH 1's assessment of Resident 39 included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) due to hyperosmolar (a condition in which the blood has a high concentration of sodium, glucose, and other substances) hyperglycemic state, dehydration (occurs when the body use or lose more fluid than it takes in), severe hypernatremia, acute (sudden) kidney injury (condition where the kidneys suddenly stop working properly), and uncontrolled diabetes (occurs when the blood sugar has been high for too long). The report indicated GACH 1's plan was to admit Resident 39 to the ICU. A review of Resident 39's Discharge/Transfer Documentation from GACH 1 dated 4/17/23, indicated Resident 39's Hemoglobin A1C, (Hb A1C, a blood test that measures the average blood sugar levels over the past 3 months) level was 10.5% (normal range is below 5.7%) on 4/12/2023. GACH 1's discharge documentation indicated Resident 39's discharge diagnosis included hyperosmolar hyperglycemic state (HHS, a life-threatening complication of diabetes, mainly Type 2 diabetes, and happens when the blood glucose levels are too high for a long period, leading to severe dehydration and confusion), hypernatremia, and dehydration. During a concurrent observation of Resident 39 and interview with Resident 39 on 4/18/2023 at 8:30 am, Resident 39 was lying in bed with Isosource 1.5 going at 60 ml/hr via G-tube. Resident 39 stated she could not eat and that she had a G-tube in place. Resident 39 stated she was thirsty, asked for water and juice, and stated, Please just a little bit of juice or water, please, I'm thirsty, please, please. Resident 39's lips and face were dry. During an interview with Licensed LVN 5 on 4/19/2023 at 4:24 pm, LVN 5 stated Resident 39 was always thirsty and asking for water, but she could have nothing by mouth. During an interview and concurrent review of Resident 39's Nurses Notes for the month of April 2023, on 4/20/2023 at 9:18 am, LVN 2 stated Resident 39 constantly asked for water. LVN 2 stated there was no documentation in Resident 39's Nurses Notes indicated Resident 39 was monitored for increased thirst and always asking for water (s/sx of hyperglycemia) as listed in Resident 39's care plan. LVN 2 stated there was no documentation that MD 1 was notified of Resident 39's increased thirst. During an interview and concurrent review of Resident 39's Medication Administration Record (MAR), dated from 12/1/222 to 4/11/2023, on 4/20/2023 at 11:01 am, Minimum Data Set Nurse 1 (MDS 1) stated there was no documentation in Resident 39's MAR indicated Resident 39's blood sugar was monitored from 12/1/2022 to 4/11/2023. MDS 1 stated there was no documentation of a physician order for the monitoring of Resident 39's blood sugar from 12/1/2022 to 4/11/2023. MDS 1 stated Resident 39's admitting diagnoses included Type 2 diabetes mellitus. MDS 1 stated it was important to monitor Resident 39's blood sugar to know if Resident 39's blood sugar was high or low. MDS 1 stated it was important to check Resident 39's blood sugar due to Resident 39 was on G-tube feeding and was at risk for having high blood sugars that could result in diabetic coma (a life-threatening disorder that causes unconsciousness [when a person is unable to respond to people and activities]), kidney failure (a condition in which one or both the kidneys no longer work on their own), or stroke. MDS 1 stated that it was important to communicate Resident 39's diagnosis of diabetes to MD 1 and obtain a physician order for blood sugar monitoring for Resident 39. During an interview and concurrent review of Resident 39's laboratory results dated [DATE], on 4/20/2023 at 2:43 pm, the Director of Nursing (DON) stated MD 1 was notified of Resident 39's laboratory results obtained on 2/6/2023 that included a blood glucose level of 293 mg/dL. The DON stated Resident 39 had slurred speech on 4/12/2023, which was a change in Resident 39's condition. The DON stated on 4/12/2023, the licensed staff (unidentified) checked Resident 39's blood sugar level which indicated HI and thought Resident 1 had a stroke. The DON stated the licensed staff sent Resident 39 to the hospital immediately via emergency services. During an attempt telephone interview with MD 1 on 4/20/2023 at 3 pm, MD 1 was not available and did not return the call. During an interview on 4/21/2023 at 8:35 am, the DON stated that it was the standard of practice to monitor the blood sugar of residents (in general) with diabetes by doing regular glucose checks. The DON stated licensed nurses (unidentified) did not monitor Resident 39's blood sugar level from 12/1/2022 to 4/11/2023. The DON stated she expected the licensed nurses to contact MD 1 and remind MD 1 that Resident 39 was diabetic. The DON stated the licensed nurses (unidentified) needed to advocate for Resident 39 and obtain the physician's order for blood sugar monitoring. The DON stated it was important to monitor Resident 39's blood sugar level to evaluate if Resident 39 required medications to control Resident 39's blood sugar level. The DON stated Resident 39 needed to be on a diabetic diet or diabetic formula, such as Diabetic Isosource or Glucerna (a meal replacement or supplement made specifically for individuals with diabetes) rather than Isosource 1.5, to help manage Resident 39's blood sugar. During an attempt telephone interview with MD 1 on 4/21/2023 at 10:25 am, MD 1 was not available and did not return the call. During an interview on 4/21/2023 at 3:14 pm, the DON stated Resident 39's hospitalization could have been prevented by informing MD 1 about Resident 39's diagnosis of diabetes and that Resident 39 had no orders for blood sugar monitoring. The DON stated uncontrolled blood sugar placed Resident 39 at risk for kidney failure, comatose (a period of prolonged unconsciousness brought on by illness or injury) state, impaired cognition, and death. A review of the facility's policy and procedures titled, Comprehensive Care Plans, revised on 9/2/2022, indicated it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. A review of the facility's policy and procedures titled, Provision of Quality of Care, revised on 9/2/2022, indicated based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the resident's choices. The policy indicated each resident will be provided care and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. A review of the Centers for Disease Control and Prevention (CDC) website under Monitoring Your Blood Sugar, dated 12/20/2022, indicated regular blood sugar monitoring is the most important thing you can do to manage diabetes. You'll be able to see what makes your numbers go up or down, such as eating different foods, taking your medicine, or being physically active. With this information, you can work with your health care team to make decisions about your best diabetes care plan. These decisions can help delay or prevent diabetes complications such as heart attack, stroke, kidney disease, blindness, and amputation. 36924 b. A review of Resident 46's Admission Record indicated the facility admitted Resident 46 on 1/27/2023, with diagnoses that included unspecified atrial fibrillation (an irregular, often rapid heart rate commonly causing poor blood flow) and dysphagia (difficulty swallowing). A review of Resident 46's Physician Order, dated 1/27/2023 and 3/30/2023, indicated for the staff to obtain weekly weights for four weeks then every month thereafter as needed. A review of Resident 46's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 2/3/23, indicated Resident 46 had severe cognitive impairment (processes of thinking and reasoning) and required extensive assistance with bed mobility, eating, and personal hygiene. The MDS indicated Resident 46 weighed 81.6 pounds (lbs.). A review of Resident 46's Weights and Vitals Summary indicated Resident 46's weights were obtained on 2/3/2023, 2/7/2023, 3/7/2023, 4/6/2023, and 4/10/2023. The summary indicated Resident 46 weighed 80.4 lbs. on 3/7/2023 and weighed 75.4 lbs. on 4/6/2023, resulting in 5 lbs. weight loss. During an interview and concurrent review of Resident 46's medical record on 4/19/2023, at 11:14 am, the Infection Prevention Nurse (IPN, staff responsible for the facility infection prevention and control program), stated the staff did not obtain and document Resident 46's weekly weight on 2/14/2023 and 2/21/2023. The IPN stated Resident 46's weights should have been obtained on 2/14/2023 & 2/21/2023. A review of the facility's policy and procedures titled, Provision of Physician Ordered Services, dated 9/2/2022, indicated this policy is to provide a reliable process for the proper and consistent provision of the physician ordered services according to professional standards of quality. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice.

Based on interview and record review, the facility failed to follow the manufacturer's safety instructions for the use of a Low Air Loss mattress (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level), for one of four sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) notified Licensed Vocational Nurse 1 (LVN 1) to place Resident 1's LAL mattress on a firm mode (set in place and unable or unlikely to move), before CNA 1 turned Resident 1 to one side to change the resident's adult brief (disposable underwear) on the LAL mattress. 2. Ensure CNA 1 raised the bed rails (are adjustable metal or rigid plastic bars that attach to the bed) in a guard (protector) position while turning and changing Resident 1's adult brief. As a result, on 8/19/2022, at 2 pm, Resident 1 fell from his bed to the floor. Resident 1 was transferred via 911 (emergency services) and was admitted to the intensive care unit (ICU, a department of a hospital in which patients who are dangerously ill are kept under constant observation) at a General Acute Care Hospital (GACH). Resident 1 sustained a subarachnoid hemorrhage (bleeding between the brain and the tissue [flesh] covering the brain. a collection of blood on your brain's surface under the skull), scalp lacerations (deep cuts to the head), and was placed under hospice care (provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members). Findings: A review of Resident 1's Admission Record, indicated the facility admitted Resident 1 on 5/17/2016 and readmitted the resident on 6/24/2016 with diagnoses of unspecified dementia (memory loss which interferes with daily functioning) and functional [CONDITION(S)] (the complete inability to move all extremities due to severe disability). A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 7/19/2022, indicated Resident 1's cognitive (ability to think and process information) status was severely impaired, and was total dependent (full staff performance every time) with toileting and personal hygiene with one staff member to assist. A review of Resident 1's Nurses Progress Note dated 8/19/2022, timed at 3 pm, indicated CNA 1 was changing Resident 1 on the resident's bed when the resident suddenly rolled out of the bed during care. The notes indicated nurses (unidentified) went to the resident's room and saw Resident 1 face down on the floor and assisted the resident back to bed. The notes indicated the nurses applied pressure to Resident 1's right eyebrow to stop the bleeding and applied an ice pack to reduce the swelling on the resident's right side of his face. The notes indicated the facility informed the resident's family and physician. The notes indicated Resident 1's physician ordered to do x-rays (digital image) to the resident's head and knees for further evaluation. A review of Resident 1's Interdisciplinary Care Conference (meeting with multiples staff with different functional expertise), dated 8/19/2022, timed at 3:07 pm, indicated the team recommended for staff (in general) to apply bilateral (both) siderails to prevent further falls, and to have two nurses during turning/care for assistance. A review of Resident 1's Change in Condition Progress Notes dated 8/19/2022, timed at 3:30 pm., indicated Resident 1's fall could best be attributed to the LAL mattress being slippery. A review of the Paramedic (emergency services) Report, dated 8/19/2022, timed at 5:37 pm, indicated the paramedic team arrived at the facility at 5:42 pm. The report indicated Resident 1 fell from his bed at approximately 2 pm and sustained a traumatic [MEDICATION(S)] head injury (physical injuries caused by non-penetrating blows from dull objects or surfaces). The report indicated the paramedic team transferred Resident 1 to a GACH at 5:48 pm. A review of Resident 1's Nurses Progress Notes dated 8/19/2022, timed at 5:53 pm, indicated the resident was sent out to the hospital via 911 as requested by Resident 1's family. During an interview with the Social Services Director (SSD), on 8/24/2022 at 10:44 am, the SSD stated Resident 1 fell on [DATE]. The SSD stated CNA 1 reported Resident 1's fall incident to the Director of Nursing (DON) when CNA 1 providing care to Resident 1 on a low air loss mattress. The SSD stated the resident rolled off the bed, landed on the floor and sustained an injury to the forehead. A review of Resident 1's GACH Progress Notes dated 8/26/2022, timed at 12:32 pm, indicated the GACH admitted the resident to the ICU on 8/19/2022. The notes indicated Resident 1 was found to have a traumatic (serious injury to the body) subarachnoid hemorrhage and scalp lacerations after a fall and his prognosis (prospects of recovery) was very poor. The notes indicated Resident 1 was placed in comfort care and hospice. During an interview on 8/29/2022 at 1:52 pm, the DON stated Resident 1's fall could have been prevented with the use of an enabler (bed rails) or additional staff present during care. During an interview on 8/30/2022 at 5 pm, CNA 1 stated that on 8/19/2022 at approximately 1 to 2 pm during an adult brief change, CNA 1 turned Resident 1 away from CNA 1 and the LAL mattress shifted Resident 1 off the bed. CNA 1 stated the bed did not have the bed rails. CNA 1 stated Resident 1 sustained injuries to his right eyebrow and scrapings to his knees. During a telephone interview on 10/7/2022 at 2:08 pm, CNA 1 stated on 8/19/2022 he was standing on Resident 1's left side and used a sheet to turn the resident by himself. CNA 1 stated Resident 1's LAL mattress pumped more air on the left side and pushed the resident to the right side and the resident fell to the floor. During a telephone interview on 10/7/2022 at 2:23 pm, Treatment Nurse (TXN) stated she and other licensed nurses (in general) were responsible to check the LAL mattress settings. TXN stated that on 8/19/2022, she did not check Resident 1's LAL mattress before CNA 1 provided care to Resident 1. TXN stated CNA 1 did not call her to check Resident 1's LAL mattress settings before CNA 1 provided care to Resident 1. TXN stated CNA 1 needed to call her to change the LAL mattress settings to firm. TXN stated Resident 1's LAL mattress needed to be firm when staff providing care to the resident. A review of facility's policy and procedure, titled Accident and Incident Prevention, with a revised date of 9/2007, indicated the facility would establish routine monitoring systems to assess, correct, and modify a safety risk factors. The policy indicated the administrators were responsible to assign an individual to perform safety inspection rounds. A review of the LAL's mattress User Manual with a copy right dated 2017, indicated the user of the LAL mattress needed to read the manual before using the LAL mattress. indicated to avoid injury from falling, the maximum firmness was recommended during resident turning or resident cleaning. The manual indicated to avoid risk of death or injury from entrapment (is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) or falling, the manufacturer suggested the rails to be in the raised or guarded position whenever a resident is on the bed. The manual indicated health care professionals assigned to each case should make the final determination whether side or assist rails were warranted after assessing residents' risks of entrapments and falls.

Based on observation, interview and record review, the facility failed to have a system in place to monitor and safely provide pharmaceutical services that assure safe administration of controlled substances (drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) to prevent drug diversion (when prescription medicines are obtained or used illegally) for four of 11 sampled residents (Residents 1, 2, 3 and 4) receiving pain control medications. 1. Resident 1 received 72 doses of [MEDICATION(S)] (a drug used to treat moderate to severe pain) 5/325 milligrams (mg, unit of measurement) between 7/3/2021 and 8/28/2021. 2. Resident 2 received eleven doses of [MEDICATION(S)] 5/325 mg and 69 doses of [MEDICATION(S)] 10/325 mg between 7/1/2021 and 8/30/2021. 3. Resident 3 received 71 doses of [MEDICATION(S)] 5/325 mg between 7/1/2021 and 8/30/2021. 4. Resident 4 received 64 doses of [MEDICATION(S)] 5/325 mg between 7/1/2021 and 8/30/2021. During an interview on 9/2/2021 at 12:45 pm, the Director of Nursing (DON) stated while in the process of investigating an allegation related to resident to employee abuse, she, and the Nurse Resource Consultant (NRC) identified a possible drug diversion that involved 11 residents that received pain medication from the Licensed Vocational Nurse (LVN 1). Four of 11 residents (Residents 1, 2 3 and 4) were interviewed during their investigation and reported they did not receive any pain medications as recorded. These deficient practices had the potential for medication diversion (when prescription medicines are obtained or used illegally) and had the potential for Residents 1, 2, 3 and 4's pain not to be controlled or to experience adverse effects (a harmful or abnormal result) possibly resulting in serious harm to the residents leading to a diminished quality of life, hospitalization , or death. On 9/7/2021 at 5:30 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Executive Director (ED) regarding the facility's failure to provide accurate pain assessment to the residents to ensure pain was controlled and prevent drug diversion for Residents 1, 2, 3 and 4. On 9/9/2021 at 12:22 pm, during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action (POA, interventions to correct the deficient practices). The POA included: a. On 9/7/2021, the facility reassessed each of the four residents (Residents 1,2, 3 and 4) for pain. The facility notified the physician for appropriate pain management for Residents 1 and 4. b. On 9/7/2021 the Registered Nurse 1 (RN 1) interviewed and assessed Residents 1, 2, 3 and 4 and plan of care updated when indicated. c. On 9/7/2021 the facility's Licensed Nurses were in serviced by the Nurse Resource Consultant, Vice President (VP) of Education and DON or DSD (Director of Staff Development) on the facility's Drug Diversion Program, Pain management policy and procedures. d. On 9/8/2021, the facility and a pharmacist consultant reviewed each resident who was on a routine or PRN pain medication for pain management efficacy. Cross Reference to F697 and F756 Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on 7/2/2021 with diagnoses of right-side [CONDITION(S)] (paralysis or unable to move one side of the body) [CONDITION(S)] (left sided weakness) following cerebral infarction (a stroke or damage to tissues in the brain due to a loss of oxygen to the area). A review of the Medication Review Report (MRR, an evaluation of all the resident's medicines with the aim of improving medicines use and improving health outcomes) dated 7/2/2021, indicated the physician ordered for Resident 1 to receive [MEDICATION(S)] ([MEDICATION(S)]) 5/325 mg (milligrams-a unit of measurement) one tablet by mouth every four hours as needed for moderate pain NTE (not to exceed) 3 grams in 24 hours. A review of Resident 1's Nursing Progress Notes, dated from 7/2/2021 to 8/30/2021, indicated no documented evidence Resident 1 requested for pain medication. Resident 1's clinical record had no documented evidence to indicate the resident's pain was evaluated. A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 7/9/2021 indicated Resident 1 was sometimes able to express ideas and usually able to understand others in verbal content. The MDS indicated when interviewed Resident 2 replied he had no pain or hurting at any time. The MDS also indicated the resident received, offered, and declined PRN medications. A review of Resident 1's Pain Assessment Flow Sheet indicated the resident received a total of 72 doses of [MEDICATION(S)] 5/325 mg between 7/3/2021 to 8/28/2021 for the pain level of 7/10 on the pain scale (0-no pain and 10 severe pain) with most medications administered on the day shift (7 a.m. to 3:30 p.m.). The flow sheet and resident's clinical record had no documented evidence indicating non-pharmacological interventions (any sort of intervention not directly involving a medication) were provided prior to administration of pain medication or that it was not effective requiring the administration of controlled medications. A review of Resident 1's plan of care, dated 7/14/2021, titled Pain, indicated Resident 1 had increased risk for recurrence of pain episodes related to Cerebral Infarction and the intervention indicated the nursing staff would evaluate the effectiveness of the pain interventions, review the compliance, alleviating symptoms. dosing schedules, resident satisfaction with results, monitor and record pain characteristics at least every shift and as needed, the onset, duration, aggravating factors and relieving factors. During an observation and interview on 9/2/2021 at 4:50 pm, Resident 1 was awake alert oriented to person, place, time and coherent stated he never received pain medication from the date the resident was admitted to the facility which was on 7/2/2021. During an interview on 9/2/2021 at 1:30 pm, DON stated when Resident 1 was interviewed (unidentified date) related to pain the resident denied ever requesting or receiving pain medication from July 2021 to August 2021. 2. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 10/29/2020 with diagnoses of fracture of the left pubis (broken bone located above the hip bone). A review of Resident 2's Physician Order dated 10/29/2020, indicated to evaluate Resident 2's pain every shift. A review of the MRR dated 11/8/2021, indicated the physician ordered for Resident 2 to receive [MEDICATION(S)] one tablet 10-325 mgs by mouth every six hours as needed for severe pain NTE 3 grams of Tylenol in 24 hours. A review Resident 2's plan of care dated 10/29/2020 with a revised date of 11/28/2020, titled At Risk for Comfort/Pain, related to fall with fracture and the interventions indicated the nursing staff would find out the location and intensity of pain and reposition for comfort. A review Resident 2's MRR dated 11/18/2020, indicated the physician ordered for the resident to receive [MEDICATION(S)] one tablet 5/325 mgs by mouth every four hours as needed for severe pain NTE 3 grams of Tylenol in 24 hours. A review of the MRR dated 12/15/2020, indicated the physician ordered for Resident 2 to receive [MEDICATION(S)] 10/325 mg one tablet by mouth every six hours as needed for moderate pain NTE 3 grams of Tylenol in 24 hours. There was no documented evidence as to why the resident's pain control medication dose had been increased. A review of Resident 2's MDS dated [DATE] indicated Resident 2 was able to express her ideas and wants, understands verbal contents and no memory of cognitive (ability to think and reason) impairment. The MDS indicated when interviewed Resident 2 replied she had no pain or hurting at any time in the last five days. The MDS also indicated the resident received, offered, and declined PRN pain medications in the last five days. A review of Resident 2's Pain Assessment Flow Sheet indicated Resident 2 received a total of eleven doses of [MEDICATION(S)] 5/325 mg for the pain level 7/10 and 69 doses of [MEDICATION(S)] 10/325 mg for the pain level 8/10 between 7/1/2021 and 8/31/2021 with the majority given during the day and evening shifts. The flow sheet and resident's clinical record indicated no documented evidence of any non-pharmacological interventions provided prior to administration of pain medication or that it was not effective requiring the administration of controlled medications. A review of Resident 2's Nursing Progress Notes, dated from 7/1/2021 to 8/31/2021, had no documented evidence Resident 2 requested for pain medication. Resident 2's clinical record had no documented evidence to indicate the resident's pain was evaluated the root cause of the pain and if the pain was alleviated by non-pharmacological intervention prior to administration of pain medication. During an interview on 9/2/2021 at 1:30 pm, DON stated Resident 2 denied ever requesting or receiving pain relief medication from July 2021 to August 2021. The DON further stated, as a means managing the resident's pain, the resident diverted her attention by participating in the facility's activity program. During an observation and interview on 9/2/2021 at 2:25 pm, Resident 2 was awake and alert and stated, she refused to take pain relief medications. 3. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included multiple fractures of the ribs and dementia (a progressive brain disorder that affects memory, judgement and ability to think and reason). A review of Resident 3's Plan of care dated 5/21/2021, indicated Resident 3 was at risk for altered comfort and pain related to fall with fracture of the ribs. The care plan indicated to relieve pain within one hour of medication intervention, the facility staff would find out the location and intensity (severity) of pain, reposition for comfort and provide pain relief medication. A review of Resident 3's MDS dated [DATE] indicated Resident 3 sometimes was able to express ideas and wants and was severely impaired in making decisions regarding task of daily life. A review Resident 3's of the MRR dated 5/21/2021, indicated the physician ordered for the resident to receive [MEDICATION(S)] 5/325 mg by mouth every six hours as needed for moderate to severe pain. A review of the MRR dated 5/21/2021, indicated the physician ordered to give Resident 3 [MEDICATION(S)] Patch (medication help alleviate severe ongoing pain) 25 microgram/hour one patch transdermal (over the skin) every 72 hours for pain management (remove old patch prior to applying new patch as scheduled). A review of the MRR, dated July 2021 to August 2021, indicated Resident 3 received [MEDICATION(S)] Patch 5% to affected area topically (on top) one time a day for pain management at 9 a.m. and off at 9 p.m. A review of Resident 3's Pain Assessment Flow Sheet for the month of July 2021 to August 2021 indicated Resident 3 received a total of 71 doses of [MEDICATION(S)] 5/325 for back and general body pain at pain level 7-8/10. The flow sheet and resident's clinical record had no documented evidence of any non-pharmacological interventions provided prior to administration of pain medication or that it was not effective requiring the administration of controlled medications. A review of Resident 3's Nursing Progress Notes and weekly assessment review had no documented evidence Resident 3's pain was evaluated to indicate nonpharmacological interventions provided which required the repeated administration on [MEDICATION(S)]. During an interview on 9/3/2021 at 6:54 pm, Licensed Vocational Nurse 2 (LVN 2) stated Residents 3 did not complain of pain and did not ask for pain relief medication. During an interview on 9/7/2021 at 10:20 am, the DON stated Resident 3 was confused, but sometimes was able to answer questions appropriately. The DON stated there was no documentation that her pain was not controlled by [MEDICATION(S)] as additional pain medication, it was not identified as a problem. 4. A review of Resident 4's Admission Record indicated the facility admitted the resident on 7/7/2021 with diagnosis of [CONDITION(S)] (skin infection) of the right lower limb. A review of Resident 4's MDS dated [DATE], indicated Resident 4 was able to express ideas and wants both in verbal and nonverbal expression. The MDS indicated Resident 4 did not exhibit behavior of rejection of care or evaluation. A review of the Progress Notes dated July 2021 to August 2021, indicated Resident 4 complained of generalized body pain three times on separate occasions in which pain medication were given to the resident. A review of Pain Assessment Flow Sheet for the month of July 2021 to August 2021 indicated Resident 4 received a total of 64 doses of [MEDICATION(S)] 5/325 for back and general body pain at pain level 7-8/10. The flow sheet and resident's clinical record had no documented evidence of any non-pharmacological interventions provided prior to administration of pain medication or that it was not effective requiring the administration of controlled medications. During an observation and interview on 9/7/2021 at 6:38 pm, Resident 4 stated he had requested for pain medication in the last months but did not like to take pain medication so much because it It knocks me out, I get sleepy all day, maybe I asked for medication a few times. During an interview on 9/8/2021 at 9:30 am, LVN 3 stated she oversaw care for Residents 1, 2, 3 and 4 during the day shift when LVN 1 was off work. LVN 3 stated she had not observed the residents complain of pain and was surprised to see the amount of medications the residents were receiving mostly on the day shift. During an interview with the MDS Nurse on 9/7/2021 at 1:13 pm, MDS Nurse stated during residents' assessments she did not assess further or interview the residents or the staff to clarify if or why the residents were receiving pain medication as recorded in the MRR. The MDS nurse further stated if residents denied having pain in the last five days, a possible drug diversion would be identified and to make sure the resident's pain was accurately assessed. The MDS nurse stated she did not report the discrepancy to the DON. During an interview with the DON on 9/7/2021 at 12:20 pm, the DON stated pain management was not part of the Quality Assurance Program Improvement (QAPI, is a process used to ensure services are meeting quality standards and assuring care reaches a certain level), and no system was in place to monitor staff compliance and to verify if residents were accurately assessed, monitored, and evaluated appropriately for pain. The DON further stated residents' pain was supposed to be documented daily and during the weekly assessment to ensure: a. Residents were observed and interviewed for specific location of pain, what makes the pain worst or what relieves the pain or if the pain was new onset or chronic pain. b. Non pharmacologically interventions were provided and why it did not work (ineffective) c. Frequency of pain medication given and the source of pain. d. The accuracy of the MDS nurse assessment of the resident during the initial, quarterly, annually and during a significant of change to ensure the residents and staffs were interviewed if there was a discrepancy in the interview and medication administration record of pain medications. e. The licensed staff provided the pain medication as prescribed by the physician. f. The pharmacy consultant identified irregularities during the monthly visits. g. The residents were observed and interviewed to determine if the pain medication prescribed was appropriate to alleviate the pain and avoid the frequent pain medication administration. During an interview on 9/7/2021 at 12:44 pm, the DON stated if the residents who were receiving pain medication were accurately assessed, monitored, evaluated and were documented daily and weekly then the possible drug diversion could had been identified sooner. During an interview on 9/2/2021 at 12:45 pm, the DON stated while in the process of investigating an allegation related to resident to employee abuse, she and the Nurse Resource Consultant (NRC) identified a possible drug diversion that involved eleven residents who received pain medication from LVN 1 and four of the eleven residents (Residents 1, 2 3 and 4), were interviewed and reported they did not receive any pain medications as recorded. During an interview with the pharmacist consultant (PC) on 9/3/2021 from 5:37 pm to 6:02 pm, the PC stated the facility reported a possible controlled drug diversion to her on 8/30/2021 which she did not identify during the drug regimen review in the facility from her previous visits. The PC stated her responsibilities during a monthly medication regimen review included to monitor the dosage, frequency of use and if appropriate pain medication was given according to pain severity to ensure accurate pain management and identify needs for evaluation that needs to be done by nurse or physician. The PC stated she did not identify any drug regimen irregularities related to increased frequency of pain medication administration to any residents during the monthly visits at the facility. The PC stated she reviewed the MAR of the residents and noted that the pain was resolved after the pain medication was administered and she did not interview the residents or licensed staff to question the reason why there was frequent administration of pain medication given to residents and did not question the practices as drug regimen irregularities because pain was subjective, (based on personal feelings). The PC stated she did not interview the residents to ensure the residents' pain was controlled or if the residents were receiving pain medication. The PC stated she was relying on the nurses to perform the assessments and give the pain medication in a, trustworthy way. The PC stated, I go by the documentation of the nurses and I am trusting their documentation is trustworthy and truthful. I have to work with a certain level of trust these are licensed professionals. A review of the Consultant Pharmacist Medication Regimen Review Recommendations Pending a Final Response for the months July 2021 and August 2021 indicated no documented evidence the PC identified any irregularities in the increased frequency of pain medication administration which mostly administered during the day shift by LVN 1 for Residents 1, 2, 3 and 4. A review of the undated, Consultant Pharmacist Services Agreement, indicated the consultant pharmacist should be responsible for rendering the following services to the facility, review drug regimen for each resident in the facility, inspect medication storage and administration in the facility and submit a monthly report to the facility administrator and DON. A review of the policy and procedure, titled Controlled Substance Storage, indicated the DON in conjunction of the pharmacist consultant or designee routinely monitors, controlled substances records) i.e. change of shift sheets, individual controlled substance accountability sheets, MARs, delivery confirmation sheets) during monthly inspections. A review of the facility's policy and procedure, dated August 2006, titled, Quality Assessment and Assurance Committee, indicated the facility should establish and maintain Quality Assessment and Assurance Committee, that oversees the identification and handling to quality issues with the primary goal to monitor and evaluate the appropriateness and quality care provided and help identify negative outcomes relative to resident care and resolve them appropriately. A review of the facility's policy and procedure undated, title Pharmacy Services for Nursing Facilities, the Director of Nursing in conjunction with the consultant pharmacist or designee would routinely monitor controlled substances storage, records that included the MAR, controlled drug substance accountability sheets during monthly inspections. The policy indicated any discrepancy in controlled substance was reported to the DON immediately.

Based on observation, interview and record review, the facility failed to identify medication regimen (a treatment plan that specifies the dosage, the schedule, and the duration of treatment) irregularities in the frequent administration of PRN (as needed) medications for four of 11 sampled residents (Residents 1, 2, 3, and 4) who were prescribed controlled substance medications (drug or other substance that is tightly controlled by the government because it may be abused or cause addiction). 1. Resident 1 received 72 doses of [MEDICATION(S)] (a drug used to treat moderate to severe pain) 5/325 milligrams (mg, unit of measurement) between 7/3/2021 and 8/28/2021. 2. Resident 2 received eleven doses of [MEDICATION(S)] 5/325 mg and 69 doses of [MEDICATION(S)] 10/325 mg between 7/1/2021 and 8/30/2021. 3. Resident 3 received 71 doses of [MEDICATION(S)] 5/325 mg between 7/1/2021 and 8/31/2021. 4. Resident 4 received 64 doses of [MEDICATION(S)] 5/325 mg between 7/1/2021 and 8/30/2021. The facility's pharmacist did not identify or address the above frequent usage of controlled substances to control resident's pain and did not identify the pattern of frequent PRN medication as a medication irregularity for Residents 1, 2,3 and 4. These deficient practices had the potential for Residents 1, 2, 3 and 4 to experience adverse effects due to the dosage frequency and residents' frequency of use of pain medication such as drowsiness and dizziness possibly resulting in serious harm to the residents leading to a diminished quality of life, hospitalization , or death. On 9/7/2021 at 5:30 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Executive Director (ED) regarding the facility's failure to provide accurate pain assessment to the residents to ensure pain was controlled and prevent drug diversion (when prescription medicines are obtained or used illegally) for Residents 1, 2, 3 and 4. On 9/9/2021 at 12:22 pm, during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action (POA, interventions to correct the deficient practices). The POA included: a. On 9/7/2021, the facility reassessed each of the four residents (Residents 1,2, 3 and 4) for pain. The facility notified the physician for appropriate pain management for Residents 1 and 4. b. On 9/7/2021 the Registered Nurse 1 (RN 1) interviewed and assessed Residents 1, 2, 3 and 4 and plan of care updated when indicated. c. On 9/7/2021 the facility's Licensed Nurses were in serviced by the Nurse Resource Consultant, Vice President (VP) of Education and DON or DSD (Director of Staff Development) on the facility's Drug Diversion Program, Pain management policy and procedures. d. On 9/8/2021, the facility and a pharmacist consultant reviewed each resident who was on a routine or PRN pain medication for pain management efficacy. Cross Reference to F697 and F755 Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on 7/2/2021 with diagnoses of right-side [CONDITION(S)] (paralysis or unable to move one side of the body) [CONDITION(S)] (left sided weakness) following cerebral infarction (a stroke or damage to tissues in the brain due to a loss of oxygen to the area). A review of the Medication Review Report (MRR, an evaluation of all the resident's medicines with the aim of improving medicines use and improving health outcomes) dated 7/2/2021, indicated the physician ordered for Resident 1 to receive [MEDICATION(S)] ([MEDICATION(S)]) 5/325 mg (milligrams-a unit of measurement) one tablet by mouth every four hours as needed for moderate pain NTE (not to exceed) 3 grams in 24 hours. A review of Resident 1's Nursing Progress Notes, dated from 7/2/2021 to 8/30/2021, indicated no documented evidence Resident 1 requested for pain medication. Resident 1's clinical record had no documented evidence to indicate the resident's pain was evaluated. A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 7/9/2021 indicated Resident 1 was sometimes able to express ideas and usually able to understand others in verbal content. The MDS indicated when interviewed Resident 2 replied he had no pain or hurting at any time. The MDS also indicated the resident received, offered, and declined PRN medications. A review of Resident 1's Pain Assessment Flow Sheet indicated the resident received a total of 72 doses of [MEDICATION(S)] 5/325 mg between 7/3/2021 to 8/28/2021 for the pain level of 7/10 on the pain scale (0-no pain and 10 severe pain) with most medications administered on the day shift (7 a.m. to 3:30 p.m.). The flow sheet and resident's clinical record had no documented evidence indicating non-pharmacological interventions (any sort of intervention not directly involving a medication) were provided prior to administration of pain medication or that it was not effective requiring the administration of controlled medications. A review of Resident 1's plan of care, dated 7/14/2021, titled Pain, indicated Resident 1 had increased risk for recurrence of pain episodes related to Cerebral Infarction and the intervention indicated the nursing staff would evaluate the effectiveness of the pain interventions, review the compliance, alleviating symptoms. dosing schedules, resident satisfaction with results, monitor and record pain characteristics at least every shift and as needed, the onset, duration, aggravating factors and relieving factors. During an observation and interview on 9/2/2021 at 4:50 pm, Resident 1 was awake alert oriented to person, place, time and coherent stated he never received pain medication from the date the resident was admitted to the facility which was on 7/2/2021. During an interview on 9/2/2021 at 1:30 pm, DON stated when Resident 1 was interviewed (unidentified date) related to pain the resident denied ever requesting or receiving pain medication from July 2021 to August 2021. 2. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 10/29/2020 with diagnoses of fracture of the left pubis (broken bone located above the hip bone). A review of Resident 2's Physician Order dated 10/29/2020, indicated to evaluate Resident 2's pain every shift. A review Resident 2's plan of care dated 10/29/2020 with a revised date of 11/28/2020, titled At Risk for Comfort/Pain, related to fall with fracture and the interventions indicated the nursing staff would find out the location and intensity of pain and reposition for comfort. A review Resident 2's MRR dated 11/18/2020, indicated the physician ordered for the resident to receive [MEDICATION(S)] one tablet 5/325 mgs by mouth every four hours as needed for severe pain NTE 3 grams of Tylenol in 24 hours. A review of the MRR dated 12/15/2020, indicated the physician ordered for Resident 2 to receive [MEDICATION(S)] 10/325 mgs one tablet by mouth every six hours as needed for moderate pain NTE 3 grams of Tylenol in 24 hours. There was no documented evidence as to why the resident's pain control medication dose had been increased. A review of Resident 2's MDS dated [DATE] indicated Resident 2 was able to express her ideas and wants, understands verbal contents and no memory of cognitive (ability to think and reason) impairment. The MDS indicated when interviewed Resident 2 replied she had no pain or hurting at any time in the last five days. The MDS also indicated the resident received, offered, and declined PRN pain medications in the last five days. A review of Resident 2's Pain Assessment Flow Sheet indicated Resident 2 received a total of eleven doses of [MEDICATION(S)] 5/325 mg for the pain level 7/10 and 69 doses of [MEDICATION(S)] 10/325 mg for the pain level 8/10 between 7/1/2021 and 8/31/2021 with the majority given during the day and evening shifts. The flow sheet and resident's clinical record indicated no documented evidence of any non-pharmacological interventions provided prior to administration of pain medication or that it was not effective requiring the administration of controlled medications. A review of Resident 2's Nursing Progress Notes, dated from 7/1/2021 to 8/31/2021, had no documented evidence Resident 2 requested for pain medication. Resident 2's clinical record had no documented evidence to indicate the resident's pain was evaluated of the root cause of the pain and if the pain was alleviated by non-pharmacological interventions prior to administration of pain medication. During an interview on 9/2/2021 at 1:30 pm, DON stated Resident 2 denied ever requesting or receiving pain relief medication from July 2021 to August 2021. The DON further stated, as a means managing the resident's pain, the resident diverted her attention by participating in the facility's activity program. During an observation and interview on 9/2/2021 at 2:25 pm, Resident 2 was observed awake. Upon interview, the resident stated she refused taking pain relief medications. 3. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included multiple fractures of the ribs and dementia (a progressive brain disorder that affects memory, judgement and ability to think and reason). A review of Resident 3's Plan of care dated 5/21/2021, indicated Resident 3 was at risk for altered comfort and pain related to fall with fracture of the ribs. The care plan indicated to relieve pain within one hour of medication intervention, the facility staff would find out the location and intensity (severity) of pain, reposition for comfort and provide pain relief medication. A review of Resident 3's MDS dated [DATE] indicated Resident 3 sometimes was able to express ideas and wants and was severely impaired in making decisions regarding task of daily life. A review Resident 3's of the MRR dated 5/21/2021, indicated the physician ordered for the resident to receive [MEDICATION(S)] 5/325 mg by mouth every six hours as needed for moderate to severe pain. A review of the MRR dated 5/21/2021, indicated the physician ordered to give Resident 3 [MEDICATION(S)] Patch (medication help alleviate severe ongoing pain) 25 microgram/hour one patch transdermal (over the skin) every 72 hours for pain management (remove old patch prior to applying new patch as scheduled). A review of the MRR, dated July 2021 to August 2021, indicated Resident 3 received [MEDICATION(S)] Patch 5% to affected area topically (on top) one time a day for pain management at 9 a.m. and off at 9 p.m. A review of Resident 3's Pain Assessment Flow Sheet for the month of July 2021 to August 2021 indicated Resident 3 received a total of 71 doses of [MEDICATION(S)] 5/325 for back and general body pain at pain level 7-8/10. The flow sheet and resident's clinical record had no documented evidence of any non-pharmacological interventions provided prior to administration of pain medication or that it was not effective requiring the administration of controlled medications. A review of Resident 3's Nursing Progress Notes and weekly assessment review had no documented evidence Resident 3's pain was evaluated to indicate nonpharmacological interventions provided which required the repeated administration on [MEDICATION(S)]. During an interview on 9/3/2021 at 6:54 pm, Licensed Vocational Nurse 2 (LVN 2) stated Resident 3 did not complain of pain and did not ask for pain relief medication. During an interview on 9/7/2021 at 10:20 am, the DON stated Resident 3 was confused, but sometimes was able to answer questions appropriately. The DON stated there was no documentation that the resident's pain was not controlled by [MEDICATION(S)] as additional pain medication, it was not identified as a problem. 4. A review of Resident 4's Admission Record indicated the facility admitted the resident on 7/7/2021 with diagnosis of [CONDITION(S)] (skin infection) of the right lower limb. A review of Resident 4's MDS dated [DATE], indicated Resident 4 was able to express ideas and wants both in verbal and nonverbal expression. The MDS indicated Resident 4 did not exhibit behavior of rejection of care or evaluation. A review of the Progress Notes dated July 2021 to August 2021, indicated Resident 4 complained of generalized body pain three times on separate occasions in which pain medication were given to the resident. A review of Pain Assessment Flow Sheet for the month of July 2021 to August 2021 indicated Resident 4 received a total of 64 doses of [MEDICATION(S)] 5/325 for back and general body pain at pain level 7-8/10. The flow sheet and resident's clinical record had no documented evidence of any non-pharmacological interventions provided prior to administration of pain medication or that it was not effective requiring the administration of controlled medications. During an observation and interview on 9/7/2021 at 6:38 pm, Resident 4 stated he had requested for pain medication in the last months but did not like taking pain medication because, It knocks me out, I get sleepy all day, maybe I asked for medication a few times. During an interview on 9/8/2021 at 9:30 am, LVN 3 stated she oversaw care for Residents 1, 2, 3 and 4 during the day shift when LVN 1 was off work. LVN 3 stated she had not observed the residents complain of pain and was surprised to see the amount of medications the residents were receiving mostly on the day shift. During an interview with the MDS Nurse on 9/7/2021 at 1:13 pm, MDS Nurse stated during residents' assessments she did not assess further or interview the residents or the staff to clarify if or why the residents were receiving pain medication as recorded in the MRR. The MDS nurse further stated if residents denied having pain in the last five days, a possible drug diversion would be identified and to make sure the resident's pain was accurately assessed. The MDS nurse stated she did not report the discrepancy to the DON. During an interview with the DON on 9/7/2021 at 12:20 pm, the DON stated pain management was not part of the Quality Assurance Program Improvement (QAPI, is a process used to ensure services are meeting quality standards and assuring care reaches a certain level), and no system was in place to monitor staff compliance and to verify if residents were accurately assessed, monitored, and evaluated appropriately for pain. The DON further stated residents' pain was supposed to be documented daily and during the weekly assessment to ensure: a. Residents were observed and interviewed for specific location of pain, what makes the pain worst or what relieves the pain or if the pain was new onset or chronic pain. b. Non pharmacologically interventions were provided and why it did not work (ineffective) c. Frequency of pain medication given and the source of pain. d. The accuracy of the MDS nurse assessment of the resident during the initial, quarterly, annually and during a significant of change to ensure the residents and staffs were interviewed if there was a discrepancy in the interview and medication administration record of pain medications. e. The licensed staff provided the pain medication as prescribed by the physician. f. The pharmacy consultant identified irregularities during the monthly visits. g. The residents were observed and interviewed to determine if the pain medication prescribed was appropriate to alleviate the pain and avoid the frequent pain medication administration. During an interview on 9/7/2021 at 12:44 pm, the DON stated if the residents who were receiving pain medication were accurately assessed, monitored, evaluated, and were documented daily and weekly for pain, then the possible drug diversion could had been identified sooner. During an interview on 9/2/2021 at 12:45 pm, the DON stated while in the process of investigating an allegation related to resident to employee abuse, she and the Nurse Resource Consultant (NRC) identified a possible drug diversion that involved eleven residents who received pain medication from LVN 1 and four of the eleven residents (Residents 1, 2 3 and 4), were interviewed and reported they did not receive any pain medications as recorded. During an interview with the pharmacist consultant (PC) on 9/3/2021 from 5:37 pm to 6:02 pm, the PC stated the facility reported a possible controlled drug diversion to her on 8/30/2021 which she did not identify during the drug regimen review in the facility from her previous visits. The PC stated her responsibilities during a monthly medication regimen review included to monitor the dosage, frequency of use and if appropriate pain medication was given according to pain severity to ensure accurate pain management and identify needs for evaluation that needs to be done by nurse or physician. The PC stated she did not identify any drug regimen irregularities related to increased frequency of pain medication administration to any residents during the monthly visits at the facility. The PC stated she reviewed the MAR of the residents and noted that the pain was resolved after the pain medication was administered and she did not interview the residents or licensed staff to question the reason why there was frequent administration of pain medication given to residents and did not question the practices as drug regimen irregularities because pain was subjective, (based on personal feelings). The PC stated she did not interview the residents to ensure the residents' pain was controlled or if the residents were receiving pain medication. The PC stated she was relying on the nurses to perform the assessments and give the pain medication in a, trustworthy way. The PC stated, I go by the documentation of the nurses and I am trusting their documentation is trustworthy and truthful. I have to work with a certain level of trust these are licensed professionals. A review of the Consultant Pharmacist Medication Regimen Review Recommendations Pending a Final Response for the months July 2021 and August 2021 indicated no documented evidence the PC identified any irregularities in the increased frequency of pain medication administration which mostly administered during the day shift by LVN 1 for Residents 1, 2, 3 and 4. A review of the undated, Consultant Pharmacist Services Agreement, indicated the consultant pharmacist should be responsible for rendering the following services to the facility, review drug regimen for each resident in the facility, inspect medication storage and administration in the facility and submit a monthly report to the facility administrator and DON. A review of the policy and procedure, titled Controlled Substance Storage, indicated the DON in conjunction of the pharmacist consultant or designee routinely monitors, controlled substances records,) i.e. change of shift sheets, individual controlled substance accountability sheets, MARs, delivery confirmation sheets) during monthly inspections. A review of the facility's policy and procedure, dated August 2006, titled, Quality Assessment and Assurance Committee, indicated the facility should establish and maintain Quality Assessment and Assurance Committee, that oversees the identification and handling to quality issues with the primary goal to monitor and evaluate the appropriateness and quality care provided and help identify negative outcomes relative to resident care and resolve them appropriately. A review of the facility's policy and procedure undated, title Pharmacy Services for Nursing Facilities, the Director of Nursing in conjunction with the consultant pharmacist or designee would routinely monitor controlled substances storage, records that included the MAR, controlled drug substance accountability sheets during monthly inspections. The policy indicated any discrepancy in controlled substance was reported to the DON immediately.

Based on observation, interview and record review the facility failed to implement a systematic method to identify and correct quality deficiencies regarding pain management by failing to accurately assess four of 11 sampled residents (Residents 1, 2, 3 and 4) who were prescribed narcotic (controlled illegal or prescription drugs regulated by the Controlled Substances Act (CSA) due to potential medication abuse and dependence) pain medications. The residents received multiple doses of PRN (as needed) pain medication between 7/1/21 and 8/30/21 to treat severe pain (documented as 7-8/10 pain score) and the following were identified: 1. Resident 1 received 72 doses of [MEDICATION(S)] 5/325 mg tablets (milligrams-unit of measurement) between 7/3/21 and 8/28/21 but was not assessed or monitored for pain upon administration of pain medications. 2. Resident 2 received 9 doses of [MEDICATION(S)] 5/325 mg tablet and 76 doses of [MEDICATION(S)] 10/325 mg between 7/1/21 and 8/30/21 but was not assessed or monitored for pain upon administration of pain medications. 3. Resident 3 received 75 doses of [MEDICATION(S)] 5/325 mg tablet but was not assessed or monitored for pain upon administration of pain medications. 4. Resident 4 received 64 doses of [MEDICATION(S)] 5/325 mg tablet between 7/1/21 and 8/30/21 but was not assessed or monitored for pain upon administration of pain medications. The resident's clinical records indicated their pain was not reassessed to determine the need for the frequent administration of controlled medication between 7/1/21 and 8/30/21. Upon interview, Residents 1-4 denied receiving the doses of the PRN pain medication identified above indicating a possible diversion of controlled medication by licensed staff. As a result of the deficient practice the residents were at risk for pain not well-managed, controlled, at risk of untreated pain with delay in pain relief, and delay in identification of other potential medical issues. Residents 1-4 could have experienced adverse effects due to the frequent dosage of pain medication such as drowsiness and dizziness possibly resulting in falls. In addition, the deficient practice had the potential for Residents 1, 2, 3 and 4's pain to not be managed or controlled or to experience adverse effects (a harmful or abnormal result) possibly resulting in serious harm to the residents leading to a diminished quality of life, hospitalization , or death. On 9/7/2021 at 5:30 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Executive Director (ED) regarding the facility's failure to provide accurate pain assessment to the residents to ensure pain was controlled and prevent drug diversion for Residents 1, 2, 3 and 4. On 9/9/2021 at 12:22 pm, during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action (POA, interventions to correct the deficient practices). The POA included: a. On 9/7/2021, the facility reassessed each of the four residents (Residents 1,2, 3 and 4) for pain. The facility notified the physician for appropriate pain management for Residents 1 and 4. b. On 9/7/2021 the Registered Nurse 1 (RN 1) interviewed and assessed Residents 1, 2, 3 and 4 and plan of care updated when indicated. c. On 9/7/2021 the facility's Licensed Nurses were in serviced by the Nurse Resource Consultant, Vice President (VP) of Education and DON or DSD (Director of Staff Development) on the facility's Drug Diversion Program, Pain management policy and procedures. d. On 9/8/2021, the facility and a pharmacist consultant reviewed each resident who was on a routine or PRN pain medication for pain management efficacy. Cross Reference F755 and F756 Findings: During an interview on 9/2/21 at 12:45 p.m., the Director of Nursing (DON) stated while in the process of investigating an allegation related to resident to employee abuse, she and the Nurse Resource Consultant (NRC) identified a possible drug diversion that involved 11 residents who received pain medication from the Licensed Vocational Nurse (LVN 1). Four of the 11 residents (Residents 1, 2 3 and 4) were interviewed during the facility's investigation and reported they did not receive any pain medications as recorded. During an interview with the pharmacist consultant (PC) on 9/3/21 at 5:37 p.m., she stated her responsibilities during a monthly medication regimen review included to monitor the dosage, frequency of use and if appropriate pain medication was given according to pain severity to ensure accurate pain management. The PC stated she did not identify any drug regimen irregularities or increased frequency of pain medication administration during her visits at the facility. 1. A review of Resident 1's Admission Record indicated the facility admitted the resident on 7/2/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 7/9/21 indicated Resident 1 was sometimes able to express ideas and usually able to understand others in verbal content. The MDS indicated when interviewed Resident 2 replied he had no pain or hurting at any time in the last five days. The MDS also indicated the resident received, offered, and declined PRN (Latin word Pro Re Nata which means as needed) medications in the last five days. A review of the Medication Review Report (MRR), the physician ordered on 7/2/21, to give Resident 1 [MEDICATION(S)] ([MEDICATION(S)]) tablet (medication use to relieve pain) 5/325 mg (milligrams-a unit of measurement) by mouth every four hours as needed for moderate pain NTE (not to exceed) 3 grams APAP (also known as Acetaminophen) in 24 hours. A review of Resident 1's Pain Assessment Flow Sheet indicated the resident received a total of 72 doses of [MEDICATION(S)] 5/325 mg between 7/3/2021 to 8/28/2021 for the pain level of 7/10 on the pain scale (0-no pain and 10 severe pain) with most medications administered on the day shift (7 a.m. to 3:30 p.m.). The flow sheet and resident's clinical record had no documented evidence indicating non-pharmacological interventions (any sort of intervention not directly involving a medication) were provided prior to administration of pain medication or that it was not effective requiring the administration of controlled medications. A review of the plan of care, dated 7/14/21, titled Pain indicated Resident 1 had increased risk for recurrence of pain episodes related to Cerebral Infarction. To ensure Resident 1 had no interruption in normal activity due to pain the facility will evaluate the effectiveness of the pain interventions, review the compliance, alleviating symptoms. dosing schedules, resident satisfaction with results, monitor and record pain characteristics at least every shift and as needed, the onset, duration, aggravating factors, and relieving factors. A review of the Nursing Progress Notes, dated from July 2, 2021 to August 30, 2021, indicated no documented evidence Resident 1 requested for or administered pain medication. Resident 1's clinical record had no documented evidence to indicate the resident's pain was evaluate the effectiveness of the pain interventions that indicated the alleviating symptoms. dosing schedules, resident satisfaction with results or the pain was monitored and recorded the pain characteristics at least every shift and as needed, the onset, duration, aggravating factors and relieving factors or which of the non-pharmacological interventions provided helped relieved the pain to avoid the administration of [MEDICATION(S)]. A review of the COMS Vitals and Pain Only Evaluation, dated 8/30/21, indicated Resident 1 stated he has no pain and had not requested for any pain medication that he can remember. During an observation and interview on 9/2/2021 at 4:50 pm, Resident 1 was awake alert oriented to person, place, time and coherent stated he never received pain medication from the date the resident was admitted to the facility which was on 7/2/2021. During an interview on 9/2/2021 at 1:30 pm, DON stated when Resident 1 was interviewed (unidentified date) related to pain the resident denied ever requesting or receiving pain medication from July 2021 to August 2021. During an interview on 9/2/21 at 1:30 pm, the DON stated, when Resident 1 was interviewed related to pain the resident denied ever requesting or receiving pain medication from July 2021 to August 2021. 2. A review of Resident 2's Admission Record indicated the facility admitted the resident on 10/29/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MDS, dated [DATE] indicated Resident 2 was able to express her ideas and wants, understands verbal contents and no memory of cognitive (ability to think and reason) impairment. The MDS indicated when interviewed Resident 2 replied he had no pain or hurting at any time in the last five days. The MDS also indicated the resident received, offered, and declined PRN medications in the last five days. A review of Resident 3's MRR indicated the physician ordered dated 11/8/20, to give Resident 2 [MEDICATION(S)] one tablet 10/325 mgs by mouth every 6 hours as needed for severe pain NTE 3 grams of Tylenol in 24 hours. A review of the MRR indicated the physician ordered on 12/5/20, to give Resident 2 [MEDICATION(S)] tablet 5/325 mgs by mouth every 4 hours as needed for moderate pain NTE 3 grams of Tylenol in 24 hours. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's Pain Assessment Flow Sheet indicated Resident 2 received a total of eleven doses of [MEDICATION(S)] 5/325 mg for the pain level 7/10 and 69 doses of [MEDICATION(S)] 10/325 mg for the pain level 8/10 between 7/1/2021 and 8/31/2021 with the majority given during the day and evening shifts. The flow sheet and resident's clinical record indicated no documented evidence of any non-pharmacological interventions provided prior to administration of pain medication or that it was not effective requiring the administration of controlled medications. A review of the plan of care, dated 10/29/20 revised on 11/28/20, titled At Risk for Comfort/Pain related to fall with fracture. The interventions indicated the nursing staff will find out the location and intensity of pain and reposition for comfort. The plan of care did not indicate to identify what alleviated the resident's pain to a level that is acceptable to the resident while minimizing the negative effects on the resident to the extent possible. A review of Resident 2's Nursing Progress Notes, dated from 7/1/2021 to 8/31/2021, had no documented evidence Resident 2 requested for pain medication. Resident 2's clinical record had no documented evidence to indicate the resident's pain was evaluated the root cause of the pain and if the pain was alleviated by non-pharmacological intervention prior to administration of pain medication. During an interview on 9/2/2021 at 1:30 pm, DON stated Resident 2 denied ever requesting or receiving pain relief medication from July 2021 to August 2021. The DON further stated, as a means managing the resident's pain, the resident diverted her attention by participating in the facility's activity program. During an observation and interview on 9/2/2021 at 2:25 pm, Resident 2 was awake and alert and stated, she refused to take pain relief medications. 3. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's Plan of care dated 5/21/2021, indicated Resident 3 was at risk for altered comfort and pain related to fall with fracture of the ribs. The care plan indicated to relieve pain within one hour of medication intervention, the facility staff would find out the location and intensity (severity) of pain, reposition for comfort and provide pain relief medication. A review of Resident 3's MDS dated [DATE] indicated Resident 3 sometimes was able to express ideas and wants and was severely impaired in making decisions regarding task of daily life. A review Resident 3's of the MRR dated 5/21/2021, indicated the physician ordered for the resident to receive [MEDICATION(S)] 5/325 mg by mouth every six hours as needed for moderate to severe pain. A review of the MRR dated 5/21/2021, indicated the physician ordered to give Resident 3 [MEDICATION(S)] Patch (medication help alleviate severe ongoing pain) 25 microgram/hour one patch transdermal (over the skin) every 72 hours for pain management (remove old patch prior to applying new patch as scheduled). A review of the MRR, dated July 2021 to August 2021, indicated Resident 3 received [MEDICATION(S)] Patch 5% to affected area topically (on top) one time a day for pain management at 9 a.m. and off at 9 p.m. A review of Resident 3's Pain Assessment Flow Sheet for the month of July 2021 to August 2021 indicated Resident 3 received a total of 71 doses of [MEDICATION(S)] 5/325 for back and general body pain at pain level 7-8/10. The flow sheet and resident's clinical record had no documented evidence of any non-pharmacological interventions provided prior to administration of pain medication or that it was not effective requiring the administration of controlled medications. A review of Resident 3's Nursing Progress Notes and weekly assessment review had no documented evidence Resident 3's pain was evaluated to indicate nonpharmacological interventions provided which required the repeated administration on [MEDICATION(S)]. During an interview on 9/3/2021 at 6:54 pm, Licensed Vocational Nurse 2 (LVN 2) stated Residents 3 did not complain of pain and did not ask for pain relief medication. During an interview on 9/7/2021 at 10:20 am, the DON stated Resident 3 was confused, but sometimes was able to answer questions appropriately. The DON stated there was no documentation that her pain was not controlled by [MEDICATION(S)] as additional pain medication, it was not identified as a problem. 4.A review of Resident 4's Admission Record indicated the facility admitted the resident on 7/7/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS dated [DATE], indicated Resident 4 was able to express ideas and wants both in verbal and nonverbal expression. The MDS indicated Resident 4 did not exhibit behavior of rejection of care or evaluation. A review of the Progress Notes dated July 2021 to August 2021, indicated Resident 4 complained of generalized body pain three times on separate occasions in which pain medication were given to the resident. A review of Pain Assessment Flow Sheet for the month of July 2021 to August 2021 indicated Resident 4 received a total of 64 doses of [MEDICATION(S)] 5/325 for back and general body pain at pain level 7-8/10. The flow sheet and resident's clinical record had no documented evidence of any non-pharmacological interventions provided prior to administration of pain medication or that it was not effective requiring the administration of controlled medications. During an observation and interview on 9/7/2021 at 6:38 pm, Resident 4 stated he had requested for pain medication in the last months but did not like to take pain medication so much because it It knocks me out, I get sleepy all day, maybe I asked for medication a few times. During an interview on 9/8/2021 at 9:30 am, LVN 3 stated she oversaw care for Residents 1, 2, 3 and 4 during the day shift when LVN 1 was off work. LVN 3 stated she had not observed the residents complain of pain and was surprised to see the amount of medications the residents were receiving mostly on the day shift. During an interview with the MDS Nurse on 9/7/2021 at 1:13 pm, MDS Nurse stated during residents' assessments she did not assess further or interview the residents or the staff to clarify if or why the residents were receiving pain medication as recorded in the MRR. The MDS nurse further stated if residents denied having pain in the last five days, a possible drug diversion would be identified and to make sure the resident's pain was accurately assessed. The MDS nurse stated she did not report the discrepancy to the DON. During an interview with the DON on 9/7/2021 at 12:20 pm, the DON stated pain management was not part of the Quality Assurance Program Improvement (QAPI, is a process used to ensure services are meeting quality standards and assuring care reaches a certain level), and no system was in place to monitor staff compliance and to verify if residents were accurately assessed, monitored, and evaluated appropriately for pain. The DON further stated residents' pain was supposed to be documented daily and during the weekly assessment to ensure: a. Residents were observed and interviewed for specific location of pain, what makes the pain worst or what relieves the pain or if the pain was new onset or chronic pain. b. Non pharmacologically interventions were provided and why it did not work (ineffective) c. Frequency of pain medication given and the source of pain. d. The accuracy of the MDS nurse assessment of the resident during the initial, quarterly, annually and during a significant of change to ensure the residents and staffs were interviewed if there was a discrepancy in the interview and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] e. The licensed staff provided the pain medication as prescribed by the physician. During an interview on 9/7/2021 at 12:44 pm, the DON stated if the residents who were receiving pain medication were accurately assessed, monitored, evaluated and were documented daily and weekly then the possible drug diversion could had been identified sooner. During an interview on 9/7/21 at 12:50 p.m., the DON stated the lack of monitoring and surveillance of the staffs administering and receiving of controlled medication from the pharmacy put the residents at risk of not having the pain controlled adequately if the medication was not administered as prescribed and at risk for medication diversion or misuse by the staffs. A review of the facility's policy and procedure, dated April 2021, titled Pain Management indicate to alleviate the resident's pain to a level that is acceptable to the resident while minimizing the negative effects on the resident to the extent possible. The licensed nurse will assess, develop a care plan and interventions including non-pharmacological interventions according to RAI (Resident Assessment Instrument-helps nursing home staff in gather definitive information on a resident's strengths and needs, which are addressed in an individualized care plan) guidelines and evaluate the effectiveness of the pain management. The IDT will review the assessment and reevaluate the effectiveness of pain management for newly admitted residents identified to have pain, annually, for significant change, new onset or worsening of pain, new pain or change in medication.

Based on observation, interview, and record review, the facility failed to provide evidence that all allegations of physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) were thoroughly investigated and failed to prevent further abuse for two of three sampled residents (Residents 1 and 2). On 8/11/2021 at 8:55 am, Resident 1 alleged Certified Nursing Assistant 1 (CNA1) pushed him to lay down on his bed after the resident asked CNA 1 to change his adult brief (protective underwear). Resident 1 alleged CNA 1 ripped his adult brief off, squeezed and pulled the resident's scrotum (part of the external male genitalia [private parts]) with a wipe and CNA 1 hit Resident 1's mouth. On 8/26/2021 at 4:39 pm, the facility's Director of Nursing (DON) stated Resident 3 informed her CNA 1 kicked Resident 2 (DON could not remember the date and time). DON stated she did not investigate and did not report the allegation because Resident 3 was lying, and stated she did not conduct the investigation to determine the alleged allegations made by Resident 3 were false. These deficient practices resulted for Resident 1 and Resident 2 to experience abuse and had the potential to expose other residents to abuse. On 8/26/2021 at 8:05 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Executive Director (ED, acting administrator) and the Director of Nursing (DON). The ED and DON were informed of the facility's failure to have systems in place to ensure Residents 1, 2, and other residents were protected from physical abuse. On 8/29/2021 at 5:07 pm, during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action (POA, interventions to correct the deficient practices). The POA included: a. The facility terminated CNA 1 on 8/26/2021. b. The facility trained all staff regarding abuse prevention and protected the residents by ensuring that all staff were trained on the facility's Abuse Program. c. The staff was re-educated by the Nurse Resource Consultant, Regional Director of Operation, and Social Service Consultant on the facility's abuse policy and procedures, emphasizing on the identification of signs and symptoms of abuse, investigating and reporting allegations of abuse and safeguarding resident's well-being. d. The facility would present a new Administrator and would be on-site daily. The new administrator would be briefed on this POA and would review and monitor for compliance on a daily basis. Cross Reference F600, F607, and F609 Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 7/2/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical (H&P) Examination dated 7/3/2021, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 7/16/2021 indicated Resident 1 was severely cognitively impaired (mental action or process of acquiring knowledge and understanding) skills for daily decision making and was total dependent (needs full staff assistance) with transfers (how the resident moves between surfaces including to and from bed, wheelchair, standing position) and on personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A review of Resident 1's Progress Notes dated 8/10/2021, and timed at 8:38 pm, indicated Resident 1 was alert and oriented and his mood was pleasant, and did not have any issues with his skin. A review of Resident 1's Incident and Accident Report Form dated 8/11/2021 and timed at 8:55 am, indicated Resident 1 alleged CNA 1 pushed him to lay down after the resident asked CNA 1 to change his adult brief and ripped his adult brief off, wiped his private area, squeezed and pulled the private area with a wipe. The form indicated Resident 1 yelled at CNA 1 to stop it with his fist closed saying that hurts. The form indicated Resident 1 sat up and CNA 1 hit the resident's mouth not hard but made contact on his face with a glancing contact, with no signs and symptoms to the face and no pain. A review of the facility's Nursing Assignment and Sign-In Sheet, dated 8/11/2021 for the 7-3 pm shift, indicated CNA 1 was assigned to Resident 1. A review of Resident 1's Progress Notes dated 8/14/2021 and timed at 12:23 pm, indicated Resident 1 remained fearful for speaking up about the alleged incident of abuse (unidentified incident). The notes indicated the resident's scrotum was sore, tender, and had slight bruising (skin discoloration). A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 6/9/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's H&P dated 6/9/2021 indicated Resident 2 had fluctuating capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE] indicated that Resident 2 had moderately cognitively impaired skills for daily decision making and required extensive assistance with one-person physical assist for bed mobility (moving and repositioning in bed) and eating. A review of Resident 3's Admission Record indicated the facility admitted Resident 1 on 7/11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's H&P dated 7/12/2021, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3's MDS, dated [DATE] indicated Resident 3 had cognitively intact skills for daily decision making and required extensive assistance with bed mobility and dressing with one-person physical assist. A review of Resident 3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an attempt telephone interview on 8/25/2021 at 1:09 pm, placed call to CNA 1, no answer and unable to leave voicemail due to voicemail not set up. During an observation and interview on 8/25/2021 at 1:10 pm, inside Resident 1's room, Resident 1 was sitting on his bed and the resident was alert and oriented. Resident 1 stated that on 8/11/21 at around 8 am, he asked CNA 1 to help him change his soiled adult brief (a disposable garment worn instead of underwear to help alleviate leaks from urinary or fecal incontinence). Resident 1 stated CNA 1 told him to lay down in bed and pushed him in bed. Resident 1 stated he told CNA 1 not to push him in bed and stated CNA 1 grabbed his balls, hard and squeezed them. Resident 1 stated CNA 1 then cleaned his private area with a washcloth and pressed down on his private area hard, and stated he was hurt. Resident 1 stated he was trying to grab the side rails (are adjustable metal or rigid plastic bars that attach to the bed) and when he pushed him down, he hurt his head on the left side rail. Resident 1 stated he kept asking CNA 1 to stop and asking why he was doing this to him, but CNA 1 did not stop and then punched him on his mandible (jaw). Resident 1 stated his roommate, Resident 3, came in the room right after CNA 1 was finished and he told him the incident. Resident 1 stated Resident 3 told him he would tell everyone, so the facility made sure CNA 1 did not do this to any other residents. Resident 1 stated he was afraid CNA 1 might do this to him again, especially after he reported the incident and said: I should have kept my mouth shut; I should not have said anything. Resident 1 stated the facility staff (unidentified) informed him CNA 1 was suspended but he learned that CNA 1 was back and stated he did not want to see CNA 1 and did not want CNA 1 to be assigned to him. During a second attempt to interview CNA 1 on 8/25/2021, at 1:59 pm, placed phone call to CNA 1, however CNA 1 did not answer the phone. During an interview on 8/25/2021 at 2:02 pm, CNA 2 stated Resident 1 was alert and oriented. CNA 2 stated that on 8/12/2021 around 8 am, Resident 1 informed him that on 8/11/2021 (no time specified), Resident 1 asked CNA 1 for an adult brief change, and CNA 1 looked upset and pushed Resident 1 on the bed and ripped his adult brief off and grabbed and squeezed his scrotum hard and Resident 1 tried to get up and defend himself, and CNA 1 hit him around his mouth. CNA 2 stated he did not see injuries on Resident 1's face but during an adult brief change on 8/12/2021, CNA 2 stated he looked at Resident 1's private area and saw some purplish discoloration, like bruising and swelling on Resident 1's scrotum. CNA 2 stated that upon leaving Resident 1's room, he informed Licensed Vocational Nurse (LVN 1). During an interview on 8/25/2021 at 3:15 pm, LVN 1 stated Resident 1 and Resident 3 were both alert and oriented and Resident 1's scrotum was sore, swollen, and had discoloration. LVN 1 stated she was concerned for the residents at the facility because CNA 1 was still working at the facility. During a concurrent record review and interview with LVN 1 on 8/25/2021 at 3:23 pm, LVN 1 stated Resident 1's Progress Notes, dated 8/14/2021, timed at 12:23 pm, indicated Resident 1 was fearful for speaking up about the alleged incident of abuse that occurred, and Resident 1 had no injury to face, scrotum was sore, tender, and had slight bruising. During a telephone interview on 8/26/21 at 10:40 am, Resident 3 stated he was Resident 1's roommate when he resided at the facility. Resident 3 stated that on 8/11/2021 (unidentified time) he was sitting on his wheelchair on the hallway near his room when he heard some noise coming from his room. Resident 3 stated he went inside his room and Resident 1 told him that CNA 1 grabbed his balls, and hit him on the face. Resident 3 stated that he confronted CNA 1 who was leaving the room and asked why he did that to Resident 1. Resident 3 stated CNA 1 answered because Resident 1[OBSCENITY] all over the place. Resident 3 stated Resident 1 was scared. Resident 3 stated he started to yell for staff to come inside his room because he wanted to make sure the incident was investigated this time. Resident 3 stated he witnessed CNA 1 kicked Resident 2 on her buttocks when he was assigned to Resident 2, the first week of August (unidentified date and time). Resident 3 stated he informed the DON about the incident. During a telephone interview on 8/26/2021 at 12:29 pm, with Resident 1's family representative (FR) stated the facility informed her there had been an incident with CNA 1 and Resident 1. FR stated the facility informed her CNA 1 wanted to change Resident 1's adult brief and Resident 1 got aggressive, and CNA 1 pushed him down and CNA 1 punched Resident 1 in the face. FR stated she told the facility Resident 1 could get ornery (bad temper), but CNA 1 should not have punched his face. FR stated the facility did not inform her that CNA 1 grabbed and squeezed Resident 1's scrotum and pressed down with a washcloth while cleaning his private area and it was Resident 1 who informed her. FR stated Resident 1 would not lie about the incident that happened with CNA 1. During an interview with Minimum Data Nurse 1 (MDS 1) stated that she performed the MDS assessment for Resident 1, eight days from his admission. MDS 1 stated at the time of her assessment, Resident 1 was lethargic (sleepy or fatigued and sluggish), but the resident was alert, oriented and more attentive. During an interview on 8/26/2021 at 4:39 pm, DON stated that when Resident 3 informed her of the abuse allegation against Resident 2 from CNA 1, she did not investigate and did not report the allegation because Resident 3 was lying. The DON stated she could not remember the date the incident was reported to her and stated that reporting the incident to Department of Public Health (DPH), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), or the Police was not justifiable because Resident 3 was making up a story because he was lying. The DON stated she was not sure if the facility had developed a care plan indicating that Resident 3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that per Facility's policy, all abuse allegations needed to be investigated and reported. During a telephone interview on 8/26/2021 at 5:15 pm, with the Social Services Director (SSD), the SSD stated Resident 3 told her that CNA 1 kicked the bottom of Resident 2's wheelchair. SSD was not sure the exact date when Resident 3 reported this to her. SSD stated Resident 2 denied the allegation. SSD stated the facility could have asked other people but since Resident 2 denied the incident, they did not report the incident. SSD stated that she did not have any notes about this incident. During an interview on 8/26/2021 at 7:40 pm, with the facility's Executive Director (ED), ED stated that he was the facility's abuse coordinator, and that all abuse allegations had to be reported and investigated. ED stated DON informed him about the abuse allegation involving Resident 2 and CNA 1, ED stated that Resident 2 denied the allegation. A record review on 8/26/2021 at 7:45 pm, with ED of the Facility's Abuse- Reporting & Investigations- Abuse Manual, revised February 2020, indicated the facility would report allegations of abuse and any reasonable suspicion of a crime against any individual who was a resident, or was receiving care from the facility as required by law and regulations to the appropriate agencies. The policy indicated the administrator or designee would notify Law Enforcement, Ombudsman, and DPH Licensing and Certification immediately by telephone and in writing as soon as possible, but no later than two hours after the allegation was made. During an interview on 8/27/2021 at 11:18 am, the facility's Administrator stated he did not interview Resident 1 regarding the incident that happened with Resident 1 and CNA 1 on 8/11/2021. The ADM stated that he would interview the resident on 8/27/2021 (16 days after the incident). During an interview on 8/27/21 at 12:56 pm, the SSD stated that on 8/11/2021 during the stand-up meeting (a team meeting organized on a daily basis to present a status update to all a development team's members), the facility's Case Manager (CM) informed the team there was an abuse allegation involving Resident 1 and CNA 1. During an interview on 8/27/2021 at 1:11 pm, CM stated that on 8/11/2021 before 9 am, she was doing her morning rounds, stated Resident told her I want you to be my witness, Resident 3 told me to go talk to Resident 1 that he would tell me everything. CM stated Resident 1 told her that CNA 1 grabbed and squeezed his scrotum and grabbed his groin area and CNA 1 punched him on the face like making a fist with his hand, then CNA 1 had cleaned his groin area with a washcloth pressing hard. CM stated she thought Resident 1 was being animated, like he was exaggerating because she knew Resident 1 and had never seen him act like that before. CM stated she did not know what to do with that information because she felt a big responsibility and the DON was not in the building, so she reported to ED. CM stated she was informed the SSD would take care of the investigation. CM stated the facility did not take her written statement of the incident. CM stated she did not know the different types of abuse or the time frames for reporting abuse and stated that the abuse coordinator was the DON. During a telephone interview on 8/27/2021 at 1:44 pm, Resident 2 stated she did not remember the incident with CNA 1. A review of the facility's Abuse-Reporting and Investigations with a revised date of February 2020, indicated to protect the health, safety, and welfare of the residents by ensuring reports of resident abuse were promptly reported and thoroughly investigated. The policy indicated when the Administrator or designee received a report of an incident or suspected incident of a crime, resident abuse, the Administrator or designee would initiate an investigation immediately and would provide a safe environment for the residents.

Based on observation, interview, and record review, the facility failed to implement a policy on physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for two of three sampled residents (Resident 1 and Resident 2) by failing to: 1. Protect Resident 1 from physical abuse on 8/11/2021 at 8:55 am by Certified Nursing Assistant 1 (CNA 1). 2. Prevent CNA 1 from continually harming Resident 1 and other residents CNA 1 cared for. 3. Report to the California Department of Public Health (CDPH) Licensing and Recertification, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and investigate Resident 3's allegations that he witnessed CNA 1 kick Resident 2 (unknown date and time). On 8/11/2021 at 8:55 am, Resident 1 alleged CNA 1 pushed him to lay down on his bed after the resident asked CNA 1 to change his adult brief (protective underwear). Resident 1 alleged CNA 1 ripped his adult brief off, squeezed, and pulled the resident's scrotum (part of the external male genitalia [private parts]) with a wipe and CNA 1 hit Resident 1's mouth. As a result, Resident 1 was left feeling afraid since CNA 1 continued caring for him. On 8/26/2021 at 4:39 pm, the facility's Director of Nursing (DON) stated Resident 3 informed her CNA 1 kicked Resident 2 (DON could not remember the date and time). DON stated she did not investigate and did not report the allegation because Resident 3 was lying. She did not conduct the investigation to determine the alleged allegations made by Resident 3 were false in accordance with the facility's policy and procedure. These deficient practices placed Residents 1, 2, and other residents at risk for further abuse. On 8/26/2021 at 8:05 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Executive Director (ED, acting administrator) and the Director of Nursing (DON). The ED and DON were informed of the facility's failure to have systems in place to ensure Residents 1 and 2 were protected from physical abuse. On 8/29/2021 at 5:07 pm, during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action (POA, interventions to correct the deficient practices). The POA included: a. The facility terminated CNA 1 on 8/26/2021. b. The facility trained all staff regarding abuse prevention and protected the residents by ensuring that all staff were trained on the facility's Abuse Program. c. The staff was re-educated by the Nurse Resource Consultant, Regional Director of Operation, and Social Service Consultant on the facility's abuse policy and procedures, emphasizing on the identification of signs and symptoms of abuse, investigating and reporting allegations of abuse and safeguarding resident's well-being. d. The facility would present a new Administrator and would be on-site daily. The new administrator would be briefed on this POA and would review and monitor for compliance daily. Cross Reference F600, F609, and F610 Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 7/2/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical (H&P) Examination dated 7/3/2021, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 7/16/2021 indicated Resident 1 was severely cognitively impaired (mental action or process of acquiring knowledge and understanding) skills for daily decision making and was total dependent (needs full staff assistance) with transfers (how the resident moves between surfaces including to and from bed, wheelchair, standing position) and on personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A review of Resident 1's Progress Notes dated 8/10/2021, and timed at 8:38 pm, indicated Resident 1 was alert and oriented and his mood was pleasant, and did not have any issues with his skin. A review of Resident 1's Progress Notes dated 8/14/2021 and timed at 12:23 pm, indicated Resident 1 remained fearful for speaking up about the alleged incident of abuse (unidentified incident). The notes indicated the resident's scrotum was sore, tender, and had slight bruising (skin discoloration). A review of Resident 1's Incident and Accident Report Form dated 8/11/2021 and timed at 8:55 am, indicated Resident 1 alleged CNA 1 pushed him to lay down after the resident asked CNA 1 to change his adult brief and ripped his adult brief off, wiped his private area, squeezed and pulled the private area with a wipe. The form indicated Resident 1 yelled at CNA 1 to stop it with his fist closed saying that hurts. The form indicated Resident 1 sat up and CNA 1 hit the resident's mouth, not hard but made contact on his face with a glancing contact, with no signs and symptoms to the face and no pain. A review of the facility's Nursing Assignment and Sign-In Sheet, dated 8/11/2021 for the 7-3 pm shift, indicated CNA 1 was assigned to Resident 1. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 6/9/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's H&P dated 6/9/2021 indicated Resident 2 had fluctuating capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE] indicated Resident 2 was assessed having moderately cognitively impaired skills for daily decision making and required extensive assistance with one-person physical assist for bed mobility (moving and repositioning in bed) and eating. A review of Resident 3's Admission Record indicated the facility admitted Resident 1 on 7/11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's H&P dated 7/12/2021, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3's MDS, dated [DATE] indicated Resident 3 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an attempt to interview CNA 1 by telephone placed on 8/25/2021 at 1:09 pm, there was no answer and surveyor was unable to leave a voicemail due to voicemail not set up. During an observation and interview on 8/25/2021 at 1:10 pm, inside Resident 1's room, Resident 1 was sitting on his bed. Resident 1 was alert and oriented. Resident 1 stated that on 8/11/21 at around 8 am, he asked CNA 1 to help him change his soiled adult brief (a disposable garment worn instead of underwear to help alleviate leaks from urinary or fecal incontinence). Resident 1 stated CNA 1 told him to lay down in bed and pushed him in bed. Resident 1 stated he told CNA 1 not to push him in bed and stated CNA 1 grabbed his, balls hard and squeezed them. Resident 1 stated CNA 1 then cleaned his private area with a washcloth and pressed down on his private area hard, and stated he was physically hurt. Resident 1 stated he was trying to grab the side rails (are adjustable metal or rigid plastic bars that attach to the bed) and when he pushed him down, he hurt his head on the left side rail. Resident 1 stated he kept asking CNA 1 to stop and asking why he was doing this to him, but CNA 1 did not stop and then punched him on his mandible (jaw). Resident 1 stated his roommate, Resident 3, came in the room right after CNA 1 was finished and he told Resident 3 about the incident. Resident 1 stated Resident 3 told him he would tell everyone, so the facility made sure CNA 1 did not do this to any other residents. Resident 1 stated he was afraid CNA 1 might do this to him again, especially after he reported the incident and said, I should have kept my mouth shut; I should not have said anything. Resident 1 stated the facility staff (unidentified) informed him CNA 1 was suspended but he learned that CNA 1 was back and stated he did not want to see CNA 1 and did not want CNA 1 to be assigned to him. During a second attempt to interview CNA 1 by telephone on 8/25/2021, at 1:59 pm, CNA 1 did not answer the phone. During an interview on 8/25/2021 at 2:02 pm, CNA 2 stated Resident 1 was alert and oriented. CNA 2 stated that on 8/12/2021 around 8 am, Resident 1 informed him that on 8/11/2021 (no time specified), Resident 1 asked CNA 1 for an adult brief change, and CNA 1 looked upset and pushed Resident 1 on the bed, ripped his adult brief off, and grabbed and squeezed his scrotum hard. Resident 1 told CNA 2 he tried to get up and defend himself, but CNA 1 hit him around his mouth. CNA 2 stated he did not see injuries on Resident 1's face, but during an adult brief change on 8/12/2021, CNA 2 stated he looked at Resident 1's private area and saw some purplish discoloration, like bruising and swelling on Resident 1's scrotum. CNA 2 stated that upon leaving Resident 1's room, he informed Licensed Vocational Nurse (LVN 1) about the alleged incident the same day. During an interview on 8/25/2021 at 3:15 pm, LVN 1 stated Resident 1 and Resident 3 were both alert and oriented. LVN 1 further stated upon assessment, Resident 1's scrotum was sore, swollen, and had discoloration. LVN 1 stated she was concerned for the residents at the facility because CNA 1 was still working at the facility. During a concurrent record review and interview with LVN 1 on 8/25/2021 at 3:23 pm, LVN 1 stated Resident 1's Progress Notes, dated 8/14/2021, timed at 12:23 pm, indicated Resident 1 was fearful for speaking up about the alleged incident of abuse that occurred, and Resident 1 had no injury to face, scrotum was sore, tender, and had slight bruising. During a telephone interview on 8/26/21 at 10:40 am, Resident 3 stated he was Resident 1's roommate when he resided at the facility. Resident 3 stated that on 8/11/2021 (unidentified time) he was sitting in his wheelchair down the hallway near his room when he heard some noise coming from his room. Resident 3 stated he went inside his room and Resident 1 told him that CNA 1 grabbed his balls, and hit him in the face. Resident 3 stated that he confronted CNA 1 who was leaving the room and asked why he did that to Resident 1. Resident 3 stated CNA 1 answered because Resident 1[OBSCENITY] all over the place. Resident 3 stated Resident 1 verbalized to him he was scared. Resident 3 stated he started to yell for staff to come inside his room because he wanted to make sure the incident was investigated this time since a prior incident he reported had not been investigated. Resident 3 stated he witnessed CNA 1 kick Resident 2 on her buttocks when he was assigned to Resident 2, the first week of August (unidentified date and time). Resident 3 stated he informed the DON about the incident. During a telephone interview on 8/26/2021 at 12:29 pm, with Resident 1's family representative (FR), she stated the facility informed her there had been an incident with CNA 1 and Resident 1. FR stated the facility informed her CNA 1 wanted to change Resident 1's adult brief and Resident 1 got aggressive, and CNA 1 pushed him down and CNA 1 punched Resident 1 in the face. FR stated she told the facility Resident 1 could get ornery (bad temper), but CNA 1 should not have punched his face. FR stated the facility did not inform her that CNA 1 grabbed and squeezed Resident 1's scrotum and pressed down with a washcloth while cleaning his private area and it was Resident 1 who informed her. FR stated Resident 1 would not lie about the incident that happened with CNA 1. During an interview on 8/26/2021 at 4:39 pm, DON stated when Resident 3 informed her of the abuse allegation that occurred against Resident 2 from CNA 1, she did not investigate and did not report the allegation because Resident 3 was, lying. The DON stated she was unable to recall the date Resident 3 reported the incident to her. She did not report the incident to Department of Public Health (DPH), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), or the Police because Resident 3 was, making up a story and that he was, lying. The DON stated she was not sure if Resident 3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that per facility's policy, all abuse allegations needed to be investigated and reported to the Department, Ombudsman, and police. During a telephone interview on 8/26/2021 at 5:15 pm, with the Social Services Director (SSD), the SSD stated Resident 3 told her CNA 1 kicked the bottom of Resident 2's wheelchair. SSD was not sure the exact date when Resident 3 reported this to her. SSD stated Resident 2 denied the allegation. SSD stated the facility could have asked other people but since Resident 2 denied the incident, they did not report the incident to the Department, Ombudsman, and to the police. SSD stated she was unable to provide any documented evidence indicating the alleged incident was reported to her and confirmed she did not document the alleged incident. During an interview on 8/26/2021 at 7:40 pm, with the facility's Executive Director (ED), ED stated that he was the facility's abuse coordinator, and that all abuse allegations had to be reported and investigated. ED stated DON informed him about the abuse allegation involving Resident 2 and CNA 1, and ED stated Resident 2 denied the allegation. The ED stated since Resident 2 denied the incident, the facility did not feel further investigation was necessary and the facility concluded Resident 3 had made false statements about the alleged incident. A record review on 8/26/2021 at 7:45 pm, with ED of the Facility's Abuse- Reporting & Investigations- Abuse Manual, revised February 2020, indicated the facility would report allegations of abuse and any reasonable suspicion of a crime against any individual who was a resident, or was receiving care from the facility as required by law and regulations to the appropriate agencies. The policy indicated the administrator or designee would notify Law Enforcement, Ombudsman, and DPH Licensing and Certification immediately by telephone and in writing as soon as possible, but no later than two hours after the allegation was made. During an interview on 8/27/2021 at 11:18 am, the facility's Administrator stated he did not interview Resident 1 regarding the incident that happened with Resident 1 and CNA 1 on 8/11/2021. The ADM stated that he would interview the resident on 8/27/2021 (16 days after the incident). During an interview on 8/27/21 at 12:56 pm, the SSD stated that on 8/11/2021 during the stand-up meeting (a team meeting organized on a daily basis to present a status update to all a development team's members), the facility's Case Manager (CM) informed the team there was an abuse allegation involving Resident 1 and CNA 1. During an interview on 8/27/2021 at 1:11 pm, CM stated that on 8/11/2021 before 9 am, she was doing her morning rounds, stated Resident 3 told her I want you to be my witness, Resident 3 asked me to talk to Resident 1 and that he would tell me everything. CM stated Resident 1 told her that CNA 1 grabbed and squeezed his scrotum and grabbed his groin area and CNA 1 punched him on the face like making a fist with his hand, then CNA 1 had cleaned his groin area with a washcloth pressing hard. CM stated she thought Resident 1 was being animated, like he was exaggerating because she knew Resident 1 and had never seen him act like that before. CM stated she did not know what to do with that information because she felt a big responsibility and the DON was not in the building, so she reported to ED. CM stated she was informed the SSD would take care of the investigation. CM stated the facility did not take her written statement of the incident. CM stated she did not know the different types of abuse or the time frames for reporting abuse and stated that the abuse coordinator was the DON. During a telephone interview on 8/27/2021 at 1:44 pm, Resident 2 stated she did not remember the alleged incident with CNA 1. A review of the facility's Abuse-Reporting and Investigations with a revised date of February 2020, indicated to protect the health, safety, and welfare of the residents by ensuring reports of resident abuse were promptly reported and thoroughly investigated. The policy indicated when the Administrator or designee received a report of an incident or suspected incident of a crime, resident abuse, the Administrator or designee would initiate an investigation immediately and would provide a safe environment for the residents. The policy indicated the Administrator or designee would provide a written report of the results of abuse allegations and appropriate action taken to CDPH within five days of the reported allegation.

Based on interview, and record review, the facility failed to report a physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) allegation and failed to provide the investigation report for one of three sampled residents (Resident 2) by failing to: 1. Report Resident 3's allegations that he witnessed CNA 1 kick Resident 2 (unknown date and time) to the California Department of Public Health (CDPH) Licensing and Recertification, LTC Ombudsman (an official appointed to investigate individuals' complaints against maladministration). 2.Investigate and report the results of the investigation of the alleged allegation made by Resident 3 witnessing CNA 1 kicked Resident 2 to CDPH within five (5) working days of the alleged incident. On 8/26/2021 at 4:39 pm, the facility's Director of Nursing (DON) stated Resident 3 informed her CNA 1 kicked Resident 2 (DON could not remember the date and time). DON stated she did not investigate and did not report the allegation because Resident 3 was lying. The DON did not investigate the allegation made by Resident 3 at this time to determine if Resident 3 had made false allegations. These deficient practices resulted in the facility to not report an alleged abuse made by Resident 3, placing Resident 2 and other residents residing in the facility at risk of abuse while CNA 1 was assigned to care for residents in the facility. On 8/26/2021 at 8:05 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Executive Director (ED, acting administrator) and the Director of Nursing (DON). The ED and DON were informed of the facility's failure to have systems in place to ensure the residents were free from abuse. On 8/29/2021 at 5:07 pm, during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action (POA, interventions to correct the deficient practices). The POA included: a. The facility terminated CNA 1 on 8/26/2021. b. The facility trained all staff regarding abuse prevention and protected the residents by ensuring that all staff were trained on the facility's Abuse Program. c. The staff was re-educated by the Nurse Resource Consultant, Regional Director of Operation, and Social Service Consultant on the facility's abuse policy and procedures, emphasizing on the identification of signs and symptoms of abuse, investigating and reporting allegations of abuse and safeguarding resident's well-being. d. The facility would present a new Administrator and would be on-site daily. The new administrator would be briefed on this POA and would review and monitor for compliance on a daily basis. Cross Reference F600, F607, and F610 Findings: A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 6/9/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's H&P dated 6/9/2021 indicated Resident 2 had fluctuating capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE] indicated that Resident 2 had moderately cognitively impaired skills for daily decision making and required extensive assistance with one-person physical assist for bed mobility (moving and repositioning in bed) and eating. A review of Resident 3's Admission Record indicated the facility admitted Resident 1 on 7/11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's H&P dated 7/12/2021, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3's MDS, dated [DATE] indicated Resident 3 had cognitively intact skills for daily decision making and required extensive assistance with bed mobility and dressing with one-person physical assist. A review of Resident 3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an attempt to interview CNA 1 by telephone placed on 8/25/2021 at 1:09 pm, there was no answer and surveyor was unable to leave a voicemail due to voicemail not set up. During an interview on 8/25/2021 at 3:15 pm, LVN 1 stated Resident 3 was alert and oriented. LVN 1 stated she was concerned for the residents at the facility because CNA 1 was still working at the facility. During a telephone interview on 8/26/21 at 10:40 am, Resident 3 stated he witnessed CNA 1 kick Resident 2 on her buttocks the first week of August 2021 (unidentified date and time). Resident 3 stated he informed the DON about the incident. During an interview on 8/26/2021 at 4:39 pm, DON stated when Resident 3 informed her of the abuse allegation against Resident 2 from CNA 1, she did not investigate and did not report the allegation because Resident 3 was lying. The DON stated she did not investigate the allegation made by Resident 3 at this time to determine if Resident 3 had made false allegations. The DON stated she was unable to recall the date Resident 3 reported the incident to her. She did not report the incident to Department of Public Health (DPH), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), or the Police because Resident 3 was, making up a story and that he was, lying. The DON stated she was not sure if Resident 3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that per facility's policy, all abuse allegations needed to be investigated and reported to the Department, Ombudsman, and police. During a telephone interview on 8/26/2021 at 5:15 pm, with the Social Services Director (SSD), the SSD stated Resident 3 told her that CNA 1 kicked the bottom of Resident 2's wheelchair. SSD was not sure the exact date when Resident 3 reported this to her. SSD stated Resident 2 denied the allegation. SSD stated the facility could have asked other people but since Resident 2 denied the incident, they did not report the incident to the Department, Ombudsman, and police. SSD stated she was unable to provide any documented evidence indicating the alleged incident was reported to her and confirmed she did not document the alleged incident. During an interview on 8/26/2021 at 7:40 pm, with the facility's Executive Director (ED), ED stated that he was the facility's abuse coordinator, and that all abuse allegations had to be reported and investigated. ED stated DON informed him about the abuse allegation involving Resident 2 and CNA 1, and ED stated Resident 2 denied the allegation. The ED stated since Resident 2 denied the incident, the facility did not feel further investigation was necessary and the facility concluded Resident 3 had made false statements about the alleged incident. A record review on 8/26/2021 at 7:45 pm, with ED of the Facility's Abuse- Reporting & Investigations- Abuse Manual, revised February 2020, indicated the facility would report allegations of abuse and any reasonable suspicion of a crime against any individual who was a resident, or was receiving care from the facility as required by law and regulations to the appropriate agencies. The policy indicated the administrator or designee would notify Law Enforcement, Ombudsman, and DPH Licensing and Certification immediately by telephone and in writing as soon as possible, but no later than two hours after the allegation was made. During an interview on 8/27/2021 at 11:18 am, the facility's Administrator stated he did not interview Resident 1 regarding the incident that happened with Resident 1 and CNA 1 on 8/11/2021. The ADM stated that he would interview the resident on 8/27/2021 (16 days after the incident). During a telephone interview on 8/27/2021 at 1:44 pm, Resident 2 stated she did not remember the incident with CNA 1. A review of the facility's Abuse-Reporting and Investigations with a revised date of February 2020, indicated to protect the health, safety, and welfare of the residents by ensuring reports of resident abuse were promptly reported and thoroughly investigated. The policy indicated when the Administrator or designee received a report of an incident or suspected incident of a crime, resident abuse, the Administrator or designee would initiate an investigation immediately and would provide a safe environment for the residents. The policy indicated the Administrator or designee would provide a written report of the results of abuse allegations and appropriate action taken to CDPH within five days of the reported allegation.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by failing to: 1. Protect Resident 1 from physical abuse when Certified Nursing Assistant 1 (CNA 1) squeezed and pulled on Resident 1's scrotum (part of the external male genitalia [private parts]) and hit Resident 1's face near his mouth. 2. Protect Resident 2 from physical abuse when CNA 1 allegedly kicked Resident 2 on her buttocks. These deficient practices resulted in Residents 1 and 2 to experience physical abuse, and for Resident 1 to feel afraid while the residents continued to reside in the facility under the care of CNA 1. On 8/26/2021 at 8:05 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Executive Director (ED, acting administrator) and the Director of Nursing (DON). The ED and DON were informed of the facility's failure to have systems in place to ensure Residents 1 and 2 were protected from physical abuse. On 8/29/2021 at 5:07 pm, during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action (POA, interventions to correct the deficient practices). The POA included: a. The facility terminated CNA 1 on 8/26/2021. b. The facility trained all staff regarding abuse prevention and protected the residents by ensuring that all staff were trained on the facility's Abuse Program. c. The staff was re-educated by the Nurse Resource Consultant, Regional Director of Operation, and Social Service Consultant on the facility's abuse policy and procedures, emphasizing on the identification of signs and symptoms of abuse, investigating and reporting allegations of abuse and safeguarding resident's well-being. d. The facility would present a new Administrator and would be on-site daily. The new administrator would be briefed on this POA and would review and monitor for compliance daily. Cross Reference F607, F609, and F610 Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 7/2/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical (H&P) Examination dated 7/3/2021, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 7/16/2021 indicated Resident 1 was severely cognitively impaired (mental action or process of acquiring knowledge and understanding) skills for daily decision making and was total dependent (needs full staff assistance) with transfers (how the resident moves between surfaces including to and from bed, wheelchair, standing position) and on personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). A review of Resident 1's Progress Notes dated 8/10/2021, and timed at 8:38 pm, indicated Resident 1 was alert and oriented and his mood was pleasant, and did not have any issues with his skin. A review of Resident 1's Incident and Accident Report Form dated 8/11/2021 and timed at 8:55 am, indicated Resident 1 alleged CNA 1 pushed him to lay down after the resident asked CNA 1 to change his adult brief and ripped his adult brief off, wiped his private area, squeezed and pulled the private area with a wipe. The form indicated Resident 1 yelled at CNA 1 to stop it with his fist closed saying that hurts. The form indicated Resident 1 sat up and CNA 1 hit the resident's mouth not hard but made contact on his face with a glancing contact, with no signs and symptoms to the face and no pain. A review of Resident 1's Progress Notes dated 8/14/2021 and timed at 12:23 pm, indicated Resident 1 remained fearful for speaking up about the alleged incident of abuse (unidentified incident). The notes indicated the resident's scrotum was sore, tender, and had slight bruising (skin discoloration). A review of the facility's Nursing Assignment and Sign-In Sheet, dated 8/11/2021 for the 7-3 pm shift, indicated CNA 1 was assigned to Resident 1. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 6/9/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's H&P dated 6/9/2021 indicated Resident 2 had fluctuating capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE] indicated that Resident 2 had moderately cognitively impaired skills for daily decision making and required extensive assistance with one-person physical assist for bed mobility (moving and repositioning in bed) and eating. A review of Resident 3's Admission Record indicated the facility admitted the resident on 7/11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's H&P dated 7/12/2021, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3's MDS, dated [DATE] indicated the resident was cognitively intact skills for daily decision making and required extensive assistance with bed mobility and dressing with one-person physical assist. A review of Resident 3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an attempt telephone interview on 8/25/2021 at 1:09 pm, placed call to CNA 1, no answer and unable to leave voicemail due to voicemail not set up. During an observation and interview on 8/25/2021 at 1:10 pm, inside Resident 1's room, Resident 1 was sitting on his bed and the resident was alert and oriented. Resident 1 stated that on 8/11/21 at around 8 am, he asked CNA 1 to help him change his soiled adult brief (a disposable garment worn instead of underwear to help alleviate leaks from urinary or fecal incontinence). Resident 1 stated CNA 1 told him to lay down in bed and pushed him in bed. Resident 1 stated he told CNA 1 not to push him in bed and stated CNA 1 grabbed his, balls hard and squeezed them. Resident 1 stated CNA 1 then cleaned his private area with a washcloth and pressed down on his private area hard, and stated he was physically hurt. Resident 1 stated he was trying to grab the side rails (are adjustable metal or rigid plastic bars that attach to the bed) and when CNA 1 pushed him down, he hurt his head on the left side rail. Resident 1 stated he kept asking CNA 1 to stop and asking why he was doing this to him, but CNA 1 did not stop and then punched him on his mandible (jaw). Resident 1 stated his roommate, Resident 3, came in the room right after CNA 1 was finished and he told Resident 3 about the incident. Resident 1 stated Resident 3 told him he would tell everyone, so the facility made sure CNA 1 did not do this to any other residents. Resident 1 stated he was afraid CNA 1 might do this to him again, especially after he reported the incident and said, I should have kept my mouth shut; I should not have said anything. Resident 1 stated the facility staff (unidentified) informed him CNA 1 was suspended, but he learned that CNA 1 was back and stated he did not want to see CNA 1 and did not want CNA 1 to be assigned to him. During a second attempt to interview CNA 1 by telephone on 8/25/2021, at 1:59 pm, CNA 1 did not answer the phone. During an interview on 8/25/2021 at 2:02 pm, CNA 2 stated Resident 1 was alert and oriented. CNA 2 stated that on 8/12/2021 around 8 am, Resident 1 informed him that on 8/11/2021 (no time specified), Resident 1 asked CNA 1 for an adult brief change, and CNA 1 looked upset and pushed Resident 1 on the bed, ripped his adult brief off, and grabbed and squeezed his scrotum hard. Resident 1 told CNA 2 he tried to get up and defend himself, but CNA 1 hit him around his mouth. CNA 2 stated he did not see injuries on Resident 1's face, but during an adult brief change on 8/12/2021, CNA 2 stated he looked at Resident 1's private area and saw some purplish discoloration, like bruising and swelling on Resident 1's scrotum. CNA 2 stated that upon leaving Resident 1's room, he informed Licensed Vocational Nurse (LVN 1) about the alleged incident the same day. During an interview on 8/25/2021 at 3:15 pm, LVN 1 stated Resident 1 and Resident 3 were both alert and oriented. LVN 1 further stated upon assessment, Resident 1's scrotum was sore, swollen, and had discoloration. LVN 1 stated she was concerned for the residents at the facility because CNA 1 was still working at the facility. During a concurrent record review and interview with LVN 1 on 8/25/2021 at 3:23 pm, LVN 1 stated Resident 1's Progress Notes, dated 8/14/2021, timed at 12:23 pm, indicated Resident 1 was fearful speaking up about the alleged incident of abuse that occurred, and Resident 1 had no injury to face, scrotum was sore, tender, and had slight bruising. During a telephone interview on 8/26/21 at 10:40 am, Resident 3 stated he was Resident 1's roommate when he resided at the facility. Resident 3 stated that on 8/11/2021 (unidentified time) he was sitting in his wheelchair down the hallway near his room when he heard some noise coming from his room. Resident 3 stated he went inside his room and Resident 1 told him that CNA 1 grabbed his, balls, and hit him in the face. Resident 3 stated he confronted CNA 1 who was leaving the room and asked why he did that to Resident 1. Resident 3 stated CNA 1 responded, because Resident 1,[OBSCENITY] all over the place.Resident 3 stated Resident 1 verbalized to him he was scared. Resident 3 stated he started to yell for staff to come inside his room because he wanted to make sure the incident was investigated this time since a prior incident he reported had not been investigated. Resident 3 stated he witnessed CNA 1 kick Resident 2 on her buttocks when he was assigned to Resident 2, the first week of August (unidentified date and time). Resident 3 stated he informed the DON about the incident. During a telephone interview on 8/26/2021 at 12:29 pm, with Resident 1's family representative (FR), she stated the facility informed her there had been an incident with CNA 1 and Resident 1. FR stated the facility informed her CNA 1 wanted to change Resident 1's adult brief and Resident 1 got aggressive, and CNA 1 pushed him down and CNA 1 punched Resident 1 in the face. FR stated she told the facility Resident 1 could get ornery (bad temper), but CNA 1 should not have punched his face. FR stated the facility did not inform her that CNA 1 grabbed and squeezed Resident 1's scrotum and pressed down with a washcloth while cleaning his private area and it was Resident 1 who informed her. FR stated Resident 1 would not lie about the incident that happened with CNA 1. During an interview on 8/26/2021 at 4:39 pm, DON stated when Resident 3 informed her of the abuse allegation that occurred against Resident 2 from CNA 1, she did not investigate and did not report the allegation because Resident 3 was, lying. The DON stated she did not conduct the investigation to determine the alleged allegations made by Resident 3 were false. The DON stated she was unable to recall the date Resident 3 reported the incident to her. She did not report the incident to Department of Public Health (DPH), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), or the Police because Resident 3 was, making up a story and that he was, lying. The DON stated she was not sure if Resident 3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that per facility's policy, all abuse allegations needed to be investigated and reported to the Department, Ombudsman, and to the police. During a telephone interview on 8/26/2021 at 5:15 pm, with the Social Services Director (SSD), the SSD stated Resident 3 told her CNA 1 kicked the bottom of Resident 2's wheelchair. SSD was not sure the exact date when Resident 3 reported this to her. SSD stated Resident 2 denied the allegation. SSD stated the facility could have asked other people but since Resident 2 denied the incident, they did not report the incident to the Department, Ombudsman, and to the police. SSD stated she was unable to provide any documented evidence indicating the alleged incident was reported to her and confirmed she did not document the alleged incident. During an interview on 8/26/2021 at 7:40 pm, with the facility's Executive Director (ED), ED stated that he was the facility's abuse coordinator, and that all abuse allegations had to be reported and investigated. ED stated DON informed him about the abuse allegation involving Resident 2 and CNA 1, and ED stated Resident 2 denied the allegation. The ED stated since Resident 2 denied the incident, the facility did not feel further investigation was necessary and the facility concluded Resident 3 had made false statements about the alleged incident A record review on 8/26/2021 at 7:45 pm, with ED of the Facility's Abuse- Reporting & Investigations- Abuse Manual, revised February 2020, indicated the facility would report allegations of abuse and any reasonable suspicion of a crime against any individual who was a resident, or was receiving care from the facility as required by law and regulations to the appropriate agencies. The policy indicated the administrator or designee would notify Law Enforcement, Ombudsman, and DPH Licensing and Certification immediately by telephone and in writing as soon as possible, but no later than two hours after the allegation was made. During an interview on 8/27/2021 at 11:18 am, the facility's Administrator stated he did not interview Resident 1 regarding the incident that happened with Resident 1 and CNA 1 on 8/11/2021. The ADM stated he would interview the resident on 8/27/2021 (16 days after the incident). During an interview on 8/27/21 at 12:56 pm, the SSD stated that on 8/11/2021 during the stand-up meeting (a team meeting organized on a daily basis to present a status update to all a development team's members), the facility's Case Manager (CM) informed the team there was an abuse allegation involving Resident 1 and CNA 1. During an interview on 8/27/2021 at 1:11 pm, CM stated that on 8/11/2021 before 9 am, she was doing her morning rounds, stated Resident 3 told her I want you to be my witness, Resident 3 asked me to talk to Resident 1 and that he would tell me everything. CM stated Resident 1 told her that CNA 1 grabbed and squeezed his scrotum and grabbed his groin area and CNA 1 punched him on the face like making a fist with his hand, then CNA 1 had cleaned his groin area with a washcloth pressing hard. CM stated she thought Resident 1 was being animated, like he was exaggerating because she knew Resident 1 and had never seen him act like that before. CM stated she did not know what to do with that information because she felt a big responsibility and the DON was not in the building, so she reported to ED. CM stated she was informed the SSD would take care of the investigation. CM stated the facility did not take her written statement of the incident. CM stated she did not know the different types of abuse or the time frames for reporting abuse and stated that the abuse coordinator was the DON. During a telephone interview on 8/27/2021 at 1:44 pm, Resident 2 stated she did not remember the alleged incident with CNA 1. A review of the facility's Abuse-Reporting and Investigations with a revised date of February 2020, indicated to protect the health, safety, and welfare of the residents by ensuring reports of resident abuse were promptly reported and thoroughly investigated. The policy indicated when the Administrator or designee received a report of an incident or suspected incident of a crime, resident abuse, the Administrator or designee would initiate an investigation immediately and would provide a safe environment for the residents.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to prevent pressure ulcer development (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or/friction) and worsening of existing pressure ulcer for one of two residents (Residents 100) with pressure ulcers in a total of 18 sampled residents by failing to: - Ensure the resident did not lie on her back directly on the pressure ulcer. - Implement the plan of care to turn and reposition the resident in bed every two hours. - Revise the plan of care to avoid positioning the resident on the pressure ulcer. - Accurately assess the Stage and location of the resident's pressure ulcer. - Apply proper settings to the resident's pressure reducing device low air loss mattress (a mattress that provides a flow of air to assist in managing the heat and humidity of the skin). - Avoid the use of plastic backed diaper that will block the airflow and may potentially trap heat and moisture against the resident's skin. - Provide staff in service training for the proper positioning of the resident with pressure ulcer to promote healing and prevent further skin breakdown. - Follow the staff in service training to prevent skin breakdown by positioning the resident with pressure ulcer every two hours when in bed. - Monitor staff implementation of the in-service training in preventing pressure ulcer development. These failures resulted in Resident 100 developing an avoidable Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough (yellow, tan, green or brown) or eschar (tan, brown or black) may be present on some parts of the wound bed which often includes undermining or tunneling) to her sacrococcyx (sacral (a triangular shaped bone at the bottom of the spine) coccyx (tailbone). Findings: A review of the Nurses' Admission Record dated [DATE], indicated Resident 100 was admitted to the facility without a pressure ulcer. Resident 100's [DIAGNOSES REDACTED]. The monthly Weight Record dated [DATE], indicated Resident 100 weighed 68.4 pounds (lbs.) A review of the Braden Scale Assessment (a nursing tool which uses a scoring system to evaluate resident's risk of developing a pressure ulcer) dated [DATE], indicated Resident 100's score was 11 and on [DATE], the score was 10 (a total of 12 or less represents high risk for developing pressure ulcer). The facility discontinued the use of Braden Scale Assessment after [DATE], and it was replaced by the weekly summary skin assessment to be completed by the licensed staff. The weekly skin assessment dated [DATE] through [DATE], indicated Resident 100 was at risk for pressure ulcer development. A review of the Minimum Data Set (MDS-a standardized assessment and care planning tool) dated [DATE], indicated Resident 100 was assessed with [REDACTED]. During multiple observations on [DATE] at 7:15 a.m., 8:10 a.m., 9:30 a.m., 10:37 a.m., 2:40 p.m.;[DATE] at 7:32 a.m., 8:40 a.m., 9:30 a.m., Resident 100 was observed lying on her back on a low air loss mattress . The pressure setting of the low air loss mattress was observed set at number 6 which indicated the resident's weight was at 245 lbs. During the treatment observation on [DATE] at 2:40 p.m., Resident 100 was observed awake, non-communicative and lying on her back. Resident 100 was wearing a plastic backed diaper and chux pad (used to protect bed from urine damage) under it. Resident 100 was observed with Stage IV pressure ulcer to her sacrococcyx. The Treatment Nurse (TN 1) measured the pressure ulcer. The pressure ulcer measured 2.2 centimeter (cm) in length (L) by 3 cm in width (W) (2.5 cm=1 inch). The depth was 0.8 cm with undermining (destruction of tissue extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface) of 2.8 cm at 3 o'clock and 1.1 cm at 4 o'clock. The wound bed (base of the wound) had small amount of yellow green colored slough (dead tissue). TN 1 cleansed the sacrococcyx pressure ulcer with Normal Saline (sterile mixture of salt and water), applied [MEDICATION NAME] ointment (antibiotic), applied Alginate dressing (absorbent wound dressing) and was covered with waterproof Alginate foam dressing. The low air loss mattress pressure setting was observed set at number 6 indicating that Resident 100 weighed 245 lbs. TN 1 was asked what it means when the pressure setting was set at number 6 and who set it? TN 1 replied, I don't know. The pressure setting knob indicated 68 lbs. should be set at number 1. On [DATE] at 2:38 p.m., Certified Nursing Assistant (CNA 1) stated she had an in-service training on [DATE], regarding turning and repositioning the resident with pressure ulcer every two hours. CNA 1 stated Resident 100 was to be turned and repositioned only to right and left side because of her pressure ulcer to sacrococcyx. CNA 1 stated the pressure ulcer will get worse when the resident was lying on her back due to pressure. CNA 1 stated she did not change Resident 100's position (back lying) for several hours after feeding breakfast on [DATE], because she was busy taking care of other residents. CNA 1 did not respond when asked why she documented on the Turning and Repositioning Log that Resident 100 was repositioned to her right and left side on [DATE], when not. CNA 1 stated, I forgot she was not supposed to wear a diaper. CNA 1 stated the pressure ulcer will not heal due to moisture from being incontinent of bowel and bladder. On [DATE] at 3:05 p.m., CNA 2 stated she was newly hired and did not receive an in-service regarding turning and repositioning the resident with pressure ulcer. She was informed by Licensed Vocational Nurse (LVN 1) to turn and reposition Resident 100 only to right and left side every two hours to avoid pressure on the sacrococcyx pressure ulcer. CNA 2 stated, I forgot to turn her to left side after breakfast. Even though Resident 100 remained on the same position (lying on her back), CNA 2 documented on Turning and Repositioning Log. On [DATE], that she repositioned the resident to the right and left side lying position. CNA 2 stated the pressure ulcer will not heal when the diaper was soaked with urine. CNA 2' stated, I put diaper on the resident. I thought I will get her up after giving a bed bath. During record review and concurrent interview with Treatment Nurse (TN 1) on [DATE] at 3:55 p.m., she stated she is also the Staff Developer of the facility. She started helping the Charge Nurses in doing the treatment on [DATE], because the facility is small (59 beds capacity). TN 1 stated that on [DATE], the licensed staff and CNAs had an in-service training regarding turning and repositioning the resident with pressure ulcer. The in-service course content dated [DATE], indicated the following: 1. Residents will be turned every two hours while in bed. 2. For residents on special beds it is important that the setting be left at the appropriate setting for the resident. The only person who should touch the setting from the facility is a licensed nurse. The in-service course content dated [DATE], did not indicate the staff were taught to avoid turning and repositioning the resident directly on the pressure ulcer to promote healing and prevent further skin breakdown. TN 1 stated no in-service training was given to licensed staff and CNAs not to apply plastic backed incontinence pads when the resident is on pressure relieving bed such as low air loss mattress. Also, the licensed staff did not receive an in-service training regarding proper settings of the low air loss mattress. The low air loss mattress of Resident 100 was delivered on [DATE]. The pressure setting of the low air loss mattress was set by the bed company (Comfort Care) upon delivery to the facility on [DATE]. The bed company was supposed to provide an in-service about the pressure setting of the low air loss mattress in Dec. (YEAR), but it was not done. TN 1 stated the Charge Nurse was responsible in monitoring the turning and repositioning of a resident with pressure ulcer every two hours in bed. The facility had a total of 31 CNAs and 10 Licensed Vocational Nurses'(LVN). However, TN 1 stated all CNAs and LVNs did not receive the in-service training on [DATE], because she did not follow up on those staffs who were absent. On [DATE] at 4:45 p.m., an interview with the director of Nursing (DON) was conducted while reviewing with her the medical record of Resident 100. The Weekly Wound Assessment indicated Resident 100 developed Stage II pressure ulcer (ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) to her coccyx on [DATE]. The pressure ulcer measured 1.6 cm (L) by 2.4 cm (W). The resident's Stage 11 pressure ulcer to her coccyx had progressed to Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed) on [DATE] (one week later). The pressure ulcer measured 3 cm (L) by 3.5 cm (W), 1 cm depth with undermining 5 cm at 10 o'clock, 4.2 cm at 3 o'clock and moderate amount of exudate (fluid discharge through a wound). On [DATE], the pressure ulcer to her coccyx had progressed to Stage IV coccyx pressure ulcer. The pressure ulcer measured 2.5 cm (L) by 3.4 cm (W), 1.5 cm depth with 3 cm undermining from 11 o'clock through 4 o'clock with small amount of exudate. On [DATE], the Stage IV pressure ulcer to coccyx had progressed to Stage IV sacrococcyx pressure ulcer. The pressure ulcer measured 2.5 cm (L) by 2.3 cm (W), 1 cm depth with 2.4 cm undermining from 12 o'clock through 4 o'clock. A review of Resident 100's initial Care Plan for pressure ulcer prevention dated [DATE], indicated she was at risk for skin breakdown due to impaired physical mobility. The nursing intervention included repositioning the resident for comfort and to relieve pressure, daily body checks for redness and open area when providing care. There was no documented evidence body check was done to Resident 100 until [DATE] at 9:20 a.m., when the morning shift CNA reported to the licensed staff that Resident 100 had an open wound to her coccyx area. The Care Plan approach/plan for pressure ulcer (coccyx Stage II, III, IV) and sacrococcyx (Stage IV) dated [DATE], [DATE], [DATE], [DATE] and [DATE], indicated Resident 100 was to be turned and repositioned every two hours in bed. The Care plan approach/plan was not revised to indicate Resident 100 should not be turned and repositioned directly on the pressure ulcer to promote healing and prevent further skin breakdown. The DON stated the Care Plan for pressure ulcer was not revised because it was overlooked by the IDT (interdisciplinary team). The DON disclosed that the facility's Turning and Repositioning Log was started approximately in (MONTH) (YEAR), as preventive skin care and to heal the pressure ulcer. The DON stated the CNAs knew that Resident 100 should be turned only to her right and left side every two hours while in bed except when feeding her meals. A review of the Turning and Repositioning Log dated [DATE] through [DATE] on 7a.m.-3 pm shift, indicated Resident 100 was not turned and repositioned every two hours. In addition, there was no documented evidence the resident was turned and repositioned every two hours on all shifts for the month of (MONTH) (YEAR), because the DON was unable to provide the Turning and Repositioning Log upon request by the Evaluator. The DON stated the Charge Nurse is responsible to monitor the log for completion every shift. The DON stated resident's daughter requested the use of diaper for Resident 100. However, alternatives to plastic backed incontinent pads was not tried for Resident 100. On [DATE] at 9:38 a.m., the Care Plan and MDS of Resident 100 was reviewed with the RN/MDS Coordinator. The MDS section MO 300 dated [DATE], indicated Resident 100 was assessed with [REDACTED]. The Care Plan dated [DATE], indicated Resident 100 had a pressure ulcer to her coccyx. The RN/MDS Coordinator stated she inaccurately coded the resident's pressure ulcer as Stage 3 instead of Stage 4. She stated the location of the resident's pressure ulcer was inaccurately documented on the Care Plan that it was coccyx instead of sacrococcyx because it started in the coccyx. The RN/MDS Coordinator stated she did not revise the Care Plan approach/plan that positioning Resident 100 on the pressure ulcer should be avoided because she thought turning and repositioning the resident every two hours was enough to heal the pressure ulcer. During an interview with LVN 1 on [DATE] at 10:44 a.m., she stated unable to monitor Resident 100 if appropriately turn and reposition to her right and left side lying position every two hours by the CNA because she was busy doing other task such as passing the medications and providing treatment to other residents. LVN 1 stated she did not know how to set the pressure setting of the low air loss mattress because she did not receive a training. A review of Medical surgical Nursing Ninth Edition pages ,[DATE],Prevention remains the best treatment for [REDACTED]. Never position directly on the pressure sore. A review of the facility's undated policy and procedures Assessment for Appropriate Repositioning indicated to assess the resident for an existing pressure ulcer. If present, positioning the resident on an existing ulcer should be avoided. A review of the manufacturer's manual for the use low air loss mattress dated (YEAR) of page 23, indicated The comfort control LED displays the patient comfort pressure levels from 0 to 9 and provides a guide to the caregiver to set approximate comfort pressure level depending on the patient weight. A review of AHCPR (Agency for Health Care Policy and Research) guidelines for pressure ulcer treatment indicated When using support surfaces that increase airflow across the patient's skin (such as air fluidized beds and low air loss beds), patient should not wear adult incontinence briefs, because these briefs obstructs airflow to the skin. http://tr.im/ahrqguidelines.