Every finding on record at Santa Fe Heights Healthcare Center, LLC

Based on interview and record review, the facility failed to ensure interventions were implemented to prevent worsening malnutrition (a physical condition where a person's body does not get the proper balance or required amount of nutrients, vitamins, and calories necessary to maintain healthy tissues and organ function) for one of two sampled residents (Resident 1) when: 1. Registered Nurse (RN) 1 did not notify the resident's physician or the facility's Registered Dietician (RD) after Resident 1 was identified as malnourished during a Mini Nutritional Assessment conducted on 6/24/2026.2. The RD failed to conduct a comprehensive nutritional assessment for Resident 1 within seven days, following admission to the facility. These deficient practices resulted in delayed interventions to assist Resident 1 in achieving gradual weight gain and prevent continued weight loss and malnutrition.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included esophageal obstruction (blockage of the tube that connects your throat to your stomach), dysphagia (difficulty swallowing), severe protein-calorie malnutrition (a life-threatening condition caused by a prolonged, severe deficiency of both protein and total calories), hypovolemia (an abnormally low volume of circulating blood plasma or other body fluids in the body), muscle wasting and atrophy, and adult failure to thrive (a syndrome characterized by a gradual, unexplained decline in physical and mental functioning). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/25/2026, the MDS indicated Resident 1 had moderate cognitive impairment (ability to think and reason). The MDS indicated Resident 1 required supervision/touch assistance from staff to eat and required substantial to maximal assistance from staff for mobility while in and out of bed. During a review of Resident 1's weigh measurement, dated 6/24/2026, the measurement indicated Resident 1 weighed 85 pounds (lbs., a unit of measuring bodyweight). During a review of Resident 1's weight measurement, dated 7/2/2026, the measurement indicated Resident 1 weighed 84 lbs. During a review of Resident 1's progress note, dated 7/7/2026, the progress note indicated Resident 1 was transferred to the General Acute Care Hospital (GACH) on 7/7/2026. During an interview on 7/21/2026 at 1:35 p.m., with Social Worker (SW) 1, SW 1 stated she assessed Resident 1 upon his admission to the GACH on 7/7/2026. SW 1 stated Resident 1's neck, arms, and thighs were very skinny. SW 1 stated Resident 1 appeared emaciated (extremely thin and weak, usually caused by a severe lack of food or a serious illness). 1. During a review of Resident 1's Mini Nutritional Assessment (MNA), dated 6/24/2026, the MNA indicated the assessment was completed by RN 1. The MNA indicated Resident 1 scored 3, indicating he was malnourished (score of 0 to 7 indicated malnourishment, score 9 to 11 indicated risk for malnutrition). During an interview on 7/21/2026 at 1:45 p.m., with RN 1, RN 1 stated he conducted Resident 1's MNA. RN 1 stated Resident 1's MNA score was not reported to Resident 1's physician or the Registered Dietician (RD). RN 1 stated he had not been instructed on what to do with MNA scores that indicated malnourishment or a risk for malnourishment. RN 1 stated malnourishment was something the RD should be made aware of. During an interview on 7/21/2026 at 3:22 p.m., with the Director of Nursing (DON), the DON stated the expectation was for nursing staff to notify the resident's physician for identified malnourishment during completion of the MNA. The DON stated this would allow the physician to order additional interventions and/or identify more specific details related to the resident's malnourished status. The DON stated nursing staff should also notify the RD. 2. During a review of Resident 1's record titled Multidisciplinary Care Conference, dated 6/24/2026, the record indicated goals of care included monitoring Resident 1 for proper nutrition and hydration, increasing the resident's oral intake of food and fluids, and increasing the resident's weight. The Multidisciplinary Care Conference did not indicate Resident 1's physician or the facility's RD were present. The record indicated the recommendations were provided by the Dietary Services Supervisor (DSS). The record did not include actionable interventions to achieve these goals. During a review of Resident 1's Nutritional Assessment, dated 7/7/2026, the assessment indicated this was the initial assessment conducted by the RD on 7/7/2026. The assessment indicated Resident 1's Body Mass Index (BMI, a screening tool used to assess potential weight-related health risks) was 13.2 (BMI less than 18.5 indicated underweight, BMI 18.5 to 24.9 indicated healthy weight). The assessment indicated Resident 1 weighed 84 lbs. and was severely underweight. The RD recommended staff to modify Resident 1's diet to a fortified (adding vitamins and minerals to commonly consumed foods) diet and provide snacks three times a day. During a telephone interview on 7/21/2026 at 2:02 p.m., with the RD, the RD stated the goal was to conduct an admission nutritional assessment within seven days from the admission date. The RD stated that due to Resident 1's clinical status, she would not want to postpone Resident 1's assessment until two weeks after admission, but she was catching up on other resident assessments and had not been notified by nursing staff of Resident 1's MNA results from 6/24/2026. The RD further stated that her scope was broader than that of the DSS and stated the DSS would be unable to provide recommendations for therapeutic diets or snacks. The RD stated her recommendation for a fortified diet and snacks three times a day would allow Resident 1 to achieve gradual weight gain. The RD stated the DSS would not be able to make these recommendations. During a review of the facility's policy and procedure titled Nutritional Assessment, revised 10/2017, the P&P indicated the dietitian was to conduct a nutritional assessment for each resident upon admission. The P&P also indicated that as part of the comprehensive assessment, the nutritional assessment was to be a multidisciplinary process that included gathering and interpreting data and using that data to help define meaningful interventions for the resident with impaired nutrition.

Based on interview and record review, the facility failed to obtain an order for routine blood glucose monitoring (measuring the amount of sugar in the blood, normal level is 70 to 140 milligrams per deciliter [mg/dL- a unit of measurement)] and hemoglobin A1C (HbA1c- measures the average blood sugar level over the past two to three months) for one of three sampled residents (Resident 1).This deficient practice resulted in Resident 1 being admitted to the general acute care hospital (GACH) with an initial blood glucose level of 591 mm/dL requiring intravenous (IV, through the vein) insulin therapy (the administration of medication used to lower blood glucose levels). Findings:During a review of Resident 1's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and Sjogren's syndrome (autoimmune disease where the immune system attacks the body's healthy tissues).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/19/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting, bathing, upper body dressing, and personal hygiene.During a review of Resident 1's Care Plan titled, Risk for Hyperglycemia (higher than normal level of sugar in the blood, normal level is 70 to 140 milligrams per deciliter [mg/dL- a unit of measurement)], dated 6/16/2026, the Care Plan indicated to check Resident 1's Finger-Stick Blood Sugar (FSBS- method of testing glucose levels by pricking the fingertip with a lancet and applying a drop of blood onto a test strip).During a review of Resident 1's Physician Orders, active on 6/23/2026, the Physician Orders did not indicate to check Resident 1's blood glucose levels.During a review of Resident 1's Progress Note, dated 6/23/2026, the Progress Note indicated Resident 1's daughter called 9-1-1 (emergency services) for evaluation of Resident 1's chronic pain and wounds and transfer to the general acute care hospital (GACH).During a review of the GACH Emergency Department (ED) Provider Note, dated 6/23/2026, the ED Provider Note indicated Resident 1 was brought to the ED for hyperglycemia and bilateral (both sides) lower extremity (legs) pain. The ED Provider Note indicated Resident 1's blood glucose upon arrival to the ED was 591 mg/dL. The ED Provider Note indicated Resident 1's blood glucose level laboratory result was 614 mg/dL.During a review of Resident 1's GACH History and Physical (H&P), dated 6/23/2026, the GACH H&P indicated Resident 1 was started on intravenous (IV) insulin therapy (the administration of medication used to lower blood glucose levels directly into the blood stream via a vein) at 10 units per hour (units/hr, rate of medication dosage in an hour).During an interview on 7/9/2026 at 9:08 a.m., with Registered Nurse (RN) 1, RN 1 stated if residents with diabetes were not on insulin, their hemoglobin A1C (HbA1c- measures the average blood sugar level over the past two to three months) would be ordered upon admission. RN 1 stated HbA1c was done to determine the resident's blood glucose baseline and to determine whether insulin treatment was necessary.During a concurrent interview and record review on 7/9/2026 at 9:15 a.m., with RN 1, Resident 1's Test Request Form, dated 6/17/2026, was reviewed. The Test Request Form did not indicate to check Resident 1's HbA1c level. RN 1 stated Resident 1's physician ordered to draw laboratory tests upon Resident 1's admission to the facility. RN 1 stated he did not indicate for Resident 1's HbA1c to be checked. RN 1 stated, on an unknown date, the laboratory technician attempted to draw Resident 1's blood, however, was unable to. RN 1 stated due to Resident 1's unknown HbA1c, the licensed nurses should have actively tried to obtain an FSBS order from Resident 1's physician. RN 1 stated monitoring Resident 1's HbA1c and FSBS were necessary to have a baseline blood glucose level and to treat if needed.During an interview on 7/9/2026 at 10:54 a.m., with the Director of Nursing (DON), the DON stated the facility did not know Resident 1's HbA1c level, therefore did not have a baseline of how controlled Resident 1's blood glucose levels were. The DON stated obtaining a baseline blood glucose level upon admission was necessary to have a baseline and intervene with medication if the values were abnormal.During a review of the facility's Policy and Procedure (P&P) titled, Nursing Care of the Older Adult with Diabetes Mellitus, revised 11/2020, the P&P indicated the purpose of the P&P was to provide an overview of diabetes in the older adult and the principles of glucose monitoring. The P&P indicated the licensed nurse would report recent labs and the provider would order the frequency of glucose monitoring.

Based on interview and record review, the facility failed to manage two of three sampled residents' (Residents 1 and 3) pain when pain medication, ordered for moderate pain (pain rated four to six on a 10-point scale), was given for severe pain (pain rated seven to ten on a 10-point scale).This deficient practice had the potential to result in the mismanagement of Residents 1 and 3's pain.Findings:1. During a review of Resident 1's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and Sjogren's syndrome (autoimmune disease where the immune system attacks the body's healthy tissues).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/19/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting, bathing, upper body dressing, and personal hygiene. The MDS indicated Resident 1 received opioid medication (powerful pain medication).During a review of Resident 1's Physician Order, dated 6/15/2026, the Physician Order indicated to administer the following:1. Morphine sulfate (an opioid) 15 milligrams (mg, a unit of measurement), by mouth, every eight hours for pain management.2. Morphine sulfate 15 mg, by mouth, every eight hours as need (PRN) for moderate pain (pain rated four to six on a 10-point scale). During a review of Resident 1's Care Plan titled, Osteoarthritis of the Bilateral (both) Knees, revised 6/16/2026, the Care Plan indicated to give analgesics (pain medication) as ordered by the physician.During a review of Resident 1's Care Plan titled, At Risk for Pain and Discomfort, revised 6/16/2026, the Care Plan indicated to assess the effectiveness of the pain medication and notify Resident 1's physician for possible need to increase the pain medication.During an interview on 7/8/2026 at 11:36 a.m., with the Treatment Nurse (TN), the TN stated Resident 1 had chronic venous ulcers (a slow-healing sore on the lower leg caused by poor circulation) on both of her legs that were very painful. The TN stated Resident 1 received morphine on a routine schedule and PRN basis. The TN stated the scheduled morphine would be given prior to Resident 1's wound treatment. During an interview on 7/9/2026 at 8:50 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 1 had chronic pain (pain that lasts longer than three months) related to her wounds and osteoarthritis. RN 1 stated although Resident 1 received morphine 15mg every eight hours, she could receive another dose of morphine 15mg, every eight hours, if Resident 1 had breakthrough pain 9a sudden, intense flare-up of pain that breaks through a regular schedule of pain medications). RN 1 stated when administering PRN morphine, the licensed nurse was responsible for assessing Resident 1's pain to ensure the ordered medication was appropriate. During a concurrent interview and record review on 7/9/2026 at 8:54 a.m., with RN 1, Resident 1's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/1/2026 through 6/30/2026, was reviewed. The MAR indicated Resident 1 received PRN morphine 15mg on the following days:a. 6/17/2026 at 2:40 a.m., pain level of 8 b, 6/18/2026 at 1 a.m., pain level of 8c. 6/21/2026 at 2 a.m., pain level of 8RN 1 stated Resident 1's pain level was eight and was administered PRN morphine. RN 1 stated a pain of eight was considered severe pain (pain rated seven to ten on a 10-point scale) and was higher than what the morphine could effectively treat. RN 1 stated Resident 1's physician should have been notified to ensure Resident 1 received the appropriate dosage of pain medication to effectively treat her pain. RN 1 stated Resident 1 suffered from chronic pain and pain management was necessary to promote a high quality of life.2. During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included type 2 diabetes mellitus, dementia (a progressive state of decline in mental abilities), and atherosclerosis of native arteries of extremities with gangrene (fatty plaque severely narrowed the arteries in the arms or legs where oxygen-rich blood could not reach the limbs, causing the tissue to die).During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 3 required substantial assistance with eating, oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 3 received opioid medication.During a review of Resident 3's Physician Order, dated 6/12/2026, the Physician Order indicated to administer Hydrocodone-Acetaminophen (an opioid) 5-325mg, by mouth, every six hours PRN for moderate pain. During a review of Resident 3's Care Plan titled, Acute Pain/Chronic Pain, dated 6/13/2026, the Care Plan indicated to administer pain medication per the physician's order.During a concurrent interview and record review on 7/9/2026 at 9:02 a.m., with RN 1, Resident 3's MAR dated 6/1/2026 through 6/30/2026 and 7/1/2026 through 7/31/2026, were reviewed. The MARs indicated Resident 3 received his PRN hydrocodone-acetaminophen 5-325 on the following days:a. 6/24/2026 at 9:05 p.m., pain level of 7b. 7/1/2026 at 9:43 p.m., pain level of 7c. 7/5/2026 at 8:01 a.m., pain level of 7d. 7/6/2026 at 9:43 a.m., pain level of 7RN 1 stated Resident 3's pain level was seven four times and was administered the PRN hydrocodone-acetaminophen. RN 1 stated a pain of seven was considered severe pain and was higher than what the hydrocodone-acetaminophen could effectively treat. RN 1 stated Resident 3's physician should have been notified to ensure Resident 3 received the appropriate dosage of pain medication to effectively treat his pain.During an interview on 7/9/2026 at 10:57 a.m., with the Director of Nursing (DON), the DON stated PRN pain medication had a pain scale to ensure the ordered medication was effective in treating the indicated pain level. The DON stated Residents 1 and 3's PRN pain medication was ordered for moderate pain; however, the pain medication was administered when Residents 1 and 3 experienced severe pain. The DON stated Residents 1 and 3 were undermedicated and were at risk for ineffective pain management. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised 12/2012, the P&P indicated, Medications must be administered in accordance with the orders.

Based on interview and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) medical records were accurately documented when:1. License Vocational Nurse (LVN) 1 intentionally fabricated (something that is fake) Resident 1's vital signs (e.g., temperature, heart rate, blood pressure, respiratory rate, oxygen saturation [amount of oxygen in the blood]).2. The Treatment Nurse (TN) did not document Resident 2's wound treatments on the Treatment Administration Record (TAR).This deficient practice resulted in Residents 1 and 2 having an inaccurate medical record that did not reflect the assessments and care provided.Findings:1. During a review of Resident 1's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and Sjogren's syndrome (autoimmune disease where the immune system attacks the body's healthy tissues).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/19/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting, bathing, upper body dressing, and personal hygiene.During a review of Resident 1's Skilled Evaluation, dated 6/17/2026, the Skilled Evaluation indicated a Late Entry was made by Licensed Vocational Nurse (LVN) 1 and the following vital signs (e.g., temperature, heart rate, blood pressure, respiratory rate, oxygen saturation [amount of oxygen in the blood]) were documented on 6/24/2026 at 11:25 p.m.:a. Temperature 97.8 degrees Fahrenheit (F, measurement of temperature)b. Blood pressure (BP) 126 over 72 (126/72) millimeters of mercury (mmHg, unit of measurement)c. Heart Rate (HR) 78 beats per minute (bpm)d. Respiratory Rate (RR) 18 breaths per minutee. Oxygen saturation (O2 sat, percentage of oxygen circulating in the blood) 97 percent (%)During a review of Resident 1's Skilled Evaluation, dated 6/18/2026, the Skilled Evaluation indicated a Late Entry was made by LVN 1 and the following vital signs were documented on 6/24/2026 at 11:09 p.m.:a. Temperature 97.8 degrees Fb. BP 124/72 mmHgc. HR 78 bpmd. RR 18 breaths per minutee. O2 sat 98%During a review of Resident 1's Skilled Evaluation, dated 6/22/2026, the Skilled Evaluation indicated a Late Entry was made by LVN 1 and the following vital signs were documented on 6/24/2026 at 11:57 p.m.:a. Temperature 98.1 degrees Fb. BP 134/76 mmHgc. HR 78 bpmd. RR 18 breaths per minutee. O2 sat 97%During a review of Resident 1's Progress Note, dated 6/23/2026, the Progress Note indicated Resident 1's family member (FM 1) called 9-1-1 (emergency services) for evaluation of Resident 1's chronic pain and wounds and transfer to the general acute care hospital (GACH).During an interview on 7/8/2026 at 12:30 p.m., with LVN 1, LVN 1 stated she completed Resident 1's Skilled Evaluation Assessments on 6/24/2026. LVN 1 stated, on 6/23/2026, Resident 1 was transferred to the GACH and she was behind on documenting Resident 1's Skilled Evaluations for 6/17/2026, 6/18/2026, and 6/22/2026. LVN 1 stated she wrote down Resident 1's vital signs for 6/17/2026, 6/18/2026, and 6/22/2026 on a piece of paper but could not find it when she documented the evaluations on 6/24/2026. LVN 1 stated she made the vitals up because Resident 1's vital signs were never abnormal and had to get the Skilled Evaluations completed. LVN 1 stated she should not have documented false vital signs in Resident 1's medical record because the vital signs were not an accurate representation of Resident 1's status on those days.During an interview on 7/9/2026 at 11:07 a.m., with the Director of Nursing (DON), the DON stated the Skilled Evaluation were assessments submitted for Medicare (a United States federal health insurance program) reimbursements for residents requiring skilled services (complex services which requires nursing or rehabilitation professionals to carry out the services). The DON states the Skilled Evaluation should always be accurate, including the vitals signs. The DON states the vital signs indicate Resident 1's condition on each day. The DON stated fabricated (something that is fake) vital signs do not allow the healthcare team to determine whether Resident 1's condition was stable. The DON stated LVN 1's fabricated vital signs lead to a concern that her other documentation was also inaccurate or false. During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, revised 4/2008), the P&P indicated, All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. 2. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included paraplegia (loss of movement and/or sensation, to some degree, of the legs), type 2 diabetes mellitus, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was intact. The MDS indicated Resident 2 required substantial assistance with toileting, bathing, upper/lower body dressing, and personal hygiene. The MDS indicated Resident 2 had three Stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) and one Stage 4 pressure injury (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) which were present upon admission.During a concurrent interview on 7/8/2026 at 3:51 p.m., with the TN, Resident 2's Treatment Administration Record (TAR), dated 6/1/2026 through 6/30/2026 and 7/1/2026 through 7/31/2026, were reviewed. The TAR indicated on 6/8/2026, the following treatments were left blank:a. Provide urinary indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) care.b. Monitor settings and functions on the low air loss mattress (LALM- special mattress designed to prevent and treat pressure injuries by reducing pressure on the body).c. Monitor pain pre- and post- treatment.d. Cleanse the sacrococcyx (area near the very bottom of the spine), stage 4 pressure injury, with normal saline (a sterile mixture of salt and purified water), pat dry, apply santyl ointment (ointment used to clean and heal wounds), top with cal-aginate (absorbent, breathable gel-material used to heal wounds), and cover with dressing.The TAR indicated on 6/13/2026, the following treatments were left blank:a. Cleanse the left buttocks, stage 3 pressure injury, with normal saline, pat dry, apply santyl ointment, top with cal-aginate and cover with dressing.b. Provide urinary indwelling catheter care.c. Cleanse the left ischium (the area of the lower back and back part of the hip) with normal saline, pat dry, apply santyl ointment, top with cal-aginate, and cover with dressing.d. Monitor settings and functions on the LALM.e. Monitor pain pre- and post- treatment.f. Cleanse the sacrococcyx, stage 4 pressure injury, with normal saline, pat dry, apply santyl ointment, top with cal-aginate, and cover with dressing.The TAR indicated on 7/6/2026, the following treatments were left blank:a. Provide urinary indwelling catheter care.b. Cleanse the left and right ischium with normal saline, pat dry, apply triad coloplast and zinc oxide (wound dressing paste), and cover with dressing.c. Cleanse the left buttocks, stage 3 pressure injury, with normal saline, pat dry, apply triad coloplast and zinc oxide, and cover with dressing.d. Monitor settings and functions on the LALM.e. Monitor pain pre- and post- treatment.f. Cleanse the sacrococcyx, stage 4 pressure injury, with normal saline, pat dry, apply medi-honey (medical-grade honey used to treat wounds), top with cal-aginate, and cover with dressing.The TN stated Resident 2 always received his wound treatments and, on 6/8/2026, 6/13/2026, and 7/6/2026, he performed Resident 2's treatment to his wounds and indwelling urinary catheter. The TN stated he forgot to document the treatments rendered. The TN stated documentation was necessary to prove the treatments were done and to prevent any confusion of Resident 2's care.During an interview on 7/9/2026 at 11:05 a.m., with the DON, the DON stated documentation was important to show Resident 2's treatments were administered. The DON stated if Resident 2's wounds declined, Resident 2's TARs would be reviewed to determine if the decline was due to missed treatments. The DON stated documentation of indwelling urinary catheters were important to determine if an infection was due to missed care. The DON stated inaccurate documentation could cause confusion within the healthcare team and mismanagement of Resident 2's wounds and indwelling urinary catheter. During a review of the facility's P&P titled, Wound Care, revised 10/2010, the P&P indicated, The following information should be recorded in the resident's medical record:1. The type of wound care given.2. The date and time the wound care was given.3. The position in which the resident was placed.4. The name and titled of the individual performing the wound care.5. Any change in the resident's condition.6. All assessment data obtained when inspecting the wound.7. How the resident tolerated the procedure.8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why.10. The signature and title of the person recording the data.

Based on interview and record review, the facility failed to verify informed consent for the administration and re ordering of the psychoactive (a medication that affects mood, thoughts, behavior, or perception) medication, Ativan (an anti-anxiety medication), for one of three sampled residents (Resident 10), despite documented evidence that the resident lacked decision making capacity. This deficient practice resulted in Resident 10 receiving psychoactive medication on multiple occasions without confirmation that the resident's responsible party (RP 1) had been informed of the risks, benefits, and alternatives, as required by facility policy. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE]. Resident 10's diagnoses included end stage renal disease (ESRD, irreversible kidney failure), anxiety disorder (an overwhelming feeling of uneasiness), and muscle wasting (thinning of the muscle). The admission record indicated Resident 10 had a responsible party (RP 1). During a review of Resident 10's Minimum Data Set ([MDS], a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 10's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 10 required maximal assistance (helper does more than half the effort) for toileting and showering. During a review of Resident 10's History and Physical (H&P), dated 3/3/2026, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Medication Administration Record (MAR), dated 5/2026 through 6/2026, the MAR indicated on 5/15/2026, Resident 10 received an intramuscular (IM, in the muscle) injection of Ativan 2 milligram (mg, metric unit of measurement, used for medication dosage and/or) per (/) milliliter (ml, metric unit of measurement, used for medication dosage and/or liquid amount) and an Ativan oral tablet 0.5 mg on 6/7/2026, 6/8/2026, and 6/9/2026. During a concurrent record review and interview on 6/10/2026 at 1:56 p.m. with Registered Nurse (RN) 1, Nursing Progress Notes, dated 5/2026, and Psychotropic Informed Consents, dated 5/2026 through 6/2026, were reviewed. The nursing notes did not indicate RP 1 was educated on the risks and the benefits of Ativan, nor verification of informed consent completed on 5/15/2026 (after the administration of the IM Ativan injection) and on 6/6/2026, when Resident 10 was reordered Ativan. RN 1 stated RP 1 should have been made aware of the risks and the benefits of Ativan on 5/15/2026 and again, on 6/6/2026. During an interview on 6/10/2026 at 2:08 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated on 6/6/2026, she transcribed Resident 10's order for Ativan. LVN 3 stated she should have verified informed consent from RP 1 but did not do so because she was unaware that Resident 10 was unable to make medical decisions. LVN 3 stated RP 1 had the right to be informed of the risks and benefits associated with the continued use of Ativan. During an interview on 6/10/2026 at 2:13 p.m. with LVN 2, LVN 2 stated on 5/15/2026, she should have verified informed consent from RP 1. During an interview on 6/10/2026 at 2:25 p.m. with RP 1, RP 1 stated she was not informed of the risks and benefits associated with the use of Ativan. RP 1 stated on 5/15/2026, she was not made aware of Resident 10's need for an Ativan injection. RP 1 also stated that she was not made aware Resident 10 was prescribed Ativan on 6/6/2026. During a review of the facility's policy and procedure (P&P) titled, Informed Consent, revised 6/2019, the P&P indicated the Attending Physician was to determine the decisioning making capacity of the resident in the H&P. The P&P indicated the following: If the resident was determined to lack capacity to make informed decisions, a surrogate decision-maker was identified.When initiating a new order, the Attending Physician would obtain informed consent from the resident or the responsible party.The licensed nurse would verify with the resident or legal representative that informed consent had been obtained.In an emergency situation, orders for psychotropic drugs may be initiated upon a physician order without informed consent for a period of 48 hours.Disclosure of the risks of a proposed treatment may be withheld if there was documentation the resident or the RP specifically requested that he or she did not want to be information of the risks of the recommended treatment.

Based on interview and record review, the facility failed to ensure timely responsible party (RP) notification for one of three sampled residents (Resident 10) when Resident 10 exhibited increased anxiety (an overwhelming feeling of uneasiness) on 5/15/2026 and required an administration of Ativan (a psychotropic medication, a medication that affects mood, thoughts, behavior, or perception) intramuscular injection (medication administered in the muscle). This deficient practice led to RP 1 being unaware of Resident 10's emergency administration of Ativan and episode of increased anxiety on 5/15/2026.Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE]. Resident 10's diagnoses included end stage renal disease (ESRD, irreversible kidney failure), anxiety (an overwhelming feeling of uneasiness) disorder, and muscle wasting (thinning of the muscle). The admission record indicated Resident 10 had a responsible party (RP 1). During a review of Resident 10's Minimum Data Set ([MDS], a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 10 required maximal assistance (helper does more than half the effort) for toileting and showering. During a review of Resident 10's History and Physical (H&P), dated 3/3/2026, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Medication Administration Record (MAR), dated 5/2026 through 6/2026, the MAR Resident 10 received an Ativan (a psychotropic medication, a medication that affects mood, thoughts, behavior, or perception) Injection Solution two milligram per milliliter (mg/mL - a unit of measurement) on 5/15/2026 and an Ativan oral tablet 0.5 mg on 6/7/2026, 6/8/2026, and 6/9/2026. During a review of Resident 10's Physician Order, dated 6/6/2026, the order indicated to administer Ativan tablet 0.5 mg, one tablet by mouth every six hours as needed for panic attacks. During a concurrent interview and record review on 6/10/2026 at 12:48. p.m. with Licensed Vocational Nurse (LVN) 2, Resident 10's Progress Note, dated 5/15/2026, was reviewed. The note indicated Resident 10 exhibited increased anxiety and was ordered an Ativan Injection Solution two mg/ml to be administered intramuscularly (in the muscle). LVN 2 recalled that on 5/15/2026, Resident 10 repeatedly used her call light for help but refused to speak with staff when they responded. LVN 2 stated Resident 10 became increasingly verbally aggressive and called staff derogatory names. LVN 2 stated she notified the physician and obtained an order for an Ativan injection. LVN 2 stated she did not make RP 1 aware, nor did she create a change of condition note. LVN 2 stated that both actions were important to allow RP 1 to be aware of Resident 10's medical condition and to allow for further monitoring of Resident 10's change of condition and adjust Resident 10's plan of care. During a concurrent record review and interview on 6/10/2026 at 1:56 p.m. with Registered Nurse (RN) 1, all of Resident 10's H&P, dated 3/3/2026, and Nursing Progress Notes, dated 5/2026, were reviewed. There were no nursing notes to indicate Resident 10's responsible party was made aware of Resident 10's change of condition on 5/15/2026. RN 1 stated Resident 10's RP should have been made aware of the change of condition and the need for an IM dose of Ativan because RP 1 had the right to know the latest medical condition of Resident 10. RN 1 also stated a change of condition note should have been authored to guide ongoing monitoring for adverse reactions and behavioral changes. During an interview on 6/10/2026 at 2:25 p.m. with RP 1, RP 1 stated she was not made aware of Resident 10's episode of increased agitation and the need for an Ativan injection on 5/15/2026. RP 1 also stated that she was not made aware Resident 10 was prescribed Ativan on 6/6/2026. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated the facility was to ensure the licensed nurse would notify the resident representative when the resident exhibited a significant change in the resident's mental or psychosocial status.

Based on interview and record review, the facility failed to ensure residents were free from sexual abuse for one of four sampled residents (Resident 2), when Resident 4 and Resident 2 were found in bed unclothed. This deficient practice resulted in Resident 2 being sexually abused by Resident 4 and had the potential for Resident 2 to experience physical harm, emotional trauma, fear, humiliation, and psychological distress. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and re admitted on [DATE]. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's History and Physical (H&P), dated 10/8/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/25/2025, the MDS indicated Resident 2's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 2 required moderate (helper does less than half the effort) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an interview on 4/15/2026 at 10:15 a.m., at Resident 2's bedside, with Resident 2, Resident 2 stated she did not want to engage in sexual activity and did not consent to sexual contact with Resident 4. b. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included dementia, schizoaffective disorder, and major depressive disorder. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognition was moderately impaired. The MDS indicated Resident 4 required moderate (helper does less than half the effort) assistance from staff for ADLs. During an interview on 4/15/2026 at 11:40 p.m., at Resident 4's bedside, with Resident 4, Resident 4 stated he liked women and liked to socialize with women. Resident 4 could not recall whether or not he engaged in sexual activity with Resident 2. During a concurrent interview and record review on 4/15/2026 at 12:00 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's progress note, authored by LVN 1, dated 11/16/2025 and timed at 11:02 a.m., was reviewed. The progress note indicated Resident 2 was observed unclothed in her bed with Resident 4. LVN 1 stated she observed both residents unclothed in Resident 2's bed. LVN 1 stated at the time of the incident, both residents verbally consented to sexual activity. LVN 1 stated she was not aware if an assessment was performed to determine either resident's capacity to consent to sexual activity. During an interview on 4/15/2026 at 12:30 p.m., with the Director of Nursing (DON), the DON stated the incident involving Resident 2 and Resident 4 was considered sexual abuse. The DON stated it was not the facility's practice to allow residents to engage in sexual activity without appropriate assessment. The DON stated that, if residents expressed a desire to engage in sexual activity, the facility was required to assess the residents' capacity to consent and, if appropriate, provide privacy. The DON stated the facility failed to ensure Resident 2 was protected from sexual abuse. During a review of the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2024, the P&P indicated all residents have the right to be free from any form of abuse including sexual abuse. The P&P indicated the facility was committed to ensuring that residents were protected from sexual abuse.

Based on interview and record review, the facility failed to report a sexual abuse allegation to the State Agency (California Department of Public Health [CDPH]), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement for two of four sampled residents (Residents 2 and 4), after Resident 4 was observed unclothed in Resident 2's bed, who was also unclothed. This deficient practice resulted in a delay of an onsite investigation by CDPH and had the potential to place all residents at risk for abuse.Findings: a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and re admitted on [DATE]. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's History and Physical (H&P), dated 10/8/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/25/2025, the MDS indicated Resident 2's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 2 required moderate (helper does less than half the effort) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an interview on 4/15/2026 at 10:15 a.m., at Resident 2's bedside, with Resident 2, Resident 2 stated she did not consent to sexual contact with Resident 4. b. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included dementia, schizoaffective disorder, and major depressive disorder. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognition was moderately impaired. The MDS indicated Resident 4 required moderate (helper does less than half the effort) assistance from staff for ADLs. During an interview on 4/15/2026 at 11:40 p.m., with Resident 4, Resident 4 stated he did not recall engaging in sexual activity with any residents. During a concurrent interview and record review on 4/15/2026 at 12:00 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's progress note, authored by LVN 1, dated 11/16/2025 and timed at 11:02 a.m., was reviewed. The progress note indicated on 11/16/2025, Resident 2 and Resident 4 were observed unclothed in Resident 2's bed. LVN 1 stated she observed Residents 2 and 4 unclothed in Resident 2's bed. LVN 1 stated such an incident was considered sexual abuse. LVN 1 stated the incident should have been reported immediately to the abuse coordinator and the appropriate state and federal agencies, including CDPH. LVN 1 stated she did not report the incident. During an interview on 4/15/2026 at 12:55 p.m., with the Administrator (ADM), the ADM stated she was the abuse coordinator and was responsible for reporting all abuse allegations to the CDPH, law enforcement, and Ombudsman. The ADM stated the staff had the ability to report to the three reporting agencies. The ADM stated staff were responsible for notifying her immediately of sexual abuse allegations so the allegation could be reported and investigated. The ADM stated immediate reporting was necessary to ensure a thorough investigation was conducted by both the facility and CDPH. During a review of the facility's policy and procedure (P&P) titled Abuse Reporting and Investigation, dated 5/2025, the P&P indicated all facility staff are required to report all allegations of abuse to the appropriate agencies within two (2) hours of becoming aware of the abuse. The P&P indicated that all staff were considered a mandated reporter and were responsible to notify appropriated authorities within 2 hours and to notify the facility Abuse Prevention Coordinator (APC) and their supervisor immediately.

Based on observation, interview, and record review, the facility failed to ensure rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) and Restorative Nurse Aide (RNA) services were provided and performed as ordered for four out of four sampled residents (Resident 16, Resident 28, Resident 11, and Resident 69) when the facility did not ensure:1. Resident 11 received appropriate services to maintain functional ability and comfort related to activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).2. RNA orders were carried out as ordered for Resident 28.3. The charge nurse or the Rehabilitation Department was made aware Resident 28 could not tolerate RNA orders for the application of a right elbow splint (a medical device designed to treat a stiff elbow with limited range of motion by providing a prolonged, low-intensity stretch to tightened soft tissues) and bilateral hand rolls (devices used to maintain the hand in a functional position).4. RNA orders were carried out as ordered for Resident 16. 5. Notify the Rehabilitation Department of Resident 69's inability to complete ordered RNA sit-to-stand interventions.These deficient practices placed the residents at risk for further range of motion (ROM, the full, functional measurement of how far a specific joint or body part can move in various directions) decline, pain, and decreased ability to perform ADLs.Findings:a. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE]. Resident 11's diagnoses included palliative care (specialized medical care for individuals living with a serious, chronic, or life-threatening illness), cachexia (a complex syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left hand, and unstageable pressure ulcer (full-thickness wound whose depth and severity cannot be determined) of the sacral region.During a review of Resident 11's Minimum Data Set ([MDS], a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 11's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 11 had functional impairments in range of motion to both sides of his upper and lower extremities The MDS indicated Resident 11 required substantial assistance (helper does more than half the effort) for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 11's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Meeting Notes, dated 1/2/2026, the notes indicated Resident 11's restorative care needs were to maintain function.During a review of Resident 11's Joint Mobility Assessment, dated 1/6/2026, the Joint Mobility Assessment lacked recommendations and indicated Resident 11 was under hospice care. The Joint Mobility Assessment indicated Resident 11's had the following ROM limitations: -Severe limitations to his left and right shoulders.- Moderate limitations to his left and right elbows, fingers of the left hand, both hips, right knee and left and right ankle.- Moderate to severe limitations to the left wrist.- Minimal limitations to his right wrist and fingers of the right hand.During a review of Resident 11's medical records, dated 1/2026 through 2/5/2026, the medical records did not indicate there were care plans to address Resident 11's ROM limitations.During an interview on 2/4/2026, at 1:11 p.m. with Resident 11's Representative Party (RP) 1, RP 1 stated Resident 11 was able to make his own decisions. RP 1 stated Resident 11 was available to consult him if he wished. RP 1 stated Resident 11 did not receive routine physical therapy and would like the resident to receive exercises.During an interview on 2/6/2026 at 8:37 a.m. with Resident 11, in the presence of Registered Nurse (RN) 1, Resident 11 stated he would like to receive RoM exercises.During an interview with 2/06/2026 at 10:46 a.m. with Physical Therapist (PT) 1, PT 1 stated he authored the Joint Mobility Assessment, dated 1/6/2026. PT 1 stated the normal process to have rehabilitation services ordered for a resident was to conduct a Joint Mobility Assessment and obtain an order for an evaluation for therapy. PT 1 stated Resident 11 had ROM limitations that would have warranted a proper evaluation for rehabilitation, but because Resident 11 was under hospice care, the evaluation was not performed. PT 1 stated it was the facility's practice to not provide RNA services to residents under hospice care. PT 1 stated Resident 11 could have at least benefitted from gentle passive ROM exercises in efforts to prevent decline and worsening contractures, which could lead to stiffness and pain. PT 1 stated this failure placed Resident 11 at risk of increased stiffness, worsening contractures, decreased comfort during end-of-life care.During a review of the facility's policy and procedure (P&P) titled, Hospice Program, revised 7/2017, the P&P indicated the coordinated care plan would reflect the resident's goals and wishes as stated in his advanced directives and during ongoing communication with the resident or representative including palliative goals and objectives, interventions, and medical treatment. The P&P indicated the coordinated care plan would be revised and updated as necessary to reflect the resident's current status including mobility and positioning.b. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 28's diagnoses included adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), dysphagia (difficulty swallowing), and hypertensive heart disease (high blood pressure).During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 28 had functional ROM limitations to his upper and lower extremities. The MDS indicated required substantial assistance (helper does more than half the effort) for ADLs.During a review of Resident 28's History and Physical (H&P), dated 2/2/2026, the H&P indicated Resident 28 had the capacity to understand and make decisions.During a review of Resident 28's care plan titled, Limited Physical Mobility Related to Impaired Bilateral Upper and Lower Extremities, revised on 8/20/2025, the care plan interventions indicated to carry out the RNA Program as ordered.During a review of Resident 28's care plan titled, At Risk for Further Functional Decline, initiated 2/21/2025, the care plan interventions were to ensure RNA documented weekly in the clinical record of the resident's progress and participation and notify the charge nurse should a decline in function is noted for possible rehabilitation intervention.During a review of Resident 28's Order Summary Report, dated 2/1/2026, the report indicated Resident 28 had the following RNA orders:1. RNA to splint (a medical device designed to treat a stiff elbow with limited range of motion by providing a prolonged, low-intensity stretch to tightened soft tissues) right elbow for two to three hours or as tolerated every day five times a week.2. RNA to provide bilateral lower extremity passive range of motion (PROM -an outside force moves the joint) exercises everyday five times a week, or as tolerated.3. RNA to monitor for pain before and applying the splint, and to notify the charge nurse for the presence of pain.4. RNA to provide bilateral upper extremity active assist range of motion (AAROM- a technique that involves a patient using their own muscles to move a joint while receiving help from a therapist), followed by the application of bilateral hand rolls (devices used to maintain the hand in a functional position) for four to five hours or as tolerated everyday five times per week.During observations and interviews made on 2/4/2025 at 8:21 a.m., 10:16 a.m., 12:16 p.m., 1:31 p.m., 2:45 p.m., 3:37 p.m., and 4:42 p.m. in Resident 28's room, observed Resident 28 did not have bilateral hand rolls and did not have a right arm splint in place. Resident 28 stated the staff did not provide ROM exercises that day.During a concurrent interview and record review on 2/5/2026 at 2:00 p.m. with RNA 1, Resident 28's RNA Task Flow Sheet, dated 2/4/2026, was reviewed. RNA 1 stated the RNA Task Flow Sheet indicated Resident 28 was provided 240 minutes (four hours) of bilateral hand roll splinting, 180 minutes of elbow splinting, and 15 minutes of range of motion exercises at 2:59 p.m. on 2/4/2026. The flow sheet indicated Resident 28 actively participated, exhibited no pain during the session, and tolerated the RNA session well on both dates. RNA 1 stated she did not apply bilateral hand rolls as ordered and instead placed bandages in the resident's palms, and she did not apply the right elbow splint because the resident could not tolerate it. RNA 1 stated she did not inform the charge nurse of Resident 28's inability to tolerate the right elbow splint and did not perform the RNA orders as ordered. RNA 1 stated that it was important to notify the charge nurse so that the Rehab department could perform another evaluation. RNA 1 stated the failure of not performing the RNA orders as ordered placed Resident 28 at risk for range of motion decline and worsening contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion).c. During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 16's diagnoses included polyneuropathy, fracture of the right femur (broken thigh bone), contractures of the left and right ankle, and disorders of the muscles.During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 16 had functional range of motion limitations to his upper and lower extremities (arms and legs). The MDS indicated Resident 16 was entirely dependent on staff for ADLs.During an observation on 2/2/2026 at 9:10 a.m., Resident 16 was in bed and did not have PRAFO boots (boots that are designed to provide pressure relief for individuals who spend extended periods in bed, and help to prevent pressure ulcers (injuries to the skin and underlying tissues due to prolonged pressure) and muscle tightness) in place.During observations made on 2/4/2026 at 8:10 a.m., 12:15 p.m., 1:48 p.m., and 2:48 p.m., observed Resident 16 in bed. Resident 16 was not wearing PRAFO boots. During a concurrent interview and record review on 2/5/2026 at 2:30 p.m. with RNA 2, Resident 16's Order Summary, dated 2/1/2026, and the RNA Task Flow sheet, dated 2/2026, were reviewed. The Order Summary indicated Resident 16 was to have bilateral (both sides) lower extremity gentle PROM (he movement of a joint through its available range by an external force—such as a therapist, machine, or gravity—without any muscle contraction from the person) exercises five times a week, bilateral lower extremity PRAFO boots applied for four hours every day five days a week or as tolerated, and AAROM (the degree of movement a person can voluntarily create at a joint using their own muscle strength, without any outside assistance) exercises to the upper extremities five days a week or as tolerated. The RNA Task Flow Sheet indicated, on 2/4/2026, Resident 16 received bilateral lower extremity gentle PROM exercises and PRAFO boots were applied. RNA 2 stated she did not apply the PRAFO boots on 2/4/2026 and did not follow the physician orders. RNA 2 stated there was no documentation slot allotted for PRAFO boot application and that the documentation for RNA orders was unclear. RNA 2 stated the boots were ordered to maintain Resident 16's foot positioning and prevent the further development of contractures and pressure ulcers to the heels. RNA 2 stated the failure to apply and document the application of the boots consistently could place the resident at risk for contractures and skin break down.5. During a review of Resident 69's admission Record, the admission Record indicated Resident 69 was admitted to the facility on [DATE] with diagnoses that included spondylopathy (any disease or condition affecting the bones of the spine), acquired absence of left leg below the knee and right leg above the knee (an individual is missing part of the leg either above or below the knee), and wedge compression fracture of T7-T8 vertebra (the front part of one or both of the mid-back bones have collapsed or broken).During a review of Resident 69's MDS, dated [DATE], the MDS indicated Resident 69's cognition was moderately impaired. The MDS indicated Resident 69 had impairment on both sides of his lower extremity (may include the hip, knee, ankle, and foot). The MDS indicated Resident 69 required substantial assistance with oral hygiene, toileting, bathing, dressing, and personal hygiene. During a review of Resident 69's H&P, dated 9/16/2025, the H&P indicated Resident 69 had fluctuating capacity to understand and make decisions. During a review of Resident 69's Order Summary Report, order dated 12/29/2025, the Order Summary Report indicated RNA to assist Resident 69 for sit-to-stand activity as tolerated, five times a week, with parallel bars using the left below the knee prosthetic device (device that replaces a missing body part) only. Resident 69's right above the knee prosthetic was sent out for modification.During a review of Resident 69's Multidisciplinary Care Conference, dated 12/19/2025, the Multidisciplinary Care Conference indicated Resident 69 had RNA therapy to stabilize his gait (the way a person walks).During a review of Resident 69's RNA Weekly Summary, dated 2/5/2026, the RNA Weekly Summary indicated Resident 69 was uncooperative and did not want to participate in RNA therapy. Resident 69 refused to participate two times. During a concurrent observation and interview on 2/5/2026 at 9:15 a.m., with Resident 69, in Resident 69's room, Resident 69 stored his left leg prosthetic in the closet. Resident 69 stated he was given a left and right leg prosthetic, but the right leg prosthetic had to be sent out because it did not fit him well. Resident 69 stated he was supposed to participate in RNA therapy with both of this leg prosthetics, however, since he was waiting for his right leg prosthetic to be modified, he did not want to participate. Resident 69 stated, it is a waste of time.During a concurrent interview and record review on 2/5/2026 at 12:44 p.m., with RNA 3, Resident 69's RNA Task Flow Sheet, dated 2/2/2026 through 2/5/2026, was reviewed. The RNA Task Flow Sheet indicated:- On 2/2/2026, Resident 69 refused RNA therapy.- On 2/3/2026, Resident 69 had 15 minutes of passive participation (received treatment without any active effort).- On 2/4/2026, Resident 69 had 15 minutes of RNA therapy with encouragement.- on 2/5/2026, Resident 69 refused RNA therapy. RNA 3 stated Resident 69 did not want to complete the full RNA order of sit-to-stand with his left leg on 2/3/2026 and 2/4/2026. RNA 3 stated Resident 69 allowed her to apply his left leg prosthetic; however, Resident 69 did not want to do the sit-to-stand activity. RNA 3 stated she approached Resident 69 multiple times on 2/2/2026 and 2/5/2026 and Resident 69 refused his therapy session. RNA 3 stated when a resident refused their RNA therapy or did not complete the ordered activity, the rehab and nursing departments should be notified. During an interview on 2/5/2026 at 2:42 p.m., with the (Director of Rehab) DOR, the DOR stated she was unaware of Resident 69's RNA therapy refusals and passive participation. The DOR stated prompt notification was important to allow the rehab department to speak with Resident 69 and uncover why he was refusing and passively participating in RNA therapy. The DOR stated the RNA orders may need to be changed to reflect Resident 69's level of participation and to encourage Resident 69 to become an active participant. The DOR stated due to Resident 69's passive participation and refusals and the lack of notification to the rehab department, Resident 69 was at risk of decline to his already limited mobility.During an interview on 2/9/2026 at 11:27 a.m., with the Director of Nursing (DON), the DON stated Resident 69's RNA therapy refusals and passive participation should have been reported to the rehab and nursing departments. The DON stated Resident 69 did not receive the full rehabilitation he required. The DON stated prompt notification would allow both departments to figure out why Resident 69 was not participating and to reevaluate his plan of care. The DON stated if Resident 69's refusal and passive participation continued to be unreported, Resident 69 was at risk of decline in his mobility. During a review of the facility's Policy and Procedure (P&P) titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated the facility was to ensure residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. The P&P indicated residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. During a review of the facility's Restorative Nursing Assistant Job Description (undated), the RNA was to ensure the following: 1. Provide restorative nursing care (ROM, exercises, ambulating) to residents as ordered by the resident's physician 2. Perform all nursing activities in compliance with the written plan of care and using established policies. 3. Document daily care provided to all residents 4. Complete weekly summaries of residents' progress in restorative program 5. Observe and report changes in residents' condition to the charge nurse-and document same

Based on observation, interview, and record review, the facility failed to ensure the restorative nursing aides (RNA) accurately documented care provided, and failed to ensure repositioning and bathing was performed and documented four of four sampled residents (Resident16, Resident 8, Resident 65, and Resident 11). These deficient practices resulted in clinical records that did not reliably reflect restorative nursing care provided to Residents 16, 28, and 65, which had the potential to impede the facility's ability to monitor implementation of restorative nursing services and timely re-evaluate resident treatment needs. These deficient practices also impeded in the facility's ability to verify implementation of pressure injury prevention and hygiene care for a resident at increased risk for skin breakdown. Findings:a. During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 65's diagnoses included spondylosis with radiculopathy (spinal degeneration) of the lumbar (low back), low back pain, intervertebral (in between the bones in the spine) disc degeneration, and history of falling. During a review of Resident 65's Minimum Data Set ([MDS], a resident assessment tool), dated 11/12/2025, the MDS indicated Resident 65's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 65 required supervision for walking, toileting, showering, and putting on footwear. During a review of Resident 65's History and Physical (H&P), dated 12/2/2024, the H&P indicated Resident 65 had the capacity to understand and make decisions. During a review of the facility's Order Listing Report, dated 2/5/2026, the report indicated Resident 65 had orders for RNA to ambulate (walk) Resident 65 with a front wheeled walker every day for five times a week or as tolerated. During an observation and interview on 2/2/2026 at 9:15 a.m. in Resident 65's room, observed Resident 65 in bed. Resident 65 stated he had not been walking and that staff had not assisted him to walk on a regular basis or offered walking exercises. Resident 65 stated he would like to participate in walking exercises to improve his strength. During an observation and interview on 2/4/2026, at 12:20 p.m., in Resident 65's room, observed Resident 65 in bed. Resident 65 stated he did not walk with RNA staff and was not offered to walk that week (2/2/2026 through 2/4/2026). During a concurrent interview and record review on 2/5/2026. 2:00 p.m. with RNA 1, Resident 65's RNA Task Flow Sheet was reviewed. The flow sheet indicated Resident 65 was ambulated on 2/2/2026 and 2/4/2026 at 2:59 p.m. RNA 1 stated that she ambulated Resident 65 during the day shift on 2/4/2026. During a concurrent observation and interview on 2/5/2026 at 2:15 p.m. with RNA 1, in Resident 65's room, observed Resident 65 in bed. Resident 65 stated he was not ambulated or offered ambulation by any staff member from 2/2/2026 through 2/4/2026, including RNA 1. RNA 1 stated she was the assigned RNA on 2/2/2026 and 2/4/2026 and could not explain the discrepancy between Resident 65's statement and her documentation. During a concurrent interview and record review on 2/5/2026. 2:27 p.m. with RNA 1, Resident 65's RNA Task Flow Sheet was reviewed. RNA 1 stated she ambulated Resident 65 after dinner on 2/4/2026 at 6:00 p.m. RNA 1 stated documentation was not entered when the service was rendered and confirmed documentation was expected to be completed as accurately and timely as possible to reflect the care provided. b. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 28's diagnoses included adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), dysphagia (difficulty swallowing), and hypertensive heart disease (high blood pressure). During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 28 had functional range of motion (ROM) limitations to his upper and lower extremities. The MDS indicated required substantial assistance (helper does more than half the effort) for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 28's H&P, dated 2/2/2026, the H&P indicated Resident 28 had the capacity to understand and make decisions. During a review of Resident 28's Order Summary Report, dated 2/1/2026, the report indicated Resident 28 had the following RNA orders:1. RNA to splint (a medical device designed to treat a stiff elbow with limited range of motion by providing a prolonged, low-intensity stretch to tightened soft tissues) right elbow for two to three hours or as tolerated every day five times a week.2.RNA to provide bilateral (both) lower extremity (legs) passive range of motion (PROM -an outside force moves the joint) exercises everyday five times a week, or as tolerated.3.RNA to monitor for pain before and applying the splint, and to notify the charge nurse for the presence of pain.4. RNA to provide bilateral upper extremity (arms) active assist range of motion (AAROM- a technique that involves a patient using their own muscles to move a joint while receiving help from a therapist), followed by the application of bilateral hand rolls (devices used to maintain the hand in a functional position) for four to five hours or as tolerated everyday five times per week. During observations and interviews made on 2/4/2025 at 8:21 a.m., 10:16 a.m., 12:16 p.m., 1:31 p.m., 2:45 p.m., 3:37 p.m., and 4:42 p.m. in Resident 28's room, observed Resident 28 did not have bilateral hand rolls applied and did not have a right elbow splint. Resident 28 stated the staff did not apply hand rolls, nor provide ROM exercises for him that day. During a concurrent interview and record review on 2/5/2026 at 2:00 p.m. with RNA 1, Resident 28's RNA Task Flow Sheet, dated 2/4/2026, was reviewed. The RNA Task Flow Sheet indicated Resident 28 was provided 240 minutes (four hours) of bilateral hand roll splinting, 180 minutes of elbow splinting, and 15 minutes of range of motion exercises at 2:59 p.m. on 2/4/2026. The flow sheet indicated Resident 28 actively participated, exhibited no pain during the session, and tolerated the RNA session well on 2/4/2026. RNA 1 stated she did not apply bilateral hand rolls as ordered and instead placed bandages in the resident's palms to prevent skin break down. RNA 1 stated she did not apply the right elbow splint because the resident could not tolerate it. RNA 1 stated her documentation did not accurately reflect the services provided and Resident 28's ability to tolerate the current RNA program. RNA 1 stated the inaccurate documentation did not capture Resident 28's true clinical condition, which had the potential to result in a lack of timely re-evaluation and modification of treatment orders. c. During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 16's diagnoses included polyneuropathy, fracture of the right femur (broken thigh bone), contractures of the left and right ankle, and disorders of the muscles. During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 16 had functional range of motion limitations to his upper and lower extremities. The MDS indicated Resident 16 was entirely dependent on staff for ADLs. During observations made on 2/4/2026 at 8:10 a.m., 12:15 p.m., 1:48 p.m., and 2:48 p.m., observed Resident 16 in bed. Resident 16 stated he did not have PRAFO boots. During a concurrent interview and record review on 2/5/2026 at 2:30 p.m. with RNA 2, Resident 16's Order Summary, dated 2/1/2026, and RNA Task Flow sheet, dated 2/2026, were reviewed. The Order Summary indicated Resident 16 was to have bilateral lower extremity gentle PROM exercises five times a week, bilateral lower extremity PRAFO boots applied for four hours every day five days a week or as tolerated, and active assist ROM exercises to the upper extremities five days a week or as tolerated. The RNA Task Flow Sheet indicated, on 2/4/2026, Resident 16 received bilateral lower extremity gentle PROM exercises and PRAFO boots were applied. RNA 2 stated she did not apply the PRAFO boots on 2/4/2026 and did not follow the physician orders. RNA 2 stated there was no designated documentation field to record PRAFO boot application and that the documentation for RNA orders was unclear. RNA 2 stated RNA documentation should be as accurate as possible to ensure RNA services were provided on a consistent basis to prevent ROM of decline for Resident 16. During a concurrent interview and record review on 2/6/2026 at 9:41 a.m. with the Director of Staff Development (DSD), Resident 16, Resident 28, and Resident 65's RNA Task Flow Sheets, dated in 2/2026, were reviewed. The DSD stated documentation should be completed at the time the service was provided. The DSD stated there were no designated documentation fields specific to the type of splinting and range of motion exercises provided. The DSD stated if there were no designated documentation fields for the type of RNA orders, and times and participation levels were inaccurately documented, then the restorative nursing documentation for Residents 16, 28, and 65 had the potential to be deemed unreliable. The DSD stated that if the documentation was unreliable, the residents' tolerance to restorative nursing interventions may not be accurately captured, which had the potential to delay re-evaluation to the residents and modification of restorative nursing orders. d. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE]. Resident 11's diagnoses included palliative care (specialized medical care for individuals living with a serious, chronic, or life-threatening illness), cachexia (a complex syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion of the left hand, and unstageable pressure ulcer (full-thickness wound whose depth and severity cannot be determined) of the sacral region (tailbone). During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 11 had functional impairments in range of motion to both sides of his upper and lower extremities The MDS indicated Resident 11 required substantial assistance (helper does more than half the effort) for ADLs. During a review of Resident 11's care plan titled, Sacrococcyx (tail bone) Pressure Injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), initiated 1/6/2026, the care plan indicated the interventions were to reposition Resident 11 as needed and every two hours. During a review of Resident 11's Braden Risk Assessment (a tool used to predict a patient's risk of developing pressure injuries), dated 1/23/2026, the assessment indicated Resident 11 was at high risk for developing a pressure injury. During a concurrent interview and record review on 2/6/2026 at 10:00 a.m. with the Director of Staff Development (DSD), Resident 11's Task Flow Sheets, dated 1/2026 to 2/6/2026, were reviewed. The Flow Sheets did not indicate Resident 11 was repositioned and bathed. The DSD stated that it was important to reposition and document repositioning for Resident 11 because the resident was prone to the development or worsening of pressure injuries. The DSD stated the facility could not verify repositioning was provided because there was no documentation. The DSD stated she could not verify when Resident 11 was last bathed. During a review of the facility's Policy and Procedure (P&P) titled, Documentation , revised 4/2008, the P&P indicated the documentation of procedures and treatments should include care-specific details and shall include at a minimum:The date and time the procedure/treatment was provided;The name and title of the individual(s) who provided the care;The assessment data and/or any unusual findings obtained during the procedure/treatment;How the resident tolerated the procedure/treatment;Whether the resident refused the procedure/treatment;Notification of family, physician or other staff, if indicated; andThe signature and title of the individual documenting. During a review of the facility's P&P titled, Activities of Daily Living, revised 3/2018, the residents would be provided with care treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The P&P indicated residents who were unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. During a review of the facility's Restorative Nursing Assistant Job Description (undated), the job description indicated the following:Provide restorative nursing care (ROM, exercises, ambulating) to residents as ordered by the resident's physicianPerform all nursing activities in compliance with the written plan of care and using established policies.Document daily care provided to all residentsComplete weekly summaries of residents' progress in restorative program

Based on interview and record review, the facility failed to ensure two of ten sampled residents' (Residents 11 and 10) Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) and advanced directive rights were reviewed, completed and accurately reflected the residents' wishes.This failure has the potential to result in Resident 11 receiving life-sustaining treatment that did not align with his preferences during a change in condition or medical emergency and Resident 10, who did not have the capacity to make medical decisions, not understanding the life-sustaining treatment she consented to. Findings:a. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE]. Resident 11's diagnoses included palliative care (specialized medical care for individuals living with a serious, chronic, or life-threatening illness), cachexia (a complex syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left hand, and unstageable pressure ulcer (full-thickness wound whose depth and severity cannot be determined) of the sacral region.During a review of Resident 11's Minimum Data Set ([MDS], a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 11's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 11 required substantial assistance (helper does more than half the effort) for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 11's History and Physical (H&P), dated 1/3/2026, the H&P indicated Resident 11 did not have the capacity to understand and make decisions.During an interview on 2/4/2026, at 1:11 p.m. with Resident 11's Representative Party (RP) 1, RP 1 stated Resident 11 was able to make his own decisions, and RP 1 was available to consult him if he wished. During a concurrent interview and record review on 2/5/2026 at 11:30 a.m. with Quality Assurance Nurse (QAN), Resident 11's Physician Orders for Life-Sustaining Treatment (POLST – a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), dated 1/1/2026, and H&P, dated 1/3/2026, were reviewed. The POLST was incomplete and lacked physician and witness signatures, and indicated Resident 11 signed do no resuscitate (DNR-a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating). The H&P indicated Resident 11 lacked the capacity to make medical decisions. The QAN stated the POLST was incomplete and required an Interdisciplinary Team (IDT) review for the form to be completed again. The QAN stated if Resident 11's current POLST was left incomplete and inaccurate, there was a risk that staff would follow an incorrect code status during an emergency. During an interview on 2/6/2026 at 8:37 a.m. with Resident 11, in the presence of Registered Nurse (RN) 1, Resident 11 stated he was able to make decisions for himself but would also prefer to consult with his brother, RP 1, to help with making medical decisions. Resident 11 stated that he wished to have the facility attempt chest compressions in the event he is found unresponsive. RN 1 stated that if Resident 11 wished to receive chest compressions, then Resident 11 would need to be considered a full code.During a concurrent interview and record review on 2/6/2026 at 9:13 a.m., with the Social Services Director (SSD), Resident 11's POLST, dated 1/1/2026, was reviewed. The POLST indicated Resident 11 signed DNR and the POLST lacked physician and witness signatures. SSD stated that the POLST was incomplete and invalid. SSD stated that it was in her process to review the POLST upon admission, during advance directive acknowledgment review, but it was missed. The SSD stated that if she had reviewed the POLST, she would have had Resident 11 or RP 1 complete the POLST to ensure it accurately reflected Resident 11's end-of-life wishes and was completed with the necessary signatures. During a concurrent interview and record review on 2/9/2026 at 9:20 a.m. with SSD, all of Resident 11's medical record documentation, dated in 2026, was reviewed. Resident 11's medical record lacked a signed advanced directive acknowledgment form. The SSD stated the form was usually completed during the admission process to review wishes regarding code status, treatment and end-of-life preferences. The SSD stated the lack of the form demonstrated the facility was unable to verify that advance directive rights were reviewed with Resident 11 or RP 1 upon admission.b. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE]. Resident 10's diagnoses included dementia (a progressive state of decline in mental abilities) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). The admission Record indicated RP 2 was Resident 10's responsible party.During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10's cognition was severely impaired. The MDS indicated Resident 10 required moderate assistance (helper does less than half the effort) with toileting, bathing, and putting on/taking off footwear.During a review of Resident 10's H&P, dated 12/24/2025, the H&P indicated Resident 10 did not have the capacity to consent.During an interview on 2/9/2026 at 9:20 a.m., with the SSD, the SSD stated when a resident was admitted to the facility, she would review the advance directive acknowledgement and the POLST with the resident or their responsible party. The SSD stated upon admission, the resident's H&P may not be completed by their physician and she was responsible for reviewing the resident's medical records from the general acute care hospital (GACH). The SSD stated reviewing the GACH medical records would indicate whether the resident had the mental capacity to understand what the advance directive and POLST were and to continue with completing those forms.During a concurrent interview and record review, on 2/9/2026 at 9:22 a.m., with the SSD, Resident 10's GACH Psychosocial Initial Assessment Note, dated 12/9/2025, was reviewed. The GACH Note indicated Resident 10 designated RP 2 as her primary surrogate decision maker. The SSD stated RP 2 was Resident 10's decision maker for any medical decisions. The SSD stated reviewing GACH medical records was important to ensure Resident 10 had someone to make all medical decisions for her.During a concurrent interview and record review, on 2/9/2026 at 9:24 a.m., with the SSD, Resident 10's Advance Directive Acknowledgement Form, dated 12/17/2025, was reviewed. The Advance Directive Acknowledgement Form indicated Resident 10 was given written materials and informed about her right to accept or refuse medical treatments, was informed of her rights to formulate an Advance Directive and understood she was not required to have an Advance Directive. The Advance Directive Acknowledgement Form indicated Resident 10 did not have an Advance Directive. The SSD stated Resident 10's Advance Directive Acknowledgement Form should have been discussed with RP 2 because Resident 10 may not have the capacity to understand the information provided regarding the Advance Directive and her wishes.During a concurrent interview and record review, on 2/9/2026 at 9:25 a.m., with the SSD, Resident 10's POLST, dated 12/19/2025, was reviewed. The POLST indicated attempting resuscitation (the process of reviving an individual from unconsciousness or apparent death) and full treatment such as long-term artificial nutrition (food and fluids provided through a tube to an individual who is unable to eat or drink normally) was to be administered if Resident 10 required life-sustaining treatment. The POLST indicated with Resident 10's signature, she consented that the resuscitative measures were consistent with her own wishes. The SSD stated Resident 10 did not have the mental capacity to complete her POLST regarding the different options of life-sustaining measures and treatments. The SSD stated reviewing the POLST with RP 2 was important to ensure Resident 10's life-sustaining wishes were correct.During an interview on 2/9/2026 at 11:06 a.m., with the Director of Nursing (DON), the DON stated the Advance Directive was the resident's written down wishes for treatment and end-of-life if they were to lose the ability to make decisions. The DON stated the POLST was the life-saving treatment the resident, or their responsible party, consented to. The DON stated reviewing and completing the Advance Directive Acknowledgement Form and the POLST with the appropriate individual, whether the resident or their responsible party, was important to ensure the resident's expressed wishes were executed. The DON stated Resident 10 did not have the capacity to understand and make medical decisions, therefore should not have completed the Advance Directive Acknowledgement Form and the POLST. The DON stated Resident 10 may not understand what life-saving measures were and potentially indicate treatments that did not align with her previous expressed wishes when she did have the decision-making capacity.During a review of the facility's Policy and Procedure (P&P) titled, Advance Directive, revised 9/2022, the P&P indicated the following:1. The resident had the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment.2. Prior to or upon admission, the social services director or designee inquired of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.3. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.4. Upon admission the interdisciplinary team assesses the residents decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity.5. If the resident or representative indicated that he or she had not established advance directives, the facility staff would offer assistance in establishing advance directives.During a review of the facility's Social Services Designee Job Description, undated, the Job Description indicated the Social Services Designee's job function was to work with residents to complete advance directive documentation when appropriate.

Based on interview and record review, the facility failed to timely submit a referral to the Office of the Long-Term Care Patient Representative (OLTCPR- office that provides a trained public representative for specified long-term care residents who may need medical treatment but lack decision-making capacity and have no legally authorized decision-maker) for one of one sampled residents (Resident 25).This deficient practice resulted in a delay in obtaining a representative for Resident 25, which resulted in the bio-ethics committee (a multidisciplinary team designed to address, guide, and resolve resident-care issues) overseeing Resident 25's care. Findings:During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 25's diagnoses included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), senile degeneration of the brain (a progressive, age-related decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Record indicated the facility's bio-ethics committee as Resident 25's responsible party (decision maker when an individual does not have the mental capacity to do so).During a review of Resident 25's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 25's cognition (process of thinking) was severely impaired. The MDS indicated Resident 25 required maximal assistance (helper does more than half the effort) with oral hygiene, toileting, bathing, dressing, and personal hygiene.During a review of Resident 25's History and Physical (H&P), dated [DATE], the H&P indicated Resident 25 had fluctuating (changing) capacity to understand and make decisions.During a review of Resident 25's H&P, dated [DATE], the H&P indicated Resident 25 did not have the capacity to understand and make decisions.During an interview on [DATE] at 8:29 a.m., with the Quality Assurance (QA) Nurse, the QA Nurse stated when a resident had fluctuating capacity to understand and make decisions and did not have any family or friends, the resident would be overseen by the bio-ethic committee. The QA Nurse stated the bio-ethics committee consisted of the resident's physician, herself, the Director of Nursing (DON), the Social Services Director (SSD), and any other department heads required to give input on the resident's plan of care. The QA Nurse stated the bio-ethics committee acted as the resident's responsible party to consent for any medical treatment the resident required. The QA Nurse stated the bio-ethics committee should only be a short-term solution and the resident should be referred to the Office of the Long-Term Care Patient Representative (OLTCPR- office that provides a trained public representative for specified long-term care residents who may need medical treatment but lack decision-making capacity and have no legally authorized decision-maker) as soon as possible. The QA Nurse stated for as long as she could remember, Resident 25's care was always overseen by the bio-ethics committee.During a concurrent interview and record review on [DATE] at 8:41 a.m., with the QA Nurse, the California Department of Aging's webpage topic, link https://aging.ca.gov/providers_and_partners/office_of_the_long-term_care_patient_representative/, titled, The Office of the Long-Term Care Patient Representative, undated, was reviewed. The webpage indicated the facility should request a public patient representative if the facility received an order for medical treatment for the resident, the medical treatment required informed consent, the physician determined the resident lacked capacity to provide informed consent, and the resident lacked a legal decision maker or family/friend who could participate in the IDT review. The QA Nurse stated Resident 25 met the requirements for a public patient representative based on her fluctuating mental capacity on [DATE]. The QA Nurse stated Resident 25 has received medical treatments which required informed consents.During a concurrent interview and record review on [DATE] at 11:13 a.m., with the QA Nurse, Resident 25's Progress Note, dated [DATE], was reviewed. The Progress Note indicated on [DATE], Resident 25 was readmitted to the facility and could make basic needs known. The Progress Note indicated Resident 25 did not have any family or friends involved in her care. The Progress Note indicated Resident 25 would be referred to the OLTCPR for medical interventions requiring informed consents. The QA Nurse stated Resident 25 should have been referred to the OLTCPR earlier than [DATE] because Resident 25's care was overseen by the bio-ethics long before then. The QA Nurse stated timely referral to the OLTCPR would allow a representative to be assigned to oversee Resident 25's care.During an interview on [DATE] at 10:53 a.m., with the Director of Nursing (DON), the DON stated when a resident, who did not have the capacity to make medical decisions, did not have any friends or family involved in their care, the facility was responsible to refer the resident to the OLTCPR. The DON stated the referral should be done as soon as the resident was admitted or when a decline in mental capacity to make decisions was determined by the physician. The DON stated timely referral would prevent any delays in the process of appointing a representative. The DON stated Resident 25's referral was not submitted timely, which resulted in the bio-ethics committee overseeing her care and consenting to all medical treatments. The DON stated timely referral to the OLTCPR was necessary to prevent any conflicts of interests regarding Resident 25's care, to appoint a representative who could be more objective and make unbiased informed decisions.During a review of the California Department of Aging's webpage topic, link https://aging.ca.gov/providers_and_partners/office_of_the_long-term_care_patient_representative/, titled, The Office of the Long-Term Care Patient Representative, undated, the webpage indicated, The Office of the Long-Term Care Patient Representative (OLTCPR) provides trained public representatives for specified long-term care residents who may need medical treatment but lack decision-making capacity and have no legally authorized surrogate. The webpage indicated, Skilled nursing and intermediate care facilities may convene an interdisciplinary team (IDT) to make medical decisions for these residents. Facilities are required to include patient representatives on the IDT. If the facility cannot find a suitable person-such as a friend or family member-OLTCPR provides a trained public patient representative to help ensure the resident's rights, preferences, and dignity are supported in medical decision-making.

Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from one of five sampled residents' (Resident 10) responsible party (decision maker when an individual does not have the mental capacity to do so) prior to the administration of psychotropic medication (medications that affect the mind, emotions, and behavior).This deficient practice resulted in Resident 10, who did not have the capacity to consent, making uninformed decisions about her care and unable to understand the use, side effects, and risks of taking psychotropic medications.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE]. Resident 10's diagnoses included dementia (a progressive state of decline in mental abilities) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). The admission Record indicated Responsible Party ([RP], decision maker when an individual does not have the mental capacity to do so) 2 was Resident 10's responsible party.During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool), dated 1/6/2026, the MDS indicated Resident 10's cognition (process of thinking) was severely impaired. The MDS indicated Resident 10 required moderate assistance (helper does less than half the effort) with toileting, bathing, and putting on/taking off footwear.During a review of Resident 10's History and Physical (H&P), dated 12/24/2025, the H&P indicated Resident 10 did not have the capacity to consent.During a review of Resident 10's General Acute Care Hospital (GACH) Psychosocial Initial Assessment Note, dated 12/9/2025, the GACH Note indicated Resident 10 designated RP 2 as her primary surrogate decision maker.During a review of Resident 10's Order Summary Report, order dated 12/18/2025, the Order Summary Report indicated to give the following:1. Divalproex Sodium (an anticonvulsant medication, used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions), 250 milligrams (mg, a unit of measurement), by mouth twice a day for bipolar disorder manifested by erratic mood swings.2. Quetiapine (an antipsychotic medication [a medication that affects the mind, emotions, and behavior]) 25mg, by mouth twice a day for bipolar disorder manifested by delusions (a firm, false belief that does not change) of being persecuted.During a concurrent interview and record review on 2/5/2026 at 10:25 a.m. with Registered Nurse (RN) 1, Resident 10's Verification of Informed Consent to Psychotropic Drug for Divalproex Sodium and Quetiapine, dated 12/17/2025, were reviewed. The Verification of Informed Consent to Psychotropic Drug indicated on 12/17/2025, Resident 10's physician obtained informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of Divalproex Sodium and Quetiapine from Resident 10. The Verification of Informed Consent to Psychotropic Drug indicated RN 1 verified informed consent was obtained from Resident 10. RN 1 stated Resident 10 should not have consented to receive Divalproex Sodium and Quetiapine because it was determined Resident 10 did not have the capacity to consent and appointed RP 2 as her surrogate decision maker. RN 1 stated due to Resident 10's impaired cognition, Resident 10 would not be completely aware of the risks associated with receiving Divalproex Sodium and Quetiapine, therefore unable to make an informed decision.During an interview on 2/9/2026 at 10:59 a.m., with the Director of Nursing (DON), the DON stated informed consent for psychotropic medication use had to be obtained from the resident, if they had decision-making capacity, or their responsible party. The DON stated psychotropic medications had associated risks and side effects which had to be conveyed and understood by the consenting individual. The DON stated Resident 10 did not have the capacity to consent to the use of psychotropic medications, which could result in Resident 10 not truly understanding the risks.During a review of the facility's Policy and Procedure (P&P) titled, Psychoactive Medication Informed Consent, dated 3/2024, the P&P indicated, It is the policy of this facility to ensure that informed consent is obtained for each resident's psychoactive medication is authorized in writing by a physician for specified time period and when necessary to protect the resident from self-injury or injury to others. The P&P indicated, If the resident is not capable of giving informed consent, consent will be obtained from resident's representative

Based on observation, interview, and record review, the facility failed to ensure the call light (a device that residents use to request assistance from staff) was within reach for three of 18 sampled residents (Residents 28, 91, and 48).This deficient practice had the potential to negatively impact Residents 28, 91, and 48's psychosocial well-being and result in delayed provision of care and services. Findings: a. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 28's diagnoses included adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), dysphagia (difficulty swallowing), and hypertensive heart disease (high blood pressure). During a review of Resident 28's Minimum Data Set ([MDS], a resident assessment tool), dated 11/19/2025, the MDS indicated Resident 28's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 28 had functional ROM limitations to his upper and lower extremities. The MDS indicated required substantial assistance (helper does more than half the effort) for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 28's History and Physical (H&P), dated 2/2/2026, the H&P indicated Resident 28 had the capacity to understand and make decisions. During a review of Resident 28's care plan titled, At Risk for Falls, initiated 2/21/2025, the care plan interventions were to keep the call light (a device that residents use to request assistance from staff) within reach and answer promptly. During observations made on 2/4/2026 at 8:21 a.m., 10:16 a.m., 12:16 p.m., 1:31 p.m., 2:45 p.m., and 3:37 p.m., in Resident 28's room, Resident 28's call light was pinned to his bed close to his right shoulder and was not within functional reach. Resident 28 had both hands clenched, and both elbows in a fixed flexed position. During a concurrent observation and interview on 2/5/2026 at 3:44 p.m. with Licensed Vocational Nurse (LVN) 3, in Resident 28's room, Resident 28's call light was pinned near his right shoulder and was not accessible to the resident. Resident 28 stated it was hard to grab the call light. LVN 3 stated the call light was not in reach and it was not an appropriate call light device for Resident 28 due to severe contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of both upper extremities. LVN 3 stated Resident 28 was at risk of being unable to call for timely assistance with toileting needs, repositioning, pain, or emergent needs because the call light was not accessible and not the appropriate type. b. During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 91's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), epilepsy (a neurological disorder), and anxiety (a feeling of fear). During a review of Resident 91's MDS, dated [DATE], the MDS indicated Resident 91's cognition (ability to think and process information) was severely impaired. The MDS indicated Resident 91 required supervision or touching assistance (helper provides verbal cues and /or touching/steadying assistance as resident completes activity) from staff for ADLs. During a review of Resident 91's care plan titled Risk for Falls, dated 1/29/2026, the care plan intervention indicated facility would ensure Resident 91's call light placed within reach and answered promptly. During observations on 2/2/2026 at 9:00 a.m., 9:55 a.m., 11:35 a.m., and 1:58 p.m., in Resident 91's room, the call light was observed on the floor behind the bed. The call light was out of Resident 91's reach. c. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE]. Resident 48's diagnoses included Parkinson's disease, schizoaffective disorder, and anxiety. During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48' cognition was moderately impaired. The MDS indicated Resident 48 required maximum (helper does more than half the effort) assistance from staff for ADLs. During a review of Resident 48's care plan with a focus of Resident had behavioral patterns of restlessness., initiated on 9/29/2025, the care plan intervention indicated the facility would ensure Resident 48's call light was placed within reach. During an observation on 2/2/2026 at 10:30 a.m., in Resident 48's room, Resident 48 was lying in bed. Resident 48's call light was on the floor behind the curtain and not within reach. During a concurrent observation and interview on 2/2/2026 at 10:45 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 48's room, Resident 48's call light was on the floor. CNA 1 stated Resident 48's call light was on the floor behind the curtain and not within reach. CNA 1 stated the call light should always be placed within the residents' reach so they could call for help when needed. CNA 1 stated having the call light on the floor and not within reach placed Resident 48 at risk for unmet care needs, delayed assistance, increased risk for falls, and potential injury. During an interview on 2/6/2026 at 12:51 p.m., with Registered Nurse (RN) 1, RN 1 stated the call light must be placed within the resident's reach at the bedside. RN 1 stated the call light was important for residents to be able to communicate their needs to staff. RN 1 stated licensed staff were responsible for ensuring residents' call lights were checked and positioned within reach at bedside. RN 1 stated when a call light was not within reach, the residents would not be able to call for help, which was a safety issue. RN 1 stated not having call lights within reach placed residents at risk for delayed care needs and avoidable harm. During a review of the facility's policy and procedure (P&P) titled Answering the Call Light, revised 10/2010, the P&P indicated the facility would ensure resident's call light would be placed within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 4) was free from unnecessary physical restraint when Resident 4's bed was placed against the wall with upper side rails raised. This failure resulted in Resident 4 being subjected to a restraint without clinical justification and had the potential for restricting Resident 4's freedom of movement, causing physical or psychological harm.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included paraplegia (loss of movement and/or sensation, to some degree, of the legs), dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), and history of falls.During a review of Resident 4's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/4/2026, the MDS indicated Resident 4's cognition was moderately impaired. The MDS indicated Resident 4 required maximum (helper does more than the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During observations on 2/2/2026 at 10:01 a.m., 12:30 p.m., and 3:45 p.m. at Resident 4's bedside, Resident 4 was observed lying in bed with the bed placed directly against the wall on the left side and both upper side rails were raised.During an interview on 2/5/2026 at 8:25 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when a resident has a history of falls and was at high risk for falls, staff were to place the bed against the wall and apply side rails on both sides of the resident's bed to prevent the resident from falling.During a concurrent observation and interview on 2/5/2026 at 8:45 a.m. at Resident 4's bedside with LVN 1, Resident 4 was observed lying in bed with the bed placed directly against the wall on the left side. LVN 1 stated having the bed against the wall with raised upper side rails restricted Resident 4's ability to freely exit the bed. LVN 1 stated the bed had been positioned against the wall and the side rails were kept up as ongoing fall- prevention measures for Resident 4. LVN 1 stated this practice limited Resident 4's ability to get out of bed and prevented her from falling. LVN 1 stated physical restraints should not be used for fall prevention or staff convenience. LVN 1 stated placing Resident 4's bed against the wall in combination with raised side rails without a care plan, physician order, and informed consent would be considered a physical restraint.During a concurrent interview and record review on 2/5/2026 at 8:45 a.m., with LVN 1, Resident 4's Electronic Medical Record (EMR), was reviewed. LVN 1 stated there was no documented evidence that least restrictive interventions had been attempted or implemented prior to placing Resident 4's bed against the wall with bilateral side rails raised. LVN 1 stated there was no physician order or informed consent for the use of physical restraint for Resident 4. LVN 1 stated that using the bed against the wall as a physical restraint placed Resident 4 at risk for entrapment (capture, catch, and trap), injury, and loss of dignity.During a review of the facility's policy and procedure (P&P) titled Use of Restraints, revised 12/2007, the P&P indicated Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. The P&P indicated Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor).

Based on interview and record review, the facility failed to develop and implement individualized care plans for four of eight sampled residents (Resident 11, Resident 3, Resident 10, and Resident 57) when care plans were not developed to address:a. Resident 11's identified range of motion impairments and comfort-focused mobility needs.b. Resident 3's use of the anticoagulant (blood thinner) medication, Apixaban (a medication used to prevent blood clots).c. Resident 10's use of grab bars for safe transfers.d. Resident 57's hearing impairment and use of hearing aids. These deficient practices placed Resident 11, Resident 3, Resident 10, and Resident 57 at risk for increased pain, stiffness, further development of contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion), bleeding complications, unsafe transfers, falls, decreased communication, and decline in comfort and functional status. Findings: a. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE]. Resident 11's diagnoses included palliative care (specialized medical care for individuals living with a serious, chronic, or life-threatening illness), cachexia (a complex syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left hand, and unstageable pressure ulcer (full-thickness wound whose depth and severity cannot be determined) of the sacral region (triangular bone at the base of the spine). During a review of Resident 11's Minimum Data Set ([MDS], a resident assessment tool), dated 1/13/2026, the MDS indicated Resident 11's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 11 required substantial assistance (helper does more than half the effort) for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 11's Joint Mobility Assessment (JMA), dated 1/6/2026, the JMA did not indicate recommendations and interventions to address Resident 11's range of motion (ROM, the full, functional measurement of how far a specific joint or body part can move in various directions) needs. The JMA indicated Resident 11 had the following range of motion (ROM) limitations: 1. Severe limitations to his left and right shoulders. 2. Moderate limitations to his left and right elbows, fingers of the left hand, both hips, right knee and left and right ankle. 3. Moderate to severe limitations to the left wrist. 4. Minimal limitations to his right wrist and fingers of the right hand. During a concurrent interview and record review on 2/05/2026 at 4:08 p.m. interview with Minimum Data Set Nurse (MDSN) 1, Resident 11's MDS Section GG, dated 1/13/2026, and all of Resident 11's care plans, dated in 2026, were reviewed. The MDS Section GG indicated Resident 11 had functional impairments in range of motion to both sides of his upper and lower extremities. There were no care plans in place to address Resident 11's ROM impairments or comfort focused mobility interventions. MDSN 1 stated the lack of a care plan that addressed Resident 11's ROM limitations placed Resident 11 at risk for increased pain, stiffness, and decline in comfort. During a review of the facility's policy and procedure (P&P) titled, Hospice Program, revised 7/2017, the P&P indicated the coordinated care plan would reflect the resident's goals and wishes as stated in his advanced directives and during ongoing communication with the resident or representative including palliative goals and objectives, interventions, and medical treatment. The P&P indicated the coordinated care plan would be revised and updated as necessary to reflect the resident's current status including mobility and positioning. b. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included acute embolism and thrombosis of the right popliteal vein (a sudden blood clot that forms in the vein behind the right knee which can block blood flow and travel to other parts of the body), presence of cardiac pacemaker (a device placed in the chest that helps the heart beat regularly), myocardial infarction (MI - heart attack), acute and chronic kidney disease (a sudden and long-term problem where the kidneys do not work remove waste and extra fluid from the body), anemia (a condition where the body does not have enough healthy red blood cells), and a history of falling. During a review of Resident 3's History and Physical (H&P), dated 10/18/2025, the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills were severely impaired. The MDS indicated Resident 3 required set-up or clean-up assistance (helper assists only prior to or following the activity) for eating and dressing. The MDS indicated Resident 3 required moderate assistance (helper does less than half the effort) with toileting and bathing. The MDS indicated Resident 3 was receiving anticoagulant therapy. During a review of Resident 3's physician order dated 10/17/2025, the order indicated to observe closely for significant side effects of anticoagulant medications. During a review of Resident 3's physician order dated 10/25/2025, the order indicated to give one tablet by mouth of Apixaban (a medication used to prevent blood clots) 5 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) one time a day for deep vein thrombosis (DVT- a blood clot that forms in a vein deep in the body) prophylaxis (PPX- action taken to prevent disease). During an interview on 2/9/2026 at 12:59 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 3 was receiving Apixaban. LVN 3 stated there was no care plan. LVN 3 stated when a resident was initially placed on an anticoagulant, the resident would require laboratory monitoring, a physician order, and initiation of a care plan. LVN 3 stated a resident who received an anticoagulant would require monitoring for signs of bleeding. LVN 3 stated an anticoagulant care plan would include signs and symptoms of bleeding, instructions on when to hold the anticoagulant medication, and when to notify the physician to ensure a plan was in place if an adverse event occurred. c. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 57's diagnoses included dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (condition characterized by persistent, excessive, and uncontrollable fear or worry). During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57's cognition was intact. The MDS indicated Resident 57 required setup or clean-up assistance with eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 57 had moderate difficulty (speaker has to increase volume and speak distinctly) with his hearing. During a review of Resident 57's H&P, dated 1/30/2026, the H&P indicated Resident 57 had the capacity to understand and make decisions. During a concurrent observation and interview on 2/2/2026 at 9:36 a.m., with Resident 57, in Resident 57's room, Resident 57 was observed with two hearing aids inside a case stored on his nightstand. Resident 57 picked up the hearing aids and stated he was given the hearing aids, however, they are no good to me. Resident 57 stated when speaking to another person, the outside noise was amplified, and he was unable to hear the other person clearly. During a concurrent interview and record review on 2/5/2026 at 11:03 a.m., with MDS Nurse (MDSN) 1, Resident 57's Care Plans, active on 2/5/2026, were reviewed. The care plan did not indicate there was a care plan to address Resident 57's hearing impairment and use of hearing aids. MDSN 1 stated Resident 57 had difficulty hearing, especially during conversations, which resulted in speaking in a louder volume during conversations. MDSN 1 stated a care plan should have been developed to address Resident 57's hearing and use of hearing aids to ensure all staff knew how to communicate with Resident 57. MDSN 1 stated a care plan would have included interventions to speak slower, clearer, and to write down communications if needed. MDSN 1 stated an important aspect of the care plan would be to assess Resident 57's hearing and use of hearing aids to determine if an audiology (examination of hearing) referral was needed. MDSN 1 stated without this care plan, Resident 57 was at risk of his needs not being met and ineffective communication with his peers and staff. During an interview on 2/9/2026 at 11:16 a.m., with the Director of Nursing (DON), the DON stated Resident 57 should have had a care plan developed to address his hearing and use of hearing aids. The DON stated the care plan should have included assessments of Resident 57's hearing and use of hearing aids. The DON stated the care plan would have outlined how to effectively communicate with Resident 57. The DON stated without a care plan, there would be no implementation of the process to care for Resident 57's hearing aids, refer to audiology if the hearing aids were not functioning properly, to monitor Resident 57's correct utilization of the hearing aids, and to monitor whether the hearing aids were effective. The DON stated without a care plan, Resident 57 was at risk of ineffective communication regarding his care. d. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included dementia and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 10 required moderate assistance (helper does less than half the effort) with toileting, bathing, and putting on/taking off footwear. During a review of Resident 10's H&P, dated 12/24/2025, the H&P indicated Resident 10 did not have the capacity to consent. During a review of Resident 10's physician orders, active on 2/5/2026, the orders did not indicate the use of grab bars (a type of side rails, which are short rails on one or both sides of the bed that can be used to assist in bed mobility). During an observation on 2/2/2026 at 9:24 a.m., in Resident 10's room, Resident 10 was observed sitting at the edge of her bed. There were bilateral (both sides) grab bars on the bed. During a concurrent observation and interview on 2/5/2026 at 8:02 a.m., with Registered Nurse (RN) 1, in Resident 10's room, Resident 10 was observed sitting at the edge of her bed with bilateral grab bars on the bed. RN 1 stated Resident 10 did not have an indication for the grab bars because Resident 10 did not need assistance in her mobility or repositioning. RN 1 stated Resident 10 may have inherited a bed from a previous resident who used the grab bars. RN 1 stated the grab bars were not removed. During a concurrent interview and record review on 2/5/2026 at 8:03 a.m., with RN 1, Resident 10's Care Plans, active on 2/5/2026, were reviewed. The care plans did not indicate a care plan was initiated to address the presence of grab bars. RN 1 stated due to the presence of grab bars on Resident 10's bed, a care plan should have been developed to address the associated safety concerns such as entrapment (becoming caught, trapped, or tangled in between a small space) and injury. During an interview on 2/9/2026 at 11:16 a.m., with the DON, the DON stated Resident 10 should have had a care plan developed for the presence of the grab bars. The DON stated although Resident 10 was independent in her mobility, the grab bars could be used as a mobility aid if needed. The DON stated without a care plan, there was no documentation detailing the use of the grab bars and the interventions the nurses had to implement to ensure safety. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive, revised 9/2010, the P&P indicated the facility was to ensure the facility's Care Planning or Interdisciplinary Team, in coordination with the resident, or the representative party, developed and maintained a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain. The comprehensive care plan was based on a thorough assessment that included but is not limited to, the MDS.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 53) received nail care and grooming services. This deficient practice had the potential to result in Resident 53 experiencing infection, compromised hygiene, skin injury from scratching, and diminished dignity.Findings: During a review of Resident 53's admission Record, the admission Record indicated Resident 53 was admitted to the facility on [DATE]. Resident 53's diagnoses included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), absence of left leg below the knee (BKA - surgical removal of the portion of the leg below the knee), chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), dementia (a progressive state of decline in mental abilities), and anxiety disorder (a mental condition that can cause worry, fear, or distress and may interfere with daily activities). During a review of Resident 53's History and Physical (H&P), dated 12/15/2025, the H&P indicated Resident 53 could make needs known but could not make medical decisions. During a review of Resident 53's Minimum Data Set (MDS - a resident assessment tool) dated 12/26/2025, the MDS indicated Resident 53's cognition (ability to think, remember, and reason) was severely impaired. The MDS indicated Resident 53 was independent (resident completes activity by themselves with no assistance) with eating and required moderate assistance (helper does less than half the effort) for toileting, bathing, dressing and personal hygiene. The MDS indicated Resident 53 required a wheelchair for mobility (the ability to move freely and safely from one place to another). During a review of Resident 53's care plan titled Activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and functional mobility, initiated 12/18/2024, the care plan indicated Resident 53 required assistance with personal hygiene and grooming. The care plan indicated the goal was to groom and meet Resident 53 daily needs. The care plan interventions indicated to assist with ADLs as needed and monitor Resident 53 for ADL needs. During an observation on 2/2/2026 at 9:25 a.m., while in Resident 53's room, observed Resident 53 lying in bed, alert and awake. Resident 53's fingernails were overgrown with jagged, uneven edges extending beyond the fingertips. Yellow discoloration and dark debris were visible beneath several fingernails. The nails were untrimmed. During an interview on 2/5/2026 at 4:30 p.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 53's nails were dirty and untrimmed. CNA 5 stated nursing staff made sure residents' nails were clean and trimmed every day. CNA 5 stated dirty nails could cause infection and spread germs. CNA 5 stated residents who were not groomed may feel uncomfortable. During a concurrent interview and record review on 2/5/2026 at 4:43 p.m., with Licensed Vocational Nurse (LVN) 5, Resident 53's nursing progress notes from 1/31/2026 to 2/3/2026 were reviewed. The progress notes did not indicate documentation of Resident 53 refusal of fingernail grooming from 1/31/2026 to 2/3/2026. LVN 5 stated Resident 53 often refused to be groomed. LVN 5 stated when residents refused ADL care, the CNAs were required to report the refusal to the charge nurse and complete a Stop and Watch (a tool used to report observed changes in a resident's condition for further assessment). LVN 5 stated the charge nurse signed the Stop and Watch and implemented and documented interventions. LVN 5 stated refusals should have been documented. LVN 5 stated the CNAs should have either reported the refusal. LVN 5 stated it was important to clean the resident's nails due to risk of infection and overall well-being. LVN 5 stated eating with dirty nails could have been a hygiene issue. During a review of the facility's policy and procedure (P&P) titled Activities of Daily Living (ADL), Supporting, revised 3/2018, the P&P indicated residents would be provided care, treatment, and services to maintain or improve their ability to carry out ADLs. The P&P indicated residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene. The P&P further indicated appropriate care and services would be provided in accordance with the plan of care, including hygiene such as bathing, dressing, grooming, and oral care. The P&P indicated when residents refused care, the resident or representative would be informed of the risks and benefits of the proposed care or treatment, alternative interventions would be offered to minimize further decline, and the refusal and related information would be documented in the resident's clinical record. The P&P further indicated the resident's response to interventions would be monitored, evaluated, and revised as appropriate. During a review of the facility's Certified Nursing Assistant (CNA) job description, not dated, the job description indicated CNAs were responsible with assisting residents with nail care, including clipping, trimming, and cleaning fingernails and toenails.

Based on interview and record review, the facility failed to implement the physician orders for Physical Therapy ([PT]- a licensed healthcare profession focused on restoring, maintaining, and promoting optimal physical function, movement, and quality of life) and Occupational Therapy ([OT]- enables people to engage in meaningful, everyday activities and promote well-being and independence) services for one of five sampled residents (Resident 12). This deficient practice placed Resident 12 at risk for avoidable decline in strength and functional status, increased dependence on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and decreased quality of life. Findings: During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial weakness of one side of the body), chronic obstructive pulmonary disease ([COPD]-a chronic lung disease causing difficulty in breathing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 12's History and Physical (H&P), dated 10/6/2025, the H&P indicated Resident 12 had the capacity to make medical decisions. During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool), dated 1/1/2026, the MDS indicated Resident 12's cognitive skills for daily decision making (ability to think and process information) was intact. The MDS indicated Resident 12 required maximum (helper does more than half the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 12's physician order, dated 1/10/2026, the order indicated a referral for PT and OT to address Resident 12's impaired mobility and ADL dependence. During an interview on 2/2/2026 at 10:01 a.m., at Resident 12's bedside, Resident 12 stated she had not been seen by PT or OT since last year (2025). Resident 12 stated she wanted therapy to get stronger and improve her ability to walk. Resident 12 stated she spent most of the day in bed and felt weaker and more dependent since her admission to the facility. During a concurrent interview and record review on 2/5/2026 at 8:30 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated there were no PT or OT evaluation notes or treatment notes in Resident 12's electronic medical record (EMR) following the physician's order dated 1/10/2026. LVN 1 stated there was no documentation that the PT/OT referrals had been sent. LVN 1 stated there was no documented evidence of any therapy services provided, and no documentation that Resident 12 refused therapy. LVN 1 stated when the physician orders PT and OT services, the licensed staff were expected to carry out the orders by initiating the referrals, follow up with the rehabilitation team to ensure the services are provided, and initiate a care plan addressing the resident's needs. During an interview on 2/5/2026 at 9:04 a.m., with the Director of Rehabilitation (DOR), the DOR stated she was not aware that Resident 12's attending physician ordered PT and OT on 1/10/2026. The DOR stated the therapy department had not received a referral or communication from nursing regarding Resident 12's need for PT and OT services. The DOR stated that timely implementation of PT and OT orders was essential to evaluate a resident's strengths, balance, ability to perform ADLs, and prevent further physical decline. During an interview on 2/6/2026 at 12:51 p.m., with Registered Nurse (RN) 1, RN 1 stated Resident 12's PT and OT orders had not been initiated. RN 1 stated the facility's failure to process and implement the therapy referrals was an oversight. RN 1 stated Resident 12 should have been receiving PT and OT to address her weakness and dependence with ADLs. RN 1 stated it was the responsibility of the licensed nursing staff to review new physician orders, notify the rehabilitation department, and follow up to make sure ordered services were started. During a review of the facility's policy and procedure (P&P) titled Registered Nurse Job Description, revised 3/12/2021, the P&P indicated Registered Nurse (RN) duties and responsibilities were to consult with the resident's physician in providing resident care, treatment, rehabilitation and ensure timely documentation and carryout new orders.

Based on observation, interview, and record review, the facility failed to follow up on two of two sampled resident's (Resident 57 and Resident 42) audiology (examining hearing) and optometry (examining eyes for visual issues) referrals. This deficient practice resulted in Resident 57 being unable to use his hearing aids (small medical device worn in or behind the ear to amplify sound for individuals with hearing loss) since 9/29/2025 and continued to have difficulty hearing, and had the potential to result in miscommunication regarding Resident 57's care. This deficient practice also resulted in delaying Resident 42's ability to obtain glasses which resulted in difficulty seeing. Findings:a. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 57's diagnoses included dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (condition characterized by persistent, excessive, and uncontrollable fear or worry).During a review of Resident 57's Minimum Data Set (MDS- a resident assessment tool), dated 1/8/2026, the MDS indicated Resident 57's cognition (process of thinking) was intact. The MDS indicated Resident 57 required setup or clean-up assistance with eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 57 had moderate difficulty (speaker has to increase volume and speak distinctly) with his hearing. During a review of Resident 57's History and Physical (H&P), dated 1/30/2026, the H&P indicated Resident 57 had the capacity to understand and make decisions. During a review of Resident 57's Physician Order, dated 9/26/2025, the order indicated for audiology (examining hearing) consultation as needed for hearing problem.During a review of Resident 57's Ear, Nose, Throat (ENT- specialty specific to conditions affecting the ears, nose, and throat) Note, dated 9/29/2025, the ENT Note indicated Resident 57 had diminished hearing. The ENT Note indicated Resident 57 had working hearing aids (small medical device worn in or behind the ear to amplify sound for individuals with hearing loss) but had difficulty using them. The ENT Note indicated a referral for an audiogram (a hearing test) and servicing to Resident 57's hearing aids. During a concurrent observation and interview on 2/2/2026 at 9:36 a.m., with Resident 57, in Resident 57's room, Resident 57 was observed with two hearing aids inside a case stored on his nightstand. Resident 57 picked up the hearing aids and stated he was given the hearing aids. Resident 57 stated, They are no good to me. Resident 57 stated when speaking to another person, the outside noise was amplified, and he was unable to hear the other person clearly. During a telephone interview on 2/5/2026 at 3:01 p.m., with the Audiology Manager, the Audiology Manager stated, on 9/29/2025, the ENT provider assessed Resident 57's hearing and noticed Resident 57 had hearing aids but did not wear them. The Audiology Manager stated the ENT recommended Resident 57 to have an audiogram and servicing to his hearing aids. The Audiology Manager stated there was a clerical error at the audiology office and the referral was inaccurately inputted. The Audiology Manager stated due to the clerical error, Resident 57 did not receive an audiogram and service to his hearing aids.During an interview on 2/9/2026 at 9:39 a.m., with the Social Services Director (SSD), the SSD stated Resident 57 had difficulty using his hearing aids. The SSD stated Resident 57 had a referral for an audiogram and servicing to his hearing aids that was not completed. The SSD stated the facility should have followed up with the audiology office to clarify why Resident 57 was not seen by the hearing aid provider. The SSD stated Resident 57 had difficulty hearing and would continue to have difficulty hearing as long as Resident 57 did not wear his hearing aids.During an interview on 2/9/2026 at 11:20 a.m., with the Director of Nursing (DON), the DON stated referrals regarding difficulty hearing was important to follow up to increase Resident 57's quality of life so he could hear. The DON stated Resident 57 was self-responsible and made his own medical decisions. The DON stated by not having functional hearing aids, Resident 57 was at risk of not hearing everything being explained to him and could result in misunderstandings. During a review of the facility's Policy and Procedure (P&P) titled, Hearing Impaired Resident, Care of, Revised 2/2018, the P&P indicated, Staff will assist the resident (or representative) with locating available resources, scheduling appointments, and arranging transportation to obtain needed services. The P&P indicated, Staff will help residents who have lost or damaged hearing devised in obtaining services to replace the devices.b. During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was initially admitted to the facility on [DATE]. Resident 42's diagnoses included fracture (broken bone) of the left femur (thigh bone) and right clavicle (collar bone), traumatic shock, motor vehicle accident and lack of coordination. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 42 required setup assistance for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 42's H&P, dated 10/23/2025, the H&P indicated Resident 42 had the capacity to understand and make decisions. During a review of Resident 42's Order Summary, dated 1/1/2026, the Order Summary indicated the facility was to ensure Resident 42 received an eye health and vision consult with follow up treatment as indicated. During an interview on 2/2/2025 at 9:15 a.m. with Resident 42, in Resident 42's room, Resident 42 stated the SSD did not provide an update regarding the status of his glasses despite repeated requests. Resident 42 stated that due to not having his glasses, he was unable to enjoy reading his books as he previously did. During a concurrent interview and record review on 2/9/2026 at 9:52 a.m. with the SSD, Resident 42's Ophthalmology (diagnosis and treatment of disorders of the eye) Referral for Optometry (the occupation of measuring eyesight, prescribing corrective lenses, and detecting eye disease) for Glasses, dated 12/23/2025, was reviewed. The SSD stated she did not follow up on the referral until the week of the interview. The SSD stated timely follow up of referrals was necessary to avoid delays on obtaining glasses. The SSD stated the lack of timely follow-up placed Resident 42 at continued risk for difficulty seeing during day-to-day activities and reading fine print due to his visual impairments. During a review of the facility's P&P titled, Care of the Visually Impaired, revised 3/2021, the P&P indicated it was facility's responsibility to assist the resident and representatives in locating available resources, scheduling appointments and arranging transportation to obtain needed services.During a review of the facility's Social Services Designee Job Description, undated, the Job Description indicated the Social Services Designee's job function was to coordinate support services as needed for optometry, dental, and audiology.

Based on observation, interview, and record review, the facility failed to provide visual monitoring every two hours and ensure floor mats were in place for two out of six sampled residents (Resident 23 and Resident 4). These deficient practices resulted in Resident 23 leaving the facility undetected and was later located approximately 9.5 miles from the facility placing the resident at risk for serious injury or harm. This deficient practice also placed Resident 4 at risk for injury from a fall. Findings: During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 23's diagnoses included atrial fibrillation (irregular heart rhythm) , schizophrenia (a mental illness that is characterized by disturbances in thought), hypertensive heart disease (high blood pressure), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), suicidal ideations, and difficulty walking. During a review of Resident 23's Minimum Data Set ([MDS], a resident assessment tool), dated 12/10/2025, the MDS indicated Resident 23's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 23 required supervision or touching assistance for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 23's Progress Note, dated 2/2026, the Progress Note did not indicate Resident 23 was monitored between 2/1/2026 at 9:50 a.m. and 2/2/2026 at 10 p.m. The Progress Note did not indicate documentation that the exit door alarms were armed or actively engaged during the 3 p.m. to 11 p.m. shift on 2/2/2026. During a review of Resident 23's Progress Note, dated 2/2/2026, timed at 10:00 p.m., the Progress Note indicated Resident 23 was not in bed during room rounds at 10:00 p.m. and a facility-wide search was conducted. The Progress Note indicated, at 11 p.m., local authorities were notified. The Progress Note indicated, at 11:50 a.m., Licensed Vocational Nurse (LVN) 2 received a phone call from the general acute care hospital (GACH), located approximately 9.5 miles from the facility, that Resident 23 had been located and arrangements would be made to return him to the facility. During an interview on 2/9/2026 at 10:19 a.m., in the presence of Certified Nursing Assistant (CNA) 2, Resident 23 stated, on 2/2/2026, during the evening hours, he wheeled himself from his room through the hallways and exited the facility though the back door without staff awareness. Resident 23 stated he did not recall hearing an alarm when he exited the facility back door. Resident 23 stated he was able to open the back gate located near the exit door and wheel himself to the street. During an interview on 2/9/2026 at 10:50 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated he was assigned to Resident 23's care on 2/2/2206 (3 p.m. to 11 p.m.). LVN 2 stated he last saw Resident 23 at approximately 7:20 p.m. in the facility's patio. LVN 2 stated nursing staff were expected to round on their assigned residents every two hours and ensure facility exits were armed or secured. LVN 2 stated he did not recall hearing any exit alarms triggered during the shift and stated that if alarms were not triggered, the alarms may not have been engaged. LVN 2 stated if Resident 23 was not effectively monitored, there was potential for the resident to experience an accident or elope (the act of leaving a facility unsupervised and without prior authorization). During an interview on 2/9/2026 at 11:20 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was Resident 23's assigned CNA on 2/2/2026 (3 p.m. to 11 p.m.). CNA 1 stated the expectation was to round on assigned residents every hour to ensure safety. CNA 1 stated she last saw Resident 23 in his room at approximately 4:30 p.m. when he asked her for clothes. CNA 1 stated at approximately 4:45 p.m., Resident 23 was no longer in his room and she assumed he went to the patio. CNA 1 stated she became busy performing CNA duties and did not verify Residents 23's whereabouts. CNA 1 stated she relied on other CNAs who reported they had seen the resident earlier. CNA 1 stated she did verify Resident 23's whereabouts, and because she did not effectively monitor Resident 23's location, Resident 23 was at higher risk of elopement. During an interview on 2/9/2026 at 2:05 p.m. with the Maintenance Staff Director (MSD), the MSD stated, prior to Resident 23's elopement, the maintenance staff were responsible for checking the exit door alarms systems once a month. During an interview on 2/12/2026 at 3:46 p.m. with the Director of Nursing (DON), the DON stated that the facility's practice was to monitor and round on the residents every two hours to ensure safety. The DON stated if adequate supervision was not rendered for Resident 23, then there was a possibility that he could have hurt himself or elope. During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents (undated) the P&P indicated the facility strived to make the environment free from accident hazards as possible and resident safety and supervision were facility-wide priorities. b. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included paraplegia (loss of movement and/or sensation, to some degree, of the legs), dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), and history of falls. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognition was moderately impaired. The MDS indicated Resident 4 required maximum (helper does more than the effort) assistance from staff for activities of daily diving (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 4's Order Summary Report, dated 1/2/2026, the order summary report indicated to apply bilateral (both sides) floormats to decrease risk of injury related to fall. During observations on 2/2/2026 at 10:01 a.m., 12:30 p.m., and 3:45 p.m., at Resident 4's bedside, Resident 4 was observed lying in bed. A floormat was to the right side of the bed. There was no floormat on the left side of her bed. During an interview on 2/5/2026 at 8:25 a.m., with LVN 1, LVN 1 stated when a resident has a history of falls and was at high risk for falls, staff were to apply floormats on both sides of the resident's bed. During concurrent interview and record review on 2/5/2026 at 8:39 a.m., with LVN 1, Resident 4's care plan titled Physical Device bilateral floor mat: due to history of fall, revised 4/7/2025, and active physician order, dated 1/2/2026, were reviewed. The care plan indicated to apply bilateral floormats to decrease risk of injury related to fall. The physician order indicated apply bilateral floormats to decrease risk of injury related to fall. LVN 1 stated Resident 4's had a history of fall and the care plan intervention indicated Resident 4 was supposed to have bilateral floormats as ordered on both sides of her bed. LVN 1 stated the purpose of the floormats was to prevent injury if Resident 4 were to fall from her bed. During a concurrent observation and interview on 2/5/2026 at 8:45 a.m., at Resident 4's bedside, with LVN 1, Resident 4 was observed lying in bed. A floormat was on the right side of the bed. LVN 1 stated there was no floormat on the left side of Resident 4's bed. LVN 1 stated Resident 4 was at risk of injury and could hurt herself if she were to fall. During a review of the facility's P&P titled Falls and Fall Risk, Managing, revised 12/2007, the P&P indicated the staff will identify interventions to the resident's specific risks and prevent the resident from falling and minimize complications from falling.

Based on observation, interview, and record review, the facility failed to protect resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), who was subjected to Resident 2's physical attack, who had diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions [strong beliefs of things that are untrue]). The facility failed to: - Implement the facility's policy and procedure (P&P) titled, Abuse Prevention/Prohibition, dated 11/2018, which indicated the facility would understand behavioral symptoms of residents that may increase the risk of abuse including aggressive and/or catastrophic reactions of residents, outbursts, or yelling out. - Develop a resident specific Schizophrenia care plan for Resident 2, with interventions to monitor behavior and re-evaluate for effectiveness. -Implement the Psychosocial Well-Being Care Plan dated 3/17/2025 to listen attentively and address concerns of Resident 2, when Resident 2 had erratic mood swings for eight days and auditory hallucinations (a perception of having seen or heard something that was not there) for five days from 5/1 - 5/13/2025. This deficient practice resulted in Resident 2 punching Resident 1 in the right eye causing bruising (traumatic injury to the skin that results in discoloration, inflammation, and pain), and swelling to the right eye. Resident 1 received pain medication, had emotional distress, stated she did not feel safe in the facility, and did not want to be alone. Findings: A review of Resident 2's admission Record indicated the resident was re-admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mental health condition characterized by a persistent low mood), alcoholic liver disease (a range of liver injuries caused by excessive alcohol consumption), and heart failure (when the heart cannot pump enough blood to meet the body's needs). Further review of the admission Record indicated there was no diagnosis included regarding Schizophrenia. A review of Resident 2's care plan titled, Psychosocial Well-Being (encompasses mental, emotional, social, and spiritual well-being, and its impact on overall health and functioning) dated 3/17/2025 indicated Resident 2 had the potential for alteration in psychosocial well-being related to feeling down depressed or hopeless. The care plan goal indicated to minimize episodes of behavioral symptoms for three months and the interventions indicated to listen attentively to Resident 2 and address concerns. A review of the Residents 2's care plan titled, Mood Pattern with depression manifested by inability to sleep dated 3/17/2025, indicated interventions to monitor for increase or decrease behavior and notify medical doctor, to evaluate effectiveness of or response to medication and report to medical doctor. A review of Resident 2's History and Physical (H&P), dated 3/18/2025 indicated the resident did not have the capacity to understand and make decisions. A review of the Medication Administration Record (MAR) dated 3/31/2025 indicated Resident 2 was to receive Trazadone (an antidepressant medication used to treat depression and anxiety) 50 milligrams (mg, unit of measurement) at bedtime for Schizophrenia spectrum disorder (a group of mental health conditions characterized by psychosis, hallucinations, delusions and disorganized thinking). A review of the Minimum Data Set (MDS, a resident assessment tool) dated 4/3/2025, indicated Resident 2's cognition (the ability to think, understand, and reason) was mildly impaired and the resident felt down, depressed or hopeless with a frequency of 7 - 11 days. The MDS indicated Resident 2 had an active diagnosis of a psychiatric mood disorder (depression) and was taking an antidepressant medication (used to treat mental health conditions like depression and anxiety). The MDS did not indicate Resident 2 had any behaviors of hallucinations or delusions (misconceptions or beliefs that were firmly held or contrary to reality), did not indicate Resident 2 had a diagnosis of Schizophrenia, nor received any antipsychotic medications (a class of medicines used to treat psychosis [a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality] and other mental and emotional conditions. According to a review of the Psychiatric Evaluation Notes dated 4/12/2025, from Resident 2's Primary Physician's Office, Resident 2 had diagnoses including Schizophrenia and Mood Disorder (a mental health condition that affects a person's emotional state, causing long periods of sadness, depression, mania, or elation). The Psychiatric Evaluation Note indicated Resident 2 had episodes of being irritable, yelling and talking to herself. A review of the Physician's Order Summary Report dated 4/14/2025, indicated Resident 2 received Depakote (a mood stabilizer medication) 250 mg three times a day for mood disorder manifested by erratic mood swings (rapid and intense moment to moment emotional changes) and received Haloperidol (Haldol, antipsychotic medication used to treat Schizophrenia symptoms like hallucinations) 5 mg three times per day for Schizophrenia manifested by auditory hallucinations (when someone perceives sounds that are not there). A review of the Physician's Order Summary Report dated 4/14/2025, indicated Resident 2 was to be monitored for mood disorder manifested by erratic mood swings every shift and monitored for Schizophrenia manifested by hallucinations every shift. A review of Resident 2's MAR dated 5/1/2025 indicated on 5/1, 5/4 - 5/6, 5/8, 5/9, 5/11 and 5/13/2025 (eight days) Resident 2 exhibited erratic mood swings but there was no description documented regarding the specific behavior or what was done about the behavior. A review of Resident 2's medical record indicated there was no documentation regarding listening attentively and addressing Resident 2's concerns, per the Psychosocial Well-Being care plan. According to a review of Resident 2's MAR, dated 5/1/2025 indicated that on dates 5/1, 5/2, 5/5, 5/9, and 5/11/2025 (five days) Resident 2 exhibited auditory hallucinations, but there was no description documented regarding the specific behavior Resident 2 exhibited or staff's interventions. A review of the Resident 2's medical record indicated there was no care plan for the diagnosis of Schizophrenia. A review of Resident 1's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (mental health condition that's characterized by a persistent low mood), and osteoporosis (a chronic condition that causes bones to gradually lose density and mass, making them more fragile and prone to fractures). A review of the MDS dated [DATE], indicated Resident 1's cognition was moderately impaired, and the resident required substantial/maximal assistance (helper did most of the work) from staff for toileting hygiene, showers, and dressing. A review of the Situation Background Assessment Recommendation (SBAR) form dated 5/15/2025 indicated Resident 2 had become increasingly verbally confrontational with roommate (Resident 1) and struck Resident 1 with an open hand in the face. The SBAR indicated Resident 2's diagnoses included heart failure and alcoholic liver disease. The SBAR did not indicate Resident 2's diagnosis of Schizophrenia, nor any mental status changes observed. The SBAR indicated the Behavioral Evaluation was not clinically applicable to the change in condition being reported, including danger to self or others, verbal aggression, physical aggression, or personality change. The SBAR indicated to describe other behavioral changes noted or observed but this area remained blank. A review of Resident 1's Skin Observation Tool, dated 5/16/2025 indicated the resident had a right orbital eye swelling and discoloration. According to a review of the Mental and Behavioral Health Treatment Progress Note dated 5/19/2025, Resident 1 was in a low mood and stated she was struck by Resident 2 for no reason. The Progress Note indicated Resident 1 stated, I was punched in my eye. I don't want to see her or have anything to do with her. A review of the Faxed Document sent from the facility to the Department dated 5/20/2025 indicated there was a physical altercation between Resident 2 and Resident 1 that occurred at approximately 8:20 p.m. on 5/15/2025. The faxed document indicated Resident 2 hit Resident 1 in the face with an open hand, which was witnessed by a staff member (Certified Nursing Assistant, CNA 2) during a verbal argument. The faxed document indicated Resident 1 was moved to another room per her request and that the facility's Interdisciplinary Team determined, Resident 2 was physically aggressive causing to hit Resident 1 with an open hand. A review of the MAR dated 5/20/2025 and 5/22/2025 indicated Resident 1 received Tylenol 325 mg for pain. During an observation on 5/22/2025 at 9:47 a.m., in Resident 1's room, Resident 1 had bruising, discoloration to the right orbital eye and the top portion of the bridge of her nose. During a concurrent interview, Resident 1 stated she and Resident 2 were both in the room they shared. Resident 1 was sitting in her wheelchair, Resident 2 came towards her, and hit her in the eye three times. Resident 1 stated, I had asked her to stop, and she put her hand over my mouth when I started to yell for help. Resident 1 stated her face was hurting after being hit. Resident 1 stated she did not feel safe in the facility, did not want to be alone, and felt that Resident 2 would come into her room when she was alone. During an interview on 5/22/2025 at 2:10 p.m., CNA 2 stated that on 5/15/2025, Resident 1 was in her wheelchair trying to cover her face while Resident 2 was standing and hitting Resident 1. CNA 2 stated Resident 2 called her (CNA 2) a derogatory name when CNA 2 told Resident 2 to stop. Resident 1 kept saying, She hit me! She hit me! CNA 2 stated Resident 1 had redness to her nose and cheek, and that this was considered physical abuse. CNA 2 stated, Resident 2 is always cussing someone out. During an interview on 5/22/2025 at 4 p.m., the Director of Staff Development (DSD) stated recently she had to come out of her office to see what was going on due to Resident 2's loud shouting and cursing, as it had disturbed her and some of the residents. The DSD stated observed Resident 2's erratic mood swings of outbursts and talking to herself, the DSD did not report this behavior to the RN Charge Nurse. During an interview on 5/22/2025 at 4:33 p.m., with Registered Nurse (RN) 1 and Resident 1, in Resident 1's room, Resident 1 stated to RN 1 that she did not feel safe after being hit by Resident 2 and would feel safe if someone was in the room with her, especially at night. RN 1 stated since the incident, Resident 1 seemed sad, withdrawn, and remained in bed. On 5/23/2025 at 9:30 a.m., during an interview in Resident 2's room, Resident 2 stated Resident 1 was talking about her (Resident 2's) mother and that Resident 2's mother was dead. Resident 2 stated, So I hit her in the face. During an interview on 5/23/2025 at 12 p.m., the DON stated Resident 2 had a potty mouth, (using profanity or foul language) and rebelled against the structure of the facility. The DON stated Resident 2 displayed aggressive behavior towards another resident (Resident 1) and it was considered abuse. The DON stated the staff were to keep frequent visual checks on Resident 2, but there was no documentation in the medical record to confirm it was completed. The DON stated it was important to keep track and document Resident 2's whereabouts to prevent harm from reoccurring. The DON stated the physical altercation of Resident 2 hitting Resident 1 could affect Resident 1 and cause psychological harm, including being scared and withdrawn. The DON stated, We need to continue to check on Resident 1, so the psychological harm does not get worse. During an interview on 5/23/2025 at 1:06 p.m., CNA 3 stated Resident 2 used profanity, would shout and say things such as Stupid, Shut up, and shout in the direction of residents when she walked down the hallway. CNA 3 stated Resident 2 would speak in Spanish, use derogatory language and say curse words. CNA 3 stated this behavior by Resident 2 could cause the other residents to feel badly and make the residents feel mad and disrespected. CNA 3 stated she did not report these recent behaviors from Resident 2 to a higher-level facility position. During a concurrent interview and record review on 5/23/2025 at 4:20 p.m. with RN 2, Resident 2's MAR was reviewed. The MAR indicated from 5/1 - 5/13/2025 Resident 2 was documented to have erratic mood swings on eight days, and from 5/2 - 5/11/2025 Resident 2 was documented to have auditory hallucinations on five days, but there was no description of Resident 2's behavior. When RN 2 was asked what the facility did regarding Resident 2 exhibiting erratic mood swings and auditory hallucinations, RN 2 stated she could not find documentation in the medical record of what was done for Resident 2. During an interview on 5/23/2025 at 4:30 p.m., RN 2 stated there was no care plan for Resident 2's diagnosis of Schizophrenia. RN 2 stated Resident 2's behaviors, such as thinking someone was speaking to her in a rude way, needed to be closely monitored for escalated behavior symptoms. RN 2 stated the Schizophrenia care plan interventions would include which non-pharmacological interventions to use and when to call the physician, so the physician could increase or decrease the resident's medications. RN 2 stated the care plan would assist the staff in identifying the aggressive behavior and knowing if the medication was working or not. On 5/28/2025 at 9:30 a.m., during an interview, Resident 1's Responsible Party (RP) stated that he was notified about Resident 1 being hit in the face by Resident 2. The RP stated, I visited on 5/16/2025 (the day after the physical altercation), and she (Resident 1) was scared and cried about being hit. The RP stated, Resident 1 was emotional and very upset about what happened. During a concurrent interview and record review on 5/29/2025 at 2:36 p.m., with RN 1, Resident 2's Psychiatric Evaluation Notes, dated 4/12/2025, from Resident 2's Primary Physician's Office were reviewed. RN 1 stated when Resident 2 used profanity it was not directed toward anyone in particular and it was a symptom of Resident 2's mood disorder and schizophrenia. RN 1 stated the facility should have managed Resident 2's mood behaviors with ongoing observations and document those behaviors as it was important to prevent physical abuse. A review of the facility's P&P titled, Abuse Prevention/Prohibition, dated 11/2018, indicated the facility would understand behavioral symptoms of residents that may increase the risk of abuse. The P&P indicated symptoms include, but are not limited to, aggressive and/or catastrophic reactions of residents, outbursts, or yelling out. A review of the facility's P&P titled, Care Planning- Interdisciplinary Team, dated 9/2013, indicated the facility's care planning/interdisciplinary team was responsible for the development of an individual comprehensive care plan for each resident. The P&P indicated the care plan was based on the resident's comprehensive assessment.

Based on interview and record review, the facility failed to ensure two of ten residents (Resident 6 and Resident 7) were free from physical abuse (intentional bodily injury) when: a. Resident 1 struck Resident 7 in the face unprovoked at Station A's hallway on 1/18/2025. b. Resident 5 slapped Resident 6 on the right side of the face near the vending machines because Resident 6 would not light Resident 5's cigarette on 1/7/2025. As a result of these failures, Resident 7 sustained an acute (severe and sudden in onset) depressed nasal bone fracture (a break in the nasal [relating to or having to do with the nose] bone that pushed the bone inward toward the maxilla [the bones that formed the upper part of the jaw, the roof of the mouth, and parts of the eye socket and nose] usually caused by a direct blow to the nose), and Resident 6 was physically abused by Resident 5. Findings: 1. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included metabolic encephalopathy (a brain disorder that occurred when there's an imbalance of chemicals in the blood), dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions were so affected that contact was lost with reality), and anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 1 was independent (resident completed the activity by herself without assistance from a helper) with eating and personal hygiene, and required supervision with oral hygiene, toileting hygiene, and showering/bathing self. During a review of Resident 1's Order Summary Report, dated 10/18/2024, the report indicated to monitor Resident 1's behavior of sudden shifts in mood from pleasant to extreme anger and striking out staff or peers every shift. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there was a change of condition among the residents), dated 1/7/2025 and untimed, the report indicated on 1/7/2025, Resident 1 slapped the hat off, of a resident (Resident 2). During a review of Resident 1's care plan titled Altercation resident to resident verbal altercation resulting to physical assault to another resident, initiated on 1/7/2025, the interventions indicated nursing staff were to distract and redirect Resident 1 by engaging the resident in alternative activities to divert attention away from triggers. During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR), dated 1/18/2025 and untimed, the SBAR indicated on 1/18/2025 Resident 1 exhibited physical aggression towards another resident (Resident 7). During a review of Resident 7's Admission Record, the Admission Record indicated Resident 7 was admitted to the facility on [DATE]. Resident 7's diagnoses included difficulty in walking, metabolic encephalopathy, diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia. During a review of Resident 7's History and Physical (H&P), dated 11/24/2024, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 7 required partial assistance (helper did less than half the effort) with eating and substantial assistance (helper did more than half the effort) with oral hygiene, toileting hygiene, showering/ bathing self, and personal hygiene. The MDS indicated Resident 1 required supervision in walking and used a wheelchair for mobility. During a review of Resident 7's SBAR, dated 1/18/2025, the SBAR indicated on 1/18/2025, Dietary Aid (DA 1) witnessed Resident 1 grab Resident 7 by the shoulder and with a closed fist and hit Resident 7 in the nose. The SBAR indicated on 1/18/2025, Resident 7 did not have pain nor changes in the skin observed. During a review of Resident 7's X-ray (a type of electromagnetic radiation that produced images of the inside of the body, used to diagnose and treat diseases and injuries) report, dated 1/19/2025, the report indicated Resident 7 had an acute depressed fracture involving the nasal bone. During a review of Resident 7's Interdisciplinary Team (IDT, a group of healthcare professionals who worked together to provide care for residents in a nursing home) Conference Record, dated 1/19/2025, the IDT record indicated on 1/18/2025, DA 1 witnessed Resident 1 unprovokedly punched Resident 7 on the nose in the Station A hallway, and the facility abuse protocol was initiated. The IDT record indicated Resident 7 had no pain, no facial discoloration or swelling, nor had any chronic (a condition that lasted for a long time and requires ongoing medical care) or acute (something was severe and sudden, or immediate) changes noted. The IDT record indicated Resident 7 continued to enjoy his daily routines. During an interview on 1/22/2025 at 10:35 am with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on the morning of 1/18/2025 (could not recall the time), she was informed by DA 1 that Resident 1 unprovokedly punched Resident 7 on the nose in the Station A hallway when they walked past each other. LVN 1 stated Resident 1 was calm and unable to indicate why he punched Resident 7 in the nose. During a telephone interview on 1/22/2025 at 11:23 a.m. with DA 1, DA 1 stated on the morning of 1/18/2025 (could not recall the time), DA 1 saw Resident 1 was using his left hand to hold Resident 7 by the shoulder and punched Resident 7 on the nose with his right fist in Station A's hallway. DA 1 stated Resident 7 was trying to push Resident 1 away but was too weak to do so. DA 1 stated he tried to separate Resident 1 and Resident 7, but DA 1 did not get to the residents on time. DA 1 stated he called LVN 2 over to check on Resident 7. During a telephone interview on 1/22/2025 at 12:29 p.m. with LVN 2, LVN 2 stated on the morning of 1/18/2025 (could not recall the time), she was informed by DA 1 that Resident 1 unprovokedly punched Resident 7 on the nose on. LVN 2 stated on 1/18/2025(could not recall the time), there was no visible injury to Resident 7's face. LVN 2 stated Resident 7 was unable to provide information on what happened. 2. During a review of Resident 5's Admission Record, the Admission Record indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizoaffective disorder (a mental illness that could affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that ranged from the lows of depression to elevated periods of emotional highs), and restlessness (a state of unable to stay still or quiet, or feeling worried or bored) and agitation (a state of extreme arousal, restlessness, or tension that could make it hard to relax). During a review of Resident 5's H&P, dated 12/21/2024, the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had mildly impaired cognitive skills for daily decision making. The MDS indicated Resident 5 was independent with eating, oral hygiene, toileting hygiene, showering/ bathing self, and personal hygiene. The MDS indicated Resident 5 had hallucinations (a false perception of a sight, sound, smell, taste, or touch that seems real but was not). During a review of Resident 5's Order Summary Report, dated 12/20/2024, the report indicated to monitor Resident 5 for auditory (hearing) and visual hallucinations. During a review of Resident 5's Order Summary Report, dated 12/30/2024, the report indicated to monitor Resident 5 for behavior of sudden angry outburst. During a review of Resident 5's care plan titled Resident has a behavioral pattern, initiated on 1/6/2025, the care plan indicated interventions included one-to-one (1:1, a situation where a dedicated healthcare professional constantly observed and attended to a single resident, maintaining close proximity [the state of being close to something or someone in space] at all times to ensure their safety and intervene as needed) supervision. During a review of Resident 5's SBAR, dated 1/8/2025, the SBAR indicated on 1/7/2025 around 11:05 p.m. Resident 5 slapped Resident 6 near the vending machines. The SBAR indicated Resident 5 stated she slapped Resident 6 because Resident 6 drank all her (Resident 5) soda and did not want to light her cigarette. During a review of Resident 6's Admission Record, the Admission Record indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hyperlipidemia (a medical condition where there were abnormally high levels of fats in the blood), schizoaffective disorder, and bipolar disorder. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had mildly impaired cognitive skills for daily decision making. The MDS indicated Resident 6 required supervision with eating and partial assistance with oral hygiene, toileting hygiene, shower/ bathe self, and personal hygiene. The MDS indicated Resident 5 used a wheelchair for mobility. During a review of Resident 6's incident report, dated 1/7/2025, the report indicated on 1/7/2025 around 11:05 p.m., Activities Aide (AA) 1 witnessed Resident 5 slap Resident 6 on the side of the head in the patio. The report indicated Resident 6 stated he was walking out and Resident 5 smacked him. During a review of Resident 6's IDT record, dated 1/8/2025, the IDT record indicated during the wee hours (the early hours of the morning) of 1/8/2025, Resident 6 stated Resident 5 slapped him on the right side of face when Resident 5 asked for a lighter and Resident 6 stated he did not have one. The IDT record indicated the mandated abuse reporting guideline had been completed and Resident 6 pressed charges (to take legal action against someone) against Resident 5. During an interview on 1/22/2025 at 10:06 a.m. with Resident 6, Resident 6 stated on the night of 1/7/2025, Resident 5 punched him with a closed fist and hit him (Resident 6) on the right side of the cheek near the vending machines, after he told Resident 5 to light her own cigarette. Resident 6 stated there was no staff present when it happened. Resident 6 stated being slapped by Resident 5 made him feel weird because he thought Resident 5 was his friend. During an interview on 1/22/2025 at 11:35 a.m., with AA 1, AA 1 stated on the night of 1/7/2025 at 11 p.m., she was supervising Resident 5 and walked with Resident 5 to the vending machine area. AA 1 stated she left Resident 5 alone for about five minutes with Resident 6 to inform the charge nurse that she needed to leave work and go home. AA 1 stated on 1/7/2025 at 11:05 p.m., she witnessed Resident 5 slap Resident 6 across the face when she returned to the vending machine area. During a review of the facility's Policy and Procedure (P&P) tilted Abuse Prevention and Prohibition, dated 11/2018, the P&P indicated the facility did not condone any form of resident abuse. The P&P indicated the facility promoted an environment free from abuse and mistreatment. The P&P also indicated physical abuse was defined as hitting, slapping, pinching, and or kicking.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Change in a Resident's Condition, which indicated the facility will notify a resident's physician when there was a significant change (major decline or improvement in the resident's status that could not normally resolve itself without intervention by the staff) in the resident's condition by failing to notify a physician timely, for one of seven sampled residents (Resident 2) when: a. Resident 2 had a change of condition of a decreased oxygen saturation (the percentage [%] of oxygen in a person's blood, normal oxygen saturation level between 95 and 100 %] rate oxygen of 84 %. Resident 2's oxygen saturation did not reach the normal oxygen saturation level of 95 to 100% after administering 5 liters per minute (LPM, unit of measurement) of oxygen, 10 LPM, and 15 LPM of oxygen via an oxygen mask (device used to deliver supplemental oxygen [treatment in which a storage tank of oxygen or a machine called a compressor is used to give oxygen to people with breathing problems]). b. Resident 2 refused the 72-Hour Neurological check (series of tests over a 72-hour period to assess for changes in neurological function [the ability of the nervous system to send and receive signals throughout the body, allowing for movement, sensation, and other bodily functions]) and Body Check Assessment after an unwitnessed fall on [DATE]. c. Resident 2 refused Skin Check Assessments during activities of daily living ([ADLs], activities such as bathing, dressing, and toileting a person performs daily). These failures resulted in Resident 2 being hypoxic (absence of oxygen in the tissues to sustain bodily functions) with labored breathing (breathing that requires more effort than normal, or an increased amount of energy) and only responsive to tactile stimuli (any form or touch or physical contact perceived by the skin), and a one hour delay in transferring the resident to a general acute care hospital (GACH) for timely evaluation and treatment. These failures also had the potential to result in the ability of Resident 2's nervous system (a complex network of nerve tissue that sends signals between the brain and the body) to send and receive signals throughout the body, allowing for movement, sensation, and other bodily functions. These failures resulted in Resident 2's covered skin area (back and buttocks) not being assessed for skin breakdown and impaired skin integrity. Findings: a. During a review of Resident 2's Admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included cellulitis (a skin infection that causes swelling and redness) of the right and left lower limb (leg), acute embolism (a blood clot that enters the blood stream and blocks blood flow) and thrombosis (a blood clot that forms in a blood vessel, partially or completely blocking blood flow) of the left calf muscular vein (part of the deep vein system that drains blood from the calf muscles back to the heart), and peripheral vascular disease ([PVD], a slow progressive narrowing of the blood flow to the arm and legs). During a review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool), dated [DATE], the MDS indicated Resident 2's cognition (process of thinking) was severely impaired. The MDS indicated Resident 2 required moderate assistance with oral hygiene, toileting, bathing, and dressing. The MDS indicated Resident 2 had four venous ulcers (an open sore on the leg that occurs when blood does not circulate properly in the leg veins) and an infection of the foot. During a review of Resident 2's Change in Condition (COC), dated [DATE], the COC indicated on [DATE] at 3:08 a.m., Resident 2 was observed with discoloration and swelling of his right first toe and bleeding from the right, lower extremity (leg). The COC indicated Resident 2 had abnormal vital signs (measurements of the body's most basic functions) and altered mental status (a change in how well your brain is working). The COC indicated [DATE] was called at 4:09 a.m., and Resident 2 was transferred to the GACH at 4:40 a.m., 92 minutes after Resident 2's initial change of condition. During a review of Resident 2's Progress Notes, dated [DATE], the Progress Notes indicated on [DATE] at 3:08 a.m., Licensed Vocational Nurse (LVN) 1 assessed Resident 2's discoloration and swelling on his right first toe. The Progress Notes indicated Resident 2 appeared confused. The Progress Notes indicated the following vital signs and assessments: 1. At 3:10 a.m., Resident 2's vital signs were the following: Blood pressure (BP, force of blood used to get through the vessels of the body) was ,d+[DATE] (normal range of ,d+[DATE] [top number] and ,d+[DATE] [bottom number) millimeters of mercury ([mm Hg], unit of measurement), respiratory rate (RR, breathing) of 21 breaths per minute (normal RR 12 to 20 bpm), heart rate (HR) was 66 beats per minute ([BPM], normal range 60 to 100 BPM), temperature of 98.8 degrees Fahrenheit ([F], a unit of measurement, normal temperature range 97 to 99 F), and oxygen saturation of 84% on room air. The Progress Note indicated supplemental oxygen was initiated at 5 LPM via an oxygen mask. 2. At 3:40 a.m., the Progress Note indicated Resident 2 had no changes from the assessment done at 3:10 a.m. The Progress Note indicated Resident 2 was making noises. Resident 2's vital signs were the following: BP was ,d+[DATE] mmHg, RR was 21 bmp, HR was 87 BPM, temperature was 98.9 F, and oxygen saturation was 87% while receiving 10 LPM of oxygen via an oxygen mask. 3. At 3:55 a.m., Resident 2's vital signs were the following: BP was ,d+[DATE] mmHg, RR was 22 bpm, HR was 87 BPM, temperature was 98.9 F, and oxygen saturation was 84% while receiving 15 LPM via an oxygen mask. 4. At 4:07 a.m., Resident 2 was observed with his eyes closed, with labored breathing, and with his (unspecified) upper extremity cold to the touch. Resident 2 was unable to respond verbally but would awake to tactile stimuli (any form or touch or physical contact perceived by the skin). Resident 2's vital signs were the following: BP was ,d+[DATE] mmHg, RR was 22 bpm, HR was 116 BPM, temperature was 99.1 F, and oxygen saturation was 87% while receiving 15 LPM of oxygen via a non-rebreather mask (oxygen mask that delivers high concentrations of oxygen). The Progress Notes dated [DATE], indicated [DATE] was called at 4:09 a.m. and the emergency medical services (EMS) arrived at the facility at 4:13 a.m. The Progress Notes indicated on [DATE], Resident 2 was transferred to the GACH at 4:40 a.m., 92 minutes after Resident 2's initial change of condition. During a review of Resident 2's GACH Emergency Department (ED) Note, dated [DATE] and timed at 5:10 a.m., the GACH ED Note indicated upon arrival to the ED, Resident 2's vital signs were the following: BP was ,d+[DATE] mmHg, RR was 22 bpm, HR was 98 BPM, temperature was 104.9 F, and oxygen saturation was 87% on 15 LMP of oxygen via an oxygen mask. The GACH ED Note indicated Resident 2 was brought to the GACH via ambulance for worsening cellulitis to the bilateral (affecting both sides) lower extremities. The GACH ED Note indicated Resident 2's legs were initially wrapped in gauze and plastic bags and when removed the legs were noted to be extremely pungent malodorous (a strong, sharp, unpleasant odor). The GACH ED Note indicated Resident 2's lactic acid level (a blood test used to help diagnose sepsis [a life-threatening blood infection]) was elevated at 3.46 millimoles per liter ([mmol/L, unit of measurement], normal value of 0.7 to 1.9 mmol/L). The GACH ED Note indicated Resident 2's white blood cell count ([WBC], a blood test that indicate the presence of inflammation or infection) was elevated at 16 microliters ([X10^3/Ul]- a unit of measurement, normal WBC count 4.5 to 11). The GACH ED Note indicated Resident 2 was diagnosed with septic shock (a life-threatening condition that occurs when an infection causes a dangerously low blood pressure and organ failure), acute renal failure (condition where kidneys suddenly lose their function), and cellulitis. During a review of Resident 2's GACH History and Physical (H&P), dated [DATE] and timed at 7:57 a.m., the H&P indicated Resident 2 had worsening right, lower extremity cellulitis. The GACH H&P indicated Resident 2 remained hypotensive (low blood pressure) despite fluid resuscitation (a medical procedure that involves replacing fluids lost by the body) and received norepinephrine (a vasopressor [drug used to make blood vessels constrict or become narrow to raise blood pressure]), vasopressin (a vasopressor), and phenylephrine (vasopressor). The H&P indicated the general surgeon was consulted and a decision was made for Resident 2 to have an emergent right, below the knee amputation. During a review of Resident 2's GACH Nursing Progress Notes, dated [DATE] and timed at 10 a.m., Resident 2 arrived in the Intensive Care Unit (ICU, a hospital ward that provides specialized care for patients who are very ill or injured) at 9:00 a.m. and was intubated (a procedure that involves the insertion of a tube to facilitate breathing) at 10:30 a.m. The notes indicated Resident 2 underwent right and left below the knee amputations (removal of a limb) and was required to be placed on maximum continuous doses of norepinephrine (a vasopressor), vasopressin, and phenylephrine. During a review of Resident 2's GACH Clinical Notes, dated [DATE] and timed at 6:21 p.m., the Clinical Note indicated Resident 2 continued to receive Levophed (used to treat life-threatening low blood pressure) and phenylephrine despite the right, lower extremity amputation and continued fluid resuscitation. The Clinical Note indicated Resident 2's left lower extremity appeared worse than at admission ([DATE]), with new ischemic changes (when the part of the body does not get enough blood or oxygen) to the soft tissue (the body's supporting tissues such as fat, skin, and muscle). The Clinical Note indicated the care team will proceed with an emergent left below the knee amputation. During a review of Resident 2's GACH Amputation Below Knee Procedure Notes, dated [DATE], the notes indicated Resident 2 underwent bilateral below the knee amputations. During a review of Resident 2's GACH Rapid Response Note, dated [DATE] and timed at 11:54 a.m., the note indicated Resident 2 became pulseless (no heartbeat), required chest compressions, and expired at 11:57 a.m. from cardiac arrest (occurs when the heart suddenly stops beating). During an interview on [DATE] at 12:52 p.m., with LVN 1, LVN 1 stated on [DATE], at approximately 3 a.m., he noticed Resident 2 looked off. LVN 1 stated Resident 2 had blood on his right lower extremity and his right toe had a dark purple discoloration. LVN 1 stated at the beginning of the shift at 11 p.m., Resident 2 did not have any bleeding or dark purple discoloration on his right toe. LVN 1 stated he began to check Resident 2's vital signs and observed the resident's oxygen saturation was low, at 84%. LVN 1 stated he initiated supplemental oxygen and had to increase the amount of oxygen to Resident 2, however, the Resident 2's oxygen saturation did not improve and fluctuated between 84 to 87%. LVN 1 stated due to Resident 2's condition, wound care was not provided to Resident 2's legs and instead was wrapped with additional gauze and a plastic bag. LVN 1 stated he attempted to notify Resident 2's physician towards the end of his shift at approximately 7 a.m., (four hours after Resident 2's initial change of condition). LVN 1 stated Resident 2's physician was not notified when Resident 2's initial change of condition was noted at 3:10 a.m. LVN 1 stated he went with his nursing judgement and acted to treat Resident 2's desaturation (decrease in oxygen saturation) instead of calling Resident 2's physician and waiting for orders. LVN 1 stated he should have notified Resident 2's physician of the resident's status and initial desaturation of 84% for guidance on how to proceed with Resident 2's care. LVN 1 stated if he notified Resident 2's physician sooner, he may have been directed to call [DATE] sooner. During an interview on [DATE] at 2:20 p.m., with Registered Nurse (RN) 1, RN 1 stated Resident 2 did not have any respiratory issues and never required supplemental oxygen. RN 1 stated if a resident required 10 LPM of oxygen, regardless of improvement, he would have to immediately call [DATE]. RN 1 stated Resident 2 requiring supplemental oxygen was a change of condition and his physician should have been notified immediately. RN 1 stated notifying the physician would provide a line of communication where the physician may give orders on how to proceed with treatment. RN 1 stated the physician may request to call [DATE] due to the need of a higher level of care for prompt assessment and treatment. RN 1 stated Resident 2 was hypoxic (having too little oxygen) for over an hour and could have been hypoxic long before LVN 1 assessed him. RN 1 stated the lack of physician notification resulted in a delay in care. During an interview on [DATE] at 3:56 p.m., with the Director of Nursing (DON), the DON stated Resident 2 should have been sent to the GACH sooner. The DON stated Resident 2 had a change in oxygenation and mental status. The DON stated Resident 2's physician should have been notified of Resident 2's initial change of condition. The DON stated Resident 2 should not have been allowed to decline to the degree of being responsive only to tactile stimuli. The DON stated Resident 2 was hypoxic for over an hour, which meant he was not getting oxygen to his vital organs. The DON stated Resident 2 suffered a delay in care. During a review of the facility's Policy and Procedure (P&P) titled, Transfer or Discharge, Emergency, revised ,d+[DATE], the P&P indicated when it was necessary to make an emergency transfer to the hospital, the facility would notify the resident's physician. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised ,d+[DATE], the P&P indicated the nurse would notify the resident's physician when there was a significant change (major decline or improvement in the resident's status that could not normally resolve itself without intervention by the staff) in the resident's condition and the resident needed to be transferred to the GACH. b. During a review of Resident 2's COC, dated [DATE], the COC indicated on [DATE] at 9:20 a.m., Resident 2 had an unwitnessed fall and was found in a sitting position on the floor by his bed. The COC indicated Resident 2's 72-Hour Neurological Check (series of tests over a 72-hour period to assess for changes in neurological function [the ability of the nervous system to send and receive signals throughout the body, allowing for movement, sensation, and other bodily functions]) was initiated. During a concurrent interview and record review on [DATE], with RN 1, Resident 2's 72-Hours Neuro Checklist, dated [DATE], was reviewed. RN 1 stated the 72-Hour Neuro Checklist indicated Resident 1's neurological assessment was initiated on [DATE] at 9:30 a.m. RN 1 stated the 72-Hour Neuro Checklist indicated assessment was to be completed twice every 30 minutes, then three times every hour, then two times every two hours, then four times every four hours, and finally six times every eight hours. RN 1 stated the 72-Hours Neuro Checklist dated [DATE], indicated: a. At 9:30 a.m., BP of ,d+[DATE] mmHg, temperature 97.8 F, HR of 80 BPM, RR of 18 bpm, alert, pupils equal and responsive, and left- and right-hand grip firm. b. At 10 a.m., Resident 2 refused assessment. c. At 1 p.m., Resident 2 refused assessment. d. At 4 p.m., Resident 2 refused assessment. e. At 7 p.m., Resident 2 refused assessment. f. At 10 p.m., Resident 2 refused assessment. RN 1 stated Resident 2 refused the neurological assessments on [DATE]. RN 1 stated the licensed nurses did not complete the 72-Hours Neuro Checklist for the full 72 hours. RN 1 stated the 72-Hours Neuro Checklist was only completed for 12 hours. RN 1 stated although Resident 2 refused the neurological assessments; the licensed nurse should have continued to try to assess Resident 2 for neurological deficits. RN 1 stated conducting the neurological assessments would help detect any changes in Resident 2's mental status and ensure his brain was functioning at its baseline. RN 1 stated not attempting to complete Resident 2's 72-Hours Neuro Checklist put the resident at risk for undetected symptoms from a brain bleed. RN 1 stated Resident 2's physician should have been notified of his refusal of the neurological assessments. RN 1 stated notifying Resident 2's physician would allow the physician to be aware of Resident 2's status, and further treatment. During a review of the facility's P&P titled, Neurological Assessment, revised ,d+[DATE], the P&P indicated, The purpose of this procedure is to provide guidelines for a neurological assessment upon physician order, when following an unwitnessed fall, subsequent to a fall with a suspected head injury, or when indicated by resident condition. The P&P indicated, Notify the physician of any changes in a resident's neurological status. Notify the supervisor if the resident refuses the procedure. Report other information accordance with facility policy and professional standards of practice. c. During a review of Resident 2's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Fall Management Follow-Up, dated [DATE], the IDT Fall Management Follow-Up indicated Resident 2 was placed on Neuro Checks and Post-Fall Monitoring. The IDT Fall Management Follow-Up indicated other interventions implemented for Resident 2 included to check the resident's vital signs, pain assessment, and body/skin check. The IDT Fall Management Follow-Up indicated an X-ray (procedure to take pictures of the inside of the body) of Resident 2's hips were ordered. The IDT Fall Management Follow-Up indicated Resident 2 did not want the licensed nurse to perform any assessments and to leave him alone. During an interview on [DATE] at 1:10 p.m., with the Quality Assurance (QA) Nurse, the QA Nurse stated after a fall, Resident 2's vital signs and exposed skin, such as arms, legs, and head were assessed. The QA Nurse stated when Resident 2 had an unwitnessed fall on [DATE] but refused to have a full body and skin assessment done. The QA Nurse stated Resident 2 was found on his buttocks and it was important to assess the area for any redness or bruising. The QA Nurse stated Resident 2's physician was not notified the resident refused the skin assessment after the fall. The QA Nurse stated she was unsure why Resident 2's physician was not notified of his refusal for a skin assessment. The QA Nurse stated Resident 2's physician should have been notified for orders to monitor Resident 2 for skin changes and any treatment, if needed. d. During a review of Resident 2's Skin Observation document, dated [DATE] through [DATE], the Skin Observation document indicated Resident 2 refused the skin observation on [DATE], [DATE], [DATE], and [DATE]. During a review of Resident 2's Wound Scan Photos, dated [DATE] and timed at 8:44 a.m., the Wound Scan Photos indicated Resident 2 had redness to the bilateral buttocks, a dark brown spot on his lower back, and a red/brown spot on his left lower back. During a review of Resident 2's GACH Nursing Note, dated [DATE] and timed at 10 a.m., the Nursing Note indicated Resident 2 had many wounds on his back and hip area indicating that he is unable to turn on his own. During an interview on [DATE] at 11:26 a.m., with the Treatment Nurse (TN), the TN stated the CNAs see the residents' skin more often than the licensed nurses. The TN stated the licensed nurses depended on the CNAs to report any skin changes immediately. The TN stated if a resident refused a shower or skin assessment, the CNA would have to inform the licensed nurse. The TN stated he was unaware of any wounds on Resident 2's buttocks and backside. The TN stated a facility-wide skin sweep would be conducted monthly and Resident 2 was set to have a full body skin assessment if he was not sent to the GACH. During an interview on [DATE] at 11:13 a.m., with CNA 7, CNA 7 stated she was assigned to Resident 2 and was familiar with the resident. CNA 7 stated Resident 2 would not allow her to touch him or allow her to assist with his ADLs or other parts of his care. CNA 7 stated Resident 2 would ask for towels and take wet wipes into the restroom to wipe himself down. CNA 7 stated Resident 2 would close the door on her and would not allow CNA 7 to observe his back side and buttocks. CNA 7 stated Resident 2 was very independent and ambulatory (ability to walk). CNA 7 stated she informed the licensed nurse of Resident 2's skin check refusals. During an interview on [DATE] at 11:44 a.m., with the DON, the DON stated the licensed nurses conduct a monthly skin sweep for each resident, and CNAs would perform a daily skin observation when providing care to a resident. The DON stated the CNAs would note any skin changes and inform the licensed nurses. The DON stated Resident 2 did not allow the CNAs or licensed nurses to assist with his care and demanded they leave his room. The DON stated Resident 2's physician was not notified the resident refused his skin assessments. The DON stated the physician should have been notified for interventions to better care for Resident 2 and prevent the resident's condition from getting worse. The DON stated notifying Resident 2's physician could have allowed for better assessment of Resident 2's skin and to identify any changes in his skin and treat accordingly. During a review of the facility's P&P titled, Refusal of Care and Treatment, revised 2017, the P&P indicated, The Attending Physician must be notified of refusal or treatment, in a time frame determined by the resident's condition and potential serious consequences of the refusal.

Based on observation, interview and record review, the facility failed to ensure six of six sampled residents ' (Residents 1, 2, 3, 4, 5, and 6) personal property (debit cards) were safeguarded and were protected from potential financial abuse (deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent), by failing to ensure: 1. Implementation of its undated policy and procedures (P&P) titled, Abuse Prevention, Screening and Training Program, which indicated the facility should not condone (allow) any form of resident financial abuse and misappropriation (unlawful use) of resident property and wrongful use of resident ' s money without the resident ' s consent (permission). 2. The Social Services Designee (SSD) did not have access to residents ' financial documents including debit cards (a bank card linked to a checking account to access money) and cash for Residents 1, 2, 3, 4, 5, and 6. On 5/17/2024, at 10 am, the SSD ' s office drawer was observed with 6 debit cards that belonged to Residents 1, 2, 3, 4, 5, and 6, and an unknown amount of cash, that should not be in the SSD ' s drawer. 3. All residents ' (Residents 1, 2, 3, 4, 5, and 6) debit cards and cash were included in the residents ' Clothing and Possessions list (document that contained the lists of all residents ' belongings). 4. The responsible parties and residents were provided with receipts indicating how much money was withdrawn from their debit cards at any given time. 5. Residents ' cash and debit cards (Residents 1, 2, 3, 4, 5, and 6) were securely kept in a facility ' s locked cabinet. 6. The SSD did not keep debit cards for Residents 5 and 6, who no longer reside in the facility. 7. The facility had a tracking system in place to identify which residents have debit cards and money. As a result, the facility placed Residents 1, 2, 3, 4, 5, and 6 at risk for unauthorized use of residents ' money and placed all 93 residents at risk for financial abuse. On 5/17/2024 at 3:38 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Director of Nursing (DON) and Administrator (ADM) due to the facility ' s failure to protect Residents 1, 2, 3, 4, 5, and 6 from financial abuse by Social Services Director (SSD) on 5/17/2024. On 5/19/2024 at 3:50 p.m., the facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After verification of IJRP ' s implementation through observation, interview, and record review, the IJ was removed while onsite on 5/19/2024 at 3:54 p.m., in the presence of the DON, ADM, and Infection Prevention Nurse (IP). The IJRP included the following immediate actions: 1. On May 18, 2024, the ADM completed 80 percent (%) of facility ' s staff re-education/re-training of the P&P titled, Investigation of Theft and/or Misappropriation of Resident Property, with strict adherence and emphasis on the facility not condoning any form of resident financial abuse, misappropriation of resident property, and wrongful use of residents ' money without the resident and/or responsible party's consent. 2. On May 18, 2024, the facility ADM gave a stern (serious) warning that any staff found to be in violation of the facility ' s resident abuse protocol may result in final disciplinary notice, with the potential termination, without progressive disciplinary actions. 3. On May 17, 2024, the SSD was placed on preventative suspension followed by termination, for violation of facility's Abuse Prevention and Prohibition policy, code of conduct and failure to follow instructions given by the ADM. 4. On May 17, 2024, to ensure that the SSD would no longer had access to residents' financial documents including debit cards and cash for Residents 1, 2,3, 4, 5, and 6, the debit cards and cash in the amount of twenty-seven dollars ($27) were removed from the SSD's office, itemized on a log and placed in a lockbox located at the Business Office for safekeeping. 5. On May 18, 2024, the facility ordered a safe (a secured container) in which the Business Office Manager/Designee will utilize to maintain all residents' (Residents 1, 2,3, 4, 5, and 6) debit cards and cash. 6. On May 18, 2024, the Quality Assurance Nurse (QA, an advocate for both the patient and health organization) completed the audit and updated the inventory list (Clothing and Possessions list), including, but not limited to, debit cards and cash, belongings for Residents 1, 2, 3, 4, 5 and 6. 7. On May 18, 2024, the QA Nurse initiated audits for all other current residents' inventory list and began updating all residents ' clothing and possessions in the residents ' inventory list to include debit cards and cash belonging to the residents to ensure accuracy. If any debit cards and cash found in residents' possession, they will be surrendered to the Business Office Manager/ Designee with the Resident and/or Responsible Party's consent. If Resident and/or Responsible Party refuses to surrender their debit cards and/or cash and have it recorded in the Inventory List, the Resident's and/or Responsible Party's consent will be obtained by facility staff, that any missing cash or debit cards, will no longer be the responsibility of the facility, using the Notice of Safekeeping Residents Personal Belongings/Cash form. Immediately upon admission/re-admission of a resident, the assigned Certified Nurse Assistant (CNA) and/or the Registered Nurse (RN) Supervisor/ Designee will initiate an inventory check of resident's debit cards and cash and these items will be immediately surrendered to the Business Office Manager/ Designee with the resident and/or Responsible Party's consent. If the admission/re-admission is after business hours, the RN Supervisor/Designee will maintain the debit cards and cash in an envelope labeled with the resident's name and locked in the narcotic drawer of Nursing Station 1. It will be immediately surrendered to the Business Office Manager/Designee the following business day for safekeeping. The debit cards and cash will be documented in the resident's inventory List, signed by a facility staff member and the resident/responsible party. 8. Medical Records Director/Designee will continue the audit of Resident's' Inventory List on resident's admission/re-admission, quarterly, and as needed for three (3) months and then annually, and as needed thereafter, until a replacement SSD is found. 9. On May 18, 2024, the facility updated the Resident Personal Belongings Inventory List to include valuables such as credit cards, debit cards, cellphones, IDs, social security card, rings, watches, and cash. 10. On May 18, 2024, The Administrator initiated a re-education/re-training for facility staff on the strict implementation of the Policy and Procedures titled: Investigation of Theft and/or Misappropriation of Resident Property which emphasizes on: a. No staff members shall perform unauthorized transactions using residents' bank cards or cash. b. appropriate handling of Residents' funds/belongings c. chain of custody and inclusion on Inventory List of Residents' debit cards/cash. d. Only the Business Office Director/Designee shall be allowed to handle residents' financial matters. 11. On May 18, 2024, the Business Office created a log which included, but not limited to, which debit cards and cash belonged to which residents, and a tracking of receipts provided to residents and/or Responsible Parties indicating how much money was withdrawn from residents ' debit cards at any given time. This log will be inspected by the Administrator twice a week and will be reviewed during the monthly Quality Assurance meeting for review and recommendation. 12. On May 18, 2024, the Business Office created a log to show residents/responsible parties were provided with receipts indicating how much money was withdrawn from resident's debit cards at any given time. A copy of these receipts will also be maintained with the log in the Business Office. Findings: a). A review of Resident 1 ' s Admission record, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and adult failure to thrive (poor appetite, weight loss, fatigue, and overall progressive decline in a person's ability to carry out everyday activities). A review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 1/5/2024, indicated Resident 1 understood and was able to make self-understood. The MDS indicated Resident 1 required set up for eating and substantial assistance (helper does more than half the effort) with oral hygiene and personal hygiene. The MDS indicated resident was dependent with toileting and showers. A review of Resident 1 ' s History and Physical (H&P), dated 10/25/2023 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Clothing and Possessions List, dated 10/24/2023, Resident 1 ' s belongings such as clothes, and shoes but did not indicate Resident 2 had a debit card/or money. During a concurrent observation and interview on 5/17/2024 at 10:40 a.m., with Resident 1, in the resident ' s room, Resident 1 was in bed, awake and alert but unable to respond to questions. During an interview on 5/23/2024 at 11:50 a.m., with Family member (FM) 1, FM 1 stated she was not aware the SSD had Resident 1 ' s debit card. FM 1 stated she never received any bank statements, or receipts for any of Resident 1 ' s transactions. b). A review of Resident 2 ' s Admission record, indicated Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 2 ' s diagnoses included schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and bipolar disorder (serious mental illness that causes unusual shifts in mood). A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 required assistance with setup or clean up with eating and oral hygiene. The MDS indicated Resident 2 required supervision with toileting, showering, and bathing. The MDS indicated Resident 2 required supervision with personal hygiene. A review of Resident 2 ' s H&P, dated 1/19/2024 indicated Resident 2 had fluctuating (changing) capacity to understand and make decisions. A review of Resident 2 ' s Clothing and Possessions List, dated 1/17/2024, indicated Resident 2 ' s belongings such as socks and one nightgown, but did not indicate Resident 2 had a debit card/or money. During interview on 5/17/2024 at 10:42 a.m., with Resident 2, Resident 2 stated the SSD took him to the bank every three months and withdrew $50.00 from his account to buy snacks. Resident 2 stated the SSD never gave him any of his bank statements. Resident 2 stated the SSD kept all bank statements each time they went to the bank to withdraw money from his account. c). A review of Resident 3 ' s Admission record, indicated Resident 3 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of adult failure to thrive and schizophrenia. A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 had the ability to understand and be understood. MDS indicated Resident 3 was independent with eating. The MDS indicated Resident 3 required supervision with oral hygiene, and required moderate assistance with toileting hygiene, shower, and bathing. A review of Resident 3 ' s H&P, dated 2/15/2024 indicated Resident 3 had fluctuating capacity to understand and make decisions. A review of Resident 3 ' s Clothing and Possessions List, dated 2/5/2024, indicated Resident 3 ' s belongings such as clothes and dentures, but did not indicate Resident 3 had a debit card/or money. During an interview on 5/17/2024 at 10:45 a.m., with Resident 3, Resident 3 stated he did not know anything about money. Resident 3 stated he could not answer any further questions because the SSD managed his money. d). A review of Resident 4 ' s Admission record, indicated Resident 4 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of adult failure to thrive and dysphagia (difficulty swallowing). A review of Resident 4 ' s MDS, dated [DATE], indicated Resident 4 had the ability to understand and be understood. The MDS indicated Resident 4 was dependent with eating, oral hygiene, toileting hygiene, shower, bathing, and personal hygiene. A review of Resident 4 ' s Clothing and Possessions List, dated 2/5/2024, indicated Resident 4 ' s belongings such as one hospital gown, but did not indicate Resident 4 had a debit card/or money. During a concurrent observation and interview on 5/17/2024 at 10:49 a.m., with Resident 4, Resident 4 was laying in bed, with eyes closed. Resident was unable to answer any questions. During an interview on 5/23/2024 at 12:10 p.m., with a Public Guardian (PG), the PG stated she was not aware the SSD was in possession of Resident 4 ' s debit card. The PG stated she was never given any statements or receipts for any of Resident 4 ' s transactions. e). A review of Resident 5 ' s Admission record, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses of bipolar disorder, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 5 ' s MDS, dated [DATE], indicated Resident 5 had the ability to understand and be understood. The MDS indicated Resident 5 required a two person assist with bed mobility, transfer, locomotion (moving from place to place), dressing, eating, toilet use and personal hygiene. A review of Resident 5 ' s ' s H&P, dated 7/10/2022 indicated Resident 5 had fluctuating capacity to understand and make decisions. A review of Resident 5 ' s ' s Clothing and Possessions List, dated 4/26/2023, indicated Resident 5 ' s belongings such as clothes and two sweaters but, did not indicate Resident 5 had a debit card and/or money. A review of facility ' s daily census dated 5/19/2024, did not indicate Resident 5 was a resident at the facility. During an interview on 5/17/2024 at 10:00 a.m., with the SSD, the SSD stated Resident 5 no longer resided in the facility. The SSD stated she forgot to return Resident 5 ' s debit card to the resident or the responsible party at the time of discharge. f). A review of Resident 6 ' s Admission record, indicated Resident 6 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 8 ' s diagnoses included schizoaffective disorder, bipolar type (a mental condition marked by alternating periods of elation and depression) and muscle wasting (weakening, shrinking, and loss of muscle caused by disease or lack of use). A review of Resident 6 ' s MDS, dated [DATE], indicated Resident 6 had the ability to understand and be understood. The MDS indicated Resident 6 required set up assistance for bed mobility, transfer, locomotion, dressing, eating, toilet use and personal hygiene. A review of Resident 6 ' s H&P, dated 3/9/2023 indicated Resident 6 had fluctuating capacity to understand and make decisions. A review of Resident 6 ' s Clothing and possessions List, dated 3/17/2023, indicated Resident 6 ' s belongings such as socks and one hospital gown but did not indicate Resident 6 had a debit card. A review of facility ' s daily census dated 5/19/2024, did not indicate Resident 6 was still a resident at the facility. During an interview on 5/17/2024 at 10:00 a.m., with the SSD, the SSD stated Resident 6 was discharged from the facility months ago. The SSD stated she forgot to return Resident 6 ' s debit card to the resident or the responsible party at the time of discharge. The SSD stated she should not have kept debit cards for residents who no longer resided in the facility. During an interview on 5/16/2024 at 2:18 p.m., with CNA 1, CNA 1 stated residents ' debit cards and money were kept by the SSD. CNA 1 stated CNAs did not list residents ' debit cards and money in the Clothing and Possession List because the SSD was the one who took care of residents ' debit cards and money. During an interview on 5/16/2024 at 2:30 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated the SSD kept residents ' money and debit cards in her office. During an interview on 5/16/2024 at 2:40 p.m., with the SSD, the SSD stated she did not have any debit cards or cash for any residents in the facility. The SSD stated if the debit cards were not noted on the residents clothing and possession list, it meant the facility did not receive the items. During a concurrent observation and interview on 5/17/2024 at 10:00 a.m., with the SSD and the Social Services Assistant (SSDA), in the SSD ' s office, the SSD opened the unlocked right bottom drawer of her (SSD) desk. The drawer was observed to have an unlocked tin box with an unknown amount of cash. The drawer also contained the following items: 1. Four residents ' (Residents 1, 5, 13 and 14) social security cards 2. Three residents ' (Residents 15, 16 and 17) birth certificates 3. One debit card belonging to Resident 1 4. Two debit cards belonging to Resident 2 5. Three debit cards belonging to Resident 3 6. One debit card and a check book belonging to Resident 4 7. One debit card belonging to Resident 5 8. One debit card belonging to Resident 6 9. Two temporary debit cards with unidentified names The SSD stated the box also contained old cards belonging to residents including Residents 5 and 6, who no longer resided (lived) in the facility. The SSD stated the drawer used to have a lock, but it broke, and was never repaired so the drawer had been unlocked for over a year. The SSD stated she was the only one with access to the contents of the drawer. The SSA stated she only had access to the drawer when instructed by SSD to get her (the SSD ' s) purse. The SSD stated she had no means of tracking the items in the drawer because she did not have a log or binder to indicate what each resident had. The SSD stated she had been working in the facility for [AGE] years, kept residents ' debit cards and money but never had any documentation or evidence of residents ' items in her possession. The SSA stated the SSD always took residents to the bank to withdraw their money. The SSD stated she did not have any receipts of residents ' funds withdrawn or amounts in her possession, because the residents kept their own receipts. During an interview on 5/17/2024 at 10:58 a.m., with Business Manager (BM), the BM stated the SSD was the one who always took residents to their banks. The BM stated she was not aware if SSD provided residents with receipts after each bank transaction. During a concurrent observation and interview on 5/17/2024 at 1:15 p.m., with the ADM, in the SSD ' s office, the office drawer was observed. The ADM opened the unlocked drawer and the tin box and stated the box contained residents ' cash, debit cards, social security cards and birth certificates. The ADM stated the items should have been locked and no one should have access to residents ' debit cards, cash, social security cards, identification cards, passport, and birth certificates. The ADM stated leaving residents ' private documents in an unlocked drawer placed the residents at risk for misappropriation of property, identity theft and unauthorized access to their funds. The ADM stated the SSD was not supposed to manage any of residents ' debit cards and cash. The ADM stated every day, she asked the SSD if she (the SSD) was in possession of any residents ' debit cards or cash and the SSD denied every time. The ADM stated she was asking SSD daily about resident ' s debit cards and cash because she wanted to ensure the facility was compliant with a previous deficiency in which the SSD had residents debit cards and cash. The ADM stated all residents ' possessions including debit cards, social security cards, cash, and identification cards should have been included in their clothing and possessions ' list. The ADM stated staff had not been listing debit cards, social security cards, cash and identification cards in the residents ' possession lists. A review of the facility ' s undated P&P titled, Personal Property, indicated a resident ' s personal belonging and clothing shall be inventoried and documented upon admission. A review of the facility ' s undated P&P titled, Management of Residents ' Personal Funds, indicated, if the resident elects to have the facility manage his or her personal funds, it must be authorized in writing by the resident or the resident's representative, and a copy of such authorization must be documented in the resident's medical record. The P&P indicated; a copy of all financial transactions will be filed in the resident's permanent records. A review of the facility ' s undated P&P titled, Abuse Prevention/Prohibition, indicated that the facility should not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment, and develops facility policies, procedures, training programs, and systems to promote an environment free from abuse and mistreatment.

Based on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 1) received appropriate foot care and podiatry (the medical care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Ensure Resident 1's feet and toes were routinely inspected. 3. Ensure Resident 1 was receiving podiatry services every two months and as needed. These deficient practices resulted in Resident 1 developing [CONDITION(S)] (an infection of the bone) and septic arthritis (a painful infection in a joint that comes from germs) to the fifth digit (toe) of the left foot which resulted in amputation (surgical removal) of the fifth toe. Findings: During a review of Resident 1's Admission Record (face sheet), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 6/9/2021, the MDS indicated Resident 1 had no cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 did not exhibit rejection of care behaviors. The MDS indicated Resident 1 required limited, one-person assistance for personal hygiene and bathing. The MDS indicated Resident 1 had no foot problems. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Baseline Care Plan, dated 6/24/2021, the care plan indicated Resident 1 required podiatry services. During a review of Resident 1's Body Assessment form, dated 6/25/2021, the form indicated Resident 1 was missing the second toe on the left foot. During a review of Resident 1's Podiatric Evaluation and Treatment form, dated 9/8/2021, approximately 2 months and 2 weeks after the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The form indicated the assessment revealed Resident 1 experienced pain in an unspecified limb, tinea unguium (toenail fungus), nail dystrophy (toenails that are deformed, thickened, or discolored), unspecified atherosclerosis of native arteries of the extremities (reduced blood flow to the legs and feet due to the narrowing and hardening of the arteries), and amputation of the second toe on the left foot. The form indicated the treatment plan was to debride (involves the significant reduction in the thickness and length of the nail) Resident 1's toenails. During a review of Resident 1's Shower Day Skin Inspection forms, dated 12/15/2021, 4/15/2022, 5/17/2022, 6/15/2022, and 7/15/2022, the section indicating the assessment of Resident 1's skin and toenails was incomplete. During a review of Resident 1's care plan titled, Skin Breakdown, dated 6/8/2022, the care plan indicated Resident 1 was at risk for further skin breakdown related to fragile skin, required assistance with activities of daily living ([ADLs] daily self-care activities such as bathing and personal hygiene) and diabetes mellitus. The care plan indicated the staff ' s interventions included to provide good skin care during showers and baths such as applying lotions and skin protectant, assess Resident 1's skin integrity when giving care and notify the physician for any abnormalities. During a review of Resident 1's care plan titled, ADL Functional/ Rehabilitation Potential, dated 6/8/2022, the care plan indicated Resident 1 had impaired physical mobility and self-care deficit related to personal hygiene and bathing. The care plan indicated Resident 1 required supervision with a one-person assistance with personal hygiene and bathing. The staff's interventions included to assist Resident 1 to the bath/shower room and assist in bathing and ADLs as needed. During a review of Resident 1's Situation Background Assessment and Recommendation (SBAR) Form, dated 8/2/2022, the SBAR indicated Resident 1's physician called the facility and informed the charge nurse to transfer Resident 1 to the hospital for further evaluation of the bilateral lower extremities (BLE). During a review of Resident 1's Transfer and Referral Record, dated 8/2/2022, the record indicated Resident 1 was transferred to the hospital for further evaluation of a foot lesion (an abnormal change in an area of skin on the foot) and the resident's toes. The record indicated Resident 1 had discoloration (any change in the skin that differs from a person's natural skin tone) on the feet and toes. During a review of Resident 1's Emergency Department (ED) Physician's Note, dated 8/2/2022, the note indicated Resident 1 presented to the ED with complaints of discoloration of the left and right toes. The note indicated Resident 1 had a left fifth toe open wound measuring 1.5 centimeters ([cm] unit of measurement) by 1.5 cm with superficial ulceration (an open sore caused by poor blood flow), surrounding [CONDITION(S)] (redness of the skin) on the proximal (situated nearer to the center of the body) areas of the toes, left worse than the right. The note indicated the acute [CONDITION(S)] (a type of skin rash caused by injured or inflamed blood capillaries) was consistent with [CONDITION(S)] (a bacterial infection of the skin). The note indicated Resident 1 was discharged back to the facility and was instructed to follow-up with a vascular physician (specialist who are highly trained to treat disease of the vascular system) and podiatrist on his care team for further management of his chronic (recurrent) disease. The note indicated Resident 1 was diagnosed with chronic foot wounds with acute infection and peripheral artery stenosis of the leg (a condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 1's medical records, Resident 1 was readmitted back to the skilled nursing facility on 8/3/2022 and transferred back to the GACH on 8/8/2022. During a review of Resident 1's Resident Transfer and Referral Record, dated 8/8/2022, the record indicated Resident 1 was transferred to the hospital for evaluation of the BLE due to discoloration. During a review of Resident 1's GACH Podiatry Consultation Report, dated 8/9/2022, the report indicated Resident 1 presented to the GACH due to discolorations on the bilateral lower extremities. The report indicated Resident 1 was seen for bilateral painful, elongated, and dystrophic nails, and a left toe wound. The report indicated Resident 1 reported having pain to his toenails during ambulation (walking) and indicated he (Resident 1) was not seeing a podiatrist on a regular basis and was very upset for the lack of care being provided at the facility. The report indicated Resident 1 was not able to perform ADLs at his baseline. The note indicated a physical exam revealed Resident 1's left foot had a full-thickness ulceration measuring 1.3 cm by 1.3 cm by 1.0 cm on the left foot dorsal (back) fifth digit and mild [CONDITION(S)] and [CONDITION(S)] of the digit. During a review of Resident 1's GACH's Radiology/Diagnostic Results, dated 8/9/2022, the note indicated Resident 1 had [CONDITION(S)] and septic arthritis (a painful infection in a joint that comes from germs) of the fifth digit of the left foot. During a review of Resident 1's GACH's Infectious Disease (ID) Consultation Report, dated 8/10/2022, the report indicated Resident 1 had [CONDITION(S)] and [CONDITION(S)] with septic joint of the left fifth toe. During a review of Resident 1's GACH Operative Podiatry Note, dated 8/12/2022, the note indicated Resident 1's left foot, fifth digit was amputated with removal of non-viable (dead) tissue. During a telephone interview with the complainant on 8/11/2022 at 8:36 a.m., the complainant stated she visited Resident 1 at the facility on 7/1/2022, and observed Resident 1's toenails were overgrown, thick, yellow in color, had black stuff between the toes, and the soles of the feet were black. The complainant stated portions of Resident 1's toenails and feet were encrusted and black in color and some of the toenails appeared to be lifting from the nailbed. The complainant stated she spoke to a charge nurse and requested for Resident 1 to be referred to a podiatrist. The complainant stated she visited Resident 1 at the facility on 4/18/2022, and the resident had not been seen by the podiatrist but was told by the charge nurse Resident 1 was on the list to be seen by the podiatrist. The complainant stated Resident 1 was last seen by the podiatrist in September 2021. The complainant stated she visited Resident 1 on 12/20/2021, and between the first visit and her last visit on 7/1/2022, she saw the deterioration of the condition of Resident 1's feet and toenails. During an interview with Licensed Vocational Nurse (LVN) 1 on 8/11/2022, at 12:40 p.m., LVN 1 stated the podiatrist came to the facility twice a month. LVN 1 stated if a resident had ingrown toenails or had any concerns with their feet, the podiatrist would be notified, and the resident would be added to the list to be seen. LVN 1 stated Resident 1's toenails were long and thick, and his feet had dry, scaly-looking skin between the toes. LVN 1 stated the podiatrist would be the one responsible for cutting Resident 1's toenails because the resident was diabetic. LVN 1 stated she never called and added Resident 1 to the list to be seen by the podiatrist because the resident already had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 stated the fourth and fifth toes on Resident 1's left foot appeared red and were warm to touch and both of the lower legs appeared red. LVN 1 stated Resident 1 was transferred to the GACH and was prescribed two oral antibiotics and an antibiotic cream for an infection on his feet. LVN 1 stated Resident 1 was independent but was non-compliant with his ADLs. LVN 1 stated residents usually showered twice a week, but Resident 1 would go longer than a week without showering due to refusal. LVN 1 stated Resident 1's non-compliance with showering and ADLs should have been care planned. During an interview with the Social Services Director (SSD) on 8/11/2022 at 2 p.m., the SSD stated she was responsible for making appointments for ancillary services (wide range of non-urgent, non-emergent services). During a concurrent interview with the Treatment Nurse (TX 1) and record review of Resident 1's Shower Day Skin Inspection forms dated 12/15/2021, 4/15/2022, 5/17/2022, 6/15/2022, and 7/15/2022, on 8/11/2022 at 2:46 p.m., TX 1 stated he performed a monthly skin sweep assessment for all the residents to assess for skin abnormalities. TX 1 stated Resident 1 was a diabetic and it was important to assess his feet. TX 1 stated foot and nail care was important for a diabetic resident because their skin was more fragile, and healing was slower. TX 1 confirmed the Shower Day Skin Inspection forms for Resident 1 were not complete, the condition of the resident's feet and toenails were not addressed and stated it should have been addressed. TX 1 stated Resident 1's nails were thick, mycotic, discolored, dark, and not well kept. TX 1 stated if he saw a resident needed nail care, he would have asked the SSD to put the resident on the list to be seen by podiatry. TX 1 stated the SSD was responsible for referring residents to ancillary services including podiatry. TX 1 stated he did not remember if he requested Resident 1 to be put on the podiatry list. TX 1 stated it was his fault Resident 1 was not followed by the podiatrist because he assumed the resident was already being seen. TX 1 stated he did not document the condition of Resident 1's toenails. During a concurrent interview with the SSD and record review of the Podiatrist Referral List dated 1/24/2022, 5/17/2022, 6/7/2022, and 7/13/2022, on 8/11/2022 at 3:22 p.m., the lists indicated Resident 1 was on the list to be seen by the podiatrist. The SSD stated there were no notes indicating Resident 1 was seen. The SSD stated she cannot explain why the podiatry appointments were missed for Resident 1. The SSD stated the podiatrist gave her the lists after completing the resident rounds and she gave the lists to her assistant to make a note on the residents' chart indicating the residents were seen. The SSD stated she assumed the podiatrist saw all the residents on the list. The SSD stated Resident 1 had not received the proper foot care due to the unexplained, missed podiatry visits and treatment. During a concurrent interview with the Director of Nursing (DON) and record review of Resident 1's Shower Day Skin Inspection forms dated 12/15/2021, 4/15/2022, 5/17/2022, 6/15/2022, and 7/15/2022, on 8/11/2022 at 5:20 p.m., the DON reviewed the forms and stated the SSD was responsible for calling and requesting ancillary services for a resident and communicating the recommendations of the podiatrist to the nursing staff. The DON confirmed the condition of Resident 1's feet and toenails were not addressed on the Shower Day Skin Inspection forms. The DON stated she used the monthly Shower Day Skin Inspection forms to compare and catch any changes on the residents. The DON stated if the Shower Day Skin Inspection forms were complete, it would have caught her attention to follow up and ensure the podiatrist was alerted to see Resident 1. During a concurrent interview with the Social Services Assistant (SSA) and record review of the Podiatrist Referral List dated 1/24/2022, on 8/17/2022 at 2:30 p.m., the SSA stated she was responsible for documenting what residents were seen by the podiatrist and placed a check mark next to a resident ' s name on the list once she documented the resident was seen. The SSA stated it was the responsibility of the SSD to follow up on the residents who were not seen by the podiatrist. During an interview with the SSD on 8/17/2022 at 3:16 p.m., the SSD stated Resident 1 was seen only once by the podiatrist on 9/8/2021. The SSD stated the ball was dropped. The SSD stated Resident 1 did not receive the care he needed, and the incident could have been avoided. The SSD stated it was her fault because it was her responsibility to ensure Resident 1 was being followed by the podiatrist. During a concurrent interview with the DON and record review of Resident 1's care plans, interdisciplinary team ([IDT] group of different disciplines working together towards a common goal of a resident) notes, and MDS on 8/17/2022 at 3:50 p.m., the DON stated there was no care plan developed for foot care. The DON stated there should have been a care plan for the condition of Resident 1's toenails before and after the podiatrist saw him on 9/8/2021. The DON stated Resident 1's care plan should have been updated after Resident 1 returned from the hospital on 8/3/2022 to address the condition of his feet. The DON stated the care plan was not specific to Resident 1 refusing foot care and hygiene. The DON stated it was important to update the care plan so Resident 1 could receive the care he needed, to have continuity of care, and to initiate the recommendations of the podiatrist. The DON stated an IDT should have been done when Resident 1 refused foot care and the purpose and importance of an IDT was to address a concern and formulate a plan to resolve a problem. During a subsequent record review of Resident 1's MDS, Section M for skin conditions, dated 6/9/2021, with the DON. The DON stated it appeared Resident 1 was not admitted to the facility with a fungal infection on his feet and the fungal infection had developed after he was admitted to the facility. The DON stated a fungal infection starts with symptoms such as itching, scaly, and crusty skin and develops over time. The DON reviewed Resident 1's notes in the chart and stated the only physician note addressing Resident 1's feet was the note written in 12/2021 regarding the wound on the resident's first toe. The DON stated there was no nursing documentation regarding the condition of Resident 1's feet and toenails, therefore the assessment of the feet and toenails was not done. The DON stated Resident 1 should have been followed by the podiatrist after the wound care treatment on the left first toe was done on 1/26/2022. The DON stated everything led to Resident 1 ending up in the hospital. The DON stated the foot infection could have been caught sooner if the podiatrist would have been following Resident 1 and possibly prevented the toe from being amputated if good foot hygiene had been done. The DON stated it was important for Resident 1 to be followed by the podiatrist who knows how to care for the feet of a diabetic resident. The DON stated she was informed Resident 1 had a toe amputated on the left foot. The DON stated the lack of foot care, the lack of follow up with the podiatrist, and the lack of communication amongst the nursing staff and social services all contributed to Resident 1's status of having his toe amputated. During an interview with Registered Nurse (RN) 1 on 8/19/2022 at 12:44 p.m., RN 1 stated Resident 1's physician called the facility on 8/2/2022 and ordered to transfer Resident 1 to the hospital for an evaluation of his lower extremities. RN 1 stated he was surprised to get the transfer order from Resident 1's physician because the facility had not reported any abnormal labs or findings regarding Resident 1. RN 1 stated he assessed Resident 1 and noted discoloration to the bilateral shin area and both feet and stated the resident's toes looked contracted (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes joints to shorten and become very stiff). RN 1 stated he did not recall the condition of Resident 1's toenails. RN 1 stated the physician called the facility again on 8/8/2022 and ordered to transfer Resident 1 to the hospital for evaluation of the discoloration of the bilateral legs. RN 1 stated he remembered making rounds with the Nurse Practitioner ([NP] health care professional qualified to treat certain medical conditions) a few months ago and the NP assessed Resident 1's shins but did not assess his toenails and the feet because his feet were not exposed. RN 1 stated Resident 1 was a diabetic and foot and nail care was very important because an ingrown toenail may lead to an infection. RN 1 stated diabetics may have poor wound healing and may lead to loss of an extremity. RN 1 stated the podiatrist would have cut the nails of a diabetic resident. RN 1 stated he had not seen Resident 1's toenails. RN 1 stated nursing staff had not reported any concerns about Resident 1's feet and stated if he had been aware, he would have called and asked the podiatrist to see the resident. RN 1 stated the SSD was responsible for following up with podiatry referrals. RN 1 stated there was a grey area as to who was responsible for checking the skin and feet of residents who were independent with showering and stated things started slipping through the cracks. RN 1 stated if a resident did not complain about foot concerns and/or pain, then the facility would not know about it. RN 1 stated TX 1 was responsible to conduct a monthly skin assessment which included an assessment of the feet and toenails for all residents. RN 1 stated the LVNs did not assess the feet of a resident unless the resident complained of pain, had a concern, or there was a change of condition then the LVN would do a full body assessment. RN 1 stated TX 1 would catch any skin, toenail, or foot issues during the monthly skin sweep. During an interview with Resident 1's Physician (Physician 1) on 8/23/2022, at 2:14 p.m., Physician 1 stated diabetic residents were referred and followed by podiatry services for toenail and foot care. Physician 1 stated his expectation was for a diabetic resident to be seen by the podiatrist at least once a month. Physician 1 stated he expected for staff to report any abnormalities they may see to the LVNs and RNs and for the abnormalities to be reported to the physician so the problem could be addressed by sending the resident to the hospital to be evaluated and/or for new orders to be given as needed to address the problem. Physician 1 stated he had not seen the wounds/infection on Resident 1's legs and feet. Physician 1 stated he did not recall who he spoke to on 8/2/2022 and what led him to ordering Resident 1 to be transferred to the hospital. Physician 1 stated he spoke to the Regional Center Medical Doctor (RCMD) on 8/8/2022 and stated she was not happy with the ER physician's evaluation of Resident 1's wound infection at the hospital and was not happy Resident 1 was sent back to the facility the next day, on 8/3/2022. Physician 1 stated the RCMD was upset and wanted Resident 1 to be transferred to another hospital for evaluation of Resident 1's foot wound. Physician 1 stated he then ordered to transfer Resident 1 to the hospital on 8/8/2022. During an interview with RCMD on 8/23/2022 at 3:27 p.m., the RCMD stated she contacted Physician 1 on 8/2/2022 and told him she wanted Resident 1 to be transferred to the hospital to be evaluated for a possible foot infection, possible bone infection of the feet, and evaluation for possible need of an amputation due to infection. RCMD stated Physician 1 gave the order and Resident 1 was transferred to the hospital and was started on antibiotics for a foot infection. RCMD stated Resident 1 returned to the facility on [DATE]. RCMD stated she called Physician 1 on 8/8/2022 and asked him to give the order to transfer Resident 1 to the hospital again. RCMD stated Resident 1 was transferred on 8/8/2022 and was diagnosed with [CONDITION(S)] (an infection of the bone) and the fifth digit on the left foot had to be amputated due to the infection he acquired in the facility due to lack of foot care and Resident 1 not being followed by the podiatrist. RCMD stated the regional center (center that provides a wide array of services for individuals with developmental disabilities) made multiple calls to the facility to request for Resident 1 to be seen by the podiatrist, but it was never done, and it resulted in Resident 1 developing an infection and having his toe amputated. RCMD stated the condition of Resident 1's feet should have never reached the point of infection and need for amputation. During an interview with NP 1 on 8/24/2022, at 10:11 a.m., NP 1 stated a diabetic resident who had issues with the toenails and/or had wounds should be seen and followed by podiatry. NP 1 stated a diabetic resident may be seen more often, according to the recommendation of the podiatrist. NP 1 stated the facility had already initiated podiatry services prior and he had placed the order for podiatry services back in 12/2021 due to Resident 1 having a wound on the left great toe. NP 1 stated he did not see Resident 1's feet when he saw him on 5/19/2022 because he knew the resident was followed by the podiatrist. NP 1 stated the nurses at the facility had not reported any issues with Resident 1's feet and toenails. During an interview with the Podiatrist (POD 1) on 8/24/2022 at 10:22 a.m., POD 1 stated according to his records, he only saw Resident 1 on 9/8/2021. POD 1 stated his recommendation for Resident 1 was debridement of the nails which was done on 9/8/2021. POD 1 stated Resident 1 was referred to podiatry for thick, long toenails. POD 1 stated after the visit on 9/8/2021, he did not receive another referral to see Resident 1. POD 1 stated the facility provided him with a list of residents to be seen. POD 1 stated some residents were noted on the list to be seen as soon as possible and he made sure to see and treat those residents the day he was making his rounds. POD 1 stated the facility did not ask him to follow Resident 1 after 9/8/2021. POD 1 stated a diabetic resident should be seen every 2-3 months for nail care and examination. POD 1 stated he went to the facility approximately once a month and depended on the facility to alert him if a resident needed podiatry services. POD 1 stated the lack of proper foot care and podiatry follow-up for nail care and examinations for a diabetic resident may lead to negative consequences including ingrown toenails, infection due to bacteria, and in worse case scenarios the infection may go to the bone and result in amputation. During an interview with the DON on 8/31/2022, at 2:35 p.m., the DON stated Resident 1 had a predisposing condition and the lack of podiatry services and foot care caused harm including the developing of an infection and the amputation of his toe. The DON stated the facility neglected Resident 1 the care he needed. During an interview with the Administrator (ADMIN) on 8/31/2022 at 2:45 p.m., the ADMIN stated after discussing the findings of the investigation, he would have to say yes, Resident 1 was neglected by the facility. During a review of the facility's policy and procedure (P&P) titled, Referrals, Social Services, dated 12/2008, the P&P indicated social services personnel shall coordinate most resident referrals with outside agencies. Referrals for medical services must be based on physician evaluation of resident need and a related physician order. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. During a review of the facility's P&P titled, Nursing Care of the Resident with Diabetes Mellitus, dated 12/2015, the P&P indicated skin should be kept as dry and clean as possible, and bathe feet in warm (not hot) water as necessary to keep clean. Keep feet dry, especially between toes, and toenails should only be trimmed by personnel qualified to do so. Care of corns and/or calluses should be referred to qualified individuals (which may require health care provider or podiatrist intervention).

Based on interview and record review, the facility failed to provide supervision and secure surroundings for one of two sampled residents (Resident 1). Resident 1, who had a history of drug abuse and wandering behavior (to wander around looking for something to do), was left unsupervised in the facility's patio with an unsecured patio gate left unlocked. Resident 1 left the facility, while unsupervised through the unlocked patio gate and went missing for an unspecified amount of time. This deficient practice resulted in Resident 1 eloping (leaving the facility without supervision and detection) and obtaining an illicit drug (substances that are illegal to possess, have no medical applications and can be dangerous to consume) and was later seen by a staff member sniffing a substance while in his room. Resident 1 required a transfer to a general acute care hospital (GACH) and was diagnosed to have high blood pressure and demand ischemia (another type of [CONDITION(S)] for which blockages in the arteries may not be present; occurs when the heart needs more oxygen than is available in the body's supply) due to drug usage. Resident 1 was admitted in the hospital for two days for close heart monitoring evaluation and treatment. Findings: During a review of Resident 1's Admission record, the Admission record indicated Resident 1 was admitted on [DATE] with diagnoses including [CONDITION(S)] (disorder that affects a person's ability to think, feel, and behave clearly), depression (a mental health disorder characterized by persistently depressed mood of loss of interest in activities, causing significant impairment in daily life), [CONDITION(S)] (a brain disorder that causes seizures [ burst of uncontrolled electrical activity between brain cells]), and [CONDITION(S)] ([[CONDITION(S)]] a condition involving [MEDICATION(S)] of the airways and difficulty or discomfort in breathing). During a review of Resident 1's history and physical (H/P), dated 9/14/2020, the H/P indicated Resident 1 had a fluctuating (to shift back and forth; with uncertainty) capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS), a comprehensive standardized assessment and care-screening tool, dated 9/18/2020, the MDS indicated Resident 1 had moderately impaired cognitive skills (thought process) for daily decision-making. The MDS indicated Resident 1 required limited assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. During a review of Resident 1's care plan initiated on 10/4/2020 titled, Altered Behavioral Status due to diagnosis of [CONDITION(S)], the care plan indicated the staff's intervention included to provide a safe environment at all times for Resident 1. During a review a Situational Background Assessment and recommendation ([SBAR] an internal report), dated 10/17/2020 and timed at 10:41 p.m., the SBAR indicated Resident 1 informed the staff (not specified) he left the facility to go to the store at approximately 2 p.m., and came back at 3:35 p.m. Resident 1 stated he did not ask to leave, because he knew he would not have been allowed him to go. During a review of an undated IDT ([interdisciplinary team] a group of professional working together to coordinate personalized health care for the resident) conference report, the IDT report indicated it was in referenced to 10/17/2020 incident and indicated Resident 1 stated while out he purchased alcohol, which he drank prior to returning to the facility. According to IDT note, Resident 1 was seen in his room sniffing white powdered substance and the physician was notified with orders to transfer to the hospital via ambulance. During a review of Resident 1's GACH history and physical (H/P) with the chief complaint listed as Substance Abuse, dated 10/18/2020, the H/P indicated the resident was brought to the hospital after he was seen inhaling crystal [MEDICATION(S)] (a form of crystals of [MEDICATION(S)] salt used illicitly for smoking, snorting ) at a skilled nursing facility (SNF). The resident had abnormal laboratory results, including an elevated CK-MB fraction (a test of a cardiac marker used to assist with diagnoses of an acute [CONDITION(S)]) and an elevated systolic blood pressure (SBP) of 188/96 (Normal Reference Range [NRR] is <120/80 mmHg [millimeters of mercury] ) requiring an admission to a telemetry unit (a unit in a hospital where residents are under continuous electronic monitoring of heart rate and vital signs [clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a resident's essential body functions) for further evaluation. Resident 1's admitting diagnosis included hypertensive urgency (severely elevated blood pressure [180 mm Hg or more systolic, or 110 mm Hg or more diastolic] without an acute target organ injury) with an elevated MB fraction. According to the GACH H/P, Resident 1 had a history of polysubstance abuse (addicted or dependent on multiple drugs, using many drugs at the same time or alternating between two or more drugs to [MEDICATION(S)] ). During a review of Resident 1's GACH progress note, dated 10/19/2020 and timed at 1900 (7 p.m.), the progress note indicated the following for 10/19/2020: At 8 a.m.: Resident 1 complained of chest pain and difficulty breathing, EKG (electrocardiogram [EKG or ECG] a test that measures the electrical activity of the heartbeat) and cardiac panel (used to qualitative determination of cardiac troponin [a test that measures the level of cardiac-specific troponin in the blood to help detect heart injury], CK-MB, and myoglobin (a red protein which carries and stores oxygen in muscle cells) in blood specimens as an aid in the diagnosis of [CONDITION(S)] ([CONDITION(S)]) ordered and nitro paste ([MEDICATION(S)] ointment prevents [CONDITION(S)] [severe pain in the chest, often spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart ] by relaxing the blood vessels so that the heart does not need to work as hard and therefore does not need as much oxygen) applied. At 8:30 a.m.: Resident 1 tried to go AWOL (absent without leave [elope]) twice and was found in the GACH's parking lot and the stairwell. Resident 1 was moved to a room with a sitter. At 10 a.m.: CKMB laboratory result was 6.1 IU/l ([International units per liter] NRR is 3 to 5% (percentage of total CK) or 5 to 25 IU/L). At 1300 (1 p.m.): PET Team (psychiatry emergency team) evaluated, and the resident was placed on a 5150 (legal involuntary hold). At 18:45 (6:45 p.m.): Resident 1 had orders to be discharged to another SNF and left at 11:07 p.m. During a review of Resident 1's GACH Discharge Summary (GDS), dated 10/19/2020, the GDS indicated the resident was restless, anxious while pacing with confusion and disorganized thinking. According to the summary, Resident 1 was seen by a cardiologist (medical doctor who studies and treats diseases and conditions of the cardiovascular system - the heart and blood vessels) and the cardiologist note, dated 10/19/2020, indicated Resident 1 had demand ischemia likely secondary to illicit drug use. During an interview on 10/23/2020 at 4:41 p.m., the Activity Assistant (AA 1) stated she had to assist with another resident and did not realize Resident 1 had left the facility. AA 1 stated no one in the facility knew Resident 1 had left the facility until Resident 1 at approximately 3:30 p.m. During an interview on 4/15/2021 at 11:29 a.m., Certified Nurse Assistant (CNA 1) stated Resident 1 was asking for change from staff for $100.00 bill and was told he needed to wait for the business office to re-open. CNA 1 stated after lunch, Resident 1 said he was going to smoke and that was the last time she saw the resident until she saw him coming back into the facility. During an interview on 4/15/2021 at 3:02 p.m., the Activity's Director (AD) stated there should always be two activities staff monitoring the patio area. The AD stated AA 1 informed her she had to take another resident inside the facility from the patio and left the area unattended. The AD stated the gate did not have a lock and the latch can be opened to exit the facility. During an interview with the Administrator (ADM) on 4/19/2021 at 3:36 p.m., the ADM stated that upon review of the facility's surveillance camera (used for the purpose of observing an area), Resident 1 was seen exiting through the gate from the patio. The ADM stated after the resident returned, the staff found him sniffing a white substance in his room. The ADM stated Resident 1 was subsequently transferred to the hospital. The ADM stated it was important for the staff to monitor and supervise residents in the patio to ensure residents were safe. During a review of the facility's Policy and Procedure (P/P), last revised on 11/2018 and titled, Wandering and Elopement the P/P indicated the facility should account for each resident on a regular basis. According to the P/P, under Prevention/Planning, the staff were supposed to account for each resident on a regular basis and use device(s) that signals when the doors and/or windows opened, if possible.

Based on observation, interviews and record review, the facility failed to ensure (7) of 7 sampled residents (Residents one (1), two (2) , three (3), four (4), five (5), six (6), seven [7]) were free from abuse and adhere to its policy and procedure (P/P), which stipulated residents would be free of abuse and all allegations of abuse would be identified, reported and investigated. The facility failed to address the following: 1. Resident 3 threw a cup of water on Resident 2. Licensed Vocational Nurse 1 (LVN 1) stated the altercation between Residents 2 and 3 was not abuse. LVN 1 did not report an incident to the abuse coordinator for further follow-up, proper investigation to prevent abuse between Residents 2 and 3 and to perform a room change to ensure Resident 2 would not be subject to further abuse by Resident 3. 2. Resident 3 yelled while aggressively threatening and pointing his cane, while standing over Resident 1. LVN 2 did not investigate and/or report the incident to the abuse coordinator and the Department of Public Health (DPH) as indicated in the facility's abuse P/P. Resident 3, also alleged he was hit on the head and roughly handled by Certified Nurse Assistant 2 (CNA 2). 3. Resident 4 was slapped on the hand by an unknown staff member. Resident 4 was not monitor for psychosocial harm (influence of social factors on a resident's mind or behavior). CNA 4 did not report to Registered Nurse 1 (RN 1) and no investigation was conducted. 4. Resident 6, who had been moved to a new room within 24 hours punched his roommate Resident 5 more than six (6) times in the face. The facility's abuse coordinator (Administrator) did not conduct a thorough investigation after being informed of the incident. Social Services was not aware of the room changes to ensure roommate compatibility prior to the room change causing Resident 6 to punch Resident 5 in the face. 5. Resident 7, who was a roommate to Residents 5 and 6, was punched in the face by Resident 6. An investigation or psychosocial follow-up was not done after Resident 7 was punched in the face. These deficient practices resulted in physical harm to Residents 5 and 7 and had the potential risk for psychosocial harm to Residents 1, 2, 3, 4, 5, 6, and 7 when the facility failed to follow-up on the abuse incidents to ensure the residents felt safe and secure. These deficient practices had the potential to affect all 84 residents who resided in the facility due to facility's failure to investigate, protect and identify abuse. On 3/4/2021 at 4:54 p.m., 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 declared, The facility's administrator (ADM.), the director of nursing (DON), the director of staff development (DSD), the Infection preventionist (IP person in charge of infection control in the facility) and the quality assurance (QA) nurse were notified of the serious findings that threatened the health and safety of the residents. On 3/6/2021 at 3:55 p.m., the ADM submitted an acceptable Plan of Action (POA) for the correction of the IJ, which included: 1. LVN 1 was provided an in-service on 3/2/2021 by the DON regarding types of abuse and the importance of reporting abuse within two (2) hrs. 2. LVN 2 was placed on suspension on 3/2/2021, pending further investigation as per the facility's P/P and was asked to report to the facility on [DATE] for a 1:1 in-service regarding the types of abuse and the importance of reporting abuse within 2 hours provided by the DON. 3. The facility conducted further investigation regarding Resident 3's allegation of abuse, including interviewing roommates and staff that were assigned to the resident in the last 48 hrs. The facility submitted a report to the DPH regarding Resident 3 and Resident 1 (Pointing a cane) on 3/4/2021. 4. All CNAs and Licensed Nurses were given a 1:1 in-service by the DSD on proper reporting and the various types of abuse. A Situation, Background, Appearance, and Review Communication form ([SBAR] an internal communication tool), was initiated for Resident 4 as of 3/4/2021 to monitor the resident for any psychosocial distress or harm. 5. The facility conducted a resident audit on 3/4/2021, including all in-house, alert and verbally responsive residents. A total of 47 residents were interviewed and all 47 residents stated they felt safe and secure in the facility. 6. All affected residents, Residents 1, 2, 3, 4, 5 and 7 were seen by a psychologist (a person who specializes in the study of mind and behavior or in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Resident 6 has been safely transferred to general acute care hospital (GACH) on 3/4/2021 for a further psychiatric evaluation (mental assessment). 8. Resident 7, roommate to Residents 5 and 6, continues to feel safe and secure. Neurological check ([neuro check] assess a person neurological functions and alertness to determine whether the person is functioning properly and react appropriately to the test) check monitoring will continue for another 72 hours (hrs). Resident 7 was seen by a psychologist on 3/5/2021 for his psychosocial needs. 9. The Social Services will be notified by the Admission Director during stand-up (a quick meeting to share and discuss important information) and before the end of the day for any residents' room changes effective immediately. The room changes will be monitored every shift for 72 hrs for roommate compatibility and will be documented in the 24hr communication book. The RN supervisor will notify the DON and Social Service personnel of any room changes over the weekend. 10. Resident's 5's Neuro check will continue for another 72 hrs., as of 3/4/2021. 11. Licensed nurses are being provided an in-service by DON, and Designee on proper communication on any change of condition ; follow up on 24hr shift endorsement including room changes; completing neuro check and updating care plan which should be patient care centered with a completion date of 3/5/2021. 12. Allegation of abuse will be reported within 2 hours to California Department of Public health (CDPH), Ombudsman, Law enforcement and APS (as applicable.) 13. Newly hired licensed staff will be provided an In-service (training) and skills competency regarding types of abuse and abuse protocols. 14. Identify residents' past behaviors, by thoroughly reviewing the referrals for any history of altercations to ensure proper placement and to prevent resident to resident altercations by DON/or designee. 15. Quality Assurance Performance Improvement (QAPI) committee will meet monthly then quarterly to review ongoing compliance. This will continue regarding Increased in Resident to Resident altercation and Abuse reporting. 16. All department heads were in-serviced regarding Abuse reporting protocols by Clinical resource consultant and DSD/IP consultant as of 3/5/2021. On 3/6/2021 at 3:58 p.m., after an onsite verification and confirmation via observation, interview, and record review to ensure the POA was implemented the ADM, DON, and the IP nurse were notified the IJ was lifted. Findings: 1a. During a review of Resident 1's Face Sheet (Admission Record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's History and Physical (H/P), dated 1/30/2021, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's care plan titled, At Risk for Abuse and Neglect Related to Behavioral Symptoms, dated 1/25/2021, the care plan indicated Resident 1 would not exhibit signs and symptoms of abuse or neglect from others daily for 90 days. The care plan did not include the staffs' interventions to be implemented to prevent abuse or neglect to Resident 1. During a review of Resident 1's Social Services Director (SSD) notes, dated 3/1/2021, the SSD's note indicated the SSD was made aware Resident 3 had his cane striking at Resident 1 aggressively. During a review of Resident 1's Departmental Notes, dated 3/4/2021 and timed at 9:40 a.m., the note indicated Resident 1 had orders for a psychologist consult. 1b. During a review of Resident 3's Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 1/29/2021, the MDS indicated Resident 3 had the ability to understand and be understood by others. The MDS indicated Resident 3 had no behaviors of physical and verbal aggression towards others during the review period. The MDS also indicated Resident 3 required limited assistance of a one-person physical assist for locomotion (how resident moves to and returns from locations), had no impairment of upper and lower extremities, and utilize a wheelchair to move around. During a review of Resident 3's SBAR, dated 2/24/2021 and timed at 10:30 p.m., the SBAR indicated on 2/24/2021 at approximately 11:20 p.m., Licensed Vocational Nurse 2 (LVN 2) heard yelling coming from Residents 1 and 3's room. The SBAR indicated upon LVN 2 entering the room, she saw Resident 3 standing with a cane on his right hand and speaking to Resident 1 aggressively. Resident 3 was not utilizing the cane to balance himself while standing, instead he was pointing the cane towards Resident 1. The SBAR indicated Resident 3 became aggressive towards Resident 1 because he wanted the remote control for the television. The SBAR concluded Resident 1 was moved to another room. During a review of Resident 3's SSD note, dated 3/1/2021, the SSD note indicated Resident 3 reported CNA 2 hit him on the head after removing the cane from him. The SSD note indicated Resident 3 was hit on the head after he was found yelling at Resident 1 and pointing the cane at him. During an interview on 3/2/2021 at 2:13 p.m., CNA 2 stated Residents 3 was upset about the television remote control. CNA 2 stated Resident 3 was saying F%@#, to Resident 1 who was sleeping. CNA 2 stated shortly after leaving the resident's room to check on his other residents, he heard a loud noise coming from the room and upon returning, Resident 3 was screaming and pointing his cane at Resident 1. CNA 2 stated Resident 1 did not feel safe being in the same room with Resident 3 anymore and requested a room change. CNA 2 stated he took Resident 3's cane away for safety purposes because Resident 3 was using his cane to threaten the residents. CNA 2 stated he notified LVN 2 and recognized the incident as being verbal abuse. During an interview on 3/2/2021 at 3:04 p.m., the DSS stated Resident 3 reported CNA 2's roughness when he took the cane away. The DSS stated Resident 3 stated he was waving his cane at Resident 1 after the argument for the television's remote control. The DSS stated Resident 1 was moved to another room for safety but she did not document it. The DSS stated the facility's P/P was to follow-up with the residents for 48 hours after a report of an altercation was made to ensure safety. The DSS stated it was the responsibility of the facility's staff (RNs, LVNs, and CNAs) to monitor the residents for safety and report. During an interview and record review with Medical Records Director (MRD) on 3/2/2021 at 3:55 p.m., she stated she was unable to find the room change documentation for Resident 1. The MRD called the DSS, who stated she had not documented a room change because the incident between Residents 1 and 3 occurred during the weekend when she was off. During an interview on 3/2/2021 at 3:58 p.m., Resident 1 stated he was sleeping, when Resident 3 was screaming and threatening him with his cane because of the remote control. Resident 1 stated he did not feel safe to sleep in the same room with Resident 3 and he asked for a room change (no date indicated). During an interview on 3/3/2021 at 11:30 a.m., LVN 2 stated on 2/24/2021 she heard yelling coming from Resident 3's room and upon entering the room, Resident 3 was standing over Resident 1's bed with the cane on his hand yelling at Resident 1. LVN 2 stated Resident 3 was not using the cane for walking, instead he was using it to threaten Resident 1. LVN 2 stated Resident 1 told her he was not feeling safe and could not stay in the same room with Resident 3, as he was aggressive towards him. LVN 2 stated the incident happened towards the end of her shift (3-11 p.m.) on 2/24/2021. LVN 2 stated she completed an SBAR regarding Residents 1 and 3's incident before going home and gave the report to the incoming shift to ensure the residents were safe. LVN 2 stated she could not say Resident 3 yelling at Resident 1 was abuse because Resident 3 did not inflict any pain on Resident 1 and Resident 3 yelling at Resident 1 while using the cane to point at him did not look like abuse to her [sic]. LVN 2 stated she did not report the incident to the abuse coordinator, DPH, ombudsman and/or the police as indicated in the facility's P/P. During an interview on 3/4/2021 at 4:28 p.m., with the DON and the ADM, the DON stated the staff was aware that all alleged abuse should be reported, and the documentations should be kept in the resident's file. The ADM stated LVN 1 was suspended because she admitted to not reporting the incident between Residents 2 and 3. The ADM stated residents yelling at each other was not consider abuse [sic] because there was no physical harm and contact. The ADM acknowledged when an allegation of abuse was made, a follow-up should be done to ensure the residents were mentally and physically safe. During an interview on 3/10/2021 at 11:38 a.m., RN 3 stated LVN 2 did not report the incident between Residents 1 and 3 to her. RN 3 stated on 2/25/2021, LVN 2 requested to move Resident 1 to a separate room because of an issue with the television. RN 3 stated she did not assess Residents 1 and 3 for physical and psychosocial harm because she was unaware of the incident. 2a. During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had the ability to understand and be understood by others. The MDS indicated Resident 3 had no behaviors of physical and/or verbal aggression towards others during the reviewed period. The MDS indicated Resident 3 required limited assistance of a one-person physical assist for locomotion and had no impairment of upper or lower extremities. According to the MDS, Resident 3 used a wheelchair for mobility. During a review of Resident 3's H/P, dated 1/20/2021, the H/P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's SBAR, dated 2/24/2021, indicated at approximately 11:20 p.m. on 2/24/21, LVN 2 heard yelling from Residents 1 and 3's room and upon entering the room, LVN 2 saw Resident 3 standing over Resident 1's bed with his cane in his right hand, while speaking aggressively towards Resident 1. The SBAR indicated the cane was not being used to steady Resident 3's gait, instead he was pointing the cane towards Resident 1. The SBAR indicated CNA 2 removed the cane from Resident 3 as a safety precaution. According to the SBAR, Resident 3 was asked what caused him to become agitated and Resident 3 stated he wanted the television's remote control. During a review of Resident 3's SSD note, dated 3/1/2021, the SSD note indicated Resident 3 reported CNA 2 hit him on the head after removing the cane from the resident. The SSD note indicated Resident 3 was hit on the head after he was found yelling and pointing the cane at Resident 1. During a review of CNA 2's employee file, the file indicated CNA 2 was suspended on 9/3/2019 due to an allegation of sexual abuse. There was no other abuse allegation or abuse misconduct documented in CNA 2's employee file. During an interview on 3/2/2021 at 12:08 p.m., the ADM stated during his investigation of Residents 1 and 3's incident, Resident 3 complained CNA 2 was rough with him. During an interview on 3/2/2021 at 2:13 p.m., CNA 2 stated he took the cane from Resident 3 after he was seen pointing it at Resident 1. CNA 2 stated he did not hit Resident 3 with the cane. During a review of Resident 3's care plan titled, History of Altercation, dated 2/25/2021, the care plan indicated Resident 3 was at risk for further or repeated altercation with other residents. Due to the resident (Resident 3) speaking aggressively to roommates and yelling at the nurses. The care plan approach indicated the staff would observe for compatibility of roommate, be alert to changes in behavior such as yelling, anger, restlessness, pacing, and redirect the resident (Resident 3) to another area when having an anger outburst. During a review of Resident 3's SBAR, dated 2/27/2021 and timed at 2:28 p.m. indicated CNA 6 notified LVN 1 that Resident 2 reported his roommate Resident 3 threw water on him. The SBAR indicated during an interview, Resident 3 stated throwing a cup of water at Resident 2 because he would not be quiet. During a review of Resident 3's Departmental Notes, dated 2/28/2021 and timed at 2:42 p.m., indicated a follow-up from 2/27/2021 SBAR, a report to police was made regarding Residents 2 and 3's incident. During a review of Resident's 3 Investigation of Incident dated 2/28/2021, indicated Resident 3 stated, He wouldn't be quiet, so I threw a little bit of water at him. The investigation indicated Resident 3 was receiving [CONDITION(S)] (drug that affect behavior, mood, thoughts, or perception) medication for agitation behaviors. During a review of Resident 3's Interdisciplinary Team ([IDT] group of health care professionals with various areas of expertise who work together toward the goals of their residents) notes dated 3/1/2021, indicated Resident 3 denied throwing water on Resident 2. 3b. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was first admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had the ability to understand and be understood by others. The MDS indicated Resident 2 had no behaviors of physical and/or verbal aggression towards others. The MDS also indicated Resident 2 required extensive assistance of one-person physical assist for locomotion had no impairment of upper and lower extremities and utilized a wheelchair to move around. During a review of Resident 2's Departmental Notes, dated 2/28/2021 at 2:34 p.m., the note indicated a follow- up from 2/27/2021 SBAR, report to the police was made aware. The note indicated no psychosocial follow up was made. During an interview on 3/2/2021 at 12:32 p.m., Resident 3 denied throwing water at Resident 2 and refused to answer any more questions. During an interview on 3/2/2021 at 1:32 p.m., LVN 1 stated on 2/27/2021 at approximately 12 p.m., CNA 6 reported that Resident 2 complained Resident 3 threw water on him and wet his bed pillow for not being quiet. LVN 1 stated during an interview, Resident 3 admitted to throwing water on Resident 2 because he was not quiet. LVN 1 stated being aware she made a mistake of not reporting the incident the same day because she was not aware if it was abuse and something that should be reported. LVN 1stated she reported the incident to the DON and the ADM on 2/28/2021 but was not able to provide the confirmation the report was sent to the Department. LVN 1 stated she was not aware of Resident 3's previous aggressive behaviors. During an interview on 3/2/2021 at 2 p.m., CNA 6 stated while providing care for Resident 2, she noticed the pillow was wet. Upon CNA 6 asking Resident 2 what happened to his pillow, Resident 2 stated Resident 3 threw water at him. CNA 6 stated Resident 3 was aggressive, often cursed at her, and called her derogatory names. CNA 6 stated abuse allegations should be reported immediately to the supervisor to prevent it from reoccurring. During an interview on 3/2/2021 at 3:04 p.m., the SSD stated she was notified of the incident between Residents 2 and 3 over the weekend and stated she did a psychosocial follow-up on Monday 3/1/2021. The SSD stated when an incident occurs during the weekend, it was the responsibility of the nurses to follow-up with the residents and report the incident timely. During a concurrent interview and review of Resident 1's clinical records on 3/2/2021 at 3:55 p.m., the MRD stated there was no room change done for Resident 2 after the altercation as indicated in the facility's abuse P/P. 4. During a review of Resident 4's Face Sheet, the Face Sheet indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's History and Physical (H/P) dated 10/9/20, the H/P indicated Resident 4 did not had the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was sometimes able to understand and understood others. The MDS indicated Resident 4 had no hallucinations or delusions (belief that are clearly false). The MDS also indicated Resident 4 required one person assist with bed mobility, transfer, and toilet. During a review of Resident's 4 care plan titled, Risk for Abuse/Neglect, dated 9/8/2020 indicated the goals was to ensure Resident 4 felt safe in the current environment. The staffs' interventions included to encourage Resident 4 to verbalize her feelings, fear, and/or frustrations, provide reassurance, visually observe for signs and symptoms of abuse and neglect and follow abuse reporting, investigation, and prohibition protocol, in accordance to State regulations and facility's abuse protocol. During a review of Resident 4's SBAR dated 2/20/2021, the SBAR indicated Resident 4 stated that a nurse hit her right hand but was unable to state the name of the staff. During a review of Resident 4's Department Note, dated 2/20/2021 and timed at 9:23 p.m., the note indicated at 5:30 p.m., on 2/20/21 Resident 4 reported to CNA 4 a staff member hit her on the hand. During a review of Resident 4's Investigation report on 2/20/2021, the report indicated Resident 4 reported a nurse hit her right hand two days ago (2/18/2021). The interview record for the investigation indicated there were various staff members interviewed from 2/19/2021 thru 2/20/2021. The investigation report indicated on 2/20/2021 at 5:30 p.m., CNA 4 who worked on the 3 p.m. to 11 p.m., was interview and CNA 4 stated Resident 4 told her a nurse hit her right hand two days prior, but Resident 4 was unable to identify the name of the nurse that hit her. The investigation report did not indicate interviews were conducted with staff members working on 2/18/2021, which was the day Resident 4 reported she was hit. During a concurrent interview and review of Resident 4's care plan on 3/2/2021 at 1:47 p.m., LVN 1 stated she could not find a care plan or interventions created for Resident 4 after she claimed a staff hit her on the hand. During a concurrent interview and review of the facility's abuse P/P on 3/4/2021 at 12:33 p.m., RN 1 stated during her interview with Resident 4, the resident stated not knowing who hit her. RN 1 stated she was the assigned staff to conduct most of the incidents reported. RN 1 stated staff-to-resident incidents were not monitored for follow-up as the incidents of resident-to resident were. RN 1 stated there was no staff followed with Resident 4's abuse report because the resident was forgetful, had dementia, and probably was not telling the truth. RN 1 stated she was not aware the abuse P/P indicated all alleged abuse had to be investigated, all possible witnesses interviewed, and residents monitor for possible abuse. RN 1 stated all residents were monitored for 72 hours following a report of abuse and reported to prevent further abuse to the same resident and/or possibly others. During an interview on 3/4/2021 at 1 p.m., CNA 4 stated on 2/20/2021 Resident 4 reported to her she had been hit by a nurse two days prior (2/18/2021). CNA 4 stated she questioned if the report was true since no visible bruises were noted and stated Resident 4 did not seemed to be telling the truth. CNA 4 stated she reported the abuse to her supervisor on 2/20/2021. CNA 4 stated the abuse coordinator was the DSD. 5a. During a review of Resident 5's Face Sheet, the Face Sheet indicated Resident 5 was first admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 5's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 was able to understand and understood others. The MDS indicated Resident 5 had no behaviors of physical and/or verbal aggression towards others. The MDS also indicated Resident 5 required a two-person physical assist for transfer and a one-person assist for locomotion, toilet use, and personal hygiene. According to the MDS, Resident 5 used a wheelchair for mobility. During a review of Resident 5's SBAR, dated 3/3/2021, the SBAR indicated Resident 5 was the victim of an altercation with Resident 6. The SBAR indicated on 3/2/2021 around 11:40 p.m. Resident 5 stated Resident 6 hit him five (5) times on the left side of the face by the jaw without provocation. During a review of Resident 5's Departmental Note, dated 3/3/2021 and timed at 9:59 a.m., the note indicated on 3/2/2021 at 11:40 p.m., Resident 5 called for help. The note indicated Resident 5 reported to CNA 8 his roommate Resident 6 hit him on the left side of the face five (5) times. The note indicated upon assessment Resident 5's face it was noted red and swollen with minimal bleeding observed in the resident's mouth (gums) and had pain 10 out of 10 (0=no pain and 10=worst pain). The note indicated Resident 5 reported to the police Resident 6 punched him on the face five times, he then went to the bathroom and upon returning, Resident 6 hit him again multiple times on the face. The note indicated Resident 5 stated he threw a cup of water at Resident 6 and called for help. During a review of Resident 5's Departmental Notes dated 3/3/2021 and timed at 1:38 a.m., indicated the facility's Medical Director ([MD] physician who provides guidance and leadership on the use of medicine in a healthcare organization) gave orders to transfer Resident 5 to the general acute care hospital (GACH) after he complained of feeling his jaw cracking. The MD gave a second order for x-ray of the skull and facial bones after Resident 5 refused to be transferred to the GACH. During a review of Resident 5's Departmental Notes dated 3/3/2021 and timed at 2:59 a.m. indicated Resident 5's physician gave orders for neuro checks for 72 hours and to transfer Resident 5 if any changes in condition were observed. A note timed at 3:15 a.m., on 3/3/2021 indicated neuro checks were done [sic] and Resident 5 had slight redness and swelling to the left side of the face. During a review of Resident 5's Pain Assessment, dated 3/3/2021, the pain assessment indicated Resident 5 complained of having constant sharp pain to the jaw. During a review of Resident 5's Investigation report, dated 3/2/2021, the report did not indicate Resident 7, who was a roommate to both Residents 5 and 6, was interviewed by the facility as indicated in their abuse P/P. During a review of Resident 5's Social Work Progress Note (SWPN), dated 3/3/2021, the SWPN indicated Resident 5 was attacked and hit on the face by his roommate. The note indicated Resident 5 had facial redness with swelling. The note indicated Resident 5 stated Resident 6 was sitting on his bed staring at him, words were exchanged between them and Resident 6 started to attack him (Resident 5) on his face. The note indicated Resident 5 stated he would feel safe if Resident 6 was not in the facility. 5b. During a review of Resident 6's Face Sheet, the Face Sheet indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 6's GACH Psychiatrist Evaluation, dated 1/28/2021, the psychiatrist evaluation indicated Resident 6 was irritable, agitated with [CONDITION(S)], aggressive behaviors, disruptive behaviors with striking out, poor compliance with care and was unsafe. During a review of Resident 6's GACH Admission Form, dated 2/2/2021, the admission form indicated Resident 6's primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 was able to understand and be understood by others. The MDS indicated Resident 6 had no behaviors of physical and/or verbal aggression towards others. The MDS also indicated Resident 6 required supervision of a one-person physical assist for set-up, bed mobility, transfer, walking, locomotion, dressing, toilet use, and personal hygiene and did not require any devices to move. During a review of Resident 6's care plan titled, Risk for Abuse and Neglect, dated 2/2/2021, the care plan indicated Resident 6 was at risk for abuse due to his aggressive behavior of striking out. The staffs' interventions indicated to approach Resident 6 calmly and attempt to re-focus his behavior to something positive. During a review of Resident 6's care plan titled, [CONDITION(S)] Medication, dated 2/2/2021, indicated Resident 6 required psychotropics (any drug that affects brain activities associated with mental processes and behavior) due to his aggressive behaviors of striking out. During a record review of Resident 6's Mental and behavioral treatment progress note, dated 3/3/2021, the progress note indicated Resident 6 was being seen for a behavioral intervention and crises following an altercation with Resident 5. The note indicated the psychologist had not previously seen Resident 6 and did not have any further data or insight to add. According to the note, Resident 6 refused to see the psychologist. During an interview on 3/3/2021 at 1:59 p.m., the ADM stated on 3/2/2021 Resident 6 hit Resident 5 on the face. The ADM stated during his investigation Resident 5 stated being upset of the incident and Resident 6 stated he hit Resident 5 because he was pointing a gun at him. During a concurrent observation and interview on 3/3/2021 at 2:07 p.m., Residents 3 and 6 were observed in the same room. During the interview, Resident 6 denied hitting Resident 5 on the face. During a concurrent observation in Resident 5's room

Based on interview and record review, the facility failed to implement safety measures to prevent falls and injury, update a care plan, and provide a two-person assist when going to the restroom for one of three sampled residents (Resident 1). Resident 1, who was assessed as a high risk for falls sustained four (4) falls in four months while in the facility and one fall on [DATE] that was not documented on Resident 1's clinical record. These deficient practices, resulted in Resident 1 sustaining multiple falls in the facility on the following dates; [DATE], [DATE], [DATE], and on [DATE] fall with left ear and temple region (located on the side of the head behind the eye between the forehead and the ear) lacerations (cuts). Resident 1 was found unresponsive without vital signs (clinical measurement of pulse rate, temperature, respiration rate, and blood pressure that indicates the state of a resident's body function) on [DATE] at approximately 9:45 p.m. Resident 1 was pronounced deceased by the paramedics in the facility on [DATE] at 10:10 p.m., 23 hours after the fall on [DATE]. On [DATE] at 6:31 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified of the 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 called for the facility's failure to provide the necessary care and emergency services immediately by assessing Resident 1's behavior of throwing himself to the floor and care planning his behavior to prevent three falls with head injury (F689). The facility's ADM and DON were notified of the immediate action to train staff members on facility policy and procedures titled, Assessing Falls and Their Causes, revised on ,[DATE] for falls and behavior management and assessment. The ADM and DON were informed of the seriousness of the residents' health and safety being threatened when accurate assessment of resident's behaviors and supervision was not provided immediately upon identification of Resident 1's behaviors of throwing himself to the floor. On [DATE] at 7:06 p.m., the ADM submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. In-service to Certified Nurse Assistant (CNA)/Licensed Vocational Nurse (LVN)/Registered Nurses (RN) by clinical nurse consultant (CNC) and Basic Life Support ((BLS) level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital) personnel on [DATE] and [DATE] on the importance of identifying changes in behavior to be able to properly assess and provide appropriate interventions, as well as recognizing the need for supervision to prevent recurrent falls. 2. Psychiatrist (medical practitioner specializing in the [DIAGNOSES REDACTED]. 3. The DON assessed 94 residents and identified all at risk for falls. The DON identified 4 residents that were affected by the deficient practice. The 4 residents will be reassessed and ensure care plans reflect appropriate interventions and care needed. 4. Licensed nurse will review clinical records for history of falls and then quarterly. 5. Nursing staff will utilize the Stop and Watch to identify changes in behavior that can lead to increase risk for falls and will be reviewed by the DON every 24 hours. 6. Licensed nurse will utilize the Fall Management Checklist to review resident's clinical records after each fall. 7. The DON/Licensed nurse will hold a fall management meeting once a week to review at least ,[DATE] resident's clinical records who are at risk for falls to review current care plan. 8. DON will re-educate nursing staff members about the importance to identified changes in behavior to be able to properly assess and provide appropriate interventions to prevent recurrent falls monthly. On [DATE] at 4:15 p.m., during a concurrent observation, interview and record review, while onsite, the ADM and DON were notified the IJ was lifted, after the team verified the Plan of Action (POA) was followed and implemented. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was first admitted to the Skilled Nursing Facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. of walking) and mobility (ability to move), and unspecified [MEDICAL CONDITION] (mental health disorder marked by a combination of symptoms such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) disorder. A review of Resident 1's History and Physical (H/P), dated [DATE] indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated [DATE] indicated the resident was always understood and could understand others. The MDS indicated the resident was totally dependent on staff, requiring two or more-person physical assist for toilet use. The MDS indicated Resident 1 was occasionally incontinent of bowel and bladder (lack of voluntary control) and was only able to stabilize himself with one-person physical assist for moving on and off the toilet. A review of Resident 1's Fall Risk Evaluation, dated [DATE] indicated Resident 1 was at high risk for fall with a score of 24. The Fall Risk Evaluation indicated a resident's score above 10 was considered a high risk for falls and a prevention protocols to prevent falls should be initiated immediately and documented on the care plan. A review of Resident 1's Change of Condition (COC) form dated [DATE] at 12:30 p.m. indicated Resident I had mood swings of intentionally throwing himself to the floor. The COC indicated on [DATE] at 12:30 p.m. Resident 1 threw himself from the wheelchair to the floor and sustain no injuries. The COC indicated Resident 1 was having mood swings due to wanting to go to the vending machine to get a soda and the staff not available to do so. The COC did not indicate interventions to prevent behavior. A review of Resident 1's COC form dated [DATE] and timed at 5:15 p.m., indicated on [DATE] at 4:30 p.m. Resident 1 had a fall while attempting to leave the facility, which resulted in a left hand laceration (cut) measuring 1.5 centimeters (cm) by (x) 1.5 cm with skin flap (lifted tissue) red and irregular in shape with scant mount of serosanguinous (containing both blood and liquid) fluid. The COC indicated the staff educated Resident 1 on safety precautions. The COC indicated the staff conducted visual checks, safety precautions and neuro checks (neurological examination assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired). A Review of Resident 1's clinical chart, no record was found of the visual checks and the neuro checks completed by the staff after the fall on [DATE]. A review of Resident 1's COC form dated [DATE] and timed at 1 p.m., indicated Resident 1 had a self-inflected (act of harming oneself) fall. The COC indicated on [DATE] at 1 p.m. Resident 1 self-inflicted a fall when he threw himself to the pavement causing abrasions (scrape) to the nose, chin, left and right knee and wrist and required a transferred to the general acute care center (GACH) for left knee contusion (region of injured tissue or skin in which blood capillaries have been ruptured; a bruise). A review of Resident 1's COC form dated [DATE] at 11:21 a.m., indicated on [DATE] at 11:21 a.m., Resident 1 was found in his restroom by CNA 1. The COC indicated upon assessment Resident 1 sustained a left temporal and ear laceration after he was attempting to transfer himself to the toilet and fell . A review of Resident 1's care plan titled, Fall Risk, re-evaluated on ,[DATE] indicated Resident 1 would have minimized falls for the next 90 days. The staff's interventions included to assist resident with transferring, mobility, positioning, provide safety education, provide physical and occupational therapy and placing call light within reach. A review of Resident 1's care plan titled, Fall Risk, dated [DATE] indicated Resident 1 would have minimized falls for the next 90 days. The staff's interventions included to assist resident with transferring, mobility, positioning, provide safety education and placing call light within reach. A review of Resident 1's care plan titled, Fall Risk, dated [DATE] indicated Resident 1 would have minimized falls for the next 30 days. The staff's interventions included to assist resident with transferring, mobility, positioning, provide safety education, placing call light within reach, increasing visual checks, and offer use of bathroom. A review of Resident 1's Rehabilitation Fall Risk Assessment, dated [DATE] indicated Resident 1 was not able to demonstrate proper use of call light, assistive devices (wheelchair and walker), proper sitting/standing balance and had no sufficient strength when sitting or standing. A review of Resident 1's GACH report, dated [DATE] indicated Resident 1 was admitted to the GACH for evaluation after sustaining a fall with injuries. The GACH report indicated Resident 1 exhibited difficulty with bed mobility (turning and repositioning in bed), transfer, impaired balance, safety, and strength on bilateral (both sides) lower and upper extremities. The GACH report indicated to discharge Resident 1 back to the facility on [DATE] to continue with physical therapy. A review of Resident 1's death certificate indicated the resident expired on [DATE] at 9:45 p.m. On [DATE] at 2:43 p.m., during an interview, LVN 2 stated on [DATE] approximately at noon time he was called into Resident 1's room by a CNA staff (did not remember who). LVN 2 stated upon entering the resident's room, Resident 1 was noted to have a laceration to the left temple and left ear. LVN 2 stated he did not initiate neuro checks on Resident 1 because they were initiated by another nurse. On [DATE] at 4:35 p.m., during an interview, CNA 2 stated Resident 1 had multiple falls on the week of his death on [DATE]. CNA 2 stated Resident 1 had been placed on a bowel and bladder program (resident is taken to the bathroom every two hours to train the bladder) to make sure the resident was monitored for falls. CNA 2 stated Resident 1 sustained two (2) falls on [DATE] the day before he was found death. On [DATE] at 4:53 p.m., during an interview and review of Resident 1's neuro checks, Medical Records Assistant (MRA) stated no neuro checks were found for [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 2:45 p.m., during a telephone interview, LVN 3 stated Resident 1 sustained two (2) falls on [DATE]. LVN 3 stated he was told by the ADM not to document the second fall Resident 1 sustained during the ,[DATE] p.m., shift. LVN 3 stated ADM wanted Resident 1's assessment documentation Resident 1 did not have any injuries after the fall. LVN 3 stated several LVN's were told by the ADM to not document all the falls Resident 1 had. On [DATE] at 5:54 p.m., during a telephone interview, LVN 5 stated Resident 1 threw himself to the floor all the time when things did not go his way. LVN 5 stated Resident 1 had multiple falls on [DATE] and on [DATE] at 9:45 p.m. was found unresponsive. On [DATE] at 6:19 p.m., during an interview and review of Resident 1's care plans and neurological checks in the presence of the ADM, the DON stated licensed staff should have updated the care plans interventions after each fall according to the facility's policy for falls. The DON stated no neurological checks were found in the chart. The DON stated the facility did not have a list of the residents at risk for fall or a monitor system to identify those with behaviors of throwing themselves to the floor. On [DATE] at 8 p.m., during an interview and review of Resident 1's care plans, neuro checks, and nurses' notes and in the presence of the ADM and DON, the RN Consultant (RNC) confirm no care plans for the behavior of throwing himself to the floor, no visual monitoring documentation, no neuro checks for each fall and no update of interventions for falls on [DATE], [DATE], [DATE] and [DATE] were found in Resident 1's clinical chart. A review of the facility's policy and procedures (P/P), titled Assessing Falls and Their Causes, revised on ,[DATE] indicated the staffs' responsibility was to review the resident's care plan to assess for any special needs, identify any current medications and equipment. The P/P indicated falls were the leading cause of mortality (subject to death) among the elderly in nursing homes and was the general guideline of the facility staff to assess residents in a timely manner for potential causes of falls. The P/P indicated appropriate interventions would be taken by the facility staff to prevent future falls.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents were free from abuse, mistreatment, and neglect (Resident 7). Licensed Vocational Nurse 4 (LVN 4) was observed physically abusing and mistreating Resident 7. LVN 4 pushed Resident 7 into a shower room and closed the door entrapping Resident 7 against the linen carts and the shower room door resulting in Resident 7 opening the shower room door and falling to the floor. Both LVNs 4 and 8 failed to perform an assessment immediately after both observed the resident fall. This deficient practice caused Resident 7 to fall to the floor and had the potential to cause physical and psychosocial harm to the resident. On 8/27/2020 at 7:39 p.m., the Administrator (ADM) and the Director of Nursing (DON) were notified of the 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) that was called for the facility's failure to ensure Resident 7 was free from abuse, mistreatment and neglect. On 8/28/2020 at 10 a.m., the ADM and DON submitted an acceptable Plan of Action (POA) for the correction of the IJ, which included: 1. Notifying the Local Ombudsman, Department of Health Services, and the Local Police Department of the incident. 2. Ensuring Resident 7 was seen and re-evaluated by a Psychiatric Nurse Practitioner. 3. Placing LVNs 4 and 8 on suspension pending outcome of the investigation. 4. Providing staff with in-services regarding resident behavioral management by a Psychiatrist. 5. Providing Certified Nursing Assistant (CNAs) with in-services on the facility's policy and procedure regarding abuse prevention by the Director of Staff Development (DSD). 6. Providing licensed nurses with in-services on the facility's policy and procedure regarding abuse prevention by the DON. 7. Providing staff with in-services on how to utilize SOC 341 (Report of Abuse and Neglect of an Elder or Dependent Adult) by the DON, DSD, and clinical resource consultant (CRC). 8. Reporting LVNs 4 and 8 inappropriate behavior towards Resident 1 to the Board of Vocational Nursing and Psychiatric Technicians. 9. Reassessing all in-house residents by a Psychiatrist. 10. Encouraging Resident 7 to verbalize his feelings and any concerns. 11. Ensuring Resident 7 was provided psychosocial visits by the Social Services Director (SSD) to allow him to continue to feel safe in the facility by the SSD 12. Encouraging Resident 7 to continue with daily activities of choice. On 9/1/2020 at 4:15 p.m., during a concurrent observation, interview and record review, while onsite, the ADM and DON were notified the IJ was lifted, after the team verified the Plan of Action (POA) was followed and implemented. Findings: On 8/27/2020 at 4:15 p.m., during a monitoring visit of the facility and concurrent observation and interview, LVN 4 was observed pushing Resident 7 with his left hand into a shower room that had a row of linen carts blocking the entrance, while closing the door with his right hand. LVN 4 was observed letting go of the door when he was asked to stop, and Resident 7 was observed falling out into the hallway's floor. LVN 8 was adjacent (next to) to the shower room at a medication cart but did not assist LVN 4 in handling Resident 7, nor did she move the medication cart when the resident fell to prevent the resident from hitting his head. LVNs 4 and 8 did not assist Resident 7 up from the floor and did not perform a head-to-toe assessment after the fall. LVN 8 was yelling in a loud tone of voice, Look, that is what he does all the time, he throws himself to the floor. LVN 8 stated Resident 7 recently returned from the general acute care hospital (GACH) after being admitted for behaviors of intentionally throwing himself to the floor. LVN 8 stated she was not going to help Resident 7 up from the floor. LVN 4 stated, He likes to throw himself from the floor that is why I was putting him in the shower room. LVN 8 stated after Resident 7's fall, she was supposed to keep the resident on the floor, reassess the resident, and check for injuries. On 8/27/2020 at 4:15 p.m., during an interview, the ADM stated LVNs 4 and 8 involved in the incident with Resident 7, would be placed on administrative leave until in-services were offered. The ADM later stated, only LVN 4 was placed on administrative leave and was asked to go home immediately while LVN 8 remained working in the facility. On 8/27/2020 at 4:48 p.m., during an interview, CNA 4 stated at the time of Resident 7's fall on 8/27/2020, she had just showered a resident and came out to see LVN 4 guiding Resident 7 and LVN 8 was trying to help LVN 4 with the resident. CNA 4 stated on 8/27/2020 she saw Resident 7 throw himself forward at the nurses' station knocking down some books and a computer. CNA 4 stated she then saw Resident 1 holding onto a door and LVN 4 attempting to hold Resident 7 from the front such as hugging him from behind. On 8/27/2020 at 4:55 p.m., during an interview, LVN 8 stated she saw LVN 4 assist Resident 7 to the shower door so he would not fall. LVN 8 stated it was the second time Resident 1 displayed behaviors of intentionally throwing himself to the floor, the first time was in the middle of the nurses' station. LVN 8 stated Resident 7 was trying to get into the shower and LVN 4 opened the door to allow Resident 7 to fall. A review of Resident 7's Face Sheet (Admission Record) indicated Resident 7 was admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident 7's [DIAGNOSES REDACTED]. A review of Resident 7's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 8/24/2020 indicated the resident had the ability to understand and be understood by others. The MDS indicated the resident required limited physical assistance of a one-person physical assist for walking, but was unsteady with turning around, and transferring. A review of Resident 7's care plan titled, Behavioral Changes, dated 8/24/2020 indicated Resident 1 had increased agitation and behaviors of throwing himself to the floor and rolling on the floor. The care plan did not indicate any staff's interventions to prevent injuries for Resident 7's behavior of throwing himself to the floor. A review of Resident 7's Fall Risk Assessment, dated 8/26/2020 indicated Resident 7 had a total score of 12. The Fall Risk Assessment indicated total scores of 10 or above represented a high risk for falls and a prevention protocol should be initiated immediately and documented on the care plan. On 8/27/2020 at 6:48 p.m., during an interview, Resident 7 stated he did not remember what happened and stated all he wanted was a smoking schedule to put in his room. Resident 7 was unable to state if he felt safe in the facility and refused to answer any other questions. On 8/27/2020 at 7:35 p.m., during an interview in the presence of the DON, the ADM stated the incident of LVN 4 pushing Resident 7 in the shower room was not considered abuse because there were no injuries sustained. On 8/28/2020 at 9:24 a.m., during a concurrent interview and review of Resident 7's care plans in the presence of the DON, the Medical Records Assistant (MRA) stated a care plan for Resident 7's behavior of falling to the floor was created on 8/24/20 but did not indicate any staff's approach to prevent the behavior. A review of LVN 4's Corrective Active Memo, dated 8/29/2020 indicated LVN 4 was terminated after the facility determined LVN 1 violated the facility's policy for zero tolerance for resident abuse, in regard to Resident's 7 incident. A review of LVN 8's Corrective Active Memo dated 8/29/2020 indicated LVN 8 was terminated after facility determined LVN 8 violated facility policy for zero tolerance for resident neglect. A review of the facility's untimed investigation, dated 8/31/2020 concluded based on the interviews and witness statements, LVNs 4 and 8 were reported to the licensing board and terminated. A review of the undated facility's policy and procedures (P/P) titled, Abuse Prevention/Prohibition, indicated the facility did not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment, and develops facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment. The facility's P/P indicated abuse was defined as the willful infliction of injury, involuntary seclusion, physical, or chemical restraint but not required to treat the residents' symptoms, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

Based on observation, interview, and record review, the facility failed to supervise and provide a safe environment for one of three sampled residents (Resident A). Resident A, who could not make decisions, was at risk for elopement (leaving unnoticed by staff), and the facility failed to ensure: 1. The front lobby exit door was equipped with a departure alarm system (activated when a resident wearing a wander guard bracelet (a system that is triggered when the person wearing the device goes beyond the contact system on a door or specific area)) was functioning. The rear doors on station A and B was each equipped with departure alarms that were both functioning and disarmed. 2. Resident A wore the wander guard bracelet as ordered by the physician and as indicated in the facility's Nursing - Wandering and Elopement policy. 3. The Medication Record for 4/2019, indicated on 4/19/19, the wander guard bracelet was not noted on Resident A during the evening shift. As a result, on 4/19/19 at 5:56 p.m., the nursing staff noticed that Resident A had eloped. Two police officers found Resident A on the same day at 8:25 p.m. and returned Resident A to the facility at 8:40 p.m. Resident A sustained an opened wound with a bump on the right occipital (back of the head) area, discolored (change in color of the skin) left lower eyelid, and an abrasion (scraped skin) on the right upper back. Resident A required a transfer to general acute care hospital (GACH), on the same day, for evaluation and treatment. Findings: On 5/13/19, at 10:32 a.m., Resident A was observed sitting on a sofa in the front lobby. During a concurrent interview, Resident A was able to communicate and was oriented to his name. Resident A did not remember leaving the facility and getting hurt. Resident A pointed to the right ankle to indicate where the wandering bracelet was placed. Resident A then stood up and walked without assistance. A review of Resident A's Admission Record (face sheet) indicated the facility admitted Resident A on 3/1/18. Resident A had diagnoses, including [MEDICAL CONDITION] (a mental illness affecting thoughts, feelings, and behavior) and anxiety disorder (an excessive and persistent sense of apprehension and fear). A review of Resident A's Minimum Data Set ((MDS) a standardized assessment and care-planning tool), dated 3/11/19, indicated there was impairment in Resident A's cognition (ability to think and reason). According to the MDS, Resident A would wander (walking around without any clear purpose or direction) daily. The MDS indicated Resident A required limited assistance from staff in walking. A review of Resident A's physician's orders [REDACTED]. The physician's orders [REDACTED]. A review of Resident A's Elopement Risk Assessment form, dated 4/14/19, indicated Resident A had a high risk to elope. The plan was for the staff to continue monitoring Resident A's whereabouts and use the wandering bracelet. A review of Resident A's history and physical examination [REDACTED]. A review of Resident A's Nursing Admission Assessment indicated the facility readmitted Resident A on 4/18/19 at 3:05 p.m. by ambulance with [DIAGNOSES REDACTED]. The Nursing Assessment indicated Resident A was awake, with periods of forgetfulness and was able to walk with supervision. A review of Resident A's physician's orders [REDACTED]. The order indicated that a wandering bracelet may be applied to any of Resident A's extremity to alert the staff when the resident was attempting to leave the facility and to check the wandering bracelet every day. A review of Resident A's C[NAME] (Change of Condition) (C[NAME])/SBAR (Situation/Background/Assessment/Recommendation) Assessment form (an internal communication), dated 4/19/19, indicated at 10:45 a.m., Resident A was attempting to leave the facility saying he wanted to go home. The licensed nurse notified Resident A's attending physician who ordered at 12:46 p.m., the same day, to visually monitor Resident A's whereabouts every 30 minutes for 72 hours. A review of Resident A's 24-hour Resident Monitor Log form, dated 4/19/19, indicated at 5:45 p.m., Resident A was in the front lobby sitting in a chair. A review of Resident A's C[NAME]/SBAR Assessment form, dated 4/19/19 and timed at 5:56 p.m., indicated Resident A was missing. The staff could not find Resident A after searching in the facility and surrounding areas. At 7:50 p.m., on 4/19/19, the C[NAME]/SBAR indicated a licensed nurse notified the Police Department. At 8:25 p.m., on 4/19/19 the police called the facility and informed the staff that they had found Resident A two miles away from the facility sitting on a curb. At 8:40 p.m., on 4/19/19, two police officers returned Resident A to the facility. A review of Resident Transfer and Referral Record/ Body Assessment form, dated 4/19/19, (no time indicated) Licensed Vocational Nurse 2 (LVN 2), who worked on the 3 p.m. to 11 p.m. shift, identified Resident A as having discolored left lower eyelid that measured 0.5 centimeter (cm) by 0.5 cm, scraped right upper back that measured two cm by 0.5 cm, and an open wound with a bump on the right occipital area that measured one cm by 0.5 cm. A review of Resident A's C[NAME]/SBAR Assessment form, dated 4/19/19 and timed at 8:50 p.m. indicated Resident A was noted with discolored left lower eyelid, scraped right upper back, and an open wound with a bump on the right occipital area. The assessment form indicated Resident A was transferred by an ambulance to the GACH at 11 p.m. on 4/19/19. A review of Resident A's Physician Order, dated 4/19/19 and timed at 9:30 p.m. indicated an order to transfer Resident A to a GACH for further evaluation and treatment due to open wound with bump on the right occipital head secondary to status [REDACTED]. A review of Resident A's Nursing Admission Assessment, dated 4/24/19, indicated the facility readmitted Resident A with an abrasion on the right back of the head, which measured 0.5 cm by 0.5 cm. Resident A also had scattered discoloration on both arms. A review of Resident A's Medication Administration Record [REDACTED]. On 6/25/19 at 3:30 p.m. during an interview with LVN 1 and a review of Resident A's MAR for the month of 4/2019 and the Body Assessment form dated 4/19/19, LVN 1 could not verify Resident A's use of the wandering bracelet on 4/18/19. LVN 1 was unable to find documentation to indicate Resident A was using the bracelet on the day (4/19/19) he eloped or after police returned him. LVN 1 stated the two back doors had alarms, but the staff activated them at 7 p.m. LVN 1 stated the rear door alarms on Station A and B should always be activated. On 6/25/19, at 4:39 p.m., during an interview with LVN 2, who worked the evening shift on 4/19/19 when Resident A went missing, stated the facility's video showed Resident A left through the back door on Station B near the kitchen. LVN 2 stated she did not hear the door alarm when Resident A left the facility. LVN 2 stated that the staff used the back door to exit and enter the facility. Later on the same day at 4:50 p.m., during an observation and tour accompanied by LVN 2, the back door (in Station B across from the kitchen) was observed open with the maintenance supervisor was observed exiting and re-entering the facility without the sound of an alarm. (Resident A exited the rear door on station B per interview). At 4:55 p.m., during observation of the back door on Station A, was slightly ajar (not completely closed). LVN 2 stated the door alarm was disabled and further stated the back/rear doors on station A and B should have alarm activation at all times. On 7/8/19, at 3:40 p.m., during an interview with LVN 3, who worked the 7 a.m. to 3 p.m. shift, stated the wander guard alarm activation during the day was only on the facility's front door in the lobby. During an observation the back door on station A, alarm did not sound when opened by LVN 3. When LVN 3 turned on the alarm with the key and opened the door, the alarm sounded loudly. The alarm on the back door on station B was also found to be off, after LVN 3 turned on the alarm by entering a code, and opening the door the alarm sounded loudly also. LVN 3 stated the alarm should be on both rear doors at all times. A review of the facility's policy and procedure, dated 6/2018 and titled, Wandering and Elopement, indicated the purpose was to enhance the safety of the residents and minimize injuries. The Wander Guard System® included door monitor alarm, a reset caregiver button, and resident wristband (bracelet) transmitter. When a resident, wearing a wrist band transmitter, attempts to exit a monitored doorway, there will be an audible (sound) and visible alert. Apply the wristband transmitter to any extremity, always monitor its use, and its placement every shift.

Based on interview and record review, the facility failed to provide a comprehensive nutritional re-assessment and nutritional care and services for two of two sampled resident (Resident 1 and 2). Resident 1 lost 12 pounds (lbs) in one week: a. The licensed nurses did not inform the physician and the registered dietitian that Resident 1 had been vomiting for a week. b. The registered dietitian was not informed that Resident 1 had a lack of tolerance to Nepro (a nutritional supplement drink) that was ordered with meals for the resident but was being refused by the resident, and that the resident ate fruits and cheese and vomited her food for a week. c. An interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) did not address Resident 1's weight loss, refusal of meals, and nausea and vomiting when the resident lost 12 lbs in one week. For Resident 2, the facility did not document accurately the resident's percentage of meal intake. These deficient practices resulted in Resident 1's weight loss of 12 lbs in one week and had the potential for Resident 2 to lose weight. Findings: 1. A review of Resident 1's Face Sheet (admission record) indicated that the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. into the food pipe causing reflux and irritation in the lining of the food pipe); anxiety disorder; [MEDICAL CONDITION] disorder (a mental disorder characterized by periods of elevated mood and periods of persistent sadness); and [MEDICAL CONDITION] (a debilitating mental disorder that affects how a person thinks, feels, and behaves, and characterized by lost touch with reality). A review of Resident 1's Minimum Data Set (MDS, a resident and care screening tool) dated 2/27/17 indicated the resident was cognitively (ability to reason and think) intact, exhibited the behavior of rejecting care one to three days within seven days, and required supervision and set up help for eating. A review of Resident 1's Nutritional Status care plan initiated on 1/17/17 indicated the resident was at risk of nutritional status as evidenced by the [DIAGNOSES REDACTED]. The care plan indicated that the goals developed was to ensure that the resident will consume greater than 75% of meal served daily for 90 days and to minimize significant weight change of 5 lbs. (plus/minus) monthly for 90 days. The care plan indicated to give Resident 1 a diet as ordered and monitor meal intake daily and to provide registered dietician consult with follow up as needed. A review of the care plan did not indicate that Resident 1 had a preference for fruits and was receiving fruit plate. A review of Resident 1 physician's orders [REDACTED]. A review of Resident 1's Nutritional Screening & Data Collection Form indicated that on 1/23/17, Resident 1 was non-compliant with diet. A review of Resident 1's Departmental Notes, dated 1/23/17 at 3:17 p.m., indicated type written documentation that the resident continue to request for fruit plates and cottage cheese. During an interview on 3/15/17 at 2 p.m., the Dietary Services Supervisor (DSS) stated Resident 1 would request for fruit plates, banana, orange, milk, and cottage cheese, and the dietary staff would provide it for the resident because the resident would only eat those food items. The DSS stated Resident 1 would rarely eat the meal tray and mostly ate the fruit plate. The DSS stated Resident 1 was given her prescribed meal for breakfast and a fruit plate with cottage cheese for lunch and dinner. During an interview on 4/18/17 at 7:10 a.m., the registered dietician (RD) stated a fruit plate was not adequate enough for a well- balanced diet. A review of Resident 1's Nutritional Assessment: Dietitian Section, dated 1/24/17, indicated a handwritten check mark that the resident was at 'High Risk for excessive weight loss/gain. The assessment indicated that Resident 1's weight was 121Lbs. and ideal body weight range was 112 to 138 Lbs. The assessment indicated the plan for Resident 1 was to monitor labs and to provide Nepro one (1) can daily at 2 p.m. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1' Medication Administration Record [REDACTED]. The resident's documented reason was I can't take that, I'll throw up. During an interview on 3/13/17 at 11:45 a.m., a certified nurse assistant (CNA 2) stated Resident 1 would have episodes of nausea and vomiting during the month of February. CNA 2 stated she observed Resident 1 with nausea after medication administration and before meals. CNA 2 stated that Resident 1 would vomit after she had tasted her meal. During an interview on 3/13/17 at 12:50 p.m., Housekeeper 1 stated she observed Resident 1 vomiting in the trash bin frequently. During an interview and concurrent record review of Resident 1's MAR indicated [REDACTED]. The DON stated Nepro was given to Resident 1 as a nutritional supplement. The DON stated that a resident who vomits constitutes a change of condition (COC) that would have necessitated a transfer of the resident to an acute hospital. The DON stated that the COC should have been reported to the physician and followed up with the facility's chain of command so that care and services could be provided. A review of Resident 1's Nutritional Screening & Data Collection Form indicated that on 2/8/17, Resident 1 refused to eat regular meals and the resident requested fruit plate for lunch and dinner. A review of Resident 1's (COC)/ SBAR (situation, background, assessment, and recommendation) Assessment Form, dated 2/8/17, indicated that the resident had a weight loss of 12 lbs. The resident's recorded weight was 122 lbs on 2/2/17 and 110 lbs on 2/8/17. During an interview and concurrent record review of the Change of Condition, dated 2/8/17 on 4/18/17 at 12:15 p.m. the DON stated that Resident 1 had a weight loss of 12lbs over a one week period. The DON stated the facility should have referred the resident to the RD for evaluation and to obtain recommendations to prevent further weight loss. During an interview on 3/13/17 at 11:20 a.m., a certified nurse assistant (CNA 1) stated that she had observed that Resident 1 would eat 60% of the breakfast meal and lunch, but would eat most of a plate of fruit that consist of watermelon, cantaloupe, and honeydew melon. CNA 1 stated that when she had provided Resident 1 with a fruit plate for lunch meal, the resident would eat most of the fruit plate. During an interview on 3/13/17 at 4 p.m., a registered nurse (RN 1) stated Resident 1 would eat 20% of her dinner (regular diet) meals. On 3/15/17 at 10:10 a.m., RN 1 stated that if Resident 1 was not eating her meals then the lack of food would contribute to the risk for weight loss. RN 1 stated that Resident 1 had the behavior of refusing her meals. During an interview on 3/15/17 at 9:15 a.m., a licensed vocational nurse (LVN 1) stated Resident 1 was picky about food and was not a big eater. LVN 1 stated that Resident 1 would taste the food and the resident would not finish the meal provided. LVN 1 stated Resident 1 would eat 30% of her meal and then ask for a fruit plate. During an interview on 3/15/17 at 9:35 a.m., the Social Service Directory (SSD) stated she was not aware that Resident 1's weight loss and non-compliance to diet. The SSD stated if she had known about Resident 1's weight loss and non-compliance to diet, then she (the SSD) would have initiated an interdisciplinary team meeting to discuss resident's issues and recommended a psychological consult. The SSD stated one-to-one counseling should have been provided to find out the cause of weight loss. During an interview and concurrent record review of Resident 1's health record on 3/15/17 at 10:10 a.m., RN 1 stated there were no IDT meetings conducted to address the resident's weight loss of 12 lbs. and refusal of the prescribed diet and the resident's request for fruit plate. During an interview on 3/15/17 at 2 p.m., the DSS stated that there was no RD's evaluation note that addressed the resident's weight loss of 12 lbs. on 2/8/17 (a Wednesday). The RD had a schedule to evaluate facility's residents every Tuesday. During an interview on 4/18/17 at 7:10 a.m., the RD stated that the facility should have requested for resident nutritional evaluation for concerns related to the nutritional status of a resident such as weight loss, lack of tolerance to food and supplement, poor nutritional intake, nausea and vomiting, and resident refusing meals. The RD stated that she was not made aware that Resident 1 had a 12-pound lbs. weight loss in one week and lacked the tolerance to Nepro supplement with nausea and vomiting. During the interview, the RD stated that if she had been made aware of Resident 1's nutritional concerns, then she (the RD) would have recommended another supplement substitute for Nepro, an appetite stimulant, and to have the resident transferred to an acute hospital for evaluation. The RD stated that the facility should have made a request for an RD to re-evaluate Resident 1 so that the facility could meet the resident's nutritional needs. A review of the facility's undated policy and procedure titled The Weight Assessment and Intervention, indicated the Dietitian will respond within 24 hours of receipt of written notification. The policy indicated assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: Resident's target weight range; approximate calorie, protein, and other nutrient needs compared with the resident's current intake; and the relationship between current medical condition or clinical situation and recent fluctuations in weight. The policy indicated the Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. According to the facility's policy and procedure titled, Refusal of Care and Treatment, dated 2017 indicated that if a resident refuses care or treatment, the facility will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences. The policy indicated that the care plan team will assess the resident's needs and offer the resident alternative care or treatments if available and pertinent, while continuing to provide other services outlined in the care plan; if the resident's refusal brings about a significant change, a reassessment will be made and such information will be incorporated into the resident's care plan; and should the resident refuse to accept care or treatment, detailed information relating to the refusal must be entered into the resident's medical record and the physician will be notified for further deem clinical interventions. 2. A review of Resident 2's Face Sheet (Admission Record) indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnoses: [REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated the resident was cognitively impaired. The MDS indicated Resident 2 required limited assistance with one person physical assistance. A review of an acute hospital record, dated 1/7/17, indicated Resident 2 was at her skilled nursing facility and was being very depressed (persistent sadness) and the resident was failing to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments that are manifested by weight loss, decreased appetite, poor nutrition, and inactivity). The note indicated Resident 2 was not eating for last three days. A record review of Resident 2's physician order, dated 1/14/17, indicated an order for [REDACTED].>A review of Resident 2's Weekly Weight Record indicated the resident's ideal body weight range was 108 to 132 lbs. The record indicated the following weights: a. 1/13/17, 93 lbs. b. 2/4/17, 96 lbs. c. 3/4/17, 99 lbs. d. 4/4/17, 103 lbs. A record review of Resident 2's Nutritional Status care plan, initiated on 4/19/17, indicated the resident was at risk of nutritional status. The care plan indicated a goal of minimizing significant weight change of plus and/or minute 5 lbs. The care plan indicated a facility intervention to give diet as ordered and monitor meal intake daily. On 3/15/17 at 12:25 p.m., during observation and concurrent interview of Resident 2's meal tray, licensed vocational nurse (LVN 2) stated the resident consumed the following for lunch: a. ½ cup of juice b. all of mashed potatoes c. all of ice cream d. ½ bowl of soup e. ¼ of pureed vegetable e. ½ of pureed meat f. ½ of pudding A record review of Resident 2's Certified Nursing Assistant Activities of Daily Living (ADL) Sheet, dated March 2017, indicated handwritten documentation of 100% meal intake for lunch. On 4/18/17 at 11:35 a.m., during an interview, a registered nurse (RN 2) stated Resident 2's meal consumption for lunch on 3/15/17 should be 70 to 75 percent. On 4/18/17 at 11:35 a.m., during interview and record review of Resident 2's Certified Nursing Assistant ADL Sheet dated March 2017, RN 2 stated the resident did not consume 100% of meal intake and it was not accurate and it should have indicated 70 to 75% meal intake. RN 2 stated Resident 2 had a known history of weight loss and failure to thrive so the potential outcome of the inaccurate documentation of the % meal intake could cause further weight loss and placed the resident on risk for failure to thrive.