Every finding on record at Santa Fe Lodge

Based on interview and record review, the facility failed to comply with the state code of regulations when Licensed Vocational Nurse (LVN) 1 initiated supplemental oxygen (medical treatment that delivers extra oxygen to the lungs) for one of three sampled residents (Resident 1) on 8/22/2026 without registered nurse (RN) supervision and direction.This failure placed Resident 1 at risk for inappropriate care and worsening medical condition.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/8/2025 and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), protein-calorie malnutrition (a lack of enough protein and total calories to meet the body's metabolic demands), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 7/16/2026, the MDS indicated Resident 1 had severely impaired cognitive skills (ability to make decisions) and was dependent (helper does all the effort to complete the activity) on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Weights and Vitals Summary (WVS), dated 8/1/2026 to 8/31/2026, the WVS indicated Resident 1 did not use supplemental oxygen from 8/21/2026 at 12:58 AM to 8/22/2026 at 5:51 PM.During a review of Resident 1's COC (Change of Condition)/Interact Assessment Form (COC), dated 8/22/2026 and timed 10:02 PM, the COC indicated Resident 1's oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) was 81% (normal level is 95% to 100%) and LVN 1 gave Resident 1 oxygen at 2 liters (L- unit of measurement) per minute.During an interview on 8/25/2026 at 3:45 PM with LVN 1, LVN 1 stated on 8/22/2026, RN 1 only worked until 7 PM. LVN 1 stated on 8/22/2026 at 8:20 PM a CNA (unidentified) came to ask LVN 1 to look at Resident 1. LVN 1 stated Resident 1 was not responsive. Resident 1's O2 sat was 81% and LVN 1 placed oxygen on Resident 1 at 2 liters per minute.During a review of the California Respiratory Care Scope of Practice (CRCSP), effective 10/1/2025, the CRCSP indicated LVNs cannot perform, Initial set up, change out, or replacement of a breathing circuit or adjustment of oxygen liter flow or oxygen concentration.According to the California Board of Vocational Nursing and Psychiatric Technicians (BVNPT), The Vocational Nursing Practice Act (California Code, Business and Professions Code, Section 2840.5, current as of 1/1/2026) authorizes LVNs to perform services under the direction of only licensed physicians, registered nurses (including nurse practitioners [NP]) and naturopathic doctors. LVNs work with Respiratory Care Practitioners as part of patient care team members but shall only work under the direction of a licensed physician, registered nurse (including NPs) and naturopathic doctors.During a review of the facility's Job Description for LVN, dated 3/7/2024, the job description indicated LVNs will comply with the State of California's Licensing Board for Vocational Nurses and remain in good standing.

Based on interview and record review, the facility failed to develop a specific and individualized care plan (CP) for one of two (Resident 1) sampled resident that addressed Resident 1's wandering, into other resident rooms, behavior.This deficient practice had the potential to result in unmet individualized needs for Resident 1 and the potential to affect Resident 1's physical and psychosocial well-being.Cross Reference F689Findings:During a review of Resident 1's Facesheet (FS, admission record), the FS indicated the facility admitted Resident 1 on 4/28/2026 with diagnoses that included dementia (a progressive state of decline in mental abilities), encephalopathy (broad term for any disease, damage, or malfunction of the brain).During a review of Resident 1's CP, initiated 5/1/2026, the CP indicated Resident 1 was at risk for purposeless wandering and potential for self-injury. The CP did not indicate Resident 1 wandered into other resident rooms or any interventions to prevent the behavior from occurring.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/2/2026, the MDS indicated Resident 1 had severe impairment in cognition (ability to think and make decisions), the MDS indicated Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene and toilet transfers.During a review of Resident 2's FS, the FS indicated Resident 2 was admitted to the facility 5/7/2026 with diagnoses that included dysphasia (a language disorder that impairs the ability to produce and understand spoken or written language) and hyperlipidemia (high amounts of fats in the blood).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired. The MDS indicated Resident 2 made self understood and was able to understand others.During an interview on 6/30/2026 at 9:35 AM with Resident 2, Resident 2 stated about two weeks ago [6/13/2026] Resident 1 entered Resident 2's room and opened Resident 2's drawers. Resident 2 stated Resident 2 told Resident 1 Resident 2's room was not Resident 1's room but Resident 1 came close to Resident 2 and touched Resident 2.During an interview on 6/30/2026 at 10:47 AM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 liked walking in the hallway and Resident 1 also entered (wander) into other resident rooms (usual behavior).During an interview on 6/30/2026 at 1:38 PM with CNA 2, CNA 2 stated CNA 2 had seen (no date recall) Resident 1 enter Room A one time, Resident 1 usually wandered into the room across Room A (unidentified resident's room).During an interview on 6/30/2026 at 2:30 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 walked around and entered (wandered) room to room every day. LVN 1 stated wandering room to room was Resident 1's [usual] behavior and no one cared about the behavior until Resident 1 was hit [by Resident 2].During a concurrent review and interview on 6/30/2026 at 3:28 PM with the Director of Nursing (DON), Resident 1's CP, initiated 5/1/2026, indicating Resident 1 was at risk for purposeless wandering and potential for self-injury. The DON stated Resident 1's CP did not address Resident 1's wandering behavior into other resident rooms. The DON stated the DON was not aware Resident 1 wandered into other resident rooms because Resident 1 usually attended activities during the daytime. The DON stated nurses (in general) who were aware of Resident 1's wandering (into resident rooms) behavior needed to inform the DON and needed to develop interventions that addressed behavior.During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated March 2023, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The P&P indicated, when possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.During a review of the facility's undated P&P titled Care of Wandering Residents the P&P indicated for residents who wandered, a plan of care shall address the wandering [behavior].

Based on interview and record review, the facility failed to ensure adequate supervision for one of two sampled residents (Resident 1), who had a history of wandering (walking aimlessly with no specific direction) into other resident rooms.This deficient practice resulted in Resident 1 wandering into Resident 2's room on 6/13/2026 and Resident 1 getting close to Resident 2 leading to Resident 2 scratching Resident 1's left upper lip.Cross Reference F656Findings:During a review of Resident 1's Facesheet (FS, admission record), the FS indicated the facility admitted Resident 1 on 4/28/2026 with diagnoses that included dementia (a progressive state of decline in mental abilities), encephalopathy (broad term for any disease, damage, or malfunction of the brain).During a review of Resident 1's care plan (CP), initiated 5/1/2026, the CP indicated resident one was at risk for unavoidable decline related to dementia. The CP's interventions indicated to provide a safe environment to Resident 1.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/2/2026, the MDS indicated Resident 1 had severe impairment in cognition (ability to think and make decisions), the MDS indicated Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene and toilet transfers.During a review of Resident 1's COC/Interact Assessment Form (change of condition, an alteration in a resident's physical health that differs from the resident's previous baseline), dated 6/13/2026, the COC indicated Resident 1 was observed wandering in the hallway at 5 PM. The COC indicated at 6 PM, Resident 1 was still wandering into [resident] rooms. The COC indicated LVN 3 was called due to a resident-to-resident altercation [with Resident 2]. The COC indicated Resident 1 had a scratch near the cheek [left upper lip] with scant bleeding.During a review of Resident 1's Skin Reassessment, dated 6/13/2026, the reassessment indicated Resident 1 had skin scratches on the left upper lip.During a review of Resident 2's FS, the FS indicated Resident 2 was admitted to the facility 5/7/2026 with diagnoses that included dysphasia (a language disorder that impairs the ability to produce and understand spoken or written language) and hyperlipidemia (high amounts of fats in the blood).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired. The MDS indicated Resident 2 made self understood and was able to understand others.During a review of Resident 2's COC, dated 6/13/2026, the COC indicated Resident 2 was involved in a possible resident to resident altercation [with Resident 1].During an interview on 6/30/2026 at 9:35 AM, Resident 2 reacted by raising Resident 2's hand and accidentally scratched Resident 1 with his fingernails. Resident 2 showed his short fingernails and stated the CNA's had already cut the nails after what happened.During an interview on 6/30/2026 at 9:35 AM with Resident 2, Resident 2 stated about two weeks ago [6/13/2026] Resident 1 entered Resident 2's room and opened Resident 2's drawers. Resident 2 stated Resident 2 told Resident 1 Resident 2's room was not Resident 1's room but Resident 1 came close to Resident 2 and touched Resident 2. Resident 2 stated Resident 2 reacted by raising Resident 2's hand and accidentally scratched Resident 1 with Resident 2's fingernails.During an interview on 6/30/2026 at 10:47 AM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 liked walking in the hallway and Resident 1 also entered (wander) into other resident rooms (usual behavior). CNA 1 stated CNA 1 did not witness Resident 2 hit Resident 1 but saw Resident 1 walking in the hallway with a cut on Resident 1's cheek.During an interview on 6/30/2026 at 1:38 PM with CNA 2, CNA 2 stated CNA 2 had seen (no date recall) Resident 1 enter Room A one time, Resident 1 usually wandered into the room across Room A (unidentified resident's room).During an interview on 6/30/2026 at 2:30 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 walked around and entered (wandered) room to room every day. LVN 1 stated wandering room to room was Resident 1's [usual] behavior and no one [staff] cared about the behavior until Resident 1 was hit [by Resident 2]. LVN 1 stated wandering into other resident rooms could make other residents mad and could lead to Resident 1 getting hurt. LVN 1 stated we [facility staff] try our best to redirect Resident 1 but Resident 1 continued to wander into other resident rooms. LVN 1 stated Resident 1 might need [interventions such as] more direct supervision (no specific supervision plan for Resident 1) such as a one-to-one (one staff supervising one resident) supervision to protect Resident 1.During an interview on 6/30/2026 at 2:53 PM with LVN 2, LVN 2 stated LVN 2 had seen Resident 1 enter other resident rooms, room to room. LVN 2 stated other residents could get mad when Resident 1 entered their rooms.During a concurrent review of Resident 1's medical records and interview on 6/30/2026 at 3:28 PM with the Director of Nursing (DON), the DON stated there was no documented evidence indicating specific monitoring/supervision as an intervention for Resident 1 wandering into other resident rooms in Resident 1's record. The DON was not aware Resident 1 wandered into other resident rooms. The DON stated nurses (in general) who were aware of Resident 1's wandering (into resident rooms) behavior needed to inform the DON and the behavior needed to be addressed to protect Resident 1.During a review of the facility's undated Policy and Procedure (P&P) titled Care of Wandering Residents the P&P indicated for residents who wander, a plan of care shall address the wandering. The P&P indicated nursing and care duties included to continuously reorienting resident to room and belongings and to monitor the resident's location with visual checks as needed.During a review of the facility's undated P&P titled, Monitoring/Supervision Residents, the P&P indicated the P&P's purpose was to identify ways in which the facility monitored residents and resident care to ensure sufficient supervision at all times. The P&P indicated staff members would provide adequate supervision to all residents in accordance with their plans of care. The P&P indicated additionally to the every two-hour monitoring/supervision from the nursing department, the facility would provide supervision/monitoring from the following duties which included, one-to one monitoring if indicated: the facility may assign nursing or non-nursing personnel for this task as necessary. The P&P indicated designate specific personnel or rotate staff as necessary and ensure all monitoring findings and corrective actions are documented in the resident's record.

Based on interview and record review, the facility failed to ensure the residents and/or the residents' responsible parties (RP) were informed in advance, of the risk and benefits of psychotropic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two of five sampled residents (Residents 7 an 8) when:1. Resident 7's Quetiapine (Seroquel) was restarted on 3/26/2026 without an informed consent (IC-a form indicating a resident or responsible party voluntarily agree to a medical treatment or procedure after understanding the risks, benefits, and alternatives) after the Quetiapine was discontinued on 10/3/2025.2. Resident 8 did not have and IC for Lexapro (a medication used to treat mental health disorders), trazodone (a medication used to treat mental health disorders and insomnia [difficulty falling asleep]) and olanzapine indicating the correct dosage (a medication used to treat mental health disorders) prior to 3/25/2026. These deficient practices violated Residents 7 and 8's rights to make an informed decision regarding the use of psychotropic medication which had the potential for unnecessary use of such medications. Findings: A. During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 4/2/2025, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear. During a review of Resident 7's Quetiapine order history with the MDSN, dated 10/3/2025, the history indicated Resident 7's Quetiapine was discontinued on 10/3/2025. During a review of Resident 7's Progress Notes dated 3/1/2026 to 3/31/2026, there was no documentary evidence Resident 7 exhibited behavior for the need to restart the Quetiapine, and no documentation of notification of Resident 7's responsible party regarding restarting Quetiapine. During a review of Resident 7's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 4/7/2026, the MDS indicated Resident 7 had severe cognitive deficit and Resident 7 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with oral hygiene, toileting hygiene and personal hygiene. During a review of Resident 7's current Medication Administration Record (MAR) dated 5/1/2026 to 5/31/2026, the MAR indicated the Resident had an order for Quetiapine 25 milligram (mg), two times a day for agitation (started on 3/26/26). During a record review of informed consent forms on 5/6/2026 at 3:08 PM with the Minimum Data Set Nurse (MDSN), there was an informed consent for Quetiapine (Seroquel) 25 mg, two times a day for agitation, dated 4/26/26. During an interview on 5/6/2026 at 3:10 PM, the MDSN stated the MDSN could not find documentation indicating Resident 7's responsible party was informed when Quetiapine was restarted on 3/26/2026 after Quetiapine was discontinued on 10/3/2025. The MDSN stated the Hospice Physician was the one who restarted Quetiapine on 3/26/2025 after it was discontinued on 10/3/2025. The MDSN stated informed consent needed to be completed because it's a patient right to be notified of new medications especially psychotropic medications. B. During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anxiety disorder (a mental illness characterized by excessive, persistent, and irrational worry or fear that can interfere with daily life), depression (a mental health disorder characterized by sadness, loss of interest, and other symptoms that impact daily life), and schizophrenia (a mental illness characterized by disturbances in thought). During a review of Resident 8's History and Physical (H&P), dated 4/23/2025, the H&P indicated Resident 8 had the capacity to understand and made decisions. During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 8's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired (makes poor decisions requiring cues or supervision). The MDS indicated Resident 8 required supervision/touching assistance with toileting hygiene, required setup or clean up assistance with showering, dressing, and personal hygiene, and was independent with eating and oral hygiene. During a review of Resident 8's Medication Administration Record (MAR), dated 2/1/2026-2/28/2026, 3/1/2026-3/31/2026, and 4/1/2026-4/30/2026, the MAR indicated Resident 8 had received: 1.Lexapro10 milligrams (mg-a unit of measurement) one time a day for depression manifested by changes in mood, social withdrawal, decreased concentration, feelings of sadness, and loss of interest in usual activities on 2/1/2026-2/28/2026, 3/1/2026-3/31/2026, and 4/1/2026-4/30/2026. 2. Trazodone 50 mg given at bedtime for depression manifested by an inability to sleep on 2/1/2026-2/28/2026, 3/1/2026-3/31/2026, and 4/1/2026-4/30/2026. 3. Olanzapine 5 mg two times a day for schizophrenia manifested by episodes of hearing and seeing someone wanting to kill Resident 8 causing stress leading to self-isolation on 2/1/2026-2/28/2026, 3/1/2026-3/31/2026, and 4/1/2026-4/30/2026. During a review of Resident 8's Psychotherapeutic Drug ICs, dated 3/25/2026 and 3/22/2025, the IC's indicated: 1.An IC was obtained on 3/25/2026 for Lexapro 10 mg to be given one time a day. 2. An IC was obtained on 3/25/2026 for trazodone 50mg to be given at bedtime. 3. An IC was obtained on 3/25/2026 for olanzapine 5mg to be given two times a day. 4. An IC was obtained on 3/22/2025 for olanzapine 2.5 mg to be given in the morning and 5mg at bedtime. During a concurrent interview and record review on 5/7/2026 at 10:24 AM with the Director of Nursing (DON), Resident 8's medical record was reviewed. The DON stated Resident 8 had received Lexapro, trazodone, and olanzapine prior to obtaining Resident 8's ICs on 3/25/26. The DON stated there was no IC indicating the dosage change for olanzapine prior to obtaining the current IC on 3/25/2026. The DON stated before administering a psychotropic medication it was the policy of the facility to obtain an informed consent from the resident representative (RR). Additionally, the DON stated it was important to obtain an IC because it informed the family or residents (in general) of medication side effects. During a review of the facility's undated Policy and Procedure (P&P) titled, Psychotherapeutic Medications, the P&P's policy indicated, Evaluate the resident's response to psychotropic medication therapy (antianxiety, antidepressant, hypnotic and antipsychotic) to determine that the medications are appropriate and resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. The P&P's procedures indicated, No psychotherapeutic medication administered prior to informed consent obtained by prescriber.

Based on interview and record review the facility failed to follow the facility's policy and procedure (P&P) for psychotropic medications titled, Psychotherapeutic Medications, undated for two of two residents (Residents 1 and 7) by: A. failing to monitor for side effects of Resident 1's mirtazapine (medication used to treat depression.)B. failing to have adequate indication for the use Seroquel for Resident 7 (Quetiapine -Quetiapine is FDA approved for schizophrenia [mental disorder characterized by abnormal social behavior and failure to understand what is real], acute manic episodes [ A manic episode is a stretch of time when you have one or more symptoms of mania. An episode typically lasts for a week or longer, unless treatment cuts it short] and monitor a specific behavior for it's use.These deficient practices had the potential for Resident 1 and Resident 7 to experience unwanted side effects that could affect their physical wellbeing.Findings: A. During a review of Resident 1's admission Record, (AR) the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including depression (mood disorder causing persistent sadness, emptiness, or irritability, along with loss of interest in activities once enjoyed), anxiety (persistent, excessive, and uncontrollable fear or worry that interferes with daily life) and dementia (a gradual decline in mental ability usually caused by a brain disease.) During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had impaired cognition (ability to understand and process information) and required substantial/ maximal assistance for toileting and bathing. During a review of Resident 1's Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) for antidepressant Remeron (brand name for mirtazapine), revised 4/20/2026, the CP indicated an intervention to observe for side effects and document occurrence of side effects per psychotropic policy. During a review of Resident 1's Order Summary Report (OSR) dated with active orders as of 5/7/2026, the OSR indicated Resident 1 had a physician order for Mirtazapine (antidepressant) tablet 7.5 milligrams (mg- unit of weight) by mouth at bedtime for depression manifested by poor oral intake of less than 50% of meals with start date 3/12/2026. During a concurrent interview and record review with the Director of Nursing (DON), on 5/8/2026, at 11:09 AM, Resident 1's Medication Administration Record (MAR) dated 5/7/2026 was reviewed. The DON stated the DON did not any side effect monitoring for Resident 1's use of Mirtazapine. The DON stated it was important to monitor side effects to know if Resident 1 experienced any undesirable effects while on the medication. During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Medications, undated, the P&P indicated the licensed nurse will assess resident to ensure: G. Monitoring of side effects on psychotherapeutic medication on medication sheets. B. During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 4/2/2025, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear. During a review of Resident 7's Quetiapine order history, the history indicated Resident 7's Quetiapine was discontinued on 10/3/2025 and restarted on 3/29/2026. During a review of Resident 7's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 4/7/2026, the MDS indicated Resident 7 had severe cognitive deficit and Resident 7 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with oral hygiene, toileting hygiene and personal hygiene. During a review of Resident 7's current Medication Administration Record (MAR) dated 5/1/2026 to 5/31/2026, the MAR indicated an order for Seroquel 25 mg. two times a day for agitation. During an interview on 5/7/2026 at 2:44 PM, Registered Nurse Supervisor 1 (RN 1) stated Resident 7's behavior would be the resident's noncompliance with activities of daily living, Resident 7 had sporadic episodes of getting up. RN 1 stated Resident 7's baseline would be awake, confused and might still attempt to get up. During a concurrent review of Resident 7's Progress Notes and Change of Condition for March 2026 and interview on 5/7/2026 at 3:15 PM, the MDS Nurse stated there was no documentary evidence Resident 7 exhibited behaviors that would need Seroquel to be restarted. The MDS Nurse stated Seroquel was restarted when Resident 7 was placed on hospice care. During an interview and a concurrent review of Resident 7's medical records on 5/07/2026 at 2:46 PM, the MDS Nurse MDSN stated there was no record of monitoring for behaviors for the use of Seroquel. Resident 7's Medication Administration Record (MAR) for March 2026, April 2026 and May 2026 indicated there was no records for behaviors for the use of Seroquel. During an interview on 5/7/2026 at 2:52 PM, the MDS Nurse stated monitoring the specific behavior ordered for the use of Seroquel would determine if the medication was effective at controlling the behavior and a gradual dose reduction could be attempted once the behavior had been controlled. The MDS Nurse stated we need to add the monitoring order when licensed nurses enter the psychotropic orders. During a concurrent review of Resident 7's physician orders and interview on 5/8/2026 at 3:26 PM, Resident 7 had an order for Seroquel 25 mg. two times a day for agitation. The Director of Nurse (DON) stated Seroquel was ordered for agitation. The DON stated the behavior needed to be specific so the behavior could be monitored by staff. During an observation on 5/08/2026 at 8:28 AM, Resident 7 was sitting on a wheelchair, awake with helmet on. During an observation on 5/8/2026 at 10:19 AM, Resident 7 was sitting inside the activity room. Resident 7 was calm. During an interview on 5/8/2026 at 2:36 PM, Certified Nursing Assistant (CNA) 6 stated Resident 7 was very confused and combative. CNA 6 stated today the resident was still combative when CNA 6 changed the resident. CNA 6 stated Resident 7 would pushed CNA 6 away, and pinch CNA 6. Resident 7 would get irritated during ADL's (activities of daily living such as grooming, baths, oral care) which was the same baseline as before, CNA 6 stated the only difference would be Resident 7 would not walk now. During a review of the facility's Policy and Procedure (P&P) titled, Psychotherapeutic Medications, the P&P indicated the licensed nurse will assess the resident to ensure proper diagnosis supporting drug order behavior that cause danger to self, danger to others, significance interference with daily activity, psychotic symptoms (hallucinations, paranoia, delusions that create frightful distress in the resident), specific behavior being monitored every shift.

Based on observation, interview and record review, the facility failed to reduce the potential for accidents and/or hazards for two of two residents (Residents 23 and 34) by failing to ensure:1. Resident 23's bed-exit alarm (designed to inform staff by letting them know when a person is attempting to leave the bed, has gotten out of bed. Whether directly attached to the resident as a garment clip or position change alarm, or part of the bed itself [e.g., pressure-sensitive mats, bedside infrared beam detectors, or in-bed pressure sensors] was kept in a place where the alarm could easily be heard by staff and was not muffled. 2. A spray bottle of bleach was not left unattended at Resident 34's bedside table. These deficient practices resulted in Resident 23's fall on 5/5/2026 and had the potential to cause harm to Resident 34. Findings: A. During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted Resident 23 on 3/8/2026, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), metabolic encephalopathy (is a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness). During a review of Resident 23's Fall Risk Evaluation dated 4/15/2026, the evaluation indicated was Resident 23 was a high risk for fall. During a review of Resident 23's Minimum Data Set (MDS – a standardized resident assessment tool) dated 4/19/2026, the MDS indicated Resident 23 rarely/never able to express ideas or wants and sometimes understands verbal content. During a review of Resident 23's Order Summary Report (OSR), dated 4/20/2026, the OSR indicated an order to apply tab alarm when resident in bed as nursing intervention to alert staff for unassisted transfer. Charge Nurse to check proper placement and function. During a review of Resident 23's Care Plan Report titled, Support & Safety Device, revised on 4/28/2026, the Care Plan indicated for staff to apply sensor pad alarm when resident is in bed as nursing intervention to alert staff for unassisted transfer. Charge nurse to check proper placement and function. The care plan interventions included to monitor the alarm for good working condition and proper placement as needed and for staff to respond promptly to resident once alarm is activated. During an observation on 5/5/2026 at 8:50 AM, there were residents inside the Activity Room with loud music playing from a speaker placed close to the wall in between the Activities Room and Resident 23's room. During an observation on 5/5/2026 at 11:24 AM, there was loud music being played from the black speaker box (approximately 2 feet in length by 1 foot in width) placed along the wall adjacent to the door leading to Resident 23's room. The Minimum Data Set Nurse (MDSN) was walking at the hallway and all of a sudden the MDSN turned and walked inside Resident 23's room. Resident 23 was lying on resident's left side away from the floor mat with the foley catheter tubing stretched taut. The foley catheter bag was hanging on the side of Resident 23's lower bed frame. Resident 23's bed alarm was ringing. The bed alarm's sound was heard ringing when the surveyor was moving closer to Resident 23's doorframe, the MDSN reached inside the drawer of a bedside table placed along the wall adjacent to the door, found the bed alarm and turned it off. During a review of Resident 23's Change in Condition (COC) Form dated 5/5/2026 at 12:01 PM, the form indicated at 7 AM, Resident 23 was in bed resting, the tab alarm was on the bed in proper placement to alert staff. During an interview on 5/5/2026 at 12:59 PM, the MDSN stated the MDSN ran to the room when the MDSN saw Resident 23 stood up and fell to the floor. The MDSN stated the MDSN heard the alarm as MDSN got into the room, the MDSN called another staff member for help and then noticed the alarm was going off and found the alarm inside a closed drawer and turned the alarm off. The MDSN stated the alarm should not be placed inside the drawer because that would affect the accessibility of hearing the alarm sound. The MDSN stated facility staff could have heard the alarm more prominently if the alarm was placed out of the drawer. The MDSN stated Resident 23 was two to three feet away from the bed when the MDSN saw Resident 23 stood up from the bed. The MDSN stated We would have heard the alarm as soon as Resident 23 got up from the bed if the bed alarm was not place inside the drawer and we could have provide intervention to prevent the fall. The MDSN stated the music was playing outside Resident 23's room and the MDSN did not hear Resident 23's bed alarm sound. During an interview on 5/5/2026 at 1:07 PM, Certified Nursing Assistant 2 (CNA 2) stated Resident 23 was sleeping when CNA 2 left for lunch break. CNA 2 stated CNA 2 would watch Resident 23 because Resident 23 would try to get up all the time, CNA 2 stated CNA 2 made sure the bed-exit alarm was on the side of the bed, if the alarm was inside the drawer, the sound of the alarm would not be the same. During a concurrent observation and interview on 5/5/2026 at 1:10 PM with the MDSN, the MDSN opened the drawer inside Resident 23's room, the alarm was placed inside the closed drawer. The MDSN stated the bed-exit alarm needed to be out of the drawer and placed outside so staff could hear the alarm sounds when the bed-exit alarm activated. During a review of the facility's Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, dated March 2023. The P&P indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. B. During a review of Resident 34's admission Record (AR), the AR indicated Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including paranoid schizophrenia (mental health condition where a person loses touch with reality through intense, irrational distrust) bipolar disorder (mental health condition characterized by extreme, alternating shifts in mood, energy, and activity level) and obsessive-compulsive personality disorder (mental health condition defined by strict, chronic preoccupation with perfectionism, orderliness, and control). During a review of Resident 34's Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments), revised 9/2/2025, the CP indicated Resident 34 had impaired visual functioning related to cataracts (a cloudy or opaque area in the lens of the eye that blocks light from passing through, resulting in blurry or dim vision). The CP indicated an intervention to provide for a safe environment, free of hazards. During a review of Resident 34's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 2/17/2026, the MDS indicated Resident 34 had severely impaired cognition (ability to understand and process information) and required partial/ moderate (helper does less than half the effort) assistance from staff for toilet and personal hygiene. During an observation on 5/7/2026 at 8:22 AM, in Resident 34's room, Resident 34's bedside table was observed with an unattended spray bottle full of clear liquid labeled, bleach, and Resident 34 in bed. During a concurrent observation and interview on 5/7/2026 at 8:24 AM in Resident 34's room with Certified Nurse Assistant (CNA) 1, Resident 34's bedside table was observed with the spray bottle labeled, bleach. CNA 1 stated it was not good for the spray bottle to be left on Resident 34's bedside table. CNA 1 stated Housekeeper (HK) 1 had recently been in the room to clean and the bottle must have been left by HK 1. CNA 1 stated the bottle's label indicated there was bleach inside and the bottle should not have been left on Resident 34's bedside table because Resident 34 could get bleach on themselves or drink it. During an interview on 5/7/2026 at 8:31 AM with the Maintenance Supervisor (MS), the MS stated the cleaning bottles used at the facility should be labeled so if the bottle is labeled bleach, that means there is bleach inside the bottle. The MS stated after the housekeepers use the cleaning bottles, they are supposed to place the bottle into the cleaning cart and lock it. The MS stated the housekeepers should not leave cleaning bottles with the residents because the residents could grab the bottles and hurt themselves if they drink it. During an interview on 5/7/2026 at 4:13 PM with the Administrator, the ADM stated the facility took resident safety very seriously and no other cleaning bottles had been found left with residents. During a review of the facility's policy and procedure (P&P) titled Safety, undated the P&P indicated to never leave cleaning equipment or chemicals unattended in a resident's room or in a corridor. During a review of the facility's policy and procedure (P&P) titled, Housekeeping Supplies and Equipment, undated the P&P indicated to store al housekeeping equipment in a designated place. Always return the equipment to its proper storage place after using it and cleaning it. The P&P further indicated chemicals were to remain secure and locked up in janitorial closets and carts.

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 13) received the right amount of water flush and enteral feeding via gastrostomy feeding tube (G-tube - a device used for providing nutrition directly to the stomach) as ordered by the physician.These deficient practices had the potential for Resident 13 to experience further weight loss and dehydration. Findings: During a review of Resident 13's admission Record (AR), the AR indicated the facility admitted Resident 13 on 1/15/2014 and readmitted the resident on 4/16/2026, with diagnoses that included adult failure to thrive (FTT-is characterized by unexplained weight loss, malnutrition and disability. FTT has been associated with multiple primary conditions (e.g., infections and malignancies), but always includes 2 defining clinical elements, namely nutritional impairment and disability), acute kidney failure (the kidneys are operating at less than 10 percent of normal function which means body wastes such as build up in the bloodstream and become ill). During a review of Resident 13's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/19/2026, the MDS indicated Resident 13 rarely/never able to express ideas and wants and sometimes understands verbal content. The MDS indicated Resident 13 had weight loss of 5% or more and Resident 13 was on feeding tube. During an observation on 5/6/2026 at 3:19 PM, the Tube Feeding (TF) pump was off and there was a full container of Glucerna 1.2 and a full bag of water hanging with a labeled date of 5/6/2026 at 2 PM. During an observation and interview on 5/6/2026 at 3:46 PM, the TF pump's setting indicated flush setting was at 30 milliliter (ml) every 20 hours (hrs) [30m//20hrs]. Licensed Vocational Nurse 2 (LVN 2), stated the TF pump was set at 30 ml every 20 hrs. During a concurrent record review and interview on 5/6/2026 at 3:51 PM, the Director of Nursing (DON) stated Resident 13's physician's order indicated Resident 13 needed 30 ml of flush every hour (30 ml/1hr) to receive 600 ml of water in 20 hours. The DON stated the G-tube feeding pump setting indicated, flush 30 ml every 20 hours. The setting on the pump would mean Resident 13 would get 30 ml. in 20 hours. The DON stated Resident 13 would be getting less hydration than the ordered amount. During an interview and observation on 5/6/2026 at 4:05 PM, the DON stated Resident 13 needed to receive the water as ordered to prevent dehydration, signs and symptoms of dehydration may include tiredness, fatigue, and changes in level of consciousness. The DON checked the resident, Resident 13 was asleep, easily arousable. During a review of the facility's undated Policy and Procedure (P&P) titled, Hydration, the P&P indicated additional fluids may be recommended by the registered dietitian to meet calculated fluid needs. For residents on enteral feedings, fluid need shall be calculated following admission by the registered dietitian. to observe for signs of dehydration, dry mouth, dry skin, and poor skin turgor. 2. During an observation on 5/08/2026 at 8:28 AM, Resident 13 was sitting on a Geri chair (geriatric recliner, a specialized medical chair designed for patients who spend long periods of time sitting) inside the Activity Room with activities ongoing, Resident 13 was awake. There was no TF running at this time. Resident 13's enteral feeding pump was off with no enteral feeding bag hanging. During a concurrent review of Resident 13's physician orders, observation and interview on 5/08/2026 at 9 AM, Resident 13's physician orders indicated Glucerna 1.2 at 45 ml/hr start at 2 PM for 20 hours, stop feeding at 10 AM or until dose is met. Registered Nurse 1 (RN 1) stated LVN 3 turned off the enteral feeding at 8 AM because the dose was completed. RN 1 checked the history of enteral feeding given in 1 day was 802 milliliters. Resident 13 did not received 900 ml of Glucerna per day as the physician ordered. During an interview on 5/8/2026 at 9:15 AM, Licensed Vocational Nurse (LVN 3) stated LVN 3 stopped the enteral feeding because the Electronic Medication Administration Record (EMAR) had turned yellow, LVN 3 stated LVN 3 thought the enteral feeding was complete because it had turned yellow on the electronic Medication Administration Record (eMAR) During an interview on 5/08/2026 at 3 PM, the Regional Registered Dietitian stated the nurses needed to follow the physician order of how much enteral feeding to administer to prevent further weight loss. During an interview on 5/8/2026 at 3:23 PM, the Director of Nursing (DON) stated Resident 13 needed to get the enteral feeding as ordered for the resident to get the required caloric intake. During a review of Resident 13's weight log, the weight log indicated the following weight. Resident 13's weight upon readmission on [DATE] was 104 pounds (lb).On 4/28/2026, weight was 102 lb.On 5/4/2026, weight was 102 lb. During a review of the facility's Policy and Procedure (P&P) titled, Weight Assessment and Intervention, dated August 2025, the P&P indicated resident-centered care plans shall be documented in the IDT - Weight Management Care Plan or thegeneral care plan, and will address:a. Identified cause of weight changesb. Assessment/evaluation for weight changesc. goals and benchmarks for improvement; andd. Interventions/Approaches, which includes but is not limited to .diet modification such as change of food texture, including use of artificial nutrition if indicated, offer food substitutes as needed, adjust the diet frequency, calorie, protein, supplement, food portion/size as needed.

Based on interview and record review, the facility failed to ensure two of 10 sampled residents (Resident 4 and Resident 7) were free from unnecessary medications:1.For Resident 4, the resident did not meet the Mc Geer's criteria (a criteria used to define true infections by providing surveillance criteria the Infection Preventionist (IP) is required to report for definitive case events (i.e., diagnosed infections) and to estimate the actual incidence/prevalence of disease conditions) for the use of Levaquin on 3/19/2026 and ciprofloxacin on 4/22/2026 for true infections. 2. For Resident 7, there was no behavior monitoring for Resident 7 when Resident 7 was prescribed Seroquel (Quetiapine -Quetiapine is FDA approved for schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real), acute manic episodes ( A manic episode is a stretch of time when you have one or more symptoms of mania. An episode typically lasts for a week or longer, unless treatment cuts it short). There was no specific behavior indicated on the order for Resident 7's use of Seroquel. These deficient practices had the potential to increase Resident 4's resistance to antibiotics and Resident 7's use of psychotropic medications that could potentially affect the residents physical and psychosocial wellbeing. Findings: 1a. During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 9/26/2025, with diagnoses that included sepsis (life-threatening condition that arises when the body's response to infection injures its own tissues and organs), urinary tract infection (UTI- infection that affects part of the urinary tract). During a review of Resident 4's urine culture results, the report indicated urine was collected on 3/13/2026 with the result released on 3/19/2026. The IP Nurse (IPN) stated Levaquin 500 milligram (mg) was ordered when the urine culture result was released on 3/19/2026. The IPN stated there was no notes to indicate there was communication with the ordering physician that Mc Geer's criteria for a UTI was not met for the use of Levaquin. During a review of Resident 4's Progress Notes dated 3/19/2026 to 3/20/2026, there was no notes to indicate Resident 4 met criteria 1 for UTI with Indwelling Catheter. During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/3/2026, the MDS indicated Resident 4 had intact cognition and Resident 4 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with oral hygiene, toileting hygiene and personal hygiene. During a concurrent interview and and a review of the facility's Order Listing Report (OLR), on 5/8/2026 at 11:33 AM, with the Infection Prevention Nurse (IPN). Resident 4's OLR dated from 3/1/2026 to 5/31/2026 indicated Resident 4 had an order for Levaquin (antibiotic) 500 mg, one time a day for UTI for 10 days (started on 3/20/2026) and Ciprofloxacin (antibiotic) 500 mg, two times a day (started pm 4/25/2026 until 4/28/2026 at 11:59 PM). The IPN stated Resident 4 had physician orders for antibiotic medications but the IPN did not complete the Mc Geer's Surveillance Collection Form for UTI with Indwelling [urinary] Catheter (Resident 4 had a urinary catheter on 3/20/2026) for the use of Levaquin on 3/20/2026. The IPN stated the facility process the licensed nurses followed when new antibiotic physician orders were received was for licensed nurses to communicate the new orders to the IPN followed by the IPN initiating the facility's antibiotic surveillance and the IPN would check if the use of antibiotics met the McGeer's criteria. The IPN stated, the IPN did not complete the Mc Geer's Surveillance Data for UTI with Indwelling Catheter for the use of Levaquin 500 mg for Resident 4. A review of the Mc Geer's Surveillance Data for UTI with Indwelling Catheter Form indicated criteria 1 and criteria 2 must be present. Criteria 1 consists of at least one of the following; fever, rigors, or new onset hypotension, either an acute change in mental status or acute functional decline, new onset suprapubic pain of costovertebral pain or tenderness, purulent discharge from around the catheter or acute pain, swelling, or tenderness of the the urinary area. Criteria 2 consists of a positive urine culture result. 1b. During a review of Resident 4's Urine Culture collected on 4/22/2026 and resulted on 4/24/2026 with the IPN, the result indicated 2 different bacteria were identified and both bacteria were resistant to Ciprofloxacin. During a review of Resident 4's Medication Administration Record (MAR) for the month of April 2026, the MAR indicated Ciprofloxacin 500 mg was administered to Resident 4 from 4/22/2026 to 4/28/2026. During an interview on 3/8/2026 at 12:15 PM, the IPN stated there was no communication to the ordering physician regarding the results of the urine culture indicating Resident 4 was resistant to Ciprofloxacin. The IPN stated Resident 4 continued to receive Ciprofloxacin. The IPN should taking Ciprofloxacin when the bacteria were resistance to Ciprofloxacin is ineffective in treating UTI and could make Resident 4 more resistant to other antibiotics. During an interview on 5/8/2026 at 3:35 PM, the Director of Nursing stated administering antibiotics to Resident 4 who was resistant to the antibiotics would not be effective in treating UTI. 2. During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 4/2/2025, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear. During a review of Resident 7's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/7/2026, the MDS indicated Resident 7 had severe cognitive deficit and Resident 7 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with oral hygiene, toileting hygiene and personal hygiene. During a review of Resident 7's Quetiapine order history for the month of March 2026, the history indicated Resident 7's Quetiapine was discontinued on 10/3/2025 and restarted on 3/29/2026. During a review of Resident 7's current Medication Administration Record (MAR) dated 3/1/2026 to 3/31/2026, the MAR indicated an order for Quetiapine 25 mg. two times a day for agitation (started on 3/26/2026). During a concurrent review of Resident 7's Progress Notes and Change of Condition for March 2026 and interview on 5/7/2026 at 3:15 PM, the MDS Nurse (MDSN) stated there was no documentary evidence Resident 7 exhibited behaviors that would need Seroquel to be restarted. The MDSN stated Seroquel was restarted when Resident 7 was placed on hospice care. During a review of Resident 7's Medication Administration Record (MAR) for March 2026, April 2026 and May 2026 on 5/07/2026 at 2:40 PM, the MDSN stated there was no record of monitoring for behaviors for the use of Seroquel. During an interview on 5/7/2026 at 2:52 PM, the MDSN stated monitoring the specific behavior ordered for the use of Seroquel would determine if the medication was effective at controlling the behavior and a gradual dose reduction could be attempted once the behavior had been controlled. The MDSN stated we need to add the monitoring order when licensed nurses enter the psychotropic orders. During a concurrent review of Resident 7's physician orders and interview on 5/8/2026 at 3:26 PM, the DON stated Seroquel was ordered for agitation, the behavior needed to be specific so the behavior can be monitored by staff. During a review of the facility's Policy and Procedure (P&P) titled, Unnecessary Medication, the P&P indicated the facility will follow state and federal regulations that all residents will be free from unnecessary psychotropic medications and unnecessary drugs. The P&P indicated licensed nurse will review resident's drug regimen based on the following criteria:Excessive doseExcessive durationAdequate indicationAdequate MonitoringPRN Medication, discontinue prn medication if it has not been used for more than 30 days.Presence of adverse consequencesAny combinations of the reasons aboveThe P& P indicated Licensed nurse will communicate with the primary physician in adjusting the medication dosage, duration, frequency and/or discontinue the medication if indicated

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices at one of one nurse's station when the residents' (in general) food from home refrigerator was observed with debris and dried liquid on the shelves for two consecutive days.This failure had the potential to result in pests and cross-contamination (transfer of harmful bacteria from one place to another) placing residents (in general) at risk and significantly impacting the residents' health.Findings:During a concurrent observation and interview on 5/7/2026 at 1 PM with the Certified Dietary Manger (CDM), in the Nurse's Station, the residents' (in general) food from home refrigerator was observed with debris on two shelves and dried brown liquid on the main bottom shelf along with dried brown liquid on the side shelf. The CDM stated this was the refrigerator where residents' food from home was stored. The CDM stated the refrigerator was not clean. Additionally, the CDM stated the importance of keeping the refrigerator clean was to prevent cross contamination.During a concurrent observation and interview on 5/8/2026 at 9:35 AM with Registered Nurse (RN) 1, in the Nurse's Station, the residents' (in general) food from home refrigerator was observed with debris on two shelves and dried brown liquid on the main bottom shelf along with dried brown liquid on the side shelf. RN 1 stated the refrigerator needed to be wiped. During a review of the facility's Policy and Procedure (P&P) titled, Refrigerators and Freezers, revised November 2022, the P&P's policy statement indicated, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. The P&P's policy interpretation and implementation indicated, Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary.

Based on observation, interview, and record review, the facility failed to implement the facility's antibiotic stewardship program (a coordinated healthcare initiative designed to promote the most appropriate, safe, and effective use of antibiotics [medication that kills or stops bacteria from reproducing]) for one of three sampled residents (Resident 4) by failing to,A. Ensure Mc Geer's criteria (a standardized, evidence-based definitions used to identify and track infections in long-term care facilities, allows healthcare workers to accurately count and monitor infections) for infection surveillance was met for Resident 4 for the use of the Levaquin (antibiotic used to treat serious bacterial infections).B. Ensure Resident 4 was not administered Ciprofloxacin when Resident 4's urine culture and sensitivity (C&S, a two-part laboratory procedure used to diagnose infections) result indicated Resident 4 was resistant (bacteria has changed so antibiotic drugs can no longer kill them or stop the growth, the bacteria causing the infection has adapted, making the disease harder to treat) to Ciprofloxacin.This deficient practice had the potential to result in a physical decline due to an unresolved infection and inappropriate use of antibiotics. Additionally, the deficient practice had the potential to result in antibiotic resistance to Resident 4.Findings:During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 9/26/2025 with diagnoses that included sepsis (a life-threatening blood infection [the invasion and growth of germs in the body]), urinary tract infection (UTI- infection that affects part of the urinary tract).During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 4/3/2026, the MDS indicated Resident 4 had intact cognitive (the ability to think and process information) and required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with oral hygiene, toileting hygiene and personal hygiene.During a review of Resident 4's Order Summary Report (OSR), dated from 3/1/2026 to 5/31/2026, on 5/8/2026 at 11:33 AM with the IPN. Resident 4's OSR indicated physician orders for the following antibiotics:1. Macrobid 100 mg. two times a day for UTI for 10 days, dated 3/13/2026.2. Levofloxacin (Levaquin, potent broad-spectrum antibiotic used to treat serious bacterial infections) 500 mg one time a day for UTI for 10 days, dated 3/20/2026.3. Ciprofloxacin (Cipro, antibiotic used to treat serious or hard-to-treat bacterial infections) 500 mg two times a day for UTI for 7 days, dated 4/22/2026.4. Ciprofloxacin 500 mg, two times a day for UTI until 4/28/2026 at 11:59 PM, dated 4/25/2026.A. During a review of Resident 4's [Mc Geer's] Surveillance Data Collection Form, dated 3/13/2026, the form indicated the following,1. Resident 4 met the criteria for the use of Macrobid 100 mg, two times a day for UTI.2. The form did not indicate if Resident 4 met the criteria for the use of Levaquin.The Surveillance Data Collection Form was not completed for the used of the Levaquin. During a review of Resident 4's urine culture result, urine collection date 3/15/2026, result reported [to the facility] on 3/19/2026. The IPN stated the culture was positive for pseudomonas aeruginosa (type of bacteria). The IPN stated Levaquin 500 mg was ordered when the urine culture result was reported to the facility on 3/19/2026. The IPN stated there was no documented evidence in Resident 4's notes indicating a Surveillance Data Collection Form was completed on 3/19/2026 or 3/20/2026. The IPN stated there was no documented evidence in Resident 4's notes indicating Resident 4 was symptomatic (presented with symptoms) for UTI on 3/20/2026 or communication with the ordering physician regarding results of Resident 4's Mc Geer's criteria for a UTI and the use of Levaquin.During a review of Resident 4's Lab Results Report, collection date 3/15/2026, the report indicated for long-term care patients [residents], most positive urine cultures represent asymptomatic bacteriuria (presence of bacteria in the urine) or contamination with urogenital flora (the natural community of harmless bacteria that normally inhabit the urinary and reproductive tracts). The report indicated antibiotic therapy is not recommended without signs and symptoms localizing to the urinary tract.During a review of Resident 4's Progress Notes dated 3/19/2026 to 3/20/2026, there was no documented evidence in the notes indicating Resident 4 met criteria 1 for the used of Levaquin.During an interview on 5/5/2026 at 8:54 AM with Resident 4, Resident 4 stated Resident 4 was being administered antibiotics at the facility but had been off antibiotics for 20 days. Resident 4 stated Resident 4 completed antibiotic treatment and had another UTI days later. Resident 4 stated the indwelling catheter (tube left in the bladder [hollow muscular balloon-like organ that stores urine] to drain urine) was removed 4 days ago.During an interview on 5/8/2026 at 11:23 AM with the Infection Prevention Nurse (IPN), the IPN stated the IPN did not complete the Mc Geer's Surveillance Collection Form for UTI with Indwelling [urinary] Catheter (Resident 4 had a urinary catheter on 3/20/2026) for the use of Levaquin on 3/20/2026. The IPN stated the facility process the licensed nurses followed when new antibiotic physician orders were received was for licensed nurses to communicate the new orders to the IPN followed by the IPN initiating the facility's antibiotic surveillance and the IPN checking if the use of antibiotics met the McGeer's criteria.B. During a review of Resident 4's urine culture, collection dated 4/22/2026, resulted on 4/24/2026, the result indicated 2 different bacteria were identified and both were resistant to Ciprofloxacin.During a review of Resident 4's Medication Administration Record (MAR), dated for the month of April 2026, the MAR indicated Ciprofloxacin 500 mg was administered from 4/22/2026 to 4/28/2026.During an interview on 5/8/2026 at 12:15 PM with the IPN, the IPN stated there was no documented evidence (notes) indicating the ordering physician was notified of the urine culture results indicating Resident 4 was resistant to Ciprofloxacin. The IPN stated Resident 4 continued to receive Ciprofloxacin and Ciprofloxacin could be ineffective in treating Resident 4's UTI and [the continuing the medication] could make Resident 4 more resistant to antibiotics.During an interview on 5/8/2026 at 3:35 PM with the Director of Nursing (DON), the DON stated administering an antibiotic that Resident 4 was resistant to [Ciprofloxacin] could result in the antibiotic not being effective, the UTI go unresolved, or recurrent UTIs to Resident 4.During a review of the facility's Policy and Procedure (P&P) titled Antibiotic Stewardship, dated 1/2020, the P&P's purpose indicated the antibiotic stewardship program is to monitor the use of antibiotics in the residents. The P&P indicated training, and education will include emphasis on the relationship between antibiotic use and gastrointestinal disorders, opportunistic infections medication interactions and the evolution of drug-resistant pathogens. The P&P indicated when a culture and sensitivity (C&S) is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

Based on interview and record review the facility failed to provide discharge notification documentation for one of one sampled resident (Resident 49) as indicated in the facility's Policy and Procedure (P&P) titled, Transfer or Discharge Notice, when Resident 49's Notice of proposed transfer and discharge (a document a nursing facility must give a resident and/or their representative before the resident is moved out of the facility, explaining why the resident is being discharged , where they are going, the effective date, their right to appeal, and how to contact the State Long Term Care Ombudsman [an advocate who helps protect the rights, safety, and well-being of residents in nursing homes and other long-term care facilities]) was not given to the Ombudsman following Resident 49's discharge on [DATE].This failure resulted in the State Long-Term Care Ombudsman being uninformed of Resident 49's discharge and had the potential to result in Resident 49's discharge needs not being met.Findings:During a review of Resident 49's admission Record (AR), the AR indicated Resident 49 was originally admitted to the facility on [DATE] and readmitted on [DATE] and 1/22/2026 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) and schizoaffective disorder (a mental illness causing a person to experience dramatic changes in thoughts, moods, and behaviors).During a review of Resident 49's History and Physical (H&P), dated 1/23/2026, the H&P indicated Resident 49 did not have the capacity to understand and make decisions.During a review of Resident 49's Minimum Data Set (MDS- a resident assessment tool), dated 2/18/2026, the MDS indicated Resident 49's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired (makes poor decisions requiring cues or supervision). The MDS indicated Resident 49 required supervision or touching assistance with oral, toileting, and personal hygiene and showering, required setup or clean-up assistance with dressing and was independent with eating.During a review of Resident 49's Notice of Proposed Transfer and Discharge, dated 2/18/2026, the notice indicated Resident 49 was discharged on 2/18/2026.During an interview on 5/7/2026 at 3:04 PM with the Social Services Director (SSD), the SSD stated it was the practice of the facility to send discharge notifications to the Ombudsman via fax within 30 days of the residents' (in general) discharge date . The SSD stated the facility did not send Resident 49's discharge notification to the Ombudsman. Additionally, the SSD stated it was important to notify the Ombudsman regarding Resident 49's discharge to ensure the Ombudsman could check on the resident if needed.During a review of the facility's P&P titled, Transfer or Discharge Notice, revised March 2021, the P&P's policy statement indicated, Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. The P&P's policy interpretation and implementation indicated, A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman.

Based on interview and record review, the facility failed to ensure one of one resident's (Resident 1) diagnosis of depression was accurately reflected in the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/14/2026.This deficient practice resulted in inaccurate Medical Record for Resident 1 and had the potential for Resident 1 to have unmet needs.Findings:During a review of Resident 1's admission Record, (AR) the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including depression (mood disorder causing persistent sadness, emptiness, or irritability, along with loss of interest in activities once enjoyed), anxiety (persistent, excessive, and uncontrollable fear or worry that interferes with daily life) and dementia (a gradual decline in mental ability usually caused by a brain disease.)During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had impaired cognition (ability to understand and process information) and required substantial/ maximal assistance for toileting and bathing. The MDS did not indicate Resident 1 had a diagnosis for depression.During a review of Resident 1's Order Summary Report (OSR) dated with active orders as of 5/7/2026, the OSR indicated Resident 1 had a physician order for Mirtazapine (antidepressant) tablet 7.5 milligrams (mg- unit of weight) by mouth at bedtime for depression manifested by poor oral intake of less than 50% of meals with start date 3/12/2026.During an interview on 5/8/2026 at 11:50 AM with the MDS nurse (MDSN), the MDSN stated there was a discrepancy on Resident 1's MDS and Resident 1 should have been marked as having depression because Resident 1 was actively taking medication for depression at the time. The MDSN stated it is important to have accurate information on the MDS so that it could be reported to Resident 1's insurance and ensure Resident 1's insurance is informed of Resident 1's current treatments.During a review of the facility's policy and procedure (P&P) titled, Record Content, dated 1/04, the P&P indicated, a resident's health record should be current and kept in detail consistent with good medical and professional practice based on the service provided to each resident.

Based on observation, interview, and record review, the facility failed to ensure a liquified diet was served as ordered by the physician for one of one sampled resident (Resident 3) who had a history of dysphagia (difficulty swallowing).The deficient practice had the potential to result in complications like aspiration pneumonia (lung infection [the invasion and growth of germs in the body] caused by inhaling foreign substances like food into the airways rather than swallowing them), choking, and a physical decline to Resident 3.Findings:During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 6/9/2016, with diagnoses that included dementia (a progressive state of decline in mental abilities) and dysphagia. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 3/7/2026, the MDS indicated Resident 3 had severe cognitive (the ability to think and process information) deficit and was dependent with activities of daily living such as eating, oral hygiene, toileting hygiene.During a review of Resident 3's Order Summary Report (OSR), the OSR indicated a physician's order, dated 4/9/2026, for a regular diet, liquidized texture. Okay with Speech Therapist (ST) for liquidized pureed (food that is smooth and easy to swallow and digest) items for all meals for ease of swallow. During an observation on 5/5/2026 at 12:28 PM, Certified Nursing Assistant (CNA) 1 assisted Resident 3 with lunch, there were three cups with liquids inside on Resident 3's bedside: 1 brown colored thickened liquid, 1 light brown colored liquified food, and a cup of dark yellow liquified food. There was one bowl of yellow colored mashed food.During the following observations on 5/5/2026,At 12:36 PM CNA 1 started to feed the mashed food to Resident 3, Resident 3 did not cough.At 12:37 PM CNA 1 continued to feed the mashed food and assisted Resident 3 to drink from a glass of milk.At 12:37 PM CNA 1 fed Resident 3 a third halfway full spoon of mashed food.At 12:41 PM, the Director of Nursing (DON) tested the mashed food with CNA 1 using the spoon tilt test (placed mashed food on the spoon and tilted the spoon down after 20 seconds) the mashed food did not fall from the spoon. During an interview on 5/5/2026 at 12:50 PM, the DON stated ordered food needed to be in the form it was ordered to prevent choking.During an observation on 5/5/2026 12:51 PM, the DON tilt tested the brown colored food, the light brown colored food, and the dark yellow food using the spoon. The liquid food fell off the spoon quickly; the other foods did not fall off the spoon.During an interview on 5/5/2026 at 1:19 PM with the Regional Registered Dietitian (RRD), the RRD stated a syringe was used to test a liquidized diet (flow test to ensure the liquid is the correct, safe thickness for individuals with swallowing difficulties, how fast the liquid flows through the syringe in 10 seconds).During an interview on 5/5/2026 at 1:30 PM, the [NAME] stated Resident 3 was on a liquified diet, and the bowl of mashed food on Resident 3's tray must have been a mistake. The [NAME] stated a liquified diet was tested by using a syringe. The [NAME] showed the facility's supply of special syringes used to conduct these tests. The [NAME] stated providing liquified diet as ordered [by the physician] prevented Resident 3 from choking. The [NAME] stated the dark brown liquified food was pork roast, the light brown liquified food was mixed vegetables, the dark yellow liquified food was rice pilaf, and the yellow-colored food was lemon bar.During a review of the facility's lunch recipe/menu, dated 5/5/2026, the menu included pork roast, rice pilaf, mixed vegetables, and lemon bar.During a review of the Complete International Dysphagia Diet Standardization Initiative (IDDSI) Framework, dated 4/2026, the IDDSI developed a standard that can be used to describe the characteristics of foods and drinks - from the point of view of a person with swallowing difficulties. To accompany this standard, the IDDSI has also developed testing methods to determine if any food or drink conforms to the requirements of the IDDSI Standard) Framework consisted of 8 levels (0-7) where Level 7 is regular food, Level 6 is soft and bite-sized (1.5 centimeter in size of adults), Level 5 is minced and moist (can be scooped and shaped, testing method includes the spoon tilt test where a full spoonful must fall off easily if the spoon if the spoon is tilted with very little food left on the spoon), Level 4 Pureed, Extremely Thick with a testing method using a spoon, a spoonful must plop off the spoon if the spoon is titled or turned sideways; a very gentle flick (using only fingers and wrist) may be necessary to dislodge the sample from the spoon, but the sample should slide off easily with very little food left on the spoon. Level 3 Liquidized (can be tested using a spoon tilt test, a full spoonful must plop off the spoon if the spoon is titled or turned sideways; a very gentle flick (using only fingers and wrist) may be necessary to dislodge the sample from the spoon, but the sample should slide off easily with very little food left on the spoon. Level 2 Mildly Thick Liquid (food flows off the spoon), Level 1 Slightly Thick Liquid (slightly thicker than water with a testing method using the syringe test and Level 0 (Thin Liquids, flows like water).During a review of the facility's undated Policy and Procedure (P&P) titled Food Preparation Policy the P&P indicated all modified diets, and thickened liquids will be prepared and served in accordance with the IDDSI Framework.

Based on interview and record review, the facility failed ensure three of six sampled staff (Certified Nursing Assistant [CNA] 1, CNA 2, and Licensed Vocational Nurse [LVN] 1) understood the facility's Policies and Procedures (P&P) on abuse reporting when:1. CNA 1, CNA 2, and LVN 1 did not know who the facility's Abuse Coordinator (a designated staff member responsible for managing and addressing issues related to abuse or neglect within the facility) was.2. CNA 1, CNA 2, and LVN 1 did not know that allegations of abuse must be reported to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement within 2 hours.This failure had the potential for residents (in general) to be subjected to abuse while residing at the facility.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/2/2026 with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), impulse disorder (a repeated failure to resist urges, behaviors, or temptations that cause harm to oneself or others), and hypertension (high blood pressure).During a review of Resident 1's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions due to schizophrenia.During an interview on 4/7/2026 at10:10 AM with CNA 1, CNA 1 stated CNA 1 did not know who the facility's Abuse Coordinator was. CNA 1 stated CNA 1 did not know what agencies (Department, law enforcement, and the Ombudsman) allegations of resident abuse needed to be reported to.During an interview on 4/7/2026 at10:20 AM with LVN 1, LVN 1 stated LVN 1 did not know who the facility's Abuse Coordinator was. LVN 1 stated LVN 1 did not know allegations of resident abuse needed to be reported to the Department and to the local law enforcement.During an interview on 4/7/2026 at 10:32 AM with CNA 2, CNA 2 did not know who the facility's Abuse Coordinator was. CNA 2 stated CNA 2 did not know what agencies allegations of resident abuse needed to be reported to.During an interview on 4/7/2026 at 11:52 AM with the Director of Staff Development (DSD), the DSD stated the facility's Abuse Coordinator is the Administrator (ADM). The DSD stated facility staff (in general) should report all allegations of abuse to the ADM. The DSD stated all facility staff (in general) are expected to know who the facility's Abuse Coordinator is. The DSD stated all facility staff (in general) are expected to know what agencies allegations of resident abuse must be reported to within 2 hours.During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, revised 11/28/2022, the P&P indicated, The P&P indicated: .Administrator, or his/her designee, as Abuse Coordinatori. To facilitate reporting, ensure confidentiality, and promote order at the Facility, the Administrator, or his/her designee, of the Facility shall be the individual who reports known or suspected instances of abuse of residents at the Facility to the proper authorities.ii. Facility Staff will report known or suspected instances of abuse to the Administrator, or his/her designee.iii. Facility Staff members shall be notified that the Administrator, or his/her designee, has this responsibility, and that inquiries concerning resident abuse and reporting requirements should be referred to the Administrator, or his/her designee.The P&P indicated, The Facility will report allegations of abuse.Immediately, but no later than two hours after forming the suspicion - if the alleged violation involved abuse. to the state survey agency, adult protective services, law enforcement, and the Ombudsman.

Based on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Abuse Prevention and Prohibition Program, revised 11/28/2022.This failure resulted in a delay in notification to the Department, the Ombudsman, and local law enforcement, and had the potential for Resident 1 to be subjected to abuse while at the facility.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/2/2026 with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), impulse disorder (a repeated failure to resist urges, behaviors, or temptations that cause harm to oneself or others), and hypertension (high blood pressure).During a review of Resident 1's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions due to schizophrenia.During an interview on 4/7/2026 at 10:32 AM with Certified Nursing Assistant (CNA) 2, CNA 2 stated CNA 2 was assigned to provide care to Resident 1 on 4/4/2026. CNA 2 stated at around 1 pm on 4/4/2026, Resident 1 yelled rape, rape, when CNA 2 walked into Resident 1's room. CNA 2 stated CNA 2 did not report Resident 1's allegation of abuse until around 2:45 PM when CNA 2 told LVN 2 about Resident 1's allegation of abuse against CNA 2.During an interview on 4/7/2026 at 10:51 AM with LVN 2, LVN 2 stated CNA 1 reported to LVN 2 on 4/4/2025 at 3 PM that Resident 1 alleged CNA 2 raped and touched Resident 1. LVN 2 stated LVN 2 did not report the allegation of abuse to the Administrator (ADM). LVN 2 stated LVN 2 reported the allegation of abuse to the DON at 5 PM. LVN 2 stated LVN 2 should have reported right away to the DON.During a concurrent interview and record review on 4/7/2026 at 12:30 PM with the Director of Nursing (DON), Resident 1's COC (Change of Condition)/Interact Assessment Form (SBAR-situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 4/4/2026, was reviewed. The SBAR indicated, on 4/4/2026, Resident 1 made an allegation of physical and sexual abuse by staff (unidentified). The SBAR indicated the RN supervisor (unidentified) reported Resident 1's allegation of abuse to the local law enforcement at 8:30 PM. The SBAR indicated the administrator (ADM) reported Resident 1's allegation of abuse to the Ombudsman at 8:24 PM, and to the Department at 8:25 PM. The DON confirmed the times Resident 1's allegation of abuse was reported to the Department, the Ombudsman, and local law enforcement, was greater than 2 hours. The DON stated the allegation of abuse was not reported to the Department, the Ombudsman, and to the local law enforcement in accordance with the P&P.During a review of the facility's P&P titled, Abuse Prevention and Prohibition Program, revised 11/28/2022, the P&P indicated, The Facility will report allegations of abuse. Immediately, but no later than two hours after forming the suspicion - if the alleged violation involved abuse. to the state survey agency, adult protective services, law enforcement, and the Ombudsman.

Based on observation, interview, and record review, the facility failed to follow through (follow up) on one of four sampled resident's (Resident 1), who was at risk for falls, fall that occurred on 1/9/2026, in accordance with the facility's policy and procedure (P&P) titled, Change of Condition. The facility failed to assess Resident 1 after the fall, report the fall to Resident 1's physician (Medical Doctor [MD] 1), and complete a change in condition (COC, an alteration in a resident's physical health that differs from their previous baseline) for Resident 1.This deficient practice had the potential to result in Resident 1 not receiving the necessary care and services affecting Resident 1's physical well-being.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including other abnormalities of gait (the pattern of walking) and mobility (ability to move freely), unspecified dementia (a progressive state of decline in mental abilities), and history of falling.During a review of Resident 1's Fall Risk Evaluation (FRE), dated 12/17/2025, timed at 6:40 PM, the FRE indicated Resident 1 was a risk for falls and to alert MD 1 if a fall occurred.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 1's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with activities of daily living (ADL).During a review of Resident 1's Progress Notes (PN), dated 1/9/2026, timed at 3:07 AM, the PN indicated, at approximately 3 AM, LVN 2 heard an alarm noise from the back hallway and entered Resident 1's room. LVN 2 noted Resident 1 to be on the floor, sitting on Resident 1's bottom in front of Resident 1's roommate's bed. LVN 2 asked Resident 1 what had happened and Resident 1 responded, I do not know, I just fell. The PN indicated Resident 1 had an abrasion (a superficial injury where the skin is scraped or rubbed off) on Resident 1's mid-back on the right side and LVN 2 notified Resident 1's primary nurse (LVN 3) who stated LVN 2 would resume follow-up. During a concurrent observation and interview on 2/5/2026 at 6:14 AM with Resident 1 and Certified Nursing Assistant (CNA) 1 in Resident 1's room. CNA 1 was monitoring Resident 1 at Resident 1's bedside. Resident 1 was lying in bed, confused (unable to answer most questions), and trying to get out of bed. Resident 1 had a pinkish colored linear scarring on the right forehead above the eyebrow. Resident 1 stated, Resident 1 had fallen a couple of times at the facility. CNA 1 stated, Resident 1 was a fall risk. CNA 1 stated, CNA 1 believed Resident 1 had fallen once in January 2026 during the evening shift (3 PM - 11 PM) and Resident 1 required stitches (special threads that doctors use to close a wound or cut).During an interview on 2/5/2026 at 10:01 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had advanced dementia with, a lot of confusion, and was a fall risk. LVN 1 stated Resident 1 had a fall (no date recollection) and Resident 1 had a laceration (cut, tear, or rip on the skin) on the forehead that was fully healed. LVN 1 stated a fall was [considered] a COC and it was important to notify the family and physician immediately [after the fall] to obtain physician orders if the resident (in general) needed to be transferred out to the hospital. During a concurrent interview and record review on 2/5/2026 at 10:31 AM with the DON, Resident 1's medical records were reviewed. Resident 1's Progress Notes (PN), dated 1/9/2026, timed at 3:07 AM, the DON stated, it sounded like [Resident 1 had a fall on 1/9/2026]. The DON stated LVN 2 was the charge nurse and was responsible for completing a COC for Resident 1's fall dated 1/9/2026. The DON stated there was no documented evidence indicating MD 1 was notified of Resident 1's fall dated 1/9/2026. The DON stated there was no COC or assessment [in Resident 1's medical record] for Resident 1's fall dated 1/9/2026. The DON stated, completing a COC immediately, as soon as it [a fall] occurs was important to ensure MD 1 was notified, [assisted with] communication amongst staff, [assisted with] reevaluating Resident 1 for rehabilitation [services], [assisted with] adjusting care plans, and [implementing interventions like] could have moved Resident 1 closer to the nursing station sooner.During an interview on 2/6/2026 at 7:47 AM, LVN 3 stated Resident 1 had a fall (no date recollection) and was transferred to the hospital where Resident 1 got stitches. LVN 3 stated LVN 2 reported early morning last month to LVN 3 that LVN 2 found Resident 1 sitting on the floor while LVN 3 was on lunch break. LVN 3 stated LVN 3 did not assess Resident 1 after Resident 1's fall dated 1/9/2026. LVN 3 stated, LVN 2 told LVN 3 LVN 2 would take care of the incident. LVN 3 stated, a fall was a COC, and it was important to assess the resident (in general), notify the physician for the overall wellbeing of the resident.During a review of the facility's undated P&P titled, Change of Condition, the P&P indicated, the facility ensured proper assessment and follow-through for any resident with a change of condition. The P&P indicated a change of condition is a sudden or marked difference in the resident like bruises, lacerations, blisters, rashes, or skin tears. The P&P indicated all changes of condition in a resident should be handled promptly, documentation of change in condition should be performed by the Licensed Nurse accordingly, and a COC would be completed as indicated. The P&P indicated upon the COC, staff members were to take the following actions: the physician shall be called [notified] promptly and daily assessments.

Based on interview and record review, the facility failed to obtain weekly weights for three of three sampled residents (Resident 34, 28, and 145) as indicated in the facility's policy and procedure (P&P) titled, Weight Change, as evidenced by: A. Resident 34's weight was not taken upon readmission to the facility on [DATE] and not taken on 3/18/2025 per the physician order. B. Resident 28 weight was not taken weekly as ordered by the physician. C. Resident 145's weight was not taken on 3/18/2025 as per the physician's order. This deficient practice had the potential to result in physical declines to Residents 34, 28, and 145 due to untreated weight loss. Findings: A. During a review of Resident 34's Admission Record (AR), the AR indicated Resident 34 was initially admitted to the facility on [DATE] and the resident was readmitted on [DATE] with multiple diagnosis including heart failure (the inability of the heart to pump blood effectively) and dementia (a gradual decline in mental ability usually caused by a brain disease.) During a review of Resident 34's Minimum Data Set (MDS - a resident assessment tool) dated 1/29/2025, the MDS indicated Resident 34 had severe impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort) on staff for bathing and toileting. During a review of Resident 34's Order Summary Report (OSR) with active orders as of 3/18/2025, the OSR indicated Resident 34 had a physician order to monitor weight every Tuesday for four weeks then monthly with a start date on 3/18/2025. During an interview on 3/19/2025 at 2:20 PM with the Restorative Nurse Assistant (RNA), the RNA stated the RNA was responsible for weighing the residents and the RNA was made aware, by the nursing staff, which residents to weigh. The RNA stated residents were weighed when they returned from the hospital because residents tended to lose weight during a hospitalization . The RNA stated the RNA did not have access to the facility's computer documentation system and typically wrote down resident weights and handed them to either the Director of Nursing (DON) or nursing staff and nursing would input the weights into the computer system right away. The RNA stated Resident 34 was weighed upon return to the facility and the RNA gave the weight to the Infection Preventionist nurse (IP). The RNA stated Resident 34 was not on the RNA's list of weekly weights and the RNA could not recall what Resident 34's weight was upon return to the facility. During an interview on 3/19/2025 at 2:43 PM with the IP, the IP stated the most recent weight recorded for Resident 34 was on 3/3/2025 prior to Resident 34's hospitalization dated from 3/8/2025 to 3/14/2025. The IP stated the RNA may have given the IP Resident 34's weight on a scrap of paper but the IP did not input the weight into the computer system and did not have any documentation to support that Resident 34's weight was taken. 40438 B. During a review of Resident 28's AR, the AR indicated, Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing), hypertension (HTN, high blood pressure), and acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). During a review of Resident 28's MDS, dated [DATE], the MDS indicated, Resident 28 had severe impaired cognition (ability to understand and process information). The MDS indicated Resident 28 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, toileting, upper and lower body dressing, and personal hygiene. During a review of Resident 28's Change of Condition (COC)/Interact Assessment Form, dated 3/5/2025, the form indicated, Resident 28 had a weight loss of 5.2 percent (%, a specified amount for every hundred). During a review of Resident 28's Weights and Vitals Summary (WVS), dated 3/18/2025, the WVS indicated the last weight recorded for Resident 28 was on 3/3/2025 for 147 pounds (lbs., unit of weight), Resident 28 had an 8-pound weight loss in thirty days. During a review of Resident 28's OSR, dated active as of 3/18/2025, the OSR included a physician's order, dated 3/5/2025, to monitor weight every Tuesday for 4 weeks. During a concurrent interview and record review on 3/18/2025 at 3:17 PM with Licensed Vocational Nurse 3 (LVN 3), Resident 28's medical record (chart) and PointClickCare (PCC, electronic medical record) were reviewed. LVN 3 stated Resident 28 had no weights recorded on 3/11/2025 and 3/18/2025. LVN 3 stated weights should be monitored for residents [who were experiencing] weight loss to address the nutritional status of the resident appropriately. During an interview on 3/18/2025 at 3:32 PM with the Registered Nurse Supervisor (RNS), the RNS stated, residents [who were experiencing] weight loss should be weigh weekly to monitor weight changes for the detection of health issues and medication management. 42307 C. During a review of Resident 145's AR, the AR indicated, Resident 145 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including anxiety disorder (mental health condition characterized by persistent, excessive fear or worry that significantly interferes with daily life), unspecified and unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic disturbance (a mental health condition characterized by a loss of contact with reality, leading to distorted perceptions, thoughts, and behaviors), mood disturbance (a significant change in a person's emotional state that persists for an extended period), and anxiety. During a review of Resident 145's MDS, dated [DATE], the MDS indicated, Resident 145's cognition (ability to understand and process information) was severely impaired. The MDS indicated, Resident 145's proportion of total calories (a unit of measurement that indicate the energy content of food and beverages) received was 25% or less while a resident at the facility. During a review of Resident 145's Care Plan (CP), titled, Resident has alteration in nutritional status ., revision date 2/24/2025, the CP's interventions indicated to monitor weight per policy. During a review of Resident 145's History and Physical (H&P), dated 3/2/2025, the H&P indicated, Resident 145 did not have the capacity to understand and make decisions. During a review of Resident 145's Nutritional Assessment DSS (NA), dated 3/2/2025, timed at 11:16 AM, the NA indicated, Resident 145 had a loss of 5% (percent, a number or ratio expressed as a fraction of 100) or more in the last month and Resident 145 was not on prescribed weight-loss regimen. During a review of Resident 145's COC, dated 3/5/2025 timed at 2:20 PM, the COC indicated, an RD (Registered Dietician) consultation and weekly weight for 4 weeks. During a review of Resident 145's OSR), active orders as of 3/20/2025, the OSR included, a physician's order, dated 3/5/2025, the order indicated to monitor weight every Tuesday for 4 weeks. During a review of Resident 145's CP, titled, Resident weight loss -5.0% change ., date initiated 3/5/2025, the CP indicated, one of the interventions was weekly weight for 4 weeks as per physician's order. During a review of Resident 145's undated WVS, the WVS indicated, Resident 145's last weight documented in PCC (PointClickCare, a healthcare software used for electronic health records) was dated 3/3/2025. During a concurrent interview and record review on 3/19/2024 at 2:45 PM with the RNA, the facility's undated Weekly Weights (WW), was reviewed. The WW indicated, the following weekly dates: Week 1 on 3/11/2025; Week 2 on 3/18/2025; Week 3 on 3/25/2025; Week 4 on 4/1/2025. The RNA stated, the RNA did not enter resident weights in PCC and the DON was the one who entered the weights in PCC. The WW did not indicate any weights for week 2 on 3/18/2025 (Tuesday) for Resident 145. The RNA stated, the RNA was responsible for weighing the residents. The RNA stated, the RNA did the weekly weights on Tuesday or Friday it depends, if [it is a] busy day. During a review of the facility's undated policy and procedure (P&P) titled, Weight Change, the P&P indicated, all residents were to be weighed and measured upon admission and once weekly for four weeks thereafter and a record should be kept in resident's chart.

Based on observation, interview, and record review, the facility failed ensure proper food storage, in one of one kitchen walk-in refrigerator (Refrigerator 1), consistent with the facility's policy and procedure (P&P), titled, Refrigerator/Freezer Storage, by failing to: a. Ensure a transparent container with sliced cheese was labeled with an open date (date to indicate when it was opened). b. Ensure a halfway-filled pickle jar was labeled with an open date. c. Ensure two unopened plastics of whipping cream were labeled with a received date. These failures had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) to the residents consuming the facility's food. Findings: During a concurrent observation and interview on 3/17/2025 at 8:58 AM with the Certified Dietary Manager (CDM) inside Refrigerator 1, the following items were found, 1. A transparent container that had sliced cheese and the container was not dated or labeled with the date when it was opened. 2. An undated halfway-filled bottle jar with hamburger pickles. 3. Two undated and unopened plastics of whipping cream. CDM stated food items inside the fridge should be labeled with open and receive dates to keep track of the quality and freshness of the food. During an interview on 3/19/2025 at 12:55 PM with the Registered Dietitian (RD), the RD stated all items in Refrigerator 1 should be labeled with an open and receive dates to keep track when food items arrived, to know when to discard food items, and to make sure food served to the residents was at its highest quality. During a review of the facility's P&P titled, Refrigerator/Freezer Storage, revised 2019, the P&P indicated, Leftover food or unused portions of packaged foods should be covered, dated, and labeled to ensure they will be used first. The P&P indicated all items should be properly covered, dated, and labeled. The P&P indicated food items should have the following appropriate dates: Delivery date - upon receipt, Open date - opened containers of PHF and Thaw date - any frozen items.

Based on interview and record review, the facility failed to provide and ensure Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) were kept in 3 of 5 sampled resident's (Residents 14, 145, 38) medical records. This failure had the potential to cause confusion among the healthcare providers in the event Residents 14, 145 and 38 required immediate medical care and/treatment and had the potential for the residents to receive inadequate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment. Findings: a. During a review of Resident 14's Admission Record (AR), the AR indicated, Resident 14 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic disturbance (a mental health condition characterized by a loss of contact with reality, leading to distorted perceptions, thoughts, and behaviors), mood disturbance (a significant change in a person's emotional state that persists for an extended period), and anxiety (a mental health condition characterized by persistent, excessive fear or worry that significantly interferes with daily life). During a review of Resident 14's History and Physical (H&P), dated 11/23/2024, the H&P indicated, Resident 14 did not have the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 2/6/2025, the MDS indicated, Resident 14's cognition (ability to understand and process information) was severely impaired. During a review of Resident 14's Care Plan (CP,) titled, Advance Directives, date initiated 2/24/2025, the CP's interventions indicated to respect my/legal representative's/DPOA's (Durable Power of Attorney) wishes/decisions as specified in the AD. b. During a review of Resident 145's AR, the AR indicated, Resident 145 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including anxiety disorder (mental health condition characterized by persistent, excessive fear or worry that significantly interferes with daily life), unspecified and unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic disturbance (a mental health condition characterized by a loss of contact with reality, leading to distorted perceptions, thoughts, and behaviors), mood disturbance (a significant change in a person's emotional state that persists for an extended period), and anxiety. During a review of Resident 145's History and Physical (H&P), dated 3/2/2025, the H&P indicated, Resident 145 did not have the capacity to understand and make decisions. During a review of Resident 145's CP, titled, Advance directive initiated as follows ., revision date 2/24/2025, the CP indicated, one of the interventions was to respect resident's and/or family's wishes. During a review of Resident 145's H&P, dated 3/2/2025, the H&P indicated, Resident 145 did not have the capacity to understand and make decisions. During a review of Resident 145's MDS, dated [DATE], the MDS indicated, Resident 145's cognition (ability to understand and process information) was severely impaired. c. During a review of Resident 38's AR, the AR indicated, Resident 38 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), single episode, unspecified and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. During a review of Resident 38's H&P, dated 1/2/2025, the H&P indicated, Resident 38 had the capacity to understand and make decisions. During a review of Resident 38's MDS, dated [DATE], the MDS indicated, Resident 38's cognition was intact. During a concurrent interview and record review on 3/19/2025 at 8:51 AM with the Social Services Assistant (SSA), Residents 14, 145, and 38's Advance Healthcare Directive Acknowledgement (AHDA), and the 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), were reviewed as follows: a.Resident 14's AHDA dated 5/23/2017 indicated, Resident 14 had executed an AD. Resident 14's POLST dated 2/21/2018 indicated, Resident 14 did not have an AD. b.Resident 145'a AHDA dated 8/8/2023 indicated, Resident 145 had executed an AD. Resident 145's POLST dated 8/8/2023 indicated, Resident 145 did not have an AD. c.Resident 38's AHDA dated 1/9/2025 indicated, Resident 38 had executed an AD. Resident 38's POLST dated 1/9/2025, did not indicate if Resident 38 had an AD. The POLST forms indicated, the POLST complemented an AD and was not intended to replace that document (AD). The SSA stated, the SSA was responsible for handling of the AHDA, for completion upon admission, and the facility should obtain a copy of the AD right away. The SSA stated, the SSA could not find an AD on file [in the medical records] for Residents 14, 145, and 38. The SSA stated, the facility should have followed thru and obtained a copy of Residents 14, 145, and 38's AD and the ADs needed to be filed in the residents' medical records so the facility could honor Residents 14, 145 and 38's wishes like their final decision for their treatment and respect their wishes. During a review of the facility's policy and procedure (P&P), titled, Advance Directives, revised date 9/2022, the P&P indicated, the resident has the right to formulate an AD, including the right to accept or refuse medical treatment. The P&P indicated, ADs are honored in accordance with state law and the facility's policy. The P&P indicated a POLST paradigm form was not an advance directive. The P&P indicated, if the resident or the resident's representative had executed one or more advance directive(s), or executed one upon admission, copies of these documents were obtained and maintained in the same section of the resident's medical record and were readily retrievable by any facility staff.

Based on observation, interview, and record review, the facility failed to ensure informed consents were obtained for one of one sampled resident (Resident 94) as indicated in the facility's policy and procedure (P&P), titled, Informed Consent and Alarm Monitor, by failing to: a. Ensure an informed consent was completed prior to the use of the bed/wheelchair alarms (a safety device, often a sensor pad or clip, that alerts caregivers when a patient attempts to leave their bed or chair, helping to prevent falls and injuries) b. Ensure informed consents were completed prior to the use of Lexapro (anti-depressant, medication used to treat depression [serious illness that negatively affects how one feels, thinks and acts]) and Remeron (medication used to treat depression). These failures resulted in violation of Resident 94/responsible party's right to understand Resident 94's treatment, including the risks and benefits of the medications and the purpose of the use of the alarms. Additionally, the failures had the potential to result in distress to Resident 94 related to the sound of the alarms. Findings: a. During a review of Resident 94's Admission Records (AR), the AR indicated, Resident 94 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities) and muscle weakness (decreased strength in the muscles). During a review of Resident 94's Minimum Data Sheet (MDS, a resident assessment tool), dated 3/19/2025, the MDS indicated, Resident 94 had severe impaired cognition (ability to understand and process information). During a concurrent observation and interview on 3/17/2025 at 10:31 AM with Certified Nurse Assistant 1 (CNA 1) inside Resident 94's room, Resident 94 was sitting on his wheelchair. CNA 1 stated, Resident 94's bed and wheelchair had pad alarms to alert staff when Resident 94 tried to get up from the bed or the wheelchair. b. During a review of Resident 94's Order Summary report (OSR), dated active as of 3/17/2025, the OSR included the following physician orders, all dated 3/13/2025, 1.wheelchair pad alarm while out of bed and up in the wheelchair to alert staff of resident unassisted transfer. The order indicated an informed consent was to be obtained from the responsible party after explanation of risks and benefits and verification with the physician. 2. Lexapro 10 milligrams (mg, a unit of measurement) by mouth daily for depression (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). 3.Remeron 7.5 mg by mouth at bedtime for depression. During a concurrent interview and record review on 3/17/2025 at 1:51 PM with Licensed Vocational Nurse 1 (LVN 1), Resident 94's medical records (chart) and PointCLickCare (PCC, a healthcare software used for electronic health records) were reviewed. LVN 1 stated, Resident 94 did not have an informed consent signed for the use of the bed and wheelchair pad alarms or for the use of Lexapro and Remeron. LVN 1 stated bed and wheelchair alarm should not be applied; Lexapro and Remeron should not be started until informed consents were signed to make sure the resident and the resident's representative were informed of the risks and benefits for the use of the bed and wheelchair pad alarms and side effects of the medications. During an interview on 3/18/2025 at 3:32 PM with the Registered Nurse Supervisor (RNS), the RNS stated, an informed consent should be obtained before the application of bed and wheelchair pad alarms and before the use of anti-depressants to make sure the resident or her responsible party were informed of the purpose of the use of the alarms and the use of the anti-depressants. During a review of the facility's undated P&P titled, Alarm Monitor, the P&P indicated, The licensed nurse will obtain an informed consent for the alarm. During a review of the facility's P&P, titled, Informed Consent, revised 12/2024, the P&P indicated, To ensure that residents and/or their representatives are fully informed of the benefits, risks, frequency/duration, and alternatives before initiating the administration of psychotherapeutic drugs or physical restraints . Informed consent may be obtained through the following means: In person, By phone, Via fax, and by email . The informed consent form shall be maintained in the resident's clinical record.

Based on observation, interview, and record review, the facility failed to ensure three of 10 sampled residents (Residents 1, 2, and 3) were free from involuntary seclusion (separation of a resident from other residents or from her/his room or confinement to her/his room with or without roommates against the resident's will, or the will of the resident representative) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 did not use two utility/linen carts (material handling cart used for bedding, linens, and other supplies) to block the entrance/exit (only one entrance and exit) to Resident 1, 2, and 3's Room (RM 1) after CNA 1 witnessed Resident 1 spilling liquid on the floor. As a result, CNA 1 violated Resident 1, 2 and 3's rights and prohibited (not allowed) Residents 1, 2, and 3 from leaving RM 1. These deficient practices had the potential for psychosocial (mental, emotional, social, and spiritual effects) harm, serious injury, serious harm, serious impairment, or death to Residents 1, 2, and 3. On 1/18/2024, at 3:34 pm, while onsite at the facility, an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified. The surveyor notified the Administrator (ADM) and the Director of Nursing (DON) regarding CNA 1 using trash bags to tie two utility/linen carts to the hallway side rail and the strike plate hole (part of a door lock) to RM 1's entrance/exit and left Residents 1, 2, and 3 involuntarily secluded in RM 1 without staff present. The IJ was called in the presence of the facility's ADM and DON. The ADM and DON were informed of the facility's failure to have a system in place to ensure Residents 1, 2, and 3 were free from involuntary seclusion that could result in serious harm that threatened the health and safety for Residents 1, 2, and 3. On 1/19/2024, at 9:30 am, while onsite at the facility, the surveyor reviewed the Plan of Action (POA, a list of steps taken to correct the deficient practices). The surveyor verified and confirmed the facility removed the IJ situation and implemented the POA through observation, interview, and record review. The surveyor removed the IJ on 1/19/2024 at 5:16 pm in the presence of the ADM, DON, and Nurse Consultant (NC). The IJ Removal Plan, dated 1/18/2024 included the following: 1. On 1/18/2024, staff immediately removed the utility carts that blocked Residents 1, 2, and 3 from leaving RM 1. 2. On 1/18/2024, the DON assessed Residents 1, 2, and 3. All three (3) residents were at their baseline condition without any signs or symptoms (S/S - observed or detectable signs, and experienced symptoms of an illness, injury, or condition) of distress. 3. On 1/18/2024, the psychiatrist evaluated Residents 1, 2, and 3 via telehealth and informed the facility that all three (3) residents did not experience any S/S of psychosocial distress. There were no new orders. 4. On 1/18/2024, the DON notified Residents 1, 2, and 3' s Medical Doctor (MD 1) regarding the involuntary seclusion with no new order. 5. On 1/18/2024, the DON notified the family members of Residents 1, 2, and 3 regarding the incident of involuntary seclusion. 6. On 1/18/2024, the ADM provided an in-service to CNA 1 regarding abuse prevention, including involuntary seclusion. 7. On 1/18/2024, CNA 1 was suspended, followed by further disciplinary action, including termination based on the determination/conclusion of the investigation. 8. On 1/18/2024, the ADM and DON notified the staff of the findings stated in the IJ template, dated 1/18/2024, and gave in-services regarding the abuse policy. During the in-services, the ADM and DON emphasized the importance of not confining any resident to a room or area against his/her will. 9. On 1/19/2024, the maintenance supervisor and the housekeeping supervisor stored all clean linens in the linen storage in different hallways and removed all the clean linen carts from the floor. Any linen carts required to be on the floor were placed against the wall, avoiding blocking the entrances, including all residents' rooms. 10. On 1/19/2024, the DON updated the plan of care for Resident 1 who had episodes of grabbing cups from other resident's rooms. The care plan included the interventions of storing extra clean cups inside Resident 1's room and encouraged Resident 1 to participate in group activities to keep Resident 1 occupied. (Cross reference F656) Findings: 1. During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia (serious mental illness in which people interpret reality abnormally), unspecified psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), and obsessive-compulsive personality disorder (a pervasive obsession with order, perfectionism, control, and specific ways of doing things). During a review of Resident 1's History and Physical (H&P), dated 2/19/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment and care screening tool), dated 11/17/2023, the MDS indicated Resident 1 had severely impaired cognition (ability to think, remember, and function). The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs but provides less than half the effort) with toileting hygiene, showering/bathing self, and personal hygiene. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity and may be provided throughout the activity or intermittently) with oral hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up while the resident completes the activity and helper assists only prior to or following the activity) with eating and required supervision or touching assistance with sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walking 10 feet. 2. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of schizophrenia, major depressive disorder (serious illness that negatively affects how one feels, thinks and acts), and anxiety disorder (persistent feeling of dread or panic that can interfere with daily life). During a review of Resident 2's untitled care plan, dated 5/2/2022, the care plan indicated Resident 2 had ineffective coping related to a past traumatic incident, manifested by uncontrollable mood swings causing anger and paranoid thoughts, thinking someone was coming after Resident 2, causing stress. Interventions included to build a trusting relationship during day-to-day activities, encourage group activities, and provide a safe environment and atmosphere of acceptance. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort) with showering/bathing self. The MDS indicated Resident 2 required partial/moderate assistance with toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 2 required supervision or touching assistance with oral hygiene. The MDS indicated Resident 2 required setup or clean up assistance with eating and required supervision or touching assistance with rolling left to right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, toilet transfers, walking 10 feet. 3. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, anxiety disorder, and major depressive disorder. During a review of Resident 3's H&P, dated 6/10/2023, the H&P indicated Resident 3 had the capacity to make decision for activities of daily living (ADL- the tasks of everyday life fundamental to caring for oneself). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderately impaired cognition. The MDS indicated Resident 3 required partial/moderate assistance with showering/bathing self. The MDS indicated Resident 3 required supervision or touching assistance with oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 3 required setup or clean-up assistance with eating. The MDS indicated Resident 3 required supervision or touching assistance with toilet transfers. The MDS indicated Resident 3 required setup or clean-up assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. During a concurrent observation and interview on 1/18/2024 at 9:50 am, while on a tour with the Social Services Director (SSD), two blue utility/linen carts were tied to the hallway siderail and the strike plate hole in front of RM 1's doorway. The SSD stated two utility carts were blocking RM 1's doorway. The SSD stated there was a clear trash bag that tied both utility carts together, a clear trash bag that tied the left utility cart to the inside of RM 1's strike plate hole, and a clear trash bag that tied the right utility cart to the right siderail in the hallway. The SSD stated the SSD was unclear why there were trash bags tying two utility carts in place to block RM 1's doorway. During a concurrent observation and interview on 1/18/2024 at 9:52 am, with CNA 1, in front of RM 1's doorway, there were two utility carts blocking the doorway. CNA 1 stated the utility carts were tied with clear trash bags. CNA 1 stated the Residents in RM 1 (Residents 1, 2, and 3) could not get out the room unless CNA 1 or another staff member (in general) untied the three trash bags and moved the two utility carts out of RM 1's doorway. CNA 1 stated the purpose of blocking RM 1's doorway was to block Resident 1 from coming out of RM 1 due to Resident 1's behavioral issues. CNA 1 stated Resident 1 stole other residents' (unidentified) cups and while walking, Resident 1 spilled water on the floor. During an interview on 1/18/2024 at 10:03 am, with Licensed Vocational Nurse (LVN) 1, in front of Resident 1's doorway, LVN 1 stated CNA 1 informed LVN 1 that CNA 1 barricaded (blocked) Resident 1's doorway with two utility carts and tied the carts with trash bags to keep Resident 1 in the room. LVN 1 stated, CNA 1 needed to keep Resident 1 in the room while housekeeping staff (in general) cleaned the floor because Resident 1 spilled liquid from Resident 1's cups all over the floor. LVN 1 stated blocking RM 1's doorway could lead to injury to Resident 1 in an emergency. During a concurrent observation and interview on 1/18/2024 at 10:11 am, with LVN 2, in front of RM 1's doorway, LVN 2 untied three, clear trash bags anchored to two utility carts in RM 1's doorway. LVN 2 stated Residents 1, 2, and 3 were in RM 1 at the time RM 1's doorway was blocked. LVN 2 stated Residents 2 and 3 were trapped inside RM 1 with Resident 1 and could not get out of the room. LVN 2 stated blocking Residents 1, 2, and 3 in their room was a type of abuse used for staff convenience. During an interview on 1/18/2024 at 10:18 am, Resident 2 stated Resident 2 did not know why staff blocked RM 1's doorway so Resident 2 could not get out of the room. Resident 2 stated Resident 2 did not like it when staff did that. Resident 2 stated staff were not nice, and it made Resident 2 feel terrible when staff blocked the doorway. Resident 2 stated Resident 2 wished staff would stop blocking the doorway because it did not make sense when he was trapped in the room with Resident 1. Resident 2 stated Resident 2 did not know how to ask for help when Resident 2 wanted to get out of the room or needed assistance. During an interview on 1/18/2024 at 11:38 am, with CNA 1, CNA 1 stated Resident 3 would yell and scream to be let out of the room to smoke cigarettes when the doorway was barricaded. During an interview with CNA 3 on 11/18/2024, at 11:56 am, CNA 3 stated CNA 1 barricaded Resident 1's doorway because housekeeping staff (in general) had to spend time cleaning up whatever Resident 1 dropped on the floor. CNA 3 stated this happened every day. CNA 3 stated when CNA 3 saw RM 1's doorway barricaded, CNA 3 untied the utility carts, but CNA 3 would get yelled at by other nursing staff (unable to identified). CNA 3 stated barricading Resident 1 inside RM 1 was abuse in the form of involuntary seclusion. CNA 3 stated Resident 3 liked to smoke cigarettes and when RM 1 was blocked by the utility/linen carts, Resident 3 could not go out to smoke. CNA 3 stated Resident 3 had to yell and scream until staff eventually let Resident 3 out of the room to smoke. During an interview on 1/18/2024 at 12:12 pm, with Resident 3, Resident 3 stated Resident 3 liked to smoke. Resident 3 stated it made Resident 3 really mad and upset because Resident 3 had to yell and scream to get someone to let Resident 3 out of RM 1 to smoke. Resident 3 stated it generally took over 15 minutes for staff to let Resident 3 out of the room. Resident 3 stated it felt like staff forget about everyone in RM 1. Resident 3 stated it was stupid Resident 3 had to ask for permission to leave the room and Resident 3 hated it. During an interview on 1/18/2024 at 12:31 pm, with the Infection Prevention Nurse (IPN), the IPN stated the IPN had put the utility carts in RM 1's doorway before, but never tied the carts with trash bags. The IPN stated this practice (blocking RM 1's doorway) was done by the IPN and other staff (unidentified) to diminish (reduce) Resident 1's traffic around the facility because Resident 1 walked around the facility with cups of water and spilled the water everywhere. The IPN stated the utility carts were generally put in RM 1's doorway in the morning when staff were busy. During a concurrent observation and interview on 1/18/2024 at 12:47 pm, with the DON and Admissions Director (AD), the facility's security footage of Camera Two was reviewed. The DON stated on 1/18/2024 at 8:29:14 am, Resident 1 went into RM 1. The DON stated on 1/18/2024 at 8:30:11 am, CNA 1 held a trash bag in CNA 1's hands. The DON stated on 1/18/2024 at 8:31:46 am, CNA 1 moved two utility carts into the doorway of RM 1. During a concurrent interview and record review on 1/18/2024 at 2:49 pm, with LVN 2, Residents 1, 2, and 3's AR were reviewed. Residents 1, 2, and 3 had diagnoses of schizophrenia and Residents 2 and 3 had anxiety. LVN 2 stated Residents 1, 2, and 3's schizophrenia could have been exacerbated from being barricaded in RM 1. LVN 2 stated Residents 2 and 3 could have anxiety attacks (intense feeling of dread, fear, or discomfort, with a feeling of losing control or that one's life is in danger when no threat is present) and pass out. LVN 2 stated staff would not know if a medical emergency (illness or injuries that need care right away) was happening in RM 1 because the residents (Residents 1, 2, and 3) were barricaded inside. During an interview on 1/16/2024 at 3:18 pm, with the DON, the DON stated the utility carts were supposed to be used for linens, towels, and blankets for the residents. The DON stated utility carts were to be stored in the hallways along the walls. The DON stated the utility carts were not supposed to be used to block RM 1's doorway and barricade Residents 1, 2, and 3 inside their room. The DON stated doing so was abuse in the form of involuntary seclusion. The DON stated Residents 1, 2, and 3 who were involuntarily secluded to their rooms were at risk for depression, anxiety, and negative behaviors. The DON stated Residents 1, 2, and 3 who had diagnoses such as schizophrenia, depression, and anxiety were at higher risk of having an exacerbation of their illness symptoms by being involuntarily secluded in their room. The DON stated Residents 1, 2, and 3 could become entangled by the barricade and become injured or die when Residents 1, 2, and 3 attempt to get out. During a review of the facility's policy and procedure (PP) titled, Involuntary Seclusion, undated, the PP indicated the goal was to ensure all residents would be free of involuntary seclusion. The PP indicated examples of involuntary seclusion included confining a resident to his or her room as form of punishment or for staff convenience, and any attempt to keep a resident confined to a certain area by blocking the exit with furniture or a closed door. The PP indicated secluding or confining a resident against his or her will was prohibited. During a review of the facility's PP titled, Resident Rights, revised 2/2021, the PP indicated employees shall treat all residents with kindness, respect, and dignity. The PP indicated residents had the right to be free from involuntary seclusion.

1. Based on observation, interview, and record review, the facility failed to provide care and services for one of two sampled residents (Resident 19), who had history of aspiration pneumonia (swelling and infection of the lungs caused when food or liquid is breathed into the airway or lungs instead of being swallowed), by failing to: Ensure Licensed Vocational Nurse 1 (LVN 1) transcribed (put into written or printed form) and followed Medical Doctor 1's (MD 1's) verbal order (spoken orders given by a physician to a person authorized to receive and record the orders in accordance with applicable policies, laws, and regulations) according to the facility's policy and procedure titled, Physician Orders and Telephone Orders. MD 1 gave LVN 1 a verbal order for Resident 19 to remain sitting upright for one to two hours after eating his meals (breakfast, lunch, and dinner) due to Resident 19 had a history of hospitalization s for sepsis (life-threatening complication of an infection) that resulted from aspiration pneumonia. Resident 19 required intubation (a breathing tube placed through the mouth, down the throat, and into the lungs), the use of a ventilator (a life support machine that moves breathable air in and out of the lungs when a person is unable to breath on his/her own), and admission to the Intensive Care Unit (ICU, a unit of a hospital that provides intensive treatment and close monitoring for seriously ill patients). These deficient practices had the potential to result in recurrent (occurring often or repeatedly) aspiration pneumonia, re-hospitalization (being hospitalized again), intubation, and death for Resident 19. On 3/9/2023, at 12:20 PM, during a recertification survey, the California Department of Public Health (CDPH) called 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) regarding the facility's failure to ensure Resident 19 remained sitting upright for one to two hours after meals, per MD 1's verbal order, in the presence of the Administrator (ADM) and the Director of Nursing (DON). The CDPH informed the ADM and the DON regarding the facility's deficient practice could cause recurrent aspiration pneumonia that could lead to serious harm to Resident 19's health. On 3/10/2023, at 1:05 PM, the facility's ADM submitted an acceptable Plan of Action (POA/IJ removal plan, a detailed plan to address the IJ findings) while onsite, the surveyors verified the implementations of the POA by observation, interview, and record review. The CDPH confirmed the removal of the IJ on 3/10/2023, at 2:37 PM while onsite, in the presence of the ADM and the DON. The acceptable IJ Removal Plan included the followings: A. On 3/9/2023 and 3/10/2023, the DON provided in services to all nurses (licensed nurses and certified nursing assistants) from all shifts regarding aspiration precautions (practices that help prevent food or fluid get into the airway/the passage by which air reaches the lungs). The in-services indicated for all nurses to keep Resident 19 sitting upright in the wheelchair during and after meals. B. On 3/9/2023, the DON called MD 1 and MD 1 ordered for Resident 19 to remain sitting upright in the wheelchair for 30 minutes after each meal. C. On 3/9/2023, the Speech Therapist (ST, also called a speech-language pathologist is a specialist who assesses, diagnoses, and treats people with communication and swallowing problems) completed a speech screening for Resident 19 who was on a puree diet (blended foods that do not need to chew, for people who have trouble chewing or swallowing). Resident 19 tolerated puree diet. D. On 3/9/2023, the DON and the Director of Staff Development (DSD) observed Resident 19 eating dinner while sitting upright in Resident 19's wheelchair and remained sitting upright for 30 minutes after dinner. Cross Reference F711 and F656. 2. Based on observation, interview, and record review, the he facility also failed to provide the necessary care and treatment for one of two sampled residents (Resident 28) in a total resident sample of 42 by failing to apply the Geri-sleeves (a breathable cotton-blend material that protects against skin tears caused by friction and shearing) to Resident 28 as ordered by the physician. This deficient practice had the potential to cause injury to Resident 28's skin. Findings: A review of Resident 19's Admission Record indicated Resident 19 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included, pneumonia (infection that swells the air sacs that might be filled with fluid or pus in one or both lungs), sepsis (a life-threatening medical emergency in which the body responds improperly to an infection,) respiratory failure (a serious condition that makes it difficult to breathe), and gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube [esophagus] connecting the mouth and stomach). A review of Resident 19's Change of Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive [ability to think and process information], behavioral, or functional domains) Assessment Form, dated 12/6/2022, indicated Resident 19 had shortness of breath (difficulty breathing), and trouble breathing when lying flat. The COC indicated at 11 AM, Resident 19 was sitting up in the wheelchair waiting for lunch. At 12:30 PM, Resident 19 was found breathing fast, looked pale with audible congestion (a sign that something blocks the airway), and rhonchi (low-pitched sounds usually indicating secretions [saliva or mucus] in the airway) in both lungs by auscultation (listening by using a stethoscope [an instrument that's used to hear the heart beats or breathings inside the chest]). The COC indicated the facility called 911 (phone number for emergency services) and the paramedics (a healthcare professional who responds to emergency calls for medical help outside of a hospital) transferred Resident 19 to the hospital. A review of Resident 19's General Acute Care Hospital 1 (GACH 1) Admission History and Physical Exam, dated 12/6/2022, indicated Resident 19 had shortness of breath, was tachypneic (breathing that is abnormally rapid and shallow) and required intubation. Resident 19 was admitted to GACH 1 for aspiration pneumonia. The GACH record indicated Resident 19 had acute (sudden) respiratory failure and depended on a respirator (depended on a mechanical ventilation/breathing machine to sustain respiration/breathing). A review of Resident 19's GACH 1 Multi-Discipline Progress Notes, dated 12/23/2022, indicated Resident 19 received a Modified Barium Swallow Study (MBSS, speech therapy evaluation with special X-ray [image study that takes pictures of the bones and soft tissues] to find the reason for difficulty swallowing) on 12/17/2022. The MBSS results indicated Resident 19 had moderate dysphagia (difficulty swallowing) characterized by poor base of the tongue retraction (action of drawing something back), and silent laryngeal aspiration (when the residents accidentally inhale food or liquid in the airway, and they do not know it) of thin and mildly thick liquids. The note indicated feeding precautions included for Resident 19 to sit entirely upright, and for staff (in general) to monitor Resident 19 for fever spike (sharp rises in body temperature) after meals, coughing, choking (severe difficulty in breathing because an object or food lodges in the throat or windpipe blocking the flow of air) or throat clearing during meals. A review of Resident 19's GACH 1 Discharge Summary, dated 12/24/2023, indicated Resident 1 had sepsis due to aspiration pneumonia, recurrent aspiration pneumonia, acute hypoxemic respiratory failure (low blood oxygen level resulting from sudden impairment of gas exchange between the lungs and the blood which may cause shortness of breath, anxiety [a feeling of worry], confusion, cardiac dysfunction [heart failure], and cardiac arrest [no heartbeat]), and respirator dependence. The discharge summary indicated for Resident 19 to have puree diet with moderately thickened liquid (liquid mixed with thickener to help prevent choking and stop fluid from entering the lungs for safer swallowing), and for staff (in general) to observe strict aspiration precautions during and immediately after meals. A review of Resident 19's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 2/22/2023, indicated Resident 19 had severe impaired cognition (ability to understand and process information). Resident 19 required extensive physical assistance (resident involved in activity, staff provide weight-bearing support) from one-person during bed mobility, transfers (moving a resident from one flat surface to another), eating and personal hygiene. A review of Resident 1's MD 1 Progress Notes, dated 1/4/2023, indicated Resident 19 needed oxygen and completed a seven-day course of Levaquin (medication that treats a wide range of infections) to treat the aspiration pneumonia. The note indicated strict aspiration precautions were to be followed given Resident 19's high-risk for re-aspiration. During an observation on 3/7/2023, at 9:32 AM, Resident 19 was lying flat on Resident 19's bed with his eyes closed. There was a printed signage (any kind of graphic display intended to convey information to an audience) above Resident 19's head of bed indicated, per MD 1, Please have resident up in wheelchair for meals and to remain sitting upright for 1-2 hrs. [hours]. During an observation on 3/7/2023, at 11:40 AM, Resident 19 was sitting up in wheelchair eating his lunch. Resident 19 had puree diet and thicken liquid on Resident 19's meal tray. During an observation and a concurrent interview with Resident 19 on 3/7/2023, at 12:19 PM, Resident 19 was lying in his bed flat. Resident 19 nodded his head when surveyor asked if he wanted to get up. During an interview on 3/7/2023 at 12:22 PM, LVN 2 stated she was aware of MD1's order for Resident 19 to remain sitting upright for one to two hours after meals due to the signage with instruction posted over Resident 19's head of bed. LVN 2 stated Resident 19 had GERD, and history of aspiration pneumonia. LVN 2 stated Resident 19 needed to be sitting upright after meals as aspiration precautions to prevent gastric secretions backflow (a flowing back or returning especially toward a source) to the airway. During a concurrent interview Certified Nursing Assistant 5 (CNA 5), CNA 5 stated she and another staff (unidentified) assisted Resident 19 back to bed after Resident 19 finished his lunch. CNA 5 stated she was aware of MD 1's instruction to have Resident 19 sitting upright in the wheelchair after meals. CNA 5 stated there were two signages with instructions to have Resident 19 up in wheelchair for meals and to remain sitting upright for 1-2 hrs. posted on the wall above Resident 19's head of bed, and at the back of Resident 19's door. During an interview, on 3/8/2023 at 1:33 PM, and a concurrent review of Resident 19's physician orders, care plans, and nurses progress notes, dated from 12/24/2022 to 3/6/2023, the DON stated the posted signages in Resident 19's room were to remind staff (in general) to keep Resident 19 sitting upright in the wheelchair for one to two hours after meals for aspiration precautions. The DON stated not following aspiration precautions could put Resident 19 on a ventilator again and or Resident 19 could die from choking. The DON reviewed Resident 19's physician orders and stated there was no written order for Resident 19 to sit upright in the wheelchair during and after meals. The DON continued to review Resident 19's care plan, nurses notes, and stated there was no documentation in the nurse's progress notes and no care plan interventions corelating with the aspiration precautions. The DON stated LVN 1 who received MD 1's instruction/verbal order needed to document MD 1's instruction/verbal order in Resident 19's progress notes. During a telephone interview on 3/9/2023 at 8:44 AM, MD 1 stated Resident 19 had a history of aspiration pneumonia which required hospitalization . MD 1 stated he gave a verbal order to LVN 1 during an onsite visit shortly after Resident 19 readmitted to the facility from the hospital. MD 1 stated he did not remember the date that he gave the verbal order. MD 1 stated the order was to have Resident 19 sitting upright in the wheelchair during meals and to remain sitting upright for one to two hours after meals. During an interview on 3/9/2023 at 9:12 AM, LVN 1 stated after Resident 19 was readmitted to the facility (on 12/24/2022), MD 1 told her to make sure to keep Resident 19 sitting upright in the wheelchair at least one to two hours after meals. LVN 1 stated she did not remember the date when MD 1 gave her the verbal order. LVN 1 stated she did not enter MD 1's verbal order in Resident 19's physician order summary. LVN 1 stated she did not document MD 1's verbal order in the nurse's notes and did not update Resident 19's care plan interventions for aspiration precautions. LVN 1 stated Resident 19 needed to remain sitting upright after meals due to Resident 19's history of GERD, aspiration pneumonia to prevent recurrent aspiration pneumonia, rehospitalization , sepsis, and death. During an interview on 3/9/2023, at 9:46 AM, the DON stated LVN 1 who received MD 1's verbal order needed to update Resident 19's care plan regarding aspiration precautions. A review of the facility's policy and procedure titled, Aspiration Precaution, undated, indicated Avoid lying down right after feeding. Remain sitting in a upright position for at least 20 to 30 minutes to prevent aspiration. A review of the facility's policy and procedure titled, Physician Orders and Telephone Orders, dated 1/2004, indicated All orders must be specific and complete with necessary details to carry out the prescribed order. The policy indicated All orders shall indicate how the order was received, the name of the prescriber, the name of the attending physician and the name of the nurse taking the order. 28074 2. A review of Resident 28's Admission Record indicated the facility admitted Resident 28 on 1/25/2023, with diagnoses that included fracture of the left femur (broken thighbone), dementia (decline in mental ability severe enough to interfere with daily life), and hypertension (high blood pressure). A review of Resident 28's Physician Order dated 1/25/2023, indicated for the staff to apply Geri-sleeves daily for safety and protection of fragile skin due to senile purpura (purplish spots appear on the arms and legs due to the thinness of the skin and frailty of the blood vessels). A review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/2/2023, indicated the resident rarely/never made herself understood, rarely/never understood others, and had severe impairment of cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 28 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from the staff for bed mobility transfer, locomotion on and off unit, and toilet use. The MDS indicated Resident 27 was at risk for developing skin injuries. A review of Resident 28's Care Plan dated 2/2/2023, indicated Resident 28 was at risk for skin discoloration, bruising secondary to fragile skin (thin skin that tears easily), aging process, and cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The care plan indicated for the staff to apply Geri-sleeves to bilateral upper extremities (BUE) due to senile purpura. During a concurrent observation and interview with Certified Nursing Assistant (CNA 3) on 3/7/2023 at 2:23 PM, Resident 28 was lying in bed without the Geri-sleeves on Resident 28's BUE. CNA 3 stated Resident 28 did not have Geri-sleeves when she received the resident in the morning. CNA 3 stated she was not aware that Resident 28 needed to wear Geri-sleeves. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 3/7/2023 at 2:23 PM, LVN 1 stated Geri-sleeves were used to protect the skin of residents with fragile skin. LVN 1 stated the staff needed to apply the Geri-sleeves on Resident 28 to protect the resident's skin. According to https://www.woundsinternational.com), consideration should be made within the healthcare setting for patients who are at risk of skin tears, in terms of minimizing the risk of potential trauma. This should include factors such as: 1. Avoiding friction and shearing - ensuring to use good manual handling techniques and using products such as hoists and glide sheets where required 2. Ensuring a generally safe environment - e.g. ensuring adequate lighting and removing any manual obstacles - particularly in patients who may have impaired vision or cognition issues 3. Encouraging use of protective clothing/devices where required, such as shin guards, long sleeves and/or tubular bandages/stockinette.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and history of falling, received care and services to prevent a fall (unintentionally coming to rest on a lower-level surface) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) redirected (changed direction or focus) Resident 1 to stay calm and remain by Resident 1's bedside when Resident 1 was confused (unable to think clearly), restless (inability to rest or relax), and tried to fight/hit CNA 1 on 1/17/2023 as indicated on Resident 1's care plan titled, Falling Star Program, and policies titled, Falling Star Program, Resident Care Plan, Dementia Care. 2. Ensure CNA 1 provided two-person physical assistance (help from two persons) during dressing (putting on and changing pajamas and housedresses) and personal hygiene (combing hair, brushing teeth, washing, and drying face and hands) for Resident 1 as indicated in Resident 1's care plan titled Protect our Patient (POP), and Resident 1's Minimum Data Set (MDS, a standardized comprehensive assessment and care screening tool). As a result, on 1/17/2023, at 12 pm, Resident 1 fell out of her bed, Resident 1 experienced severe left leg pain (pain that interferes with some or all activities of daily living), and a left hip fracture (complete or partial bone break). The facility transferred Resident 1 to General Acute Care Hospital 1's (GACH 1) Emergency Department (ED) via ambulance (911, phone number to call for emergency services). Resident 1 had a surgery on 1/19/2023 to repair the left hip fracture. Cross reference F689 and F656. Findings: A review of Resident 1's Admission Record indicated the facility originally admitted Resident 1 on 9/28/2017 and readmitted the resident to the facility on [DATE]. Resident 1's medical diagnoses included history of falling with a displaced fracture (a fracture with the end of the bone has come out of alignment) of the neck of the left femur (thigh bone), osteoporosis (condition where bones become weak and brittle), and dementia. A review of Resident 1's care plan titled, Falling Star Program, revised on 6/23/2022, indicated Resident 1 was at risk for falls and injuries secondary to cognitive (ability to understand and process information) impairment, poor safety awareness, a history of falls, balance deficit (loss/absence), and impaired mobility (ability to move freely). The goal was for Resident 1 to have no falls or injuries. The nursing interventions included to observe Resident 1 for restlessness and redirect the resident as needed/indicated. A review of Resident 1's untitled Care Plan, revised on 6/23/2022, indicated Resident 1 had self-care deficits related to cognitive deficits and poor safety awareness. The goal was for Resident 1 to be clean, and well-groomed daily. The nursing interventions included to assist Resident 1 with activities of daily living (ADLs, activities related to personal care such dressing, eating and personal hygiene), and if the resident resisted (avoid/repel) care, nursing staff (in general) should try to provide care again later or have another staff approach the resident. A review of Resident 1's care plan titled, Protect our Patient/POP, revised on 6/23/2022, indicated the goal was to prevent Resident 1 from sustaining bone fractures. The nursing interventions included for staff (in general) to provide Resident 1 with assistance from two persons during bed mobility, transfers, and ADL care. A review of Resident 1's History and Physical (H&P), dated 7/19/2022, indicated Resident 1 did not have the capacity to make decisions due to dementia. A review of Resident 1's MDS, dated [DATE], indicated Resident 1 had severe impaired cognition (when a person has very hard time remembering things, making decisions, concentrating, or learning). The MDS indicated Resident 1 required extensive physical assistance (resident involved in activity, staff provide weight bearing support) from two-persons with dressing and personal hygiene. A review of Resident 1's Fall Risk Assessment, dated 12/2/2022, indicated Resident 1 was assessed at high risk for falls due to Resident 1 being disoriented (lost sense of direction), unable to stand without assistance, had unsteady gait, and poor sitting or standing balance. Resident 1 scored 18 on the fall risk assessment (a score of 18 or more represents high risk for fall). The assessment indicated to initiate a falling star program and implement useful interventions to reduce falls and injuries for Resident 1. A review of Resident 1's Change of Condition (COC, a sudden clinically important deviation from the resident's baseline in physical, cognitive, behavioral, or functional domains) Note, dated 1/17/2023, at 12:04 pm, indicated at 7 am, Resident 1 was confused and disoriented, and at 12 pm, Resident 1 fell from the resident's bed. Licensed Vocational Nurse (LVN) 1 heard Resident 1 yells and went into Resident 1's room. The note indicated Resident 1 showed signs of pain (level not rated) with grimacing, crying out, and guarding of the left leg. A review of Resident 1's Licensed Nurse Note, dated 1/17/2023, indicated CNA 1 tried to get Resident 1 up for lunch, then CNA 1 left Resident 1's bedside to get clean linen. The note indicated CNA 1 returned a few seconds later and saw Resident 1 lost balance and fell on to the residents' knees. The note indicated CNA 1 ran over to Resident 1 and called for help. LVN 1 went into Resident 1's room and found Resident 1 on her knees, continued to strike out, hit, spit, and cursed at CNA 1. LVN 1 and CNA 1 attempted to lift Resident 1 off the floor but Resident 1 cried out in pain (level not listed) and guarded her left leg. The note indicated Resident 1's physician (MD 1, Medical Doctor) ordered STAT (urgent or rush) X-rays (a photographic or digital image of the inside of the body) of the left hip, femur, tibia (shin bone), and fibula (calf bone) due to pain. The note indicated at 2:35 pm, the X-ray results showed Resident 1 sustained a left hip fracture. MD 1 ordered to transfer Resident 1 to GACH 1's ED. A review of Resident 1's GACH 1 H&P, dated 1/18/2023, at 3:20 pm, indicated Resident 1 had a fall and sustained a left hip fracture. The H&P indicated Resident 1 complained of bilateral (both) hip and left leg pain (level not rated). A review of Resident 1's GACH 1 X-Rays Report, dated 1/18/2023, timed 6:46 pm, indicated Resident 1 had an acute (sudden) left intertrochanteric (bony protrusions of the thighbone) hip fracture. A review of Resident 1's GACH 1 Progress Note, dated 1/22/2023, indicated Resident 1 had a hip surgery on 1/19/2023. A review of Resident 1's GACH 1 Progress Note, dated 1/25/2023, indicated Resident 1 had an intramedullary nailing (IM nailing, a surgery done to repair a broken bone) of left intertrochanteric hip fracture. During an observation of Resident 1 in Resident 1's room on 2/7/2023, at 11:57 am, Resident 1 was lying in bed awake. Resident 1 had an abductor pillow (a foam pillow placed between the thighs and strapped onto the resident's leg to keep the leg stable and prevent pain or further injury after a hip surgery) between Resident 1's legs and the resident was not able to move her legs. During an interview on 2/7/2023, at 12:12 pm, CNA 1 stated Resident 1 did not like when staff (in general) changed the resident's clothes or incontinent pads. CNA 1 stated Resident 1 fought/hit (violent struggle involving the exchange of physical blows) staff when staff changed Resident 1's clothes or incontinent pads. CNA 1 stated, Resident 1 bit, kicked, and said bad words when staff provided ADL care to the resident. CNA 1 stated, Resident 1 was confused and would try to roll out of the resident's bed. CNA 1 stated Resident 1's behavior was the reason nursing staff had to keep their eyes on Resident 1 and monitor Resident 1 closely. CNA 1 stated, she (CNA 1) had to kneel on the floor mat when changing Resident 1's clothes and incontinent pads because Resident 1 would get combative (ready or eager to fight) during care. CNA 1 stated Resident 1 was a fighter. CNA 1 stated on the day that Resident 1 fell (1/17/2023), she (CNA 1) attempted to change Resident 1's incontinent pad. CNA 1 stated she removed Resident 1's gown but Resident 1 got combative and hit CNA 1. CNA 1 stated she left Resident 1's bedside, walked out of Resident 1's room to get clean linen from the linen cart that was located outside of Resident 1's room. CNA 1 stated as she got the linen, she heard a noise, turned around, and saw Resident 1 lying on the floor. During an interview on 2/7/2023, at 1:17 pm, CNA 1 stated on 1/17/2023, when she removed Resident 1's gown, Resident 1 fought/hit CNA 1. CNA 1 stated Resident 1 did not have a POP sign (a sign to remind staff to provide two-person physical assistance) on the wall by the resident's bed. CNA 1 stated she was not aware that Resident 1 required assistance from two-persons during ADL care. CNA 1 stated she knew how to change Resident 1 by herself. During an interview on 2/7/2023, at 1:34 pm, the Director of Nursing (DON) stated the POP program was for residents (in general) who required assistance from two persons during ADL care. The DON stated residents who had diagnosis of osteoporosis or were combative during care would be placed on the POP program. The DON stated Resident 1 was on the POP program and the resident had a POP sign posted on the wall above Resident 1's bed. During an interview with the Director of Staff Development (DSD) on 2/7/2023, at 1:48 pm, and a concurrent review of the POP sign, the DSD stated, POP meant Protect our Patients from Pathological (caused by the nature of a physical or mental disease) Fractures. The POP sign indicated to provide two-person physical assistance, gentle handling of the residents, and following the residents' plan of care. During an observation of Resident 1's room on 2/7/2023, at 1:53 pm, and a concurrent interview with the DON, there was no POP sign posted on Resident 1's wall. The DON stated Resident 1 probably had a room change, that was why the POP sign was not posted on the wall inside Resident 1's room. During an interview on 2/7/2023, at 2:01 pm, CNA 2 stated Resident 1 was in the POP program before the resident's fall (1/17/2023). CNA 2 stated Resident 1 did not have a POP sign posted on Resident 1's bedroom wall on 1/17/2023. CNA 2 stated the POP sign indicated Resident 1 required assistance from two-persons during ADL care. CNA 2 stated Resident 1 did not have the POP sign posted on Resident 1's wall, and nursing staff (in general) could miss Resident 1 required assistance from two-persons during ADL care. During an interview on 2/7/2023, at 2:06 pm, LVN 2 stated Resident 1's ADL care should be provided by two-persons due to Resident 1's combative behavior during ADL care. During an interview on 2/7/2023, at 2:32 pm, the DON stated the POP program was an intervention in Resident 1's POP Care Plan. The DON stated it was important to have the POP sign in Resident 1's room for nursing staff (in general) to know Resident 1 required two-person assistance during ADL care. The DON stated Resident 1 was assessed as being high risk for falls, pathological fractures due to osteoporosis, and the resident needed the assistance from two-persons during ADL care. The DON stated nursing staff (in general) needed to follow Resident 1's plan of care. A review of the facility's undated policy and procedure titled, Dementia Care, indicated the facility would develop and implement person-centered care plans with useful interventions to include and support the care needed identified in the comprehensive assessment for residents with dementia. A review of the facility's undated policy and procedure titled, The Resident Care Plan, indicated the residents' care plan shall be implemented for each resident on admission and developed throughout the assessment process. The policy indicated the care plan included facility's staff responsible to implement nursing interventions to meet the resident's care plan goals. A review of the facility's undated policy and procedure titled, Falling Star Program, indicated facility's staff would utilize the residents' Fall Risk Assessment form and provide appropriate nursing interventions to the residents. A review of the facility's undated POP sign, indicated to protect the residents from pathological fractures by: 1. Providing physical assistance from two persons to the residents. 2. Handle the residents gently. 3. Follow the residents' plan of care.