Every finding on record at Santa Monica Rehabilitation Center

Based on observation, interview, and record review the facility failed to ensure staff are wearing proper identification (ID) according to their policy. This deficient practice may cause Residents to feel unsafe and unfamiliar with new or visiting staff members.A review of the facility in-service lesson plan titled, Proper Badging/Identification dated 8/11/2026 indicated staff will always demonstrate proper use and display of identification badges while on duty to ensure proper identification, professionalism, safety and compliance with facility policy. The in-service sign in sheet does not include the signatures of the certified nursing assistant (CNA) nor the Registered Nurse (RN). During a concurrent observation and interview on 8/31/2026 at 2:05pm with the CNA in the hallway near the laundry room. The CNA was not wearing an ID badge. The CNA stated, I'm from the registry and I picked up the shift late. I did not have time to print out a badge. Today is my first day here. No one asked me to wear an ID badge, nor did they offer an ID badge. During a concurrent observation and interview on 8/31/2026 at 2:13pm with the RN in the surveyor office. The RN was wearing a badge with a handwritten name in marker and no picture. The RN stated, I have been working here since April 2026. The RN stated the ID badge machine was broken but thinks it may be working now. The RN stated, I just haven't gone back to the director of staff development (DSD) to get a badge. The RN stated no one has asked the RN to follow up and get the ID badge. During a telephone interview on 9/1/2026 at 11:06 am with the Director of Staff Development (DSD). The DSD stated, All staff should have ID badges, we had temporary badges because the machine was broken. We are still providing temporary badges with no picture. It is important for staff to wear ID badges for safety. Registry staff should be given a badge when they arrive. A review of the facility policy and procedure titled, Identification Name Badges reviewed 1/29/2026 indicated, In order to promote safety ai1d security measures established by our facility, each employee must wear his/her identification name badge at all times while on duty.Policy Interpretation and ImplementationAll personnel are required to wear identification name tags or badges during their work shift.2. An identification name tag or badge must be clearly visible and contain a picture of the employee (optional), the employee's first name initial, last name and job title (i.e., J. Doe, RN; S. Day, Activity Director, etc.).3. The Personnel/Human Resources Director, or designee, will be responsible for preparing the employee's identification tag or badge. Department directors or supervisors will issue a newly hired or reassigned employee his/her identification tag or badge upon reporting for work.4. Employees will be responsible for maintaining their identification tags or badges and wearing them to work. Employees who chronically lose or forget their identification tags or badges may be subject to disciplinary action. (Note: Chronically losing or forgetting an identification tag or badge is defined as three (3) or more times during a pay period.)5. Employees must report lost identification tags or badges to their supervisors so that replacement tags/badges can be issued.6. The facility will provide the initial identification name tag or badge at no cost to the employee. However, the employee will be required to pay for lost identification name tags or badges.7. Payment for a replacement tag or badge may be made to the Personnel/Human Resources Director. at the time of reissue, or payment may be deducted from the employee's paycheck, whichever the employee chooses.

Based on observation, interview, and record review the facility failed to hire a qualified social worker (SW). This deficient practice places residents at risk of social needs not being met.On 8/17/2026 The California Department of Public Health (CDPH) received a complaint alleging the facility hired the former receptionist with no previous experience to assume the role of the social worker. A review of the SW employment application dated 11/7/2025 indicated the following:-The SW's desired position was receptionist.-The SW has a Bachelor of Arts degree but does not specify which field of study.-The SW worked as marketing support and graphic design (using visual art and design tools to build the material that promotes a business, product or service) from 6/2015 to 8/2019.-The SW worked as a specimen processor (worker who receives, sorts, labels and prepares biological samples like blood, urine and tissue for laboratory testing) for a lab company from 6/2021 to 8/2022.-The SW worked as an operations associate (helps an organization run smoothly by supporting daily business tasks) from 9/2024 to 7/2025. A review of the document entitled, Social Worker dated 8/10/2026 indicated a signature from the SW with a shift assignment from 8:00am to 5:00pm. It further indicates requirements for the desired position of social worker to include the following: High School diploma or GED. Bachelor's in social work or human services from an accredited school or college, certified, licensed or registered in the state of practice required. During an interview with the Administrator (Adm) on 8/31/2026 at 3:00pm. The Adm stated the facility is licensed for 144 beds and should have a qualified social worker. The Adm stated the SW has a bachelor's degree but was not sure what field of study. The Adm stated the social worker is not currently licensed nor certified but is going through corporate online training to become the social worker. On 8/31/2026 at 3:39pm Attempted to reach the SW via telephone with no response.On 9/1/2026 at 12:00pm The Director of Medical Records (DMR) confirmed there was no copy of The SW Bachelor's degree on file. On 9/1/2026 at 2:00pm a second attempt was made to reach the social worker via telephone with no response. A review of the Social Worker job description indicates the following: REQUIREMENTS Education / Licensure High school diploma or GED Bachelor's in social work or human services from an accredited school or college Certified, licensed, or registered in the state of practice required Qualifications / Experience Experience at a skilled nursing facility

Based on observation, interview, and record review the facility failed to follow up timely on a grievance filed for lost dental partial (removable dental appliance that replaces one or more missing teeth while you still have some natural teeth left). per policy for one of three sampled residents, (Resident 1). This deficient practice places Resident 1 at nutritional risk due to inability to eat without dental partial. A review of Resident 1's admission record indicated the facility originally admitted this [AGE] year-old female on 11/01/2021 and most recently on 3/1/2026 with diagnoses including metabolic encephalopathy (chemical imbalance in the blood), urinary tract infection (UTI- an infection in the bladder/urinary tract), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), morbid obesity (overweight), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the knee, anemia (a condition where the body does not have enough healthy red blood cells), depression (low mood), hyperlipidemia (high fat in the blood), hypertension (high blood pressure), glaucoma (long term eye condition), dementia (a progressive state of decline in mental abilities) and anxiety(feelings of worry or fear). A review of Resident 1's physician order dated 5/19/2026 indicated heart healthy diet, soft and bite sized texture, soup or salad with each meal. A review of Resident 1's Minimum Data Set (MDS-resident assessment) dated 8/21/2026, indicated Resident 1's cognition (mental ability to make decisions for daily living) was not intact. The MDS indicated Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. Resident 1 had no swallowing disorder however was on a mechanically altered diet (require change in texture of food or liquids). On 8/17/2026 The California Department of Public Health (CDPH) received a complaint alleging the social worker does not follow up on grievances. A review of Resident 1's Nursing Progress Note dated 8/17/2026 indicated the family member (FM) complained about missing dentures and the SW was notified. During a concurrent observation and interview on 8/31/2026 at 11:38am with the FM standing at the door to the social worker office. The door was closed and the Surveyor knocked on door, however no answer. The FM stated, I am looking for the social worker, Resident's 1 top dental partial has been missing for three weeks now, they were supposed to look for it, but no one has gotten back to me about it. We brought Resident 1 soup today, but she cannot eat and she feels depressed. During a concurrent observation and interview on 8/31/2026 at 11:41am with Resident 1 and the FM on the patio. Resident 1 was sitting in the wheelchair at the table. Two large teeth in the right upper mouth and multiple broken and missing teeth on the top and bottom. The FM stated Resident 1 feels angry and wants the partial. During an interview on 8/31/2026 at 1:34pm with the Director of Medical Records (DMR). The DMR confirmed there was no belonging list on file and no theft loss form found regarding the partial denture for Resident 1. During an interview on 8/31/2026 at 3:00 pm with the administrator (Adm). The Adm stated the grievance process is as follows: Anyone can file a grievance form and once it is completed the form is brought to the Adm and the respective departments, then we address it as soon as possible. The Adm could not give a time frame in which the grievance should be completed stating, I would have to review the policy. Lastly, The Adm stated, I am not aware of any missing items for Resident 1. During a telephone interview on 9/1/2026 at 11:00am. The Adm called surveyor to inform the SW was out sick again today. A review of the facility policy and procedure titled, Grievance/Complaints reviewed 1/16/2025 indicated: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances ( e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.Policy Interpretation and Implementation 1 . Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished.2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal.3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response.4. Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedure is posted on the resident bulletin board.5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously.6. The contact information for the individual(s) with whom a grievance may be filed is provided to the resident and/or representative upon admission.7. The Administrator has delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is ___________________ and can be contacted by8. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint.9. The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law.10. The Grievance Officer, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated.11. The Administrator will review the findings with Grievance Officer to determine what correctiveactions, if any, need to be taken.12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.a. The Administrator, or his or her designee, will make such reports orally within __ working days of the filing of the grievance or complaint with the facility.b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office.13. If the grievance was filed anonymously, the Grievance Officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance(s) and report the findings. The Grievance Officer will reiterate to the resident that it is against facility policy and federal regulations to discriminate or sanction a resident who has filed or verbalized a complaint against the facility, and that his or her rights to be free of discrimination or reprisal will be protected.14. The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.15. This policy will be provided to the resident or the resident's representative upon request.

Based on interview and record review, the facility failed to ensure that the resident rights to be informed regarding informed consent (provider explaining a treatment's risks, benefits, and alternatives so a patient can freely agree to or refuse care) for psychotropic (any substance or medication that changes how the brain works, affecting a person's mood, thoughts, feelings, behavior, or perception) medication was adhered to for one of one sampled residents (Resident 1) according to according to the facility's policy and procedures (P&P) titled Informed Consent for Psychotropic Drugs -Pharmacy services dated 1/29/2026. This deficient practice resulted in the violation of Resident 1's rights to be informed and make decisions about psychotropic medication.Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 7/3/2026 with diagnoses including dysphagia (difficulty swallowing), depression (a medical brain condition that causes deep sadness, low energy, and a loss of joy that lasts for weeks or more), and encephalopathy (when a person has trouble thinking clearly). A review of Resident 1's skilled Nursing facility orders dated 7/3/2026 at 9:54 A.M., indicated .bipolar disorder (very large and intense shifts in their mood, energy, and activity levels) A review of Resident 1's history and physical (H&P - a doctor's complete health check) dated 7/4/2026, indicated . has fluctuating capacity (a person's ability to make sound decisions changes over time) to understand and make decisions. A review of Resident 1's physician order dated 7/4/2026 indicated Resident 1 to receive Bupropion (medication mainly used to treat depression) tablet 100 milligram (mg -unit of measure for weight), give 1 tablet via gastrostomy tube (g-tube) two times a day for depression . A review of Resident 1's psychotherapeutic (treating mental health) drug informed consent dated 7/4/2026 indicated Bupropion 10omg .Resident/Resident's representative signature line was blank/not signed . A review of Resident 1's psychotherapeutic drug informed consent dated 7/4/2026 indicated Diazepam 5mg .Resident/Resident's representative signature line blank/not signed . A review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 7/10/2026, indicated Resident 1 has severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 was dependent on staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. A review of Resident 1's physician order dated 7/21/2026 indicated Resident 1 to receive Zyprexa (medication used to treat serious mental health conditions) oral tablet 10 mg give 1 tablet via g-tube two times a day for bipolar disorder . A review of Resident 1's psychotherapeutic drug informed consent dated 7/21/2026 indicated Zyprexa 10mg .Resident/Resident's representative signature line with a scribble on the line. A review of Resident 1's physician order dated 7/25/2026 indicated Resident 1 to receive Diazepam (medication used to calm the brain) 5 mg give 1 tablet via g-tube every 6 hours as needed for anxiety for 14 days manifested by restlessness, screaming and yelling for no apparent reason. During a concurrent interview and record review, on 7/29/2026, at 10:16 A.M., with the Director of Nursing (DON), Resident 1's medical record was reviewed. The DON stated that an informed consent is a verification that the physician has informed the resident and/or representative that a certain medication will be given including alternate treatments/side effects of the medication which is done at the time of admission or at the start of a medication that requires an informed consent. The DON stated that if a resident is admitted to the facility on a psychotropic medication, the facility obtains the facility's own informed consent from the residents regarding that specific medication. The DON stated that the informed consent is signed by the physician, resident or the resident's representative if the resident does not have the capacity. The DON stated that Resident 1 has a physician order for psychotropic medications Zyprexa, informed consent was signed by the resident, Buspirone and diazepam consents signature line was left blank which means it was neither signed for by the resident or their representative. The DON stated that a brief interview for mental states (BIM) score of 6 means the resident is severely cognitively impaired. The DON stated that a resident with fluctuating capacity and a severe cognitive impairment is unable to sign for an informed consent because they have impaired cognition. A review of the facility's P&P, titled Informed Consent for Psychotropic Drugs -Pharmacy services dated 1/29/2026, indicated,PurposeThis policy ensures compliance with federal Centers for Medicare & Medicaid Services (CMS) regulations (e.g., 42 CFR S483.45(e), F605 -Chemical Restraints and Unnecessary Psychotropic Medications; F757 - Unnecessary Drugs; F758 -PRN Psychotropic Medications; F552 -Resident Rights to be Informed)regarding informed consent for psychotropic drugs. It outlines responsibilities for obtaining, verifying,and documenting informed consent to protect resident rights, promote safety, and facilitate appropriate use of these medications for residents with behavioral or psychotic symptoms, such as those associated with dementia. Facilities must also comply with any additional state-specific requirements.ScopeThis policy applies to all residents in Medicare-and/or Medicaid-certified skilled nursing facilities (SNFs) prescribed psychotropic drugs, including new initiations, dose increases, or changes. It covers allpsychotropic drugs as defined by CMS. It does not apply to emergency situations where immediateaction is needed, though post-emergency consent and documentation are required. Definitions . Informed Consent: Disclosure of material information (e.g., reasons for use, benefits, risksincluding black box warnings, alternatives including non pharmacological approaches) to theresident or their representative/surrogate, allowing them to accept, refuse, or revoke consent.Consent must be obtained prior to initiation or increase. Representative/Surrogate: A legally authorized decision-maker, such as a guardian, durable power of attorney for health care, or other surrogate identified per state law if the resident lacks decision-making capacity.Responsibilities. Obtain informed consent for all psychotropic medications prior to initiation or dose increase. Discuss material information with the resident/representative in a language they understand. For residents lacking capacity without a representative: Follow state-specific procedures forsurrogate decision-making or unbefriended residents (e.g., ethics committee, court appointment) . Facility role Verify (but not obtain) informed consent; ensure documentation in the medical record. Maintain written policies/procedures on consent processes, documentation methods, andidentifying surrogates for residents lacking capacity.

Based on observation and interview, the facility failed to ensure that the resident was cared for in a manner that promoted and enhanced the wellbeing, feeling of self-worth and self-esteem for one of one sampled resident (Resident 2) according to the facility's policy and procedures (P&P) tiled Dignity, revised 1/29/2026. This deficient practice resulted in Resident 2 not being cared for in a manner that promoted and enhanced her wellbeing and feeling of self-worth.Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 7/3/2025 and readmitted Resident 2 on 7/3/2026 with diagnoses including hypotension (low blood pressure), major depressive disorder (deep, ongoing feeling of sadness, hopelessness, and a loss of interest in daily activities), and vascular dementia (blocked blood vessels [flexible tube or pipeline that carries blood through your body] or tiny strokes [part of the brain loses its blood supply] in the brain). A review of Resident 2's Minimum Data Set (MDS - resident assessment tool) dated 6/21/2026, indicated Resident 2 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 2 required setup/clean up to dependence on assistance from staff with Activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care. During an observation on 7/29/2026, at 8:05 A.M., in Resident 2's room, Certified Nursing Assistant (CNA) 1 was seen standing over Resident 2 while assisting her with eating her breakfast. During an interview on 7/29/2026, at 8:07 A.M., with CNA 1, CNA 1 stated that when assisting residents with eating, to provide dignity, she needs to make sure the resident swallows her food, have the resident's head of bed high, make sure that the resident is comfortable and provide the resident with privacy. During an interview on 7/29/2026, at 10:01 A.M., with the Director of Nursing (DON), the DON stated that facility staff expectation when assisting resident with eating is that staff should be sitting down at eye level with the resident not standing, for dignity and respect for the resident. A review of the Facility P&P titled Dignity, revised 1/29/2026 indicated,Policy StatementEach resident shall be cared for in a manner that promotes and enhances his or her sense of well being, level of satisfaction with life, and feelings of self-worth and self-esteem.1.Residents are treated with dignity and respect at all times.2. The facility 'culture supports dignity and respect for 'residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission andcontinues throughout the resident's facility stay.3. Individual needs and preferences. of the resident are identified through the assessmentprocess.e. provided with a dignified dining experience.

Based on observation, and interview, the facility failed to ensure that guidelines for the use if a pump for enteral feeding were adhered to according to the facility's policy and procedure (P&P) titled Enteral Tube Feeding Via Continuous Pump, dated 1/21/2026 for one of one sampled resident (Resident 1) when, tube enteral feeding formular was hang without a date or rate, enteral feed free water was hang without a label and tube feeding formula was not labeled. This deficient practice had the potential to cause infection and/or possible hospitalization.Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 7/3/2026 with diagnoses including dysphagia (difficulty swallowing), depression (a medical brain condition that causes deep sadness, low energy, and a loss of joy that lasts for weeks or more), and encephalopathy (when a person has trouble thinking clearly). A review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 7/10/2026, indicated Resident 1 has severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 was dependent on staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. A review of Resident 1's physician order dated 7/14/2026 indicated Resident 1 to receive enteral feed order every shift . lsosource 1.5 (nutritional formula) via g-tube for a total of 1 000 cubic centimeter (cc -unit of measure in volume) per1500 calories (kcal -unit of measure for energy) at rate of 50cc per hour (hr) for 20hrs or until dose met. During an observation on 7/29/2026, at 8:02 A.M., in Resident 1's room, the tube feeding formular lsosource 1.5 was connected to resident 1 and running at 50cc/hr via a tube feeding tube that was not labelled, free water bag did not have a label on it and the label on the formular did not have a date or rate on it. During a concurrent observation and interview on 7/29/2026, at 8:56 A.M., with Licensed Vocation Nurse (LVN) 1 in Resident 1's room, the tube feeding formular was connected to Resident 1 and running at 50cc/hr via a tube feeding tube that was not labelled, free water bag did not have a label on it and the label on the formular did not have a date or rate on it. LVN 1 stated that the tube feeding formular bag, water bag should have a label with the resident's name, date, time, formular and rate, and the tube feeding tube needed to be labeled with the date and time to prevent infection. LVN 1 stated that Resident 1's formular label was missing the date and rate, the water bag and the tube feeding tube did not have labels on them for infection control. During an interview, on 7/29/2026, at 10:16 A.M., with the Director of Nursing (DON), the DON stated that tube feeding formular, water bag and tube feeding tube need to have a label on them which includes the date name, initials, date, time for infection prevention and for nurses to know when they need to be changed. A review of the facility's P&P, titled Enteral Tube Feeding Via Continuous Pump dated 1/21/2026, indicated,PurposeThe purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings.General guidelines .3. Check the enteral nutrition label against the order before administration. Check the following information:a. Resident name, ID and room number;b. Type of formula;c. Date and time formula was prepared;d. Route of delivery;e. Access site;f. Method (pump, gravity, syringe); andg. Rate of administration (mL/hour). Steps in the procedure .5. Check the label on the enteral formula against the physician order.

Based on interview and record review, the facility failed to ensure nursing staff met the specific competency requirement of their respective licensure and certification for one of two sampled staff (Certified Nursing assistant [CNA] 1) according to the facility's policy and procedures (P&P) tiled Competency of Nursing Staff, revised 1/29/2026. This deficient practice had the potential to negatively impact on the safety and wellbeing of the residents in the facility.Findings: During an observation on 7/29/2026, at 8:05 A.M., in Resident 2's room, CNA 1 was seen standing over Resident 2 while assisting her with eating her breakfast. During an interview on 7/29/2026, at 8:07 A.M., with CNA 1, CNA 1 stated that when assisting residents with eating, to provide dignity, she needs to make sure the resident swallows her food, have the resident's head of bed high, make sure that the resident is comfortable and provide the resident with privacy. During an interview on 7/29/2026, at 8:40 A.M., with Registered Nurse Supervisor (RNS ) 1, RNS 1 stated that when assisting residents with eating, to provide them with dignity, facility staff needed to keep an eye level with the resident by making sure the bed is the same height as the staff feeding the resident and make sure that the staff can reach the food without leaning over. During an interview on 7/29/2026, at 10:01 A.M., with the Director of Nursing (DON), the DON stated that facility staff expectation when assisting resident with eating is that staff should be sitting down at eye level with the resident not standing, for dignity and respect for the resident. A review of the facility's (P&P) tiled Competency of Nursing Staff, revised 1/29/2026 indicatedPolicy statementAll nursing staff must meet specific competency requirements of their respective licensure and certification requirements defined by State law.In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: .b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents . A review of the Facility P&P titled Dignity, revised 1/29/2026 indicated that,Policy StatementEach resident shall be cared for in a manner that promotes and enhances his or her sense of well being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1.Residents are treated with dignity and respect at all times.2. The facility 'culture supports dignity and respect for 'residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission andcontinues throughout the resident's facility stay.3. Individual needs and preferences. of the resident are identified through the assessmentprocess.e. provided with a dignified dining experience.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure that the facility was free of pests (cockroaches). This deficient practice had the potential to place all 144 residents residing in the facility at risk of vector-borne diseases (Illness that results from infections transmitted to humans by insects, such as cockroaches) and infectious diseases transmitted by pests (cockroaches). During a review of Resident 2's admission record indicated that Resident 2 was admitted on [DATE] with diagnoses including cerebral infarction (when a blood vessel to the brain is blocked stopping blood and oxygen from reaching the brain resulting in brain cell death), generalized anxiety disorder (a mental health condition marked by excessive worry, constant tension, and feeling restless), and hypertension (HTN-high blood pressure). During a review of Resident 2's History and Physical (H&P - when a physician assesses and interviews a patient then documents findings) dated 6/22/2026 indicated Resident 2 lacked capacity to make medical decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2026, the MDS indicated Resident 2 had severe cognitive impairments (a major loss of brain function where a person is unable to remember well, think clearly, or make safe choices and loses the ability to live on their own and need full-time help with daily tasks). The MDS indicated Resident 2 was dependent on staff for all Activities of Daily Living (ADLs such as eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, sit to stand, toilet transfer, sit to lying, sit to stand, toilet transfer, tub shower transfer, walk 10 feet, and personal hygiene). During a concurrent observation of Resident 2's room and interview of Family Member (FM) 1 on 7/21/2026 at 12:10 pm, FM 1 stated that she (FM 1) came in to visit Resident 2 at least every other day and that she (FM 1) had observed roaches almost every time which were mostly observed along the Resident 2's wall which separated his room from the unit hallway. FM 1 stated that she had notified multiple facility staff and administration including the Director of Nursing (DON) and was told that they would spray but felt that they had not. During the observation of Resident 2's room which included behind the nightstand, FM 1 removed some items that were on the nightstand on the bed while stating that Resident 2 refused to drink the water from the facility because he (Resident 2) thought that roaches had crawled all over it. Resident was then heard shouting, look! Look!, look!, look! while pointing to a yellow blanket which was wrapped in a plastic covering. A cockroach was observed crawling over the plastic covering. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 1 on 7/21/2026 12:24 pm, CNA 1 confirmed the observation of the roach crawling in Resident 2's room and stated that they could potentially cause infection to the residents. During an observation with the DON on 7/21/2026 12:33 pm of Resident 2's room, the DON confirmed the observation of the roach in Resident 2's room which had been crushed on the floor at this point. During a follow-up interview with the DON on 7/21/2026 at 4:04 pm, the DON confirmed that pests such as roaches could potentially spread infection. During a review of the facility's policy and procedures (P&P) titled, Pest Control, reviewed 1/26/2026, the P&P indicated, Our facility shall maintain an effective pest control program. The same P&P indicated under policy interpretation and implementation which included the following: - This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.- Garbage and trash are not permitted to accumulate and are removed from the facility daily.- Maintenance services assist, when appropriate and necessary, in providing pest control services. During a review of the P&P titled, Infection Prevention and Control Program, reviewed 1/26/2026, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The same P&P indicated, The IPCP [Infection Prevention and Control Program] provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement.

Based on observation, interview, and record review the facility failed to document the resident's assessment accurately in the medical record for one of five sampled residents (Resident 1). This failure resulted in inaccurate/ incomplete documentation of Resident 1's special treatments, procedures, and programs in the Minimum Data Set (MDS - a resident assessment tool), and had the potential to affect the services and treatments rendered. During a review of Resident 1's admission Record, dated 7/17/26 indicated, the resident was admitted to the facility on [DATE] with diagnoses including; chronic obstructive pulmonary disease (COPD - chronic lung disease causing difficulty in breathing), hypertension (HTN - high blood pressure) muscle weakness, abnormalities of gait and mobility, sleep apnea (chronic medical condition where a person's breathing repeatedly stops and starts during sleep), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and vascular dementia (memory and thinking problems caused by decreased blood flow to the brain). During a review or Resident 1's History and Physical (H&P) dated 7/13/26 indicated Resident 1 did not have decision make had the capacity to understand and make decisions. During a review of Resident 1's MDS dated [DATE] indicated, Resident 1 had severe cognitive (thinking, remembering, reasoning and judgment processes in the brain) impairment and was dependent to requiring substantial/maximum assistance with activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's care plan for at risk for altered respiratory status/difficulty breathing, BIPAP (bilevel positive airway pressure - a non-invasive breathing device used to push pressurized air into the airways) at bedtime and oxygen when needed revised 5/1/26 indicated, interventions of resident uses CPAP (continuous positive airway pressure - a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) for sleep, at bedtime for sleep apnea. During a review of Resident 1's Order Summary Report dated 7/12/26 indicated orders for: Apply BIPAP during bedtime, Apply BIPAP during naps within the day and Oxygen at 1 to 2 liters/minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). as needed. During an observation on 7/16/26 at 2:35 pm Resident 1 is observed sitting in wheelchair at bedside with BiPAP on and eyes closed (napping). During a concurrent telephone interview and record review on 7/22/26 at 10:57 am with the MDS nurse, Resident 1's MDS Section O Special Treatments, Procedures, and Programs dated 7/14/26 was reviewed. The MDS nurse verified the assessment was missing indications of the ordered respiratory treatments of intermittent Oxygen therapy and BiPAP, the MDS nurse stated they missed documenting those treatments in the assessment but it is important for the assessment to be accurate to follow the plan of care. During a review of the facility's policy and procedures (P&P) titled Certifying Accuracy of the Resident Assessment reviewed 1/21/26 indicated, person who completes any portion of the MDS assessment. is required to sign the assessment certifying the accuracy of that portion of that assessment. During a review of the facility's P&P titled, Charting and Documentation reviewed 1/29/26 indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on record review and interview, the facility failed to ensure comprehensive care plans were updated and revised for one of five sampled residents (Resident 1) after hospitalization. This failure had the potential to affect resident care, services and treatments. During a review of Resident 1's admission Record, dated 7/17/26 indicated, the resident was admitted to the facility on [DATE] with diagnoses including; chronic obstructive pulmonary disease (COPD - chronic lung disease causing difficulty in breathing), hypertension (HTN - high blood pressure) muscle weakness, abnormalities of gait and mobility, sleep apnea (chronic medical condition where a person's breathing repeatedly stops and starts during sleep), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and vascular dementia (memory and thinking problems caused by decreased blood flow to the brain). During a review or Resident 1's History and Physical (H&P) dated 7/13/26 indicated Resident 1 did not have decision make had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 7/14/26 indicated, Resident 1 had severe cognitive (thinking, remembering, reasoning and judgment processes in the brain) impairment and was dependent to requiring substantial/maximum assistance with activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Order Summary Report dated 7/12/26 indicated orders for: Apply BIPAP (A BiPAP [Bilevel Positive Airway Pressure] machine is a non-invasive ventilator used to assist breathing) during bedtime, Apply BIPAP during naps within the day and Oxygen at 1 to 2 liters/minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). as needed. During a concurrent telephone interview and record review on 7/22/26 at 10:57 am with the MDS nurse, Resident 1's care plan for altered respiratory status revised 5/1/26 was reviewed. The MDS nurse verified care plan had not been revised after the resident's recent hospitalization (7/10/26-7/12/26) and stated it should have been to capture the new interventions for the BiPAP that were ordered. During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered reviewed 1/29/26 indicated, The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The interdisciplinary team reviews and updates the care plan. when there has been a significant change in the resident's condition. when the resident has been readmitted to the facility from the hospital stay.

Based on observation, interview, and record review, the facility failed to develop and implement a discharge plan in the comprehensive care plan for three of three sampled residents (Residents 1,2, and 3). This deficient practice resulted in unsafe discharge, with a potential of worsened health outcomes, severe medical errors, and hospitalization. a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was readmitted on [DATE] (original admission date 6/1/2021). With diagnoses including but not limited to type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Cellulitis (bacterial skin infection) of right lower limb, and dysphagia (difficulty swallowing). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/27/2026, the MDS indicated Resident 1 had a brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 (cognitively intact) During a review of Resident 1's Order Summary Report (OSR) dated 7/3/2026, the OSR indicated Resident 1 was to be discharged on 7/2/2026 to Boarding Care Facility (BCF) 1. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted on [DATE]. With a diagnoses including but not limited to traumatic subdural hemorrhage (brain bleed due to trauma to the head), fracture of unspecified parts of lumbosacral spine and pelvis (broken spine, broken pelvic bone), Intracerebral hemorrhage (stroke where a blood vessels bursts and causes bleeding directly into the brain) During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 5/22/2026, the MDS indicated Resident 2 had a brief interview for mental status BIMS score of 4 (severe cognitive impairment). During a review of Resident 2's OSR dated 7/3/2026, the OSR indicated Resident 2 was to be discharged on 7/2/2026 to BCF 1. During a review of Resident 2's Progress notes dated 7/3/20026, The progress notes indicated that there was an IDT meeting held with Resident 2 and his family member agreeing that Resident 2 will be transferred to Assisted Living (AS) 1. c. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted on [DATE]. With a diagnoses including but not limited to Malignant Neoplasm of Sigmoid Colon (Colon Cancer), chronic kidney disease (progressive kidney damage), and type 2 DM. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had a brief interview for mental status BIMS score of 11 (moderate cognitive impairment) During a review of Resident 3's OSR dated 7/3/2026, the OSR indicated Resident 3 was to be transferred on 6/13/2026 to General Acute Care Hospital (GACH) 1. During an interview with Assistant Director of Nursing (ADON), on 7/3/2026 at 2:16p.m, the ADON stated care plans are to be completed during the admission process, quarterly and as needed per resident. The importance of a care plan is to maintain residents' safety and inform them of their care. ADON stated that when a resident is being discharged the care plan will help notify the residents why they are being discharged and when they will be discharged . The ADON stated if there is no care plan this can cause frustration for the residents and confusion for the staff. Staff may not be informed of the plan for the residents and can cause medical mistakes during discharge for the residents. During a review of the facility's policy and procedures (P&P) titled Care plans, Comprehensive person- Centered, dated 1/29/2026, the P&P indicated, each resident's care plan is consistent with the residents rights to participate in the development and implementation of his or her plan of care. A care plan will be developed and implemented during any resident change or change in condition

Based on observation, interview, and record review the facility failed to provide a notification of transfer to one of three sampled residents (Resident 1).This deficient practice resulted in Resident 1 experiencing emotional distress and uncertainty.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was readmitted on [DATE] (original admission date 6/1/2021). With diagnoses including but not limited to type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Cellulitis (bacterial skin infection) of right lower limb, and dysphagia (difficulty swallowing). During a review of Resident1's Minimum Data Set (MDS- a resident assessment tool), dated 5/27/2026, the MDS indicated Resident 1 had a brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 (cognitively intact) During a review of Resident 1's Order Summary Report (OSR) dated 7/3/2026, the OSR indicated Resident 1 was to be discharged on 7/2/2026 to Boarding Care Facility (BCF) 1. During an interview on 7/3/2026 at 10:30am with Resident 1, Resident 1 stated he was not notified that he was being transferred to another facility. Resident 1 stated they have been living at the facility for years and are now being evicted. Resident 1 stated a nurse walked into their room and said pack your things you're going to BCF 1, Resident 1 stated he was never told that the facility was going to transfer them to BCF 1. Resident 1 stated they were I the process of choosing a facility to go to but had yet to formally decide where to go. This facility was chosen without his knowledge and feels like it's personal they are being evicted. During an interview with Licensed Vocational Nurse (LVN) 1, on 7/3/2026 at 11:48am LVN 1 stated Resident 1 has trust issue with transportation and needs concise communication. Per LVN 1 Resident 1 is excited to transfer but wants to visit the facility before making the decision which facility to go to. During an interview with Social Services Director (SSD), on 7/3/2026 at 12:45pm, the SSD stated they do not provide a transfer notice to residents who are being transferred. SSD stated the transfer form is given to the residents at the time of transfer not before. During an interview with the Assistant Director of Nursing (ADON), on 7/3/2026 at 2:16pm, the ADON stated it is important to notify residents that they are being transferred to prevent psychosocial distress. when residents don't know where they are going or why they can become frustrated and lose trust in their facility. During an interview with the Acting Administrator (AA), on 7/3/2026 at 2:25pm, the AA stated they get everything ready for the resident before being discharged either to home or to another facility. The AA stated the importance of keeping residents informed is to keep communication open between facility and residents. This is to prevent residents from feeling pushed out and feeling like the move is their choice. The AA stated that not informing the resident in a timely manner can cause the resident to become depressed and feel abused to a certain extent because this right now is his home. During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, dated 1/29/2026, the P&P indicated that an appropriate notice will be provided to the resident and or legal representative of said transfer or discharge. The P&P also states that upon notifying the resident of the transfer or discharge, the resident will be allowed to appeal the transfer or discharge. If the resident chooses exercise their right to appeal they will not be transferred or discharged while the appeal is pending.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 was in-serviced and given clear instruction on the protocols of how to mitigate physical and environmental hazards including falls for one of four sampled residents (Resident 1) according to Resident 1's care plan (CP-a personalized, written roadmap that outlines a patient's specific health issues, medical goals, and the exact treatments or services needed to achieve them). On 6/12/2026, CNA 1 was assigned to monitor and supervise Resident 1 who was using a Merry [NAME] (MW- a specialized/mobility device that combines a fully enclosing, 4-wheeled walker with an attached trailing chair which enables independent ambulation for Residents with poor balance) for ambulation, had a history of falls, and had a behavior of suddenly getting up and walking very fast. This deficient practice resulted in Resident 1 falling on 6/12/2026and suffering a nasal (nose) fracture (break in a bone) and laceration (skin tear) to the forehead respectively. Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation and management. Findings: A review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that include encephalopathy (malfunction of the brain that alters its structure or function), protein calorie malnutrition (inadequate intake or absorption of protein, calories), dementia (loss of cognitive functioning-including thinking, remembering, and reasoning-that is severe enough to interfere with a person's daily life), muscle weakness, disorder of bone density and structure, fracture of the fifth metacarpal (a break in the hand bone connecting your pinky to your wrist) bone left hand, Alzheimer's disease (an irreversible, progressive neurodegenerative brain disorder that gradually destroys memory, thinking skills, and the ability to carry out simple tasks), anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable worry or fear that is out of proportion to the actual situation), depression (mood disorder characterized by a persistent feeling of sadness, emptiness, and a severe loss of interest in activities), hypertension (high blood pressure) and adult failure to thrive. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/15/2026, indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired The MDS indicated Resident 1 was independent with eating and oral hygiene, required supervision for upper body dressing, partial moderate assistance with toileting hygiene, shower/bathe self and personal hygiene, Resident 1 required substantial/maximal assistance with lower body dressing and was dependent for putting on/taking off footwear. A review of Resident 1's medical record titled Clinical-assessment dated [DATE] indicated Resident had a total of 12 separate falls in the facility on 4/8/2025, 8/15/2025, 9/5/2025, 11/17/2025, 12/29/2025, 1/4/2025, 1/6/2026, 1/13/2026, 1/16/2026, 2/8/2026, 2/20/2026, 4/30/2026 and 6/12/2026. A review of Resident 1's CP undated indicated Resident 1 had unavoidable risk for falls related to gait/balance problems, dementia, non-compliance using a walker.with care plan interventions that included helmet during ambulation, Merri walker for ambulation and a 1:1 sitter (a staff member assigned to continuously observe an at-risk patient by providing one-to-one supervision to prevent injuries, falls, wandering, or self-harm). A review of facility in services and lesson plan regarding proper use of a MW dated 5/13/2026 and 6/18/2026, indicated there was no evidence of course content detailing the materials, topics, readings, covered during the in-service. During an interview on 6/25/2026 at 11:26 am, CNA1 stated that on 6/12/2026 approximately 2pm, CNA 1 was walking beside Resident 1 who was walking using a MW when the resident stopped to rest and sat on the seat on the MW for about 2 (two) minutes to rest. CNA 1 stated Resident 1 then got up abruptly held on to the front of the MW and started walking. CNA1 stated Resident 1 lost balance and fell face forward on the floor while in the MW. CNA1 stated she had been employed at the facility for 1 month and had not received in-services on potential risks and hazards associated with a Resident is using a MW. CNA1 stated she was not provided with a report on why Resident 1 was using a MW and/or potential risks to watch out for when Resident 1 is ambulating in the MW. During an interview on 6/29/2026 at 10:19 am Director of Nursing (DON) stated a staff assigned as a sitter should receive a report prior to attending to a Resident. The sitter (a healthcare worker who provides continuous supervision to a patient/resident at risk of injuring themselves, falling or wandering) is supposed to know why they are sitting with the Resident, the behavior to watch out for, what to expect from the resident because of the resident behavior. A review of facility policy and procedures (P&P) titled Assistive Device and Equipment dated 1/29/2026 indicated, certain devices and equipment that assist with resident mobility, safety and independence are provided for Residents. Staff. are trained on the safe use of equipment and devices. A review of facility P&P titled Staffing, Sufficient and Competent Nursing dated 1/29/2026 indicated, Licensed nurses and certified nursing assistants . provide competent resident care including assuring resident safety .

Based on observations, interview, and record review, the facility failed to follow its' policy and procedure (P&P) titled, Bioethics Committee- Residents Rights and Dignity, revised 1/29/2026, by failing to honor the rights of one of the three sampled residents (Resident 5) who had fluctuating capacity to make decisions. This deficient practice resulted in Resident 5 being unable to make decisions regarding her care.During a review of Resident 5's admission record indicated that Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial muscle weakness or reduced control on one entire side of the body) following cerebral infarction (cerebrovascular accident - CVA-stroke, loss of blood flow to a part of the brain), chronic kidney disease stage 4 (severely damaged kidneys and which do not properly filter waste from the blood), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 5's history and physical (H&P) dated 2/19/2026, the H&P indicated that Resident 5 had fluctuating capacity to make medical decisions. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool) dated 6/15/2026, the MDS indicated Resident 5 had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions). The MDS indicated Resident 5 was dependent on staff for most of her Activities of Daily Living (ADLs such as, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, and putting on/taking off footwear). During a review of Resident 5's facility document titled, Psychotherapeutic Drug Informed Consent Form, dated 6/3/2026, indicated, mirtazapine [Remeron - a prescription antidepressant primarily used to treat major depressive disorder] 7.5 mg [milligrams - unit of measure] with a frequency QHS (at bedtime) with an indefinite duration. The consent indicated under reason for use as, Depression m/b [manifested by] poor oral intake. The same consent indicated Resident 5 had signed on 6/3/2026. The licensed nurse signature as week as the interpreter sections were left blank. During a review of Resident 5's physician orders dated 6/20/2026 indicated, Mirtazapine Oral Tablet 7.5 MG (Mirtazapine) Give 7.5 mg by mouth at bedtime for Appetite Stimulant. During an interview with Licensed Vocational Nurse (LVN) 4 on 6/23/2026 at 10:22 am, LVN 4 stated that she was familiar with Resident 5 and that she was totally dependent on facility staff for all her needs. LVN 4 stated that Resident 5 was Farsi speaking and stated that the facility staff used Resident 5's Family Member (FM) as the translator because Resident 5 did not understand English. During an interview with Certified Nursing Assistant (CNA) 4 on 6/23/2026 at 12:01 pm, CNA 4 stated that she was familiar with Resident 5 and that she (Resident 5) was dependent on staff for her care. CNA 4 stated that she did not understand Resident 5 because she spoke another language which she thought was Russian. CNA 4 was not aware of any translation services provided by the facility. During a follow up interview with LVN 4 on 6/23/2026 at 12:06 pm, LVN 4 stated that after reviewing Resident 5's chart she noticed that there were no FMs or responsible parties listed. LVN 4 stated that when providing care such as administering medications, she (LVN 4) used simple instructions but could not verify if the resident understood stating, I don't know what to tell you. LVN 4 stated that she used an interpreter application that was not approved by the facility. LVN 4 stated that at other instances, she (LVN 4) had asked other Resident's private caregivers to help interpret for her. LVN 4 confirmed that the methods she had used for translation were not appropriate and that a formal service approved by the facility could be helpful in ensuring that Resident 5 fully understood her care. LVN 4 stated that the importance of using an approved service for translation could impact resident outcomes in a positive way. LVN 4 stated that when a resident with severe cognitive impairments could not make decisions or give consent. During an interview with the Director of Nursing (DON) 6/23/2026 at 2:25 pm, the DON stated that Resident 5 did not speak but was able to say, yes and no. the DON stated that it could be a language barrier but that it could also be due to her medical condition. The DON was unable to respond how the facility concluded that she was alert to self only if they could not determine what language she spoke.During a concurrent observation of Resident 5 and interview with the DON on 6/23/2026 at 2:50 pm in Resident 5's room, the DON confirmed that there was no communication board posted in the room. Resident 5 was noted to be lying down in bed with her eyes closed. Resident 5 responded to a greeting in Armenian with, good, thank you, During a review of a P&P titled, Bioethics Committee- Residents Rights and Dignity, revised 1/29/2026, indicated, It is the policy of this facility to uphold the rights of residents to participate in the planning and decision-making process concerning their care and treatment. When situations arise that involve complex bioethical situations, the Bioethics Committee shall meet to address the situation. The same P&P indicated, Bioethical situations include, but are not limited-to the following situations:When the facility IDT (Interdisciplinary Team - consist of a variety of medical professionals and supporting personnel, including physicians, therapists, nurses, social workers, dieticians, case managers and anyone else deemed necessary to help a patient recover from an acute injury or thrive in their current condition) is the resident's Healthcare Surrogate, and there is a recommendation from the primary care physician to withhold treatment; and Other unresolved bioethical issues During a review of a P&P titled, Informed Consent for Psychotropic Drugs - Pharmacy Services, reviewed 1/292/2026, indicated, This policy ensures compliance with federal Centers for Medicare & Medicaid Services (CMS) regulations, regarding informed consent for psychotropic drugs. It outlines responsibilities for obtaining, verifying, and documenting informed consent to protect resident rights, promote safety, and facilitate appropriate use of these medications for residents with behavioral or psychotic symptoms, such as those associated with dementia. Facilities must also comply with any additional state-specific requirements. The same P&P defined the following: Psychotropic Drugs: Any drug that affects brain activities associated with mental processes and behavior, including but not limited to antipsychotics (e.g., haloperidol, risperidone), antidepressants, anxiolytics, hypnotics, mood stabilizers, anticonvulsants, central nervous system agents, muscle relaxants, anticholinergics, antihistamines, NMDA receptor modulators, arid over-the-counter natural/herbal products.Informed Consent: Disclosure of material information (e.g., reasons for use, benefits, risks including black box warnings, alternatives including nonpharmacological approaches) to the resident or their representative/surrogate, allowing them to accept, refuse, or revoke consent. Consent must be obtained prior to initiation or increase.Representative/Surrogate: A legally authorized decision-maker, such as a guardian, durable power of attorney for health care, or other surrogate identified per state law if the resident lacks decision-making capacity. During a review of the P&P titled, Translation and/or Interpretation of Facility Services, reviewed, 1/29/2026, indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. The same P&P indicated under policy interpretation and implementation which included the following: - When encountering LEP individuals, staff members will conduct the initial language assessment (e.g., I Speak Cards) and notify the staff person in charge of the language access program.- The coordinator of this facility's language access program is the director of social services, or his/her designee.- All LEP persons shall receive a written notice in their primary language of their rights to obtain competent oral translation. services free of charge. If written notice is not possible, such notice shall be given orally.The same P&P indicated, Family members and friends shall not be relied upon to provide interpretation services for the resident, unless explicitly requested by the resident. If family or friends are used to interpret, the resident must provide written consent for disclosure of protected health information.

Based on observations, interview, and record review, the facility failed to follow its' own policy and procedures (P&P) titled, Resident Rights, revised 1/29/2026 for one of the three sampled residents (Resident 1) by failing to prevent the loss of her compression hose (compression stockings - specialized, snug-fitting elastic garments worn on the legs. They apply gentle, graduated pressure that is tightest at the ankle and decreases as it moves up the leg. This pressure helps improve blood flow and prevents swelling). This deficient practice resulted in Resident 1 being unable to wear her compression hose when she wanted to.During a review of Resident 1's admission record indicated that Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (altered brain function or structure caused by an illness, chemical imbalance, or organ failure elsewhere in the body such as the liver or kidneys rather than a direct injury to the brain itself), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's inventory list dated 9/20/2024 indicated, 4 pairs of compression hoses. During a review of Resident 1' s Minimum Data Set (MDS - a resident assessment tool) dated 6/21/2026, the MDS indicated Resident 1 had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions). The MDS indicated Resident 1 was dependent on staff for most of her Activities of Daily Living (ADLs such as, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, and putting on/taking off footwear). During an interview with Resident 1's Representative (RP) on 6/23/2026 AT 10:47 am, RP stated that the facility did not have a system in place to ensure that residents' belongings were protected from getting lost or misplaced. RP stated that Resident 1's personal blanket as well as several pairs of compression hose were missing. RP stated that she had spoken with the Facility Administrator (FA) and Social Worker to resolve the issue but had not gotten them to replace the missing items. During an interview with the SW on 6/23/2026 at 1:57 pm, the SW stated that the facility procedure in ensuring personal items did not go missing was to make sure that staff or family members labeled personal items but that not all residents and families were on board with this procedure. The SW stated that she had been made aware (unable to recall whom) of the missing items compression hose and two nightgowns. The SW stated that facility had purchased some compression socks which RP had stated were not the right one. The facility was in the process of purchasing the specific brand requested by RP. The SW also stated that specific nightgowns were long sleeves and that being that it was summer, she had asked RP to confirm via email the type she would prefer. The SW stated that she was awaiting an email response from RP. During a review of the facility policy and procedure (P&P) titled, Resident Rights, revised 1/29/2026, indicated, Employees shall treat all residents with kindness, respect, and dignity. The same P&P indicated under policy interpretation and implementation which included: Be free from abuse, neglect, misappropriation of property, and explo1tat10n;Retain and use personal possessions to the maximum extent that space and safety permit.

Based on observation, interview, and record review, the facility failed to ensure two of two Certified Nursing Aides (CNA 1 and CNA 2) were competent (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully), spoke English according to the facility's job description titled Certified Nurses Assistant and the facility's policy and procedures (P&P) titled Job Descriptions and Performance Evaluation with a revision date of 2/2026, and are able to identify and report abuse. This failure resulted in CNA 1 and CNA 2 inability to name types of abuse with the potential for the residents to suffer abuse resulting in psychological trauma, pain, and physical injuries. Findings: During a record review of CNA 2's Employment Application form signed by CNA 2 on 7/17/2025, under Work Availability, line 4, CNA 2 failed to check one of the boxes yes or no when asked if CNA 2 have now or have previously had a health care related license and/or certification. The employment application form also indicated CNA 2 did not complete the anything under Employment Experience and Education. The employment application form indicated CNA 2 checked yes if CNA 2 had any experience, training, qualifications, or skills which CNA 2 feels especially suited for the job. However, CNA 2 did not provide any description of any experience, training, qualifications, or skills that CNA 2 was suited for. During a record review of CNA 2's Payroll/Personal/Emergency Contact Information form signed by CNA 2 on 7/19/2026, indicated that CNA 2 is a new grad no experience. During a record review of CNA 1's Employment Application form, under Skills, page 1, CNA 1 wrote English a little. CNA 1 signed the form on 2/18/2026. The form also indicated, CNA 1 did not have any work experience as a CNA prior to the facility hiring. During a record review of CNA 1's Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders form signed by CNA 2indicated, CNA 1 received education of suspected abuse of dependent adults and elderson 3/19/2026. During a record review of CNA 1's Staff Member Statement Regarding Knowledge of Mandated Reporting Requirements form signed by CNA 2, indicated, CNA 1 received education on mandated reporting requirements on 3/19/2026. During an observation and interview on 6/17/2026 from 1:48 PM with CNA 1, when asked at least five types of abuse, CNA 1 stated shower, they go to the room.they like shower. When CNA 1 was asked again to name at least five types of abuse, CNA 1 became quiet for 10 seconds then turned his head side to side as if looking for someone down the hallway. CNA 1 then looked at the surveyor, took a deep sigh then scoffed. CNA then shook his head slowly and did not provide any answers to name at least five types of abuse. CNA 1 abruptly said What are you trying to tell me? I tell you already. They go shower.okay so they need blanket here too they cold but it's no cold. While CNA 1 proceeded to ask the surveyor You speak French, huh? .you speak Spanish? CNA 1 put his right hand out towards the surveyor with open palm facing up while speaking. When the writer asked asked CNA 1 why CNA 1 wanted to know if the writer speaks French or Spanish, CNA 1 responded because I speak Spanish, I speak French.but I.ehhh.also speak English, no, just little and then smiled. When asked what a mandated report is, CNA 1 stated I don't know. C'mon, no. You speak French or Spanish, I talk. CNA 1 then stated, I'm sorry.ehh you no French, no Spanish.I speak little English (gestured with his right index finger and right thumb almost touching.to express little). CNA 1 also stated, Why? Who? Why talk to me? .ehh.I only give blankets, the food to.ehh .people. CNA 1 said something unintelligible/babbling/gibberish. CNA 1 looked at the writer sarcastically, scoffed, then said no. CNA 1 then turned to look at the writer, looked away, and then shrugged both shoulders. During an observation and interview on 6/17/2026 at 2:05 PM with CNA 2, when asked to name at least five types of abuse, CNA 2 looked the writer, giggled nervously, and did not give any answers. When asked to define abuse, CNA 2 stated When the patient call me about me.when the patient needs shower Monday you didn't give shower but only Wednesday.that's abuse, the patient is suppose to get shower Monday.it is abuse. CNA 2 also stated CNA 2 is not a mandated reporter. and when the question was rephrased, are you required to report to your supervisor about witnessing something or having knowledge on inappropriate behavior towards the residents while working here, CNA 2 replied, no, I don't report then CNA 2 followed that with this statement Oh.I know. Okay.so.When sometimes report about me when the reporter they are not the CNA in their coming. You have an assignment and you are not working in the assignment, you didn't change the bed, the linens are dirty, the resident dirty. CNA 2 straightened both shoulders and smiled at the writer. During a record review of the facility's job description titled Certified Nurses Assistant indicated one of the qualifications of a CNA was must be able to read, write, speak and understand the English language. The form did not indicate any effective by or revision dates. During a record review of the facility's policy and procedures (P&P) titled Job Descriptions and Performance Evaluation with a revision date of 2/2026 indicated, the objective of the job description is to prevent misunderstanding about job responsibilities.

Based on interview, and record review, for two of twelve sampled residents (Residents 1 and 9):For Resident 1:A. The facility failed to provide adequate supervision and implement effective interventions to prevent elopement (when a resident leaves the facility grounds or a designated safe area without the staff knowing and/or without the supervision the resident needs) for one of three sampled residents (Resident 1) who had moderate cognitive impairment by failing to:1. Monitor and supervise the whereabouts of Resident 12. Accurately assess Resident 1's risk for elopement on 3/30/26 when Resident 1 displayed wandering behavior and attempted to elope from the facility.3. Create and implement a Risk for elopement care plan after Resident 1 attempted to elope on 3/30/2026 and eloped on 5/27/2026.4. Ensure that the patio gate leading to the alley had a functioning alarm system to alert staff when opened.On 3/30/2026, Resident 1 attempted to elope from the facility.As a result, Resident 1 eloped from the facility on 5/27/2026 and 6/2/2026 during the night. On the same dates, Resident 1 walked to General Acute Care Hospital (GACH) 1 to seek medical attention/services. For Resident 9:B. The facility failed to ensure staff closely supervised and monitored Resident 9, and ensured Resident 9 was within staff reach to prevent the resident from falls and or injuries. The facility was aware that Resident 9 is confused (a condition when unable to think as clearly or quickly as normally one can do), has a history of falls, and impulsive behavior (actions that are taken without sufficient thought or considerations of consequences) of getting up from a wheelchair (WC) without assistance.As a result, Resident 9 fell out of a wheelchair (WC) on 5/21/2026 at 11:45 AM. Xray (a low radiation light passed through the body to see body and organs) of the left ribs dated 5/22/2026, indicated Resident 9 had non-displaced rib fractures. On 5/22/2026, the facility transferred Resident 9 to General Acute Care Hospital (GACH) for further evaluations and imaging tests. Findings: Cross Reference F684 A. During a review of Resident 1's admission record indicated that Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Paroxysmal (irregular) atrial fibrillation (AFib) is an intermittent heart condition where the upper chambers of the heart beat chaotically and out of sync with the lower chambers, heart failure (a serious, progressive condition where the heart muscle weakens or stiffens, preventing it from pumping enough oxygen-rich blood to meet the body's needs), and acute myocardial infarction (heart attack - occurs when blood flow to a section of the heart is suddenly blocked, depriving the heart muscle of oxygen and causing irreversible tissue damage). During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool) dated 5/6/2026, the MDS indicated Resident 1 had severe cognitive impairment (a significant decline in thinking, memory, and reasoning that makes it impossible to live independently). The MDS indicated Resident 1 required staff setup or clean up assistance for most of Activities of Daily Living (ADLs such as toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, sit to stand, toilet transfer, and personal hygiene). The MDS indicated Resident 1 required staff supervision or touching assistance for walking between 10-to-150 feet. During a review of Resident 1's History and Physical (H&P – when a physician assesses and interviews a patient then documents findings) dated 2/2/2025 indicated Resident 1 had mild cognitive impairment of uncertain or unknown etiology. During a review of the physician orders dated 3/30/2026 indicated, Check Wander Guard Placement Q [every]. During a review of Resident 1's Situation Background Assessment Recommendation (SBAR- a tool used in healthcare to improve patient safety by enabling fast, accurate, and concise information transfer between clinicians) dated 3/30/2026 at 6:23 pm., the SBAR indicated, post-wandering, and that a wander guard was placed to the right wrist. The SBAR indicated, wonder guard close monitoring reorientation and redirection of behavior. During a review of Resident 1's Elopement Risk assessment dated [DATE] indicated that Resident 1 was not an elopement risk. During a review of Resident 1's =Care Plan (CP - is a structured, individualized document created by healthcare professionals in collaboration with the patient to outline specific health conditions, treatment goals, and necessary services) initiated on 5/28/2026 with a focus, Elopement Risk: Places resident at significant risk of getting to a potentially dangerous place/stairs/outside of the facility, indicated Resident 1 had eloped on 5/27/2026 and that she (Resident 1) needed to be considered for a locked unit. The CP goals indicated, Resident safety will be maintained, and Resident will not leave facility unattended. The CP interventions included the following: - Place resident in a room near nurses/station for close observation - Perform frequent safety rounds every 1/2 [half] hour - initiate and follow through with Psychologist and Psychiatrist consult. During a review of Resident 1's SBAR dated 5/27/2026 at 11 pm., the SBAR indicated a high elopement risk level. The SBAR indicated, Around 11 pm (5/27/2026) noted resident wasn't in her room, search every room and bathroom she was nowhere to find, also check the around the building, unable to find her, MD notified, DON family and called the police, more notes on the progress. The SBAR indicated Resident 1 was returned to the facility from GACH 1 via ambulance service on 5/28/2026 at 5:05 am During a review of Resident 1's SBAR dated 6/2/2026 at 10:22 pm., the SBAR indicated Resident 1 left the facility and went to GACH 1. The same SBAR indicated that at, [10 pm] Charge nurse [Licensed Vocational Nurse] reported that the patient [Resident 1] was not found in her room during routine observation. Patient's (Resident 1) room and bathroom were immediately checked, and the patient was not located. Charge nurse and CNA [Certified Nursing Assistant] conducted a thorough search of the facility, including 3rd floor, lobby, and designated smoking area; however, the patient was not found. Upon further assessment of the patient's room, the wander guard was noted on the bedside table, indicating it had been removed. Immediate follow-up was initiated, checked in with [GACH 1] Emergency Department and patient was located sitting in the Emergency Department in the waiting area. Per Emergency Department nurse, the patient had already checked in for evaluation and would need to sign discharge paperwork if she wished to leave and return to the facility. Patient refused to return to the facility, stating, I don't want to go back to that place anymore. I want to stay here. During a review of Resident 1's Nursing Notes documented by LVN 8, dated 5/27/2026 3:28 pm., indicated the following, [Resident 1] would get up, walk to her room and back to the dining room. [Resident 1] came to the station to get water. [Resident 1] did a lot of walking back in front to the station. [Resident 1] stayed at the station for couple of minutes and go back to her room. The Nursing Notes further indicated LVN 8 usually tells Resident 1 to stay in her (Resident 1's) room because Resident 1 needs to be close to her heart monitoring (pacemaker- a device used to control an irregular heart rhythm). On 5/27/2026 at around 5 pm, dinner was served, medications were administered to Resident 1, that Resident 1 walked to the nurses' station, and that a(unidentified) staff usually monitors Resident 1's whereabouts. On 5/27/2026 at around 9:30 pm, LVN 8 was charting (documenting) at the nurses' station when Resident 1 came to the nurses' station, walked by the nurses' stations and then headed to back to Resident 1's room. On 5/27/2026 at 11 pm, during change of shift Resident 1 was not in her room. LVN 8 checked all the bathrooms and rooms on 3rd floor, however, Resident 1 was nowhere to be found. LVN 8 went downstairs and checked around the building, but was unable to find Resident 1, and that LVN 8 told a Registered Nurse (RN-unidentified) that Resident 1 was missing, on 5/27/2026 at 12:15 AM, a Police officer came and was later joined by 2 (two) police officers who asked questions regarding what the resident looks like, height, weight and race etc. The police officers were at the facility for more than an hour, asked permission to check all the rooms, also checked all the exits. The 2 police officers showed LVN 8 a picture of a person obtained from a street camera and LVN 8 identified and confirmed that, yes that's our resident (Resident 1). Few minutes the two police officers told us that they found the resident she's at GACH 1. During a review of Resident 1's Nursing Notes dated 6/2/2026 11:25 pm., documented by Certified Nursing Assistant (CNA) 9 indicated the following: [Resident 1] received in bed alert and oriented, was not in pain, no shortness of breath or distress noted. On 6/2/2026 at 5 pm Resident 1 received medication, and dinner, and the resident was walking in the hallway. On 6/2/2026 at 8:30 pm, Resident 1 complained of chest pain and nitroglycerine [fast-acting prescription medication used to prevent and rapidly relieve chest pain] 0.4 milligrams [mg- units of measurement] was administered. After 5 minutes CNA 9 checked on Resident 1 and that Resident 1 told CNA 9 that, I am [Resident 1] doing okay. Resident 1 left the faciity on 6/2/2026 at 9:40 pm. During a concurrent observation of the facility smoking patio located on the first floor and interview with the Activities Coordinator (AC) on 5/30/2026 at 11:25 am, the facility patio was inspected/observed. The patio is located to the left and back of the facility reception desk and is separated by a door. Behind the door, is a hallway which is about 10 feet (ft) long with 2 bathrooms to the left side, and to the right is another hallway about 90 ft long with a door at the end which leads out to the smoking patio. The door remained unlocked. The smoking patio is not visible from the inside the facility. The smoking patio is connected to pathways to the left and to the right of the smoking patio which are about 50 ft long. Both pathways are secured with gates which have alarms. The alarm gate to the right side (Gate 1) of the smoking patio is triggers when opened. However, the gate to the left side (Gate 2) was observed to have brown paper jammed into the locking mechanism, preventing the gate from locking and triggering the alarm. The AC opened Gate 2 and confirmed and stated that the alarm did not trigger. The AC removed the paper that was jammed into the locking mechanism of the gate, closed and reopened the gate however, the alarm still did not trigger. The AC confirmed and stated that the paper should not be placed anywhere around any locking mechanism because the paper will prevent the gate from locking and preventing the alarm from engaging/triggering. The AC stated that the potential for jamming the locking mechanism of a gate can result in a resident leaving the facility without staff knowledge. The AC stated that the door should be locked. During an interview with Registered Nurse Supervisor (RNS) 2 on 5/30/2026, RN 2 stated that an elopement is when a resident leaves without staff knowledge or permission. RNS 2 stated that the interventions for residents who are an elopement risk included frequent visual monitoring (unable to state frequency) and placing a wander guard. RNS 2 stated that on 5/27/2026, she came in for her shift around 11 pm and was told that Resident 1 had not been located in the facility and that law enforcement was called. RNS 2 stated that when Resident 1 returned the following day, 5/28/2026, Resident 1 notified RNS that she (Resident 1) left the faciity on 5/27/2026 at around 8:30 pm using the facility back elevator. RNS 2 stated that it was during change of shift between the evening shift and night shift (3pm and 11pm), on 5/27/2026, that the facility discovered that Resident 1 had left the facility. During a concurrent interview and record review of Resident 1's medical chart with Licensed Vocational Nurse (LVN) 4 on 5/30/2026 at 12:39 pm, LVN 4 confirmed and stated that the SBAR dated 3/30/3036 indicated that Resident 1 attempted to elope on 3/30/2026. LVN 4 stated that residents must be reassessed with every attempt of elopement or successful elopement. LVN 4 stated that the residents score for elopement will generally increase on the resident elopement risk assessment form. LVN 4 stated that elopement risk score of 10 or greater indicates that a resident is at a high risk for eloping. LVN 4 confirmed that Resident 1's elopement risk assessment completed on 3/30/2026, indicated the resident scored 9 which did not show that Resident 1 was an elopement risk. LVN 4 confirmed and stated that the following questions on elopement risk assessment where inaccurately answered/responded to: - Yes, for a question asking if Resident 1 was cognitively intact. - No, for question asking if Resident 1 wandered around the unit. LVN 4 confirmed and stated that Resident 1's elopement risk assessment dated [DATE] was inaccurate. LVN 4 stated that the elopement risk assessment should have indicated that Resident 1 was a high elopement risk because in the past, Resident 1 attempted to elope from the facility on 3/30/2026. LVN 4 confirmed and stated that there was no care plan in place for Resident 1 for elopement before 5/28/2026. LVN 4 stated that a care plan should have been initiated as soon as the facility identified that Resident 1 was a high elopement risk with interventions outlined to notify nursing on elopement prevention strategies. During a concurrent observation of the smoking patio gate and interview with Kitchen Staff (KS) 1 on 6/3/2026 at 1:31 pm, the gate leading to the alley at the back of the facility was observed to be propped open with a black plastic bag. KS 1 stated she had propped the door open because she had to take something (did not specify) out quickly. KS 1 confirmed and stated she (KS 1) left the door propped open, unsupervised, making it easily accessible for residents to exit the facility, a resident could have eloped into the main road on the other side of the gate, get hit by a car, be assaulted, or fall. KS 1 stated staff were required to keep the door locked at all times and use a key to unlock and lock it when exiting and entering. KS 1 stated that there is a key available in the kitchen but does not bring the key when she takes the trash out. During an interview with the Maintenance Supervisor (MS) on 6/3/2026 at 1:40 pm, MS stated that the alarm to the Gate 2 of the patio gate was functioning well and that when Kitchen staff going and out of the gate, the kitchen staff tend to disarm the gate alarm and forgot to rearm the gate alarm. MS admitted and stated that the behavior of staff disarming the gate alarm had occurred a few times within the last week (was unable to state how many times). MS stated that he had checked the same gate (Gate 2) alarm on Friday 5/29/2026 after reports of the alarm not getting triggered when opened which is when he found that the alarm was not being rearmed. MS stated that he (MS) provided the dietary supervisor (DS) with an extra key to Gate 2 to ensure that the kitchen staff had one available for when they had to use the gate to return and emphasized the importance of rearming the alarm. The MS stated that the potential of leaving the gate alarm unarmed was that a resident can escape and get hurt, get run over or attacked by homeless people in the alley. During a concurrent observation and interview with Resident 1 on 6/3/2026 at 1:55 pm, Resident 1's room was not in direct view of the nurses' station. Resident 1's room is located opposite the nurses' station about 2 doors down (about 20 feet away). The back elevator was located to the right side of Resident 1's room away from the nurse's station about 25 feet from her room and not in direct view of the nurses' station. The main elevator was located to the left side of Resident 1's room just past the nurses' station and in view of the station. During the same concurrent observation and interview, Resident 1 was observed passing back and forth in the hallway, from her room to the nurses' station. Resident 1 stated that she returned from GACH 1 a few minutes prior to this same interview. She (Resident 1) stated that she walked to GACH 1 the previous night on 6/2/2026 because she was experiencing chest pain and she felt that nursing staff were not appropriately addressing. Resident 1 stated that she used the facility back elevator and the side gate on the smoking patio to exit the facility. Resident 1 stated that she did not hear any alarm trigger when she left the facility. Resident 1 was observed without a wander guard. Resident 1 stated that she removed the wander guard and left the wander guard on the bedside table and left the faciity on 6/2/2026 night. During a concurrent observation of Resident 1 and interview with RNS 1 on 6/3/2026, RNS 1 confirmed and stated that Resident 1 did not have a wander guard on. RNS 1 stated that Resident 1 needed to always wear a wander guard because the resident is a risk for elopement. During a concurrent interview and record review of Resident 1's medical chart with the Director of Nursing (DON) on 6/4/2026 at 10:34 am, the DON stated Resident 1 ambulated (walked) with steady gait and sometimes used a wheelchair. The DON stated Resident 1 displayed behaviors of wanting to go out and often stated that [Resident 1] has chest pain. The DON stated that the facility called 911 (emergency services) a few times (did not specify) in the past because Resident 1 complained of chest pain. The DON stated that on 6/2/2026, Resident 1 complained of chest and the facility administered Nitroglycerine to Resident 1. The DON stated that an elopement risk assessment must be completed upon resident's admission and at change of condition of an attempt or successful elopement. The DON stated that elopement risk assessment answers must be accurate in order to take care of specifics of the elopement risk. The DON stated that inaccurately answering questions on the assessment can affect the resident elopement risk scoring because there is a potential of scoring a resident as a no risk when in fact the resident is at a risk of elopement. The DON stated that when resident assessments are inaccurate, everything will be affected such as interventions provided for the resident and the facility may fail to safeguard and prevent a resident from eloping. The DON stated that if a resident attempts to elope or successfully elopes, she (DON) expects the resident's elopement risk assessment score to be 10 or higher and Interventions including placing a wander guard and frequent supervision initiated for the resident. The DON stated staff are trained to monitor residents that constantly wander the unit hourly or every two hours. The DON stated that no staff was assigned to monitor Resident 1. The DON admitted and stated that Resident 1 was not safe in the facility because Resident 1 was able to remove the wonder guard. The DON confirmed and stated that Resident 1's elopement risk assessment was inaccurate and there should have been a care plan initiated when Resident 1 attempted to elope on 3/30/2026. During a review of a policy and procedures (P&P) titled, Care Planning - Interdisciplinary Team, reviewed 1/29/2026, indicated, The interdisciplinary team is responsible for the development of resident care plans. The same P&P indicated, Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). During a review of a P&P titled, Elopements – Residents Behavior and Facility Practices, reviewed 1/26/2026 indicated, Staff shall promptly report any resident who ties to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. If an employee observes a resident leaving the premises, he/she should: Attempt to prevent the departure in a courteous manner. Get help from other staff members in the immediate vicinity, if necessary; and Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. When a departing individual returns to the facility, 1i1e Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of incident/Accident e. Document the event in the resident's medical record. During a review of the P&P titled, Safety and Supervision of Residents, reviewed 1/29/2026, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. the same P&P indicated under the policy interpretation and implementation indicated: Facility-Oriented Approach to Safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. 5. The QAPI Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary. Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently; b. Evaluating the effectiveness of interventions; c. Modifying or replacing interventions as needed; and d. Evaluating the effectiveness of new or revised interventions. Systems Approach to Safety 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: . e. Unsafe Wandering . B. During a review of Resident 9's admission Records, the Records indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses including history of falling, unspecified abnormalities of gait and mobility (when the pattern in which you walk and move is not normal), malignant neoplasm of left female breast ( the development of cancer in the female breast), vascular dementia without behavioral disturbance (a brain disorder that affects a person's ability to carry out daily activities and that may cause changes in mood and personality caused by a reduced blood flow to the brain), anxiety disorder (a condition when often worried or anxious about many things and finds it hard to control). During a review of Resident 9's H&P dated 4/11/2026, the H&P indicated Resident 9 had a history of dementia (a brain disorder that affects a person's ability to carry out daily activities and that may cause changes in mood and personality), malignant left breast cancer (the development of cancer in the breast), cannot make medical decisions. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) to make decisions on self-care activities. The MDS indicated Resident 9 was dependent on staff for toileting hygiene, transferring from bed to chair/chair to bed, shower/bath, personal hygiene, eating, and dependent on wheelchair for mobility. During a review of Resident 9's initial Fall Risk assessment dated [DATE], Resident 9's fall risk assessment score was 12 (a score of less than 25 is an indicator the resident is a low to moderate fall risk). During a revie of Resident 9's CP created on 10/12/2025 and revised on 1/13/2026 indicated Res[TRUNCATED]

Based on interviews and record review, the facility failed to have a system in place to ensure the safety of one of the three sampled residents (Resident 1) by failing to: Licensed nursed comprehensively assessed Resident 1 after the resident complained of chest pain on 6/2/2026.Licensed nurses re-assessed Resident 1 after administering nitroglycerine [fast-acting prescription medication used to prevent and rapidly relieve chest pain] 0.4 milligrams [mg- units of measurement] for chest pain on 6/2/2026 at 8:30 pm.Review, Identify, and notify a physician of critical laboratory values for potassium (a vital mineral and electrolyte that the body uses to conduct electrical charges, maintain fluid balance, and support nerve signals, muscle contractions, and heart health) which was at 2.7 millimoles per liter (mmol/L - unit of measurement that quantifies the concentration of a substance in specific volume of blood with normal levels between 3.5 mmol/L to 5.0 mmol/L) As a result, Resident 1 eloped from the facility on 5/27/2026 and 6/2/2026 during the night and walked to General Acute Care Hospital (GACH) 1 both times to seek medical services placing the resident at increased risk for accidents such as being run over by a vehicle or being attacked and death. Findings: Cross Reference F689 During a review of Resident 1's admission record indicated that Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Paroxysmal (irregular) atrial fibrillation (AFib) is an intermittent heart condition where the upper chambers of the heart beat chaotically and out of sync with the lower chambers, heart failure (a serious, progressive condition where the heart muscle weakens or stiffens, preventing it from pumping enough oxygen-rich blood to meet the body's needs), and acute myocardial infarction (heart attack - occurs when blood flow to a section of the heart is suddenly blocked, depriving the heart muscle of oxygen and causing irreversible tissue damage). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/6/2026, the MDS indicated Resident 1 had severe cognitive impairment (a significant decline in thinking, memory, and reasoning that makes it impossible to live independently). The MDS indicated Resident 1 required staff setup or clean up assistance for most of Activities of Daily Living (ADLs such as toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, sit to stand, toilet transfer, and personal hygiene). The MDS indicated Resident 1 required staff supervision or touching assistance for walking between 10-to-150 feet. During a review of Resident 1's History and Physical (H&P - when a physician assesses and interviews a patient then documents findings) dated 2/2/2025 indicated Resident 1 had mild cognitive impairment of uncertain or unknown etiology. During a review of the physician orders dated 3/30/2026 indicated, Check Wander Guard Placement Q [every]. During a review of Resident 1's Situation Background Assessment Recommendation (SBAR- a tool used in healthcare to improve patient safety by enabling fast, accurate, and concise information transfer between clinicians) dated 3/30/2026 at 6:23 pm., the SBAR indicated, post-wandering, and that a wander guard was placed to the right wrist. The SBAR indicated, wonder guard close monitoring reorientation and redirection of behavior. During a review of Resident 1's Elopement Risk assessment dated [DATE] indicated that Resident 1 was not an elopement risk. During a review of Resident 1's Care Plan (CP - is a structured, individualized document created by healthcare professionals in collaboration with the patient to outline specific health conditions, treatment goals, and necessary services) initiated on 5/28/2026 with a focus, Elopement Risk: Places resident at significant risk of getting to a potentially dangerous place/stairs/outside of the facility, indicated Resident 1 had eloped on 5/27/2026 and that she (Resident 1) needed to be considered for a locked unit. The CP goals indicated, Resident safety will be maintained, and Resident will not leave facility unattended. The CP interventions included the following: - Place resident in a room near nurses/station for close observation - Perform frequent safety rounds every 1/2 [half] hour - initiate and follow through with Psychologist and Psychiatrist consult. During a review of Resident 1's SBAR dated 5/27/2026 at 11 pm., the SBAR indicated a high elopement risk level. The SBAR indicated, Around 11 pm (5/27/2026) noted resident wasn't in her room, search every room and bathroom she was nowhere to find, also check the around the building, unable to find her, MD notified, DON family and called the police, more notes on the progress. The SBAR indicated Resident 1 was returned to the facility from GACH 1 via ambulance service on 5/28/2026 at 5:05 am During a review of Resident 1's SBAR dated 6/2/2026 at 10:22 pm., the SBAR indicated Resident 1 left the facility and went to GACH 1. The same SBAR indicated that at, [10 pm] Charge nurse [Licensed Vocational Nurse] reported that the patient [Resident 1] was not found in her room during routine observation. Patient's (Resident 1) room and bathroom were immediately checked, and the patient was not located. Charge nurse and CNA [Certified Nursing Assistant] conducted a thorough search of the facility, including 3rd floor, lobby, and designated smoking area; however, the patient was not found. Upon further assessment of the patient's room, the wander guard was noted on the bedside table, indicating it had been removed. Immediate follow-up was initiated, checked in with [GACH 1] Emergency Department and patient was located sitting in the Emergency Department in the waiting area. Per Emergency Department nurse, the patient had already checked in for evaluation and would need to sign discharge paperwork if she wished to leave and return to the facility. Patient refused to return to the facility, stating, I don't want to go back to that place anymore. I want to stay here. During a review of Resident 1's Nursing Notes documented by LVN 8, dated 5/27/2026 3:28 pm., indicated the following, [Resident 1] would get up, walk to her room and back to the dining room. [Resident 1] came to the station to get water. [Resident 1] did a lot of walking back in front to the station. [Resident 1] stayed at the station for couple of minutes and go back to her room. The Nursing Notes further indicated LVN 8 usually tells Resident 1 to stay in her (Resident 1's) room because Resident 1 needs to be close to her heart monitoring (pacemaker- a device used to control an irregular heart rhythm). On 5/27/2026 at around 5 pm, dinner was served, medications were administered to Resident 1, that Resident 1 walked to the nurses' station, and that a(unidentified) staff usually monitors Resident 1's whereabouts. On 5/27/2026 at around 9:30 pm, LVN 8 was charting (documenting) at the nurses' station when Resident 1 came to the nurses' station, walked by the nurses' stations and then headed to back to Resident 1's room. On 5/27/2026 at 11 pm, during change of shift Resident 1 was not in her room. LVN 8 checked all the bathrooms and rooms on 3rd floor, however, Resident 1 was nowhere to be found. LVN 8 went downstairs and checked around the building, but was unable to find Resident 1, and that LVN 8 told a Registered Nurse (RN-unidentified) that Resident 1 was missing, on 5/27/2026 at 12:15 AM, a Police officer came and was later joined by 2 (two) police officers who asked questions regarding what the resident looks like, height, weight and race etc. The police officers were at the facility for more than an hour, asked permission to check all the rooms, also checked all the exits. The 2 police officers showed LVN 8 a picture of a person obtained from a street camera and LVN 8 identified and confirmed that, yes that's our resident (Resident 1). Few minutes the two police officers told us that they found the resident she's at GACH 1. During a review of Resident 1's Nursing Notes dated 6/2/2026 11:25 pm., documented by Certified Nursing Assistant (CNA) 9 indicated the following: [Resident 1] received in bed alert and oriented, was not in pain, no shortness of breath or distress noted. On 6/2/2026 at 5 pm Resident 1 received medication, and dinner, and the resident was walking in the hallway. On 6/2/2026 at 8:30 pm, Resident 1 complained of chest pain and nitroglycerine [fast-acting prescription medication used to prevent and rapidly relieve chest pain] 0.4 milligrams [mg- units of measurement] was administered. After 5 minutes CNA 9 checked on Resident 1 and that Resident 1 told CNA 9 that, I am [Resident 1] doing okay. Resident 1 left the faciity on 6/2/2026 at 9:40 pm. During a review of Resident 1 discharge summary from GACH dated 5/27/20 indicated the reason for visit was chest pain. During a review of Resident 1 after discharge summary from GACH dated 6/3/2026 indicated the reason for visit was chest pain. The same summary indicated diagnoses of epigastric pain (discomfort or a burning sensation felt in the upper abdomen, just below the ribs) and hypokalemia (a condition characterized by abnormally low levels of potassium in the blood, typically below 3.5) with Resident 1's value at 2.7mmol/L. The discharge summary indicated home care instructions which included, If you take certain types of diuretics, you will need to take potassium supplements. Talk to your health care provider. During a concurrent observation of the facility smoking patio located on the first floor and interview with the Activities Coordinator (AC) on 5/30/2026 at 11:25 am, the facility patio was inspected/observed. The patio is located to the left and back of the facility reception desk and is separated by a door. Behind the door, is a hallway which is about 10 feet (ft) long with 2 bathrooms to the left side, and to the right is another hallway about 90 ft long with a door at the end which leads out to the smoking patio. The door remained unlocked. The smoking patio is not visible from the inside the facility. The smoking patio is connected to pathways to the left and to the right of the smoking patio which are about 50 ft long. Both pathways are secured with gates which have alarms. The alarm gate to the right side (Gate 1) of the smoking patio is triggers when opened. However, the gate to the left side (Gate 2) was observed to have brown paper jammed into the locking mechanism, preventing the gate from locking and triggering the alarm. The AC opened Gate 2 and confirmed and stated that the alarm did not trigger. The AC removed the paper that was jammed into the locking mechanism of the gate, closed and reopened the gate however, the alarm still did not trigger. The AC confirmed and stated that the paper should not be placed anywhere around any locking mechanism because the paper will prevent the gate from locking and preventing the alarm from engaging/triggering. The AC stated that the potential for jamming the locking mechanism of a gate can result in a resident leaving the facility without staff knowledge. The AC stated that the door should be locked. During an interview with Registered Nurse Supervisor (RNS) 2 on 5/30/2026, RN 2 stated that an elopement is when a resident leaves without staff knowledge or permission. RNS 2 stated that the interventions for residents who are an elopement risk included frequent visual monitoring (unable to state frequency) and placing a wander guard. RNS 2 stated that on 5/27/2026, she came in for her shift around 11 pm and was told that Resident 1 had not been located in the facility and that law enforcement was called. RNS 2 stated that when Resident 1 returned the following day, 5/28/2026, Resident 1 notified RNS that she (Resident 1) left the faciity on 5/27/2026 at around 8:30 pm using the facility back elevator. RNS 2 stated that it was during change of shift between the evening shift and night shift (3pm and 11pm), on 5/27/2026, that the facility discovered that Resident 1 had left the facility. During a concurrent interview and record review of Resident 1's medical chart with Licensed Vocational Nurse (LVN) 4 on 5/30/2026 at 12:39 pm, LVN 4 confirmed and stated that the SBAR dated 3/30/3036 indicated that Resident 1 attempted to elope on 3/30/2026. LVN 4 stated that residents must be reassessed with every attempt of elopement or successful elopement. LVN 4 stated that the residents score for elopement will generally increase on the resident elopement risk assessment form. LVN 4 stated that elopement risk score of 10 or greater indicates that a resident is at a high risk for eloping. LVN 4 confirmed that Resident 1's elopement risk assessment completed on 3/30/2026, indicated the resident scored 9 which did not show that Resident 1 was an elopement risk. LVN 4 confirmed and stated that the following questions on elopement risk assessment where inaccurately answered/responded to: - Yes, for a question asking if Resident 1 was cognitively intact. - No, for question asking if Resident 1 wandered around the unit. LVN 4 confirmed and stated that Resident 1's elopement risk assessment dated [DATE] was inaccurate. LVN 4 stated that the elopement risk assessment should have indicated that Resident 1 was a high elopement risk because in the past, Resident 1 attempted to elope from the facility on 3/30/2026. LVN 4 confirmed and stated that there was no care plan in place for Resident 1 for elopement before 5/28/2026. LVN 4 stated that a care plan should have been initiated as soon as the facility identified that Resident 1 was a high elopement risk with interventions outlined to notify nursing on elopement prevention strategies. During a concurrent observation and interview with Resident 1 on 6/3/2026 at 1:55 pm, Resident 1's room was not in direct view of the nurses' station. Resident 1's room is located opposite the nurses' station about 2 doors down (about 20 feet away). The back elevator was located to the right side of Resident 1's room away from the nurse's station about 25 feet from her room and not in direct view of the nurses' station. The main elevator was located to the left side of Resident 1's room just past the nurses' station and in view of the station. During the same concurrent observation and interview, Resident 1 was observed passing back and forth in the hallway, from her room to the nurses' station. Resident 1 stated that she returned from GACH 1 a few minutes prior to this same interview. She (Resident 1) stated that she walked to GACH 1 the previous night on 6/2/2026 because she was experiencing chest pain and she felt that nursing staff were not appropriately addressing. Resident 1 stated that she used the facility back elevator and the side gate on the smoking patio to exit the facility. Resident 1 stated that she did not hear any alarm trigger when she left the facility. Resident 1 was observed without a wander guard. Resident 1 stated that she removed the wander guard and left the wander guard on the bedside table and left the faciity on 6/2/2026 night. During a concurrent interview and record review of Resident 1's medical chart with the Director of Nursing (DON) on 6/4/2026 at 10:34 am, the DON stated Resident 1 ambulated (walked) with steady gait and sometimes used a wheelchair. The DON stated Resident 1 displayed behaviors of wanting to go out and often stated that [Resident 1] has chest pain. The DON stated that the facility called 911 (emergency services) a few times (did not specify) in the past because Resident 1 complained of chest pain. The DON stated that on 6/2/2026, Resident 1 complained of chest and the facility administered Nitroglycerine to Resident 1. The DON stated that an elopement risk assessment must be completed upon resident's admission and at change of condition of an attempt or successful elopement. The DON stated that elopement risk assessment answers must be accurate in order to take care of specifics of the elopement risk. The DON stated that inaccurately answering questions on the assessment can affect the resident elopement risk scoring because there is a potential of scoring a resident as a no risk when in fact the resident is at a risk of elopement. The DON stated that when resident assessments are inaccurate, everything will be affected such as interventions provided for the resident and the facility may fail to safeguard and prevent a resident from eloping. The DON stated that if a resident attempts to elope or successfully elopes, she (DON) expects the resident's elopement risk assessment score to be 10 or higher and Interventions including placing a wander guard and frequent supervision initiated for the resident. The DON stated staff are trained to monitor residents that constantly wander the unit hourly or every two hours. The DON stated that no staff was assigned to monitor Resident 1. The DON admitted and stated that Resident 1 was not safe in the facility because Resident 1 was able to remove the wonder guard. The DON confirmed and stated that Resident 1's elopement risk assessment was inaccurate and there should have been a care plan initiated when Resident 1 attempted to elope on 3/30/2026. During a follow up interview with the DON 6/4/2026 at 12:02 pm, The DON stated that when a resident is readmitted to the facility, the RNS or desk nurse reviews the discharge summary to ensure that any recommendations or abnormal values are identified and reported to the resident's physician for further orders as needed. The DON stated that she also reviewed discharge summaries the following day for oversite and ensure that nothing was missing. The DON had not reviewed the discharge summary as of the time of this interview. The DON was unaware about Resident 1's potassium levels being at 2.7 mmol/L until this surveyor asked her about the levels. The DON stated that a level of 2.7mmol/L was significantly low and some of the signs and symptoms of hypokalemia included muscle cramps, weakness, shortness of breath, heart problems such as chest palpitations which may present as chest pain. The DON confirmed that a low potassium could have potentially caused Resident 1 to complain of chest pain. During an interview with Licensed Vocational Nurse (LVN) 7 on 6/4/2026 at 4:31 pm, LVN 7 stated that she was assigned as a desk nurse on 6/3/2026 when Resident 1 was readmitted to the facility on [DATE]. LVN 7 stated that duties of being a desk nurse included admissions and readmissions which included reviewing the admission paperwork or discharge summaries and ensuring that abnormal results were reported to the physician promptly. LVN 7 stated that she reviewed the admission orders but had not noticed the abnormal potassium levels. LVN 7 stated that a level of 2.7mmol/L must reported to the physician promptly. During a review of a policy and procedures (P&P) titled, Care Planning - Interdisciplinary Team, reviewed 1/29/2026, indicated, The interdisciplinary team is responsible for the development of resident care plans. The same P&P indicated, Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). During a review of the facility's P&P titled Change in a Resident's Condition or Status: reviewed 1/29/2026, the P&P indicated that, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.)Policy Interpretation and Implementation1. The nurse will notify the resident's attending physician or physician on call when there has been a(an) .: d. significant change in the resident's physical/emotional/mental condition; During a review of a P&P titled, Charting and Documentation, reviewed 1/29/2026, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The same P&P indicated, The following information is to be documented in the resident medical record:Objective observations;Medications administered;Treatments or services performed;Changes in the resident's condition;Events, incidents or accidents involving the resident; andProgress toward or changes in the care plan goals and objectives.

Based on interview, and record review, the facility failed to staff accurately assess one out of three sampled residents (Resident 1) who was experiencing chest pain and had abnormal laboratory results by failing to ensure that:Licensed nursed comprehensively assessed Resident 1 after the resident complained of chest pain on 6/2/2026.Licensed nurses re-assessed Resident 1 after administering nitroglycerine [fast-acting prescription medication used to prevent and rapidly relieve chest pain] 0.4 milligrams [mg- units of measurement] for chest pain on 6/2/2026 at 8:30 pm.Review, Identify, and notify a physician of critical laboratory values for potassium (a vital mineral and electrolyte that the body uses to conduct electrical charges, maintain fluid balance, and support nerve signals, muscle contractions, and heart health) which was at 2.7 millimoles per liter (mmol/L - unit of measurement that quantifies the concentration of a substance in specific volume of blood with normal levels between 3.5 mmol/L to 5.0 mmol/L)As a result, Resident 1 successfully eloped (when a resident leaves the facility grounds or a designated safe area without the staff knowing and/or without the supervision the resident needs)form the facility on 5/27/2026 and 6/2/2026 and walked to general acute care hospital (GACH) 1 to seek medical services. This deficient practice placed Resident 1 at increased risk for accidents, injuries, hospitalization and death. Findings: Cross Reference F684 & F689 During a review of Resident 1's admission record indicated that Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Paroxysmal (irregular) atrial fibrillation (AFib) is an intermittent heart condition where the upper chambers of the heart beat chaotically and out of sync with the lower chambers, heart failure (a serious, progressive condition where the heart muscle weakens or stiffens, preventing it from pumping enough oxygen-rich blood to meet the body's needs), and acute myocardial infarction (heart attack - occurs when blood flow to a section of the heart is suddenly blocked, depriving the heart muscle of oxygen and causing irreversible tissue damage). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/6/2026, the MDS indicated Resident 1 had severe cognitive impairment (a significant decline in thinking, memory, and reasoning that makes it impossible to live independently). The MDS indicated Resident 1 required staff setup or clean up assistance for most of Activities of Daily Living (ADLs such as toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, sit to stand, toilet transfer, and personal hygiene). The MDS indicated Resident 1 required staff supervision or touching assistance for walking between 10-to-150 feet. During a review of Resident 1's History and Physical (H&P - when a physician assesses and interviews a patient then documents findings) dated 2/2/2025 indicated Resident 1 had mild cognitive impairment of uncertain or unknown etiology. During a review of the physician orders dated 3/30/2026 indicated, Check Wander Guard Placement Q [every]. During a review of Resident 1's Situation Background Assessment Recommendation (SBAR- a tool used in healthcare to improve patient safety by enabling fast, accurate, and concise information transfer between clinicians) dated 3/30/2026 at 6:23 pm., the SBAR indicated, post-wandering, and that a wander guard was placed to the right wrist. The SBAR indicated, wonder guard close monitoring reorientation and redirection of behavior. During a review of Resident 1's Elopement Risk assessment dated [DATE] indicated that Resident 1 was not an elopement risk. During a review of Resident 1's Care Plan (CP - is a structured, individualized document created by healthcare professionals in collaboration with the patient to outline specific health conditions, treatment goals, and necessary services) initiated on 5/28/2026 with a focus, Elopement Risk: Places resident at significant risk of getting to a potentially dangerous place/stairs/outside of the facility, indicated Resident 1 had eloped on 5/27/2026 and that she (Resident 1) needed to be considered for a locked unit. The CP goals indicated, Resident safety will be maintained, and Resident will not leave facility unattended. The CP interventions included the following:- Place resident in a room near nurses/station for close observation- Perform frequent safety rounds every 1/2 [half] hour- initiate and follow through with Psychologist and Psychiatrist consult. During a review of Resident 1's SBAR dated 5/27/2026 at 11 pm., the SBAR indicated a high elopement risk level. The SBAR indicated, Around 11 pm (5/27/2026) noted resident wasn't in her room, search every room and bathroom she was nowhere to find, also check the around the building, unable to find her, MD notified, DON family and called the police, more notes on the progress. The SBAR indicated Resident 1 was returned to the facility from GACH 1 via ambulance service on 5/28/2026 at 5:05 am During a review of Resident 1's SBAR dated 6/2/2026 at 10:22 pm., the SBAR indicated Resident 1 left the facility and went to GACH 1. The same SBAR indicated that at, [10 pm] Charge nurse [Licensed Vocational Nurse] reported that the patient [Resident 1] was not found in her room during routine observation. Patient's (Resident 1) room and bathroom were immediately checked, and the patient was not located. Charge nurse and CNA [Certified Nursing Assistant] conducted a thorough search of the facility, including 3rd floor, lobby, and designated smoking area; however, the patient was not found. Upon further assessment of the patient's room, the wander guard was noted on the bedside table, indicating it had been removed. Immediate follow-up was initiated, checked in with [GACH 1] Emergency Department and patient was located sitting in the Emergency Department in the waiting area. Per Emergency Department nurse, the patient had already checked in for evaluation and would need to sign discharge paperwork if she wished to leave and return to the facility. Patient refused to return to the facility, stating, I don't want to go back to that place anymore. I want to stay here. During a review of Resident 1's Nursing Notes documented by LVN 8, dated 5/27/2026 3:28 pm., indicated the following, [Resident 1] would get up, walk to her room and back to the dining room. [Resident 1] came to the station to get water. [Resident 1] did a lot of walking back in front to the station. [Resident 1] stayed at the station for couple of minutes and go back to her room. The Nursing Notes further indicated LVN 8 usually tells Resident 1 to stay in her (Resident 1's) room because Resident 1 needs to be close to her heart monitoring (pacemaker- a device used to control an irregular heart rhythm). On 5/27/2026 at around 5 pm, dinner was served, medications were administered to Resident 1, that Resident 1 walked to the nurses' station, and that a(unidentified) staff usually monitors Resident 1's whereabouts. On 5/27/2026 at around 9:30 pm, LVN 8 was charting (documenting) at the nurses' station when Resident 1 came to the nurses' station, walked by the nurses' stations and then headed to back to Resident 1's room. On 5/27/2026 at 11 pm, during change of shift Resident 1 was not in her room. LVN 8 checked all the bathrooms and rooms on 3rd floor, however, Resident 1 was nowhere to be found. LVN 8 went downstairs and checked around the building, but was unable to find Resident 1, and that LVN 8 told a Registered Nurse (RN-unidentified) that Resident 1 was missing, on 5/27/2026 at 12:15 AM, a Police officer came and was later joined by 2 (two) police officers who asked questions regarding what the resident looks like, height, weight and race etc. The police officers were at the facility for more than an hour, asked permission to check all the rooms, also checked all the exits. The 2 police officers showed LVN 8 a picture of a person obtained from a street camera and LVN 8 identified and confirmed that, yes that's our resident (Resident 1). Few minutes the two police officers told us that they found the resident she's at GACH 1. During a review of Resident 1's Nursing Notes dated 6/2/2026 11:25 pm., documented by Certified Nursing Assistant (CNA) 9 indicated that On 6/2/2026 at 8:30 pm, Resident 1 complained of chest pain and nitroglycerine [fast-acting prescription medication used to prevent and rapidly relieve chest pain] 0.4 milligrams [mg- units of measurement] was administered. After 5 minutes CNA 9 checked on Resident 1 and that Resident 1 told CNA 9 that, I am [Resident 1] doing okay. Resident 1 left the faciity on 6/2/2026 at 9:40 pm. During an interview with Registered Nurse Supervisor (RNS) 2 on 5/30/2026, RN 2 stated that an elopement is when a resident leaves without staff knowledge or permission. RNS 2 stated that the interventions for residents who are an elopement risk included frequent visual monitoring (unable to state frequency) and placing a wander guard. RNS 2 stated that on 5/27/2026, she came in for her shift around 11 pm and was told that Resident 1 had not been located in the facility and that law enforcement was called. RNS 2 stated that when Resident 1 returned the following day, 5/28/2026, Resident 1 notified RNS that she (Resident 1) left the faciity on 5/27/2026 at around 8:30 pm using the facility back elevator. RNS 2 stated that it was during change of shift between the evening shift and night shift (3pm and 11pm), on 5/27/2026, that the facility discovered that Resident 1 had left the facility. During a concurrent interview and record review of Resident 1's medical chart with Licensed Vocational Nurse (LVN) 4 on 5/30/2026 at 12:39 pm, LVN 4 confirmed and stated that the SBAR dated 3/30/3036 indicated that Resident 1 attempted to elope on 3/30/2026. LVN 4 stated that residents must be reassessed with every attempt of elopement or successful elopement. LVN 4 stated that the residents score for elopement will generally increase on the resident elopement risk assessment form. LVN 4 stated that elopement risk score of 10 or greater indicates that a resident is at a high risk for eloping. LVN 4 confirmed that Resident 1's elopement risk assessment completed on 3/30/2026, indicated the resident scored 9 which did not show that Resident 1 was an elopement risk. LVN 4 confirmed and stated that the following questions on elopement risk assessment where inaccurately answered/responded to:- Yes, for a question asking if Resident 1 was cognitively intact.- No, for question asking if Resident 1 wandered around the unit.LVN 4 confirmed and stated that Resident 1's elopement risk assessment dated [DATE] was inaccurate. LVN 4 stated that the elopement risk assessment should have indicated that Resident 1 was a high elopement risk because in the past, Resident 1 attempted to elope from the facility on 3/30/2026. LVN 4 confirmed and stated that there was no care plan in place for Resident 1 for elopement before 5/28/2026. LVN 4 stated that a care plan should have been initiated as soon as the facility identified that Resident 1 was a high elopement risk with interventions outlined to notify nursing on elopement prevention strategies. During the same concurrent observation and interview, Resident 1 was observed passing back and forth in the hallway, from her room to the nurses' station. Resident 1 stated that she returned from GACH 1 a few minutes prior to this same interview. She (Resident 1) stated that she walked to GACH 1 the previous night on 6/2/2026 because she was experiencing chest pain and she felt that nursing staff were not appropriately addressing. Resident 1 stated that she used the facility back elevator and the side gate on the smoking patio to exit the facility. Resident 1 stated that she did not hear any alarm trigger when she left the facility. Resident 1 was observed without a wander guard. Resident 1 stated that she removed the wander guard and left the wander guard on the bedside table and left the faciity on 6/2/2026 night. During a concurrent observation of Resident 1 and interview with RNS 1 on 6/3/2026, RNS 1 confirmed and stated that Resident 1 did not have a wander guard on. RNS 1 stated that Resident 1 needed to always wear a wander guard because the resident is a risk for elopement. During a concurrent interview and record review of Resident 1's medical chart with the Director of Nursing (DON) on 6/4/2026 at 10:34 am, the DON stated Resident 1 ambulated (walked) with steady gait and sometimes used a wheelchair. The DON stated Resident 1 displayed behaviors of wanting to go out and often stated that [Resident 1] has chest pain. The DON stated that the facility called 911 (emergency services) a few times (did not specify) in the past because Resident 1 complained of chest pain. The DON stated that on 6/2/2026, Resident 1 complained of chest and the facility administered Nitroglycerine to Resident 1. The DON stated that an elopement risk assessment must be completed upon resident's admission and at change of condition of an attempt or successful elopement. The DON stated that elopement risk assessment answers must be accurate in order to take care of specifics of the elopement risk. The DON stated that inaccurately answering questions on the assessment can affect the resident elopement risk scoring because there is a potential of scoring a resident as a no risk when in fact the resident is at a risk of elopement. The DON stated that when resident assessments are inaccurate, everything will be affected such as interventions provided for the resident and the facility may fail to safeguard and prevent a resident from eloping. The DON stated that if a resident attempts to elope or successfully elopes, she (DON) expects the resident's elopement risk assessment score to be 10 or higher and Interventions including placing a wander guard and frequent supervision initiated for the resident. The DON stated staff are trained to monitor residents that constantly wander the unit hourly or every two hours. The DON stated that no staff was assigned to monitor Resident 1. The DON admitted and stated that Resident 1 was not safe in the facility because Resident 1 was able to remove the wonder guard. The DON confirmed and stated that Resident 1's elopement risk assessment was inaccurate and there should have been a care plan initiated when Resident 1 attempted to elope on 3/30/2026. During a follow up interview with the DON 6/4/2026 at 12:02 pm, The DON stated that when a resident is readmitted to the facility, the RNS or desk nurse reviews the discharge summary to ensure that any recommendations or abnormal values are identified and reported to the resident's physician for further orders as needed. The DON stated that she also reviewed discharge summaries the following day for oversite and ensure that nothing was missing. The DON had not reviewed the discharge summary as of the time of this interview. The DON was unaware about Resident 1's potassium levels being at 2.7 mmol/L until this surveyor asked her about the levels. The DON stated that a level of 2.7mmol/L was significantly low and some of the signs and symptoms of hypokalemia included muscle cramps, weakness, shortness of breath, heart problems such as chest palpitations which may present as chest pain. The DON confirmed that a low potassium could have potentially caused Resident 1 to complain of chest pain. During an interview with Licensed Vocational Nurse (LVN) 7 on 6/4/2026 at 4:31 pm, LVN 7 stated that she was assigned as a desk nurse on 6/3/2026 when Resident 1 was readmitted to the facility on [DATE]. LVN 7 stated that duties of being a desk nurse included admissions and readmissions which included reviewing the admission paperwork or discharge summaries and ensuring that abnormal results were reported to the physician promptly. LVN 7 stated that she reviewed the admission orders but had not noticed the abnormal potassium levels. LVN 7 stated that a level of 2.7mmol/L must reported to the physician promptly. During a review of a policy and procedures (P&P) titled, Care Planning - Interdisciplinary Team, reviewed 1/29/2026, indicated, The interdisciplinary team is responsible for the development of resident care plans. The same P&P indicated, Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). During a review of the facility's P&P titled Change in a Resident's Condition or Status: reviewed 1/29/2026, the P&P indicated that, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.)Policy Interpretation and Implementation1. The nurse will notify the resident's attending physician or physician on call when there has been a(an) .: d. significant change in the resident's physical/emotional/mental condition; During a review of a P&P titled, Charting and Documentation, reviewed 1/29/2026, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information is to be documented in the resident medical record:Objective observations;Medications administered;Treatments or services performed;Changes in the resident's condition;Events, incidents or accidents involving the resident; andProgress toward or changes in the care plan goals and objectives.

Based on interview and record review, the facility failed to follow its policy and procedures (P&P) titled, Change in a Resident's Condition or Status, reviewed 1/29/2026 by failing to accurately assess one of the four sampled residents (Resident 1) for risk of elopement after the resident by attempted to elope (when a resident leaves the facility grounds or a designated safe area without the staff knowing and/or without the supervision the resident needs) from the facility on 3/30/2026. This deficient practice resulted in Resident 1 successfully eloping from the facility on 5/27/2026 and 6/2/2026. Findings: Cross Reference F684 & F689 During a review of Resident 1's admission record indicated that Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Paroxysmal (irregular) atrial fibrillation (AFib - is an intermittent heart condition where the upper chambers of the heart beat chaotically and out of sync with the lower chambers, heart failure (a serious, progressive condition where the heart muscle weakens or stiffens, preventing it from pumping enough oxygen-rich blood to meet the body's needs), and acute myocardial infarction (heart attack - occurs when blood flow to a section of the heart is suddenly blocked, depriving the heart muscle of oxygen and causing irreversible tissue damage). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/6/2026, the MDS indicated Resident 1 had severe cognitive impairment (a significant decline in thinking, memory, and reasoning that makes it impossible to live independently). The MDS indicated Resident 1 required staff setup or clean up assistance for most of Activities of Daily Living (ADLs such as toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, sit to stand, toilet transfer, and personal hygiene). The MDS indicated Resident 1 required staff supervision or touching assistance for walking between 10-to-150 feet. During a review of Resident 1's History and Physical (H&P - when a physician assesses and interviews a patient then documents findings) dated 2/2/2025 indicated Resident 1 had mild cognitive impairment of uncertain or unknown etiology. During a review of the physician orders dated 3/30/2026 indicated, Check Wander Guard Placement Q [every]. During a review of Resident 1's Situation Background Assessment Recommendation (SBAR- a tool used in healthcare to improve patient safety by enabling fast, accurate, and concise information transfer between clinicians) dated 3/30/2026 at 6:23 pm., the SBAR indicated, post-wandering, and that a wander guard was placed to the right wrist. The SBAR indicated, wonder guard close monitoring reorientation and redirection of behavior. During a review of Resident 1's Elopement Risk assessment dated [DATE] indicated that Resident 1 was not an elopement risk. During a review of Resident 1's Care Plan (CP - is a structured, individualized document created by healthcare professionals in collaboration with the patient to outline specific health conditions, treatment goals, and necessary services) initiated on 5/28/2026 with a focus, Elopement Risk: Places resident at significant risk of getting to a potentially dangerous place/stairs/outside of the facility, indicated Resident 1 had eloped on 5/27/2026 and that she (Resident 1) needed to be considered for a locked unit. The CP goals indicated, Resident safety will be maintained, and Resident will not leave facility unattended. The CP interventions included the following:- Place resident in a room near nurses/station for close observation- Perform frequent safety rounds every 1/2 [half] hour- Initiate and follow through with Psychologist and Psychiatrist consult. During a review of Resident 1's SBAR dated 5/27/2026 at 11 pm., the SBAR indicated a high elopement risk level. The SBAR indicated, Around 11 pm (5/27/2026) noted resident wasn't in her room, search every room and bathroom she was nowhere to find, also check the around the building, unable to find her, MD notified, DON family and called the police, more notes on the progress. The SBAR indicated Resident 1 was returned to the facility from GACH 1 via ambulance service on 5/28/2026 at 5:05 am During a review of Resident 1's SBAR dated 6/2/2026 at 10:22 pm., the SBAR indicated Resident 1 left the facility and went to GACH 1. The same SBAR indicated that at, [10 pm] Charge nurse [Licensed Vocational Nurse] reported that the patient [Resident 1] was not found in her room during routine observation. Patient's (Resident 1) room and bathroom were immediately checked, and the patient was not located. Charge nurse and CNA [Certified Nursing Assistant] conducted a thorough search of the facility, including 3rd floor, lobby, and designated smoking area; however, the patient was not found. Upon further assessment of the patient's room, the wander guard was noted on the bedside table, indicating it had been removed. Immediate follow-up was initiated, checked in with [GACH 1] Emergency Department and patient was located sitting in the Emergency Department in the waiting area. Per Emergency Department nurse, the patient had already checked in for evaluation and would need to sign discharge paperwork if she wished to leave and return to the facility. Patient refused to return to the facility, stating, I don't want to go back to that place anymore. I want to stay here. During a review of Resident 1's Nursing Notes documented by LVN 8, dated 5/27/2026 3:28 pm., indicated the following, [Resident 1] would get up, walk to her room and back to the dining room. [Resident 1] came to the station to get water. [Resident 1] did a lot of walking back in front to the station. [Resident 1] stayed at the station for couple of minutes and go back to her room. The Nursing Notes further indicated LVN 8 usually tells Resident 1 to stay in her (Resident 1's) room because Resident 1 needs to be close to her heart monitoring (pacemaker- a device used to control an irregular heart rhythm). On 5/27/2026 at around 5 pm, dinner was served, medications were administered to Resident 1, that Resident 1 walked to the nurses' station, and that a(unidentified) staff usually monitors Resident 1's whereabouts. On 5/27/2026 at around 9:30 pm, LVN 8 was charting (documenting) at the nurses' station when Resident 1 came to the nurses' station, walked by the nurses' stations and then headed to back to Resident 1's room. On 5/27/2026 at 11 pm, during change of shift Resident 1 was not in her room. LVN 8 checked all the bathrooms and rooms on 3rd floor, however, Resident 1 was nowhere to be found. LVN 8 went downstairs and checked around the building, but was unable to find Resident 1, and that LVN 8 told a Registered Nurse (RN-unidentified) that Resident 1 was missing, on 5/27/2026 at 12:15 AM, a Police officer came and was later joined by 2 (two) police officers who asked questions regarding what the resident looks like, height, weight and race etc. The police officers were at the facility for more than an hour, asked permission to check all the rooms, also checked all the exits. The 2 police officers showed LVN 8 a picture of a person obtained from a street camera and LVN 8 identified and confirmed that, yes that's our resident (Resident 1). Few minutes the two police officers told us that they found the resident she's at GACH 1. During a review of Resident 1's Nursing Notes dated 6/2/2026 11:25 pm., documented by Certified Nursing Assistant (CNA) 9 indicated the following: [Resident 1] received in bed alert and oriented, was not in pain, no shortness of breath or distress noted. On 6/2/2026 at 5 pm Resident 1 received medication, and dinner, and the resident was walking in the hallway. On 6/2/2026 at 8:30 pm, Resident 1 complained of chest pain and nitroglycerine [fast-acting prescription medication used to prevent and rapidly relieve chest pain] 0.4 milligrams [mg- units of measurement] was administered. After 5 minutes CNA 9 checked on Resident 1 and that Resident 1 told CNA 9 that, I am [Resident 1] doing okay. Resident 1 left the faciity on 6/2/2026 at 9:40 pm. During a concurrent observation of the facility smoking patio located on the first floor and interview with the Activities Coordinator (AC) on 5/30/2026 at 11:25 am, the facility patio was inspected/observed. The patio is located to the left and back of the facility reception desk and is separated by a door. Behind the door, is a hallway which is about 10 feet (ft) long with 2 bathrooms to the left side, and to the right is another hallway about 90 ft long with a door at the end which leads out to the smoking patio. The door remained unlocked. The smoking patio is not visible from the inside the facility. The smoking patio is connected to pathways to the left and to the right of the smoking patio which are about 50 ft long. Both pathways are secured with gates which have alarms. The alarm gate to the right side (Gate 1) of the smoking patio is triggers when opened. However, the gate to the left side (Gate 2) was observed to have brown paper jammed into the locking mechanism, preventing the gate from locking and triggering the alarm. The AC opened Gate 2 and confirmed and stated that the alarm did not trigger. The AC removed the paper that was jammed into the locking mechanism of the gate, closed and reopened the gate however, the alarm still did not trigger. The AC confirmed and stated that the paper should not be placed anywhere around any locking mechanism because the paper will prevent the gate from locking and preventing the alarm from engaging/triggering. The AC stated that the potential for jamming the locking mechanism of a gate can result in a resident leaving the facility without staff knowledge. The AC stated that the door should be locked. During an interview with Registered Nurse Supervisor (RNS) 2 on 5/30/2026, RN 2 stated that an elopement is when a resident leaves without staff knowledge or permission. RNS 2 stated that the interventions for residents who are an elopement risk included frequent visual monitoring (unable to state frequency) and placing a wander guard. RNS 2 stated that on 5/27/2026, she came in for her shift around 11 pm and was told that Resident 1 had not been located in the facility and that law enforcement was called. RNS 2 stated that when Resident 1 returned the following day, 5/28/2026, Resident 1 notified RNS that she (Resident 1) left the faciity on 5/27/2026 at around 8:30 pm using the facility back elevator. RNS 2 stated that it was during change of shift between the evening shift and night shift (3pm and 11pm), on 5/27/2026, that the facility discovered that Resident 1 had left the facility. During a concurrent interview and record review of Resident 1's medical chart with Licensed Vocational Nurse (LVN) 4 on 5/30/2026 at 12:39 pm, LVN 4 confirmed and stated that the SBAR dated 3/30/3036 indicated that Resident 1 attempted to elope on 3/30/2026. LVN 4 stated that residents must be reassessed with every attempt of elopement or successful elopement. LVN 4 stated that the residents score for elopement will generally increase on the resident elopement risk assessment form. LVN 4 stated that elopement risk score of 10 or greater indicates that a resident is at a high risk for eloping. LVN 4 confirmed that Resident 1's elopement risk assessment completed on 3/30/2026, indicated the resident scored 9 which did not show that Resident 1 was an elopement risk. LVN 4 confirmed and stated that the following questions on elopement risk assessment where inaccurately answered/responded to:- Yes, for a question asking if Resident 1 was cognitively intact.- No, for question asking if Resident 1 wandered around the unit.LVN 4 confirmed and stated that Resident 1's elopement risk assessment dated [DATE] was inaccurate. LVN 4 stated that the elopement risk assessment should have indicated that Resident 1 was a high elopement risk because in the past, Resident 1 attempted to elope from the facility on 3/30/2026. LVN 4 confirmed and stated that there was no care plan in place for Resident 1 for elopement before 5/28/2026. LVN 4 stated that a care plan should have been initiated as soon as the facility identified that Resident 1 was a high elopement risk with interventions outlined to notify nursing on elopement prevention strategies. During a concurrent observation of the smoking patio gate and interview with Kitchen Staff (KS) 1 on 6/3/2026 at 1:31 pm, the gate leading to the alley at the back of the facility was observed to be propped open with a black plastic bag. KS 1 stated she had propped the door open because she had to take something (did not specify) out quickly. KS 1 confirmed and stated she (KS 1) left the door propped open, unsupervised, making it easily accessible for residents to exit the facility, a resident could have eloped into the main road on the other side of the gate, get hit by a car, be assaulted, or fall. KS 1 stated staff were required to keep the door locked at all times and use a key to unlock and lock it when exiting and entering. KS 1 stated that there is a key available in the kitchen but does not bring the key when she takes the trash out. During an interview with the Maintenance Supervisor (MS) on 6/3/2026 at 1:40 pm, MS stated that the alarm to the Gate 2 of the patio gate was functioning well and that when Kitchen staff went in and out of the gate, the kitchen staff tend to disarm the gate alarm and forgot to rearm the gate alarm. MS admitted and stated that the behavior of staff disarming the gate alarm had occurred a few times within the last week (was unable to state how many times). MS stated that he had checked the same gate (Gate 2) alarm on Friday 5/29/2026 after reports of the alarm not getting triggered when opened which is when he found that the alarm was not being rearmed. MS stated that he (MS) provided the dietary supervisor (DS) with an extra key to Gate 2 to ensure that the kitchen staff had one available for when they had to use the gate to return and emphasized the importance of rearming the alarm. The MS stated that the potential of leaving the gate alarm unarmed was that a resident can escape and get hurt, get run over or attacked by homeless people in the alley. During a concurrent observation and interview with Resident 1 on 6/3/2026 at 1:55 pm, Resident 1's room was not in direct view of the nurses' station. Resident 1's room is located opposite the nurses' station about 2 doors down (about 20 feet away). The back elevator was located to the right side of Resident 1's room away from the nurse's station about 25 feet from her room and not in direct view of the nurses' station. The main elevator was located to the left side of Resident 1's room just past the nurses' station and in view of the station. During the same concurrent observation and interview, Resident 1 was observed passing back and forth in the hallway, from her room to the nurses' station. Resident 1 stated that she returned from GACH 1 a few minutes prior to this same interview. She (Resident 1) stated that she walked to GACH 1 the previous night on 6/2/2026 because she was experiencing chest pain and she felt that nursing staff were not appropriately addressing. Resident 1 stated that she used the facility back elevator and the side gate on the smoking patio to exit the facility. Resident 1 stated that she did not hear any alarm trigger when she left the facility. Resident 1 was observed without a wander guard. Resident 1 stated that she removed the wander guard and left the wander guard on the bedside table and left the faciity on 6/2/2026 night. During a concurrent observation of Resident 1 and interview with RNS 1 on 6/3/2026, RNS 1 confirmed and stated that Resident 1 did not have a wander guard on. RNS 1 stated that Resident 1 needed to always wear a wander guard because the resident is a risk for elopement. During a concurrent interview and record review of Resident 1's medical chart with the Director of Nursing (DON) on 6/4/2026 at 10:34 am, the DON stated Resident 1 ambulated (walked) with steady gait and sometimes used a wheelchair. The DON stated Resident 1 displayed behaviors of wanting to go out and often stated that [Resident 1] has chest pain. The DON stated that the facility called 911 (emergency services) a few times (did not specify) in the past because Resident 1 complained of chest pain. The DON stated that on 6/2/2026, Resident 1 complained of chest and the facility administered Nitroglycerine to Resident 1. The DON stated that an elopement risk assessment must be completed upon resident's admission and at change of condition of an attempt or successful elopement. The DON stated that elopement risk assessment answers must be accurate in order to take care of specifics of the elopement risk. The DON stated that inaccurately answering questions on the assessment can affect the resident elopement risk scoring because there is a potential of scoring a resident as a no risk when in fact the resident is at a risk of elopement. The DON stated that when resident assessments are inaccurate, everything will be affected such as interventions provided for the resident and the facility may fail to safeguard and prevent a resident from eloping. The DON stated that if a resident attempts to elope or successfully elopes, she (DON) expects the resident's elopement risk assessment score to be 10 or higher and Interventions including placing a wander guard and frequent supervision initiated for the resident. The DON stated staff are trained to monitor residents that constantly wander the unit hourly or every two hours. The DON stated that no staff was assigned to monitor Resident 1. The DON admitted and stated that Resident 1 was not safe in the facility because Resident 1 was able to remove the wonder guard. The DON confirmed and stated that Resident 1's elopement risk assessment was inaccurate and there should have been a care plan initiated when Resident 1 attempted to elope on 3/30/2026. During a review of a policy and procedures (P&P) titled, Care Planning - Interdisciplinary Team, reviewed 1/29/2026, indicated, The interdisciplinary team is responsible for the development of resident care plans. The same P&P indicated, Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). During a review of a P&P titled, Care Plans, Comprehensive Person-Centered, reviewed 1/29/2026, 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 same P&P indicated under policy interpretation and implementation including:- The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required IvIDS assessment (Admission, Annual or Significant Change in-Status), and no more than 21 days after admission.- The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. - Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:Receive the services and/or items included in the plan of care: andSee the care plan and sign it after significant changes are made.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. During a review of a P&P titled, Elopements - Residents Behavior and Facility Practices, reviewed 1/26/2026 indicated, Staff shall promptly report any resident who ties to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing.If an employee observes a resident leaving the premises, he/she should:Attempt to prevent the departure in a courteous manner.Get help from other staff members in the immediate vicinity, if necessary; andInstruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises.When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall:a. Examine the resident for injuries;b. Notify the Attending Physician;c. Notify the resident's legal representative (sponsor) of the incident;d. Complete and file Report of incident/Accidente. Document the event in the resident's medical record. During a review of a P&P titled, Change in a Resident's Condition or Status, reviewed 1/29/2026, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). A significant change of condition is a major decline or improvement in the resident's status that:will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status;requires interdisciplinary review and/or revision to the care plan; andultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from mental abuse (intentional, willful, or reckless verbal or nonverbal action) and physical abuse (deliberate aggressive or violent behavior with the intention to cause harm) for two of four sampled residents (Residents 2 and 3) by failing to: 1. Ensure unidentified facility corporate staff (Person from the main company not a regular employee of the facility) did not forcefully pull and remove Residents 2 and 3 from motorized power wheelchairs (MPWC - a battery-operated device designed for individuals with mobility impairments, providing assisted motion with motorized base and a control system, typically a joystick) on 8/29/2025, and place Residents 2 and 3 into manual wheelchairs (MWC - mobility device on wheels that provides support for individuals with limited mobility propelled by the user or the care giver manually pushing the chair) against the residents wishes/will/consent. 2. Ensure Residents 2 and 3 were not confined in bed, and denied mobility from 8/29/2025 to 8/30/2025, when the facility deprived the residents of their preferred mobility device without clinical justification or consent. 3. Residents 2 and 3 were not subjected to intimidation (to make them feel frightened, afraid, or timid, often to force them to do something or to discourage them from acting) when the unidentified facility corporate staff forcefully pulled and removed Residents 2 and 3 from MPWC. These deficient practices resulted in Residents 2 and 3 being subjected to mental and physical abuse while under the care of the facility. Residents 2 and 3 experienced a loss of autonomy (the right and ability to govern or control oneself and make one's own choices), dignity, and independence, which caused psychosocial harm (is the negative mental or physical health impact resulting from psychosocial hazards, which are factors in the design or management of work that cause stress), including anxiety (nervousness), helplessness, and emotional distress. On 9/3/2025, Resident 2 was transferred to a general acute care hospital for further evaluation and management for left shoulder and arm pain.Findings: a. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including cellulitis (a skin infection that causes swelling and redness) of the buttock, seizures, obesity (excessively overweight), pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of left buttocks and sacral region unstageable, overactive bladder (OAB- problem with bladder causes sudden urge to urinate), acute kidney failure (rapid loss of kidney function), chronic pain syndrome, essential hypertension (high blood pressure), pain in both shoulders, weakness, gastro-esophageal reflux disease (GERD- heartburn and indigestion), dependence on wheelchair. A review of Resident 2's care plan titled With Motorized (Power) Wheelchair dated 5/17/2025 indicated no documented goals. The care plan intervention included, resident has been provided education of being aware of surroundings and being extra cautious to minimize risk of injury. A review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 8/14/2025, indicated Resident 2's cognition (the mental ability to make decisions of daily living) was intact. Resident 2 required set up or clean up assistance with eating. Resident 2 required moderate assistance with toileting, showering and transfers. The MDS indicated walking assessment was not completed due to medical condition or safety concerns. The same MDS indicated Resident 1 was independent with the use of MPWC. A review of Resident 2's GACH record titled Shoulder Pain dated 9/3/2025, indicated, Many things can cause shoulder pain including: An injury. Wear the sling Put ice and leave ice on for 20 minutes 2-3 times a day. A review of Resident 2's GACH Xray of the left shoulder dated 9/3/2025, indicated, Impression of no fracture (break in the bone) or dislocation. During an interview on 9/3/2025 at 1:46 p.m. the Assistant Director of Nursing (ADON) regarding the events surrounding Resident 2's transition from a motorized power wheelchair (MPWC) to a manual wheelchair (MWC). The ADON appeared hesitant to speak and expressed concern about potential retaliation. The ADON stated that unidentified corporate staff (Person from the main company not a regular employee of the facility) spoke with Resident 2 with the intent of minimizing the use of the MPWC and transition her to an MWC. According to the ADON, on 8/29/2025, Resident 2 initially agreed to the switch, with the understanding that her need for the MPWC would be evaluated. However, on 9/1/2025, ADON reported hearing that Resident 2 had changed her mind. Despite this, corporate staff allegedly proceeded with the plan and attempted to force Resident 2 out of the MPWC. ADON did not witness the incident directly but was informed of it afterward. The ADON stated that staff contacted the police, who arrived at the facility but only spoke with corporate representatives and not with Resident 2. The ADON then showed the surveyor a typed note on a laptop screen that read: The resident was portrayed by corporate to the police for not having capacity. Following the incident, ADON and the Director of Nursing (DON) spoke with Resident 2. During that conversation, Resident 2 asked what had happened with the police, expressing that she did not have an opportunity to speak with them. Resident 2 then requested that the police be called again and stated that she did not want the Central Supply Manager (CSM) near her room or person. During an interview on 9/3/2025 at 3:18 p.m. with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated that on 9/1/2025, while passing medications down the hall, she heard Resident 2 yelling, Back up, don't touch me. Although she did not know the exact circumstances at the time, LVN 1 heard that staff were attempting to transfer Resident 2 from her MPWC into a manual wheelchair (MWC). LVN 1 stated she did not approach the situation because there were already several individuals around Resident 2, and she did not want to intervene in an unfamiliar situation. LVN 1 reported seeing the [NAME] President of the Corporate (VP) and several unfamiliar individuals present. She also observed the CSM but did not see the DON or the Administrator (Adm) until after the incident had concluded. Later that day, LVN 1 noted that Resident 2 remained in her room, appeared visibly upset, and expressed a desire to be left alone. At that time, LVN 1 observed a manual wheelchair in Resident 2's room. She later saw Resident 2 seated in the MWC both that day (9/1/2025) and the following day, 9/2/2025. Later on, 9/2/2025, LVN 1 observed Resident 2 back in her MPWC and described her as very happy. During an interview on 9/3/2025 at 4:02 p.m. the Administrator (Adm) regarding events surrounding the transition of Resident 2 from a power MPWC to an MWC. The Adm stated that corporate staff visited the facility and conducted rounds, during which they observed several residents using power wheelchairs. On 8/29/2025, corporate staff began approaching residents who used MPWCs. The Adm reported that on Saturday, 8/30/2025, corporate staff spoke directly with Resident 2 about transitioning from the MPWC to the MWC, and Resident 2 agreed at that time. The Adm stated that he was not present at the facility on 9/1/2025 but received a phone call from the DON, who reported that some residents were concerned about potentially losing access to their MPWCs. The DON informed the Adm that she had spoken with Resident 2 on that day and conducted an Interdisciplinary Team (IDT) meeting with her. The Administrator also stated that, to their knowledge, the police were called to the facility at least once on 9/1/2025, around 8 p.m. The Administrator believed that Resident 2 had requested to speak with law enforcement due to feeling uncomfortable about the transition from the MPWC to the MWC. The Administrator concluded by stating that corporate staff had been present in the facility, speaking with residents about switching from MPWCs to MWCs. During an interview on 9/3/2025 at 4:31 p.m. the Director of Medical Records (DMR), stated that upon returning to work on the morning of 9/2/2025, at approximately 7 a.m., she observed Resident 2 seated in a mechanical wheelchair. The DMR expressed surprise, noting that she typically sees Resident 2 using a motorized power wheelchair (MPWC). When the DMR inquired about the change, Resident 2 responded, They took my chair (MPWC) yesterday, referring to 9/1/2025. During an interview on 9/4/2025 at 11:55 a.m. with the CSM regarding an incident that occurred on 9/1/2025, involving Resident 2, the CSM stated that on 9/1/2025, while in the laundry room, he received a call from the VP requesting assistance in transferring Resident 2 from her MPWC to a manual MWC. Upon arriving on the floor, the CSM observed Resident 2 seated in her MPWC in the hallway, surrounded by several unidentified individuals. According to the CSM, the VP explained to Resident 2 that she wanted to transfer her to a manual wheelchair so that the MPWC could be placed in storage. Resident 2 appeared surprised by this request, as she had been using the MPWC for an extended period. Resident 2 responded, No, why? The VP reiterated the reason for the transfer, though the CSM could not recall the exact wording. Resident 2 then stated, I can't walk. I need help. The VP instructed the CSM and another unnamed Certified Nurse Assistant (CNA) to assist with the transfer. The CSM reported that when he attempted to take hold of Resident 2's arm, she said, No, I don't want you to touch me. Despite this, the CSM held one of Resident 2's arms while the unnamed CNA held the other, and they attempted to lift her from the MPWC. However, they were unable to complete the transfer due to Resident 2's weight and subsequently released her. Resident 2 then began yelling and calling us bad names, becoming verbally aggressive. Following this, the CSM stated he left the area and returned to the laundry room. Later that same day, the CSM returned to the floor and observed Resident 2 seated in a manual wheelchair in her room. He also noted that Resident 2's MPWC had been placed in a storage room located downstairs near the kitchen and was covered with a blanket. The CSM stated he does not know how the MPWC was moved to the storage area. During an interview on 9/4/2025 at 12:22pm with Resident 2 regarding events that occurred on 9/1/2025. Resident 2 stated that she was in bed when she was awakened by a man who identified himself as a social worker. The man informed her that the facility was going to take her MPWC and replace it with an MWC. Resident 2 responded, Wait, let me talk to someone because I don't know you. According to Resident 2, the unnamed social worker replied, No you're not, you are going to get out of this chair, and then physically blocked the doorway. Resident 2 stated that she managed to get herself into her MPWC and that the VP instructed the unnamed social worker to allow her to leave the room. Resident 2 then wheeled herself into the hallway in search of someone she recognized. She went downstairs to speak with the receptionist (RCPT), whom she knew, and explained the situation. The RCPT accompanied her back upstairs. Upon returning to the floor, Resident 2 saw the VP, the CSM, the unnamed social worker, and two other unidentified women. At that point, the VP allegedly told her, If you don't get out of that chair, we are going to forcibly remove you. Resident 2 stated that she repeatedly asked to speak with someone she knew, but the VP told her there was no one for her to talk to and that the decision had already been made. On the same interview, Resident 2 stated that the incident occurred in the hallway in front of her room. She reported that the CSM and the unnamed social worker were on her left side, each holding one of her arms, while the two unidentified women were on her right side pulling her other arm. Resident 2 stated that the CSM bent her fingers back on her left hand as she tried to hold onto the armrest of her MPWC. At the same time, the two women on her right side were pulling her arm. Resident 2 recalled yelling, Stop pulling, you're hurting my arm. Let's talk to my doctor first so you can understand my medical condition-why are you doing this? She stated that only at that point did the facility staff stop their actions. Resident 2 then heard the VP instruct Licensed Vocational Nurse 2 (LVN 2) to call the police.Resident 2 became emotional and began crying while recounting the incident. She returned to her room and put on pants, as she had only been wearing a shirt at the time. Resident 2 also stated that she witnessed the facility staff take Resident 3's MPWC. She said, I felt bad, and observed Resident 3 crying in her room with an MWC left behind. Resident 2 stated she felt she had no choice and told the VP she would voluntarily give up her MPWC and use the MWC. Resident 2 stated that when she returned to her room, she saw the police speaking with the VP. The VP allegedly told her, Now that you agree to give up the chair, no need for you to talk to the police. Resident 2 then drove herself downstairs in her MPWC to place it in storage, followed by one of the unidentified women from corporate carrying an MWC. Resident 2 stated she saw Resident 3's MPWC already stored in the same closet. On the same interview, Resident 2 stated that she stayed in bed the entire night of 9/1/2025. The next day, the DON and ADON checked on her. Resident 2 told them her left arm was throbbing. She was informed that the facility attempted to send her out for evaluation but could not locate a bariatric gurney (A heavy-duty, reinforced stretcher designed to safely transport and support patients with high body weight). Resident 2 stated she went to the hospital on 9/3/2025, for her shoulder. Resident 2 further stated that on 9/3/2025, the DON asked her if she had been trained to use the MPWC. Resident 2 responded, I have had that chair for seven years. The company showed me how to use it. They just came here three months ago; this is my fourth chair. The DON then asked if Resident 2 knew where the MPWC was being stored. Resident 2 said yes, and the DON instructed her to go get your chair. Resident 2 stated she self-propelled the MWC using both feet and went downstairs to the closet where the MPWC was stored. She retrieved her MPWC that same day (9/3/2025). During an interview on 9/4/2025 at 1:17 p.m., the RCPT stated, she was on duty beginning at 7 a.m. and typically sees Resident 2 in the mornings. At approximately 9:45 a.m., she observed Resident 2 coming off the elevator into the lobby, appearing visibly upset while speaking with the VP. The conversation appeared to concern Resident 2 being asked to transfer from her MPWC to an MWC. The RCPT heard Resident 2 say, No, I'm not getting out of my chair. Shortly afterward, the RCPT saw the CSM enter the lobby with a high-back MWC. At the same time, Resident 2 drove off in her MPWC down the rear hallway toward the rear elevator. The VP and the CSM followed her with the MWC. The RCPT stated she was unsure what was happening but then heard Resident 2 yelling. Although she could not make out the words, Resident 2 sounded upset, which was unusual, as she is typically cheerful and in a good mood. RCPT stated she went to the back hallway to check on Resident 2. Upon turning the corner, she observed Resident 2, the VP, the CSM, and three unidentified individuals who had arrived with the VP. One of the individuals was speaking to the CSM in Spanish, which the RCPT could not understand. She then heard Resident 2 say to the VP, You don't even know me, why would you say that about me? RCPT decided to remain present, noting that Resident 2 did not appear to know any of the individuals involved. The group then entered the rear elevator and returned to the floor in front of Resident 2's room. Once upstairs, the RCPT asked Resident 2 what was happening. Resident 2 explained that she was being told to get out of her MPWC and into an MWC, which she did not want to do. When the RCPT asked why, Resident 2 said the VP claimed she was driving too fast and could hurt people. Resident 2 responded that the VP didn't even know her and questioned how such an assumption could be made. Resident 2 then asked the RCPT to retrieve her cell phone from her room, which the RCPT did. Resident 2 stated, I need to make a call. The VP then said, You can make your call in this chair, pointing to the MWC. The VP addressed Resident 2 by her first name and said, You need to get into this MWC; if you can't transfer yourself, then we will assist you. Resident 2 replied, Oh, so you're going to physically remove me? At that point, the RCPT intervened and said, Can you please just get into the chair, to de-escalate the situation, as she had a good rapport with Resident 2. Resident 2 looked directly at the RCPT and said, NO. The VP then instructed the RCPT to return to the front desk, which she did. Approximately 10 minutes later, the RCPT saw Resident 2 return to the lobby via the rear hallway in her MPWC, visibly upset, and proceed outside to the smoking area. The RCPT stated she felt the VP, and the others were trying to portray Resident 2 as aggressive, but in her observation, Resident 2 was not aggressive. The RCPT also stated she was unaware that the VP was coming to the facility or the reason for the visit. The RCPT further stated that on 9/3/2025, she returned to the facility and stopped by the DON's office to pick up some papers. While there, she observed Resident 2 enter the office in an MWC and say to the DON, I need my MPWC because I have to go do something. The DON responded that she would contact the Director of Rehabilitation to conduct an in-service with Resident 2 on how to maneuver the MPWC and get that documented before returning the chair. During an interview on 9/4/2025 at 1:58 p.m. LVN 2 stated that she had started working at the facility on 9/1/2025. Earlier that morning, she observed the VP) the CSM, and several other individuals, including an unnamed social worker, speaking with Resident 2 about transferring from her MPWC to an MWC. During that conversation, LVN 2 heard Resident 2 say to the VP, I want to keep my chair, I will leave. LVN 2 then walked away and returned to the nursing station located near Resident 2's room. Between approximately 11:30 a.m. and 12 p.m., LVN 2 heard a commotion and got up to investigate. She observed Resident 2 in her MPWC in the hallway in front of her room. The RCPT was on Resident 2's right side, and an unnamed staff member who had arrived with the VP was standing behind Resident 2. The CSM was on Resident 2's left side, with the VP standing next to her. LVN 2 saw the RCPT rubbing Resident 2's shoulders, apparently trying to persuade her to switch chairs. LVN 2 heard Resident 2 say, I don't want to; I want to keep my chair. LVN 2 briefly stepped away and, upon returning, noticed the RCPT was no longer present. The VP then instructed LVN 2 to call the police. LVN 2 asked why and what was happening, to which the VP responded that Resident 2 was having a behavior. LVN 2 then heard Resident 2 say, No I am not, you don't even know me. Following the VP's directive, LVN 2 called 911 (Universal emergency number for citizens throughout the United States to request emergency assistance). At this time, Resident 2 was visibly upset. The CSM continued attempting to verbally persuade her to transfer, saying, Come on, let's just transfer into the chair. The CSM placed one hand on top of Resident 2's left forearm and the other underneath it, attempting to assist the unnamed staff member on the right side. Simultaneously, the VP was yelling, You guys need to transfer her, at the CSM and the unnamed staff member. The assigned CNA then touched Resident 2's right forearm, appearing ready to assist. LVN 2 intervened and told the CNA, Don't touch her, as Resident 2 had already refused the transfer. Resident 2 then began yelling at the CSM, Don't touch me, get off, that's my arm that hurts. The CSM then removed her hands and said, Okay. During this time, Resident 2 was flailing her arms and nearly slid out of the MPWC. The CSM and the unnamed CNA helped her back into the chair. Resident 2 then told the CSM, Don't you touch me, and told the VP to go away. LVN 2 assisted Resident 2 in adjusting her clothing, as her tank top had ridden up, exposing her abdomen in the hallway. LVN 2 stated that Resident 2 was breathing heavily, visibly upset, and crying. She remained with Resident 2 to console her. Resident 2 denied pain at the time but expressed distress over the situation, stating that it was her right to have the MPWC. LVN 2 reiterated that she had told the CNA not to touch Resident 2 because she had clearly refused the transfer. After the incident, LVN 2 went to the DON office and was surprised to see the DON present, as it was a holiday. LVN 2 informed the DON, Did you hear what's going on out there? You need to come and see what is happening. The DON and the ADON then went to speak with Resident 2.LVN 2 concluded by stating, I was disturbed because Resident 2 was crying after this happened, and I told the DON because they needed to go and check on Resident 2. LVN 2 added, I feel like Resident 2's rights were violated. During an interview on 9/4/2025 at 2:56 p.m. with DON, the DON stated she arrived at the facility on 9/1/2025, around 10 or 10:30 a.m. Upon arrival, she stopped by the nursing station and asked if there were any concerns; no issues were reported at that time. Around 11 a.m. or 12 p.m., LVN 2 came to DON's office and reported a commotion involving a wheelchair. The DON responded, What wheelchair? and then called the Adm to give a heads-up about the concern. The Adm informed her that corporate staff were checking wheelchairs, but it was unclear whether any had been removed. Around 1 p.m., the DON went to the lobby and saw the VP and another woman from corporate. The DON stated, I did not know they were going to be here. She also observed someone from Human Resources present but did not know who had called them or why they were there. The DON then went to speak with Resident 2, who was visibly upset and reported that staff had tried to remove her from her MPWC. Resident 2 stated that she had initially agreed to the transfer but later changed her mind. The DON emphasized that if a resident is to be removed from a wheelchair in such a manner, a physician's order is required. She was told that corporate was checking the safety of the MPWC, but the situation appeared chaotic, prompting her to speak directly with Resident 2. The DON asked Resident 2 how she was feeling without the MPWC, and Resident 2 responded that she only needed the MPWC when she wanted to go out. Resident 2 also stated she had used the MPWC for a long time. The DON explained to Resident 2 that a doctor's order was required for continued use of the MPWC, citing concerns that Resident 2 could potentially hit another resident while operating it. Resident 2 asked the DON who the individuals were that had tried to remove her from the MPWC. The DON responded, Honestly, I don't know, and I did not know they (Corporate) were coming. On the same interview, the DON stated, I have not heard any complaints or any incidents of Resident 2 hitting anyone in the MPWC. She then asked Resident 2 if she wanted her MPWC back, and Resident 2 replied, No, I'm okay with the MWC at this time. The DON informed Resident 2 that the Director of rehabilitation would evaluate her for safety with the MPWC before it could be returned. During an interview on 9/4/2025 at 3:45 p.m., the VP stated that she was instructed by corporate leadership to visit the facility due to ongoing concerns. On 8/30/2025, the VP spoke with Resident 2 but noted that Resident 2 kept leaving the facility. The VP returned on 9/1/2025, accompanied by a social worker, and directed the social worker to speak with Resident 2. The VP stated that Resident 2 made inappropriate comments to the social worker and then went down to the lobby. The facility had an MWC prepared for Resident 2 to transfer into. The VP acknowledged that no communication had occurred with Resident 2's physician prior to requesting the transfer. The VP stated she did not know the medical reason for Resident 2's use of a MPWC but recalled Resident 2 saying, I can't walk. The VP added, But then we went to Resident 2's room and saw Resident 2 transferring from bed to chair unassisted. The VP stated that Resident 2 initially agreed to switch chairs but later changed her mind. During the attempted transfer, the CSM and an unnamed CNA supported Resident 2 from behind to move her from the MPWC to the MWC. The VP described Resident 2 as a very heavy person and stated that while Resident 2 was initially cooperative, she began to resist, at which point the staff stopped the transfer attempt. Later, Resident 2 called the VP back to her room while crying. According to the VP, Resident 2 then voluntarily agreed to give up the MPWC and drove it downstairs to a locked service area in the rear hallway. One of the VP's staff members followed with the MWC, and Resident 2 transferred independently into the MWC. The VP described Resident 2 as not rational and just screaming loudly, though she could not recall the exact words Resident 2 used. The VP stated, It was my social worker and my consultant that were holding Resident 2 to remove Resident 2 from the MPWC, but once Resident 2 refused, they stopped. The VP characterized the situation as a regular transfer until Resident 2 became uncontrollable and allegedly attempted to run them over in the MPWC. The VP also stated that she interviewed 15 residents who claimed that Resident 2 had previously tried to hit them with the MPWC. However, the VP was unable to provide the names of those residents. b. A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] and most recently on 6/8/2024 with diagnoses including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), Parkinson's Disease (PD- a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (broad term to describe involuntary, uncontrollable movements), scoliosis (condition where the spine twists and curves to the side), neuromuscular dysfunction of bladder(neurological disorder that disrupts bladder control), generalized muscle weakness, OAB, osteoarthritis (OA-a progressive disorder of the joints, caused by a gradual loss of cartilage), insomnia (trouble falling asleep or staying asleep), depression, neuralgia (nerve pain), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), allergic rhinitis (allergies), carpal tunnel syndrome (inflamed nerve in the wrist) and dependence on wheelchair. A review of Resident 3's care plan initiated 7/24/2025 indicated Resident enjoys participating in activities and socializing with peers. Resident also independently participates in community activities however at risk for decreased participation due to Parkinsons scoliosis, muscle weakness and dependence on electric wheelchair and staff for ADLs. The goal was for Resident 3 to maintain or improve the current level of engagement in activities to enhance quality of life and psychosocial well-being. Interventions included assisting Resident 3 in accessing patio for fresh air and leisure. A review of Resident 3's MDS dated [DATE] indicated Resident 3's cognition was intact. Resident 3 required maximal assistance (the helper does more than half the effort to complete the activity) with toileting, bathing, and showering. Resident 1 was dependent (Helper does all the effort, resident does none of the effort to complete the activity) with transfers (moving between surfaces) from bed to chair. The same MDS indicated Resident 3 was dependent on the use of the MWC. During a concurrent observation and interview on 9/3/2025 at 12:12 p.m. with Resident 3 inside her room, Resident 3 was observed seated in her MPWC during the interview. Resident 3 stated, The facility took my MPWC because they said it was dangerous. I did not have my MPWC for three days and I just stayed in bed all day. Resident 3 explained that she was provided with a manual wheelchair (MWC), but it lacked footrests, and she could only use her right arm. She stated, I complained about it and had my family call, and they gave me my chair back yesterday (9/2/2025) evening. Resident 3 reported that she has never had any accidents or hit anyone or anything while using her MPWC. She stated she has had an MPWC for 12 years and is currently using her second chair. She added that the company trained her on how to use the chair each time she received a new one. Resident 3 disclosed that she has multiple sclerosis (MS), which limits her ability to walk or use her legs and arms. Regarding the events of 9/1/2025, Resident 3 stated that approximately six unidentified individuals entered her room and kind of ganged up on me. She said she had never seen these people before. They informed her that she could no longer use her MPWC inside the facility and would only be allowed to use it outside. Resident 3 recalled that a Hoyer lift (A type of patient lift used to safely transfer individuals with limited mobility from one place to another) was used to transfer her from the MPWC to her bed. She could not recall the exact time the MPWC was taken but remembered crying in bed all day because she no longer had access to it. She was told the MPWC was downstairs charging. Resident 3 stated that when the MWC was brought to her, she was told, The nurses will push you around the facility where you want to go. She expressed skepticism, saying, Yeah right, they don't have enough staff for that because I like to go a lot of places. Resident 3 became tearful during the interview and shared that she enjoys going to the local college for facials and haircuts. She had planned to go on 9/2/2025 but was unable to because she did not have her MPWC. During an interview on 9/3/2025 at 1:09 p.m. Resident 1 stated, On 9/1/2025 there was a lady (unidentified) here from corporate barking orders. She came with a social worker guy and some other people (unidentified staff). She observed the group speaking with both Resident 2 and Resident 3 about their use of motorized power wheelchairs (MPWCs). Resident 1 stated, I know Resident 3 has had the MPWC for a very long time with no problems until these people showed up demanding to confiscate the chairs and store them in the garage. Resident 1 became tearful during the interview and added, Resident 3 was in bed for two days crying after they took the MPWC and I felt so bad. They took away Resident 3's chair (MPWC) and by doing that they took away Resident 3's independence-and that was not okay. During an interview on 9/3/2025 at 3:49 p.m., Resident 4 stated she and Resident 1 went to check on Resident 3 after her MPWC was taken. Although she could not recall the exact date, she stated, Resident 3 just stayed in bed crying all day. We checked on her for two days. Resident 4 recalled that on 9/1/2025, she observed facility staff entering Resident 3's room with a Hoyer lift. She stated, They lifted Resident 3 out of the chair (MPWC) and put Resident 3 in the bed. Shortly afterward, she saw a maintenance staff member driving Resident 3's MPWC down the hallway toward the back elevator. Resident 4 stated there were approximately five individuals involved, none of whom introduced themselves. She said, We had no clue who they were. They just said, 'We're taking your chair. During an interview on 9/4/2025 at 2:56 p.m. with DON, the DON stated that she spoke with Family Member 1 (FM 1) on 9/2/2025, regarding Resident 3's MPWC and informed FM 1 that an evaluation would be conducted. The DON visited Resident 3 on the same day but could not recall whether the MPWC was present in the room. She noted that Resident 3 was in bed during the visit. The DON asked Resident 3 whether she had ever been trained on how to use the MPWC. According to the DON, Resident 3 either[TRUN

Based on observation, interview, and record review, the facility failed to ensure the resident, who was assessed as risk for falls, did not fall and sustained injury for one of four residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was supervised and monitored to prevent repeated falls and injuries from 9/13/2024 to 3/15/202 per care plan titled; Falling Star dated 9/13/24. 2. Revise and evaluate the effectiveness of interventions of Resident 1's care plan titled, Falling Star Program, dated 9/13/24 after Resident 1 was found on floor11/14/2024, to prevent Resident 1 from future falling. 3. Ensure there was no urine on the floor by the Resident 1's bedside that led Resident 1 to slip on the paddle of urine and fall. 4. Ensure Resident 1 was place on one to one (1:1-staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act) care with a sitter per Falling Star Program, dated 9/13/2024. 5. Ensure staff followed the facility's policy and procedures (P&P) titled, Falls and Fall Risk, managing dated 11/21/2024, which indicated, staff will identify interventions related to the resident's specific risk and causes to prevent the resident from falling and to minimize complications from falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As a result, Resident 1 had three falls on 9/13/2024, 11/14/2024, and 3/15/2025 where Resident 1 suffered severe pain and left sub-capital (below) left femoral (thigh bone) neck fracture requiring hospitalization to undergo hemiarthroplasty (a surgical procedure where half of a joint is replaced with an artificial implant) of the left hip. Findings: A review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included Osteoarthritis (degenerative joint disease, in which the tissues in the joint break down over time), repeated falls, protein malnutrition (deficiency or imbalance of protein and energy), atherosclerosis (disease characterized by the buildup of plaque in the inner walls of the arteries), major depressive disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities, significantly impacting daily functioning) and epilepsy (disorder of the brain characterized by sudden alteration of behavior due to a temporary change in the electrical functioning of the brain) A review of Resident 1s Minimum Data Set (MDS - a standardized resident assessment tool) dated 1/13/2025, indicated Resident 1 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 1 required supervision or touching assistance with personal hygiene, upper body dressing and ambulating up to 10 feet, Resident 1 required partial moderate assistance with personal hygiene and lower body dressing. The MDS indicated Resident 1 is continent (ability to voluntary release of urine or feces). A review of Resident 1's Fall Risk assessment dated [DATE], indicated Resident 1 had decreased muscular coordination, and an unsteady gait/balance while standing and walking, placing the resident at a moderate risk for falls. A review of Resident 1's Rehab Admission Rehabilitation Screening notes dated 9/18/2024, indicated Resident 1 was totally dependent on staff and required two persons assistance for bed mobility and transfer. The Rehab Admission Rehabilitation Screening notes indicated Resident 1 was not evaluated for ambulation. The Rehab Admission Rehabilitation Screening notes indicated Resident 1 used a wheelchair for locomotion (movement), and that the resident was totally dependent and required two persons assistance with sitting balance. The Rehab Admission Rehabilitation Screening notes indicated Resident 1 was unsteady, and had mild difficulty with cognition, decision making due to a memory problem. A review of Resident 1's Change of Condition (COC - a deviation from a patient's baseline state of health, often involving a sudden or clinically significant worsening) Situation-Background-Assessment-Recommendation (SBAR- is a technique used to provide a framework for communication between members of the health care team) form and progress notes dated 9/13/2024, at 6:45 AM indicated a certified nurse assistant (CNA) found Resident 1 sitting on the floor at foot of her bed and had blood on the hair and on the left hand. The COC-SBAR indicated that upon assessment, Resident 1 sustained a cut to the left side of the head and a cut underneath the left eye. The COC-SBAR indicated Resident 1 did not respond to verbal stimuli, blood pressure, heart rate, respirations, temperature and oxygen saturation were taken and 911 (emergency response telephone number) was called. Resident 1 was transferred to an acute care hospital for a higher level of care. A review of Resident 1's care plan titled, Falling Star Program, dated 9/13/2024, indicated Resident 1 was at risk for falls related to history of falls, dementia, muscle wasting. The care plan goal indicated to reduce risk of falls and/or injury through appropriate intervention(s) daily until the next assessment. The care plan interventions include bed in lowest position, wheelchair's wheels locked, call light within reach, environment-maintained clutter free, non-skid shoes/slipper when out of bed, room organization, safety round checks, and may apply pad alarm on the bed to alert staff to assist resident to prevent falls. A review of Resident 1's care plan titled, Resident has had an actual fall created on 9/13/2024, indicated that: -On 9/13/2024, Resident 1 with cut of left side of the head and underneath left eye. Resident 1 was found sitting on the foot of her bed. Resident 1 was transferred to GACH via 911. - On 11/14/2024, Resident 1 was found on floor sitting on buttocks against bed sitting in upright position. -On 3/15/2025, Resident 1 had an actual fall. Resident 1 was found lying at the foot of her bed, positioned on the left side. Patient's muscles are tensed and shaking continuously. Risk factors include poor balance, poor communication, unsteady gait and dementia. The interventions indicated Resident 1 to have resident's bed at lowest position when in bed three times a day for fall precaution, floor pads for safety precaution. A review of Resident 1's Fall Risk assessment dated [DATE] at 9:25 AM, indicated Resident 1 had unwitnessed fall inside her room obtained left forehead skin tear s/p (status post-after) seizure. The Fall Risk Assessment - fall interventions included skilled rehab (rehabilitation) services for Physical Therapy (PT - is a healthcare specialty that focuses on improving physical function and movement using exercises, manual therapy, and other modalities), Occupational Therapy (OT - The practice of helping individuals with disabilities or health conditions improve their ability to participate in daily activities and maintain independence), and Safety awareness. A review of Resident 1's GACH Vascular Neurology (a specialized field within neurology that focuses on diagnosing, treating, and managing diseases and conditions related to the blood vessels of the brain and spinal cord) Progress Note dated 9/15/2024, indicated Resident 1 was brought to the emergency roiagnom on [DATE] after unwitnessed fall. A review of Resident 1's Computerized Tomography (CT - is a medical imaging technique that uses x-rays to create detailed, cross-sectional images of the body's internal structures, such as bones, organs, and blood vessels) from the GACH indicated the CT scan was unremarkable, and Resident 1 was discharged from ED. A review of Resident 1's GACH Hospitalist (a Physician whose primary focus is caring for hospitalized patients only) Progress Notes signed by GACH medical doctor (MD) dated 9/15/2024 at 1:05 PM, indicated that on 9/13/2024 at 1:05 PM, Resident 1 presented to the GACH from the skilled nursing facility (SNF) due to unwitnessed fall. The GACH hospitalist progress notes assessment and plan included . Staples (fasteners used to close wounds or surgical incisions) to be removed in 7-10 days from head laceration after fall at SNF. A review of Resident 1 Interdisciplinary Team (IDT- group of healthcare professionals from various disciplines who work together to provide comprehensive and coordinated care for patients) Review-Fall dated 9/16/2024 at 11:40 AM, indicated Resident 1 had unwitnessed fall inside her room obtained left forehead skin tear s/p seizure . was transferred to hospital via 911. The IDT Review- Fall interventions include skilled rehab services for PT and OT, and safety awareness. The IDT Review-Fall did not address interventions to prevent future falls. A review of Resident 1's COC-SBAR dated 11/14/2024 at 11:50 AM, indicated Resident 1 was found on floor sitting on buttocks back against bed sitting in upright position, increased confusion noted, complaining of dizziness and unsteady gait. The COC-SBAR indicated Resident 1 was not sent to GACH after the fall. A review of Resident 1 IDT Review-Fall dated 11/24/2024 at 12:00 AM, indicated [Resident 1] found on floor sitting on buttocks back against bed sitting in upright position. Bed in lowest level, call light within reach. The IDT Review- Fall assessment/root cause analysis indicated (Resident 1) was demented, periods of not calling for assistance due to forgetfulness. Intervention was to leave the bed to lowest level for prevention of injury. The IDT Review- Fall interventions include bilateral (both) upper rails for enabler and mobility use due to generalized muscle weakness. Monitor side effects from antidepressant medication, Zoloft. On skilled PT to promote gait and safe functional transfer and mobility. The IDT Review-Fall did not address interventions to prevent future falls. A review of Resident 1's COC-SBAR dated 3/15/2025 at 1:15 AM, indicated that on 3/15/2025 at 1:15 AM, the charge nurse (unidentified) notified the writer (a registered Nurse -RN) that Residen1 was found lying on the left side on the floor at the foot of the bed. The COC-SBAR indicated Resident 1 was experiencing significant discomfort and pain evidenced by the resident guarding of the left hip. The COC-SBAR indicated Resident 1's left hip muscle was tensed, and the muscle was shaking continuously. The COC-SBAR indicated Resident 1 refused the charge nurse to take the vital signs (measurable physiological indicators that reflect a person's overall health and well-being including blood pressure - BP 129/68 millimeters of mercury [mmHg- unit of measurement -normal is less than 120/80 mmHg], temperature [Temp] 97.5 degrees Fahrenheit [F - normal range 97-99], Pulse [heart rate-HR] 72 beats per minute [normal 60-100], respirations [RR] 18 breaths per minute [normal 12-18], and Oxygen saturation [O2 Sat - percentage of oxygen present in the blood] . The COC-SBAR indicated Resident 1 stated that she was trying to go the bathroom. The COC-SBAR indicated Paramedics (healthcare professionals, who provides advanced emergency medical care and transportation) were contacted immediately, came to the facility, assessed Resident 1 and determined that Resident 1 needed to be transferred to the emergency room (ER-a specialized hospital area equipped to handle and treat patients with sudden, serious illnesses or injuries requiring immediate medical attention). A review of Resident 1's x-ray dated 3/15/2025 at 10:42 AM, indicated an impression of Redemonstrated (a finding or condition has been observed again on a follow-up examination) sub-capital left femoral neck fracture (a fracture of the neck of the femur specifically in the sub-capital region (the area just below the head of the femur) on the left side. A review of Resident 1's GACH History and Physical dated 3/15/2025 at 11:34 AM, indicated Resident 1 presenting from Skilled Nursing facility (SNF) with unwitnessed fall with left hip pain (pain level not indicated). A review of Resident 1's GACH Operative Report dated 3/16/2025 at 3.11 PM, indicated Resident 1 had a pre-operative (before surgery) diagnosis of displaced left femoral neck fracture and that on 3/16/2025 at 3:11 PM Resident 1 had left hip hemiarthroplasty. A review of Resident 1's GACH Orthopedic (medical specialty focused on the diagnosis, treatment, and prevention of conditions related to the musculoskeletal system (bones, joints, muscles, tendons, ligaments, and nerves) Consult Notes dated 3/15/2025 at 1:21 PM indicated Resident 1, with a history of dementia, who presented with severe pain in the left hip which began after an unwitnessed fall yesterday (3/14/2025) at the skilled nursing facility (SNF) where she was found in a puddle of urine. has continued severe pain in the left hip that is worse with movement and improved with rest . A review of Resident 1's COC-SBAR dated 3/18/2025 at 4:53 PM and documented by RN Consultant, indicated that on 3/15/2025 at 1:15 AM, indicated that Resident 1 was transferred to hospital via 911 due to unwitnessed fall . 2 CNAs heard the loud noise from Resident 1's room then rushed to the resident. The 2 CNAs called the Charge Nurse (unidentified), and RN (unidentified) assessed Resident 1. The COC-SBAR indicated that 1 (one) transferred the resident back to bed and paramedics called because Resident 1 was in pain. During a concurrent observation and interview on 4/1/2025 at 12:37 PM, in Resident 1's room, with licensed vocational nurse (LVN) 1, Resident 1's call light was observed on the resident's dresser drawer and not within reach. LVN 1 stated Resident 1's call light was probably moved away from the resident by a Certified Nurse Assistant (CNA) 1, who cleaned Resident 1 in the morning (4/1/2025). LVN 1 stated the CNA1 must have forgotten to put the call light back to be within Resident 1's reach. LVN 1 stated Resident 1, is forgetful, sometimes she (Resident 1) stands on her own and is a fall risk. LVN 1 stated Resident 1 fell and sustained an injury last month (unable to recall the exact date). LVN 1 stated residents call light is supposed to be within the residents reach so that it is easier for the residents to call for assistance. During an interview on 4/1/2025 at 12:41pm, CNA 1 stated Resident 1 is confused, pleasant, and can communicate some needs. CNA 1 stated Resident 1 is incontinent bowel and bladder (inability to prevent the involuntary release of urine or feces). CNA 1 stated Resident 1 used to ambulate (walk) but does not walk since the resident was readmitted on [DATE]. CNA1 stated Resident 1 does not have situational awareness (conscious knowledge of the immediate environment and the events that are occurring in it) and is unable to recognize that she (Resident 1) is a risk for falls. During an observation in Resident 1's room on 4/1/2025 at 1:30 pm, Resident 1 was observed getting out of bed unsupervised, and stepped on a wet floor mat with water. Resident 1 unsteadily bent forward and down and picked up a water pitcher that was on the floor. Resident 1 then placed the water pitcher on top of her bedside table. During an observation on 4/1/2025 at 1:34 pm, CNA 1 was observed enter Resident 1's room as Resident 1 was trying to get back in bed. CNA 1 then assisted Resident 1 back to bed. During an interview with director of nursing (DON) on 4/1/2025 at 5:18 pm, DON stated Resident 1 fell in the facility on 3/15/2025, because Resident 1 is confused more than usual, there was urine was on the floor by the Resident 1's bedside, and that Resident 1 slipped on the paddle of urine and fell . DON stated Resident 1 should have been place on one to one (1:1-staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act.) care with a sitter. A review of facility policy and procedures (P&P) titled Falls and Fall Risk, Managing, dated 11/21/2024, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to prevent the resident from falling and to minimize complications from falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. A review of facility P&P titled, Falls - Clinical Protocol dated 11/21/2024 indicated, Based on preceding assessment, the staff and physician will identify pertinent interventions to prevent subsequent falls and to address the risks of clinically significant consequences of falling. The staff with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and complications have been resolved. A review of facility Mandatory facility in-service (training programs designed for healthcare professionals to update their knowledge and skills and improve their professional development) and lesson plan dated 3/18/2025 titled Clinical Protocol for falls and fall prevention, assessments dated 3/18/2025, indicated, Upon completion of this activity, participant/s will be able to: Understand the risk factors associated with falls Identify strategies to prevent falls.

Based on observation, interview, and record review, for one of six sampled residents (Resident 1) who was a fall risk, deaf, and blind, the facility failed to ensure: 1) Resident 1 was supervised to prevent falls 2) The bed alarm (is an effective device that alerts caregivers when someone attempts to get out of bed. It typically works with a sensor pad placed under the mattress or sheets that detects pressure) was transferred with the Resident 1 and was activated/functional when Resident 1 was transferred to another room. These deficient practices resulted in Resident 1 falling on 2/07/2025 and sustaining a small cut on the forehead and a fracture (break in a bone) to the right hip bone near hip prosthesis (a device that replaces or enhances a missing or impaired body part). On 2/07/2025, Resident 1 was transferred to a general acute care hospital (GACH - a health facility having a professional responsibility and an organized medical staff that provides 24-hour inpatient care) via ambulance for further evaluation. Findings: During a record review, Resident 1's Admission Record (a document containing demographic and diagnostic information) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including: metabolic encephalopathy (a general term that describes a brain disease, damage or malfunction; brain function is disturbed), muscle weakness (when muscles are weak causing difficulty performing normal activities that require strength), unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems interfering with the person's daily life and activities), unspecified glaucoma (a condition in which there is a build-up of fluid in the eye, causing vision loss and blindness), unsteadiness on feet, abnormalities of gait (a person's manner of walking) and mobility (ability to move freely and easily), history of falling, and presence of right artificial hip joint (a surgical implant that replaces a damaged hip joint). During a record review, Resident 1's Admission Summary Progress Note, dated 11/09/2024, indicated, Resident 1 had the following diagnoses: metabolic encephalopathy, glaucoma, history of fall, clinical bilateral blindness (a complete loss of vision in both eyes), was hard of hearing, and had a surgical scar to the right hip. During a record review, Resident 1's Physician Order Summary Report (a list of all types of physician orders) dated 11/09/2024, indicated, Resident 1 had orders for bed alarm (a device that detects when someone leaves their bed and alerts caregivers so they can prevent falls) and bilateral (both sides) floor mats applied as fall precaution devices. During a record review of Resident 1's Fall Risk Assessment (a tool to assess a patient's likelihood of falling) dated 11/09/2024, indicated, Resident 1 was at risk for falls. During a record review, Resident 1's History and Physical (H&P - a physician's complete patient examination), dated 11/11/2024, indicated, Resident 1 was a fall precaution, confused, and had episodes of mania (mental state of an extreme highs or depressive lows). The H&P indicated Resident 1 was not able to understand and make decisions due to altered mental status (AMS - a group of clinical symptoms rather than a specific diagnosis, and includes cognitive disorders, attention disorders, arousal disorders, and decreased level of consciousness). During a record review, Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/15/2024, indicated, Resident 1 had moderately impaired cognition (make poor decisions, cues and supervisions required). The MDS indicated Resident 1 used a wheelchair for mobility. During record review, Resident 1's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) on behavior problem dated 11/16/2024, indicated, Resident 1 had a behavior problem (restlessness) related to dementia with psychotic (a mental health condition characterized by a loss of touch with reality) behavior. The CP goal indicated that Resident 1 will have fewer episodes of restlessness by 12/26/2024. The CP interventions included to monitor Resident 1's behavior episodes while attempts are made to determine underlying cause. During a record review, Resident 1's Physician Order Summary Report dated 2/04/2025, indicated, to monitor Resident 1 for persistent episodes of aggressive behavior every shift. During a record review of Resident 1's GACH hospitalization from [DATE] through 2/11/2025, Resident 1 was in the GACH emergency room (ER) on 2/07/2025 for a mid-forehead wound and a closed fracture of the right hip (a break in the hip joint that does not break the skin). During a record review, GACH x-ray of the right femur (thigh bone) taken on 2/07/2025, indicated Resident 1 sustained a new fractured line (visible line or crack where a bone has broken) inside the right hip arthroplasty (a surgical procedure to replace parts of the right hip joint with artificial parts). During a record review, GACH Computed Tomography (CT - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body) scan taken on 2/08/2025, indicated Resident 1 sustained a fracture (a break in a bone) within the right hip. During a record review, GACH H&P dated 2/08/2025, indicated, Resident 1 was admitted to the medical surgical unit (a specialized area that provides care for patients who need medical and surgical care) of the hospital on 2/08/2025 for periprosthetic fracture (a bone fracture that occurs around or near an orthopedic [bone or muscle] implant). During a record review, the facility Interview Statement document dated 2/11/2025 documented by Social Services Director (SSD), indicated SSD interviewed Resident 2. The facility Interview Statement indicated Resident 2 said he [Resident 2] did not hear a bed alarm. The facility Interview Statement indicated that Resident 2 heard Resident 1 say, He [Resident 1] broke his hip and leg that's why [Resident 1] was unable to walk this whole time. The facility Interview Statement indicated Resident 2 did not see or hear Resident 1 fall. The facility interview statement document did not indicate the date or time of the incident. During a record review, the facility report titled Final Investigation for Resident 1, dated 2/14/2025, indicated that on 2/7/2025, Resident 1 had an episode of altercation (heated argument) with facility roommates. Resident 1 grabbed the roommate's (unidentified) arm. Resident 1 was confused, agitated, and sustained a skin tear on the forehead. Resident 1 was not able to verbalize the detail of the incident because of the dementia. First aid was provided to Resident 1 and Resident 1's physician ordered to transfer the resident to general acute care hospital (GACH) for further evaluation. The final investigation report indicated that per ED (Emergency Department) assessment (no date), indicated Resident 1 presented with a small wound to the mid forehead, and a CT showed that Resident 1 had nondisplaced oblique (a fracture at an angle) fracture lucency (dark area on x-ray image that indicates a bone fracture) within R (right) subtrochanteric (below the bony part of the thigh bone) region concern of periprosthetic fracture (a fracture occurring near a hip replacement implant) . Resident 1 had right hip tenderness. During a record review, Resident 2's Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (damage to the tissues in the brain due to loss of oxygen to the area) affecting right dominant side, Type 2 Diabetes Mellitus (T2DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (abnormally high blood pressure not caused by a medical condition). During a record review, Resident 2's MDS dated [DATE], indicated Resident 2 was cognitively intact (mental ability to make decisions on activities of daily living). During a record review, Resident 3's Admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: including congestive heart failure (a long-term condition in which a person's heart cannot pump blood well enough to meet a person's body's needs), atrial fibrillation (an irregular and often very rapid heart rhythm), T2DM, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a condition of excessive worry about daily issues and situations), essential hypertension, and history of falling. During a record review, Resident 3's MDS dated [DATE] indicated Resident 3 was cognitively intact. During an interview on 2/24/25 at 1:27 PM, Resident 2 stated, that between 5:30 PM and 6 PM, Resident 2, unsure of the date, was in his room watching TV (television) when facility staff brought and placed Resident 1 in the bed next to [Resident 2's] bed. Resident 2 stated, minutes after [Resident 1] arrived, [Resident 1] stood up and said, I got to get out of here. Resident 2 stated Resident 1 grabbed the bed curtain between them and I grabbed the curtain from my side to stop Resident 1 from pulling the curtain down. Resident 2 stated Resident 1 grabbed Resident 2's left arm through the curtain and then Resident 1 said, I'll kill you. I'll kill you. Resident 2 stated he screamed for help then Resident 1 let go of my arm. Resident 2 stated Certified Nurse Assistant (CNA) 1 came in and helped me. Resident 2 stated, I saw his [Resident 1] legs and feet under the curtain. Resident 2 stated CNA 1 and another nurse (unable to identify the nurse) helped Resident 1 off the floor and on to Resident 1's bed. Resident 2 stated Registered Nurse Supervisor (RNS) 1 assessed both Resident 2 and Resident 1. Resident 2 stated, I didn't hear any alarm at all. During an interview on 2/24/2025 at 1:57 PM, Resident 3 (Resident 1's roommate) stated Resident 1 pulled the curtain between us many, many times, almost daily. Resident 3 stated Resident 1 had to get out of bed to do this because Resident 1 cannot reach the curtain. Resident 3 stated Resident 1 gets out of bed frequently. During an interview with RNS 1 on 2/24/2025 at 2:56 PM, RNS 1 stated Resident 1 had a bed alarm to alert staff when the resident would attempt to get out of bed. RNS 1 stated that on 2/07/2025 at around 5:30 PM, Resident 1 was transferred to another room, however, the bed alarm was not transferred with Resident 1. During a concurrent observation and interview in the Compliance Office with CNA 1 on 2/24/2025 at 5:15 PM, CNA 1 stated that on 2/07/2025, Resident 1 was agitated and was throwing things on Resident 8's bedside table onto the floor. CNA 1 stated that on 2/07/2025, Resident 1 was transferred in a wheelchair to a different room because there's already a bed in the current room. CNA 1 stated that on 2/07/2025 at 6 PM, he went to Resident 1's room because, I heard someone screaming for help. CNA 1 stated CNA 1 found Resident 1 on the floor. CNA 1 lay on the floor and demonstrated how CNA 1 found Resident 1 on the floor. CNA 1 both legs were stretched out with the back leaning against a chair. CNA 1 stated CNA 1 did not hear Resident 1's bed alarm go-off to alert staff that the resident was getting out of bed. CNA 1 stated another nurse (unable to identify nurse's name) helped CNA 1 return Resident 1 back to bed. During a telephone interview with Resident 1's family member (FMR1) on 2/25/2025 at 2:48 PM, FMR1 stated that on 2/07/2025 around 9:15 PM and 9:30 PM Licensed Vocational Nurse (LVN) 1 told FMR1 that the facility sent Resident 1 to GACH emergency room (ER) because the resident was confused. FMR1 stated LVN 1 told FMR1 that Resident 1 was going room to room, walking. FMR1 stated to LVN 1 that Resident 1 was not supposed to walk because he [Resident 1] will fall. FMR1 stated that RNS 1 told FMR1 that Resident 1 was sent to GACH ER because the resident was confused and agitated. FMR1 stated FMR1 contacted the GACH and an ER Nurse informed FMR1 that Resident 1 had a fresh laceration on the forehead and that Resident 1 was complaining of extreme pain to the right hip and leg. During a telephone interview on 2/25/2025 at 4:14 PM, LVN 1 stated that Resident 1 was identified as a fall risk. LVN 1 stated that on 2/07/2025, CNA 1 transferred Resident 1 in a wheelchair to a different room. LVN 1 stated Resident 1 had a small little cut on the bridge of his nose ., seemed agitated, didn't want to sit in the wheelchair, didn't want to be touched, and was confused. LVN 1 stated LVN 1 performed a visual assessment of the Resident 1 because Resident 1, didn't want to be touched .when I touched him, he would just jerk away. When LVN 1 was asked what Resident 1 was trying to jerk away from, LVN 1 stated I don't know .I think he was very agitated. During a record review, the facility Policy and Procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled 'Tab Alarms (Bed Alarms), Bed Alarms, Wanderguard System (a bracelet with sensors that trigger alerts when a resident attempts to leave a designated area),' reviewed on 11/21/2024, indicated, 'the bed alarms may be used on a resident who is deemed unsafe . The bed alarm will be utilized on the resident while they are in bed. When bed alarms are in place, a safety check to ensure bed alarm is in proper working condition before leaving the resident. During a record review, the facility P&P titled Safety and Supervision of Residents, reviewed on 11/21/2024, indicated, the care team shall . reduce individual risks related to hazards .including adequate supervision . During a record review, the facility P&P titled Assessing Falls and Their Causes, reviewed on 11/21/2024, indicated, residents are to be evaluated for possible injuries to the head, neck, spine, and extremities (arms, legs, fingers and toes) and if an assessment rules out significant injury .

Based on interview and record review, the facility failed to assess the right lower leg with a short leg splint (SLS - a devise that holds/supports a fracture [broken bone] or dislocated bone in place) which is at risk to develop pressure injuries (are localized damage to the skin as well as underlying soft tissue, usually occurring over a bony prominence or related to medical devices) for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1's developing unstageable pressure-induced tissue damage (full thickness pressure injuries in which the base is covered by slough/eschar [dead tissues]) of the right lower leg related to a medical device (short leg splint). Cross Reference (F656, F697, and F842) Findings: A review of Resident 1's Face Sheet, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dislocation (an injury where a joint is forced out of normal position) of right ankle joint, syncope (fainting or passing out) and osteoporosis (weak and brittle bones). A review of Resident 1's GACH Discharge Summary (DCS) record, dated 12/15/2023, indicated, a reduction (uses traction-countertraction to disengage [separate] the talus [ankle bone] from the distal tibia [bony structure of the ankle joint]) of tibiotalar (junction between the lower leg bones and the ankle bone) dislocation at bedside was performed on Resident 1's right lower extremity (RLE- leg). The DCS also indicated a SLS was applied on Resident 1's RLE. A review of Resident 1's Pressure Sore (pressure injury) Risk (PSR) document, dated 12/15/2024, indicated Resident 1 was at risk for pressure injury. A review of Resident 1's Data Collection (DC), dated 12/18/2024, under skin condition indicated, Resident 1 was assessed and noted to have dislocated (separation of two ends of the bones where they meet at a joint) right ankle with SLS cast, blanchable (skin that remains white or pale for longer than normal when pressed) redness on the sacral area and bilateral upper extremities (both arms) discolorations (any change in your natural skin tone). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 12/21/2023, indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making. The MDS indicated Resident 1 required moderate staff assistance for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS indicated Resident 1 was at risk of developing pressure injuries. A review of Resident 1's medical chart (MC-progress notes, physician order and skin assessment documentation) dated from 12/15/2023 to 12/20/2023, indicated there was no documentation of assessments and monitoring for Resident 1's RLE with SLS. A review of Resident 1's Treatment Administration Record (TAR), dated from 12/15/2023 to 12/21/2023, indicated no splint care treatment was provided to Resident 1's RLE. A review of Resident 1's Physician Order Report (POR), dated from 12/15/2023 to 1/26/2024, indicated, no splint care treatment order to Resident 1's RLE. A review of Resident 1's pressure ulcer risk care plan, dated, 12/17/2023, care plan indicated Resident 1 was at risk for pressure injury. The care plan goal was for Resident 1 to maintain skin integrity. The care plan indicated the facility will identify risks factors placing Resident 1 at risk for developing pressure injuries. The care plan indicated Resident 1 to have weekly skin check. The care plan did not specify the plan of care for Resident 1's RLE with the SLS. A review of Resident 1's Situation, Background, Appearance and Review/Notify (SBAR - structured tool for healthcare provider that provides communication between members and to document change of condition [COC - clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains]), dated, 12/21/2023, indicated Resident 1 had developed new wound with possible infection to the RLE. A review of Resident 1's POR, dated 12/21/2023, indicated Resident 1 for wound consult regarding right lower leg median area wound due to (d/t) friction from the cast/splint. A review of Resident 1's medical record, titled, Skilled Nursing Facility Wound Care (SNF WC) Progress Notes, dated 12/21/2023, indicated Resident 1 was seen by a Wound Care Physician (WC MD). The SNF WC progress note indicated Resident 1 was assessed with right lower leg medical device related, unstageable pressure injury (Full - thickness [wounds that extend past two layers of the skin] pressure injuries in which the base is obscured by slough [yellow/white material in a wound] and or eschar [dead tissue]) induced tissue damage measuring 2.5 centimeters (cm - unit of measurement) by 3.5 cm by 0.1 cm with subcutaneous (beneath, or under the layers of skin) tissues. The SNF WC progress note indicated WC MD performed necrotic (dead) subcutaneous tissue debridement (removal of damaged tissue from a wound) procedure on the right medial leg wound. The SNF WC progress note indicated that after the procedure [debridement], Resident 1's right medial leg wound was fragile and with erythema (redness) on the peri-wound (surrounding area of the wound). A review of Resident 1's POR, dated 12/21/2023, indicated to cleanse Resident 1's new found wound on the right lower leg median area wound with normal saline (NS - solution for wound care), pat dry, apply a thin amount of Santyl (medication used to remove damaged/necrotic tissue) ointment and cover with dry dressing daily and as needed if soiled (dirty), saturated (thoroughly soaked) or dislodged (out of position). A review of Resident 1's TAR, dated from 12/21/2023 to 1/26/2024, indicated to cleanse Resident 1's right lower leg median area wound with normal saline (NS), pat dry, apply a thin amount of Santyl (medication used to remove damaged tissue) ointment and cover with dry dressing daily and as needed if soiled (dirty), saturated (thoroughly soaked) or dislodged (out of position). During an interview with Resident 1's family 1 (R1F1) and Resident 1's family 2 (R1F2) on 2/16/2024 at 10:08 a.m., R1F1 and R1F2 stated that they had been begging and pleading with facility staff to assess Resident 1's right lower leg because Resident 1's had been complaining of right leg pain from 12/16/2023 to 12/18/2023 and on 12/20/2023. R1F1 and R1F2 stated that on 12/21/2023, the Treatment Nurse (TXN) finally opened Resident 1's RLE cast and found a wound on the right medial leg area. R1F1 and R1F2 stated that the surrounding skin of the wound on Resident 1's right lower leg was red and warm to touch. During a concurrent interview and record review with the Interim Director of Nursing (IDON) on 2/17/2024 at 10:36 a.m., Resident 1's medical chart (progress notes, physician order and skin assessment documentation) was reviewed. IDON confirmed and stated Resident 1's chart was missing monitoring, assessment, and documentation of Resident 1's right lower leg SLS prior to 12/21/2023. IDON stated any resident admitted to the facility with a cast/splint should be assessed and monitored for any site issues such as redness, pain, drainage, smell, presence of infection etcetera (etc.). IDON also stated importance of proper documentation of the site's assessment at least daily. During a concurrent interview and record review with the IDON on 2/17/2024 at 10:36 a.m., Resident 1's comprehensive care plan was reviewed dated 12/15/2023. IDON confirmed and stated Resident 1's comprehensive care plan was missing individualized care plan specific for Resident 1's right leg SLS. IDON stated Resident 1 should have a care plan for the right leg SLS and that Resident 1 was at risk for not receiving the appropriate care. IDON stated TNX notified Resident 1's physician and received an order to open and check the SLS, however, TNX forgot to document and write the order. During a concurrent interview and record review with the TXN on 2/17/2024 at 11:31 a.m., the TXN stated and validated that there was no SLS care monitoring order for Resident 1's right leg cast. The TXN stated that the TXN did not monitor or document assessment regarding Resident 1's right lower leg skin condition. The TXN stated that on 12/21/2023, Resident 1's family notified and requested the TXN to open Resident 1's SLS and check on the right lower leg skin condition. The TXN stated that upon opening Resident 1's right SLS, the TNX observed a wound on Resident 1's right medial leg. The TNX stated the TNX notified Resident 1's physician and received an order to remove the SLS to identify and assess the skin issue inside per family request, however, the TNX forgot to document and write the order. A review of facility's policy and procedures (P&P), titled, Splints, Orthotics (a support, brace, or splint used to support, align, prevent, or correct the function of movable parts of the body), & Immobilizers Application dated, 12/22/2023, indicated, residents/patients utilizing splints, orthotics and/or immobilizers will be monitored for proper application, skin integrity, pressure, and circulation. Nursing will have monitoring form to ensure routine monitoring of the splint for redness, swelling, circulation and pain. A review of facility's P&P, titled, Pressure Ulcer/Injury Preventive Measures, dated 12/22/2023, indicated that Residents at risk for the development of pressure ulcers/injuries receive interventions to reduce the risk of pressure ulcers/injuries. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application, and ability to secure the device and monitor regularly for comfort and signs of pressure-related injury. On the care plan, document approaches and interventions to prevent pressure ulcers/injuries. A review of facility's P&P, titled, Wound Care and Treatment, dated, 4/28/2023, indicated to verify that there is a physician's order for the procedure. The P&P also indicated, under documentation that the following information will be recorded in the resident's medical record: Type of wound care given Date/time of wound care was given. Name and title of the individual performing the wound care. Any change in resident's condition All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. How the resident tolerated the procedure Any problems or complaints made by the resident related to the procedure. Signature and title of the person recording the data.

Based on observation, interviews, and record reviews the facility failed to implement procedures to ensure safe dispensing and administration of medications from one out of four observed medication carts (medication cart 2) by failing to: 1. Ensure two marked (with name and room number of Resident5 and Resident 6) medicine cups containing pills were not left unattended on top of the unlocked medication cart 2. Inside the unlocked drawer were additional 10 marked (with name and room number of Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16) medicine cups stacked on top of each other with pills inside each cup. 2. Ensure the licensed nurses prepared medications immediately prior to administration and other safe preparation practices, as per facility policy and national standard of practice. 3. Ensure licensed nurses documented the actual time of medication administration in the Electronic Medication Administration Record (EMAR- software solution that helps to keep track of your residents' medication information, including current medications, schedules, and dosing details. It helps to streamline and automate workflows, saving valuable time and mitigating mistakes). These deficient practices placed Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16 at risk for being administered the wrong medication, wrong dosages, wrong time, and placed the residents at risk for severe allergic reactions, medication pilferage (theft) and/or tampering, and death. On 12/30/2023 at 8:29 p.m., an Immediate Jeopardy was called (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the facility. The Administrator (ADM) and Interim Director of Nursing (IDON) were notified of the findings regarding the unattended and unlocked medication carts, safe medication administration, and the use of personal laptop for medication administration documentation. On 1/03/24 at 6:11 p.m., the IJ situation was removed in the presence of the Administrator, Regional Director Compliance Officer, and Regional Director Nursing Consultant (RDCO), while on site, after verifying and confirming the implementation of the facility's submitted IJ Removal Plan (a detailed plan to address the IJ findings) through observation, interview, and record review. The acceptable IJ Removal Plan included the following summarized actions: 1. On 12/30/2023, Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16 were assessed for any signs or symptoms of adverse effects or allergies. The physicians for all residents were notified and all 12 residents were placed on 72-hour monitoring. Resident family and representatives were notified of the deficient practice. On 1/1/24 the interdisciplinary team (IDT) met, and the residents care plans were updated. 2. On 12/30/2023 Residents 17, 18, ad 19 were notified by the facility of the Licensed Vocational Nurses use of the personal laptop for medication administration. The facility's information technology (IT) department reviewed the electronic health records (EHR) for the residents to ensure breach in privacy occurred. Per the facility's IT department, no breaches in privacy laws were detected. 3. On 12/31/23 the use of all personal laptops/computers/phones/smart devices was stopped. Eight laptops were made available for all documentation and their functionality ensured. 4. On 12/31/2023 the nurse consultant provided one to one in service education to LVN 6 on the facility's policy on Medication Pass Guidelines and a medication administration skills competency was conducted to ensure safe dispensing and administration of medications focusing on not leaving the medication cart unattended and unlocked and follow proper administration of medication according to facility's policy and procedure. 5. On 12/31/2023 field support nurse consultants began to in service all facility licensed nurses on medication administration with competency verification. Findings: During an observation with Licensed Vocational Nurse (LVN 9) on 12/30/23 at 5:40 p.m., on the second-floor unit, an unattended medication cart 2 was observed with two marked (with the name and room number of Resident 5 and Resident 6) medication cups each containing pills on top of the cart. The cart was also noted to be unlocked. The top drawer had approximately 10 more (with the name and room number of Residents 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16) marked medication cups stacked on top of each other and each containing medications. LVN 9 confirmed the observation and stated that she did not know where the LVN assigned to medication cart 2 was. During an interview with LVN 6 (who was assigned for medication cart 2) on 12/30/23 at 5:58 p.m., LVN 6 confirmed by stating she left the medications on top of the medication cart 2 and left medication cart 2 unlocked with pre-poured (prepared ahead of time) medications in medication cups. LVN 6 stated she went for a bathroom break. When asked what the risks of leaving medications unattended, LVN 6 stated the medications were easily accessible to not only other residents, but staff, family/visitors which could result in possible allergic reactions resulting in serious adverse effects and or death. When asked about the risks of pre-pouring medications, LVN 6 stated that the medications could have been given to the wrong residents resulting in serious side effects, allergic reactions and or death. During a concurrent observation of medication cart 2 and interview with Registered Nurse (RN 2) on 12/30/23 at 6 p.m., RN 2 stated that medication cart 2 was left unattended, unlocked, with 12 pre-poured medications in medication cups, two of which were on top of the cart. RN 2 stated the risk of facility residents, staff, and family taking the medications was very high. RN 2 stated the risk of giving residents the wrong medications was also very high. RN 2 stated the facility had ambulatory (able to walk through the hallways) and confused residents on the unit. During an interview with the LVN 6 and the interim Director of Nursing (IDON) on 12/30/23 at 6:14 p.m., IDON returned to medication cart 2. LVN 6 stated that she (LVN 6) had administered all 12 cups of the medications. When asked what the seven rights of medication administration (standard for safe medication practices) were, LVN 6 replied: Right Person, Right Medication, Right Dose, Right Time, Right Route, Right Reason, and Right Documentation. When asked the procedure on how to verify the right medication was being given to a resident, LVN 6 stated that the medication container had to be checked against the medication orders while also verifying the resident by checking the name band against their photo on the Electronic Medication Administration Record. LVN 6 also stated she could not verify that the 12 cups of pre-poured medications were not tampered with, or if any medication was missing. LVN 6 admitted to not following all the rights of medication administration when administering the pre-poured medication. IDON stated that leaving the cart unlocked and unattended was unacceptable. IDON stated that pre-pouring medications increased the risk of medication errors, was unsanitary, and could result in medication errors by giving residents the wrong medications. When asked what could happen if medications were given to the wrong resident, IDON stated that the medications could cause serious side effects and could result in allergic reaction which could result in hospitalization s or even death. During an interview and record review of the Residents' MARs on 12/30/2023 at 7:15 p.m., LVN 6 was asked to show the documented time that the medications were administered for the twelve residents she was, LVN 6 stated that she had not documented the medications administered as given yet because she did not have a facility laptop and that she would document the medication administration later when a laptop was available. During a concurrent observation and interview with LVN 11 on 12/30/23 at 7:39 p.m., LVN 11 was observed with a laptop that was not labelled with the facility name. LVN 11 confirmed that that the laptop she (LVN 11) was using was her personal laptop and that she had frequently been using her (LVN 11's) personal laptop to access and document medication administration. During an interview with LVN 4 on 1/2/24 at 10:06 a.m., LVN 4 stated that it was not acceptable to pre-pour medication because there was a risk of mixing the medications up. LVN 4 stated nurses should follow safe preparation and medication administration. A review of Resident 5's Medication Administration Record (MAR) dated 12/30/2023, indicated the resident had orders for metoprolol (high blood pressure medication) 50 milligrams (mg) twice a day (9 a.m. and 5 p.m.) medication for 5 p.m. documented as given at 10:28 p.m. The MAR indicated the resident had an order for Lamictal (anticonvulsant medication) 25 mg per tablet, give 50 mg to be administered at 5 p.m. and documented as given at 10:24 p.m. The MAR indicated the resident had an order for Eliquis (a blood thinner) 5 mg to be administered twice a day (9 a.m. and 5 p.m.) and 5 p.m. dose was documented as given at 10:24 p.m. A review of Resident 6's MAR dated 12/30/2023, indicated the resident had an order for Depakote sprinkles capsules (medication used to treat seizure disorders, mental/mood conditions) 125 mg per capsule, administer 500 mg twice a day 9 a.m. and 5 p.m. The dose for 5 p.m. was documented as given at 10:24 p.m. A review of Resident 7's MAR dated 12/30/2023, indicated the resident had an order for memantine (used to treat memory loss) 5 mg per tablet, administer 5 mg twice a day 9 a.m. and 5 p.m. The dose for 5 p.m. was documented as given at 10:39 p.m. A review of Resident 8's MAR dated 12/30/2023, indicated the resident had an order for vitamin C (supplement) 500 mg per tablet, administer 500 mg twice a day 9 a.m. and 5 p.m. The dose for 5 p.m. was documented as given at 10:36 p.m. A review of Resident 9's MAR dated 12/30/2023, indicated the resident had a gastrostomy tube (G-Tube- a tube inserted through the belly that brings nutrition directly to the stomach) and had an order for metoprolol 10mg/milliliter, give 40mg/4ml to be administered via G-tube every 12 hours at 6 a.m., and 6 p.m. The dose for 6 p.m. was documented as given at 10:55 p.m. The MAR indicated the resident had an order for Keppra (a widely used seizure [sudden, uncontrolled burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings, and levels of consciousness] medicine) 500mg/ml to be administered twice a day with the evening dose to be administered at 5 p.m. The dose for 5 p.m. was documented as given at 10:55 p.m. The MAR indicated the resident had an order for metoprolol (treats high blood pressure. It also prevents chest pain or further damage after a heart attack) 100 mg tablet to be administered via g-tube twice a day. The evening dose scheduled for 5 p.m., was documented as given at 10:55 p.m. A review of Resident 10's MAR dated 12/30/2023, indicated the resident had an order for Tylenol (medication used to relieve mild to moderate pain as well as reducing fever) 500 mg per tablet, administer 1000 mg twice a day 9 a.m. and 5 p.m. The dose for 5 p.m. was documented as given at 10:28 p.m. The MAR indicated the resident had an order for carbidopa-levodopa (combination of medications used to treat Parkinson's disease [a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves]) 50-200 mg tablets, administer 50-500 mg twice a day 9 a.m. and 5 p.m. The dose for 5 p.m. was documented as given at 10:28 p.m. Dorzolamide (used to treat glaucoma, a condition in which increased pressure in the eye) 2% eye drops, instill 1 drop in each eye twice a day 9 a.m. and 5 p.m. The dose for 5 p.m. was documented as given at 10:28 p.m. The MAR indicated the resident had an Eliquis 2.5 mg tablets, administer 2.5 mg twice a day 9 a.m. and 5 p.m. The dose for 5 p.m. was documented as given at 10:28 p.m. The MAR indicated the resident had an Metoprolol tartrate 25 mg, administer half a tablet 12.5 mg twice a day 9 a.m. and 5 p.m. The dose for 5 p.m. was documented as given at 10:28 p.m. A review of Resident 11's MAR dated 12/30/2023, indicated the resident had an order for Eliquis 5 mg to be administered twice a day at 9 a.m. and 5 p.m. The MAR indicated that the 5 p.m., dose was documented at 8:51 p.m. A review of Resident 12's MAR dated 12/30/2023, indicated the resident had an order gabapentin (medications to prevent and control seizures and to relieve nerve pain) 300 mg per capsule, administer 300 mg twice a day 9 a.m. and 5 p.m. The dose for 5 p.m. was documented as given at 8:54 p.m. A review of Resident 13's MAR dated 12/30/2023, indicated the resident had an order for Flovent hydrofluoroalkane (HFA) aerosol inhaler (a medication used to treat asthma) 220 micrograms/actuation, administer 1 puff twice a day 9 a.m. and 5 p.m. The dose for 5 p.m. was documented as given at 10:31 p.m. A review of Resident 14's MAR dated 12/30/2023, indicated the resident had an order for Eliquis 5 mg to be administered twice a day at 9 am and 5 pm. The MAR indicated the 5 p.m. dose was administered as given at 10:21 p.m. The MAR indicated the resident had an order for gabapentin (works in the brain to prevent seizures and relieve pain for certain conditions in the nervous system) 300 mg to be administered three times a day (9 a.m., 1 p.m. and 5 p.m.). The 5 p.m. dose was documented as given at 10:21 p.m. A review of Resident 15's MAR dated 12/30/2023, indicated the resident had an order for metformin (antidiabetic agent that manages high blood sugar levels) 100 mg tablet to be administered twice a day (7:30 am and 5:30 p.m.). The 5:30 p.m. dose was documented as administered at 10:38 p.m. A review of Resident 16's MAR dated 12/30/2023, indicated the resident had an order for Depakote 125 mg to be administered three times a day (9 am, 1 pm, and 5 pm). The 5 p.m. dose was documented as given at 10:56 p.m. The MAR indicated the resident had an order for metoprolol 25 mg, administer half a tab (12.5 mg) to be administered twice a day (9 am and 5 pm) and was documented as given at 10:56 p.m. During an interview with the IDON on 1/3/2024 at 4:11 p.m., IDON was asked if it was ok to document medications that were administered at 6 p.m. to be documented around 10 p.m., IDON stated that it was not acceptable because documentation was part of the seven medication rights of safe medication administration. During an interview with the Administrator (Admin) on1/3/24 at 4:20 p.m., the administrator confirmed that he (the administrator) had found staff using a personal laptop to verify and document medication administration. A review of an undated facility's P&P titled Medication Pass Guidelines, indicated the purpose which included to systematically distribute medications to residents in accordance with state and federal guidelines. The same P&P indicated to follow safe preparation practices such as preparing medications immediately prior to administration. A review of an undated facility's P&P titled Oral Medication Administration indicated to administer oral medications in an accurate, safe, timely, and sanitary manner. Procedure. 1. Verify physician's orders. 2. Verify resident's identity and provide privacy. 3. Wash hands. 4. Explain the procedure to the resident. 5. Check labels on the medication three times as follows before administering it to the resident: a. When taking container from the shelf or drawer. b. When pouring medication, and. c. When returning container to the shelf or drawer. If administering a unit-dose medication, check the label for a final time at the resident's bedside immediately after pouring the medication and before discarding wrapper. 6. Crosscheck the Do not crush list, before crushing medications. Documentation on Electronic Medication Administration Record A review of the National Institutes of Health (NIH) U.S. National Library of Medicine Medline Plus article titled Nursing Rights of Medication Administration, dated September 4, 2023, indicated, Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration.

Based on interview and record review the facility failed to provide emergency medical services in accordance with professional standards of practice for one out of two sampled residents (Resident 4) as indicated in the resident's code status (level of medical interventions a person wishes to have started if their heart or breathing stops), by failing to: 1. Perform Cardiopulmonary resuscitation (CPR) as indicated in Resident 4's physician order and Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner, or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness). 2. Call 911 (designated as a universal emergency number) for emergency medical services assistance and transport to the hospital. As a result, on [DATE] at 5:30 a.m., Certified Nursing Assistant (CNA5) found Resident 4 not breathing, motionless and without vital signs, called Licensed Vocational Nurse 1 (LVN 1) and Registered Nurse (RN1) to Resident 4's room. All three facility staff members (CNA5, LVN1, RN1) did not provide CPR on Resident 4. RN1 pronounced Resident 4 dead on [DATE] at 5:35 a.m. On [DATE] at 3:30 p.m., an Immediate Jeopardy was called (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the facility. The Administrator (ADM) and Interim Director of Nursing (IDON) were notified of the findings regarding facility staff not providing emergency medical services to Resident 4 upon finding the resident not breathing, motionless, and without vital signs on [DATE] at 5:30 a.m., as well as RN1 pronouncing Resident 4 dead. On [DATE] at 6:11 p.m., the IJ situation was removed in the presence of the Administrator, Regional Director Compliance Officer, and Regional Director Nursing Consultant, while on site, after verifying and confirming the implementation of the facility's submitted IJ Removal Plan (a detailed plan to address the IJ findings) through observation, interview, and record review. The acceptable IJ Removal Plan included the following summarized actions: 1. Licensed nurses will not be allowed to work on the floor until in-service education of Registered Nurse (RN), Licensed Vocational Nurse (LVN), and Certified Nursing Assistant's (CNA) scope of practice and job description, CPR on residents with full code status, and facility's policy and procedure titled, change of condition have been completed. 2. IDON will start providing in-service education training to Licensed Nurses on [DATE] regarding Change of Condition, CPR on residents with full code status during monthly in-service meeting times three months then quarterly thereafter. 3. IDON will start with the in-service education training on [DATE] regarding scope of practice and job description with the licensed nurses during monthly in-service meeting times three months then quarterly thereafter. 4. IDON will start with the in-service education training on [DATE] regarding CPR with CPR trained staff that includes CNAs, RNAs, licensed nurses and rehab during monthly in-service meeting times three months then quarterly thereafter. 5. Any trends from the daily change of condition audits will be reported by the IDON to the facility's Quality Assessment and Assurance (QA&A)/Quality Assurance (QA) and Performance Improvement (PI) committee, monthly times three and quarterly thereafter starting on [DATE]. 6. The facility's QA&A/QAPI committee will provide further recommendations when indicated to confirm that the facility follows established protocols and regulations. 7. QAPI plan implemented regarding change of condition and scope of practice of Licensed Nurses specifically the Registered Nurses, and basic life support measures as indicated in the resident's full code status order when a resident is found unresponsive. 8. The committee agreed with the plan of continuing in-services monthly with Licensed Nurses and IDON completing audits of changes of condition. 9. The QA&A committee will monitor compliance with change of condition policy and staff is following scope of practice and job description. Findings: A review of Resident 4's face sheet (background information; a document containing demographic and diagnostic information) indicated the facility admitted the resident originally on [DATE] and readmitted the resident on [DATE] and [DATE] with diagnoses that included malignant neoplasm of pelvis (cancerous tumor in the pelvis), bilateral nephrostomy tubes (tubes inserted through the back directing into each kidney that drain urine from the kidneys), and acute respiratory failure (sudden onset of difficulty breathing or loss of ability to breath) ([DATE]). A review of Resident 4's Minimum Data Set (standardized data collection tool used to assess cognitive and functional status, and care needs) dated [DATE] indicated the resident was cognitively intact (the mental ability to make decisions of daily living). A review of Resident 4's Physician Order Report with a start date of [DATE] through [DATE] indicated vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) to be done every shift and to notify medical doctor (MD) as needed. A review of Resident 4's Physician Order Report with a start date of [DATE] through [DATE] indicated CPR was ordered. A review of the Resident 4's undated Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner, or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) indicated Medical Interventions under Section B, full treatment (primary goal of prolonging life by all medically effective means) was checked. POLST form did not have a signature from a physician, nurse practitioner, or physician assistant. POLST form showed Resident 4 signed the form undated. A review of Resident 4's Vital Signs (VS) Report indicated oxygen saturation (the amount of oxygen carried by the blood) of 94% (normal 90%-100%) was taken by LVN1 on [DATE] at 2:59 a.m,. No other vital signs were documented. A review of Resident 4's Medication Administration History for [DATE], indicated for a physician order of vital signs every shift, notify MD as needed. An entry documented by LVN1 on [DATE] at 3:01 a.m., indicated vital signs were not administered with a comment sleeping soundly. A review of Resident 4's progress notes by LVN1 dated [DATE] at 6:11 a.m., indicated 0400: Assigned CNA (CNA5) attended to resident's needs without any indication of acute changes. Resident typically sleeps off and on during night while on his iPad. Writer had stopped in his room earlier in the shift to say hello and see how he was doing after a brief transfer to another room. Resident was pleasant as usual. Resident has always been able to communicate needs effectively. Resident occasionally removes oxygen (O2) cannula (tube that delivers oxygen through the nostril) ad lib (as often as needed) and then reapplies. Resident denied any respiratory changes or chest pain. Repositioned with needs met. 0530: Upon returning to room at 0530 CNA (CNA5) noted resident was not moving. Assigned CNA (CNA5) had returned to room to provide activities of daily living (ADL, activities related to personal care such as bathing or showering, dressing, getting in and out of bed or chair, walking, using the toilet, and eating) and comfort care. CNA (CNA5) noted resident was not moving. Writer called into room STAT (immediately). RN supervisor present. Crash cart (a set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medication and equipment at site of medical or surgical emergency for life support to potentially save someone's life) made available to initiate CPR. RN/writer unable to obtain any VS at this time. Eyes noted to be fixed. A review of Resident 4's progress notes by RN1 dated [DATE] at 7:33 a.m., indicated At about 5:30 AM, was called to patient's room. Upon assessment, patient was not breathing, motionless and without vital signs. This writer attempted CPR on patient, but patient was rigor mortis (stiffening of the joints and muscles of a body a few hours after death, usually lasting from one to four days). CNA 5 stated patient was last seen at about 4 a.m., charge nurse (LVN1) stated patient was last seen with headphones on and responded to nurse. MD (physician) was called and pronounced patient dead. Patient was pronounced dead by RN 1 at 5:35 AM. A review of Resident 4's progress notes by LVN1 with original date of [DATE] at 6:11 a.m., indicated edited version was created on [DATE] at 12:28 AM, LVN1 added the sentences it was at this time that CNA (CNA5) immediately called writer to room and writer noted resident to be deceased via a visual check. LVN1 changed the sentence to crash cart available. LVN1 deleted eyes noted to be fixed. A review of Resident 4's progress notes by LVN1 with original date of [DATE] at 6:11 a.m., indicated another edited version was created on [DATE] at 12:29 AM, LVN1 changed the sentence to RN [RN 1] supervisor called to room. During an interview on [DATE] at 12:25 p.m., CNA1 stated that when a resident has a full code status it means you try your best to keep the patient alive. CNA1 was asked what immediate intervention is required when a full code status resident is found unresponsive with no pulse? CNA1 stated I will call the nurse (LVN or RN, whoever is available) to check on the resident. During a telephone interview on [DATE] at 1:06 p.m., Family Member 1 (FM1) stated on [DATE] the facility called FM1 to report Resident 4 had passed away. FM1 stated she (FM1) FM1 was told facility staff walked past Resident 4's room and noticed the resident was not breathing. FM1 denied being told CPR or any life saving measures were performed. FM1 stated Resident 4 wanted everything done to save his (Resident 4's) life and confirmed Resident 4 was a full code (attempt all life saving measures). During an interview on [DATE] at 1:12 p.m., LVN2 stated a full code status means everything must be attempted to save their life. When asked to describe what everything means, LVN2 stated we attempt to start an intravenous (a small, short plastic tube that is placed through the skin into a vein,), attempt CPR, suctioning, everything within our scope of practice, call 911 to get them on their way. LVN2 was asked what is the facility's protocol when a full code resident becomes incapacitated, unresponsive, no pulse, dilated pupils, not breathing? LVN2 stated we start CPR, call MD, call out for help, someone is running the code so call for help, call 911. During a telephone interview on [DATE] at 1:48 p.m., Licensed Vocational Nurse 1 (LVN1) was assigned to care for Resident 4 on [DATE]. LVN1 stated Resident 4 was Young had a lot of life but had so many comorbidities (the presence of two or more diseases or medical conditions in a patient at the same time) that limited him. Wonderful man. Poor prognosis (a prediction of what's to come, concerning advancement of the disease and its outcome). LVN1 stated on [DATE] around 5 AM, LVN1 was called into Resident 4's room because the resident was unresponsive. LVN1 stated Went into room, saw he (Resident 4) had expired, nothing you could really do, could just tell. LVN1 asked if CPR was performed, LVN replied drawing a blank and stated she (LVN1) could not remember. LVN1 then stated a code was called and RN1 entered the room. LVN1 asked if RN1 performed CPR on Resident 4 and replied, drawing a blank for some reason. LVN1 asked if she (LVN1) placed her (LVN1's) hands on the resident to perform compressions and replied no, did not perform CPR. LVN1 stated found him (Resident 4) expired and it was pronounced. LVN1 stated the protocol for full code status was CPR should be done. LVN1 confirmed CPR was not performed on Resident 4 by facility staff when found unresponsive and not breathing on [DATE] at 5 AM. LVN1 stated Even if we don't know exact time of passing for a full code absolutely not negotiable. CPR is required, CPR has to go into full effect. During an interview on [DATE] at 1:55 p.m., IDON stated the different types of patient code status: full code, no code DNR (do not resuscitate). IDON was asked what full code status means you do CPR on the patient; you do everything you need to do to keep them alive. IDON was asked what the facility protocol was regarding finding a resident who was a full code status unresponsive with no pulse, IDON stated we start CPR-start chest compressions and give oxygen, get help, call 911, call the doctor, call family. IDON stated the information on the resident's code status can be found on the very first page of the chart, it's on the POLST (Physician Orders for Life Saving Treatment-a written medical order from a physician, nurse practitioner, or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness). During an interview on [DATE] at 2:27 p.m., the ADM stated a full code status is when everything must be done for the resident - do chest compressions, give oxygen, call MD call family, call 911. ADM stated there are different types of patient code status: full code, no code, and DNR. ADM was asked where one can find the information on resident's code status, ADM stated on the chart, it's the first thing you see on the chart. During an interview on [DATE] at 3:30 p.m., IDON was asked if RNs are allowed to pronounce a resident dead when resident expired? IDON stated Here? oh yes we can when we are here. ADM interrupted IDON then stated no, that is outside the scope of nurse's practice. IDON stated we cannot pronounce as RNs because it's outside the scope of practice. IDON was asked when charting should be done after a resident expires, as soon as possible. IDON stated late entries are not supposed to happen and does not know what the protocol indicated as to how much time is allowed to chart a late entry after an incident has happened. IDON stated change of condition should be written after a resident expired for documentation purposes. IDON added that progress notes should be documented from the time nurses found the resident, what was done to and for the resident, 911 call, when paramedics took over, call made to physician, call made to family must also be written by the nurses (LVN, RN). IDON stated every measure done on a patient must be documented on the care plan. During a telephone interview on [DATE] at 4:22 p.m., RN1 stated on [DATE] around 5:30 a.m., she (RN1) was alerted of an emergency in Resident 4's room. RN1 stated she (RN1) responded to the emergency with the crash cart and was ready to start CPR but Resident 4 was already gone .gone. RN1 stated the last time the Resident was seen alive was two hours prior (around 3:30 AM) and RN1 was going to start compressions but Resident 4 was stiff, really stiff so RN1 stopped and pronounced the resident dead and then called the doctor. RN1 confirmed the crash cart was not used and CPR was not performed on Resident 4 and paramedics were never called. RN1 stated RNs were allowed to pronounce residents dead. A review of facility's undated P&P, titled, Cardiopulmonary Resuscitation: One person Rescue, indicated Basic CPR consists of assessing the victim, calling for help, and then following the C-A-B scheme: chest Compressions, opening Airway and restoring Breathing. Procedure: Initial Assessment: 1. Assess the resident to determine if he/she is unconscious. Gently shake shoulders and shout, Are you okay? 2. Check whether resident has an injury. If a head or neck injury is suspected, move resident as little as possible to reduce the risk of paralysis. 3. Call out for help. Send someone to contact the Emergency Medical Service and call a code.

Based on observation, interview, and record review, the facility failed to protect two of three sampled residents (Resident 1 and 2) from verbal and mental abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) from Resident 3 by failing to: 1. Immediately correct and intervene in reported or identified situations in which verbal abuse, physical threats, and intimidation from Resident 3 whenever Resident 1 and Resident 2 used a bathroom shared with Resident 3. 2. Investigate allegations of ongoing bullying, verbal abuse, physical threats, and intimidation from Resident 3 to Resident 1 and Resident 2. 3. Protect Resident 1 from Resident 3 by responding to the call light when Resident 1 called for help to use the shared bathroom. On 11/30/2023 at 10 a.m., after waiting for staff for more than 30 minutes Resident 1 walked to the bathroom and Resident 3 opened the door and began yelling at Resident 1 to get out of the bathroom. Resident 1 got scared and hurried out of the bathroom and went to sit on the wheelchair where Resident 1 fell to the ground. As a result, Resident 1 and Resident 2 were exposed to verbal, and mental abuse from Resident 3 and experienced psychosocial harm, suffered mental anguish (suffering) and emotional distress. On 12/31/2023 at 12:40 p.m., while onsite the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (ADM) and Interim Director of Nursing (IDON) because of the seriousness related to the facility's failure to protect Resident 1 and Resident 2 from ongoing abuse from Resident 3. Resident 1 fell because of she became scared and hurried out of the bathroom and went to sit on the wheelchair, and Resident 1 fell to the ground. On 1/3/2024 at 4:17 p.m., the facility provided acceptable IJ Removal Plan (interventions to correct the deficient practice). While onsite, the survey team confirmed implementation of the IJ corrective actions through interview, and record review. The SSA removed the IJ on 1/3/2023 at 6:13 pm in the presence of the Regional Director of Clinical Operations (RDCO), ADM and IDON, [NAME] President of Operations (VPO), and Compliance Manager. A review of the IJ removal plan included the following: 1. On 12/31/2023 Resident 1 was assessed by a Registered Nurse (RN) for signs of emotional distress, none were observed. The resident's representative and physician were notified of the abuse. The physician ordered a psychology (study of the mind and behavior) referral for 1/2/2024. The facility medical director and interdisciplinary team (IDT) assessed and met with the resident and recommendations made for emotional support, psychosocial (social interactions that affect thoughts and behavior) visits, monitoring for emotional wellbeing every shift. The resident's care plan was updated. Resident 3 was moved, and Resident 1 no longer had to share a restroom with Resident 3. 2. On 12/31/2023 Resident 2 was assessed by a RN for signs of emotional distress, none were observed. The resident's physician was notified of the abuse. The physician ordered a psychology referral for 1/2/2024. The facility medical director and interdisciplinary team (IDT) assessed and met with the resident and recommendations made for emotional support, psychosocial visits, monitoring for emotional wellbeing every shift. The resident's care plan was updated. Resident 3 was moved, and Resident 2 no longer had to share a restroom with Resident 3. 3. On 12/31/2023 Resident 3 was moved to a single occupancy room. Resident 3's physician ordered a psychology and psychiatry referral. The facility medical director and IDT assessed and met with the resident and recommendations made for 1:1 monitoring until the resident was assessed by a psychologist (physician who specializes in the study of the mind and behavior) and psychiatrist (physician who specializes in diagnosis and treating mental disorders). The resident's care plan was updated. 4. On 1/1/24 and 1/3/24 the Nurse Consultant and Social Services Director interviewed the 71 interviewable residents to identify any other residents potentially affected by the same deficiency. No other residents were identified as having been abused or having the potential to abuse another resident. 5. On 12/31/2023 the Nurse Consultant and Chief Compliance Officer began conducting in services to all facility staff on Abuse Neglect and Exploitation Prohibition policy, Abuse investigation and reporting policy, Resident to Resident Altercation policy, and Answering of call lights policy. 6. On 1/2/24 facility department managers began daily ambassador rounds with a checklist observing for any issues with resident safety, call light response, and quality of care. 7. On 1/3/24 the Social Services Director provided facility residents education on resident rights and abuse reporting. Cross Reference: F609, F610, F645, F689, F740 Findings: a. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a disease characterized by high levels of sugar in the blood), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), hypertension (high blood pressure), cerebral infarction (a disrupted blood flow and oxygen to the brain due to problems with the blood vessels that supply it), and hemiplegia (paralysis that affects only ones side of the body) and hemiparesis (weakness or inability to move one side of the body) affecting the left non-dominant side. A review of Resident 1's History and Physical (H&P) dated 5/5/2023 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's progress notes dated 11/30/2023 at 11:06 a.m. indicated Resident 1 was found on the floor (on 11/30/2023) following an unwitnessed fall, the resident denied hitting any part of her (Resident 1's) body, or having any pain, a head-to-toe assessment was done, no injuries or bleeding or swelling was found, medical doctor (MD) was made aware. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 12/12/2023 indicated Resident 1 had moderately impaired cognition (the mental ability to understand and make decisions of daily living), was non-ambulatory (unable to walk), and was dependent on staff for toileting hygiene. A review of Resident 1's progress notes dated 12/1/2023 at 3:39 p.m., indicated the doctor was notified due to Resident 1 having back pain related to her (Resident 1's) fall on 11/30/2023. The progress notes indicated an order for x-ray (image of bones) of the lumbar (lower back) and thoracic spine (mid to upper back) was issued and carried out. A review of Resident 1's progress notes dated 12/2/2023 at 12:39 p.m., indicated x-ray results were positive for a lumbar fracture. The progress notes indicated Resident 1's Medical Doctor (MD) was notified, A review of Resident 1's progress notes dated 12/2/2023 at 7:05 p.m., indicated a physician order was received to transfer Resident 1 to emergency room (ER) for evaluation and assessment. b. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that include anxiety disorder (symptoms of intense panic that are directly caused by a physical health problem), congestive heart failure (CHF-a weakened heart condition that causes fluid to build up in the feet, arms, lungs and other organs), osteo arthritis (a degenerative joint disease , in which the tissues in the joint break down over time), muscle weakness and difficulty walking. A review of Resident 2's MDS dated [DATE] indicated Resident 2 was cognitively intact and required setup or clean-up assistance with all her activities (eating, toileting, dressing bathing, personal hygiene, walking, etcetera). c. A review of Resident 3's admission record indicates Resident 3 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things that once brought joy) , extrapyramidal and movement disorder (involuntary movement disorders most commonly caused by exposure to dopamine-blocking medications such as antipsychotics[medications to treat and reduce/control symptoms of mental disorders]), abnormalities of gait and mobility (deviation from normal walking) and repeated falls. A review of Resident 3's MDS dated [DATE] indicated Resident 3 had moderate cognitive impairment and required supervision for activities of daily living (eating, toileting, dressing bathing, personal hygiene, walking etcetera). A review of current Resident 3's Behavioral Symptoms care plan initiated on 9/30/2020 (most current care plan in medical record), indicated interventions to be implemented by facility staff included identify situations that might have caused behavioral problem and assist resident in resolving identified issues. A review of Resident 3's physician order report dated 10/13/2022 indicated no psychiatric [medication to treat mood swings and unwanted behaviors] medication with behavior to be monitored: Paranoid delusional ideation. Notify MD accordingly further interventions when indicated. A review of Resident 3's psychiatric evaluation dated 1/5/2023 indicated the resident was referred for evaluation because of a recent involvement in an altercation with a resident on the unit. The psychiatric evaluation indicated a mental status evaluation (MSE) indicated Resident 3 was oriented to name only, was inattentive, incoherent with loose thought process, was anxious but not severely depressed and talked to herself. The psychiatric evaluation indicated recommendations included close observation and monitoring of behaviors to avoid close encounters with other patients. During an interview on 12/29/2023 at 8:45 a.m., Resident 1 stated on 11/30/2023 she (Resident 1) had to use the restroom and had been calling facility staff for over 30 minutes and no staff responded. Resident 1 stated she (Resident 1) could no longer hold the need to urinate and lost control and wet herself and the bed. Resident 1 then felt embarrassed and dirty, and staff had still not responded so the resident went to use the bathroom to change. Resident 1 went the bathroom alone and at that point Resident 3 entered the restroom and began yelling and threatening to hit Resident 1. Resident 1 felt scared and left the bathroom undressed and went back to the bed. Resident 1 stated she (Resident 1) did not want to sit on the bed because it was wet and soiled and went to sit on her (Resident 1's) wheelchair to finish changing. Resident 1 stated the wheelchair in the room was too tall and the brakes were too hard and did not work so the resident slipped and fell on the floor. Resident 1 stated at that point Resident 2 went to help the resident and started yelling for help. Resident 1 stated certified nursing assistant 5 (CNA 5) wanted to help the resident up and wanted Resident 2 to help but Resident 1 did not want Resident 2 to get hurt and they began to yell for more help. Resident 1 stated she (Resident 1) was afraid of Resident 3 because Resident 3 would always lock the bathroom door, yell at Resident 1 if she tried to use the restroom and threaten to hurt Resident 1 if she (Resident 1) did not get out of the bathroom. Resident 1 reported having to hold her urine and feces out of fear of Resident 3 on multiple occasions. Resident 1 stated Resident 3 would make me suffer and still makes me suffer, may God forgive me, but she is evil. Resident 1 stated facility staff were aware of Resident 3's violent behavior and would do nothing to help Resident 1. During an interview on 12/29/2023 at 9 a.m., Resident 2 (Resident 1's roommate) stated upon admission to the facility the nurses told the resident to beware of Resident 3, because Resident 3 had a cane and would hit people with it and was very possessive of the shared bathroom. Resident 2 stated Resident 3 was demented and violent and would lock the bathroom door to prevent Resident 1 and Resident 2 from entering. Resident 2 stated the only way to open the door was to use a knife Resident 1 and Resident 2 kept in the room to turn the lock on the door. Resident 2 stated if Resident 1 or Resident 2 wanted to use the restroom they would call staff and wait for them to come because Resident 3 would open the bathroom door and yell and threaten to hit them with a cane. Resident 2 stated staff would not answer call lights often and Resident 1 and Resident 2 would have to use the bread knife in the room to slowly unlock the bathroom door and crack the door open to peak and make sure Resident 3 was not in the restroom or Resident 3's bathroom door was not open. Resident 2 stated once it was confirmed Resident 3 was not in the bathroom Resident 1 and Resident 2 then had to quickly lock Resident 3's entry to the bathroom and use the restroom. When Resident 3 realized Resident 1 and Resident 2 were in the bathroom and Resident 3 would unlock the bathroom door and yell at them to get out and threaten to hit them with a cane. Resident 2 stated often Resident 1, and Resident 2 had to hold the need to use the bathroom until Resident 3 was not around. Resident 2 stated she (Resident 2) had reported on multiple occasions to facility staff being afraid of Resident 3 and Resident 3's threats and possessiveness over the bathroom and the facility staff would just tell Resident 1 and Resident 2 to be careful and avoid Resident 3. Resident 2 stated facility staff would say that was just how Resident 3 was. During the same interview on 12/29/2023 at 9 a.m., Resident 2 stated on 11/30/2023 Resident 1 had been calling for the nurses to help Resident 1 to go to the restroom but the nurses did not answer the call lights. Resident 2 stated Resident 1 then walked to the bathroom and shortly after entering the bathroom, Resident 3 opened the door and began yelling at Resident 1 to get out of the bathroom. Resident 2 stated Resident 1 got scared and hurried out of the bathroom and went to sit on the wheelchair, but the wheelchair was too tall, and Resident 1 fell to the ground. Resident 2 stated only CNA 5went to help Resident 1 so Resident 1 and Resident 2 began calling out for more help. Resident 2 stated Resident 3 continued to threaten them (Resident 1 and 2) when they go to the restroom. Resident 2 stated Resident 1 would become very anxious and facility staff was not protecting them (Resident 1 and Resident 2) from Resident 3. Resident 2 confirmed having told facility staff about Resident 3's continued abuse and the facility staff's only response had been be careful. Resident 2 stated Resident 3 denied Resident 1 and Resident 2 the right to use the restroom, and facility staff would not answer Resident 1's call light for help, and that is why Resident 1 fell . Resident 2 stated Resident 3's verbal abuse was ongoing, and the facility staff were aware. During an observation of Resident 3's room and interview on 12/29/2023 at 10:37 a.m., Resident 3 was observed seated on a chair, with 4-point/quad cane (a cane that has four posts as a base) next to her. Resident 3 stated, she shared a bathroom with Resident 1 and Resident 2 in the adjacent room. Resident 3 stated the residents in the next room (room of Resident 1 and 2) spoke another language and liked to listen in on her (Resident 3's) phone conversations when Resident 3 used the shared bathroom. Resident 3 stated Resident 1 soiled the restroom and walls and she (Resident 3) had to ask staff to clean it up. During an observation on 12/29/2023 at 10:45 a.m., Resident 1 and Resident 2 (roommates) shared a [NAME] and [NAME] type bathroom (a bathroom that has two doors and is usually accessible from two bedrooms) with Resident 3. During an interview on 12/29/2023 at 1 p.m., CNA4 stated Resident 3 hurried Resident 1 and Resident 2 when they used the shared bathroom and had threatened them (Resident 1, Resident 2, and staff) with a quad cane which she (Resident 3) used to walk and as a weapon. CNA4 stated facility staff (licensed and CNAs) had been aware of Resident 3's bullying and aggressive behavior for a while. CNA4 stated facility staff talked to Resident 3 about her (Resident 3's) behavior but she (Resident 3) did not listen. CNA4 stated Resident1 and Resident 2 had reported to her (CNA4) their fear of Resident 3, but CNA4 did not feel Resident 3 was dangerous. During an interview on 12/29/2023 at 2:45 p.m., CNA7 stated he had heard afternoon and night shift staff complain that Resident 3 had raised her (Resident 3's) quad cane towards the staff aggressively and threatened them with harm. CNA7 stated he had heard Resident 1 and Resident 2 complained that Resident 3 would take a long time in the bathroom and would sometimes lock Resident 1 and Resident 2's bathroom entrance door. CNA7 stated he taught Resident 2 how to unlock the bathroom door with a bread knife and instructed the resident to always knock and make sure no one was using the bathroom before opening the door. During an interview on 12/29/2023 at 6:29 p.m., the IDON stated Resident 1 had an unwitnessed fall on 11/30/2023 and was found seated on the floor. The IDON stated upon interview Resident 1 stated she slid off the wheelchair. The IDON stated on 12/1/2023 Resident 1 complained of back pain, the doctor was notified, and x-rays were ordered which were positive for a fracture. The IDON stated Resident 1 was sent to the general acute care hospital (GACH) for a higher level of care. The IDON stated he was aware of Resident 3's aggressive behavioral problems. During an interview on 12/30/2023 at 1 p.m., Certified Nursing Assistant (CNA5) was assigned to care for Resident 1 on 11/30/2023. CNA5 confirmed Resident 1 had been calling for assistance but CNA5 was busy with another resident. CNA5 stated sometimes other staff would assist and answer call lights but that depended on who was working. CNA 5 confirmed Resident 1 had been calling for over 20 minutes with no staff assistance. CNA5 heard yelling and ran to Resident 1's room and the resident was on the floor in front of the wheelchair. CNA5 confirmed Resident 1's bed was wet with urine and stated that was why the resident was placed on the wheelchair. During an interview on 12/31/2023 at 11:05 a.m., licensed vocational nurse 2 (LVN2) stated Resident 3 had a history of schizophrenia, was very rude, and would tell Resident 1 and Resident 2 go back to your country. LVN2 stated Resident 3 had been verbally abusive towards LVN2, CNAs and other licensed staff. LVN2 stated Resident 3 had delusions (a false belief or judgment about external reality), would say people were harming or doing things to her (Resident 3) and did not like to have roommates. LVN2 stated Resident 3 had arguments with Resident 1 and Resident 2 regarding toilet paper usage and being in the bathroom too long. LVN2 stated she (LVN2) had intervened during the arguments to make peace between Resident 1, Resident 2, and Resident 3 by seeking a compromise. LVN2 stated the past Directors of Nursing (DONs), and current interim Director of Nursing (IDON) were aware of Resident 3's aggression and conflicts towards Resident 1 and Resident 2. LVN2 stated I am just a charge nurse; I do not have authority to move or change Resident 3's room. LVN2 stated she had made the facility administration aware on numerous occasions of Resident 3's aggression and abusive behavior towards Resident 1 and Resident 2 but nothing was done. LVN2 stated no documentation was done and care plan done regarding Resident 3's abusive behavior. LVN2 stated, the current Administrator was new to the facility I don't think he knows of Resident 3's behavioral problems. A review of the undated facility's policy and procedure titled Abuse, Neglect and Exploitation Prohibition, indicated each Resident had the right to be free from mistreatment, abuse. The policy indicated the facility staff had to screen for potentially abusive residents. The policy indicated facility supervisors would have to immediately correct and intervene in reported or identified situations in which abuse of Resident was occurring. The policy indicated residents observed by staff as being or exhibiting abusive behavior by facility staff had to be reviewed by the physician and treatment plans modified as appropriate, company will report all investigations such as allegations to the state as per state regulations. The policy indicated the facility had to report findings to the state and law enforcement agencies as per state regulations.

Based on interview and record review, the facility failed to identify accident risks and hazards and prevent falls and injuries for one of three sampled residents (Resident 1), who required maximum assistance with transfers (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and locomotion (moving from place to place). On 10/27/2020, Certified Nursing Assistant 1 (CNA 1) wheeled Resident 1 in a shower chair (four-legged chair with a back rest, and a plastic seat with an opening in the center, used to provide additional support in the shower and easily moves in and out of the shower and directly over a standard size toilet), without using the safety lap bar for maximum support. Resident 1 slipped from the chair onto the floor, hitting the back of the head and right knee. As a result, Resident 1 required transfer to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident on 10/10/2012 with [DIAGNOSES REDACTED]. (brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), and [MEDICAL CONDITION] (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, causing numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue). A review of Resident 1's Falls Care Plan, updated on 8/23/2020, indicated the resident had a high fall risk. The care plan interventions included keeping the environment free of hazards and identifying type of assistance the resident needs. The care plan interventions did not indicate the level of assistance Resident 1 required. A review of Resident 1's Occupational Therapy Evaluation & Plan of Treatment, dated 9/15/2020, indicated Resident 1's sitting balance was poor and needed maximum support to maintain balance. According to a review of the Vitals Report, dated 9/30/2020, Resident 1's weight was 164 pounds and Body Mass Index (BMI - an indicator / measurement of body fat) was 24.25 (normal BMI = 18 -24 for normal to healthy weight). A review of Resident 1's Activities of Daily Living / Rehabilitation Potential Care Plan, dated 10/1/2020, indicated Resident 1 had a self-care deficit and needed extensive assistance with bed mobility, dressing and bathing. The care plan indicated Resident 1 was totally dependent on staff with transfers, locomotion, and toileting. The interventions included providing Resident 1 with the needed assistance, but did not indicate the level of assistance needed. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool), dated 10/10/2020, indicated Resident 1 was able to understand, communicate needs, remember, and make decisions. Resident 1 was totally dependent with transfers and locomotion and had impairment on one arm and impairment on both legs. A review of Resident 1's Nursing Progress Notes, dated 10/27/2020, timed at 10 a.m., indicated Resident 1 was being wheeled to the shower room, upon entering the shower room, the resident fell out of the shower chair. Resident 1 slipped from the chair to the floor and hit the back of her head and the right knee. Resident 1's right knee was swollen, with 4-7/10 pain (rating pain scale from zero to 10, zero indicating no pain and 10 the worst pain possible) on the back of the head and right knee and pain medicine was given. Resident 1 was sent to the GACH for evaluation. According to a review of Resident 1's GACH Emergency Department After Visit Summary, dated 10/27/2020, the [DIAGNOSES REDACTED]. Resident 1 was returned to the facility on the same day with a right leg immobilizer due to tibial fracture. On 11/9/2020 at 2:37 p.m., during an interview, CNA 1 stated at the entrance of the shower room, the resident was moving a lot and slipped out of the shower chair. CNA 1 stated the shower chair lap security bar (goes across the front of chair) was not closed. On 12/4/2020 at 2:35 p.m., during a phone interview, CNA 1 explained the safety lap bar could not be used due to Resident 1's size. CNA 1 stated there were other shower chairs, but they did not have the safety lap bar. During a telephone interview, on 12/7/2020 at 9:36 a.m., the Occupational Therapist (OT) stated Resident 1 required total assistance with transfers and had poor trunk control. During an observation and concurrent interview, on 1/11/2021 at 12:35 p.m., Resident 1 was observed resting in bed and leaning to her right side. Resident 1 stated, CNA 1 was pushing me fast and came to a sudden stop. I slipped out of the shower chair. I don't remember there being a safety bar. There used to be a safety bar on the shower chair, but this time, I don't remember. Resident 1 stated, I slipped out of the chair and fell on my knee. During an observation of the facility's third floor shower room, on 1/11/2021 at 12:48 P.M., there were two shower chairs with a secure lap bar. During a concurrent interview, the DON stated, This is the only type of shower chair we have. During an interview on 1/15/2021 at 9:30 a.m., the Rehabilitation Nurse Assistant 1 (RNA 1) stated due to Resident 1's diagnosis, it was hard to transfer her without assistance. RNA 1 stated Resident 1's legs did not have a lot of movement and were not of any help when transferring her. Before the accident on 10/27/20, staff always called for assistance when transferring Resident 1 to the bathroom or shower. A review of the facility's policy titled, Fall Prevention Policy, dated 12/1/2005, indicated the policy was designed to make a concerted effort to provide each resident with adequate supervision and assistive devices to prevent or decrease the risk of injury from falls.

Based on observation, interview and record review, the facility failed to ensure, one of three sampled residents (Resident 1), who was assessed as a high risk for falls and had a history of [REDACTED]. 1) Follow the physicians order to Monitor Wander-Guard (a device that alarms when residents attempt to elope or wander from a safe environment) placement for Resident 1. 2) Conduct 15 minutes checks to ensure placement of the bed alarm and Wander Guard 3) Revise the plan of care and notify the physician when Resident 1, turned off his Wander Guard, bed alarm and attempted to get out of the bed and wheelchair without calling for assistance. These deficient practices resulted in Resident 1 falling and complaining of pain to his left hip. Resident 1was transferred to the acute hospital for an evaluation of his left hip pain, where he was diagnosed with [REDACTED]. Resident 1 stayed in the acute hospital for eight days, and underwent a left hip hemiarthroplasty (a surgical procedure that replaces one half of the hip joint with an artificial limb). Findings: A review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the admission assessment dated [DATE], indicated Resident 1 required assistance with ambulation and transfers. A review of Resident 1's fall risk assessments dated 10/13/16, indicated a score of 16, and on 1/24/17 a score of 18. According to the fall risk assessment a total score of 10 or above represents a high risk for falls. A review of the Risk Meeting (a team that identifies and prevents problems from occurring) Team Notes dated 10/14/16, indicated Resident 1 was at risk for falls, and was offered a body alarm monitor for safety purposes, but the staff noticed the resident had more aggressive behaviors as a result. The Risk Meeting Team Notes further indicated the interventions were not appropriate and can only pose as a risk. and the Interdisciplinary Team (IDT) would review the approaches, monitor and modify if indicated. Resident 1 was maintained on fall precautions at all times. A review of the physician's orders [REDACTED]. Apply Wander- Guard to alert staff when resident attempts to leave the facility and to monitor the whereabouts of the resident every shift due to risk for wandering and elopement. A review of the Minimum Data Sheet (MDS-a standardized assessment and screening tool) dated 10/24/16, indicated Resident 1 was cognitively impaired and was dependent on staff for toileting, transfers, eating and personal hygiene. The assessment also indicated Resident 1 was always incontinent (lack of voluntary control over urination or defecation) of bladder function, used a walker and a wheelchair as mobility devices. The Care Area Assessment (CAA) of the MDS indicated Resident 1 triggered the area of falls, urinary incontinence and noted a fall risk care plan would be developed. A review of Resident 1's plan of care titled Falls dated 10/26/16, indicated the resident was at risk for falls due to a history of falls, balance problems, wandering and anti-anxiety, anti-depressant, or hypnotic medications. The listed interventions included to provide assistance in transfers and mobility, conduct a fall risk assessment quarterly or as needed, address identified risk factors, identify the time of the day the resident is most vulnerable to falls and provide a safety reminder. A review of an undated plan of care for Resident 1 titled Non-Compliant indicated Resident 1 was non-compliant with morning care. The care plan further indicated Resident 1 was unable to be re-directed, became aggressive and belligerent with the staff and was observed urinating on the floor. The listed interventions included to monitor Resident 1's whereabouts and to keep the Wander-Guard in place. A review of the Nursing Weekly Summary dated 1/12/17, indicated Resident 1 ambulated alone, required limited assistance with one person, used the grab bars for positioning, did not sustain a fall and had a low bed. The Weekly Summary did not contain information regarding use of a Wander Guard. A review of the Nursing Weekly Summary dated on 1/19/17, indicated Resident 1 propelled himself with a wheelchair for long distances, and required limited assistance with one person physical assistance, used a grab bar for positioning, did not sustain a fall and had a low bed. The Weekly Summary did not contain information regarding use of a Wander Guard. A review of the Situation, Background, Assessment and Recommendation (SBAR- a licensed staff communication tool) dated 2/5/17, at 5 a.m., indicated on 2/5/17 at 4:30 a.m., Resident 1 was calling out for assistance and was found lying in a supine (on the back) position on the floor in his room. According to the SBAR Resident 1 fell on the floor as a result of urinating on the floor and complained of pain to the left hip and thigh area and was assisted back to bed. The SBAR did not contain information regarding use of a Wander Guard. A review of the physician's orders [REDACTED]. The x-ray report for Resident 1 dated 2/5/17, indicated Resident 1 sustained a left neck femur fracture. A review of the facility's investigative report dated 2/5/17 indicated Resident 1 was assessed and noted to be a high risk for falls upon admission on 10/13/16. The investigative report did not contain documentation as to the cause of the fall and did not include information regarding the use of a Wander Guard. A review of the Resident Transfer Form dated 2/6/17, indicated Resident 1 was transported from the facility to the GACH via gurney by a private ambulance company at 11:50 a.m., the following day due to a fractured left femur. During interviews on 2/9/17, at 1:20 p.m. and 2 p.m., with the Assistant Director of Nursing (ADON), she stated Resident 1 was able to ambulate, but had an unsteady gait and usually used a wheelchair for mobility. During an interview on 2/10/17, at 12:38 p.m., the Registered Nurse Supervisor (RNS) stated Resident 1 fell on [DATE] at 4:30 a.m. A review of the acute hospital history and physical (H &P) dated 2/12/17, Resident 1 had an unwitnessed ground level fall at the nursing home and was found to have a femur neck fracture. Resident 1 underwent a left hip hemiarthroplasty. During a telephone interview on 5/8/17 at 9:48 a.m., Licensed Vocational Nurse (LVN 1) indicated on 2/5/17, Resident 1 had gotten out of the bed and displayed non-complaint behaviors, which included, turning off his bed alarm and attempting to get out of bed and/or wheelchair without calling for assistance. LVN 1 stated when the resident disarmed his bed alarm, staff made visual rounds every 15 minutes. LVN 1 was asked to provide documentation of the every 15 minute rounds. LVN 1 stated the documentation is located on the Medication Administration Record (MAR) form. LVN 1 further stated Resident 1 had a bed alarm due to multiple falls in the past. The resident also had a Wander guard bracelet because he attempted to elope from the facility. Resident 1 was not able to ambulate independently, used a walker and a wheelchair and would hold on to the door or the hallway rail and had balance issues. LVN 1 stated Resident 1 required assistance to the bathroom, and was provided a urinal and a diaper, but he would continuously urinate on the floor. She further stated Resident 1 would not use the call light to call for assistance, however he was placed next door to the nurses station, but he would somehow manage to maneuver himself partially out of the bed where the bed alarm would not sound off. She also stated Resident 1 did not have one to one monitoring. During a review of Resident 1's clinical record there was no documented evidence the plan of care was revised to address Resident 1's identified behavior of disarming and turning off his bed alarm and attempting to get out of the bed and wheelchair without calling for assistance. This was confirmed via interview with LVN 1 on 5/8/17, at 9:48 a.m. During an interview on 5/8/17 at 10:20 a.m. the Certified Nurses' Assistant (CNA 1) stated Resident 1 would get very aggressive if he could not get his way. CNA 1 stated although the resident had a urinal he would not use the urinal, yet urinated on the floor. CNA 1 further stated prior to the resident's fall on 2/5/17, he was not able to walk independently, had a chair and an ankle alarm. CNA 1 was not able to recall if Resident 1 had a bed alarm prior to 2/5/17. During an interview on 5/8/17, at 11:10 a.m., the Director of Nursing (DON) stated Resident 1 was close to the nurses' station with frequent nursing rounds by the RN's, LVN's, and Certified Nurses' Assistants (CNA's). The DON was asked when the current measures were not effective for Resident 1, what other plans of care did the facility have in place for the resident. The DON stated the facility would contact the resident's conservator, use personal safety alarms such as an alarm for the bed and the wheelchair. The DON was asked if Resident 1 had a plan of care in place for disarming the bed alarm. The DON stated no. The DON was asked how the staff monitored the resident's safety needs, she stated the staff performed bed alarm checks and the staff documented the checks on the MAR. During a telephone interview on 5/8/17, at 11:55 a.m., CNA 2 stated on 2/5/17, Resident 1's bed alarm was on but he would turn off the alarm. Resident 1 required assistance with ambulation. The resident was assisted to the bathroom and back to bed. Resident 1 would urinate in the bed and on the floor. CNA 1 was asked if he performed bed alarm checks every 15 minutes, CNA 2 stated no. During a review of Resident 1's MAR's for the months of 11/2016, 12/2016, 01/2017 and 02/2017, there was no documentation of bed alarm checks by the staff. Furthermore, there was no documentation of bed alarm checks in the residents' entire clinical record from admission to the facility on [DATE], to the time the resident was transferred to the GACH on 2/6/17. A review of the facility's revised policy dated on 5/2011 and titled Fall Prevention indicated a fall prevention program will be developed for each patient that will provide patient care staff with creative functional strategies to minimize falls and undue injuries from such incidents, while recognizing the patient's rights and their need to maintain the highest level of functioning. A review of the facility's revised policy dated on 8/9/13, titled Fall Prevention (Falling Star) indicated the following criteria will be utilized by the facility's IDT to determine the appropriateness of Patient/Resident to be included in the program. The Fall Prevention policy further indicated residents who are placed on the Falling Star Program will be assessed by the IDT for appropriateness of interventions for safety. Interventions may include, but not limited to, depending on Patient/Resident-specific safety needs as follows: -Use of pressure pad/alarm (safety alarms). -Initiating safety watch -Safety watch is done every 30 minutes, on the hour by the Licensed Nurses, and 30 minutes by the CNA's. Schedule is documented in the Licensed Nurses/ CNA's assignment sheets. The IDT will evaluate for need of the Patient/Resident to be placed on: a. Close Supervision- Patient/Resident is placed within the areas with direct view of facility staff, such as closer to the nurses' station, activities, dining room, etc. b. One-on-One Monitoring- If close supervision fails and resident may be at increased risk for hurting self/others, an employee will solely be assigned with the resident at a designated time of the day, which could be twenty four (24) hours a day/ seven (7) days a week, depending on Patient/Resident specific needs and assessment/judgement by the IDT.