Every finding on record at Skyline Healthcare Center - La

Based on interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for four of four sampled residents (Residents 1, 4, 5, and 6) by failing to: 1. Develop a care plan for Resident 1's use of cane (walking stick). 2. Develop a care plan for Residents 1, 4, 5, and 6's out on pass (a resident is temporarily allowed to leave a hospital, long-term care facility, or rehabilitation center without being officially discharged ). These failures had potential for Residents 1, 4, 5, and 6's delays in the delivery of necessary care and services and could place the residents at risk of accidents. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/4/2025, with diagnoses that included unspecified (unconfirmed) fracture (break in the bone) of the left tibia shaft (between the knee and ankle), and difficulty in walking. During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 11/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 used wheelchair (a mobility device with wheels, a seat, and footrests, designed to help people move around when walking is difficult or impossible) and needed supervision with ambulating. During a review of Resident 1's Care Plan, dated 11/4/2026, on activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily), the Care Plan indicated an intervention to provide assistance with ADL care as needed. During a review of Resident 1's Progress Notes, dated 5/11/2026, timed at 5:32 p.m., the Progress Notes indicated Resident 1 requested to go out on pass. The Progress Notes indicated Licensed Vocational Nurse (LVN) 3 notified the Physician and the Physician approved Resident 1's out on pass for four hours.During a review of Resident 1's Physician Order, dated 5/11/2026, the Physician Order indicated Resident 1 may go out on pass today (5/11/2026) to be with family for maximum of four hours. During an interview on 5/14/2026 at 9:42 a.m. with LVN 2, LVN 2 stated on 5/11/2026, at 6:20 p.m., Resident 1 left the faciity on out on pass, took his (Resident 1) cane and left the wheelchair at the facility. LVN 2 stated she (LVN 2) informed Resident 1 where to place his (Resident 1) wheelchair. LVN 2 stated she (LVN 2) had only seen Resident 1 use the wheelchair and was not sure where he (Resident 1) got the cane. LVN 2 stated she (LVN 2) knows Resident 1 depends on his (Resident 1) wheelchair. During a concurrent interview and record review on 5/14/2026 at 10:11 a.m. with the Minimum Data Set Nurse (MDSN), Resident 1's MDS, dated [DATE], and Care Plans were reviewed. The MDSN stated the MDS, dated [DATE], indicated Resident 1 needed supervision to limited assistance with walking and uses front wheeled walker (FWW-a lightweight, height-adjustable metal frame with two small wheels on the front legs and stationary rubber caps or glides on the back legs) and wheelchair. The MDSN stated there were no care plans developed for the use of cane. The MDSN stated she (MDSN) had never seen Resident 1 use a cane before. The MDSN stated Resident 1 had a higher chance of falling using a cane. During a concurrent interview and record review on 5/14/2026 at 10:30 a.m., with the Director of Rehabilitation (DOR), Resident 1's Care Plan dated 4/29/2026, was reviewed. The DOR stated residents were assessed for use of durable medical equipment (DME-reusable medical devices prescribed by a doctor for long-term use in home) for safety before use. The DOR stated Resident 1 was assessed with the use of FWW with Restorative Nursing Assistant (RNA) and the use of wheelchair on his (Resident 1) own. The DOR stated there were no care plans developed for the use of cane. During an interview on 5/14/2026 at 10:37 a.m. with the DOR, the DOR stated there was no documentation on Resident 1's medical record for the use of cane. The DOR stated the FWW provides more support for balance than a cane. The DOR stated there is a higher risk for fall with using cane than FWW. During an interview on 5/14/2026 at 10:44 a.m. with the Director of Nursing (DON), the DON stated Resident 1 left the facility using a cane. The DON stated Resident 1 could have safety issues with the use of cane and could fall as a result. The DON stated if she was informed that Resident 1 used the cane, she (DON) would have asked rehab to evaluate Resident 1 for the safe use of cane and care plan would have been created for Resident 1's safety. The DON stated if rehab did not evaluate Resident 1 for cane it means cane was not safe for Resident 1's use.During a concurrent interview and record review on 5/15/2026 at 8:42 a.m., with LVN 4, Resident 1's Care Plans, were reviewed. LVN 4 stated there was no care plan developed for Resident 1's out on pass. 2a. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 4/23/2026, with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN - high blood pressure) and unsteadiness on feet. During a review of Resident 4's H&P, dated 4/24/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 4 needed moderate assistance from staff for ambulating 10 feet and used wheelchair. During a review of Resident 4's Physician Order, dated 5/11/2026, the Physician Order indicated Resident 4 may go out on pass with the Administrator (ADM) on 5/11/2026, until 11:59 p.m. 2b. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 3/2/2023, with diagnoses that included HTN, DM and localized edema (swelling in one specific area of your body caused by trapped fluid). During a review of Resident 5's Physician Order, dated 8/10/2025, the Physician Order indicated Resident 5 may go out on pass for four hours if not in conflict with care. During a review of Resident 5s H&P, dated 2/13/2026, the H&P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decisions were intact. The MDS indicated Resident 5 uses walkers and wheelchair. 2c. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 12/14/2022, with diagnoses that included lymphedema (an abnormal buildup of protein-rich lymph fluid in the body's tissues that causes persistent swelling), and acute thyroiditis (the swelling or inflammation of your thyroid gland. Located in the front of your neck, thyroid is a small, butterfly-shaped organ that acts as the body's engine, producing hormones that control metabolism and energy). During a review of Resident 6's Physician Order, dated 9/30/2025, the Physician Order indicated Resident 6 may go out on pass for four hours.During a review of Resident 6's H&P, dated 12/5/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decisions were intact. The MDS indicated Resident 6 used wheelchair. During a review of facility's Resident Out on Pass Log, the Out on Pass Log indicated the following:1. Resident 6 signed out on pass on 3/12/2026, at 1:30 p.m.2. Resident 5 signed out on pass on 4/12/2026, at 1 p.m.3. Resident 4 signed out on pass on 5/11/2026, at 9: 20 a.m.4. Resident 1 signed out on pass on 5/11/2026, at 6:20 p.m. During an interview on 5/15/2026 at 8:42 a.m. with LVN 4, LVN 4 stated the nurses do not develop a care plan for residents out on pass order. LVN 4 stated care plan should have been developed to list interventions specific to residents' care while on out on pass and to monitor if treatment is effective or not and for residents' safety. During an interview on 5/15/2026 at 9:18 a.m. with the DON, the DON stated care plans are problems and ongoing intervention that communicates care to all departments in the facility. The DON stated without developing a care plan for out on pass, it can result in miscommunication among staff on what is expected when residents go out on pass. During a review of facility's policy and procedure (P&P) titled, Comprehensive Person- Centered Care Planning, dated 11/2017, and last reviewed on 4/4/2026, the P&P indicated, It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary (a collaborative approach where professionals from diverse medical and social fields unite to manage a patient's care) care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well being. a. The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. c. Since the baseline care plan is developed before the comprehensive assessment, goals and interventions may change. If the comprehensive assessment and thecomprehensive care plan identified a change in the resident's goals, or physical, mental or psychosocial functioning, which was not previously identified on the baseline care plan, those changes must be incorporated into an updated summary provided to the resident and his or her representative, if applicable. Within seven days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan. b. Additional changes or updates to the residents' comprehensive care plan will be made based on the assessed needs of the residents. These subsequent changes will not need to be included in the baseline care plan. It is no longer required to revise/update the base line care plan.

Based on interview and record review, the facility failed to maintain accurate and complete medical record for four of four sampled residents (Residents 1, 4, 5, and 6) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 2 documented that Resident 1 went out on pass (a resident is temporarily allowed to leave a hospital, long-term care facility, or rehabilitation center without being officially discharged ) on 5/11/2026, using a cane (walking stick) and leaving behind his (Resident 1) wheelchair (a mobilized seating device with wheels, used by individuals who have difficulty or are unable to walk due to injury, illness, disability, or age-related conditions). 2. Ensure LVN 1 and LVN 5 documented the date and time Residents 4, 5, and 6 returned to the facility after an out on pass. This failure had the potential to cause confusion in care and the medical records containing inaccurate documentation. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/4/2025, with diagnoses that included unspecified (unconfirmed) fracture (break in the bone) of the left tibia shaft (between the knee and ankle), and difficulty in walking. During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 11/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 used wheelchair and needed supervision with ambulating. During a review of Resident 1's Progress Notes, dated 5/11/2026, timed at 5:32 p.m., the Progress Notes indicated Resident 1 requested to go out on pass. The Progress Notes indicated LVN 3 notified the Physician and the Physician approved Resident 1's out on pass for four hours. During a review of Resident 1's Physician Order, dated 5/11/2026, the Physician Order indicated Resident 1 may go out on pass today (5/11/2026) to be with family for maximum of four hours. During an interview on 5/14/2026 at 9:42 a.m. with LVN 2 LVN 2 stated on 5/11/2026, at 6:20 p.m., Resident 1 took his (Resident 1) cane and left the wheelchair at the facility. LVN 2 stated Resident 1 left the facility unaccompanied on out on pass and was picked up by a taxi. During an interview on 5/14/2026 at 10:44 a.m. with the Director of Nursing (DON), the DON stated Resident 1 left the facility using a cane. The DON stated if she was informed that Resident 1 used the cane, she (DON) would have asked rehab to evaluate Resident 1 for the safe use of cane. The DON stated if rehab did not evaluate Resident 1 for cane it means cane was not safe for Resident 1's use. During a concurrent interview and record review on 5/15/2026 at 8:42 a.m. with LVN 4, Resident 1's Progress Notes, dated 5/11/2026, were reviewed. LVN 4 stated there was no documentation in Resident 1's medical record that Resident 1 left with a cane. LVN 4 stated the facility had a Resident Out on Pass Log where nurse's documents date and time when residents leave and when residents return to the facility and signed by nurses. 2a. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 4/23/2026, with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN - high blood pressure) and unsteadiness on feet. During a review of Resident 4's H&P, dated 4/24/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 4 needed moderate assistance from staff for ambulating 10 feet and used wheelchair. During a review of Resident 4's Physician Order, dated 5/11/2026, the Physician Order indicated Resident 4 may go out on pass with the Administrator (ADM) on 5/11/2026, until 11:59 p.m. During a review of facility's Resident Out on Pass Log, the Resident Out on Pass Log indicated Resident 4 signed out on pass on 5/11/2026, at 9: 20 a.m. During a concurrent interview and record review on 5/14/2026 at 9:14 a.m. with LVN 4, Residents Out on Pass log was reviewed. LVN 4 stated Resident Out on Pass Log indicated Resident 4 went out on pass 5/11/2026, at 9:20 a.m. but did not indicate the following:1. License Nurse initial of when Resident 4 left the facility.2. Expected return time.3, Time Returned4. License Nurse initial of when Resident 4 returned. During a concurrent interview and record review on 5/15/2026 at 8:42 a.m. with LVN 4, Resident 4's Progress Notes, dated 5/11/2026, were reviewed. LVN 4 stated there was no documentation in Resident 4's medical record of when Resident 4 returned to the facility on 5/11/2026. LVN 4 stated LVN 5 did a late entry documentation on 5/14/2026, timed at 9:28 p.m., that Resident 4 left the faciity on 5/11/2026, at 9:20 a.m. with the Activity Director (AD), and returned at 10:10 a.m. and left again at 11:23 a.m., with the Administrator (ADM) and returned at 11:46 a.m. LVN 4 stated LVN 5 should have documented the date and time of Resident 4's return to the facility on 5/11/2026, to show Resident 4's safe return to the facility. 2b. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 3/2/2023, with diagnoses that included HTN, DM and localized edema (swelling in one specific area of your body caused by trapped fluid). During a review of Resident 5's Physician Order, dated 8/10/2025, the Physician Order indicated Resident 5 may go out on pass for four hours if not in conflict with care. During a review of Resident 5s H&P, dated 2/13/2026, the H&P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decisions were intact. During a review of facility's Resident Out on Pass Log, the Resident Out on Pass Log indicated Resident 5 signed out on pass on 4/12/2026, at 1 p.m. During a concurrent interview and record review on 5/14/2026 at 9:14 a.m. with LVN 4, Residents Out on Pass log was reviewed. LVN 4 stated Resident Out on Pass Log indicated Resident 5 went out on pass on 4/12/2026, at 1 p.m., but did not indicate the following:1. License Nurse initial of when Resident 4 left the facility.2. Expected return time.3, Time Returned4. License Nurse initial of when Resident 4 returned. During a concurrent interview and record review on 5/15/2026 at 8:42 a.m. with LVN 4, Resident 5's Progress Notes dated 5/11/2026, were reviewed. LVN 4 stated there was no documentation in Resident 5's medical record of when Resident 5 returned to the facility on 4/12/2026. LVN 4 stated LVN 1 did a late entry documentation on 5/14/2026 timed at 9:51 p.m., that Resident 5 left the faciity on 4/12/2026, with a friend and returned at 8 p.m. LVN 4 stated LVN 1 should have documented the date and time of Resident 5's return to the facility on 4/12/2026, to show Resident 5's safe return to the facility. 2c. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 12/14/2022, with diagnoses that included lymphedema (an abnormal buildup of protein-rich lymph fluid in the body's tissues that causes persistent swelling), and acute thyroiditis (the swelling or inflammation of your thyroid gland. Located in the front of your neck, thyroid is a small, butterfly-shaped organ that acts as the body's engine, producing hormones that control metabolism and energy). During a review of Resident 6's H&P, dated 12/5/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decisions were intact. During a review of Resident 6's Physician Order, dated 9/30/2025, the Physician Order indicated Resident 6 may go out on pass for four hours. During a review of facility's Resident Out on Pass Log, the Resident Out on Pass Log indicated Resident 6 signed out on pass on 3/12/2026, at 1:30 p.m. During a concurrent interview and record review on 5/14/2026 at 9:14 a.m. with LVN 4, Residents Out on Pass log was reviewed. LVN 4 stated Resident Out on Pass Log indicated Resident 6 went out on pass on 3/12/2026, at 1:30 p.m., but did not indicate the following:1. License Nurse initial of when Resident 4 left the facility.2. Expected return time.3, Time Returned4. License Nurse initial of when Resident 4 returned. During a concurrent interview and record review on 5/15/2026 at 8:42 a.m. with LVN 4, Resident 6's Progress Notes, dated 3/12/2026, were reviewed. LVN 4 stated there was no documentation in Resident 6's medical record of when Resident 6 returned to the facility on 3/12/2026. LVN 4 stated LVN 5 did a late entry documentation on 5/14/2026, timed at 8:06 p.m., that Resident 6 returned to the facility on 3/12/2026 at 8:06 pm. LVN 4 stated LVN 5 should have documented the date and time of Resident 6's return to the facility on 3/12/2026, to show Resident 6's safe return to the facility. During an interview on 5/15/2026, at 9:18 a.m. with the DON, the DON stated the facility's Resident Out on Pass Log was incomplete. The DON stated there was also no documentation of the accurate time of Residents 4, 5, and 6 return to the facility. The DON stated nurses should complete the Resident Out on Pass Log and document in the Progress Notes of the time Resident 4, 5, and 6's return to the facility for residents' safety. The DON stated when residents return from out on pass, the nurses assess residents' skin for any breakdown, injury or any accidents. The DON stated all intervention provided to the residents should be documented. The DON stated if it was not documented, intervention was not done. The DON stated nurses should document timely and make sure residents medical records are complete and accurate. During a review of facility's policy and procedure (P&P) titled, Completion and Correction, dated 3/25/2026, was reviewed. The P&P indicated, Entries will be recorded in a timely manner and will be complete, legible, and accurate.IV. Documentation will reflect medically relevant information concerning the Resident and will be documented in a professional manner.During a review of facility's P&P, titled, Progress Notes, dated 1/1/2012, and last reviewed on 4/4/2026, the P&P indicated, Progress notes will reflect the resident's current status, progress or lack of progress, changes in condition, adjustment to the Facility, and other relevant information. Progress notes are to be documented in a timely manner.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was safely assessed for the use of a cane before allowing to leave the facility on an Out on Pass (a resident is temporarily allowed to leave a hospital, long-term care facility, or rehabilitation center without being officially discharged ) order on 5/11/2026. This failure had the potential for Resident 1 to fall outside of the facility that could potentially cause injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/4/2025, with diagnoses that included unspecified (unconfirmed) fracture (break in the bone) of the left tibia shaft (between the knee and ankle), and difficulty in walking. During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 11/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 used wheelchair (a mobility device with wheels, a seat, and footrests, designed to help people move around when walking is difficult or impossible) and needed supervision with ambulating. During a review of Resident 1's Care Plan, dated 11/4/2026, on activities of daily living (ADL - activities such as bathing, dressing and toileting a person performs daily), the Care Plan indicated an intervention to provide assistance with ADL care as needed. During a review of Resident 1's Fall Risk Evaluation, dated 1/20/2026, the Fall Risk Evaluation indicated Resident 1 had one to two fall incidents in the past three months. The Fall Risk Evaluation indicated Resident 1 required use of assistive device. During a review of Resident 1's Progress Notes, dated 5/11/2026, timed at 5:32 p.m., the Progress Notes indicated Resident 1 requested to go out on pass. The Progress Notes indicated Licensed Vocational Nurse (LVN) 3 notified the Physician and the Physician approved Resident 1's out on pass for four hours. During a review of Resident 1's Physician Order, dated 5/11/2026, the Physician Order indicated Resident 1 may go out on pass today (5/11/2026) to be with family for maximum of four hours. During an interview on 5/14/2026 at 9 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 can walk but used a wheelchair all the time. During an interview on 5/14/2026 at 9:20 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 ambulates with assistance and uses wheelchair. During an interview on 5/14/2026 at 9:42 a.m. with LVN 2, LVN 2 stated on 5/11/2026, at 6:20 p.m., Resident 1 left the faciity on out on pass, took his (Resident 1) cane (walking stick) and left the wheelchair at the facility. LVN 2 stated she (LVN 2) informed Resident 1 where to place his (Resident 1) wheelchair. LVN 2 stated she (LVN 2) had only seen Resident 1 use the wheelchair and was not sure where he (Resident 1) got the cane. LVN 2 stated she (LVN 2) knows Resident 1 depends on his (Resident 1) wheelchair. During a concurrent interview and record review on 5/14/2026 at 10:11 a.m. with the Minimum Data Set Nurse (MDSN), Resident 1's MDS, dated [DATE], was reviewed. The MDSN stated the MDS, dated [DATE], indicated Resident 1 needed supervision to limited assistance with walking and uses front wheeled walker (FWW - a lightweight, height-adjustable metal frame with two small wheels on the front legs and stationary rubber caps or glides on the back legs) and wheelchair. The MDSN stated she (MDSN) had never seen Resident 1 use a cane before. The MDSN stated Resident 1 had a higher chance of falling using a cane. During an interview on 5/14/2026 at 10:30 a.m. with the Director of Rehabilitation (DOR), the DOR stated residents were assessed for use of durable medical equipment (DME - reusable medical devices prescribed by a doctor for long-term use in home) for safety before use. The DOR stated Resident 1 was assessed for the use of a FWW with Restorative Nursing Assistant (RNA) and the use of wheelchair on his (Resident 1) own. During an interview on 5/14/2026 at 10:37 a.m. with the DOR, the DOR stated there was no documentation on Resident 1's medical record for the use of cane. The DOR stated Resident 1 was able to walk 100 feet on 4/28/2026, using a FWW when he (Resident 1) was discharged from the rehab therapy on 4/28/2026. The DOR stated the FWW provides more support for balance than a cane. The DOR stated there is a higher risk for fall with using cane than FWW. During an interview on 5/14/2026 at 10:44 a.m. with the Director of Nursing (DON), the DON stated Resident 1 left the facility using a cane. The DON stated Resident 1 could have a safety issue with the use of a cane and could fall as a result. The DON stated the facility failed to assess Resident 1's safety on the use of a cane before allowing him (Resident 1) to leave out on pass on his (Resident 1) own. The DON stated LVN 2 should have advised Resident 1 to bring the FWW or wheelchair instead of the cane and educate Resident 1 that it was not safe to use cane. During a review of the facility's policy and procedure (P&P) titled, Out on Pass, dated 2/2/2026, was reviewed. The P&P indicated, Prior to the Resident leaving on pass, a Licensed Nurse will assess the resident's physical and mental status and ensure that:1. The Resident and responsible person (if applicable) has been instructed of any special needs of the Resident during the pass as applicable (special diet, needs, medications) .5. The Resident is provided with required assistive devices (walker, wheelchair, cane).

Based on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 2) who complained of pain received medication according to the physician orders. This failure resulted in Resident 2's pain management to be ineffective resulting in Resident 2 being in pain.Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 11/4/2025 and re-admitted the resident on 12/14/2026 with diagnoses including fracture of lower end of left tibia (a broken or cracked shinbone[the large, inner bone of the lower leg] just above your ankle joint), fracture of shaft of left tibia (a break in the middle, long part of the left shinbone), difficulty in walking, and pain due to internal orthopedic prosthetic device (man-made, artificial part surgically placed inside the body to replace or support damaged bones or joints), implants (a thing implanted in something else, especially a piece of tissue, prosthetic device, or other object implanted in the body), and grafts (a piece of living tissue that is transplanted surgically).During a review of Resident 2's Physician History and Physical (H&P- a process used by doctors to understand a resident's health and it combines medical history and a physical examination), dated 11/11/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2025, the MDS indicated Resident 2 had the ability to understood and was understood. The MDS indicated Resident 2 was dependent (helper does all the effort) with putting on taking off footwear, and lower body dressing, required substantial assistance (helper does more than half the effort) with toileting, showering, and required partial assistance (helper does less than half the effort) with oral hygiene, upper body dressing and personal hygiene.During a review of Resident 2 Order Summary Report (OSR), dated 11/4/2025, the OSR indicated acetaminophen 325 milligrams (mg- a unit of measurement) to give two (2) tablets by mouth every four (4) hours as needed for mild pain (1-4).During a review of Resident 2 OSR, dated 12/4/2025, the OSR indicated:- Hydrocodone-acetaminophen oral tablet 10-325 mg give one (1) tablet by mouth every four (4) hours as needed for moderate pain (5-7) every four (4) hours as needed for moderate pain.- Hydrocodone-acetaminophen oral tablet 10-325 mg give two (2) tablets by mouth every six (6) hours as needed for severe pain (8-9).During a review of the facility provided fax dated 1/18/2026 at 11:48a.m, the fax indicated a request to fill the following prescriptions:- Hydrocodone-acetaminophen oral tablet 10-325 mg take one (1) tablet every four (4) hours by mouth as needed for 30 days for moderate to severe pain.- Hydrocodone-acetaminophen tablet 10-325 mg take one (1) tablet every four (4) hours by mouth as needed for moderate pain (5-7) and take two (2) tablets by mouth every six (6) hours as needed for sever pain (8-9).During a review of Resident 2's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for January, the MAR indicated on 1/19/2026 at 8:56 p.m. Resident 2 was given acetaminophen 325 two (2) tablets by mouth every four (4) hours as needed for mild pain (1-4) for a pain rating or 9 (sever pain 8-9).During an interview on 1/20/2026 at 11:40a.m. with Resident 2, Resident 2 stated was told the facility ran out of his Norco (Hydrocodone-acetaminophen 10-325 mg) has not gotten it since 1/18/2026 at night. Resident 2 stated his pain is currently 9 out of 10 (pain scale - a tool usually rated 0 to 10 used to measure pain, 0: no pain, 1-3: Mild barely noticeable, 4-6: moderate hard to ignore interferes with activities, 7-9: severe strong pain hard to concentrate prevents normal activity, 10: worst possible unbearable crying or unable to move) it hurt so bad it is causing him a headache. Resident 2 stated was given Tylenol (acetaminophen 325 mg), but it did not help. Resident 2 stated his pain is bad and he takes the pain medication every six (6) hours on the dot because his pain is bad. Resident 2 stated he (Resident 2) did therapy today (1/20/2026) the pain did not impede his therapy.During a concurrent interview and record review on 1/20/2026 at 12:33 p.m. of Resident 2's MAR with Licensed Vocational Nurse (LVN) 1, LVN 1 stated found out Resident 2 was out of his pain medication yesterday (1/19/26) on her first day back to work. LVN 1 stated usually she reorders the medication prior to running out usually when there is six (6) tablets left. LVN 1 stated the request for a refill was sent via fax on 1/18/26 at 11:48 a.m., LVN 1 stated she was planning to follow up with pharmacy today. LVN 1 reviewed MAR for the date of 1/19/2026 8:56 p.m. and LVN 1 stated she (LVN 1) gave Resident 2 Tylenol (acetaminophen 325 mg) for a pain level of 9 but the Tylenol is ordered for a pain level of 1-4. LVN 1 stated there can be a possibility that Resident 2's pain may not be alleviated. During a concurrent interview and record review on 1/20/2026 at 4 p.m. of Resident 2's MAR with the Director of Nursing (DON), the DON stated staff should have at least two to three days' worth of medication. The DON stated medications should never run out. The DON reviewed Resident 2's MAR for 1/19/26 at 8:56 p.m. and stated there is a potential for there to be ineffective management of pain for Resident 2. During a review of the facility's policy and procedure (P&P) titled, Pain Management, last reviewed on 4/4/2025, the P&P indicated facility staff will help the resident attain or maintain their highest-level of well-being while working to prevent or manage the resident's pain to the extent possible. The licensed nurse will administer pain medication as ordered and document medication administered on the MAR.

Based on interview and record review, the facility failed to ensure interventions to prevent falls were in place for one of three sampled residents (Resident 2) by failing to update Resident 2's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling) when Resident 1 had a fall on 12/10/2025.This deficient practice had the potential for an inaccurate assessment of Resident 2, placing Resident 2 at a risk for a fall.Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 11/4/2025 and re-admitted the resident on 12/14/2026 with diagnoses including fracture of lower end of left tibia (a broken or cracked shinbone [the large, inner bone of the lower leg] just above your ankle joint), fracture of shaft of left tibia (a break in the middle, long part of the left shinbone), difficulty in walking, and pain due to internal orthopedic prosthetic device (man-made, artificial part surgically placed inside the body to replace or support damaged bones or joints), implants (a thing implanted in something else, especially a piece of tissue, prosthetic device, or other object implanted in the body), and grafts (a piece of living tissue that is transplanted surgically).During a review of Resident 2's Physician History and Physical (H&P- a process used by doctors to understand residents' health it combines medical history and a physical examination), dated 11/11/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2025, the MDS indicated Resident 2 had the ability to understood and was understood. The MDS indicated Resident 2 was dependent (helper does all the effort) with putting on taking off footwear, and lower body dressing, required substantial assistance (helper does more than half the effort) with toileting, showering, and required partial assistance (helper does less than half the effort) with oral hygiene, upper body dressing and personal hygiene. During a review of Resident 2's Change of Condition (COC) Evaluation, dated 12/10/2025 at 3:43 a.m., the COC evaluation indicated Resident 2 had an unwitnessed fall.During a review of Resident 2's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling), dated 12/10/2025, the Fall Risk Evaluation indicated Resident 2's fall risk score was 6 (a total score of 10 or greater, the resident should be considered at high risk for potential falls). The Fall Risk Evaluation indicated Resident 2 had no falls in the last three (3) months. During a review of Resident 2's Care Plan (CP) for status post (after) unwitnessed fall, initiated on 12/10/2025, the interventions included to transfer Resident 2 to the general acute care hospital for further evaluation and treatment. During a review of Resident 2's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling), dated 12/14/2025, the Fall Risk Evaluation indicated Resident 2's fall risk score was 9. The Fall Risk Evaluation indicated Resident 2 had no falls in the last three (3) months.During a concurrent interview and record review on 1/20/2026 at 4 p.m. of Resident 2's Fall Risk Evaluation with the Director of Nursing (DON), the DON stated Resident 2 had a fall on 12/10/2025 and the Fall Risk Evaluation dated 12/10/2025 did not indicate the fall Resident 2 had. The DON stated the Fall Risk Evaluation for 12/10/2025 should have a higher score. The DON stated for the Fall Risk Evaluation dated 12/14/2025 staff should have indicated the fall when Resident 2 returned from the hospital the Fall Risk Evaluation indicates Resident 2 does not have any history of falls in the last three (3) months. The DON stated if the Fall Risk Evaluation is not accurately documented then the facility will not be doing the proper interventions to prevent falls.During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, last reviewed on 4/4/2025 the P&P indicated to reduce the risk of avoidable falls and falls-related injuries and to ensure timely, evidence-based post-fall evaluation and management consistent with the best practice, federal and state guidance requirements for resident safety, supervision and quality of care.

Based on interview and record review. the facility failed to ensure one of three sampled residents (Resident 2) was free of any significant medication error when Licensed Vocational Nurse (LVN) 1, failed to administer medications as ordered.This deficient practice had the potential to negatively affect Resident 2. Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 11/4/2025 and re-admitted the resident on 12/14/2026 with diagnoses including fracture of lower end of left tibia (a broken or cracked shinbone[the large, inner bone of the lower leg] just above your ankle joint), fracture of shaft of left tibia (a break in the middle, long part of the left shinbone), difficulty in walking, and pain due to internal orthopedic prosthetic device (man-made, artificial part surgically placed inside the body to replace or support damaged bones or joints), implants (a thing implanted in something else, especially a piece of tissue, prosthetic device, or other object implanted in the body) and grafts (a piece of living tissue that is transplanted surgically).During a review of Resident 2's Physician History and Physical (H&P- a process used by doctors to understand patients' health it combines medical history and a physical examination) dated 11/11/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2025, the MDS indicated Resident 2 had the ability to understand and was understood. The MDS indicated Resident 2 was dependent (helper does all the effort) with putting on taking off footwear, and lower body dressing, required substantial assistance (helper does more than half the effort) with toileting, showering, and required partial assistance (helper does less than half the effort) with oral hygiene, upper body dressing and personal hygiene.During a review of Resident 2's Order Summary Report (OSR), dated 11/4/2025, the OSR indicated acetaminophen 325 milligrams (mg- a unit of measurement) give two (2) tablets by mouth every four (4) hours as needed for mild pain (1-4).During a review of Resident 2's OSR, dated 12/4/2025, the OSR indicated:- Hydrocodone-acetaminophen oral tablet 10-325 mg give one (1) tablet by mouth every four (4) hours as needed for moderate pain (5-7) every four (4) hours as needed for moderate pain.- Hydrocodone-acetaminophen oral tablet 10-325 mg give two (2) tablets by mouth every six (6) hours as needed for sever pain (8-9).During a review of the facility provided fax document, dated 1/18/2026 at 11:48 a.m., the fax document indicated a request to fill the following prescriptions:- Hydrocodone-acetaminophen oral tablet 10-325 mg take one (1) tablet every four (4) hours by mouth as needed for 30 days for moderate to severe pain.- Hydrocodone-acetaminophen tablet 10-325 mg take one (1) tablet every four (4) hours by mouth as needed for moderate pain (5-7) and take two (2) tablets by mouth every six (6) hours as needed for severe pain (8-9).During a review of Resident 2's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for January 2026, the MAR indicated on 1/19/2026 at 8:56 p.m. Resident 2 was given acetaminophen 325 two (2) tablets by mouth every four (4) hours as needed for mild pain (1-4) for a pain rating or 9 (sever pain 8-9).During an interview on 1/20/2026 at 11:40a.m. with Resident 2, Resident 2 stated was told the facility ran out of his Norco (Hydrocodone-acetaminophen 10-325 mg) has not gotten it since 1/18/2026 at night. Resident 2 stated his pain is currently 9 out of 10 it hurt so bad it is causing him a headache. Resident 2 stated was given Tylenol (acetaminophen 325 mg) but it did not help. Resident 2 stated his pain is bad and he takes the pain medication every six (6) hours on the dot because his pain is bad.During a concurrent interview and record review on 1/20/2026 at 12:33 p.m. of Resident 2's MAR with Licensed Vocational Nurse (LVN) 1, LVN 1 stated found out Resident 2 was out of his pain medication yesterday (1/19/26) on her first day back to work. LVN 1 stated usually she reorders the medication prior to running out usually when there is six (6) tablets left. LVN 1 stated the request for a refill was sent via fax on 1/18/26 at 11:48 a.m., LVN 1 stated she was planning to follow up with pharmacy today. LVN 1 reviewed MAR for the date of 1/19/2026 8:56 p.m. and LVN 1 stated she (LVN 1) gave Resident 2 Tylenol (acetaminophen 325 mg) for a pain level of 9 but the Tylenol is ordered for a pain level of 1-4. LVN 1 stated there can be a possibility that Resident 2's pain may not be alleviated. During a concurrent interview and record review on 1/20/2026 at 4 p.m. of Resident 2's MAR with the Director of Nursing (DON), the DON stated staff should have at least two to three days' worth of medication. The DON stated medications should never run out. The DON reviewed Resident 2's MAR for 1/19/26 at 8:56 p.m. and stated there is a potential for ineffective management of Resident 2's pain. During a review of the facility's policy and procedure (P&P) titled, Pain Management, last reviewed on 4/4/2025 the P&P indicated facility staff will help the resident attain or maintain their highest-level of well-being while working to prevent or manage the resident's pain to the extent possible. The licensed nurse will administer pain medication as ordered and document medication administered on the MAR.During a review of the facility's P&P titled, Reordering, Changing, and Discontinuing Medication Orders, last reviewed on 4/4/2025, the P&P indicated:B. Reorder/Refills Orders:1. Refills can be requested via facilities EMAR system; this is the most preferred method. Facility may also request refills by placing the refill strip portion of the medication label on the Refill Order Form and faxing it to the pharmacy

Based on interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one of three sampled residents (Resident 2) by failing to respect Resident 2's right to refuse care. This deficient practice had the potential to result in Resident 2's rights to be violated. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and depression (a mental illness that involves a persistent low mood, a loss of interest in activities, and affects daily functions like sleep, appetite, and concentration, leading to significant problems in a person's life, work, or relationships). During a review of Resident 2's History and Physical (H&P- a comprehensive evaluation by a healthcare provider that includes two main parts: a History where the doctor asks you about your symptoms, past illnesses, family health, and lifestyle, and a Physical where the doctor examines your body by checking your vital signs and inspecting different body systems) Examination dated 2/19/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2025, the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 requires partial assistance (helper does less than half the effort) with toileting, showering, lower body dressing, and putting on and taking off footwear, and required supervision assistance (helper provides verbal cues and or touching assistance as resident completes activity) with eating, and oral hygiene. During a review of Resident 2's Progress Notes dated 8/24/2025 at 1:36 p.m., the Progress Notes indicated Resident 2 verbalized in the morning not wanting Certified Nursing Assistant (CNA) 2. Registered Nurse (RN) 2 offered to do her morning personal care such as changing her brief. After meals Resident 2 was offered to be changed by CNA 2 but Resident 2 refused. RN 2 and CNA 2 assisted Resident 2 back in bed and changed Resident 2. Per CNA 2 and RN 2 Resident 2 became aggressive during the transfer and clawed her (Resident 2) nails into RN 2 hand, RN 2 had a skin tear on her (RN 2) forearm. During a concurrent interview and record review on 9/2/2025 at 12:18 p.m. of Resident 2's text messages with the Adm, Resident 2 stated on 8/24/2025 around 2 p.m. was afraid of RN 2 who was from registry (an independent staff who works on a temporary, as needed basis, hired by healthcare facilities or patients through a nursing agency or registry) that came in with CNA 2. Resident 2 stated did not want CNA 2 and asked for another CNA. Resident 2 stated at around 2 p.m. RN 2 and CNA 2 came into Resident 2 room and shut the door, Resident 2 stated RN 2 told Resident 2 RN 2 and CNA 2 would be changing Resident 2. Resident 2 stated she told RN 2 and CNA 2 she (Resident 2) wanted to wait for the next shift, but RN 2 told her no and then proceeded to transfer Resident 2 who was at that time sitting up in her wheelchair next to her bed back into Resident 2's bed. Resident 2 stated RN 2 grabbed Resident 2's left arm and CNA 2 grabbed Resident 2 right arm and put her (Resident 2) back into bed. Resident 2 stated she (Resident 2) was upset because RN 2 and CNA 2 did not listen to her (Resident 2) request of wanting to wait to be changed by the next shift and then Resident 2 grabbed CNA 2 by her long hair. Resident 2 stated she (Resident 2) asked for RN 2 and CNA 2 to leave her (Resident 2) alone and they (RN 2 and CNA 2) refused. Resident 2 stated she did ask RN 2 and CNA 2 multiple times to stop, and she (Resident 2) would wait for the next shift, but all RN 2 said was grabbed an arm to CNA 2. Resident 2 stated this incident was traumatizing to her (Resident 2) because she asked RN 2 and CNA 2 to stop and they did not it was physical abuse. During an interview on 9/2/2025 at 1:54 p.m. with CNA 2, CNA 2 stated worked on 8/24/2025 from 7 a.m. to 3 p.m. and was assigned Resident 2 but around 8 a.m. Resident 2 called the receptionist and asked not to have CNA 2. CNA 2 stated she was told Resident 2 was going to be reassigned but that did not occur instead RN 2 took over her care in the morning. CNA 2 stated around 2:30 p.m. was pulled aside by RN 2 and told Resident 2 needed to be changed and RN 2 would assist CNA 2. CNA 2 stated when RN 2 and CNA 2 entered Resident 2's room Resident 2, Resident 2 stated she (Resident 2) had urine running down her (Resident 2) leg, CNA 2 stated Resident 2 was in the wheelchair for about one and half hours, CNA 2 stated Resident 2 was soaked and reeked of urine. CNA 2 stated offered to change Resident 2 and Resident 2 became aggressive. CNA 2 stated she (CNA 2) and RN 2 assisted Resident 2 back into bed and then Resident 2 grabbed CNA 2 by the hair and began to pull on CNA 2's hair and hit and claw at RN 2. CNA 2 stated she was put into a situation that she did not feel comfortable with when Resident 2 refused CNA 2 Resident 2's wishes should have been respected and have been assigned to another CNA. CNA 2 stated Resident 2 never refused the care, all Resident 2 stated was I have Parkinson's, I have urine running down my leg, CNA 2 stated this was not an answer and we decided to change Resident 2 because she was soaked in urine. CNA 2 stated when Resident 2 was hitting and kicking staff it was because Resident 2 was scared. CNA 2 stated has not been suspended was only talked to about the situation, has not worked with Resident 2 since then. During an interview on 9/2/2025 at 2:35 p.m. with Licensed Voactional Nurse (LVN) 1, LVN 1 stated on 8/24/2025 Resident 2 had an issue with CNA 2, Resident 2 did not want CNA 2 to be assigned to her (Resident 2). LVN 1 stated Resident 2 stated CNA 2 was not providing care Resident 2 needed. LVN 1 stated RN 2 stated she (RN 2) would provide the morning care for Resident 2. LVN 1 stated CNA 2 was not reassigned to another resident and was still assigned to Resident 2. LVN 1 stated then CNA 2 and RN 2 went to change Resident 2 around 2 to 2:15p.m. LVN 1 stated saw RN 2 and CNA 2, RN 2 had scratch marks like Resident 2 had dug her (Resident 2) nails into RN 2 arm and thinks CNA 2 had bruises. During an interview on 9/2/2025 at 3:19 p.m. with RN 2, RN 2 stated is not employed by the facility but a registry and worked at the facility on 8/24/2025 from 7a.m. to 3 p.m. RN 2 stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated she (RN 2) volunteered to care for Resident 2 this was around 9 a.m. did Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. went with CNA 2 to Resident 2's room and Resident 2 was upset stated did not want CNA 2 RN 2 stated RN 2 explained to Resident 2 there was limited assistance and Resident then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair Resident 2 stated she was soaked in urine. RN 2 stated Resident 2 was soaked. RN 2 stated placed Resident 2 back into bed Resident was upset and wanted things done a certain way. RN 2 stated Resident grabbed CNA 2 by the hair and scratched RN 2.During an interview on 9/2/2025 at 4 p.m. with the Administrator (Adm), the Adm stated Resident 2 informed Adm she (Resident 2) did not get her (Resident 2) preferred CNA had CNA 2 and RN 2 stepped in to change Resident 2. The Adm stated if residents refuse care, it is their right to refuse care. The Adm stated if a resident's right to refuse is not respected then it can lead to a low quality of care and not honoring the resident's right. During a review of the facility's Policy and Procedures (P&P) titled, Refusal of Treatment, last reviewed on 4/4/2025, the P&P indicated to ensure that residents are able to exercise their right to refuse treatment. The Facility will honor a resident's request not to receive medical treatment as prescribed by their Attending Physician, as well as care services outlined on the resident's assessment and care plan. Treatment defined as care provided for purpose of maintaining, restoring health, improving functional level, or relieving symptoms.I. The resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by their Attending Physician.II. When a resident refuses treatment, the Charge Nurse or Director of Nursing Services (DNS) interviews the resident to determine what and why the resident is refusing. The Charge Nurse or DNS will attempt to address the residents' concerns and explain the consequences of the refusal.III. The Charge Nurse or DNS will document information relating to the refusal in the resident's medical record. During a review of the facility's P&P titled, Resident Right, Quality of life, last reviewed on 4/4/2025, the P&P indicated each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his or her highest practicable well-being.I. Residents are groomed as they wish, including bathing, dressing and oral care.

Based on interview and record review, the facility failed to ensure a thorough investigation was completed following an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of three sampled residents (Resident 2) when on 8/24/2025 Resident 2 reported to the Administrator (Adm) that staff started fighting with me (Resident 2) physically. This deficient practice had the potential to place Resident 2 at risk for further abuse. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and depression (a mental illness that involves a persistent low mood, a loss of interest in activities, and affects daily functions like sleep, appetite, and concentration, leading to significant problems in a person's life, work, or relationships). During a review of Resident 2's History and Physical (H&P- a comprehensive evaluation by a healthcare provider that includes two main parts: a History where the doctor asks you about your symptoms, past illnesses, family health, and lifestyle, and a Physical where the doctor examines your body by checking your vital signs and inspecting different body systems) Examination dated 2/19/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2025, the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 requires partial assistance (helper does less than half the effort) with toileting, showering, lower body dressing, and putting on and taking off footwear, and required supervision assistance (helper provides verbal cues and touching assistance as resident completes activity) with eating, and oral hygiene. During a review of Resident 2's Progress Notes dated 8/24/2025 at 1:36 p.m., the Progress Notes indicated Resident 2 verbalized in the morning not wanting Certified Nursing Assistant (CNA) 2. Registered Nurse (RN) 2 offered to do her morning personal care such as changing her brief. After meals Resident 2 was offered to be changed by CNA 2 but Resident 2 refused. RN 2 and CNA 2 assisted Resident 2 back in bed and changed Resident 2. Per CNA 2 and RN 2 Resident 2 became aggressive during the transfer and clawed her (Resident 2) nails into RN 2 hand, RN 2 had a skin tear on her (RN 2) forearm. During a concurrent interview and record review on 9/2/2025 at 12:18 p.m. of Resident 2's text messages with the Adm, Resident 2 stated on 8/24/2025 around 2 p.m. was afraid of RN 2 who was from registry (an independent staff who works on a temporary, as needed basis, hired by healthcare facilities or patients through a nursing agency or registry) that came in with CNA 2. Resident 2 stated did not want CNA 2 and asked for another CNA. Resident 2 stated at around 2 p.m. RN 2 and CNA 2 came into Resident 2 room and shut the door, Resident 2 stated RN 2 told Resident 2 RN 2 and CNA 2 would be changing Resident 2. Resident 2 stated she told RN 2 and CNA 2 she (Resident 2) wanted to wait for the next shift but RN 2 told her no and then proceeded to transfer Resident 2 who was at that time sitting up in her wheelchair next to her bed back into Resident 2's bed. Resident 2 stated RN 2 grabbed Resident 2's left arm and CNA 2 grabbed Resident 2 right arm and put her (Resident 2) back into bed. Resident 2 stated she (Resident 2) was upset because RN 2 and CNA 2 did not listen to her (Resident 2) request of wanting to wait to be changed by the next shift and then Resident 2 grabbed CNA 2 by her long hair. Resident 2 stated she (Resident 2) asked for RN 2 and CNA 2 to leave her (Resident 2) alone and they (RN 2 and CNA 2) refused. Resident 2 stated she did ask RN 2 and CNA 2 multiple times to stop, and she (Resident 2) would wait for the next shift, but all RN 2 said was grab an arm to CNA 2. Resident 2 stated this incident was traumatizing to her (Resident 2) because she asked RN 2 and CNA 2 to stop and they did not it was physical abuse. Resident 2 stated she (Resident 2) contacted the Adm via text to inform Adm of the incident. Resident 2 reviewed text messages to Adm and stated text was sent on 8/24/2025 at 2:02 p.m. and based on text the incident occurred around 1:30 p.m., Resident 2 stated she (Resident 2) told Adm she had told RN 2 and CNA 2 that she would wait for the next shift to change me (Resident 2) but they (RN 2 and CNA 2) started fighting with me physically. Resident 2 stated what I (Resident 2) meant by RN 2 and CNA 2 physically fighting is that they were grabbing me against my will it was abuse. Resident 2 stated the only response I (Resident 2) received from the Adm was if I had reported it to the charge nurse. Resident 2 stated, told Adm she (Resident 2) reported the incident to the oncoming nurse Licensed Vocational Nurse (LVN) 2, and nothing else was said by the Adm. Resident 2 stated on 8/25/2025 at 7:38 a.m. she (Resident 2) asked the Adm via text that she wanted to file a police report, Resident 2 stated once again no response from the Adm. During an interview on 9/2/2025 at 1:06 p.m. with LVN 2, LVN 2 stated worked on 8/24/2025 and worked a sixteen (16) hour shift that day from 7 a.m. to 11 p.m. and was Resident 2's nurse for the 3 p.m. to 11 p.m. shift. LVN 2 stated was informed by the morning nurse, LVN 1 that a progress note had been made regarding RN 2 stating Resident 2 had harassed or abused RN 2. LVN 2 stated around 5 p.m. she (LVN 2) spoke to Resident 2 and Resident 2 stated she (Resident 2) did not want to be too specific and talk about the incident because it was too traumatic for Resident 2. LVN 2 stated Resident 2 alleged she (Resident 2) had an altercation with RN 2 and CNA 2. LVN 2 stated an altercation is a resident to resident and or resident to staff fight this could be verbal or physical. LVN 2 stated as far as she was aware no reporting of the alleged altercation. LVN 2 stated the policy is that the abuse coordinator who is the Adm must be notified of any alleged abuse within two (2) hours. LVN 2 stated this would be considered abuse because Resident 2 verbally stated that she (Resident 2) was abused by RN 2 and CNA 2, LVN 2 stated the abuse was not reported within two (2) hours, because LVN 1 only did a behavioral note. LVN 2 stated abuse must be reported to the ombudsmen, Adm, SSA, and police and if it is not reported it will be neglect. LVN 2 stated can also be a concern for abuse to continue to happen, because if not reported the resident can feel like we are not doing anything and not trust us. During an interview on 9/2/2025 at 1:54 p.m. with CNA 2, CNA 2 stated worked on 8/24/2025 from 7 a.m. to 3 p.m. and was assigned Resident 2 but around 8 a.m. Resident 2 called the receptionist and asked not to have CNA 2. CNA 2 stated she was told Resident 2 was going to be reassigned but that did not occur instead RN 2 took over her care in the morning. CNA 2 stated around 2:30 p.m. was pulled aside by RN 2 and told Resident 2 needed to be changed and RN 2 would assist CNA 2. CNA 2 stated when RN 2 and CNA 2 entered Resident 2's room Resident 2, Resident 2 stated she (Resident 2) had urine running down her (Resident 2) leg, CNA 2 stated Resident 2 was in the wheelchair for about one and half hours, CNA 2 stated Resident 2 was soaked and reeked of urine. CNA 2 stated offered to change Resident 2 and Resident 2 became aggressive. CNA 2 stated she (CNA 2) and RN 2 assisted Resident 2 back into bed and then Resident 2 grabbed CNA 2 by the hair and began to pull on CNA 2's hair and hit and claw at RN 2. CNA 2 stated she was put into a situation that she did not feel comfortable with when Resident 2 refused CNA 2 Resident 2's wishes should have been respected and have been assigned to another CNA. CNA 2 stated Resident 2 never refused the care, all Resident 2 stated was I have Parkinson's, I have urine running down my leg, CNA 2 stated this was not an answer and we decided to change Resident 2 because she was soaked in urine. CNA 2 stated when Resident 2 was hitting and kicking staff it was because Resident 2 was scared. CNA 2 stated has not been suspended was only talked to about the situation, has not worked with Resident 2 since then. During an interview on 9/2/2025 at 3:19 p.m. with RN 2, RN 2 stated is not employed by the facility but a registry and worked at the facility on 8/24/2025 from 7a.m. to 3 p.m. RN 2 stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated she (RN 2) volunteered to care for Resident 2 this was around 9 a.m. did Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. went with CNA 2 to Resident 2's room and Resident 2 was upset stated did not want CNA 2 RN 2 stated explained to Resident 2 there was limited assistance and Resident then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair. Resident 2 stated she was soaked in urine. RN 2 stated Resident 2 was soaked. RN 2 stated when placed Resident 2 back into bed Resident was upset and wanted things done a certain way. RN 2 stated Resident grabbed CNA 2 by the hair and scratched RN 2. During an interview on 9/2/2025 at 3:33 p.m. with the Director of Staff Development (DSD) the DSD stated spoke to Resident 2 on 8/28/2025 and Resident 2 stated RN 2 and CNA 2 had scratched her (Resident 2). The DSD stated when a resident alleges, they have been scratched that would be considered abuse, this would have been a physical abuse. The DSD stated not sure if we did anything the Adm knew about this incident as of 8/24/2025 was told by RN 2. The DSD stated any type of abuse must be reported within two (2) hours to the three (3) agencies ombudsmen (OMB), police and SSA. The DSD stated would have to check with Adm not sure if it was reported.During a concurrent interview and record review of Resident 2's text messages with the Adm on 9/2/2025 at 4 p.m. with the Adm, the Adm stated he (Adm) is the abuse coordinator. The Adm reviewed text between Resident 2 and Adm, the Adm stated on 8/24/2025 Resident 2 alleged staff (RN 2 and CNA 2) started fighting physical. The Adm stated abuse would be any physical, verbal, or wrongdoing against someone. The Adm stated I (Adm) would consider this abuse, the Adm stated I (Adm) should have told the nurse at that time to report to OMB, SSA, police and start the investigation. The Adm stated did not do any investigation for Resident 2 allegation of abuse. The Adm stated potential for not investigating can be a resident continues to be at risk for further abuse. During a review of the facility's P&P titled, Abuse, Reporting and Investigations, last reviewed on 4/4/2025, the P&P indicated allegation of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime are to be reported to the Administrator or designated representative immediately.ii. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with the facility policies.3. Notification of Outside Agencies for all other Cases of Abuse.a. The Adm or designated representative will notify law enforcement by telephone immediately, or as soon as practicable possible, but no longer than (2) hours of the initial report.b. The Adm or designated representative will send a written SOC341 report to the OMB and Law Enforcement and CDPH Licensing and Certification within (24) hours.8. Suspension of Employeesa. Employees of this facility who have been accused of resident abuse or a crime will be suspended from duty until the results of the investigation have been reviewed by the Adm.9. Informing Resident of Result of Investigation and Corrective Actiona. The Adm will inform the resident and his or her representative of the results of the investigation and the corrective action taken within five (5) working days of the reported incident.10. Providing State Survey Agency and Other Agencies of the Resulta. The Adm will provide a written report on the result of all abuse investigations and appropriate action taken, to the California Department of Public Health Licensing and Certification and others that may be required by state or local law, within five (5) working days of the reported allegation.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Reporting and Investigations, by failing to report an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) to the State Survey Agency (SSA) no later than two hours for one of three sampled residents (Resident 2) when on 8/24/2025 Resident 2 reported to the Administrator (Adm) that staff started fighting with me (Resident 2) physically. This deficient practice had potential to result in unidentified abuse and placed Resident 2 at risk for further abuse. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and depression (a mental illness that involves a persistent low mood, a loss of interest in activities, and affects daily functions like sleep, appetite, and concentration, leading to significant problems in a person's life, work, or relationships). During a review of Resident 2's History and Physical Examination dated 2/19/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2025, the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 requires partial assistance (helper does less than half the effort) with toileting, showering, lower body dressing, and putting on and taking off footwear, and required supervision assistance (helper provides verbal cues and touching assistance as resident completes activity) with eating, and oral hygiene. During a review of Resident 2's Progress Notes dated 8/24/2025 at 1:36 p.m., the Progress Notes indicated Resident 2 verbalized in the morning not wanting Certified Nursing Assistant (CNA) 2. Registered Nurse (RN) 2 offered to do her morning personal care such as changing her brief. After meals Resident 2 was offered to be changed by CNA 2 but Resident 2 refused. RN 2 and CNA 2 assisted Resident 2 back into bed and changed Resident 2. Per CNA 2 and RN 2 Resident 2 became aggressive during the transfer and clawed her (Resident 2) nails into RN 2's hand, RN 2 had a skin tear on her (RN 2) forearm. During a concurrent interview and record review on 9/2/2025 at 12:18 p.m. of Resident 2's text messages with the Adm, Resident 2 stated on 8/24/2025 around 2 p.m. Resident 2 was afraid of RN 2 who was from registry (an independent staff who works on a temporary, as needed basis, hired by healthcare facilities or patients through a nursing agency or registry) that came in with CNA 2. Resident 2 stated did not want CNA 2 and asked for another CNA. Resident 2 stated at around 2 p.m. RN 2 and CNA 2 came into Resident 2 room and shut the door, Resident 2 stated RN 2 told Resident 2 RN 2 and CNA 2 would be changing Resident 2. Resident 2 stated she told RN 2 and CNA 2 she (Resident 2) wanted to wait for the next shift, but RN 2 told her no and then proceeded to transfer Resident 2 who was at that time sitting up in her wheelchair next to her bed back into Resident 2's bed. Resident 2 stated RN 2 grabbed Resident 2's left arm and CNA 2 grabbed Resident 2 right arm and put her (Resident 2) back into bed. Resident 2 stated she (Resident 2) was upset because RN 2 and CNA 2 did not listen to her (Resident 2) request of wanting to wait to be changed by the next shift and then Resident 2 grabbed CNA 2 by her long hair. Resident 2 stated she (Resident 2) asked for RN 2 and CNA 2 to leave her (Resident 2) alone and they (RN 2 and CNA 2) refused. Resident 2 stated she did ask RN 2 and CNA 2 multiple times to stop, and she (Resident 2) would wait for the next shift, but all RN 2 said was grab an arm to CNA 2. Resident 2 stated this incident was traumatizing to her (Resident 2) because she asked RN 2 and CNA 2 to stop and they did not it was physical abuse. Resident 2 stated she (Resident 2) contacted the Adm via text to inform Adm of the incident. Resident 2 reviewed text messages to Adm and stated text was sent on 8/24/2025 at 2:02 p.m. and based on text the incident occurred around 1:30 p.m., Resident 2 stated she (Resident 2) told Adm she had told RN 2 and CNA 2 that she would wait for the next shift to change me (Resident 2) but they (RN 2 and CNA 2) started fighting with me physically. Resident 2 stated what I (Resident 2) meant by RN 2 and CNA 2 physically fighting is that they were grabbing me against my will it was abuse. Resident 2 stated the only response I (Resident 2) received from the Adm was if I had reported it to the charge nurse. Resident 2 stated told Adm she (Resident 2) reported the incident to the oncoming nurse Licensed Vocational Nurse (LVN) 2, and nothing else was said by the Adm. Resident 2 stated on 8/25/2025 at 7:38 a.m. she (Resident 2) asked the Adm via text that she wanted to file a police report, Resident 2 stated once again no response from the Adm. During an interview on 9/2/2025 at 1:06 p.m. with LVN 2, LVN 2 stated LVN 2 worked on 8/24/2025 and worked a sixteen (16) hour shift that day from 7 a.m. to 11 p.m. and was Resident 2's nurse for the 3 p.m. to 11 p.m. shift. LVN 2 stated was informed by LVN 1, the morning nurse, that a progress note had been made regarding RN 2 stating Resident 2 had harassed or abused RN 2. LVN 2 stated around 5 p.m. she (LVN 2) spoke to Resident 2 and Resident 2 stated she (Resident 2) did not want to be too specific and talk about the incident because it was too traumatic for Resident 2. LVN 2 stated Resident 2 alleged she (Resident 2) had an altercation with RN 2 and CNA 2. LVN 2 stated an altercation is a resident to resident and or resident to staff fight this could be verbal or physical. LVN 2 stated as far as she was aware there was no reporting of the alleged altercation. LVN 2 stated the policy is that the abuse coordinator who is the Adm must be notified of any alleged abuse within two (2) hours. LVN 2 stated this would be considered abuse because Resident 2 verbally stated that she (Resident 2) was abused by RN 2 and CNA 2. LVN 2 stated the abuse was not reported within two (2) hours, because LVN 1 only did a behavioral note. LVN 2 stated abuse must be reported to the ombudsmen, Adm, SSA, and police and if it is not reported it will be neglect. LVN 2 stated it can also be a concern for abuse to continue to happen, because if not reported the resident can feel like we are not doing anything and not trust us. During an interview on 9/2/2025 at 1:54 p.m. with CNA 2, CNA 2 stated worked on 8/24/2025 from 7 a.m. to 3 p.m. and was assigned Resident 2 but around 8 a.m. Resident 2 called the receptionist and asked not to have CNA 2. CNA 2 stated she was told Resident 2 was going to be reassigned but that did not occur instead RN 2 took over her care in the morning. CNA 2 stated around 2:30 p.m. was pulled aside by RN 2 and told Resident 2 needed to be changed and RN 2 would assist CNA 2. CNA 2 stated when RN 2 and CNA 2 entered Resident 2's room Resident 2, Resident 2 stated she (Resident 2) had urine running down her (Resident 2) leg, CNA 2 stated Resident 2 was in the wheelchair for about one and half hours, CNA 2 stated Resident 2 was soaked and reeked of urine. CNA 2 stated offered to change Resident 2 and Resident 2 became aggressive. CNA 2 stated she (CNA 2) and RN 2 assisted Resident 2 back into bed and then Resident 2 grabbed CNA 2 by the hair and began to pull on CNA 2's hair and hit and claw at RN 2. CNA 2 stated she was put into a situation that she did not feel comfortable with when Resident 2 refused CNA 2 Resident 2's wishes should have been respected and have been assigned to another CNA. CNA 2 stated Resident 2 never refused the care, all Resident 2 stated was I have Parkinson's, I have urine running down my leg, CNA 2 stated this was not an answer and we decided to change Resident 2 because she was soaked in urine. CNA 2 stated when Resident 2 was hitting and kicking staff it was because Resident 2 was scared. CNA 2 stated has not been suspended was only talked to about the situation, has not worked with Resident 2 since then. During an interview on 9/2/2025 at 3:19 p.m. with RN 2, RN 2 stated is not employed by the facility but a registry and worked at the facility on 8/24/2025 from 7a.m. to 3 p.m. RN 2 stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated she (RN 2) volunteered to care for Resident 2 this was around 9 a.m. did Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. went with CNA 2 to Resident 2's room and Resident 2 was upset stated did not want CNA 2 RN 2 stated explained to Resident 2 there was limited assistance and Resident then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair Resident 2 stated she was soaked in urine, RN 2 stated Resident 2 was soaked. RN 2 stated placed Resident 2 back into bed Resident was upset and wanted things done a certain way. RN 2 stated Resident grabbed CNA 2 by the hair and scratched RN 2. During an interview on 9/2/2025 at 3:33 p.m. with the Director of Staff Development (DSD) the DSD stated spoke to Resident 2 on 8/28/2025 and Resident 2 stated RN 2 and CNA 2 had scratched her (Resident 2). The DSD stated when a resident alleges, they have been scratched that would be considered abuse, this would have been a physical abuse. The DSD stated not sure if we did anything the Adm knew about this incident as of 8/24/2025 was told by RN 2. The DSD stated any type of abuse must be reported within two (2) hours to the three (3) agencies ombudsmen (OMB), police and SSA. The DSD stated would have to check with Adm not sure if it was reported. The DSD stated CNA 2 has no disciplinary action, only a one-to-one in-service for customer services regarding Resident 2, Resident 2 stated CNA 2 response was not good, the DSD stated CNA 2 has not been suspended. During a concurrent interview and record review of Resident 2's text messages with the Adm on 9/2/2025 at 4 p.m. with the Adm, the Adm stated he (Adm) is the abuse coordinator. The Adm reviewed text between Resident 2 and Adm, the Adm stated on 8/24/2025 Resident 2 alleged staff (RN 2 and CNA 2) started fighting physical. The Adm stated abuse would be any physical, verbal, or wrongdoing against someone. The Adm stated I (Adm) would consider this abuse, the Adm stated I (Adm) should have told the nurse at that time to report to OMB, SSA, police and start the investigation. The Adm stated potential for delayed reporting can be that the resident continues to be at risk for further abuse. During a review of the facility's P&P titled, Abuse, Reporting and Investigations, last reviewed on 4/4/2025, the P&P indicated allegation of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime are to be reported to the Administrator or designated representative immediately. ii. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with the facility policies. 3. Notification of Outside Agencies for all other Cases of Abuse. a. The Adm or designated representative will notify law enforcement by telephone immediately, or as soon as practicable possible, but no longer than (2) hours of the initial report. b. The Adm or designated representative will send a written SOC341 report to the OMB and Law Enforcement and CDPH Licensing and Certification within (24) hours. 8. Suspension of Employees a. Employees of this facility who have been accused of resident abuse or a crime will be suspended from duty until the results of the investigation have been reviewed by the Adm. 9. Informing Resident of Result of Investigation and Corrective Action a. The Adm will inform the resident and his or her representative of the results of the investigation and the corrective action taken within five (5) working days of the reported incident. 10. Providing State Survey Agency and Other Agencies of the Result a. The Adm will provide a written report of the results of all abuse investigations and appropriate action taken, to the California Department of Public Health Licensing and Certification and others that may be required by state or local law, within five (5) working days of the reported allegation.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Reporting and Investigations, for one of three sampled residents (Resident 2) when on 8/24/2025 Resident 2 reported to the Administrator (Adm) that staff started fighting with me (Resident 2) physically (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) was investigated for events that may constitute abuse. This deficient practice resulted in a delayed investigation of an alleged abuse and had the potential to place Resident 2 at risk for further abuse and psychosocial harm. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and depression (a mental illness that involves a persistent low mood, a loss of interest in activities, and affects daily functions like sleep, appetite, and concentration, leading to significant problems in a person's life, work, or relationships). During a review of Resident 2's History and Physical (H&P- a comprehensive evaluation by a healthcare provider that includes two main parts: a History where the doctor asks you about your symptoms, past illnesses, family health, and lifestyle, and a Physical where the doctor examines your body by checking your vital signs and inspecting different body systems) Examination dated 2/19/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2025, the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 requires partial assistance (helper does less than half the effort) with toileting, showering, lower body dressing, and putting on and taking off footwear, and required supervision assistance (helper provides verbal cues and or touching assistance as resident completes activity) with eating, and oral hygiene. During a review of Resident 2's Progress Notes dated 8/24/2025 at 1:36 p.m., the Progress Notes indicated Resident 2 verbalized in the morning not wanting Certified Nursing Assistant (CNA) 2. Registered Nurse (RN) 2 offered to do her morning personal care such as changing her brief. After meals Resident 2 was offered to be changed by CNA 2 but Resident 2 refused. RN 2 and CNA 2 assisted Resident 2 back into bed and changed Resident 2. Per CNA 2 and RN 2, Resident 2 became aggressive during the transfer and clawed her (Resident 2) nails into RN 2's hand. RN 2 had a skin tear on her (RN 2) forearm. During a concurrent interview and record review on 9/2/2025 at 12:18 p.m. of Resident 2's text messages with the Adm, Resident 2 stated on 8/24/2025 around 2 p.m. she was afraid of RN 2 who was from the registry (an independent staff who works on a temporary, as needed basis, hired by healthcare facilities or patients through a nursing agency or registry) that came in with CNA 2. Resident 2 stated she did not want CNA 2 and asked for another CNA. Resident 2 stated at around 2 p.m. RN 2 and CNA 2 came into Resident 2 room and shut the door, Resident 2 stated RN 2 told Resident 2 RN 2 and CNA 2 would be changing Resident 2. Resident 2 stated she told RN 2 and CNA 2 she (Resident 2) wanted to wait for the next shift but RN 2 told her no and then proceeded to transfer Resident 2 who was at that time sitting up in her wheelchair next to her bed back into Resident 2's bed. Resident 2 stated RN 2 grabbed Resident 2's left arm and CNA 2 grabbed Resident 2's right arm and put her (Resident 2) back into bed. Resident 2 stated she (Resident 2) was upset because RN 2 and CNA 2 did not listen to her (Resident 2) request of wanting to wait to be changed by the next shift and then Resident 2 grabbed CNA 2 by her long hair. Resident 2 stated she (Resident 2) asked for RN 2 and CNA 2 to leave her (Resident 2) alone and they (RN 2 and CNA 2) refused. Resident 2 stated she did ask RN 2 and CNA 2 multiple times to stop and she (Resident 2) would wait for the next shift, but all RN 2 said was grab an arm to CNA 2. Resident 2 stated this incident was traumatizing to her because she asked RN 2 and CNA 2 to stop and they did not it, was physical abuse. Resident 2 stated she contacted the Adm via text to inform the Adm of the incident. Resident 2 reviewed text messages to the Adm and stated text was sent on 8/24/2025 at 2:02 p.m. and based on text the incident occurred around 1:30 p.m., Resident 2 stated she (Resident 2) told Adm she had told RN 2 and CNA 2 that she would wait for the next shift to change me (Resident 2) but they (RN 2 and CNA 2) started fighting with me physically. Resident 2 stated what I meant by RN 2 and CNA 2 physically fighting is that they were grabbing me against my will. It was abuse. Resident 2 stated the only response I (Resident 2) received from the Adm was if I had reported it to the charge nurse. Resident 2 stated she told the Adm she (Resident 2) did report the incident to the oncoming nurse Licensed Vocational Nurse (LVN) 2, and nothing else was said by the Adm. Resident 2 stated on 8/25/2025 at 7:38 a.m. She (Resident 2) asked the Adm via text that she wanted to file a police report, Resident 2 stated once again no response from the Adm. During an interview on 9/2/2025 at 1:06 p.m. with LVN 2, LVN 2 stated worked on 8/24/2025 and worked a sixteen (16) hour shift that day from 7 a.m. to 11 p.m. and was Resident 2's nurse for the 3 p.m. to 11 p.m. shift. LVN 2 stated was informed by the morning nurse, LVN 1 that a progress note had been made regarding RN 2 stating Resident 2 had harassed or abused RN 2. LVN 2 stated around 5 p.m. she (LVN 2) spoke to Resident 2 and Resident 2 stated she (Resident 2) did not want to be too specific and talk about the incident because it was too traumatic for Resident 2. LVN 2 stated Resident 2 alleged she (Resident 2) had an altercation with RN 2 and CNA 2. LVN 2 stated an altercation is a resident to resident and or resident to staff fight this could be verbal or physical. LVN 2 stated as far as she was aware there was no reporting of the alleged altercation. LVN 2 stated the policy is that the abuse coordinator who is the Adm must be notified of any alleged abuse within two (2) hours. LVN 2 stated this would be considered abuse because Resident 2 verbally stated that she (Resident 2) was abused by RN 2 and CNA 2. LVN 2 stated the abuse was not reported within two (2) hours, because LVN 1 only did a behavioral note. LVN 2 stated abuse must be reported to the ombudsmen, Adm, SSA, and police and if it is not reported it will be neglect. LVN 2 stated it can also be a concern for abuse to continue to happen, because if not reported the resident can feel like we are not doing anything and not trust us. During an interview on 9/2/2025 at 1:54 p.m. with CNA 2, CNA 2 stated CNA 2 worked on 8/24/2025 from 7 a.m. to 3 p.m. and was assigned Resident 2 but around 8 a.m. Resident 2 called the receptionist and asked not to have CNA 2. CNA 2 stated she was told Resident 2 was going to be reassigned but that did not occur instead RN 2 took over her care in the morning. CNA 2 stated around 2:30 p.m. CNA 2 was pulled aside by RN 2 and told Resident 2 needed to be changed and RN 2 would assist CNA 2. CNA 2 stated when RN 2 and CNA 2 entered Resident 2's room Resident 2 stated she (Resident 2) had urine running down her (Resident 2) leg. CNA 2 stated Resident 2 was in the wheelchair for about one and half hours. CNA 2 stated Resident 2 was soaked and reeked of urine. CNA 2 stated CNA 2 offered to change Resident 2 and Resident 2 became aggressive. CNA 2 stated she (CNA 2) and RN 2 assisted Resident 2 back into bed and then Resident 2 grabbed CNA 2 by the hair and began to pull on CNA 2's hair and hit and claw at RN 2. CNA 2 stated she was put into a situation that she did not feel comfortable when Resident 2 refused. CNA 2 stated Resident 2's wishes should have been respected and have been assigned to another CNA. CNA 2 stated Resident 2 never refused the care. All Resident 2 stated was I have Parkinson's. I have urine running down my leg. CNA 2 stated this was not an answer and we decided to change Resident 2 because she was soaked in urine. CNA 2 stated when Resident 2 was hitting and kicking staff it was because Resident 2 was scared. CNA 2 stated CNA 2 has not been suspended, was only talked to about the situation, and has not worked with Resident 2 since then. During an interview on 9/2/2025 at 3:19 p.m. with RN 2, RN 2 stated RN 2 is not employed by the facility but a registry and worked at the facility on 8/24/2025 from 7a.m. to 3 p.m. RN 2 stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated she (RN 2) volunteered to care for Resident 2 around 9 a.m. RN 2 provided Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. RN 2 went with CNA 2 to Resident 2's room and Resident 2 was upset and did not want CNA 2. RN 2 explained to Resident 2 there was limited assistance and Resident 2 then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair and was soaked in urine. RN 2 stated Resident 2 was soaked. RN 2 stated Resident 2 was placed back into bed and was upset and wanted things done a certain way. RN 2 stated Resident 2 grabbed CNA 2 by the hair and scratched RN 2. During an interview on 9/2/2025 at 3:33 p.m. with the Director of Staff Development (DSD) the DSD stated spoke to Resident 2 on 8/28/2025 and Resident 2 stated RN 2 and CNA 2 had scratched her (Resident 2). The DSD stated when a resident alleges, they have been scratched that would be considered abuse, this would have been considered physical abuse. The DSD stated not sure if we did anything. The Adm knew about this incident as of 8/24/2025 and was told by RN 2. The DSD stated any type of abuse must be reported within two (2) hours to the three (3) agencies ombudsmen (OMB), police and SSA. The DSD stated the DSD would have to check with Adm not sure if it was reported. The DSD stated CNA 2 has no disciplinary action, only a one-to-one in-service for customer services regarding Resident 2. Resident 2 stated CNA 2 response was not good. The DSD stated CNA 2 has not been suspended. During a concurrent interview and record review of Resident 2's text messages with the Adm on 9/2/2025 at 4 p.m. with the Adm, the Adm stated he (Adm) is the abuse coordinator. The Adm reviewed text between Resident 2 and Adm, the Adm stated on 8/24/2025 Resident 2 alleged staff (RN 2 and CNA 2) started fighting physical. The Adm stated abuse would be any physical, verbal, wrongdoing against someone. The Adm stated Adm would consider this abuse. The Adm stated Adm should have told the nurse at that time to report to OMB, SSA, police and start the investigation. The Adm stated Adm did not do any investigation for Resident 2's allegation of abuse. The Adm stated the potential for not investigating can be a resident continues to be at risk for further abuse. During a review of the facility's P&P titled, Abuse, Reporting and Investigations, last reviewed on 4/4/2025, the P&P indicated allegation of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime are to be reported to the Administrator or designated representative immediately.ii. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with the facility policies.3. Notification of Outside Agencies for all other Cases of Abuse.a. The Adm or designated representative will notify law enforcement by telephone immediately, or as soon as practicable possible, but no longer than (2) hours of the initial report.b. The Adm or designated representative will send a written SOC341 report to the OMB and Law Enforcement and CDPH Licensing and Certification within (24) hours.8. Suspension of Employeesa. Employees of this facility who have been accused of resident abuse or a crime will be suspended from duty until the results of the investigation have been reviewed by the Adm.9. Informing Resident of Result of Investigation and Corrective Actiona. The Adm will inform the resident and his or her representative of the results of the investigation and the corrective action taken within five (5) working days of the reported incident.10. Providing State Survey Agency and Other Agencies of the Resulta. The Adm will provide a written report of the result of all abuse investigations and appropriate action taken, to California Department of Public Health Licensing and Certification and others that may be required by state or local law, within five (5) working days of the reported allegation.

Based on interview and record review, the facility failed to inform the attending physician (MD) of one of three sampled residents (Resident 2) behavioral Change of Condition (COC) on 8/24/2025. This deficient practice had the potential to result in a delay in care. Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and depression (a mental illness that involves a persistent low mood, a loss of interest in activities, and affects daily functions like sleep, appetite, and concentration, leading to significant problems in a person's life, work, or relationships). During a review of Resident 2's History and Physical (H&P- a comprehensive evaluation by a healthcare provider that includes two main parts: a History where the doctor asks you about your symptoms, past illnesses, family health, and lifestyle, and a Physical where the doctor examines your body by checking your vital signs and inspecting different body systems) Examination dated 2/19/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Care plan (CP) created on 3/26/2025, the CP indicated Resident 2 behavior and scratched and pushed CNA using inappropriate racial comments. The CP interventions included to monitor resident behavior and notify MD if significant changes present. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2025, the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 requires partial assistance (helper does less than half the effort) with toileting, showering, lower body dressing, and putting on and taking off footwear, and required supervision assistance (helper provides verbal cues and or touching assistance as resident completes activity) with eating, and oral hygiene. During a review of Resident 2's CP created on 8/7/2025, the CP indicated Resident 2 noted with behavioral manifested by verbally aggressive towards staff, screaming and cursing, recent episode on 8/17/2025 refusing CNA care. The CP interventions indicated to approach the residents with respect, being supportive of their issues and problems and use non-threatening body language when approaching the resident. During a review of Resident 2's Progress Notes dated 8/24/2025 at 1:36 p.m., the Progress Notes indicated Resident 2 verbalized in the morning not wanting Certified Nursing Assistant (CNA) 2. Registered Nurse (RN) 2 offered to do her morning personal care such as changing her brief. After meals Resident 2 was offered to be changed by CNA 2 but Resident 2 refused. RN 2 and CNA 2 assisted Resident 2 back in bed and changed Resident 2. Per CNA 2 and RN 2 Resident 2 became aggressive during the transfer and clawed her (Resident 2) nails into RN 2 hand, RN 2 had a skin tear on her (RN 2) forearm. During a concurrent interview and record review on 9/2/2025 at 12:18 p.m. of Resident 2's text messages with the Adm, Resident 2 stated on 8/24/2025 around 2 p.m. was afraid of RN 2 who was from registry (an independent staff who works on a temporary, as needed basis, hired by healthcare facilities or patients through a nursing agency or registry) that came in with CNA 2. Resident 2 stated did not want CNA 2 and asked for another CNA. Resident 2 stated at around 2 p.m. RN 2 and CNA 2 came into Resident 2 room and shut the door, Resident 2 stated RN 2 told Resident 2 RN 2 and CNA 2 would be changing Resident 2. Resident 2 stated she told RN 2 and CNA 2 she (Resident 2) wanted to wait for the next shift, but RN 2 told her no and then proceeded to transfer Resident 2 who was at that time sitting up in her wheelchair next to her bed back into Resident 2's bed. Resident 2 stated RN 2 grabbed Resident 2's left arm and CNA 2 grabbed Resident 2 right arm and put her (Resident 2) back into bed. Resident 2 stated she (Resident 2) was upset because RN 2 and CNA 2 did not listen to her (Resident 2) request of wanting to wait to be changed by the next shift and then Resident 2 grabbed CNA 2 by her long hair. Resident 2 stated she (Resident 2) asked for RN 2 and CNA 2 to leave her (Resident 2) alone and they (RN 2 and CNA 2) refused, Resident 2 stated she (RN 2) scratched RN 2 and CNA 2 stated RN 2 was bleeding. Resident 2 stated she did ask RN 2 and CNA 2 multiple times to stop and she (Resident 2) would wait for the next shift, but all RN 2 said was grab an arm to CNA 2. Resident 2 stated this incident was traumatizing to her (Resident 2) because she asked RN 2 and CNA 2 to stop and they did not it was physical abuse. During an interview on 9/2/2025 at 1:06 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated on 8/24/2025 was working with Resident 2 from 3 p.m. to 11 p.m. LVN 2 stated Resident 2 asked LVN 2 to wipe her (Resident 2) hand because Resident 2 had a lot of blood on her (Resident 2) hand this was her (Resident 2) left hand. LVN 2 stated Resident 2 alleged she (Resident 2) had an altercation with RN 2 and CNA 2, LVN 2 stated all she (LVN 2) saw was blood under Resident 2 fingernails, no actual site of bleeding, no active bleeding. LVN 2 stated this was around 5p.m., just washed the hand, then put triple antibiotic cream under Resident 2's nails. During an interview on 9/2/2025 at 1:54 p.m. with CNA 2, CNA 2 stated worked on 8/24/2025 from 7 a.m. to 3 p.m. and was assigned Resident 2 but around 8 a.m. Resident 2 called the receptionist and asked not to have CNA 2. CNA 2 stated she was told Resident 2 was going to be reassigned but that did not occur instead RN 2 took over her care in the morning. CNA 2 stated around 2:30 p.m. was pulled aside by RN 2 and told Resident 2 needed to be changed and RN 2 would assist CNA 2. CNA 2 stated when RN 2 and CNA 2 entered Resident 2's room Resident 2, Resident 2 stated she (Resident 2) had urine running down her (Resident 2) leg, CNA 2 stated Resident 2 was in the wheelchair for about one and half hours, CNA 2 stated Resident 2 was soaked and reeked of urine. CNA 2 stated offered to change Resident 2 and Resident 2 became aggressive. CNA 2 stated she (CNA 2) and RN 2 assisted Resident 2 back into bed and then Resident 2 grabbed CNA 2 by the hair and began to pull on CNA 2's hair and hit and claw at RN 2. CNA 2 stated she was put into a situation that she did not feel comfortable with when Resident 2 refused CNA 2 Resident 2's wishes should have been respected and have been assigned to another CNA. CNA 2 stated when Resident 2 was hitting and kicking staff it was because Resident 2 was scared. During an interview on 9/2/2025 at 2:35 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 8/24/2025 Resident 2 had an issue with CNA 2, Resident 2 did not want CNA 2 to be assigned to her (Resident 2). LVN 1 stated Resident 2 stated CNA 2 was not providing care Resident 2 needed. LVN 1 stated RN 2 stated she (RN 2) would provide the morning care for Resident 2. LVN 1 stated CNA 2 was not reassigned to another resident was still assigned to Resident 2. LVN 1 stated then CNA 2 and RN 2 went to changed Resident 2 around 2 to 2:15p.m. LVN 1 stated saw RN 2 and CNA 2, RN 2 had scratch marks like Resident 2 had dug her (Resident 2) nails into RN 2 arm and thinks CNA 2 had bruises. During an interview on 9/2/2025 at 3:19 p.m. with RN 2, RN 2 stated is not employed by the facility but a registry and worked at the facility on 8/24/2025 from 7a.m. to 3 p.m. RN 2 stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated she (RN 2) volunteered to care for Resident 2 this was around 9 a.m. did Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. went with CNA 2 to Resident 2's room and Resident 2 was upset stated did not want CNA 2. RN 2 stated explained to Resident 2 there was limited assistance and Resident then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair Resident 2 stated she was soaked in urine, RN 2 stated Resident 2 was soaked. RN 2 stated placed Resident 2 back into bed Resident was upset and wanted things done a certain way. RN 2 stated Resident grabbed CNA 2 by the hair and scratched RN 2. During an interview on 9/2/2025 at 4 p.m. with the Administrator (Adm), the Adm stated Resident 2 does have behavioral issues but scratching and drawing blood from staff is a brand-new behavior. The Adm stated because this is a new behavior a COC should have been created for Resident 2's behavior. The Adm stated a COC is to monitor the residents for the COC. The MD must be notified to get new orders. The Adm stated the MD was not notified of Resident 2's COC. The Adm stated there is a potential for a delay of care because no COC was done to address the resident's behavioral change. During a review of the facility's Policy and Procedures (P&P) titled, Change in Condition Notification, last reviewed on 4/4/2025, the P&P indicated the facility will promptly inform the resident, consult with the resident's Physician and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition cause by, but not limited to:b. A significant change in the residents' physical, mental or psychosocial statusII. Change of Condition related to Physician notification is defined as when the Physician must be notified when any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denotes a new problem, complication or permanent change in status and requires medical assessment, coordination and consultation with a Physician and a change in treatment plan.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) who had a diagnosis of type 2 diabetes mellitus (DM - a disease that occurs when your blood sugar [BS] is too high), had a change of condition (COC - a major decline in a resident's status) on 7/19/2025 at 4 a.m., when Resident 1 complained of nausea (a feeling of sickness in the stomach that can be accompanied by an urge to vomit), had one episode of vomiting, and a documented blood sugar of 382 (normal range is between 70 to 99) milligrams per deciliter (mg/dl - unit of measurement) obtained by Licensed Vocational Nurse 1(LVN 1), and had a physician's order dated 7/15/2025, instructing staff to notify Medical Doctor 1 (MD 1) if the BS is greater than 350 mg/dl. The facility failed to: 1. Follow the physician's order dated 7/15/2025 to notify MD 1 when Resident 1's BS level reached 382 mg/dl on 7/19/2025 at 4 a.m., exceeding 350 mg/dl. 2. Ensure that Resident 1's vital signs (measurements of the body's most basic functions) were obtained during a COC on 7/19/2025 at 4 a.m. 3. Perform a comprehensive nursing assessment of Resident 1 during a COC on 7/19/2025 at 4 a.m. 4. Ensure that License Vocational Nurse 1 (LVN 1) provided a shift endorsement (process where a licensed nurse is transferring responsibility for resident care to another licensed nurse providing a detailed summary of the resident's condition, treatment, and ongoing needs) to the oncoming (7 a.m. to 3 p.m. shift) staff (Registered Nurse 2 [RN 2] and Licensed Vocational Nurse 2 [LVN 2]) regarding Resident 1's COC that occurred during LVN 1's shift on 7/19/2025 at 4 a.m. This deficient practice resulted in Resident 1 being found unresponsive (not reacting or responding to touch, sounds or verbal commands) on 7/19/2025 at 7:50 a.m. and subsequently died at the facility on 7/19/2025 at 8:05 a.m. On 8/7/2025 at 1:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and Registered Nurse (RN) 1 due to the facility's failure to provide treatment and care in accordance with professional standards of practice when Resident 1 had a COC on 7/19/2025 at 4 a.m. On 8/9/2025 at 12:54 p.m., the ADM submitted an IJ Removal Plan (a detailed plan that identifies all actions the facility will take to immediately address the IJ findings) for the facility's failure to provide treatment and care in accordance with professional standards of practice when Resident 1 had a COC on 7/19/2025 at 4 a.m. On 8/9/2025 at 3:01 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to provide treatment and care in accordance with professional standards of practice when Resident 1 had a COC on 7/19/2025 at 4 a.m. was no longer present. The SSA removed the IJ situation on 8/9/2025 at 3:01 p.m. in the presence of the ADM and LVN 8. The acceptable IJ Removal Plan included the following summarized actions: 1. After the IJ was called on 8/7/2025 at 1:31p.m., regarding not notifying the physician of Resident 1's COC, the facility immediately implemented a corrective process requiring all licensed nurses to notify the physician promptly as ordered. The corrective process will include a physical hand-off report (a process of transferring resident care responsibility and information from one healthcare provider to another), called the Shift-to-Shift COC Report, by the licensed nurses every shift. The hand-off report will include any changes of condition that occurred throughout their shift with confirmation that the incoming nurse received the report. The Shift-to-Shift COC Report is audited by the RN 1 and/or designee (assigned Desk Nurse) on every shift. 2. On 8/7/2025 at 2:30 p.m., 6 p.m., and 11 p.m., 8/8/2025 at 2:45 p.m., and ongoing, the Director of Staff Development (DSD) and/or designee provided in-service (training and educational session provided to facility staff) training to the licensed nurses. The training emphasized the importance of timely physician notification, documenting vital signs (measurements of the body's most basic functions), performing resident assessments and observations during a change of condition, following physician's orders and adhering to the facility's policy and procedure (P&P), titled Alert Charting Documentation. During the ongoing in-services provided by the Director of Nursing (DON) and/or designee, all licensed nurses will be re-educated and reminded that Licensed Nurses are able to reach out and contact a physician 24 hours a day, seven days a week (24/7), at any given time whether it is early morning or late evening. 3. On 8/7/2025 at 4:28 p.m., RN 1 and DSD had given a verbal one-on-one in-service (individualized training) and a corrective action warning to LVN 1. 4. On 8/7/2025 at 6:06 p.m., the Corporate Office responded after the ADM reached out on 8/6/2025 at 2:25 p.m., stating that there was no specific policy regarding the process for following physician orders. The Corporate Office indicated that a new policy would be developed including procedures to address non-compliance specifically outlining the steps to be taken when a physician's order is not followed and revisions will also be made to the facility's existing P&P titled, Change of Condition Notification. 5. On 8/7/2025 at 7:30 p.m., the ADM initially conducted a facility-wide audit using the Change of Condition Alert Audit Tool to identify any residents with a COC and verify whether the physician was notified. The audit tool indicated the resident's name, room number, physician notification status, any discrepancies found, and the licensed nurse responsible for completing the documentation. From 7/31/2025 to 8/7/2025, no other residents were identified as being affected by the alleged deficient practice. 6. On 8/7/2025 at 7:19 pm, the ADM notified the Medical Director regarding the IJs received. The ADM and Medical Director discussed training, competencies, the current P&P, and planned revisions. 7. On 8/8/2025 at 6 p.m., the DON, RN 1, DSD, and Infection Preventionist (IP) communicated to the licensed nurses through text messages the critical importance of timely physician notifications for COCs, including elevated BS levels, nausea, vomiting, or any other significant change. 8. On 8/8/2025 at 6 p.m. and 11:45 p.m., and on 8/9/2025 at 8 a.m., and ongoing, a Licensed Nurse (IP) provided in-service training to the CNAs, emphasizing the importance of identifying COCs in residents. CNAs were instructed to report any unusual or off behaviors such as a resident (Resident 1) requesting water every 20 minutes. All observed or suspected COCs must be reported immediately to the charge nurse, treatment nurse, or RN. 9. On 8/9/2025 at 10:30 a.m., the ADM and DON had given a verbal one-on-one in-service and a corrective action warning to CNA 1. 10. On 8/9/2025 at 10:15 a.m., the DON conducted a facility-wide audit using the Change of Condition Alert Audit Tool to identify any residents with a COC, and verify whether the physician was notified. The audit tool indicated the resident's name, room number, physician notification status, any discrepancies found, and the licensed nurse responsible for completing the documentation. From 8/7/2025 to 8/9/2025, no other residents were identified as being affected by the alleged deficient practice. 11. All ongoing audits using the Change of Condition Audit Tool will be conducted daily by the DON or designee. In the absence of the DON, the DSD, IP, Minimum Data Set (MDS - a resident assessment tool) Nurse (a licensed nurse who specializes in the MDS process) RN, or another member of the nursing leadership team will be responsible for completing the audit. 12. Licensed nurses who have not received in-service training due to a leave of absence or vacation will be in-serviced by the DON and/or designee prior to the start of their next scheduled shift. The goal is to achieve 100 percent (% - per one hundred) completion of in-service training for all licensed nurses upon their return from leave of absence or vacation. 13. The DON and/or designee will provide ongoing monthly in-service education to all licensed nurses for the next six months to ensure consistent reinforcement of the following: adherence to physician orders, timely physician notification, accurate documentation of vital signs, and thorough assessment of residents.14. During the ongoing in-services provided by the Director of Nursing and/or designee, all licensed nurses will be re-educated and reminded to reach out and contact a physician 24/7, at any time whether early morning or late evening. 15. The DON and/or designee will conduct facility-wide daily audits reviewing the previous 24 hours to identify and address any deficient practices. As part of the audit process, the RN or desk nurse will use the Blood Sugar Parameter Audit Tool to monitor BS levels for all residents. If any BS readings fall outside the parameters specified in the physician's orders, appropriate protocols will be followed, and any discrepancies will be immediately addressed and corrected. 16. The DON will emphasize to all licensed nurses the importance of participating in Shift Huddles (a brief, informal, and stand-up meeting, usually lasting 10 to 15 minutes or less, at the beginning of a shift to share important information, discuss resident safety, and align the team for the day ahead) and review clinical communications at the beginning of each shift. Additionally, a new Shift-to-Shift COC Report will be implemented and utilized during shift changes to enhance communication and continuity of care among licensed nurses. 17. Nursing P&P will be compiled into a binder and placed at each nursing station to ensure easy access for all nursing staff. 18. The licensed nurses will complete the Shift-to-Shift COC Report every shift. The hand-off report will include any COCs that occurred during the shift, along with confirmation that the oncoming nurse received and acknowledged the report. The RN and/or designee (assigned desk nurse) will audit the Shift-to-Shift COC Report daily using the COC Audit Tool. The audit process will include a thorough review of all Alert Charting documentation and any documented COC for all residents. Any discrepancies will be immediately addressed and corrected. 19. The Governing Body will hold a meeting on 8/29/2025 to develop and reassess the facility's P&P regarding compliance with following physician orders, obtaining vital signs, and performing resident assessments. 20. The DON/designee and/or ADM/designee will be responsible for ensuring compliance. Audit findings will be reported to the ADM and/or designee who will then present and discuss the findings during monthly Quality Assurance and Performance Improvement (QAPI - a structured data-driven approach to improving healthcare quality and resident outcomes) meetings for three months or until sustained compliance is achieved for further recommendations and follow-up actions. Cross reference to F580. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 12/3/2021 and readmitted the resident on 5/27/2025 with diagnoses including type 2 DM, hypertension (high blood pressure), hyperlipidemia (a medical condition characterized by elevated levels of lipids [fats] in the bloodstream), and chronic kidney disease (a condition where the kidneys are damaged and cannot filter waste and excess water from the blood). During a review of Resident 1's care plan regarding non-compliance with nursing care and interventions, initiated on 8/6/2022, the care plan includes an intervention to notify the MD of any significant COC. During a review of Resident 1's History and Physical (H&P - comprehensive assessment conducted by a healthcare provider that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern), dated 9/13/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's MDS, dated [DATE], the MDS indicated that Resident 1 had an intact thought process and required supervision from staff to complete activities of daily living (ADLs - basic, essential tasks for self-care and mobility such as eating, bathing, dressing, transferring and toileting). During a review of Resident 1's Physician's Orders, dated 7/15/2025, the Physician's Order indicated to monitor Resident 1's BS before meals and at bedtime, and to notify the MD if BS is greater than 350 mg/dl or less than 70 mg/dl. During a review of Resident 1's care plan regarding type 2 DM, initiated on 7/15/2025, the care plan includes an intervention to notify the MD if BS is greater than 350 mg/dl or less than 70 mg/dl. During a review of Resident 1's Progress Notes, dated 7/19/2025, timed at 8:32 a.m., the Progress Notes indicated that on 7/19/2025 at 4 a.m. Resident 1 requested LVN 1 to check his (Resident 1) blood sugar due to complaints of nausea, and the BS result was 382 mg/dl. The Progress Notes further indicated that on 7/19/2025 at 4 a.m. Resident 1 had an episode of vomiting. During an interview on 8/4/2025 at 1:44 p.m., with RN 2, RN 2 stated that she (RN 2) did not receive any endorsement from LVN 1 regarding Resident 1's nausea, vomiting, and elevated BS of 382 mg/dl. RN 2 stated that three nurses (RN 1, LVN 1, and one unidentified licensed nurse) from the previous shift (11 p.m. to 7 a.m. shift) had informed her (RN 2) that everyone (referring to all residents) was fine. RN 2 further stated that on 7/19/2025 at around 7:50 a.m., LVN 2 called and notified her (LVN 2) that Resident 1 was unresponsive. RN 2 stated that upon receiving the call, RN 2 immediately responded and assessed Resident 1, noting that the resident (Resident 1) was cold to the touch. RN 2 stated she (RN 2) was unable to obtain any vital signs, at which point she (RN 2) called 911 (a phone number used to contact emergency services), and initiated chest compressions (using hands to push down hard and fast in a specific way on a resident's chest in order to help blood flow through the heart in an emergency situation). During a concurrent interview and record review on 8/5/2025 at 6:24 a.m., with LVN 1, Resident 1's Progress Notes dated 7/19/2025, Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 7/2025, and Resident 1's Vital Signs Record dated 7/19/2025 were reviewed. LVN 1 stated that Resident 1's last BS check was conducted on 7/19/2025 at 4 a.m., with a high result of 382 mg/dl. LVN 1 stated that on 7/19/2025 at 4 a.m., Resident 1 was nauseated and had one episode of vomiting. LVN 1 stated that the MAR indicated the MD (MD 1) should be notified if Resident 1's BS exceeded 350 mg/dl, however, he (LVN 1) did not contact MD 1 because he (LVN 1) assumed notification was only needed if the BS reading was over 400 mg/dl. LVN 1 stated he (LVN 1) did not recheck the elevated BS reading of 382 mg/dl taken at 4 a.m. on 7/19/2025 and stated he (LVN 1) should have rechecked and monitored Resident 1's BS for any changes. LVN 1 stated that there was no documented evidence of Resident 1's vital signs or nursing assessments being completed during Resident 1's COC as it was not done. LVN 1 stated that he (LVN 1) did not notify MD 1 and stated that he (LVN 1) should have contacted MD 1 promptly to obtain orders for Resident 1's nausea, vomiting and elevated BS (382 mg/dl). LVN 1 stated that Resident 1 could have recurring episodes of nausea and vomiting and did not have any prescribed medication for nausea and vomiting. LVN 1 stated that if Resident 1's condition was left unreported and unchecked, Resident 1 could have developed hyperglycemia (a condition in which blood sugar levels are abnormally high), diabetic ketoacidosis (a life-threatening complication of diabetes mellitus [DM - when the body can't produce enough of a hormone called insulin {which regulates the amount of sugar in the blood}, or the insulin it produces isn't effective]) and potentially become unresponsive. During an interview on 8/5/2025 at 9:37 a.m., with MD 1, MD 1 stated that he (MD 1) does not recall being notified on 7/19/2025 at 4 a.m. regarding Resident 1's COC. MD 1 further stated that, had he been notified, he (MD 1) would have ordered an insulin injection (the method of delivering insulin into the body using a needle or pen), implemented aspiration precaution (steps taken to prevent food, liquids, or vomit from accidentally entering the lungs), and initiated hydration (process of replacing water in the body) measures, depending on Resident 1's vital signs. During a concurrent interview and record review on 8/5/2025 at 9:56 a.m., with RN 1, Resident 1's Progress Notes dated 7/19/2025 and Resident 1's Physician's Order, dated 7/15/2025, were reviewed. RN 1 stated that on 7/19/2025 at 4 a.m., Resident 1 had a BS level of 382 mg/dl, complained of nausea, and had an episode of vomiting. RN 1 stated that there was no documented evidence that Resident 1's vital signs were taken or that an assessment was conducted when Resident 1 had a COC on 7/19/2025 at 4 a.m. RN 1 stated that LVN 1 should have checked Resident 1's vital signs and notified MD 1 if any abnormalities (one or more key body functions like heart rate, breathing rate, blood pressure, or temperature, fall outside normal range, indicating a potential health problem that requires medical attention) were present. RN 1 further stated that LVN 1 did not recheck the elevated BS level of 382 mg/dl and that there was no ongoing monitoring of vital signs to justify that Resident 1 was not in distress (negative state). RN 1 stated that LVN 1 should have immediately notified MD 1 regarding the elevated BS result (382 mg/dl), nausea and vomiting, as these symptoms indicated a potential underlying medical issue that required further medical intervention. RN 1 stated that MD 1 might have ordered an insulin injection due to the high BS level. RN 1 also stated that Resident 1's Physician's Order dated 7/15/2025 instructed staff to notify MD 1 if Resident 1's BS exceeded 350 mg/dl. RN 1 stated that failure to act on these symptoms could have led to a worsening condition, and potentially death. During an interview on 8/7/2025 at 11:05 a.m., with RN 1, RN 1 stated that Resident 1's BS level greater than 350 mg/dl, along with nausea and vomiting constituted a COC, as these symptoms were abnormal for Resident 1. RN 1 stated that Resident 1 required a thorough assessment and appropriate medical intervention from MD 1. RN 1 further stated that LVN 1 was responsible for obtaining Resident 1's vital signs and reporting all presenting symptoms to MD 1 in order to receive appropriate medical orders to address Resident 1's COC. During a review of Resident 1's Certificate of Death , dated 8/6/2025, the Certificate of Death indicated that the immediate cause of death for Resident 1 was cardiopulmonary arrest (a life-threatening medical emergency where the heart stops effectively pumping blood and the body stops breathing), with underlying conditions contributing to the cause of death listed as respiratory failure (a life-threatening medical condition where the lungs can't adequately exchange gases to meet the body's needs) and type 2 DM. During a review of the current facility-provided P&P titled, Change of Condition Notification, last reviewed on 4/4/2025, the P&P indicated, To ensure . physicians are informed of changes in the resident's condition in a timely manner. During a review of the current facility-provided P&P titled, Blood Glucose (refers to the concentration of glucose [simple sugar that serves as the body's primary source of energy] in the bloodstream) Monitoring, last reviewed on 4/4/2025, the P&P indicated, Notify the healthcare provider of a Blood Sugar Level . higher than 250 (mg/dl) unless otherwise indicated in the physician order. During a review of the current facility-provided P&P titled, Diabetic Care, last reviewed on 4/4/2025, the P&P indicated, In any case where the resident's blood sugar is . greater than 350 (mg/dl), the Attending Physician must be notified: unless otherwise noted on the Physician's order. Nursing staff will monitor the resident for signs and symptom of hypoglycemia (low BS level) or hyperglycemia, initiate intervention if necessary, and notify the Attending Physician and responsible party if the signs and symptoms are present. During a review of the current facility-provided P&P titled, Obtaining Vital Signs, last reviewed on 4/4/2025, the P&P indicated, To take clinical measurements that indicate the stated of a resident's basic body functions. Vitals signs will be taken with the following frequency but not limited to when there is a change in the resident's condition. During a review of the current facility-provided P&P titled, 24-hour Communication Log, last reviewed on 4/4/2025, the P&P indicated, To provide a communication system that will alert facility staff of changes in residents' condition and other important aspects of care and treatment. The facility will utilize a 24-hour report system in the form of a 24-Hour Communication Log as a means of communication changes in condition, other important aspects of residents' care. The log will be maintained at each nursing station to facilitate inter-shift communication and assist in the provision of optimum resident care. During a review of the current facility-provided P&P titled, Alert Charting Documentation, last reviewed on 4/4/2025, the P&P indicated, To ensure the timely, ongoing assessments and documentation of residents who have had a change in condition while at the facility.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Change of Condition Notification, last reviewed on 4/4/2025 for one of three sampled residents (Resident 1) by failing to notify Medical Doctor 1 (MD 1) when on 7/19/2025 at 4 a.m., Resident 1 who had a diagnosis of type 2 diabetes mellitus (DM - a disease that occurs when your blood sugar [BS] is too high), had a change of condition (COC - a major decline in a resident's status). Resident 1 complained of nausea (a feeling of sickness in the stomach that can be accompanied by an urge to vomit), had one episode of vomiting, a documented blood sugar of 382 milligrams per deciliter (mg/dl - unit of measurement) obtained by Licensed Vocational Nurse 1(LVN 1), and had a physician's order dated 7/15/2025, instructing staff to notify the MD if the BS is greater than 350 mg/dl. This deficient practice resulted in Resident 1 being found unresponsive (not reacting or responding to touch, sounds or verbal commands) on 7/19/2025 at 7:50 a.m. and subsequently died at the facility on 7/19/2025 at 8:05 a.m. On 8/7/2025 at 1:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and Registered Nurse (RN) 1 due to the facility's failure to notify MD 1 regarding Resident 1's COC on 7/18/2025 during the 11 p.m. to 7 a.m. shift and on 7/19/2025 at 4 a.m. On 8/9/2025 at 12:54 p.m., the ADM submitted an IJ Removal Plan (a detailed plan that identifies all actions the facility will take to immediately address the IJ findings) for the facility's failure to notify the physician when Resident 1 had a COC on 7/19/2025 at 4 a.m. On 8/9/2025 at 3:01 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to notify the physician when Resident 1 had a COC on 7/19/2025 at 4 a.m. was no longer present. The SSA removed the IJ situation on 8/9/2025 at 3:01 p.m., in the presence of the ADM and LVN 8. The acceptable IJ Removal Plan included the following summarized actions: 1. After the IJ was called on 8/7/2025 at 1:31p.m., regarding not notifying the physician of Resident 1's COC, the facility immediately implemented a corrective process requiring all licensed nurses to notify the physician promptly as ordered. The corrective process will include a physical hand-off report (a process of transferring resident care responsibility and information from one healthcare provider to another), called the Shift-to-Shift COC Report, by the licensed nurses every shift. The hand-off report will include any changes of condition that occurred throughout their shift with confirmation that the incoming nurse received the report. The Shift-to-Shift COC Report is audited by the RN 1 and/or designee (assigned Desk Nurse) on every shift. 2. On 8/7/2025 at 2:30 p.m., 6 p.m., and 11 p.m., 8/8/2025 at 2:45 p.m., and ongoing, the Director of Staff Development (DSD) and/or designee provided in-service (training and educational session provided to facility staff) training to the licensed nurses. The training emphasized the importance of timely physician notification, documenting vital signs (measurements of the body's most basic functions), performing resident assessments and observations during a change of condition, following physician's orders and adhering to the facility's P&P, titled Alert Charting Documentation. During the ongoing in-services provided by the Director of Nursing (DON) and/or designee, all licensed nurses will be re-educated and reminded that Licensed Nurses are able to reach out and contact a physician 24 hours a day, seven days a week (24/7), at any given time whether it is early morning or late evening. 3. On 8/7/2025 at 4:28 p.m., RN 1 and DSD had given a verbal one-on-one in-service (individualized training) and a corrective action warning to LVN 1. 4. On 8/7/2025 at 6:06 p.m., the Corporate Office responded after the ADM reached out on 8/6/2025 at 2:25 p.m., stating that there was no specific policy regarding the process for following physician orders. The Corporate Office indicated that a new policy would be developed including procedures to address non-compliance specifically outlining the steps to be taken when a physician's order is not followed and revisions will also be made to the facility's existing P&P titled, Change of Condition Notification. 5. On 8/7/2025 at 7:30 p.m., the ADM initially conducted a facility-wide audit using the Change of Condition Alert Audit Tool to identify any residents with a COC and verify whether the physician was notified. The audit tool indicated the resident's name, room number, physician notification status, any discrepancies found, and the licensed nurse responsible for completing the documentation. From 7/31/2025 to 8/7/2025, no other residents were identified as being affected by the alleged deficient practice. 6. On 8/7/2025 at 7:19 pm, the ADM notified the Medical Director regarding the IJs received. The ADM and Medical Director discussed training, competencies, the current P&P, and planned revisions. 7. On 8/8/2025 at 6 p.m., the DON, RN 1, DSD, and Infection Preventionist (IP) communicated to the licensed nurses through text messages the critical importance of timely physician notifications for COCs, including elevated BS levels, nausea, vomiting, or any other significant change. 8. On 8/8/2025 at 6 p.m. and 11:45 p.m., and on 8/9/2025 at 8 a.m., and ongoing, a Licensed Nurse (IP) provided in-service training to the CNAs, emphasizing the importance of identifying COCs in residents. CNAs were instructed to report any unusual or off behaviors such as a resident (Resident 1) requesting water every 20 minutes. All observed or suspected COCs must be reported immediately to the charge nurse, treatment nurse, or RN. 9. On 8/9/2025 at 10:30 a.m., the ADM and DON had given a verbal one-on-one in-service and a corrective action warning to Certified Nurse Assistant 1 (CNA 1). 10. On 8/9/2025 at 10:15 a.m., the DON conducted a facility-wide audit using the Change of Condition Alert Audit Tool to identify any residents with a COC, and verify whether the physician was notified. The audit tool indicated the resident's name, room number, physician notification status, any discrepancies found, and the licensed nurse responsible for completing the documentation. From 8/7/2025 to 8/9/2025, no other residents were identified as being affected by the alleged deficient practice. 11. All ongoing audits using the Change of Condition Audit Tool will be conducted daily by the DON or designee. In the absence of the DON, the DSD, IP, Minimum Data Set (MDS - a resident assessment tool) Nurse (a licensed nurse who specializes in the MDS process) RN, or another member of the nursing leadership team will be responsible for completing the audit. 12. Licensed nurses who have not received in-service training due to a leave of absence or vacation will be in-serviced by the DON and/or designee prior to the start of their next scheduled shift. The goal is to achieve 100 percent (% - per one hundred) completion of in-service training for all licensed nurses upon their return from leave of absence or vacation. 13. The DON and/or designee will provide ongoing monthly in-service education to all licensed nurses for the next six months to ensure consistent reinforcement of the following: adherence to physician orders, timely physician notification, accurate documentation of vital signs, and thorough assessment of residents.14. During the ongoing in-services provided by the Director of Nursing and/or designee, all licensed nurses will be re-educated and reminded to reach out and contact a physician 24/7, at any time whether early morning or late evening. 15. The DON and/or designee will conduct facility-wide daily audits reviewing the previous 24 hours to identify and address any deficient practices. As part of the audit process, the RN or desk nurse will use the Blood Sugar Parameter Audit Tool to monitor BS levels for all residents. If any BS readings fall outside the parameters specified in the physician's orders, appropriate protocols will be followed, and any discrepancies will be immediately addressed and corrected. 16. The DON will emphasize to all licensed nurses the importance of participating in Shift Huddles (a brief, informal, and stand-up meeting, usually lasting 10 to 15 minutes or less, at the beginning of a shift to share important information, discuss resident safety, and align the team for the day ahead) and review clinical communications at the beginning of each shift. Additionally, a new Shift-to-Shift COC Report will be implemented and utilized during shift changes to enhance communication and continuity of care among licensed nurses. 17. Nursing P&P will be compiled into a binder and placed at each nursing station to ensure easy access for all nursing staff. 18. The licensed nurses will complete the Shift-to-Shift COC Report every shift. The hand-off report will include any COCs that occurred during the shift, along with confirmation that the oncoming nurse received and acknowledged the report. The RN and/or designee (assigned desk nurse) will audit the Shift-to-Shift COC Report daily using the COC Audit Tool. The audit process will include a thorough review of all Alert Charting documentation and any documented COC for all residents. Any discrepancies will be immediately addressed and corrected. 19. The Governing Body will hold a meeting on 8/29/2025 to develop and reassess the facility's P&P regarding compliance with following physician orders, obtaining vital signs, and performing resident assessments. 20. The DON/designee and/or ADM/designee will be responsible for ensuring compliance. Audit findings will be reported to the ADM and/or designee who will then present and discuss the findings during monthly Quality Assurance and Performance Improvement (QAPI - a structured data-driven approach to improving healthcare quality and resident outcomes) meetings for three months or until sustained compliance is achieved for further recommendations and follow-up actions. Cross reference to F684. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 12/3/2021 and readmitted the resident on 5/27/2025 with diagnoses including type 2 DM, hypertension (high blood pressure), hyperlipidemia (a medical condition characterized by elevated levels of lipids [fats] in the bloodstream), and chronic kidney disease (a condition where the kidneys are damaged and cannot filter waste and excess water from the blood). During a review of Resident 1's care plan regarding non-compliance with nursing care and interventions, initiated on 8/6/2022, the care plan includes an intervention to notify the MD of any significant COC. During a review of Resident 1's History and Physical (H&P - comprehensive assessment conducted by a healthcare provider that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern), dated 9/13/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's MDS, dated [DATE], the MDS indicated that Resident 1 had an intact thought process and required supervision from staff to complete activities of daily living (ADLs - basic, essential tasks for self-care and mobility such as eating, bathing, dressing, transferring and toileting). During a review of Resident 1's Physician's Orders, dated 7/15/2025, the Physician's Order indicated to monitor Resident 1's BS before meals and at bedtime, and to notify the MD if BS is greater than 350 mg/dl or less than 70 mg/dl. During a review of Resident 1's care plan regarding type 2 DM, initiated on 7/15/2025, the care plan includes an intervention to notify the MD if BS is greater than 350 mg/dl or less than 70 mg/dl. During a review of Resident 1's Progress Notes, dated 7/19/2024, timed at 8:32 a.m., the Progress Notes indicated that on 7/19/2025 at 4 a.m. Resident 1 requested LVN 1 to check his (Resident 1) blood sugar due to complaints of nausea, and the BS result was 382 mg/dl. The Progress Notes further indicated that on 7/19/2025 at 4 a.m. Resident 1 had an episode of vomiting. During an interview on 8/4/2025 at 1:44 p.m., with RN 2, RN 2 stated that she (RN 2) did not receive any endorsement (process where a licensed nurse is transferring responsibility for resident care to another licensed nurse providing a detailed summary of the resident's condition, treatment, and ongoing needs) from LVN 1 regarding Resident 1's nausea, vomiting, and elevated BS of 382 mg/dl. RN 2 stated that three nurses (RN 1, LVN 1, and one unidentified licensed nurse) from the previous shift (11 p.m. to 7 a.m. shift) had informed her (RN 2) that everyone (referring to all residents) was fine. RN 2 further stated that on 7/19/2025 at around 7:50 a.m., LVN 2 called and notified her (LVN 2) that Resident 1 was unresponsive. RN 2 stated that upon receiving the call, RN 2 immediately responded and assessed Resident 1, noting that the resident (Resident 1) was cold to the touch. RN 2 stated she (RN 2) was unable to obtain any vital signs, at which point she (RN 2) called 911 (a phone number used to contact emergency services), and initiated chest compressions (using hands to push down hard and fast in a specific way on a resident's chest in order to help blood flow through the heart in an emergency situation). During a concurrent interview and record review on 8/5/2025 at 6:24 a.m., with LVN 1, Resident 1's Progress Notes dated 7/19/2025, Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 7/2025, and Resident 1's Vital Signs Record dated 7/19/2025 were reviewed. LVN 1 stated that Resident 1's last BS check was conducted on 7/19/2025 at 4 a.m., with a high result of 382 mg/dl. LVN 1 stated that on 7/19/2025 at 4 a.m., Resident 1 was nauseated and had one episode of vomiting. LVN 1 stated that the MAR indicated the MD (MD 1) should be notified if Resident 1's BS exceeded 350 mg/dl, however, he (LVN 1) did not contact MD 1 because he (LVN 1) assumed notification was only needed if the BS reading was over 400 mg/dl. LVN 1 stated he (LVN 1) did not recheck the elevated BS reading of 382 mg/dl taken at 4 a.m. on 7/19/2025 and stated he (LVN 1) should have rechecked and monitored Resident 1's BS for any changes. LVN 1 stated that there was no documented evidence of Resident 1's vital signs or nursing assessments being completed during Resident 1's COC as it was not done. LVN 1 stated that he (LVN 1) did not notify MD 1 and stated that he (LVN 1) should have contacted MD 1 promptly to obtain orders for Resident 1's nausea, vomiting and elevated BS (382 mg/dl). LVN 1 stated that Resident 1 could have recurring episodes and did not have any prescribed medication for nausea and vomiting. LVN 1 stated that if Resident 1's condition was left unreported and unchecked, Resident 1 could have developed hyperglycemia (a condition in which blood sugar levels are abnormally high), diabetic ketoacidosis (a life-threatening complication of DM) and potentially become unresponsive. During an interview on 8/5/2025 at 9:37 a.m., with MD 1, MD 1 stated that he (MD 1) does not recall being notified on 7/19/2025 at 4 a.m. regarding Resident 1's COC. MD 1 further stated that, had he been notified, he (MD 1) would have ordered an insulin injection (the method of delivering insulin into the body using a needle or pen), implemented aspiration precaution (steps taken to prevent food, liquids, or vomit from accidentally entering the lungs), and initiated hydration (process of replacing water in the body) measures, depending on Resident 1's vital signs. During a concurrent interview and record review on 8/5/2025 at 9:56 a.m., with RN 1, Resident 1's Progress Notes dated 7/19/2025 and Resident 1's Physician's Order, dated 7/15/2025, were reviewed. RN 1 stated that on 7/19/2025 at 4 a.m., Resident 1 had a BS level of 382 mg/dl, complained of nausea, and had an episode of vomiting. RN 1 stated that there was no documented evidence that Resident 1's vital signs were taken or that an assessment was conducted when Resident 1 had a COC on 7/19/2025 at 4 a.m. RN 1 stated that LVN 1 should have checked Resident 1's vital signs and notified MD 1 if any abnormalities (one or more key body functions like heart rate, breathing rate, blood pressure, or temperature, fall outside normal range, indicating a potential health problem that requires medical attention) were present. RN 1 further stated that LVN 1 did not recheck the elevated BS level of 382 mg/dl and that there was no ongoing monitoring of vital signs to justify that Resident 1 was not in distress (negative state). RN 1 stated that LVN 1 should have immediately notified MD 1 regarding the elevated BS result (382 mg/dl), nausea and vomiting, as these symptoms indicated a potential underlying medical issue that required further medical intervention. RN 1 stated that MD 1 might have ordered an insulin injection due to the high BS level. RN 1 also stated that Resident 1's Physician's Order dated 7/15/2025 instructed staff to notify MD 1 if Resident 1's BS exceeded 350 mg/dl. RN 1 stated that failure to act on these symptoms could have led to a worsening condition, and potentially death. During an interview on 8/7/2025 at 11:05 a.m., with RN 1, RN 1 stated that Resident 1's BS level greater than 350 mg/dl, along with nausea and vomiting constituted a COC, as these symptoms were abnormal for Resident 1. RN 1 stated that Resident 1 required a thorough assessment and appropriate medical intervention from MD 1. RN 1 further stated that LVN 1 was responsible for obtaining Resident 1's vital signs and reporting all presenting symptoms to MD 1 in order to receive appropriate medical orders to address Resident 1's COC. During a review of Resident 1's Certificate of Death , dated 8/6/2025, the Certificate of Death indicated that the immediate cause of death for Resident 1 was cardiopulmonary arrest (a life-threatening medical emergency where the heart stops effectively pumping blood and the body stops breathing), with underlying conditions contributing to the cause of death listed as respiratory failure (a life-threatening medical condition where the lungs can't adequately exchange gases to meet the body's needs) and type 2 DM. During a review of the current facility-provided P&P titled, Change of Condition Notification, last reviewed on 4/4/2025, the P&P indicated, To ensure . physicians are informed of changes in the resident's condition in a timely manner. During a review of the current facility-provided P&P titled, Blood Glucose (refers to the concentration of glucose [simple sugar that serves as the body's primary source of energy] in the bloodstream) Monitoring, last reviewed on 4/4/2025, the P&P indicated, Notify the healthcare provider of a Blood Sugar Level . higher than 250 (mg/dl) unless otherwise indicated in the physician order. During a review of the current facility-provided P&P titled, Diabetic Care, last reviewed on 4/4/2025, the P&P indicated, In any case where the resident's blood sugar is . greater than 350 (mg/dl), the Attending Physician must be notified: unless otherwise noted on the Physician's order. Nursing staff will monitor the resident for signs and symptom of hypoglycemia (low BS level) or hyperglycemia, initiate intervention if necessary, and notify the Attending Physician and responsible party if the signs and symptoms are present.

Based on interview and record review, the facility failed to ensure staff were competent when providing care for one of three sample residents (Resident 1), by failing to:1. Ensure License Vocational Nurse (LVN 1) notified the physician when Resident 1 had a change of condition on 7/19/2025, at 4 a.m. when Resident 1 felt nauseated, had one episode of vomiting and had a blood sugar of 382 milligram per deciliter (mg/dl-unit of measurement).2. Ensure LVN 1 follows physicians order when physicians order indicated to notify physician if Resident 1 blood sugar was greater than 350 mg/dl.3. Ensure LVN 1 obtains Resident 1 vital signs (include body temperature, pulse (heart rate), respiration rate (breathing), and blood pressure. These measurements help healthcare professionals assess a person's overall health and identify potential problems) when Resident 1 had a change of condition.4. Ensure LVN 1 follows an infection control policy and procedure by offering a trash can when Resident 1 had an episode of vomiting.5. Ensure staff competency (a combination of knowledge, skills, abilities, and behaviors that enable an individual to perform a task or role successfully) were performed annually (yearly) for two of five sampled staff (Certified Nursing Assistant 1 [CNA 1], and Registered Nurse 2 [RN2]) and four of five sampled staff (CNA 1, CNA 2,LVN 8 and RN 2) had annual performance evaluationThese failures placed Resident 1 at immediate risk. The resident was subsequently found unresponsive on 7/19/2025, at 7:50 a.m., which ultimately led to his death at 8:05 a.m. the same day. Also had the potential to affect the care necessary to provide nursing care and related services to meet residents' needs safely. Findings: a. During a review of Resident 1’s admission Record, the admission Record indicated the facility initially admitted Resident 1 on 12/3/2021, and readmitted on [DATE], with a diagnoses of type 2 Diabetes Mellites (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar) and hypertension (HTN-high blood pressure). During a review of Resident 1’s History and Physical (H & P), dated 9/13/2024, the H & P indicated that Resident 1 had the capacity to understand and make decisions. During a review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 6/12/2025, the MDS indicated Resident 1’s thought process was intact and required supervision assistance from staff to complete activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1’s Physician’s Orders, dated 7/15/2025, the Physician’s Order indicated to monitor Resident 1’s blood sugar before meals and bedtime. Call the physician if blood sugar is greater 350 mg/dl or less than 70 mg/dl before meals and at bedtime. During a review of Resident 1 Progress Notes, dated 7/19/2025, the Progress Notes indicated Resident 1 requested his (Resident 1) blood sugar to be checked due to feeling nauseated and blood sugar result was high. Resident 1 had an episode of vomiting and trash can was provided to Resident 1 in case he had another episode of vomiting. Resident 1’s last blood sugar check was 382 mg/dl. During a concurrent interview and record review on 8/5/2025, at 6:24 a.m. with LVN 1, Resident 1 Progress Notes, dated 7/19/2025, were reviewed. The Progress Notes indicated that Resident 1’s last blood sugar check result was high with a result of 382 mg/dl per LVN 1, Resident 1 was nauseated and vomited one time. LVN 1 stated that he (LVN 1) did not notify the physician. LVN 1 stated that he (LVN 1) explained to Resident 1 that Resident 1’s previous standing order of sliding scale insulin was removed and offered ice chips since there was no as needed medication for nausea. LVN 1 stated that Resident 1 requested to receive his (Resident 1) 6 a.m. medication early instead since there was no medication available. LVN 1 stated that he (LVN 1) gave Resident 1’s 6 a.m. medication at around 4:25 a.m. as Resident 1 requested and did not call the physician to report that Resident 1 blood sugar was 382 mg/dl, nauseated, vomited once and did not call that Resident 1 was requesting to take his 6 a.m. medication early. LVN 1 stated he (LVN 1) should have notified the physician right away to get an order for nausea, vomiting and Resident 1’s blood sugar of 382 mg/dl. LVN 1 stated Resident 1 could possibly have another episode of nausea and vomiting again possibly related to hyperglycemia, diabetic ketoacidosis (a serious complication of diabetes characterized by high blood sugar and excess ketones in the blood or urine), and unresponsiveness. During a concurrent interview and record review on 8/5/2025, at 6:24 a.m. with LVN 1, Resident 1’s Medication Administration Record (MAR), dated 7/2025, was reviewed. The MAR indicated that call the physician if Resident 1’s blood sugar was greater than 350 mg/dl and or less than 70 mg/dl. MAR indicated that Resident 1 blood sugar reading at 6:30 a.m. was 394 mg/dl. LVN 1 stated he (LVN 1) did not notify the physician and skimmed the order and assumed that he (LVN 1) would call the physician if Resident 1 blood sugar was greater than 400 mg/dl. LVN 1 stated that it was a typographical error (a mistake made while typing or printing text), and the blood sugar should be 382 mg/dl instead of 394 mg/dl and the blood sugar of 382 mg/dl was taken at 4 a.m. LVN 1 stated he (LVN 1) did not recheck Resident 1 blood sugar since 4 a.m. that it was last check and just record the last reading of blood sugar of 382 mg/dl at 6:30 a.m. LVN stated that he (LVN 1) should recheck and monitor Resident 1 blood sugar to see any changes. During a concurrent interview and record review on 8/5/2025, at 6:24 a.m. with LVN 1, Resident 1’s Vital Signs, dated 7/19/2025, were reviewed. LVN 1 stated there were no recorded vital signs taken on 7/19/2025. LVN 1 stated if it was not documented, it was not done. During a concurrent interview and record review on 8/5/2025, at 9:56 a.m. with RN 1, Resident 1’s Progress Notes, dated 7/19/2025, was reviewed. The Progress Notes indicated that Resident 1’s blood sugar was 382 mg/dl and had episode of nausea and vomiting. RN 1 stated that there was no documentation that LVN 1 checked Resident 1 vital signs at 4 a.m. when Resident 1’s complained of nausea. RN 1 stated that LVN 1 should check Resident 1 vital signs and notify the physician if it’s abnormal. RN 1 stated LVN 1 indicated that Resident 1 was okay, but it would be hard to determine if Resident 1 was okay if LVN 1 did not even recheck blood sugar after getting a 382 mg/dl result, and no monitoring of vital signs was taken for Resident 1 to justify that Resident 1 had no distress. RN 1 stated that LVN 1 should have notified the physician right away because Resident 1’s blood sugar was greater than 350 mg/dl, nauseated and vomited. RN 1 stated it means there was something going on and needed more intervention from the physician. RN 1 stated the physician could possibly order an insulin (medication to lower blood sugar) due to Resident 1’s high blood sugar. During a concurrent interview and record review on 8/5/2025, at 9:56 a.m. with RN 1, Resident 1’s Physician Order, dated 7/16/2025, were reviewed. The Physicians Order indicated that to call the physician if Resident 1’s blood sugar was greater than 350 mg/dl. RN 1 stated that physicians ordered to notify the physician when blood sugar was greater than 350 mg/dl. RN 1 stated Resident 1’s condition could worsen and could possibly lead to death. During a concurrent interview and record review on 8/5/2025, at 12:30 p.m. with Director of Staff Development (DSD), LVN 1’s Employee File, dated 5/17/2025, were reviewed. The Employee File indicated that LVN 1 received an orientation skills check on change of condition, notification requirement, documentation requirement and infection control on 5/17/2025. During a concurrent interview and record review on 8/6/2025, at 2:31 p.m. with Infection Preventionist (IP), Resident 1’s Progress Notes, dated 7/19/2025, were reviewed. IP stated it indicated that LVN 1 offered trashcan to Resident 1 in case Resident 1 had an episode of vomiting again. IP stated that LVN 1 should not offer trash can because it contains a lot of bacteria and must offer a clean basin instead. During an interview on 8/6/2025, at 2:49 p.m. with RN 1. RN 1 stated LVN 1 should not offer trash can to Resident 1 and must provide a clean basin due to cross contamination Resident 1 could get infection from the trash can. During an interview on 8/7/2025, at 11:05 a.m. with RN 1. RN 1 stated blood sugar of greater than 350 mg/dl, nausea and vomiting was a change of condition for Resident 1 because this was all abnormal for Resident 1 and needed a proper assessment and intervention from the physician. RN 1 stated if LVN 1 considers this as a change of condition LVN 1 must take the vital signs of Resident 1 and report all the symptoms of Resident 1 to the physician to get a proper intervention. During a review of the facility’s policy and procedure(P&P), titled, “Infection Control – Policies and Procedures,” last reviewed on 4/4/2025, indicated, “To provide infection control policies and procedures required for a safe and sanitary environment.” During a review of the facility’s P&P, titled, “Staff Competency Validation,” last reviewed on 4/4/2025, indicated, “Staff are required to have competency validation based on their job description or assigned duties.” During a review of the facility’s P&P, titled, “Obtaining Vital Signs,” last reviewed on 4/4/2025, indicated, “To take clinical measurements that indicate the stated of a resident’s basic body functions. Vitals signs will be taken with the following frequency but not limited to when there is a change in the resident’s condition.” During a review of the facility’s P&P, titled, “Change of Condition Notification,” last reviewed on 4/4/2025, indicated, “To ensure … physicians are informed of changes in the resident’s condition in a timely manner.” During a review of the facility’s P&P, titled, “Blood Glucose Monitoring,” last reviewed on 4/4/2025, indicated, “Notify the healthcare provider of a Blood Sugar Level lower than 70 mg/dl or higher than 250 mg/dl unless otherwise indicated in the physician order.” During a review of the facility’s P&P, titled, “Diabetic Care,” last reviewed on 4/4/2025, indicated, “In any case where the resident’s blood sugar is less than 70 mg/dl or greater than 350 mg/dl, the Attending Physician must be notified: unless otherwise noted on the Physician’s Order. Nursing staff will monitor the residents for signs and symptom of hypoglycemia (low blood sugar) or hyperglycemia, initiate intervention if necessary, and notify the Attending Physician and responsible party if the signs and symptoms are present.” b. During a concurrent interview, and record review on 8/8/2025, at 12:32 p.m., with the Assistant Director of Staff Development (ADSD), four employee files were reviewed: 1. CNA 1’s Date of Hire was 6/20/2024, and the latest Competency Checklist was dated 8/7/2025. No Performance Evaluation on file. 2. CNA 2’s Date of Hire was 5/15/2024, - No Performance Evaluation on file. 3. LVN 8’s Date of Hire was 6/23/2015, - no Performance Evaluation on file. 4. RN 2’s Date of Hire was 11/22/2016, - and the latest Licensed Nurse Orientation Skills Checklist and Annual Skills Check, was dated 11/19/2023, and the latest Performance Evaluation was dated 11/22/2017. The ADSD stated CNA 1 and RN 2’s competency was not assessed annually. The ADSD stated CNA 1, CNA 2, LVN 8 and RN2’s performance evaluation was not on the employee file. The ADSD stated the Infection Preventionist (IP), and the Director of Staff Development (DSD) are responsible for competency oversight. The ADSD stated she (ADSD) was not sure how frequently staff competency should be assessed but based on the Licensed Nurse Orientation Skills Checklist and Annual Skills Check, competency check should be yearly. The ADSD stated she was not sure also how frequently the performance evaluation was done. During an interview on 8/8/2025, at 1:28 p.m. with the Director of Nursing (DON), the DON stated performance evaluation and competency checklist should be in the employee file. During an interview on 8/8/2025, at 2:48 p.m., with the DON, the DON stated staff competency and performance evaluation should be assessed annually to identify areas that needed further teaching or education. The DON stated the competency and performance evaluation determines if licensed nurses are competent to perform their responsibilities. The DON stated if competency and performance evaluation were not done annually it could result in potential harm for the residents. The DON stated it was her (DON) and the DSD’s responsibility to make sure it was done. During a concurrent interview, and record review on 8/9/2025, at 2:28 p.m., with the Administrator (Admin), facility’s policy and procedure (P&P), titled, “Staff Competency Validation”, dated 6/4/2024, and last reviewed on 4/4/2025, the P&P indicated, “Competency validation is completed to evaluate an individual’s performance, evaluate group performance, meet standards set by regulatory agencies, address problematic issues and enhance performance reviews. Competency validation is a determination based on an individual’s satisfactory performance or each specific element of his or her job description and of the specific requirements for the area in which he or she is employed. To protect the health, safety and wellbeing of resident.” The Admin stated the facility’s P&P did not indicate how frequent should the competency check and performance evaluation. The Admin stated CNA’s, LVNs and RNs should be checked for competency annually to ensure the safety of residents and to ensure that all staff are competent when they provide care. The Admin stated the facility does not have a policy on performance evaluation. During a concurrent interview, and record review on 8/9/2025, at 2:28 p.m., with the Administrator (Admin), facility’s Facility Assessment Tool, dated 3/3/2025, was reviewed. The Facility Assessment Tool indicated, “List all staff training and competencies needed by type of staff. Consider if it would be helpful to indicate which competencies are reviewed at the time the staff member was hired and how often they are reviewed after that.” The Admin stated the Facility Assessment Tool did not indicate frequency of competency and performance evaluations. The Admin stated he (Admin) will update the Facility Assessment Tool. [NAME] an interview on 8/9/2025, at 2:50 p.m., with the DON, the DON stated the facility should ensure that staff are competent on an annual basis and if any gaps in competency, the facility can identify it and address it. During a review of facility’s Employee Handbook dated 1/2024, the Employee Handbook indicated, “PERFORMANCE EVALUATIONS: Employees may receive periodic performance reviews. The review will generally be conducted by their supervisor. The first performance evaluation may be after completion of the Introductory Period. After that review, performance evaluations may be conducted annually, on or around their anniversary date. The frequency of performance evaluations may vary depending upon length of service, job position, past performance, changes in job duties or recurring performance problems. Performance evaluations· will Include factors such as the quality and quantity of the work performed, knowledge of the job, their Initiative, their work attitude and their demeanor toward others. Performance evaluations are designed to help employees become aware of progress, areas for Improvement and objectives or goals for future work performance.”

Based on interview, and record review, the facility failed to ensure the facility's License Vocational Nurse (LVN) 1 were competent to follow the current plan of correction to endorse to incoming nurse using the shift-to-shift report. This deficient practice placed Resident 1 at risk of dehydration due to delay of care. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/13/2023 with a diagnosis of anemia (a condition where the body does not have enough healthy red blood cells) and osteoarthritis (a disease that worsens over time also known as wear and tear). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/12/2025, the MDS indicated Resident 1 thought process was intact and required supervision assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1 Change of Condition, dated 9/6/2025, the Change of Condition indicated Resident 1 has nausea, vomiting and complaining of feeling sick, stating that his food is not digesting and has a bitter taste in his mouth. During a review of Resident 1's Shift to Shift Change of Condition Report, dated 9/6/2025, the Shift-to-Shift Change of Condition Report indicated If no COC during your shift, a form must be completed indicating no COC during shift and both nurses will sign and on shift nurse name, signature, shift, and cart was blank. During a concurrent interview and record review on 9/17/2025 at 4:06 p.m. of with Shift-to-Shift Change of Condition Report, with License Vocational Nurse (LVN) 1 was reviewed. LVN 1 stated that there was no name, no signature, no date, no shift, and no cart indicated in Shift-to-Shift Change of Condition Report in on shift nurse portion. LVN 1 stated that outgoing nurse was the responsible person who needed to ask for signature from incoming nurse to make the incoming nurse receive the endorsement. During an interview on 9/18/2025 at 11:49 a.m. with LVN 2, LVN 2 stated that LVN 2 gave an endorsement to LVN 3 and leave the paper on the top of medication cart. During an interview on 9/18/2025 at 12:50 p.m. with LVN 3, LVN 3 stated that LVN 2 did not give an endorsement regarding the shift-to-shift report paper that needs to be signed and done at the end of the shift. LVN 3 stated that after counting medication with LVN 2, LVN 2 left and LVN 3 thought that LVN 2 would come back to give endorsement, but LVN 2 only endorse that there was no issue during LVN 2 shift. During a concurrent interview and record review on 9/18/2025 at 12:15 p.m. with Director of Staff Development (DSD), LVN 2 Employee File, dated 5/17/2025, were reviewed. The Employee File indicated that LVN 2 received, and orientation skills check on change of condition, notification requirement, documentation requirement and infection control was provided on 5/17/2025. DSD stated still looking for LVN 2 in service regarding shift to shift report. During a concurrent interview and record review on 9/19/2025 at 2:03 p.m. reviewed Shift to Shift Change of Condition Report dated 9/6/2025, 11 to 7 shift and 7 to 3 shifts with Director of Staff Development (DSD) and the presence of Administrator. DSD stated that there was no shift-to-shift endorsement report that was made from LVN 3 shift. DSD stated that on 9/6/2025 11 to 7 shift there was no signature, no name, and no date from incoming nurse. DSD stated that if there was no signature from incoming nurse it means that the endorsement was not done. DSD stated that the facility failed to comply with the facility plan of correction by not following the proper giving of endorsement to the incoming shift, if there was no documentation it meant it was not done. DSD and Administrator were unable to provide an in-service for LVN 2 regarding shift to shift report. During an interview on 9/19/2025 at 3:30 p.m. with Registered Nurse (RN) 1. RN 1 stated that the facility failed to make sure LVN 2 was competent to follow the procedure of giving endorsement to incoming nurse and this could possibly lead to the fact that resident condition might get worse and the incoming nurse does not know what to do with the resident because there was no proper endorsement given. During a review of the facility policy and procedure titled, Staff Competency Validation, last reviewed on 4/4/2025, indicated, Staff are required to have competency validation based on their job description or assigned duties.

Based on observation, interview, and record review, the facility failed to ensure a call light's request for assistance were answered promptly for one of three sampled residents (Residents 4).This deficient practice had the potential to not meet Resident 4's needs.Findings:During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 5/5/2025, with diagnoses including left lower limb (leg) cellulitis (a skin infection that causes swelling and redness), pneumonia (an infection/inflammation in the lungs), and history of falling.During a review of Resident 4's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/6/2025, the H&P indicated Resident 4 had the capacity to understand and make decisions.During a review of Resident 4's Care plan on Fall Risk Prevention and Management, dated 5/12/2025, the Care Plan indicated Resident 4 had a history of fall related to limited mobility and an intervention that indicated the following:1. to have call light within reach2. remind resident to use the call lightDuring a review of Resident 4's Minimum Data Set (MDS-a resident assessment tool), dated 5/14/2025, the MDS indicated Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 4 required moderate assistance from staff for eating, oral hygiene, and personal hygiene. The MDS indicated Resident 4 needed maximum assistance from staff walking at least 10 feet.During an observation on 8/9/2025, at 11:45 p.m., in the hallway, Resident 4's call light turned on. Respiratory Therapist 1 (RT 1) standing in front of his cart two doors away from Resident 4's room. Observed RT 1 browsing on his cellphone, did not pay attention to his surroundings and did not answer the call light.During an interview on 8/9/2025, at 11:48 a.m., RT 1 still had not answered the call light and stated he (RT 1) did not hear the call light sound, and he (RT 1) should have answered the call light when it turned on. During an interview on 8/9/2025, at 11:51 a.m., Resident 4 stated he cannot find his water pitcher and was also looking for his toothbrush and toothpaste.During an interview on 8/9/2025, at 1:48 p.m., with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated all staff including RTs are required to answer the call light. LVN 7 stated delay in answering the call light can delay the care and needs of Resident 4.During an interview on 8/9/2025, at 2:28 p.m., with Administrator (Admin), the Admin stated answering call light was everyone's responsibility. The Admin stated Resident 4 could experience delays in care when the call light was not answered.During a review of facility's policy and procedure (P&P), titled, Communication-Call System dated 10/9/2024, the P&P indicated, The Facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting/bathing facilities. To ensure that residents have a means of contacting Facility staff for assistance. Facility Staff will answer call alerts promptly and in a courteous mannerDuring a review of facility's Employee Handbook, dated 1/2024, the Employee handbook indicated, The Company recognizes that cell phones and other personal communication devices have become valuable tools in managing our professional and personal lives. However, workplace use of these devices can raise a number of Issues involving safety, security, and privacy.Therefore, the Company has adopted the following rules regarding the use of personal communication devices in the workplace. during working hours. Employees should conduct personal business during lunch breaks and other rest periods. This Includes the use of personal communication devices (including cell phones) for personal business (including personal phone conversations and text messages, personal e-mails, and Internet use for personal reasons). Minimal or incidental use Is permitted (like a child confirming safe arrival at home after school).Violation of this policy may result in discipline, up to and including termination of employment.Unless properly authorized, employees must refrain from the use of any form of personal electronic communication devices during normal work hours.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Residents 5) by failing to follow the physician's order to hold (temporarily suspending its administration) midodrine (medication used to treat low blood pressure) for systolic blood pressure (sbp- the top number in a blood pressure reading, representing the pressure in your arteries when your heart beats) more than 110 millimeter of mercury (mmHg-unit of measurement).This failure had the potential to result in unnecessarily elevating Resident 5's blood pressure.Findings:During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 5/8/2025, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a stroke where brain tissue dies due to a lack of blood supply), essential hypertension (persistently high blood pressure for which no specific underlying cause can be identified), and history of falling.During a review of Resident 5's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/16/2025, the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions.During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool), dated 6/7/2025, the MDS indicated Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 5 was dependent on staff for eating and showering.During a review of Resident 5's Physician Order, dated 6/3/2025, the Physician Order indicated midodrine hydrochloride oral tablet five milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet enterally (the process of delivering food or medication directly into the gastrointestinal system, allowing for absorption and processing by the body) three times a day for hypotension (low blood pressure). The Physician Order indicated to hold if Resident 5's blood pressure is over 110 mmHg.During a record review of Resident 5's Medication Administration record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 8/2025, the MAR indicated midodrine was administered on the following dates and times:1. 8/2/2025, at 10 p.m., with a blood pressure of 132/80 mmHg.2. 8/4/2025, at 6 a.m. with a blood pressure of 124/87 mmHg.3. 8/7/2025, at 6 a.m. with a blood pressure of 124/76 mmHg.During an interview on 8/9/2025, at 2:50 p.m., with the Director of Nursing (DON), the DON stated the nurses failed to follow the physician's order to hold the midodrine for blood pressure above 110 mmHg. The DON stated Resident 5 could have elevated blood pressure and experienced adverse effects (harmful or undesirable consequences that occur because of a treatment, medication, or medical procedure) from the medication.During a review of facility's policy and procedure (P&P), titled, Medication Administration, dated 1/1/2012, and last reviewed on 4/4/2025, the P&P indicated, Medication will be administered directed by a Licensed nurse and upon the order of a physician or licensed independent practitioner.

Based on observation, interview, and record review, the facility failed to maintain an accurate and complete medical record for two of three sampled residents (Resident 1 and Resident 6) when: 1. The facility failed to ensure Licensed Vocational Nurse (LVN) 1 accurately documented Resident 1's glipizide (medication used to treat type two diabetes [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing]) and Protonix (also known as pantoprazole, a medication used to decrease the amount of acid in the stomach) administration, and blood sugar check. 2. The facility failed to document the time and the physician's response after the physician (MD) was notified of Resident 6's urine test result on 8/6/2025. These failures had the potential to cause confusion in the care and the medical records containing inaccurate documentation. Findings: 1. During a review of Resident 1’s admission Record, the admission Record indicated the facility initially admitted Resident 1 on 12/3/2021 and readmitted on [DATE] with diagnoses including type two DM, hypertension (high blood pressure), hyperlipidemia (a medical condition characterized by elevated levels of lipids [fats] in the bloodstream which can increase the risk of cardiovascular diseases such as heart disease and stroke), and chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood as well as they should, leading to a gradual loss of kidney function over time). During a review of Resident 1’s History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 9/13/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 6/12/2025, the MDS indicated Resident 1’s thought process was intact and required supervision assistance from staff to complete activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1’s Physician’s Orders, dated 7/15/2025, the Physician’s Order indicated to monitor Resident 1’s blood sugar (BS) before meals and at bedtime and to call MD if BS is greater than 350 milligram (mg – a unit of measure for mass) per (/) deciliter (dl – a unit of measure for volume) and/or less than 70 mg/dl. The physician’s orders indicated to give two glipizide 10 mg by mouth two times a day, before breakfast and dinner, for DM. The physician’s orders indicated to give Protonix tablet delayed release 40 mg one tablet by mouth two times a day related to gastroesophageal reflux disease (GERD - a condition where stomach contents flow back up into the esophagus [body part that connects the throat to the stomach]). During a concurrent interview and record review on 8/5/2025 at 6:24 a.m. with LVN 1, Resident 1’s Medication Administration Record (MAR), dated 7/2025, was reviewed. Resident 1’s MAR indicated on 7/19/2025 at 6:30 a.m., LVN 1 documented Resident 1’s BS was 394 mg/dl. LVN 1 stated he (LVN 1) checked Resident 1’s BS at around 4 a.m. and not at 6:30 a.m. LVN 1 stated he (LVN 1) should have documented that he (LVN 1) checked Resident 1’s BS at around 4 a.m. LVN 1 stated Resident 1’s BS was 382 mg/dl at around 4 a.m., not 394 mg/dl. LVN 1 stated he (LVN 1) input 394 mg/dl instead of 382 mg/dl. LVN 1 stated he (LVN 1) did not check Resident 1’s BS at 6:30 a.m. as ordered. Resident 1’s MAR indicated LVN 1 administered glipizide and Protonix to Resident 1 on 7/19/2025 at 6:30 a.m. LVN 1 stated he (LVN 1) did not administer glipizide and Protonix to Resident 1 on 7/19/2025 at 6:30 a.m. and administered both medications to Resident 1 between 4:20 a.m. to 4:25 a.m. per Resident 1’s request. During a concurrent interview and record review on 8/5/2025 at 9:56 a.m. with Registered Nurse (RN) 1, Resident 1’s Progress Notes, dated 7/19/2025, and Resident 1’s MAR, dated 7/2025, were reviewed. Resident 1’s Progress Notes indicated LVN 1 documented Resident 1 had a BS of 382 mg/dl at around 4 a.m. Resident 1’s MAR indicated on 7/19/2025 at 6:30 a.m., LVN 1 documented Resident 1’s BS was 394 mg/dl. RN 1 stated LVN 1 inaccurately documented Resident 1’s BS. During a concurrent interview and record review on 8/5/2025 at 9:56 a.m. with RN 1, Resident 1’s Progress Notes, dated 7/19/2025, and Resident 1’s MAR, dated 7/2025, were reviewed. RN 1 stated LVN 1 administered Resident 1’ glipizide and Protonix early as requested by Resident 1. RN 1 stated LVN 1 documented Resident 1’s glipizide and Protonix administration in the MAR on 7/19/2025 at 6:30 a.m. RN 1 stated LVN 1 documented in Resident 1’s Progress Notes that Resident 1 received his (Resident 1) glipizide and Protonix at 4:20 a.m. to 4:25 a.m. During a review of the facility policy and procedure (P&P) titled, “Completion and Correction,” last reviewed on 4/4/2025, indicated, “The Facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation.” 2. During a review of Resident 6’s admission Record, the admission Record indicated the facility admitted Resident 6 on 7/21/2025, with diagnoses that included right side skull (bone of the head) and facial bones fracture (break in the bone) and history of falling. During a review of Resident 6’s H&P, dated 7/23/2025, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6’s MDS, dated [DATE], the MDS indicated Resident 6’s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 6 was dependent on staff for toileting, showering, and dressing. The MDS indicated Resident 6 was always incontinent (unable to control) bladder and bowel functions. During a concurrent interview and record review on 8/9/2025 at 10:28 a.m. with RN 2, Resident 6’s Progress Notes, dated 8/1/2025 to 8/6/2025, and Urinalysis (urine test) Result, collected on 8/1/2025 at 2:30 p.m. and with a test report date of 8/2/2025 at 9:42 p.m., was reviewed. The Urinalysis Result indicated on 8/6/2025, the physician was notified. RN 2 stated there was no documentation in Resident 6’s medical record of the time the physician was notified on 8/6/2025. RN 2 stated there was no documentation on what the physician’s response was after notification. During an interview on 8/9/2025 at 11:41 a.m. with the Director of Nursing (DON), the DON stated she (DON) cannot find documentation of the time the physician was notified and the physician’s response in the Progress Notes. During an interview on 8/9/2025, at 2:50 p.m., with the DON, the DON stated Resident 6’s medical record was incomplete. The DON stated LVN 3 should have documented that she (LVN 3) spoke to the physician and documented the date and time urine test was received, the date and time the physician was notified, and the physician's response. During a review of facility’s P&P, titled, “Completion and Correction”, dated 1/1/2012 and last reviewed on 4/4/2025, the P&P indicated, “The facility will work to complete and correct medical records in a standard manner to provide the highest quality and accuracy in documentation…. Entries will be complete, legible, descriptive and accurate…. Documentation content… I. Each time a physician is notified via phone or in person regarding the resident’s condition.”

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 followed an infection control policy and procedure for one of three sample residents (Resident 1) by offering a trash can when Resident 1 had an episode of vomiting.This deficient practice had the potential risk of transmission of bacteria that can lead to infection of Resident 1.During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 12/3/2021 and readmitted on [DATE] with a diagnosis of type 2 diabetes mellites with hyperglycemia (body isn't using insulin properly, causing blood sugar and hypertension (high blood pressure).During a review of Resident 1's History and Physical (H & P), dated 9/13/2024, the H & P indicated that Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/12/2025, the MDS indicated Resident 1 thought process was intact and required supervision assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).During a concurrent interview and record review on 8/6/2025 at 2:31 p.m. with Infection Preventionist (IP) 1, Resident 1's Progress Notes, dated 7/19/2025, were reviewed. IP stated it indicated that LVN 1 offered trashcan to Resident 1 in case Resident 1 had an episode of vomiting again. IP stated that LVN 1 should not offer trash can because it contains a lot of bacteria and must offer a clean basin instead.During an interview on 8/6/2025 at 2:49 p.m. with RN 1, RN 1 stated LVN 1 should not offer trash can to Resident 1 and must provide a clean basin due to cross contamination Resident 1 could get infection from the trash can.During a review of the facility policy and procedure titled, Infection Control - Policies and Procedures, last reviewed on 4/4/2025, indicated, To provide infection control policies and procedures required for a safe and sanitary environment.

3. During a review of Resident 19's admission Record, the admission Record indicated the facility admitted the resident on 1/18/2023 with diagnoses including chronic pain syndrome, history of falling, and muscle wasting and atrophy. During a review of Resident 19's H&P, dated 2/28/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 was able to understand others and make her needs known and had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 19 required substantial/maximal assistance to total assistance from staff with all ADLs. During a review of Resident 19's Order Summary Report, dated 5/22/2025, the Order Summary Report did not indicate a physician's order for the use of concave or bolstered mattress. During a review of Resident 19's CP on risk for fall, initiated on 1/18/2023, the CP indicated to evaluate the resident's environment to identify factors known to increase risk of falls as one of the interventions to keep Resident 19 free of falls. During a review of Resident 19's fall risk evaluations, dated 11/5/2024, 2/5/2025, and 5/6/2025, the fall risk evaluations indicated Resident 19 was at a risk for fall. During an observation on 5/19/2025 at 10:17 a.m. inside Resident 19's room, observed the resident lying in bed asleep with bolsters around the edges of the entire bed mattress. During a concurrent observation and interview on 5/20/2025 at 2 p.m. inside Resident 19's room with LVN 2, LVN 2 confirmed and stated Resident 19 had bolsters around the edges of the mattress and the facility calls it as a concave mattress to prevent the resident from falling out of bed. LVN 2 stated Resident 19 appeared sunk in bed. LVN 2 stated the bolstered mattress can be considered a restraint as it prevents Resident 19 from getting out of bed freely. During a concurrent interview and record review on 5/20/2025, at 2:40 p.m., with LVN 3, Resident 19's Order Summary Report, informed consent, restraint assessment, and care plan were reviewed and LVN 3 stated Resident 19 did not have a physician's order, informed consent, and restraint assessment on the use of bed with bolsters/concave mattress. LVN 3 stated Resident 19 did not have a care plan on the use of a bed with bolstered mattress. LVN 3 stated the bed with bolstered mattress can be considered a restraint as it restricts Resident 19's movement to get out of bed freely. LVN 2 stated if a device is used as a restraint, there should be restraint assessment, physician's order, informed consent, and developed a care plan. LVN 3 stated it was important to have a physician's order, restraint assessment to ensure the restraint use is safe and appropriate. LVN 3 stated it is important to have an informed consent to honor the resident's or representative's right to be informed of the plan of care and give a chance to agree or decline the proposed treatment plan. During an interview on 5/22/2025 at 11:54 a.m. with the DON, the DON stated it is important to have a physician's order, informed consent, restraint assessment, and developed care plan on the use of bed with bolsters and concave mattress as a restraint to ensure restraint use is appropriate and safe for the resident and the resident will not be subjected to potential injury associated to its use. The DON stated Resident 19's restraint assessment should have been completed prior to the use of a bolstered mattress for appropriateness. The DON stated a physician's order, informed consent, and care plan should have been obtained, developed, and implemented to ensure restraint use was appropriate, safe, and that all staff are aware of the current plan of care. During a review of the facility's recent P&P titled Restraints, last reviewed on 4/4/2025, the P&P indicated a purpose to ensure that all restraints are used properly and only when necessary for residents in the facility. The P&P further indicated: - The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients), and in accordance with the resident's assessment and Plan of Care. - The facility will document that the resident/ resident representative has given informed consent to the procedure when initiating restraints. During a review of the facility's recent P&P titled Informed Consent, last reviewed on 4/4/2025, the P&P indicated the facility provides a mechanism for all Residents to exercise their right to make informed decisions regarding their medical care. The P&P further indicated: - Except in an emergency situation, before administration or increasing the dose of a psychoactive medication, applying physical restraints or the prolonged use of a medical device, the Resident's physician will: a. Provide the Resident or Resident's surrogate decisionmaker with all information required to obtain informed consent. b. Obtain informed consent from the Resident or surrogate decisionmaker. c. Document the informed consent in the Resident's medical record. - The Facility will confirm that the resident's medical record contains documentation that the physician has obtained informed consent prior to initiating the medical intervention. During a review of the facility provided manufacturer's guideline on the use of PM 1, undated, the manufacturer's guideline indicated the defined perimeter mattress cover creates a raised bed rail and defined perimeter for enhanced fall prevention. During a review of the facility provided manufacturer's guideline on the use of PM 2, copyright 2011, the manufacturer's guideline indicated wedge-foam sections line the perimeter of the covers and help provide a gentle reminder to those lying in bed of the location of the mattress edges and provide a less restrictive environment than side rails. The manufacturer's guideline further indicated a warning that PM 2 is not a substitute for side rails or other protective devices for patients at risk for injury from falls due to unassisted bed exit and to always follow the facility's policies and procedures for patient assessment, monitoring, and rehabilitation. During a review of the facility's recent P&P titled Comprehensive Person-Centered Care Planning, last reviewed on 4/4/2025, the P&P indicated the facility ensures that a comprehensive person-centered care plan is developed for each resident. The P&P further indicated the comprehensive care plan will be developed within seven (7) days from the completion of the comprehensive MDS assessment. All goals, objectives, etc. from the current baseline care plan will be included in the resident's comprehensive care plan. 4. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 1/19/2015 and readmitted in the facility on 3/7/2025 with diagnoses including dementia, quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and muscle wasting and atrophy. During a review of Resident 2's H&P, dated 3/9/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 2 required supervision or touching assistance with eating and total assistance from staff with all other ADLs. During a review of Resident 2's Order Summary Report, dated 5/22/2025, the Order Summary Report did not indicate a physician's order for the use of concave or bolstered mattress. During a review of Resident 2's CP on risk for fall, initiated on 10/18/2024, the CP indicated to provide an environment that supports minimized hazards over the facility has control as one of the interventions to minimize complications associated with falls. During a review of Resident 2's fall risk evaluations, dated 12/26/2024, 1/25/2025, and 3/7/2025, the fall risk evaluations indicated Resident 19 was at a risk for fall. During an observation on 5/19/2025 at 10:47 a.m. inside Resident 2's room, Resident 2 laid asleep in bed with bolsters around the edges of the entire bed mattress. During a concurrent observation and interview on 5/20/2025 at 2 p.m. inside Resident 19's room with Treatment Nurse (TN) 1, TN 1 confirmed and stated Resident 2 had bolsters around the edges of the mattress and the facility calls it as a concave mattress to prevent the resident from falling out of bed. TN 1 stated Resident 2 appeared sunk in bed. TN 1 stated the bolstered mattress can be considered a restraint as it prevents Resident 19 from getting out of bed freely. During a concurrent interview and record review on 5/20/2025 at 2:50 p.m. with LVN 3, Resident 2's Order Summary Report, informed consent, restraint assessment, and care plans were reviewed. LVN 3 stated Resident 19 did not have a physician's order, informed consent, and restraint assessment on the use of a bed with bolsters/concave mattress. LVN 3 stated Resident 19 did not have a care plan on the use of bed with bolstered mattress. LVN 3 stated the bed with bolstered mattress can be considered a restraint as it restricts Resident 19's movement to get out of bed freely. LVN 3 stated if a device is used as a restraint, there should be a restraint assessment, physician's order, informed consent, and a developed care plan. LVN 3 stated it was important to have a physician's order and restraint assessment to ensure the restraint use is safe and appropriate. LVN 3 stated it was important to have an informed consent to honor the resident's or representative's right to be informed of the plan of care and give a chance to agree or decline the proposed treatment plan. During an interview on 5/22/2025 at 11:54 a.m. with the DON, the DON stated it is important to have a physician's order, informed consent, restraint assessment, and develop a care plan on the use of bed with bolsters and concave mattress as a restraint to ensure the restraint use is appropriate and safe for the resident and the resident will not be subjected to potential injury associated to its use. The DON stated Resident 2's restraint assessment should have been completed prior to the use of bolstered mattress for appropriateness, a physician's order and informed consent should have been obtained and develop and implement a care plan to ensure of restraint was appropriate and safe, and that all staff are aware of the current plan of care. During a review of the facility's recent P&P titled Restraints, last reviewed on 4/4/2025, the P&P indicated a purpose to ensure that all restraints are used properly and only when necessary for residents in the facility. The P&P further indicated: - The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients), and in accordance with the resident's assessment and Plan of Care. - The facility will document that the resident/ resident representative has given informed consent to the procedure when initiating restraints. During a review of the facility's recent P&P titled Informed Consent, last reviewed on 4/4/2025, the P&P indicated the facility provides a mechanism for all Residents to exercise their right to make informed decisions regarding their medical care. The P&P further indicated: - Except in an emergency, before administration or increasing the dose of a psychoactive medication, applying physical restraints or the prolonged use of a medical device, the Resident's physician will: a. Provide the Resident or Resident's surrogate decisionmaker with all information required to obtain informed consent. b. Obtain informed consent from the Resident or surrogate decisionmaker. c. Document the informed consent in the Resident's medical record. - The Facility will confirm that the resident's medical record contains documentation that the physician has obtained informed consent prior to initiating the medical intervention. During a review of the facility provided manufacturer's guideline on the use of PM 1, undated, the manufacturer's guideline indicated the defined perimeter mattress cover creates a raised bed rail and defined perimeter for enhanced fall prevention. During a review of the facility provided manufacturer's guideline on the use of PM 2, copyright 2011, the manufacturer's guideline indicated wedge-foam sections line the perimeter of the covers and help provide a gentle reminder to those lying in bed of the location of the mattress edges and provide a less restrictive environment than side rails. The manufacturer's guideline further indicated a warning that PM 2 is not a substitute for side rails or other protective devices for patients at risk for injury from falls due to unassisted bed exit and to always follow the facility's policies and procedures for patient assessment, monitoring, and rehabilitation. During a review of the facility's recent P&P titled Comprehensive Person-Centered Care Planning, last reviewed on 4/4/2025, the P&P indicated the facility ensures that a comprehensive person-centered care plan is developed for each resident. The P&P further indicated the comprehensive care plan will be developed within seven (7) days from the completion of the comprehensive MDS assessment. All goals, objectives, etc. from the current baseline care plan will be included in the resident's comprehensive care plan. Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for four of five sampled residents (Residents 13, 43, 19, and 2) reviewed for physical restraints by failing to ensure Residents 13 and 43's bed with bolsters/ concave mattress (a type of mattress designed with raised sides to prevent residents from rolling or falling out of bed) had a/an: 1. Physician's order 2. Informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the resident and/or representative 3. Physical restraint assessment for its safe use. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (an occurrence involving a patient who is caught, trapped, or entangled in a hospital bed system), and death of residents. Findings: 1. During a review of Resident 13's admission Record, the admission Record indicated the facility admitted the resident on 3/10/2023, and readmitted the resident on 4/29/2025, with diagnoses including nontraumatic subarachnoid hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery), syncope (fainting or passing out) and collapse, and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use) and atrophy (decrease in size or wasting away of a body part or tissue). During a review of Resident 13's History and Physical (H&P), dated 5/16/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated 5/5/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had impaired cognition (having difficulty with thinking and remembering things). The MDS indicated the resident required substantial to setup assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 13's Order Summary Report, dated 5/22/2025, the Order Summary Report did not indicate an order for bed with bolsters/concave mattress. During a review of Resident 13's Fall Risk Evaluation, dated 4/29/2025, the Fall Risk Evaluation indicated the resident was high risk for potential falls. During a review of Resident 13's Care Plan (CP) Report titled The resident has had an actual fall with minor injury due to poor balance, last revised on 10/24/2024, the CP indicated an intervention to visibly observe resident frequently. During a concurrent observation, interview, and record review on 5/20/2025 at 1:53 p.m. with Licensed Vocational Nurse (LVN) 3, inside Resident 13's room, Resident 13's bed had bolsters/concave mattress on. LVN 3 reviewed Resident 13's Order Summary Report, Informed Consent, Restraint Assessment, and Care Plan and stated there was no physician's order, informed consent, and restraint assessment on the use of restraint bed with bolsters/concave mattress. LVN 3 stated it was important to have a physician's order and restraint assessment to ensure its safe use. LVN 3 stated it was important to obtain an informed consent to honor resident's right to informed consent to give a chance for the resident to ask questions, agree or to disagree about the proposed treatment plan. During an interview on 5/22/2025 at 11:54 a.m. with the Director of Nursing (DON), the DON stated it is important to have a physician's order, informed consent, restraint assessment on the use of restraint bed with bolsters and concave mattress for Resident 13 to ensure the restraint is appropriate and the resident will not be subjected to potential injury associated to its use. During a review of the facility's recent policy and procedure (P&P) titled, Restraints, last reviewed on 4/4/2025, the P&P indicated to ensure that all restraints are used properly and only when necessary for residents in the facility. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the interdisciplinary Team (IDT), and in accordance with the resident's assessment and Plan of Care. The facility will document that the resident/ resident representative has given informed consent to the procedure when initiating restraints. During a review of the facility's recent P&P titled Informed Consent, last reviewed on 4/4/2025, the P&P indicated the facility provides a mechanism for all Residents to exercise their right to make informed decisions regarding their medical care . B. Psychoactive medications, Physical Restraints or Prolonged Use of Medical Devices i. Except in an emergency situation, before administration or increasing the dose of a psychoactive medication, applying physical restraints or the prolonged use of a medical device, the Resident's physician will: a. Provide the Resident or Resident's surrogate decisionmaker with all information required to obtain informed consent. b. Obtain informed consent from the Resident or surrogate decisionmaker. c. Document the informed consent in the Resident's medical record. ii. The Facility will confirm that the Resident's medical record contains documentation that the physician has obtained informed consent prior to initiating the medical intervention. During a review of the facility-provided Information on the use of Perimeter Mattress (PM) 1, undated, the information indicated the defined perimeter mattress cover creates a raised bed rail and the defined perimeter enhanced fall prevention. During a review of the facility-provided Information on the use of PM 2, Copyright 2011, the information indicated Wedge-foam sections line the perimeter of the covers and help provide a gentle reminder to those lying in bed of the location of the mattress edges, and provide a less restrictive environment than side rails. WARNING: This device is not a substitute for side rails or other protective devices for patients at risk for injury from falls due to unassisted bed exit. ALWAYS follow your facility's policies and procedures for patient assessment, monitoring, and rehabilitation. 2. During a review of Resident 43's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2023, with diagnoses including dementia (a progressive state of decline in mental abilities), muscle wasting and atrophy, and abnormalities of gait (a manner of walking or moving on foot) and mobility. During a review of Resident 43's H&P, dated 2/13/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 43's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and usually understand others and had severe cognitive impairment (someone has significant difficulty with thinking, learning, remembering, and making decisions, to the point where they cannot live independently). The MDS indicated the resident was dependent to requiring supervision on mobility and ADLs. The MDS indicated the resident had a fall with no injury. During a review of Resident 43's Fall Risk Evaluation, dated 4/23/2025, the Fall Risk Evaluation indicated the resident was high risk for potential falls. During a review of Resident 43's CP Report titled Seizure, initiated on 4/18/2023, the CP indicated an intervention to maintain a safe environment for the resident. During a concurrent observation, interview, and record review on 5/20/2025 at 9:40 a.m. with LVN 3, inside Resident 43's room, Resident 43's bed had bolsters/concave mattress on. LVN 3 reviewed Resident 43's Order Summary Report, Informed Consent, Restraint Assessment, and Care Plan and stated Resident 43 did not have a physician's order, informed consent, and restraint assessment on the use of restraint bed with bolsters/concave mattress. LVN 3 stated it was important to have a physician's order and restraint assessment to ensure its safe use. LVN 3 stated it was important to have an informed consent to honor the resident's right to informed consent to give a chance for the resident to ask questions, agree or to disagree about the proposed treatment plan. During an interview on 5/22/2025 at 11:54 a.m. with the DON, the DON stated it is important to have a physician's order, informed consent, restraint assessment on the use of restraint bed with bolsters and concave mattress for Resident 43 to ensure the restraint is appropriate and the resident will not be subjected to potential injury associated to its use. During a review of the facility's recent P&P titled Restraints, last reviewed on 4/4/2025, the P&P indicated to ensure that all restraints are used properly and only when necessary for residents in the facility. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the interdisciplinary Team (IDT), and in accordance with the resident's assessment and Plan of Care. The facility will document that the resident/ resident representative has given informed consent to the procedure when initiating restraints. During a review of the facility's recent P&P titled Informed Consent, last reviewed on 4/4/2025, the P&P indicated the facility provides a mechanism for all Residents to exercise their right to make informed decisions regarding their medical care . B. Psychoactive medications, Physical Restraints or Prolonged Use of Medical Devices i. Except in an emergency situation, before administration or increasing the dose of a psychoactive medication, applying physical restraints or the prolonged use of a medical device, the Resident's physician will: a. Provide the Resident or Resident's surrogate decisionmaker with all information required to obtain informed consent. b. Obtain informed consent from the Resident or surrogate decisionmaker. c. Document the informed consent in the Resident's medical record. ii. The Facility will confirm that the Resident's medical record contains documentation that the physician has obtained informed consent prior to initiating the medical intervention. During a review of the facility-provided Information on the use of PM 1, undated, the information indicated the defined perimeter mattress cover creates a raised bed rail and the defined perimeter for enhanced fall prevention. During a review of the facility-provided Information on the use of PM 2, copyright 2011, the Information indicated Wedge-foam sections line the perimeter of the covers and help provide a gentle reminder to those lying in bed of the location of the mattress edges, and provide a less restrictive environment than side rails. WARNING: This device is not a substitute for side rails or other protective devices for patients at risk for injury from falls due to unassisted bed exit. ALWAYS follow your facility's policies and procedures for patient assessment, monitoring, and rehabilitation.

Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1). On 4/22/2025 at 8:40 p.m., Resident 1 and Resident 2, who were both inside Room A (Residents 1 and 2 ' s room), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 punched Resident 1 on the left side of the face with a left closed fist. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. On 4/22/2025, Resident 1 sustained left face swelling and pain level of seven (severe pain) out of ten on the numeric pain rating scale (a pain assessment tool that uses a scale ranging from zero [no pain] to ten [worst pain imaginable], to quantify pain intensity). Resident 1 was sent to General Acute Care Hospital 1 (GACH 1) on 4/23/2025 at 11:25 a.m. where Resident 1 was diagnosed with a displaced nasal bone fracture (occurs when the bone on the nose was broken into two or more parts allowing the bones to shift out of alignment). Findings: During a review of Resident 1 ' s Admission Record (undated), the Admission Record indicated the facility admitted Resident 1 on 12/20/2022 with diagnoses including monoplegia (a paralysis that affects a single limb) of lower limb following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting the right dominant side, and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 1 ' s cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The MDS indicated Resident 1 required supervision (assistance may be provided throughout the activity or intermittently) on rolling left and right, sitting to lying, lying to sitting on the side of the bed, and sitting to standing. During a review of Resident 1 ' s Progress Notes, dated 4/22/2025 at 11 p.m., the Progress Notes indicated Resident 1 ' s skin was checked and documented that Resident 1 had left facial swelling related to the altercation with Resident 2. During a review of Resident 1 ' s Neurological Flowsheet (used to assess, monitor, and record specific neurological [referred to anything related to the nervous system including the brain, spinal cord, and nerves] status following an injury resulting in suspected or actual head trauma), dated 4/22/2025 to 4/23/2025, the Neurological Flowsheet indicated on 4/22/2025 at 10 p.m., Resident 1 had seven out of ten on the numeric pain rating scale. During a review of Resident 1 ' s Change in Condition (COC - when there is a sudden change in a resident ' s condition) Evaluation, dated 4/23/2025 at 12:30 a.m., the COC Evaluation indicated Resident 1 had a physical and verbal abuse with Resident 2 on 4/22/2025 (time not indicated). The COC Evaluation indicated Resident 1 had swelling on the face. During a review of Resident 1 ' s Physician Orders, dated 4/23/2025, the Physician Orders indicated transferring Resident 1 to GACH 1 due to facial swelling. During a review of Resident 1 ' s Progress Notes, dated 4/23/2025 at 12:35 p.m., the Progress Notes indicated an ambulance transported Resident 1 to GACH 1 on 4/23/2025 at 11:25 a.m. During a review of Resident 1 ' s Physician History and Physical (H&P - comprehensive assessment conducted by a healthcare provider that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern) from GACH 1, the Physician H&P indicated on 4/23/2025, Resident 1 was admitted to GACH 1 after Resident 2 hit Resident 1 on the face. The Physician H&P indicated Resident 1 had left side nasal and facial pain and swelling. During a review of Resident 1 ' s GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the face, dated 4/23/2025, the CT indicated Resident 1 had displaced nasal bone fracture. During a review of Resident 2 ' s Admission Record (undated), the Admission Record indicated the facility admitted Resident 2 on 12/3/2021 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), unspecified mood disorder (a person experiencing symptoms related to mood changes that were significant enough to cause distress in daily life but did not meet a mood disorder diagnoses), and schizophrenia (mental disorder in which people interpret reality abnormally). During a review of Resident 2 ' s H&P (from the facility), dated 9/13/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognition was intact. The MDS indicated Resident 2 had verbal behavioral symptoms directed toward others such as threatening others, screaming at others, and cursing at others that occurred one to three days. During a review of Resident 2 ' s care plan on aggression, last revised on 3/18/2025, the care plan indicated Resident 2 had the potential for verbal aggression (any communication intended to harm someone through words, tone, or manner, such as threats, insults, or harsh criticism). The care plan interventions indicated to document observed Resident 2 ' s behavior and attempted interventions. During a review of Resident 2 ' s COC Evaluation, dated 4/22/2025, the COC Evaluation indicated Resident 2 had a change of behavior that led to physical aggression (actions that involve inflicting physical harm or damage) and verbal aggression towards Resident 1. During an interview on 5/6/2025 at 9:33 a.m. with Resident 1, Resident 1 stated Resident 2 yelled at Resident 1 to turn the television off. Resident 1 stated he (Resident 1) refused to turn the television off. Resident 1 stated Resident 2 stood up on the right side of Resident 1 ' s bed and punched the resident on the left side of the face twice with a left closed fist. Resident 1 stated he (Resident 1) required assistance on moving and was not able to defend himself from Resident 2 ' s punches. Resident 1 stated the left side of his (Resident 1) face became swollen and painful. Resident 1 stated he (Resident 1) was anxious (feeling fear, dread, and uneasiness) and did not feel safe in the facility knowing Resident 2 was in the facility. Resident 1 stated he (Resident 1) was hesitant to go to the activity room knowing Resident 2 also attended activities. During a telephone interview on 5/6/2025 at 11:19 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she (LVN 1) heard someone yelling with an angry tone. LVN 1 stated she (LVN 1) went inside Room A and found Resident 1 lying in his (Resident 1) bed, while Resident 2 was standing on the right side of Resident 1 ' s bed. LVN 1 stated she (LVN 1) witnessed Resident 2 punching Resident 1 ' s face with his (Resident 2) left closed fist twice. LVN 1 stated Resident 1 and Resident 2 were separated by transferring Resident 1 to Room B. LVN 1 stated maybe one to two hours after Resident 2 punched Resident 1, Resident 1 ' s left side of the face (around the cheekbone) and nose were observed swollen that required an ice pack and pain medication. LVN 1 stated Resident 1 refused the pain medication. LVN 1 stated Resident 2 punching Resident 1 was physical abuse. During an interview on 5/6/2025 at 12:39 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she (CNA 1) heard Resident 2 yelling with an angry tone. CNA 1 stated she (CNA 1) ran to Room A and found Resident 2 standing on the right side of Resident 1 ' s bed. CNA 1 stated Resident 1 ' s face looked shocked and Resident 2 ' s face was mad. CNA 1 stated after Resident 1 was transferred to Room B, Resident 1 ' s left side of the face was observed swollen. CNA 1 stated Resident 2 punching Resident 1 was physical abuse. During an interview on 5/6/2025 at 4:30 p.m. with the Director of Nursing (DON), the DON stated residents should be free from abuse. The DON stated a person intentionally punching another person was considered a physical abuse. The DON stated Resident 2 punching Resident 1 was considered as an abuse. The DON stated Resident 1 sustained injury from Resident 2 ' s punch. The DON stated Resident 1 had the potential for negative psychosocial effects (the interrelation of social factors and individual thoughts and behavior). The DON stated the facility failed to ensure Resident 1 was not subjected to any abuse and to ensure the safety and overall well-being of the residents. During a review of the current facility-provided policy and procedure (PnP) titled, Abuse Prevention, Screening, and Training Program, last reviewed on 4/4/2025, the PnP indicated the purpose is To address the health, safety, welfare, dignity, and respect of residents by preventing abuse The Facility does not condone any form of resident abuse . and develops Facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse Definitions: ' Abuse ' is defined as the willful, deliberate infliction of injury It includes verbal abuse, . physical abuse ' Verbal abuse ' is defined as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability (physical or mental condition that limits a resident ' s movements, senses, or activities) ' Physical abuse ' is defined as, but not limited to, hitting, slapping, punching, and/or kicking

Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of two sampled residents (Resident 1) when on 3/21/2025 at 7 a.m., Resident 2 scratched Resident 1 ' s right lower foot. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 had a scratched mark measuring 10 centimeters (cm- a unit of measurement) in length and 0.3 cm in width on Resident 1 ' s right lower foot that needed first aid (initial assistance and care given to a resident who has been injured) and daily wound treatments. Resident 1 was visibly upset. Resident 1 verbalized that when Resident 2 scratched Resident 1 ' s right lower foot it brought (back) her (Resident 1) post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) from a previous incident (did not indicate the specific incident), shook (emotionally or physically disturbed; upset) her (Resident 1), and made her (Resident 1) scared. Findings: a. During a review of Resident 1 ' s Admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/12/2025 with diagnoses including parkinsonism (a broad term that refers to brain conditions that caused slowed movements, rigidity [stiffness], and tremors), quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs [arms and legs] and the torso [the main part of the body that contains the chest, abdomen, pelvis, and back), and depression (a persistent state of sadness and loss of interest that can significantly affect how you feel, think, and behave, making it hard to enjoy life or carry out daily activities). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 2/16/2025, the MDS indicated Resident 1 had intact cognition (refers to the mental processes involved in knowing, learning, and understanding). The MDS indicated Resident 1 was dependent (helper does all the effort and resident does none of the effort to complete the activity) with toileting hygiene, and shower. During a review of Resident 1 ' s Change in Condition (COC- when there is a sudden change in a resident ' s condition) Evaluation, dated 3/21/2025 at 7:50 a.m., the COC Evaluation indicated Resident 1 stated Resident 2, a roommate, scratched Resident 1 ' s right lower foot while Resident 2, seated on Resident 2 ' s wheelchair 1 while being wheeled out of Residents 1 and 2 ' s room by a staff member (name not indicated). The COC Evaluation indicated there was a noted red line (no other descriptions indicated) in Resident 1 ' s right lower foot and staff (LVN 2) cleaned the skin area (the skin area with the red line). During a review of Resident 1 ' s COC Evaluation, dated 3/21/2025 at 8:30 a.m., the COC Evaluation indicated Resident 1 had a red line scratched mark measuring 10 cm in length by 0.3 cm in width which Resident 1 got from Resident 2 who scratched Resident 1 ' s right lower foot. During a review of Resident 1 ' s Order Summary Report (OSR), dated 3/21/2025, the OSR indicated Resident 1 ' s Physician/Medical Doctor (MD) 1 ordered to clean Resident 1 ' s right foot red line scratched mark with normal saline (a mixture of water and salt with a salt concentration of 0.9 percent [% - per one hundred], for every 1 liter [L - 1,000 milliliter, a unit of measurement] of water, there are nine grams [unit of measurement] of salt), pat dry, apply bacitracin ointment (a topical antibiotic ointment, essentially a cream, used to prevent infection in minor skin injuries like cuts, scrapes, and burns), and leave the wound open to air every day shift for 21 days. During a review of Resident 1 ' s Skin Check (SC), dated 3/21/2025 at 4:47 p.m., the SC indicated Resident 1 ' s right lower foot was noted with a red line scratched mark measuring 10 cm in length by 0.3 cm in width. During a review of Resident 1 ' s Psychiatric Follow Up Note (PN - a clinical document used by mental health professionals to record the progress of a resident ' s treatment after the initial evaluation), dated 3/21/2025, the PN indicated Resident 1 alleged that her roommate (Resident 2) became agitated and while staff was managing Resident 2 ' s behavior (the way in which one acts or conducts oneself, especially toward others, Resident 2 scratched Resident 1 ' s foot (right lower foot). The PN indicated Resident 1 did not answer questions when prompted (encourage to say something) as she (Resident 1) was visibly upset. The PN indicated Resident 1 had a diagnosis of depression. During a review of Resident 1 ' s Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident), dated 3/2025, the TAR indicated on 3/21/2025 Resident 1 ' s right foot scratch was cleaned with normal saline, patted dry, bacitracin ointment applied, and left the wound open to air. b. During a review of Resident 2 ' s AR, the AR indicated the facility admitted the resident on 4/16/2024 and readmitted the resident on 5/13/2024, with diagnoses that included dementia (a general term for a decline in mental ability that interferes with daily life, encompassing symptoms like trouble remembering, thinking, or making decisions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities, and other symptoms that significantly affect daily functioning), and general anxiety disorder (a mental health condition that produces fear, worry, and a constant feeling of being overwhelmed). During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (a significant and substantial decline in a person ' s ability to think, learn, remember, and make decisions, which significantly impacts their daily functioning). The MDS indicated Resident 2 needed substantial/maximal assistance with sit to stand. During a review of Resident 2 ' s COC Evaluation, dated 3/21/2025 at 7 a.m., the COC Evaluation indicated Resident 2 was noted with episode of increased aggression through striking out for no apparent reason. The COC indicated Resident 2 was noted yelling and screaming to Certified Nurse Assistant (CNA) 1, and was combative. During an interview on 4/1/2025 at 11 a.m. with Resident 1, Resident 1 stated Resident 1 did not recall the date of the incident, but it was early in the morning at around 6 a.m. Resident 1 saw her roommate Resident 2 swung a detachable bed remote control at CNA 1. Resident 1 stated Resident 2 was walking out of the room to the door with CNA 1, but Resident 2 turned towards Resident 1 and scratched Resident 1 ' s right foot. Resident 1 stated Resident 1 was lying in bed and could not defend herself. Resident 1 stated, Resident 1 sustained a 10 cm-scratch. During an interview on 4/1/2025 at 2:14 p.m. with Resident 1, Resident 1 stated the incident with Resident 2 scratching Resident 1 ' sright lower foot brought (back) her PTSD from a previous incident. Resident 1 stated it (Resident 2 scratching her right lower foot) shook her and made her (Resident 1) scared. During an interview on 4/1/2025 at 2:23 p.m. with CNA 1, CNA 1 stated she worked on 3/20/2025 from 11 p.m. to 7 a.m. and was assigned to care for Residents 1 and 2. CNA 1 stated on 3/21/2025 at around 6:45 a.m., Resident 2 sat up in Resident 2 ' s bed upset and began to shout and yell at the Housekeeper (HK) 1 who was cleaning Resident 1 and Resident 2 ' s room. CNA 1 stated Resident 2 stood up wanting to walk, grabbed the detachable remote control of the bed, and began to swing the bed remote control at CNA 1. CNA 1 stated Licensed Vocational Nurse (LVN) 2 and LVN 3 came to Resident 2 ' s room. CNA 1 stated Resident 2 had the bed remote control in Resident 2 ' s left hand and was walking towards the door. CNA 1 stated CNA and the LVNs (LVNs 2 and 3) were walking around Resident 2 to support Resident 2 from falling but also avoiding getting hit by Resident 2. CNA 1 stated CNA 1 saw Resident 2 walked all the way to Resident 1 ' s bed (nearest the door) and scratched Resident 1 ' s foot (right lower foot). CNA 1 stated Resident 1 said, She (Resident 2) scratched my foot. During an interview on 4/1/2025 at 3:57 p.m. with the Director of Nursing (DON), the DON stated Resident 2 scratched Resident 1 ' s right lower foot on 3/21/2025 at around 7 a.m. to 7:30 a.m. The DON stated she saw Resident 1 on 3/21/2025 at around 9 a.m. in the hallway and Resident 1 told her (DON) Resident 2 scratched Resident 1 ' s right lower foot. The DON stated Resident 2 scratching Resident 1 ' s right lower foot is considered physical abuse. The DON stated the facility does not allow abuse because Resident 1 can psychosocially (refers to how both the psychological [relating to the mental and emotional state] and social factors contribute to a person ' s overall well-being, development, and functioning) feel unsafe in Resident 1 ' s environment and the potential for further harm. During a review of the current facility-provided Policy and Procedures (P&P) titled, Abuse Prevention and Management, revised on 5/30/2024 and effective on 6/12/2024, the P&P indicated The facility does not condone any form of resident abuse During a review of the facility ' s P&P titled, Reporting Abuse, last reviewed on 4/4/2024, the P&P indicated, The facility will ensure that the resident has the right to be free from . physical . abuse

Based on observation, interview, and record review, the facility failed: A. To have a system in place to ensure safeguarding of all prescribed medications (a drug that can be obtained only by means of a physician ' s order) including controlled medications (medications with a high potential for abuse) for three of ten sampled residents (Resident 1, Resident 2, and Resident 3), by failing to: 1. Implement its policy and procedure titled, Medication Dispensing Controlled Substances, that indicated an inventory count of all Controlled Dangerous Substances (CDS, a drug or chemical whose manufacture, possession, or use is regulated by a government because it may be abused or cause addiction) medications stored in each nursing unit shall be performed at each change of shift. Both the incoming and outgoing nurse on each unit that is responsible for handling-controlled substances will sign the inventory count. 2. Ensure two licensed nurses counted the CDS before and after the nursing shift and signed in the untitled sign-in sheet for CDS (form signed by both incoming and outgoing nurse indicating the CDS count was completed). The four medication carts ' CDS sign in sheets, dated 8/2024, had missing signatures for the following: a. Station 1 Medication Cart (Cart 1) CDS sign in sheet indicated 12 missing signatures. b. Station 1 Middle Medication Cart (Cart 2) CDS sign in sheet indicated 18 missing signatures. c. Station 2 Medication Cart (Cart 3) CDS sign in sheet indicated three missing signatures. d. Station 2 Middle Medication Cart (Cart 4) CDS sign in sheet indicated 18 missing signatures. 3. On 8/18/2024 at 7:30 a.m., the facility failed to account for three CDS for Residents 1, 2, and 3: a. Resident 1 was missing ten tablets of hydrocodone-acetaminophen (an opioid [a class of drug used to reduce moderate to severe pain] medication used to manage pain) 5-325 milligrams (mg, unit of measurement). b. Resident 2 was missing six tablets of hydrocodone-acetaminophen 5-325 mg. c. Resident 3 was missing four tablets of oxycodone-acetaminophen (a drug used to treat moderate to severe pain) 5-325 mg. 4. Ensure medication carts and cabinets that contained controlled medications and other medications, were maintained locked, when not in use to prevent unauthorized access to medications that included non-controlled medications for one of four medication carts (Cart 4). These deficient practices resulted in a facility wide system failure to secure, accurately account for and reconcile controlled medications for Residents 1, 2, and 3. These deficient practices placed Residents 1, 2, and 3 at risk for medication errors, to receive more or less medication than prescribed, adverse reactions (harmful or unpleasant reaction, resulting from an intervention related to the use of a medication) such as falls, hospitalization s, harm, and inability to readily identify the loss or drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. B. To provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biological) for three of six sampled resident (Resident 1, 9 and 10) by failing to: 1. Ensure Resident 1 was medicated with hydrocodone-acetaminophen (medication used to treat pain) on 7/21/2024 at 6:30 a.m. and 7/28/2024 at 9 p.m. when LVN 1 and LVN 2 took hydrocodone-acetaminophen from Resident 1 ' s Controlled Drug Inventory (a document used to document and track the administration of controlled substances). 2. Ensure Resident 9 was medicated with hydrocodone-acetaminophen on 8/21/2024 at 2 a.m. and 8/22/2024 at 9:30 a.m., when LVN 2 and LVN 5 took hydrocodone-acetaminophen from Resident 9 ' s Controlled Drug Inventory. 3. Ensure Resident 10 was medicated for pain with hydrocodone-acetaminophen on 8/17/2024 at 10 a.m., when LVN 16 took hydrocodone-acetaminophen from Resident 10 ' s Controlled Drug Inventory. These deficient practices had the potential to result in Resident 1, 9 and 10 ' s uncontrolled pain management. On 8/29/2024 at 5:23 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) ) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to ensure Resident 1, Resident 2, and Resident 3 received pharmacy services in relation to CDS under 42 California Federal Regulation (CFR) S483.45 Pharmacy Services. On 9/4/2024 at 12:56 p.m., the ADM and DON submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified that the IJ situation was no longer present and confirmed the facility ' s implementation of the IJ Removal Plan through observations, interviews, and record reviews. The SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM and DON on 9/4/2024, at 3:54 p.m. The acceptable IJ Removal Plan for F755 included the following summarized actions: 1. On 8/30/2024, the Administrator notified the Medical Director regarding the IJ received on F755 (Pharmacy Services). The DON, ADM, and Medical Director discussed training and competencies on 'Individual Narcotic Records' of Licensed Nurses on Medication Dispensing Controlled Substances, that indicated an inventory count of all CDS medications stored and each nursing shall be performed at each change of shift. Both the incoming and outgoing nurse on each unit that is responsible for handling-controlled substances will sign the inventory count. All narcotics will be stored under double locked and separate from all other medications. The medication cart keys to the locked areas containing CDS medication will always be in the possession of Licensed Nurses, Licensed Vocational Nurses (LVNs), and Registered Nurses (RNs), for handling CDS medications in the facility. 2. On 8/30/2024, LVN 3 had completed pain assessments, care plans, and Interdisciplinary Team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient) meetings for Resident 1 and Resident 2 while Resident 3 was discharged against medical advice (AMA, a resident chooses to leave the hospital before the treating physician recommends discharge) on 8/27/2024. LVN 3 notified the residents (Resident 1 and Resident 2) and/or their responsible parties regarding the missing controlled substances. 3. On 8/18/2024, the (11 p.m. to 7 am shift) RN Supervisor started the investigation based on order listing report of residents that had an order for CDS. There's no discrepancy aside from three residents (Residents 1, 2, and 3) affected by the said deficient practice. RN Supervisor and (7 a.m. to 3 p.m. shift) Desk Nurse checked all med carts, resident rooms, and trash bins. 4. On 8/19/2024, the (7 a.m. to 3 p.m. shift) RN Supervisor conducted a search again in all carts and medication rooms, and containers for medication destruction. None of the missing CDSs were found. 5. On 8/20/2024, the DON and (7 a.m. to 3 p.m.) Desk Nurse conducted a search and checked all four medication carts and all narcotics were accounted for except the three missing controlled substances. The DON provided an in-service to LVN 1 on Medication Dispensing Controlled Substance and inventory count of all CDS. 6. On 8/20/2024, the DON provided an in-service to LVN 1 on Medication Dispensing Controlled Substance and inventory count of all CDS given and was provided with a written disciplinary action. 7. On 8/21/2024, the DON provided an in-service to RN 1 on Medication Dispensing Controlled Substance and inventory count of all CDS given and was provided with a written disciplinary action. 8. On 8/22/2024, the DON provided an in-service to the LVN 2 on Medication Dispensing Controlled Substance and inventory count of all CDS. LVN 2 was given two written disciplinary actions which resulted in suspension. LVN 2 was later terminated from the facility on 8/26/2024. 9. On 8/21/2024, the Administrator reported to California Department of Public Health (CDPH) as an unusual occurrence. The late reporting was a result of a thorough investigation and search as well as the conduction of interviews with staff. 10. On 8/20/2024, 8/23/2024, and 8/24/2024, the DON provided an in-service to Licensed Nurses, LVNs and RNs, on Medication Dispensing Controlled Substance and inventory count of all CDS. A percentage of 90 percent (% - one part in every hundred) of Licensed Nurses had participated in the in-services. The target date for a completion of 100% of Licensed Nurses will be on 9/22/2024 once returned from leave of absence or vacation. Licensed Nurses who have not been in-serviced due to leave of absence or on vacation will be in-serviced by the DON prior to the start of their next scheduled shift. 11. On 8/30/2024, the DON reported LVN 1, LVN 2, and RN 1 to the California Department of Consumer Affairs/ Board of Nursing because of the missing narcotics. 12. On 8/30/2024, the Administrator had reported to the Department of Justice - Drug Enforcement Administration using form DEA-106, reporting a theft or loss of controlled substances. 13. On 9/1/2024 and 9/2/2024, the DON initiated Competency Validation of licensed Nurses on Medication Dispensing Controlled Substances, that indicated an inventory count of all Controlled Dangerous Substance (CDS) medications stored and each nursing shall be performed at each change of shift. Both the incoming and outgoing nurse on each unit that is responsible for handling controlled substances will sign the inventory count. Narcotic competency validation will be due upon hire and annually afterwards. A percentage of 100% of actively scheduled Licensed Nurses, LVNs and RNs had participated in the competency validation. 14. On 8/29/2024, the DON and DSD conducted a facility wide audit on the controlled substances and initiated CDS inventory count and sign-in sheet, there was no discrepancy found. 15. On 8/29/2024, 8/30/2024, and ongoing, the DON provided additional in-services to Licensed Nurses, LVNs and RNs, on Medication Dispensing Controlled Substances and Drug Diversion based on the Policy and Procedure of 11. 7 loss of Theft of Drugs was given. 16. The RN Supervisor or Designee will observe the endorsement of incoming and outgoing nurses of CDS per shift to ensure compliance with Medication Dispensing Controlled Substances and inventory count. The RN supervisor or Designee will initial under the Comments column section on the Controlled Substance Sign in and Out Sheet to indicate the CDS had been counted and the quantity indicated in the Controlled Drug Administration Record were verified. The RN Supervisor or Designee will observe the endorsement for three months and will be a continuing audit process at random. 17. The Director of Nursing and/or Designee will review the CDS inventory count daily including the weekend and address any deficient findings. The DON or Designee performed the audit process by doing a controlled drug count with the Licensed Nurse, LVNs or RNs, and compare the count against the inventory count sheet. The DON or Designee will ensure that the sign in and out control sheet is properly signed. The signature on this audit verifies an outcome that all CDS were accounted for on the designated shift or time. 18. On 9/2/2024, the Pharmacist Consultant along with the DON, conducted a facility wide audit on all residents on controlled substances. All four medication carts were audited of all residents who had CDS orders. No other residents besides Resident 1, Resident 2, and Resident 3 were affected. The Pharmacist Consultant and the DON utilized the Controlled Substances Audit Form with Pharmacist, on each medication cart every two weeks for three months to verify that all CDS of all residents were accounted for. The audit process goes by counting the CDS for each resident and comparing it to the CDS count sheet. The Pharmacist and the DON indicated the name of the CDS on the audit form with the number of tablets counted. The signature on the audit will verify an outcome that all CDS were accounted for and that there were no missing CDS. 19. In the absence of the Pharmacist Consultant, the DON and RN or LVN will audit each medication utilizing the Controlled Substance Audit Form with DON every two weeks for three months to verify that all residents ' CDS were accounted for. The audit process goes by counting the CDS for each resident and comparing it to the CDS count sheet. The DON and RN or LVN will indicate the name of the CDS on the audit form with the number of tablets counted. The signature on this audit will verify an outcome that all residents ' CDS were accounted for and that there were no missing CDS. 20. The DON/Designee and/or the Administrator/Designee will be responsible for compliance. Findings will be reported to the Administrator and/or Designee who will then present and discuss the findings during Quality Assurance Agency (QAA) meetings monthly for three months for any further recommendations and follow-up or until compliance is achieved. Findings: A. a. During a review of Resident 1 ' s Admission Record, the Admission Record indicated the facility admitted the resident on 6/28/2024 with diagnoses that included multiple fractures (broken bone) of ribs on the right side, liver cell carcinoma (a disease in which malignant (cancer) cells form in the tissues of the liver), and pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of the right elbow and sacral region (a triangular-shaped bone at the bottom of the spine). During a review of Resident 1 ' s Physician Orders, dated 6/28/2024, the Physician Orders indicated to assess for pain every shift and chart intensity of pain using one to ten numeric pain scale (a series of numbers ranging from zero to ten where the two respective endpoints were no pain and worst pain). During a review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/4/2024, the MDS indicated the resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 had received scheduled and as needed pain medications. The MDS indicated Resident 1 received non-medication intervention for pain. The Pain Assessment section of the MDS indicated Resident 1 had experienced pain that interrupted sleep. During a review of Resident 1 ' s Physician Orders, dated 7/17/2024, the Physician Orders indicated to administer hydrocodone-acetaminophen 5-325 mg tablet every six hours as needed for severe pain (eight to nine on the numeric pain scale). b. During a review of Resident 2 ' s Admission Record, the Admission Record indicated the facility admitted the resident on 8/23/2021 with diagnoses that included end stage renal disease (the kidneys cease functioning on a permanent basis), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow). During a review of Resident 2 ' s Physician Orders, dated 9/1/2023, the Physician Orders indicated to administer hydrocodone-acetaminophen 5-325 mg tablet every six hours as needed for severe pain. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decisions were intact. The MDS indicated Resident 2 received non-medication intervention for pain. c. During a review of Resident 3 ' s Admission Record, the Admission Record indicated the facility admitted the resident on 2/7/2024 with diagnoses that included type 2 diabetes mellitus, essential hypertension (an abnormally high blood pressure that was not a result of a medical condition), and gastro-esophageal reflux disease (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach [esophagus]). During a review of Resident 3 ' s Physician Orders, dated 12/15/2023, the Physician Orders indicated to administer oxycodone-acetaminophen 5-325 mg tablet every four hours as needed for severe pain. During a review of Resident 3 ' s MDS, dated [DATE], The MDS indicated the resident ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 3 received scheduled pain medication regimen. During a record review of the facility-provided Investigation Letter, dated 8/21/2024, The Investigation Letter indicated that on 8/18/2024 at 7:30 a.m., Resident 1, Resident 2, and Resident 3 had missing medications as follows: a. Resident 1 was missing ten tablets of hydrocodone-acetaminophen 5-325 mg. b. Resident 2 was missing six tablets of hydrocodone-acetaminophen 5-325 mg. c. Resident 3 was missing four tablets of oxycodone-acetaminophen 5-325 mg. During an observation and concurrent interview on 8/28/2024 at 9:51 a.m., Cart 4 was observed locked, however, the third left drawer remained unlocked. The third medication drawer had residents ' (multiple residents) prescribed medications in it. Licensed Vocational Nurse 3 (LVN 3) stated she noticed the medication cart ' s third drawer was not locking since 8/26/2024. LVN 3 stated she did not report the medication cart drawer that was not locking to the DON because she thought the other licensed nurses had reported it. LVN 3 stated unlocked medication carts were a hazard and had the potential for other residents, facility staff, and visitors to take the medications and overdose (taking more than the recommended amount of medication). During an interview and a concurrent record review of the station 1 CDS sign in sheet, on 8/28/2024 at 10:11 a.m., the Cart 1 CDS sign in sheet, dated 8/2024, indicated there were no signatures on 8/17/2024 at 3 p.m. to 11 p.m. outgoing shift and 8/18/2024 at 7 a.m. to 3 p.m. incoming shift. LVN 5 stated signatures of the licensed nurses on the CDS sign in sheet indicated the licensed nurse worked that day and counted the CDS with another licensed nurse. LVN 5 stated CDS sign in sheet that were not signed had a potential for CDS medications to be lost and not accounted for. During an interview and concurrent review of the Controlled Drug Inventory (a physical count of all quantities of each federal controlled substance) on 8/28/2024 at 11:20 a.m., Resident 1, Resident 2, and Resident 3 ' s Controlled Drug Inventory were reviewed with the DON. The DON stated Resident 1 had ten tablets of hydrocodone-acetaminophen 5-325 mg that were missing. The DON stated Resident 2 had six tablets of hydrocodone-acetaminophen 5-325 mg that were missing. The DON stated Resident 3 had four tablets of oxycodone 5-325 mg that were missing. The DON stated the licensed medication nurse was the only person that had the medication cart and the CDS drawer keys. The DON stated the medication cart and CDS drawer keys were given to the next licensed medication nurse after the CDS count. During a telephone interview on 8/29/2024 at 10:54 a.m., LVN 2 stated she came to work late for the 11 p.m. to 7 a.m. shift on 8/17/2024. LVN 2 stated LVN 1 and Registered Nurse 1 (RN 1) informed her that Cart 1 CDS count was done. LVN 2 stated she did not count the CDS during her shift on 8/17/2024. LVN 2 stated RN 1 had possession of the Cart 1 and CDS drawer keys when RN 1 assisted with resident (unnamed) care. LVN 2 stated she counted the CDS with LVN 15, the 7 a.m. to 3 p.m. medication nurse for 8/18/2024, at the end of LVN 2 ' s shift. LVN 2 stated during the CDS count, LVN 1 and LVN 2 identified a total of three residents (Residents 1, 2, and 3) with missing CDS medications. LVN 2 stated each resident (Residents 1, 2, and 3) had one bubble pack of CDS missing. During a telephone interview on 8/29/2024 at 11:18 a.m., LVN 1 stated she worked the 3 p.m. to 11 p.m. shift on 8/17/2024 and was assigned at station 1. LVN 1 stated LVN 2 arrived late (time not indicated) in the facility. LVN 1 stated RN 1 refused to count the CDS with her and informed her to wait for LVN 2. LVN 1 stated she counted the Cart 1 CDS without another licensed nurse as witness. LVN 1 stated RN 1 was near the Cart 1 but was not actively involved on the CDS count. LVN 1 stated she should count the CDS with another licensed nurse. LVN 1 stated RN 1 gave LVN 1 permission to sign out for her shift and leave the facility after LVN 1 informed RN 1 that the CDS count was complete. During an interview and concurrent record review on 8/29/2024 at 1:03 p.m., the policy titled, Medication Dispensing Controlled Substances, last reviewed on 4/4/2024, was reviewed with the DON and was missing page five of five. The DON stated she did not complete a controlled substance loss form per facility policy. During a telephone interview on 8/29/2024 at 1:10 p.m., RN 1 stated on 8/17/2024, he saw LVN 1 flipping the pages of the CDS logbook, but RN 1 did not see LVN 1 count the Cart 1 CDS. RN 1 stated he saw LVN 2 at the station 1 hallway and thought LVN 1 and LVN 2 counted the station 1 CDS. RN 1 stated LVN 1 and LVN 2 did not ask him for assistance on counting the CDS. RN 1 stated he did not have possession of the Cart 1 and CDS drawer keys on 8/17/2024 and 8/18/2024. RN 1 stated on 8/18/2024 at 7:30 a.m., he was informed that one CDS bubble pack was missing. RN 1 stated he witnessed LVN 2 and LVN 15 count the CDS and identified a total of three missing bubble packs of CDS. RN 1 stated he instructed the facility staff to perform a search for the missing CDS inside resident rooms, facility bins, and trash cans. RN 1 stated on 8/18/2024 at 7:45 a.m., RN 1 reported the missing CDS to the DON via text message. RN 1 stated the missing CDS were not found. RN 1 stated as an RN supervisor, he was responsible for checking and making sure two licensed nurses completed and signed the CDS count. During a follow up interview on 8/29/2024 at 4:32 p.m., the DON stated Resident 1, Resident 2, and Resident 3 were not assessed and monitored for pain after identifying the missing CDS. During a record review of the four medication carts ' CDS sign in sheets, dated 8/2024, the Cart 1 CDS sign in sheet indicated 12 missing signatures. The Cart 2 CDS sign in sheet indicated 18 missing signatures. The Cart 3 CDS sign in sheet indicated three missing signatures. The Cart 4 CDS sign in sheet indicated 18 missing signatures. During an interview and concurrent record review of station 2 CDS sign in sheet, dated 8/2024, the Cart 3 CDS sign in sheet that the facility provided on 8/28/2024, indicated three missing signatures that included 8/27/2024 (outgoing 3p.m. to 11 p.m. shift). On 8/30/2024 at 12:15 p.m., Registered Nurse 2 (RN 2) stated the CDS entry dated 8/27/2024 (3 p.m. to 11 p.m. outgoing shift) was signed and the licensed nurse (unknown) changed the documented signature. These documents were initially reviewed and observed with no signatures and when presented with the same documents again, the documents now have signatures. RN 2 stated the CDS sign in sheet should not be signed days after the shift was worked and signature should not be altered because this is considered falsification of documents. During an interview and concurrent record review of station 2 middle CDS sign in sheet, dated 8/2024, the Cart 4 CDS sign in sheet that the facility provided on 8/28/2024, indicated 18 missing signatures that included 8/1/2024 (3 p.m. to 11 p.m. incoming and outgoing shift). On 8/30/2024 at 12:22 p.m., Registered Nurse 2 (RN 2) stated the licensed nurses (unknown) signed the CDS entry dated 8/1/2024 (3 p.m. to 11 p.m. incoming and outgoing shift). These documents were initially reviewed and observed with no signatures and when presented with the same documents again, the documents now have signatures. RN 2 stated the CDS sign in sheet should not be signed days after the shift was worked because that was considered falsification of documents. During an interview and concurrent record review of Cart 2 CDS sign in sheet, dated 8/2024, the Cart 2 CDS sign in sheet that the facility provided on 8/28/2024, indicated 18 missing signatures that included 8/1/2024, (3 p.m. to 11 p.m. incoming and outgoing shift), 8/3/2024 (7 a.m. to 3 p.m. and 3 p.m. to 11 p.m. incoming and outgoing shift), 8/4/2024 (7 a.m. to 3 p.m. incoming and outgoing shift), 8/5/2024 (3 p.m. to 11 p.m. incoming and outgoing shift), 8/8/2024 (7 a.m. to 3 p.m. incoming and outgoing shift), 8/14/2024 (3 p.m. to 11 p.m. incoming and outgoing shift), 8/17/2024 (11 p.m. to 7 a.m. outgoing shift and 7 a.m. to 3 p.m. incoming and outgoing shift), and 8/27/2024 (3 p.m. to 11 p.m. incoming and outgoing shift) . On 8/30/2024 at 12:26 p.m., Registered Nurse 2 (RN 2) stated the licensed nurses (unknown) signed the CDS entry dated 8/1/2024, (3 p.m. to 11 p.m. incoming and outgoing shift), 8/3/2024 (7 a.m. to 3 p.m. and 3 p.m. to 11 p.m. incoming and outgoing shift), 8/4/2024 (7 a.m. to 3 p.m. incoming and outgoing shift), 8/5/2024 (3 p.m. to 11 p.m. incoming and outgoing shift), 8/8/2024 (7 a.m. to 3 p.m. incoming and outgoing shift), 8/14/2024 (3 p.m. to 11 p.m. incoming and outgoing shift), 8/17/2024 (11p.m. to 7 a.m. outgoing shift and 7 a.m. to 3 p.m. incoming and outgoing shift), and 8/27/2024 (3 p.m. to 11 p.m. incoming and outgoing shift). These documents were initially reviewed and observed with no signatures and when presented with the same documents again, the documents now have signatures. RN 2 stated the CDS sign in sheet should not be signed days after the shift was worked because that was considered falsification of documents. During a follow up interview on 8/30/2024 at 1:49 p.m., the DON stated that LVN 1 and LVN 2 should count the CDS with another licensed nurse or with RN 1, who was present and working in the facility on 8/17/2024 and 8/18/2024. The DON stated that missing CDS would be considered as a drug diversion. The DON defined drug diversion as medications that can be used for other than what they were intended for. The DON stated that licensed nurses were informed that CDS sign in sheet should be signed before and after the CDS count. The DON stated that the CDS sign in sheet with missing signatures should not be filled with signatures on a later date. The DON stated that is considered as fraud. The DON stated the facility failed to follow the policy and procedure on accounting for all the CDS every change of shift. During an interview and record review on 8/30/2024 at 3:16 p.m., Resident 1, Resident 2, and Resident 3 ' s clinical records were reviewed with LVN 7. LVN 7 was not able to provide documented evidence that pain assessment, care plans, resident monitoring, and Interdisciplinary team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) meeting were done for Resident 1, Resident 2, and Resident 3. LVN 7 stated Resident 1 was asked about the resident ' s pain level on 8/18/2024 at 12:57 p.m., five hours and 27 minutes after the resident ' s CDS was identified as missing. LVN 7 stated Resident 2 was asked about the resident ' s pain level on 8/18/2024 at 1:24 p.m., five hours and 56 minutes after the resident ' s CDS was identified as missing. LVN 7 stated Resident 3 was asked about the resident ' s pain level on 8/18/2024 at 12:10 p.m., four hours and 40 minutes after the resident ' s CDS was identified as missing. LVN 7 stated the facility failed to monitor and assess Resident 1, Resident 2, and Resident 3 ' s pain levels. During a review of the facility ' s policy and procedure (P&P) titled, Medication Dispensing Controlled Substances, last reviewed on 4/4/2024, the P&P indicated the controlled Dangerous Substances are handled by the facility in a manner that promotes proper storage, security, and compliance with applicable State and Federal regulations. The policy indicated the DON is designated by the facility to be responsible for the control of such drugs. The policy indicated an inventory count of all CDS medications stored on each nursing unit shall be performed at each change of shift. Both the incoming and outgoing nurse on each unit that is responsible for handling the controlled substances will sign the inventory count. The Loss of a Controlled Dangerous Substance section of the policy indicated the facility will complete a report of theft or loss of controlled substances form. During a review of the facility ' s policy and procedure titled, Loss or Theft of Drugs, last reviewed on 4/4/2024, the P&P indicated the DON notifies the Administrator of controlled substance discrepancies. If discrepancies are not reconciled, the ADM, in conjunction with the facility ' s legal counsel is responsible for directing a. the notification of appropriate enforcement agencies according to State or Federal regulation. B. any other actions to be taken such as notifying the pharmacy, initiating quality improvement measures to prevent future occurrences. During a review of the facility ' s policy and procedure titled, Alert Charting Documentation, last reviewed on 4/4/2024, the P&P indicated the purpose to ensure the timely, ongoing assessment and documentation of residents who had a change in condition while in the facility. The policy indicated alert charting is required for but not limited to . A. special monitoring. The policy indicated the licensed nurses must note the change of condition that justifies alert charting when assessing the resident and thereafter which included to document the findings in the nursing notes, notify the physician, and responsible party, and . assessing residents, including vital signs, and documenting the resident ' s status. B. a. During a record review of Resident 1 ' s Admission Record indicated the facility admitted Resident 1 on 6/28/2024, with diagnoses that included multiple fractures of ribs (broken rib occurs when one of the bones in the rib cage breaks or cracks), fracture of nasal bones and liver cell carcinoma (causes cancer cells [grow out of control] to form in the liver tissues. During a record review of Resident 1 ' s History and Physical, dated 7/29/2024, indicated Resident 1 had fluctuating capacity to make decisions. During a record review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/4/2024, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 had frequent pain level of nine out of ten (A score of 0 means no pain, and 10 means the worst pain you have ever felt). During a record review of Resident 1 ' s Order Summary Report, dated 7/17/2024, indicated an order for Norco (hydrocodone acetaminophen, medication used to treat pain) tablet 5-325 milligrams (mg-unit of measurement), give one tablet by mouth every six hours as needed for severe pain level of eight to nine. During a record review of Resident 1 ' s Controlled Drug Inventory for hydrocodone-acetaminophen indicated on 7/21/2024 at 6:30 a.m. and 7/28/2024 at 9 p.m., indicated hydrocodone-acetaminophen was signed as taken out of Resident 1 ' s Controlled Drug Inventory. During a record review of Resident 1 ' s Medication Administration Record (MAR), dated 7/2024, indicated on 7/21/2024 at 6:30 a.m., and 7/28/2024 at 9 p.m., there was no documentation in Resident 1 ' s MAR that Resident 1 receive the hydrocodone-acetaminophen. During a concurrent interview and record review on 8/30/2024 at 12:02 p.m., with Registered Nurse 2 (RN 2), Resident 1 ' s Order Summary Report dated 7/17/2024, Controlled Drug Inventory for hydrocodone-acetaminophen dated 7/21/2024 and 7/28/2024 and MAR dated 7/2024 were reviewed. RN 2 stated Licensed Vocational Nurse 2 (LVN 2) d

Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for one of three sampled residents (Resident 7) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility. The facility failed to: 1. Provide Resident 7 with passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) in both arms and both legs from 8/3/2022 to 9/30/2022 in accordance with the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities) and Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge recommendations dated 8/3/2022, and physician's orders dated 8/3/2022, for the Restorative Nursing Aide ([RNA] a certified nursing aide program that helps residents to maintain their function and joint mobility) to provide PROM to both arms and both legs. 2. Apply the resting hand splint [material secured to the arm with straps which extends from the fingertips to the forearm to position the wrist and the fingers to maintain ROM and prevent the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness)] to Resident 7's right arm from 8/3/2022 to 2/10/2023 (for six months) in accordance with the OT's discharge recommendations dated 8/3/2022, and physician's orders dated 8/3/2022, for the RNA to apply a right resting hand splint for up to six hours, five times per week. 3. Obtain both knee splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to Resident 7's knees as indicated in the PT Discharge Summary dated 8/3/2022, for positioning and contracture prevention from 8/3/2022 to 3/26/2024 (for 19 months). 4. Monitor Resident 7's ROM in each joint of both arms and legs quarterly in accordance with Resident 7's care plan for limitation in ROM dated 9/7/2022, which indicated to assess Resident 7's joint mobility quarterly. 5. Apply both hand rolls (rolled towel placed in the palm) to Resident 7's hands on 6/11/2023 in accordance with the physician's orders dated 5/12/2024, for the RNA to apply both hand rolls for four to six hours (4 to 6 hours), five times per week as tolerated. 6. Apply the elbow extension splint (splint which prevents bending at the elbow) on Resident 7's right arm on 6/11/2024 in accordance with the physician order dated 6/3/2024, for the RNA to apply the right elbow extension splint for 4-6 hours, five times per week as tolerated. 7. Ensure the facility's policy and procedure titled, Rehab Rounding and Screening: Rehabilitation Services, included objective assessments to monitor a decline in both arms and both legs for Resident 7. These failures resulted in Resident 7's developing further ROM limitations in both arms and both legs, including the development of contractures of the right hand, right elbow, both shoulders, and both legs, which caused Resident 7 to feel pain with movement and ROM, and prevented Resident 7 from getting out of the bed, including receiving a shower. Findings: A review of Resident 7's Admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including hemiplegia (severe or complete loss of strength or paralysis of one side of the body) or hemiparesis (partial weakness or inability to move one side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant (used more often) side, dysphagia (difficulty swallowing), gastrostomy tube status ([G-tube] a tube surgically placed directly into the stomach for administration of medications and nutrition), aphasia (loss of ability to understand or express speech as a result of brain damage), and functional quadriplegia (complete immobility due to frailty or severe physical disability). A review of Resident 7's Rehabilitation Screening Form, dated 7/15/2022, indicated Resident 7 had contractures present in both arms (unspecified joints and severity) and both legs (unspecified joints and severity). The Rehabilitation Screening Form indicated PT and OT evaluations were requested for Resident 7. A review of Resident 7's OT Evaluation and Plan of Care, dated 7/15/2022, indicated Resident 7 had ROM in both shoulders and both elbows within functional limits (WFL, sufficient movement without significant limitation). The OT Evaluation indicated Resident 7 had impairment in both wrists and minimal (unspecified) limitation in both hands. The OT Evaluation indicated Resident 7 was dependent (helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity) on staff for oral hygiene (ability to clean teeth and mouth), toileting, showering/bathing, upper body dressing, and lower body dressing. A review of Resident 7's PT Evaluation and Plan of Care, dated 7/15/2022, indicated Resident 7 had severe (unspecified) contractures in both hips, both knees, and both ankles. The PT Evaluation indicated Resident 7 was dependent for rolling to both sides, chair/bed-to-chair transfers, and toilet transfers. A review of Resident 7's OT Discharge Summary, dated 8/3/2022, indicated Resident 7 had a resting hand splint applied to the right hand for six hours and a hand roll applied to the left hand for six hours. The OT Discharge Summary indicated recommendations for an RNA program to provide PROM to both of Resident 7's arms followed by the application of a hand roll on Resident 7's left hand and a resting hand splint on Resident 7's right hand for up to six hours, five days per week. A review of Resident 7's PT Discharge Summary, dated 8/3/2022, indicated the RNA (unknown) demonstrated 100 percent (%) competence with PROM exercises in both legs in a comfortable range to decrease Resident 7's risk for further contractures. The PT Discharge Summary also indicated Resident 7 would benefit from both knee splints for positioning and to prevent further contracture, pending health insurance approval. A review of Resident 7's physician orders, dated 8/3/2022, indicated an RNA program to provide PROM to both arms and both legs, to apply a left-hand roll for up to 6 hours, and to apply a right resting hand splint for up to six hours, five times per week as tolerated. A review of Resident 7's Restorative Nursing Flow Sheets (record of RNA session) indicated the Restorative Nursing Flow Sheets did not include RNA sessions for the month of 8/2022. A review of Resident 7's physician's orders, dated 8/30/2022, indicated an order to discontinue RNA for PROM to both legs. A review of Resident 7's census (record of hospitalization s, room changes, and payer source changes) indicated Resident 7 was transferred to the general acute hospital (GACH) on 8/31/2022. A review of Resident 7's physician orders, dated 9/2/2022, indicated to discontinue RNA for PROM to both arms, the application of the left hand roll up to 6 hours, and application of the right resting hand splint for up to six hours due to Resident 7's hospitalization . A review of Resident 7's census indicated Resident 7 was readmitted to the facility on [DATE]. A review of Resident 7's care plan for limitation in ROM related to history of cerebral vascular accident ([CVA] a condition when blood flow stops to a part of the brain, brain damage due to blocked blood flow) with right sided weakness, initiated on 9/7/2022, indicated an intervention to assess Resident 7's joint mobility (ROM at each joint) upon admission and quarterly or as needed. A review of Resident 7's Rehabilitation Screening Form, dated 9/7/2022, indicated Resident 7 did not have any changes in ROM and positioning. The Rehabilitation Screening Form did not include Resident 7's joint mobility assessment in both arms and both legs. The Rehabilitation Screening Form indicated therapy services were not indicated and Resident 7 was referred to RNA. A review of Resident 7's physician orders, dated 9/7/2022, indicated for RNA to provide PROM to both arms and both legs, five time per week as tolerated. Resident 7's physician's orders did not include RNA for the application of the left-hand roll and right resting hand splint. A review of Resident 7's RNA Flow Sheets indicated the Restorative Nursing Flow Sheets did not include RNA sessions for the month of 9/2022. A review of Resident 7's RNA flow sheet for 10/2022 indicated RNA provided Resident 7 with PROM to both arms and both legs, five times per week as tolerated. The RNA flow sheet for 10/2022 did not include for the RNA to apply Resident 7's left hand roll or right resting hand splint. A review of Resident 7's Rehabilitation Screening Form, dated 10/21/2022, indicated Resident 7 did not have any changes in ROM and positioning. Resident 7's Rehabilitation Screening Form did not include Resident 7's joint mobility assessment in both arms and both legs. The Rehabilitation Screening Forms indicated to continue with the RNA plan of care. A review of Resident 7's RNA Flow Sheets from 11/2022 to 1/2023 indicated RNA provided Resident 7 with PROM to both arms and legs, five times per week as tolerated, and did not include for the RNA to apply Resident 7's left hand roll or right resting hand splint. A review of Resident 7's Rehabilitation Screening Forms, dated 1/5/2023, indicated Resident 7 did not have any changes in ROM and positioning. The Rehabilitation Screening Form did not include Resident 7's joint mobility assessment in both arms and legs. The Rehabilitation Screening Forms indicated to continue with the RNA plan of care. A review of Resident 7's physician's orders, dated 2/10/2023, indicated for RNA program to apply both hand rolls for four to six hours (4 to 6 hours), five times per week as tolerated. A review of Resident 7's RNA Flow Sheet for 2/2023 indicated the RNA applied both hand rolls for 4 to 6 hours, five times per week as tolerated, starting on 2/10/2023. A review of Resident 7's RNA Flow Sheets from 3/2023 to 11/2023, indicated the RNA provided Resident 7 with PROM to both arms and legs and applied both hand rolls for 4 to 6 hours, five times per week. A review of Resident 7's Rehabilitation Screening Form, dated 12/5/2023 (11 months since the last Rehabilitation Screening on 1/5/2023), indicated the RNA (unknown) reported a change of condition, including Resident 7 screaming when attempting to place left hand roll. The Rehabilitation Screening Form indicated a new RNA program included applying a right-hand roll. A review of Resident 7's physician's orders, dated 12/5/2023, indicated for RNA to apply the right-hand roll for 4 to 6 hours, five times per week. A review of Resident 7's Rehabilitation Screening Form, dated 12/28/2023, indicated Resident 7 did not have any noted changes in ROM. Resident 7's Rehabilitation Screening Form did not include Resident 7's joint mobility assessment in both arms and legs. The Rehabilitation Screening Form indicated to refer Resident 7 to RNA to maintain ROM in both arms and both legs. A review of Resident 7's RNA Flow Sheets for 1/2024 and 2/2024 indicated the RNA provided Resident 7 with PROM to both arms and legs and applied both hand rolls for 4 to 6 hours, five times per week, from 1/1/2024 to 2/8/2024. A review of Resident 7's census indicated Resident 7 was transferred to the GACH on 2/8/2024 and was readmitted back to the facility on [DATE]. A review of Resident 7's Rehabilitation Screening Form, dated 2/15/2024, indicated to refer the resident to the OT and PT evaluations for details. A review of Resident 7's OT Evaluation and Plan of Care, dated 2/15/2024, indicated Resident 7 had impaired ROM in both arms, including right shoulder flexion (lifting the arm upward) 0 to 45 degrees (0 to 45 degrees, normal 0 to 180 degrees), right elbow flexion (bending the elbow) 90 to 150 degrees (normal 0 to 150 degrees), left shoulder flexion 0 to 10 degrees, left elbow flexion 20 to 150 degrees, and left wrist flexion (bending the wrist downward) 0 to 45 degrees (normal 0 to 90 degrees). A review of Resident 7's PT Evaluation and Plan of Care, dated 2/15/2024, indicated Resident 7 had impaired ROM in both legs, including both hips fixed (unable to move) to 130 degrees of hip flexion (bending the leg at the hip joint toward the body, normal 0 to 130 degrees) and both knees fixed to 150 degrees of knee flexion (bending the knee, normal 0 to 135 degrees). A review of Resident 7's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 4/22/2024, indicated Resident 7 was dependent on staff with oral hygiene, toileting, showering/bathing oneself, upper and lower body dressing, rolling to both sides and tub/shower transfers. The MDS indicated Resident 7 did not attempt chair/bed-to-chair transfers due to medical condition or safety concerns. A review of Resident 7's OT Discharge Summary, dated 4/24/2024, indicated the RNA program for ROM exercises was established and Resident 7 tolerated wearing both hand rolls and a right elbow extension splint for five hours. The OT discharge recommendations included RNA to provide Resident 7 with PROM to both arms, apply both hand rolls, and apply the right elbow extension splint. A review of Resident 7's PT Discharge Summary, dated 4/26/2024, indicated knee splints were applied to both of Resident 7's knees starting on 3/26/2024. The PT Discharge Summary indicated Resident 7 had both knee splints applied for up to four hours and had improved ROM to 95 to 110 degrees. The PT Discharge Summary also indicated the RNA (unknown) provided a 100% return demonstration for PROM to both legs through the available ROM. The PT Discharge recommendations included for RNA to provide Resident 7 with PROM to both legs, five times per week as tolerated, and to apply both knee extension splints. A review of Resident 7's physician's orders, dated 4/26/2024, indicated for RNA to provide PROM to both legs and apply the right elbow extension splint for 4 to 6 hours, five times per week as tolerated. Another physician order, dated 4/26/2024, indicated for the RNA to apply both of Resident 7's knee extension splints (duration unspecified), seven times per week as tolerated. A review of Resident 7's physician's orders, dated 5/13/2024, indicated for RNA to apply both hand rolls for 4 to 6 hours, five times per week as tolerated. A review of Resident 7's RNA Flow Sheet for 5/2024 indicated the RNA provided PROM to both arms and legs, applied both hand rolls for four hours, and applied both knee splints for four hours, five times per week. During a telephone interview on 6/11/2024 at 11:45 a.m. with Family Member 1 (FM 1), FM 1 wanted to know whether Resident 7 was receiving any intervention since FM 1 was concerned Resident's was developing hands and legs contractures. During an observation on 6/11/2024 at 12:38 p.m. in Resident 7's bedroom, Resident 7 was lying in bed awake but did not verbally respond to questions. Resident 7 was observed actively moved the left arm at the shoulder and elbow joints, but the left hand was positioned in a closed fist. Resident 7 shook the head, No, when asked if Resident 7 could open the left hand. Resident 7 did not have any active movement in the right arm. Resident 7's right elbow was in a bent position and the right wrist was bent downward. Resident 7's right thumb was positioned immediately next to the index finger while the middle, ring, and small fingers were bent completely into a fist. Resident 7 did not have any splints applied to either arm. Resident 7 had a blanket covering both legs. During an interview on 6/11/2024 at 1:33 p.m. with the Director of Rehabilitation (DOR), the DOR stated the facility monitored residents' ROM quarterly using the Rehabilitation Screening Form. The DOR stated the Rehabilitation Screening Form (in general) did not include a resident's ROM assessment in each joint. During an observation on 6/12/2024 at 7:30 a.m. in Resident 7's bedroom, Restorative Nursing Aide 1 (RNA 1) was standing on the left side of Resident 7's bed. Resident 7 was lying awake in bed and had a right elbow splint and a right knee splint already applied. RNA 1 rubbed Resident 7's left knee prior to applying the left knee splint. Resident 7's winced (involuntary grimace or shrinking movement caused by pain or distress), moaned, and cried as RNA 1 proceeded to apply the straps of the knee splint to Resident 7's left leg. Both of Resident 7's knees were observed in a bent position while wearing both knee splints. Both of Resident 7's hands were positioned in closed fists. Hand rolls were not applied to either of Resident 7's hands. RNA 1 left the room momentarily and then returned, stating the nurse (unknown) was notified of Resident 7's pain. Resident 7 moaned and cried as RNA 1 repositioned Resident 7 higher up in bed. During an interview on 6/12/2024 at 7:44 a.m. with RNA 1, RNA 1 stated the night shift nurse (unknown) informed RNA 1 that Resident 7 received pain medication at 5:30 a.m. RNA 1 stated Resident 7's RNA session started at approximately 7 a.m. with PROM exercises to both arms and both legs. RNA 1 stated PROM to both shoulders were not performed because Resident 7 could not tolerate the pain. RNA 1 stated the splints needed to be applied after Resident 7 received pain medication because Resident 7 was sensitive to touch and required slow movement during ROM due to pain. RNA 1 stated both of Resident 7's hand rolls were placed later in the day after Resident 7 received additional pain medication because both hands, especially the left hand, were difficult to open. During an interview on 6/12/2024 at 8 a.m., RNA 1 stated Resident 7 was not seen for RNA session yesterday (6/11/2024), including application of both arm splints, because Resident 7 screamed when RNA 1 attempted to work with Resident 7. During a follow-up interview on 6/12/2024 at 8:10 a.m., RNA 1 stated she attempted to see Resident 7 multiple times yesterday (6/11/2024) but Resident 7 refused due to pain and despite receiving pain medication. RNA 1 stated Resident 7's knee splints were applied but no other RNA intervention, including ROM and application of the right elbow splint and both hand rolls, was provided to Resident 7 on 6/11/2024. During a concurrent interview and record review on 6/12/2024 at 2:25 p.m. with the DOR, Resident 7's OT Evaluations, dated 7/15/2022 and 2/15/2024, and OT Discharge Summaries, dated 8/3/2022 and 4/26/2024, were reviewed. The DOR stated the OT Evaluation, dated 7/15/2022, indicated Resident 7 had ROM WFL in both shoulder and elbows. The DOR stated Resident 7's ROM in the left hand was impaired in the fingers but not the wrist. The DOR stated the left hand was more severe than the right hand since the recommendation was for a left-hand roll. The DOR stated a hand roll was a rolled-up face towel placed in the palm of the hand for residents with severe contractures. The DOR stated Resident 7's right wrist and hand ROM were impaired and recommended a resting hand splint, to position the right wrist and fingers in extension. The DOR stated the purpose of applying a splint (in general) included contracture prevention. The DOR reviewed the OT Discharge Summary, dated 8/3/2022, and stated Resident 7 tolerated wearing the left-hand roll and right resting hand splint for up to six hours. The DOR stated the OT Discharge Summary recommendations included for the RNA to provide Resident 7 with PROM of both arms, apply the left-hand roll, and apply the right resting hand splint. The DOR stated Resident 7 was recently hospitalized and returned to the facility on [DATE]. The DOR stated Resident 7 received an OT Evaluation, dated 2/15/2024, which indicated Resident 7's had limited ROM in both shoulders, both elbows, and both wrists. The DOR stated Resident 7 tolerated wearing both hand rolls and a right elbow splint for five hours. The DOR stated Resident 7's OT Discharge Summary, dated 4/26/2024, included recommendations for RNA to provide PROM to both arms, to apply both hand splints, and to apply the right elbow splint. During a concurrent interview and record review on 6/12/2024 at 3:23 p.m. with the DOR, Resident 7's PT Evaluations, dated 7/15/2022 and 2/15/2024, and PT Discharge Summaries, dated 8/3/2022 and 4/26/2024, were reviewed. The DOR reviewed Resident 7's PT Evaluation, dated 7/15/2022, indicated Resident 7 had severe contractures in both hips, both knees, and both ankles. The DOR reviewed Resident 7's PT Discharge Summary, dated 8/3/2022, and stated recommendations included RNA for PROM to both legs and recommendations for both knee splints for positioning and to prevent further contractures. The DOR stated the PT who discharged Resident 7 did not work at the facility anymore and did not set any therapy goals for Resident 7 to have both knee splints. The DOR stated Resident 7 did not receive the knee splints and did not know the reason Resident 7 never received both knee splints. The DOR reviewed the PT Evaluation, dated 2/15/2024, and stated Resident 7's knees were fixed into full flexion. The DOR reviewed Resident 7's Discharge Summary, dated 4/26/2024, and stated Resident 7's goals were updated on 3/26/2024 to apply both knee splints. The DOR stated Resident 7's Discharge Summary indicated Resident 7 tolerated wearing both knee splints for four hours and had improved ROM to both knees. The DOR stated the PT Discharge Summary recommendations included for the RNA to provide PROM to both legs and to apply both knee splints for four hours. During an interview on 6/13/2024 at 9:03 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 7's shower days were on Monday and Thursday. CNA 1 stated Resident 7 received bed baths and did not go to the shower because it was difficult and caused Resident 7 pain to position Resident 7 in the shower chair. During a concurrent interview and record review on 6/13/2024 at 11:25 a.m. with the DOR and the Director of Nursing (DON), the Rehabilitation Screening Form (in general) was reviewed. The DOR stated the purpose of the Rehabilitation Screening Form was to determine a resident had any changes in function, strength, or ROM which required therapy intervention. During a concurrent interview and record review on 6/13/2024 at 1:50 p.m. with the DOR and DON, Resident 7's OT Evaluations, dated 7/15/2022 and 2/15/2024, OT Discharge Summary, dated 8/3/2022, Rehabilitation Screening Forms, dated 9/7/2022, 10/21/2022, and 1/5/2023, and RNA flow sheets from 8/2022 to 2/2023 were reviewed. The DOR stated the OT Evaluation, dated 7/15/2022, indicated Resident 7 had ROM WFL in both shoulders and both elbows. The DOR stated the OT Discharge Summary, dated 2/15/2024, indicated for Resident 7 to receive RNA for PROM to both arms, application of the left-hand roll, and application of the right resting hand splint. The DON reviewed Resident 7's RNA Flow Sheets and stated Resident 7 did not have any RNA Flow Sheets for 8/2022 and 9/2022. The DON stated Resident 7 did not receive any RNA services for PROM to both arms and both legs, including the application of the left-hand roll and the right resting hand splint, for 8/2022 and 9/2022 since there was no documentation. The DOR and DON reviewed Resident 7's RNA flow sheets from 10/2022 to 2/2023. The DON stated the RNAs did not apply the left-hand roll and the right resting hand splint from 8/2022 to 2/2023 (for 6 months). The DOR reviewed the RNA flow sheet for 2/2023 and stated Resident 7 had a decline in ROM in the right hand on 2/10/2023 since Resident 7 started receiving RNA for the application of both hand rolls. The DOR and the DON reviewed Resident 7's Rehabilitation Screening Forms, dated 9/7/2022, 10/21/2022, and 1/5/2023. The DOR stated the Rehabilitation Screening Forms did not indicate any ROM assessment in both of Resident 7's arms and legs, did not indicate Resident 7's RNA program was reviewed, and did not indicate Resident 7's splints were checked. The DOR stated the quarterly Rehabilitation Screening should have caught that Resident 7's right resting hand splint and left-hand roll were not being applied from 8/2022 to 2/2023. The DON stated Resident 7's decline in ROM in the right hand was preventable since the right resting hand splint was not applied for six months. The DOR and DON reviewed Resident 7's OT Evaluation, dated 2/15/2024, which indicated Resident 7 had ROM decline in both shoulders and elbows. The DON stated assessments of both arms and both legs should have been completed on the quarterly Rehabilitation Screening Form to determine whether Resident 7's ROM in both arms and both legs were declining. The DON stated the facility's Rehabilitation Screening Form was not an effective system to monitor ROM since there was no assessment and documentation of Resident 7's ROM at each joint for both arms and both legs. The DOR stated Resident 7's ROM limitations could have been slowed down with proper assessment of both arms and both legs during the quarterly Rehabilitation Screening. During an observation on 6/13/2024 at 3:13 p.m. in Resident 7's bedroom with Physical Therapist 1 (PT 1), Resident 7 was awake while lying in bed. PT 1 described Resident 7's arms as contracted at both shoulders and elbows. PT 1 attempted but was unable to fully extend Resident 7's right-hand fingers. Resident 7 winced due to pain during PT 1's attempts to extend the right-hand fingers. PT 1 attempted to perform ROM to Resident 7's left arm but Resident 7 resisted PT 1's attempts. A review of the facility's policy and procedure (P&P) titled, Range of Motion Exercise Guidelines: Nursing Manual - Restorative Nursing Program, revised 1/1/2012, indicated the facility would maintain or increase ROM of the joint and to prevent or decrease contractures. A review of the facility's P&P titled, Restorative Nursing Program Guidelines, revised 9/19/2019, indicated the Restorative Nursing Program included nursing interventions that promote a patient's ability to attain, and maintain his/her optimal functional potential. Restorative care implies that the possibility for progress exists, and that improvement can be expected, or there is a risk of imminent decline which can be prevented. A review of the facility's P&P titled, Rehab Rounding and Screening: Rehabilitation Services, revised 7/22/2021, indicated the purpose of the P&P included to identify residents with changes and to allow those residents to receive therapy services if functional decline or improved are present. The P&P indicated screening did not require objective data and assessments. During an interview on 6/13/2024 at 7:05 p.m. with the Administrator (ADM), the ADM stated the facility did not have a general ROM policy which did not include Restorative Nursing since all residents were provided RNA if they were not receiving therapy.

Based on interview and record review, the facility failed to prevent a fall and injury for one of eight sampled residents (Resident 1), who was identified as a high fall risk. On 12/4/2023, the facility failed to provide Resident 1, who was assessed as needing extensive assistance with bed mobility (how a resident moves from lying position, turning side to side, or positioning of body), with two-person physical assistance when Certified Nursing Assistant 1 (CNA 1) did a one-person assistance while giving care and turning Resident 1 in his bed. As a result, on 12/4/2023 at 2:50 p.m., Resident 1 had an avoidable fall resulting to Resident 1 experiencing pain, acute (sudden onset) fracture (break in bone) to the left femur (thigh bone), and an operation procedure called Intramedullary (inner part) hip screw fixation (to firm or stabilize) left hip at the General Acute Care Hospital 1 (GACH 1). Findings: A record review of Resident 1 ' s Admission Record indicated an admitted [DATE] with diagnoses of encephalopathy (dysfunction in the brain causing confusion or memory loss), polyneuropathy (damaged nerves that cause problems in sensation, coordination or have effect on body functions), and personal history of transient ischemic attack (temporary blockage of blood flow to the brain), and cerebral infarction (damage to the brain due to lack of oxygen). A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/13/2023, indicated that Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making tasks were severely impaired. The MDS further indicated that Resident 1 required extensive assistance with bed mobility, transfers (moving from bed to wheelchair), and total dependence from staff for toileting needs (use of toilet including cleansing after toilet use) requiring the assistance of two staff members for physical assist to complete the tasks. A review of Resident 1 ' s Fall Risk Evaluation, dated 6/7/2023, indicated that Resident 1 scored a fall risk total score of 18 (tool does not indicate highest score). The assessment tool stated that a score of 10 or higher placed Resident 1 at high risk for falls. The assessment also indicated, If Resident is a fall risk, initiate fall risk precautions. On 12/19/2023 at 9:52 a.m., during a phone interview with CNA 1, CNA 1 stated Resident 1 ' s fall incident took place on 12/4/2023 around 2:50 p.m. CNA 1 stated knowing Resident 1 was a two-person assist, but while providing care to Resident 1, CNA 1 did not realize Resident 1 was already at the edge of the bed, causing Resident 1 to fall off the bed. CNA 1 stated that since it was at the end of the shift, there were no other staff members available to assist in providing care to Resident 1. CNA 1 stated Resident 1 ' s fall could have been prevented if assistance from another staff member was provided. On 12/19/2023 at 10:10 a.m., during a phone interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 to be alert and having weakness to one side of the body. LVN 1 stated, We do a daily huddle at the start of each shift, and we tell the CNAs which residents require two-staff assistance. LVN 1 stated that Resident 1 had a red-colored star sticker on the nameplate at the doorway to the room which meant that Resident 1 required two-person assist. LVN 1 stated that the facility is trying to prevent falls with injury, and that Resident 1 received surgery (repair or removal of body parts involving cutting into the body) after the fall. LVN 1 stated that the risks of surgery include infection to the surgical site, excessive bleeding, pain including severe pain, emotional harm, and risk for death. On 12/19/2023 at 10:38 a.m., during an interview with Resident 1, Resident 1 stated having a fall in the facility happening a couple of weeks ago. Resident 1 stated the staff member (CNA 1) was working alone with Resident 1 during the time of the fall. When asked how Resident 1 felt about the incident, Resident 1 stated, I felt bad because I told the CNA that I don ' t like being turned from my left side. I am weak on my left side. I had a stroke (blood that clumps together blocking blood flow to the brain) and my right side is my stronger side. I ended up having a fall and I had surgery on my left hip. On 12/21/2023 at 1:35 p.m., during an interview with the Director of Staff Development (DSD), the DSD stated CNA 1 received training for fall prevention management including the color coding meaning of a red star sticker which always meant the resident identified with the sticker on a nameplate is a two-person assist. During a concurrent review of the document titled, Shift Huddle, dated 12/2/2023, 12/3/2023, and 12/4/2023, indicated that CNA 1 signed-in participating in the shift updates. The DSD stated that CNA 1 participated in three separate dates and signed the participation of residents ' safety concerns with Resident 1 included in the list as high risk for falls. The DSD stated that on 12/4/2023 around 2:50 p.m., CNA 1 did not follow the instructions of having two staff members to assist Resident 1 as Resident 1 has left sided weakness to the body. The DSD stated Resident 1 always had a red star sticker on the nameplate. DSD stated that the failure was that CNA 1 did not follow the two-staff assist for Resident 1, that Resident 1 encountered a fall which resulted in left hip fracture and need for surgery. The DSD stated the risks for surgery include risk for infection on surgical site, further decline in Resident 1 ' s mobility (ability to move), Resident 1 could be depressed (state of feeling unhappy or hopelessness) afterwards as not being able to participate in activities of daily living because of the weakness and being tired, bleeding, and develop a blood clot (clumps of blood that harden) from decreased mobility. The DSD stated, All this could lead to death. On 12/21/2023 at 2:35 p.m., during an interview with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 required two (2) persons assist meaning when Resident 1 turns, there should be another staff to assist on each side as Resident 1 was not able turn independently. RN 1 stated that Resident 1 ' s fall could have been prevented by following the required assistance needed by Resident 1 and providing two staff members. RN 1 stated the risks involved with going through surgery include pulmonary embolism which is a blood clot going into the lungs that could impair breathing and could cause death. RN 1 stated Resident 1 already had history of embolism. RN 1 stated that the open surgical sites can lead to infection, and it can lead to depression (constant feeling of sadness and loss of interest) for the resident, maybe secondary to severe pain caused by limitation in movement. RN 1 stated symptoms of depression are decreased activity, poor appetite which is not eating or decreased participation with activities including rehabilitation therapy (care that can help you get back, keep, or improve abilities that you need for daily life), or insomnia or difficulty sleeping. A review of Resident 1 ' s record titled, Change in Condition Evaluation, dated 12/4/2023 at 2:50 p.m., indicated that Resident 1 was found on the floor lying on his right side. The evaluation indicated Resident 1 complained of pain on his left shoulder and left leg with pain level of four out of 10 (which means moderate pain using the pain rating scale). The evaluation indicated CNA 1 was changing Resident 1 and while turning Resident 1 on his side, Resident 1 rolled off the bed hitting his left shoulder on the bedside table. A review of Resident 1 ' s Physician ' s Order, dated 12/4/2023 at 3:31 p.m., indicated a stat (immediately) order to conduct an x-ray (an image of internal body parts) of Resident 1 ' s left humerus (upper arm bone) and left femur (upper leg bone) due to Resident 1 ' s pain. A review of Resident 1 ' s record titled, Radiology Report, with date of service on 12/4/2023, indicated, Conclusion: Limited exam with only 1 view of the hip which is suspicious for a nondisplaced (when the bone cracks or breaks but remains in correct position) fracture. A review of Resident 1 ' s Physician ' s Order, dated 12/4/2023 at 10:55 p.m., indicated to transfer Resident 1 to GACH 1 for Computed Tomography ([CT] produces detailed images of internal parts of the body) scan for a possible fracture. A review of Resident 1 ' s GACH 1 record titled, Radiology Report, dated 12/5/2023 at 9:55 a.m., indicated a CT scan was done on Resident 1 ' s left hip without use of contrast (a chemical substance used to enhance images of internal body parts). Resident 1 ' s CT scan result was an acute fracture to the left femur. A review of Resident 1 ' s GACH 1 record titled, Operative and Procedure Reports, dated 12/7/2023 at 11:31 a.m., indicated Resident 1 had an operation procedure Intramedullary (inner part) hip screw fixation (to firm or stabilize) left hip. The indication for surgery also stated that the risks of this procedure include, but are not limited to bleeding, infection, neurovascular damage (damage to major blood vessels supplying brain), malunion (healing of bone in abnormal position), nonunion (failure of fractured bone to heal), implant failure, anesthesia risk (risks with use of medications that block pain), loss of limb, loss of life. A review of Resident 1 ' s Care Plan, initiated on 6/8/2023, with the focus indicating, Potential changes in mental status, lethargy (feeling drowsy or without energy) related to compromised brain function associated with encephalopathy included the intervention to Provide necessary assistance as needed. A review of the current facility-provided policy and procedure titled, Resident Safety, with last revised date of 4/15/2021, indicated the purpose, To provide a safe and hazard free environment. A review of the current facility-provided policy and procedure titled, Falling Star Program, with last revised date of 2/1/2023 included the purpose to ensure residents will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A review of the current facility-provided policy and procedure titled, Fall Management Program, with last revised date of 3/13/2021, indicated, The facility will implement a Fall Management Program that supports providing an environment free from fall hazards.

Based on interview and record review the facility failed to identify and ensure one of two sampled residents (Resident 1), diagnosed with dementia (loss of memory, thinking and reasoning), received care, treatment, and services in accordance with professional standards of practice and the comprehensive assessment by failing to: -Implement Resident 1's comprehensive person-centered care plan interventions on anticoagulant therapy (commonly known as blood thinners, medicine to prevent blood clots), to avoid activities that could result in injury and to take precautions to avoid falls. -Implement Resident 1's comprehensive person-centered care plan interventions for at risk for falls and have a two-persons assist for bed mobility and transfers. -Provide Resident 1 extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility and transfers per the comprehensive assessment. -Notify and consult with Resident 1's physician, after the resident fell , in accordance with the facility's policy. As a result, on 9/14/2022 at 2:46 p.m., Resident 1 was found with multiple discolorations on the left lateral (side) head, left hand, the left shoulder, right thumb and a contusion (a region of injured tissue or skin in which blood capillaries have been ruptured; a bruise) on the left head. Resident 1 had a fracture of the left clavicle (collar bone), a left fourth rib fracture, required an arm sling to the left arm, and was prescribed Tylenol (pain medication) 325 milligrams (mg - unit of measurement) for pain management for seven days. Findings: A review of the admission record indicated Resident 1 was readmitted on [DATE] with diagnoses including dementia, muscle wasting and atrophy (decrease in size of muscle), and atrial fibrillation (a-fib, an irregular and often very rapid heart rate that can lead to blood clots in the heart). A review of the Care Plan dated 7/19/2022, indicated Resident 1 was on anticoagulant therapy related to a-fib. The care plan goal indicated the resident will be free from discomfort or adverse reactions related to anticoagulant use. The interventions included to avoid activities that could result in injury and to take precautions to avoid falls. A review of the history and physical dated 3/24/2022 indicated Resident 1 did not have the capacity to understand and make decisions. According to a review of the Fall Risk assessment dated [DATE], Resident 1 was confused, had poor eyesight, and required assistance with elimination. The fall risk assessment indicated Resident 1 had a score of 10 and a total score of 10 or above indicated Resident 1 was at risk for fall. A review of the Care Plan dated 7/19/2022, indicated Resident 1 was at risk for falls due to limited mobility, poor balance, lack of awareness, incontinence, and an unsteady gait. The care plan goal indicated to provide a safe environment that minimizes complications associated with falls. The care plan interventions included to assist with two-persons for bed mobility and transfers, provide an environment that supports minimized hazards over which the facility has control, and position the resident in the middle of the bed using supportive devices such as pillows. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 8/26/2022, indicated Resident 1 was disoriented to year, month, and day and required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, transfers, dressing and total dependence (full staff performance) with eating, toilet use, personal hygiene, and bathing. The MDS further indicated Resident 1 was on anticoagulation therapy (medication given to prevent blood clots). A review of the Medication Administration Record (MAR) dated from 9/1 - 9/14/2022 indicated Resident 1 received Eliquis tablets (medicine used to reduce the risk of stroke and blood clots in people with a-fib) 2.5 milligrams (mg.) one tablet orally two times a day for a-fib at 9 a.m. and 5 p.m. According to a review of the Eliquis Medication Guide dated 9/2021, it indicated while taking ELIQUIS you may bruise more easily, it may take longer than usual for any bleeding to stop, to call the doctor or healthcare provider right away if you fall or injure yourself, especially if you hit your head, as the doctor or healthcare provider may need to check you. A review of the Change in Condition (COC) note dated 9/14/2022 at 2:46 p.m., indicated Resident 1 was found with multiple discolorations in the following areas: -the left lateral head. -the left back of hand. -the left shoulder. -right thumb. -a contusion on the left head measuring four (4) centimeters (cm) by four (4) centimeters (cm). The 9/14/2022, the COC notes further indicated Resident 1 had facial grimacing with a pain rated at a six (using the pain rating scale from zero to ten, zero indicating no pain, 10 indicating the worst pain possible pain). Tylenol 325 mg two tablets was administered to Resident 1 for pain. An immobilizer was applied to the right thumb and a cold compress was applied on the left lateral head. The COC notes indicated a neurological check (assessment of mental status, reflex, and movement) was started with no changes in Resident 1's level of consciousness. The primary physician (PMD) was notified and gave an order to obtain an x-ray of Resident 1's skull, left and right hand, left shoulder and spine. The primary medical physician (PMD) also gave an order to stop administering Eliquis to Resident 1 for five days. A review of the Radiology Report dated 9/14/2022, indicated Resident 1 had a fracture of the left clavicle and the physician was notified. A review of the Physician's Order dated 9/15/2022 at 3:31 p.m., indicated to apply an arm sling to the left arm and administer Tylenol 325 mg. two tablets by mouth every shift for pain management for seven days and obtain an orthopedic consultation (physicians who specialize in treating muscles, joints, and bones). A review of the Orthopedic Surgeon Consultation dated 9/28/2022 indicated to apply the left shoulder sling and a repeat x-ray was completed. The Radiology Report dated 9/28/2022 indicated Resident 1 had a probable left fourth rib fracture. During an interview on 10/12/2022, at 12:09 p.m., the restorative nursing assistant (RNA, certified nursing assistant with specialized training) stated Resident 1 needed two persons when turning and during transfer. During an interview on 10/12/2022, at 12:20 p.m., the administrator (ADM) stated after Resident 1 was found with multiple bruises on the left side of his body, an investigation was conducted. The ADM stated during the facility's investigation, CNA 1 informed her Resident 1 had a fall on 9/13/2022 at 6 a.m. and CNA 1 did not report the fall to anyone. The ADM stated after a fall, a full body assessment should be done, range of motion should be checked, assist the resident back to bed and to notify the ADM, DON, and the PMD. During a telephone interview on 10/12/2022 at 1:30 p.m., licensed vocational nurse (LVN 1) stated he worked with CNA 1 on 9/13/2022 and CNA 1 did not inform him Resident 1 had a fall during their shift on 9/13/2022 at 6 a.m. On 10/12/2022 at 3:54 p.m., during a telephone interview CNA 1 stated on 9/13/2022 at about 6 a.m. he was providing care to Resident 1 by himself, turned Resident 1 on his side and left the room to get additional linen. CNA 1 stated he heard a noise coming from Resident 1's room and when he returned, Resident 1 was on the floor, lying on his left side. CNA 1 stated he informed LVN 1 that Resident 1 had a fall. CNA 1 stated Resident 1 was not assessed right after the fall. CNA 1 stated Resident 1 should be assessed right after the fall because Resident 1 could sustain a fracture or Resident 1 could bleed because Resident 1 was taking blood thinners. CNA 1 stated he was aware that Resident 1 needed two persons when turning or during care. CNA 1 stated looking back, he should have asked another staff for assistance during care to prevent the fall. During a telephone interview on 10/19/2022, the director of nursing (DON) stated Resident 1 needed two persons when changing the resident. The DON stated Resident 1 sustained fracture of the clavicle and the X-ray done on 9/28/2022 indicated a fracture of the fourth rib. During a telephone interview on 10/24/2022 at 12:06 p.m., Resident 1's PMD stated when Resident 1 had a fall, he should have been notified immediately as Resident 1 was on Eliquis and had the potential to bleed. A review of the facility's policy and procedure titled, Fall Management Program, revised on 3/13/2021, indicated the licensed nurse will notify the DON and/or administrator regarding the fall incident as soon as possible. The licensed nurse will notify the resident's attending physician and residents responsible party of the fall incident. Documentation of the incident in the medical record may include: -Time, date, and location of the fall. -Detailed description of the incident. -Resident's condition (e.g., no injuries noted, size and location of skin discoloration). -Notification of the attending physician. -Any physician orders given. -Notification of resident's representative (if applicable) A review of the facility policy titled, Change of Condition, created on 11/18/2021, indicated the facility will promptly inform the resident, consult with the resident's primary physician, and notify the residents legal representative or an interested family member when the resident experiences a significant change in their condition caused by, but not limited to the following. -an accident. -any significant change in the resident's physical, mental or psychological status. -a significant change in treatment. Any staff member who observes a change of condition will report the change to the licensed nurse. The same policy indicated any staff member who observes a change of condition will report the change to the licensed nurse. The licensed nurse will assess the change of condition and determine what interventions are appropriate. The licensed nurse will notify the residents primary care physician, legal representative or an appropriate family member and assigned lasting power of attorney when there is an: -Incident or accident involving the resident -An accident involving the resident which results in injury and has the potential for requiring physician intervention. -A significant change in the resident's physical, mental or psychosocial status.

Based on observation, interview and record review, the facility failed to provide a two plus person physical assist (to be assisted by two or more staff persons) for one of three residents (Resident 1) to transfer from the bed to the shower chair on 7/3/2022. Resident 1 who was morbidly obese (weight is more than 80 to 100 pounds above ideal body weight), assessed as a high fall risk, and needing two plus persons physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). This deficient practice resulted in Resident 1 sustaining a right leg fracture (broken leg bones) on 7/3/2022 when resident fell while being transferred from bed to chair. Resident 1 was sent on 7/4/2022 to the General Acute Care Hospital 1 (GACH 1) for further evaluation and treatment. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 9/13/2019, with diagnoses including morbid (severe) obesity, muscle wasting (weakening, shrinking, and loss of muscle caused by disease or lack of use), and chronic pain syndrome (pain that lasts for over three months). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 5/24/2022, indicated resident's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated that for activities at daily living (ADLs), Resident 1 required extensive assistance and two plus persons physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and toilet use (transfers on/off toilet). A review of Resident 1's Fall Risk assessment dated [DATE], indicated a score of 14 which is considered a high fall risk according to the guide attached to the fall risk evaluation. It indicates that scores greater than 10 are considered high risk for potential falls. A review of Resident 1's Care Plan for fall risk prevention and management, dated 6/3/2022, indicated the goal for Resident 1 was to minimize complications associated with falls over the next quarter. The care plan included interventions to provide staff education on Resident 1's special care needs. A review of Resident 1's Change of Condition (COC) Report, dated 7/3/2022, indicated Registered Nurse 1 (RN 1) heard Certified Nursing Assistant 1 (CNA 1) calling out for help at around 3:30 a.m. As RN 1 entered Resident 1's room he found Resident 1 kneeling on the floor with the right leg twisted. The COC indicated Resident 1 had pain and rated it at seven in the pain scale (0=no pain, 4-5=moderate pain, 6-9= severe pain, 10=excruciating pain). A review of Resident 1's General Acute Care Hospital 1 (GACH 1) notes, dated 7/4/2022, indicated right knee x-ray (image of the right knee) with a comminuted mildly displaced fracture of the right proximal tibia and proximal fibula (fracture to the leg where the bones are broken in several fragments and are not aligned due to high-energy trauma). A review of Resident 1's Progress Notes, dated 7/16/2022 at 12:02 p.m., indicated a late entry documentation for 7/3/2022 at 3:30 p.m., indicating that on 7/3/2022 at 3:30 p.m. RN 1 heard CNA 1 calling for help and RN 1 went immediately to Resident 1's room and found Resident 1 in front of the shower chair kneeling on the floor with her right leg twisted. Resident 1 stated she lost her balance. Resident 1 was placed back in bed by four-person assist using a blanket. Resident 1 was noted with slight swelling on right knee and with pain. A review of Resident 1's Progress Notes, dated 7/16/2022 at 12:03 p.m., indicated an entry documentation for 7/4/2022 at 12:03 p.m., indicating Resident 1's x-ray report was received on 7/4/2022 at 10:47 p.m. and the physician ordered to transfer Resident 1 to GACH 1 for further evaluation. During an interview on 7/19/2022, at 11:19 a.m., CNA 1 stated on 7/3/2022 at around 3:30 a.m., he (CNA1) passed by Resident 1's room and the Resident 1 requested to go to the restroom. CNA 1 stated he notified Resident 1 to give him a few minutes while he finishes with another resident, he (CNA1) currently helping. CNA 1 stated he returned to Resident 1's room and assisted her with the transfer from bed to a shower chair. CNA 1 further stated he usually transfers Resident 1 by himself but should have been a two person assist. CNA 1 stated he was helping Resident 1 to be transferred from bed to shower chair when the resident slipped causing the resident to slide to the floor. CNA1 further stated resident started screaming after. CNA 1 stated he called for help, and it took more than four minutes before help arrived. CNA 1 stated, there was no huddle to discuss the level of care for each resident prior to providing care. CNA1 further stated I feel really bad that this happened in my [AGE] years, and I strongly feel that this could have been prevented if only we were given information about the resident's conditions and if we did handover with the CNAs from previous shifts. During an interview on 7/19/2022 at 11:45 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was evaluated by physical therapy since admission and required a two person assist. During concurrent observation at Resident 1's room and interview with Resident 1 on 7/19/2022 at 11:58 a.m., Resident 1 was observed lying on bed with right leg brace (a device used to immobilize a joint or body segment). Resident 1 stated she just came back from the hospital because she fell and have broken bones. Resident 1 stated she had some pain when she fell and took Tylenol (pain medication). On 7/19/2022 at 2:20 p.m., during concurrent interview and review of CNA 1's Competency Checklist dated 4/4/2022 and 6/30/2022, the Director of Staff Development (DSD) stated CNA 1 had completed a training and demonstrated a competency which included resident transfer for the month of April 2022 and June 2022. During an interview on 9/2/2022 at 12 p.m., the Registered Nurse (RN 1) stated that when a resident is assessed as a high fall risk, the physical therapy evaluates and notifies staff about the high fall risks assessment. RN 1 stated that the facility also places some star stickers by the door which serves as a visual reminder about the fall risk status of the resident. RN 1 further stated that when a resident who required a two-person assist is transferred by one staff, there is a risk for accident or fall and the resident might sustain injuries such as fractures. A review of the facility's current policy and procedure titled, Transfer, revised on 6/15/2011, indicated to provide residents with a safe movement from one surface to another by knowing the resident's abilities and limitations. In addition, the policy further explained a two-person transfer as the following: Place the chair at a slight angle next to the go to bed or toilet. Ask the resident to lean slightly to the side (away from the go to surface) and place one end of the sliding board under the resident's buttocks. Stand on both sides of the resident and place the hands through the gait belt. Instructs the resident to fold his/her arms across the chest. On the count of three, slide the resident into the chair or bed.

Based on observation, interview, and record review, the facility failed to prevent fall and injury to one of three sample residents (Resident 1) by: 1. Not providing adequate supervision to Resident 1. 2. Not identifying accident hazards. 3. Not providing a safe environment per policy. As a result, on 11/5/19 at 5:53 p.m., Resident 1 propelled the wheelchair, went through the front door and fell three steps of stairs and out of the wheelchair sustaining a hematoma (collection of blood due to trauma) and an abrasion (skin scrape) with bleeding on the left side of the forehead. Resident 1 required transfer to General Acute Care Hospital 1 (GACH 1) and was diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1 on 2/16/10 with last readmitted d 2/7/13. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Fall Risk Prevention and Management Care Plan initiated 1/17/19, indicated Resident 1 was at risk for falls, had vision problem, lack of awareness, and impulsive behavior. The goal was to minimize complications associated with falls. The approaches included orienting Resident 1 to the environment each time changes were made, providing an environment that supported minimized hazards over which the facility had control, and implementing the Falling Star Program. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 7/15/19, indicated Resident 1 could not remember and make decisions, required limited assistance with locomotion on the unit, and used a wheelchair. According to a review of the Fall Risk Data Collection form, dated 10/14/19, Resident 1 scored a 9 for fall risk. A score of 10 or above represented a high fall risk. Further review of the fall risk form under predisposing conditions (make susceptible) indicated Resident 1 scored a zero. This indicated Resident 1's [MEDICAL CONDITION] condition was not included in the total score, which would have increased to a total score of 11, indicating Resident 1 was a high fall risk. A review of Resident 1's [MEDICAL CONDITION] Care Plan revised on 10/19/19, indicated Resident 1 was at risk for fracture related to [MEDICAL CONDITION]. The approaches included encouraging/reeducating Resident 1 on not hitting self on hard surfaces, assisting with all transfers and ambulation, and preventing accidents. A review of Resident 1's Falls Change of Condition form dated 11/4/19, indicated at 5:53 p.m., Resident 1 was found on the ground outside, at the front of the facility, below three steps of stairs. Resident 1 had a hematoma and an abrasion with minimal bleeding on the left side of the forehead. Resident 1 could not say what happened and was placed back in the wheelchair. A review of Resident 1's Nurse's Note dated 11/5/19, timed at 6:15 p.m., (noted as a late entry), indicated the licensed nurse called 911 (call number for emergency assistance) due to Resident 1's bleeding from the forehead. The fall occurred at 5:50 p.m. on 11/4/19, outside the front door from Nursing Station 1. Resident 1 wheeled herself to the front door, was trying to open the door, and a lady passing by opened the door. Resident 1 fell down the stairs and out of her wheelchair. Paramedics transported Resident 1 to GACH 1. A review of Resident 1's Post Fall Assessment form dated 11/5/19, included in the recommendations locking the exit/entrance door by Nursing Station 1 at 5 p.m., with a sign for visitors to enter the facility near Nursing Station 2. Also, installing a retractable belt barrier by the entrance hall of Nursing Station 1 door to keep residents from the entrance hall. A review of Resident 1's GACH 1 Emergency Department (ED) Note dated 11/4/19, indicated Resident 1 presented with a low blood pressure of 107/59 (normal for the resident was 125/65), pain secondary to a left forehead hematoma measuring two centimeters (cm - unit of measurement) by four cm and a contusion (injured blood vessels leak blood into the surrounding area). Resident 1's [DIAGNOSES REDACTED]. A review of the GACH 1 Assessment report dated 11/5/19 at 2:35 a.m., indicated the ambulance was at the bedside of Resident 1 for transport back to the skilled facility. A review of the skilled facility nursing notes dated 11/5/19 at 3 a.m., indicated Resident 1 was refused re-admission due to a low blood pressure of 70/45 mmHg. The Death Summary report indicated Resident 1 had a low blood pressure and was admitted to GACH 1. Resident 1 received intravenous fluids and two units of blood. Physicians pronounced Resident 1 dead at 10:40 a.m. on 11/11/19. A review of Resident 1's Certificate of Death indicated Resident 1's cause of death was a cardiopulmonary arrest. During an observation of the facility's environment, on 11/20/19, at 9:05 a.m., when walking in the hallway leading to the facility front door, it was noted the top of the stairs blended with the city sidewalk, with no depth perception of the steps. The facility's front door lead to steps without any caution sign. The color of the ground to the front access door was painted gray, the same color hue as the city sidewalk. During an interview, on 11/20/19, at 9:05 a.m., the receptionist at Nursing Station 1 stated she was in the facility from 8 a.m. to 4 p.m. When she leaves for the day, the nurses supervise the entrance door. During an interview, on 11/20/19 at 9:37 a.m., Certified Nursing Assistant 1 (CNA 1) stated she had been Resident 1's CNA for five months. Resident 1 would like to sit by the front door and would say she wanted to return to her hometown. During an interview, on 11/20/19 at 9:55 a.m., Resident 2 (Resident 1's roommate) stated Resident 1 would go to the front door and staff would wheel Resident 1 back to her room, then, Resident 1 would go back to the front door. During an interview, on 11/20/19 at 11:45 a.m., with the DON and Administrator, the DON stated at the time of the incident there was no staff at Station 1 because the nurse was at Station 2 with another resident. The DON stated she was aware Resident 1 wanted to go to her place of origin. The Administrator stated and verified there was no depth perception to indicate that there were stairs right in front of the front access door. During an interview, on 11/21/19 at 2:30 p.m., with Registered Nurse 1 (RN 1) she stated she was working the day of the fall, but at the time of the incident she was at Station 2 with another resident. During an interview with the DON on 12/26/19 at 12:20 p.m., she stated there was no care plan for Resident 1 regarding exit seeking behavior. On 12/26/19, at 12:33 p.m. during an interview, the DON stated Resident 1's Fall Risk Data Collection form was inaccurate, and the score should be 11 (high fall risk). The DON stated, Station 1 exit is a risk if a resident got out and it faces a very busy street. A review of the facility's current policy titled, Resident Rooms and Environment, dated 1/1/12, indicated the purpose was to provide residents with a safe and comfortable environment. A review of the facility's current policy and procedure titled, Fall Prevention and Management Program, dated 8/1/14, indicated the facility would provide a safe environment that minimizes complications associated with falls. A review of the facility's current policy and procedure titled, Fall Management Program, revised 11/7/16, indicated the licensed nurse and/or Interdisciplinary Team would develop a Plan of Care according to the residents identified risk factors.

Based on observation, interview, and record review, the facility failed to ensure pain management is provided consistent with professional standards of practice and the person-centered care plan and goals for one of three sampled residents (Resident 1), including: 1. Failure to re-assess and re-evaluate Resident 1's pain and pain management and to notify the physician the pain management was ineffective. 2. Failure to administer Resident 1 [MEDICATION NAME] (narcotic used for severe pain) as ordered by the physician. 3. Failure to implement the Care Plan for Resident 1's chronic/history of pain, by not administering pain medication as ordered, assessing pain medication and pain during treatment for [REDACTED]. 4. Failure to implement the facility's policy on Pain Management, by not assuring accurate assessment of Resident 1's pain and respond in a timely manner with administration of pain medication and non-drug interventions as appropriate and re-assess Resident 1's pain when there was new pain or worsening of existing pain. As a result, Resident 1 experienced constant and unrelieved moderate to severe pain, requiring transfer to General Acute Care Hospital 1 (GACH 1). Findings: On 3/19/18, an unannounced visit was made to investigate a complaint regarding Quality of Care. A review of the Admission Record indicated, Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the nursing Admission Assessment, dated 2/28/18, indicated Resident 1 was alert and oriented, had clear speech, was able to make needs known and had no complaint of pain. Resident 1 required limited assistance with all activities of daily living (ADLs - transfers, locomotion, walking, dressing, personal hygiene, and toilet use). A review of the Pain Assessment form, dated on admission, indicated Resident 1 verbalized or displayed no pain in the last five days. A review of the Care Plan initiated on admission, 2/28/18, for Resident 1's chronic/history of occasionally mild pain, indicated a goal for Resident 1 to verbalize or show decreased signs and symptoms of pain and achieve self-reported pain goal of 0/10 level (rating pain scale from zero to 10, zero indicating no pain and 10 the worst possible pain). The interventions included administering pain medication as ordered, assessing pain medication and treatment for [REDACTED]. A review of the physician's orders [REDACTED]. -[MEDICATION NAME]® (a brand name for the combination prescription drug [MEDICATION NAME]/[MEDICATION NAME]. It is used to treat moderate to severe pain) 325/5 milligrams (mg - 325 mg of with 5 mg of [MEDICATION NAME]) every four hours, as needed, for moderate pain (5-6/10 pain level), and -Aspirin® 325 mg, one tablet, routinely every 12 hours for pain management. A review of the physician's orders [REDACTED]. -Treatment (cleansing and dressing change) to the right hip surgical wound daily, and -Pain assessment prior, during, and post treatment daily. A review of the Pain Assessment Shift Monitor form indicated the pain rating scale was as follows: -0/10 - no pain, - 1-2/10 least pain, - 3-4/10 mild pain, - 5-6/10 moderate pain, - 7-8 severe pain, and - 9-10 excruciating pain. The Pain Assessment Shift Monitor form indicated the on 3/1/18, during the 7 a.m. to 3 p.m. shift, Resident 1's pain level to the right hip was 6/10; during the 3 p.m. to 11 p.m. shift Resident 1's pain level was left blank; and during the 11 p.m. to 7 a.m. shift, Resident 1 had no pain. A review of the Pain Assessment Flowsheet indicated on 3/1/18, the resident was given [MEDICATION NAME]® 5/325 mg one tablet for moderate pain (rated 6/10) at 10 a.m. A review of the Nurses' Notes dated 3/2/18, timed at 10 a.m., indicated the Physician was made aware Resident 1 needed pain medication prior to wound treatment for [REDACTED].® one tablet every day prior to wound treatment and two tablets every six hours, as needed, for severe pain. Not to exceed 3 gm in 24 hours. A review of the Treatment Administration Record (TAR) along with the Pain Assessment Flowsheet, indicated no specific time Resident 1's treatment was done and no evidence Resident 1 was assessed prior, during and after treatment to the right hip. A review of the Pain Assessment Flowsheet indicated on 3/2/18, during the 3 p.m. to 11 p.m., shift, Resident 1's pain to the right hip was moderate (rated 6/10). The MAR indicated [REDACTED]. According to Nurses' Notes on 3/3/18 during 11 p.m. to 7 a.m. shift Resident 1 complained of severe pain (rated 7/10) and [MEDICATION NAME]® was given on 3/4/18 at 1:25 a.m. A review of the physician's orders [REDACTED].® 500 mg one tablet twice a day for pain (pain level not indicated). According to Nurse's Notes on 3/4/18 during 7 a.m. to 3 p.m. shift Resident 1 complained of severe pain (rated 7/10) and [MEDICATION NAME]® was given at 1 p.m. According to Nurses' Notes dated 3/4/18 during 11 p.m. to 7 a.m. shift Resident 1 complained of severe pain (rated 7/10) and was given [MEDICATION NAME] 30 mg tablet at 5 p.m. from the emergency supply kit. A review of the Nurses' Notes dated 3/4/18, at 6:30 p.m., indicated the Resident 1 was upset because [MEDICATION NAME]® was not working. The Licensed Nurse documented [MEDICATION NAME] sulfate ordered (at 8:40 a.m.) was not yet delivered from the pharmacy. A review of the Nurses' Notes dated 3/5/18 during the 7 a.m. to 3 p.m. and 3 p.m. to 11p.m. shifts, Resident 1's pain to the left hip was severe (rated 8/10) and during the 11 p.m. to 7 a.m. shift Resident 1's right hip pain was severe (rated 7/10). A review of the physician's orders [REDACTED].®, [MEDICATION NAME] sulfate, and [MEDICATION NAME]®. Give Resident 1 [MEDICATION NAME] sulfate 30 mg one tablet at bedtime and [MEDICATION NAME]® 5/325 mg two tablets prior to wound treatment. There was documentation to explain why the [MEDICATION NAME] sulfate twice a day was discontinued. A review of the Nurses' Notes dated 3/5/18 indicated Resident 1 complained [MEDICATION NAME]® and [MEDICATION NAME]® did not help him with pain and preferred [MEDICATION NAME]. At 11:30 p.m., Resident 1 was very upset complaining of increased pain and demanded to call the Physician or he would call 911 (paramedics). When Resident 1 was told he received [MEDICATION NAME] on the evening shift he responded screaming accusing the nurses of not giving him [MEDICATION NAME]. Resident 1 stated when he uses [MEDICATION NAME] it works right away. A review of the physician's orders [REDACTED]. On 3/19/18, at 9:30 a.m., during an interview, Resident 1's friend stated she visited daily and Resident 1 was always crying out in severe right hip pain and nothing was done to control the pain and Resident 1 needed to go back to the hospital due to unmanaged pain. Attempts to interview Resident 1 were not successful. On 5/30/18, at 11:45 a.m., an interview and record review with Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated Resident 1 was given [MEDICATION NAME] sulfate from the e-kit on 3/4/18, at 5 p.m. and on 3/5/18, at 9 p.m. The [MEDICATION NAME] sulfate ordered on [DATE] was not received from the pharmacy. A review of the Medication Administration Record [REDACTED]. There was no documentation of the reason [MEDICATION NAME] was not given. LVN 2 was not able to explain the Nurses' Note on 3/4/18 from the 11 p.m. to 7 a.m. shift which indicated Resident 1 received [MEDICATION NAME] at 5 p.m. A review of the facility's policy and procedure titled, Pain Management, revised (MONTH) (YEAR), indicated the purpose was to assure an accurate assessment of the resident's pain and respond in a timely manner with administration of pain medication and/or non-drug interventions as appropriate for the resident. Assess residents for pain upon admission, quarterly, when there is significant change in condition, when there is onset of new pain, and when worsening of existing pain.