Every finding on record at The Rehabilitation Center on Pico

Based on observation, interview, and record review, the facility failed to ensure that oral care was provided for one of three sampled residents (Resident 1) who required total assistance with personal hygiene according to care plan.This deficient practice result in that Resident 1 had white debris on his tongue requiring oral cleaning, placing Resident 1 at risk for developing fungal infection (any disease or condition you get from a fungus). During a review of Resident 1's admission records dated 6/10/2026, the admission record indicated Resident 1 was admitted on [DATE] with the diagnoses that included but not limit to: muscle weakness, dysphagia (a condition when someone can't swallow normally, which can make eating or drinking difficult), malnutrition (a condition when someone isn't eating enough of the right foods, causing their body to become weak or unhealthy), and syphilis (a disease caused by bacteria that usually spreads through sexual contact).During a review of Resident 1's history and physical (H&P) dated 5/30/2026, the H&P indicated Resident 1 had profound function declined and required assistance with activities of daily living.During a review of Resident 1's Minimum Date Set (MDS, a resident assessment tool) dated 6/4/2026, the MDS indicated Resident 1 had intact cognition (ability to think, remember and reason for daily decision making). Resident 1 was dependent on staff for oral hygiene.During a review of Resident 1's care plan date 6/9/2026, the care plan indicated Resident 1 required total assistance with personal hygiene.During an interview on 6/9/2026 at 11:31 AM, Certified Nursing Assistant (CNA) 1 stated Resident 1 was very depressed, frequently refused to eat, refused repositioning, and refused incontinent care/change the morning of 6/9/2026. CNA 1 further stated that she had reported to the Charge Nurse that Resident 1 was looking worse.During a current observation and interview on 6/9/2026 at 12:10 PM with the Treatment Nurse. Resident 1's mouth was assessed by the Treatment Nurse. The Treatment nurses verified that Resident 1's tongue had a white film present that required cleaning. The Treatment Nurse stated no staff had reported Resident 1 refusing care. The Treatment nurse further stated that any resident refusing care, nursing staff should continue offer, provide patient education and report.During an interview with the Director of Nursing (DON) on 6/9/2026 at 12:30 PM, the DON stated that the white film observed on Resident 1's tongue indicated a need for oral care. The DON explained that oral care is typically provided each shift, and failure to do so increases the Resident 1's risk of developing a fungal infection.During a review of the facility's policy and procedure (P&P) titled, ADL[activities of daily living] care provided for dependent residents, dated 1/2026, the P&P indicated oral care should be provide to residents to maintain of a health mouth.when resident refuse care, facility should document effects to inform and educated the resident.

Based on observation, interview and record review, the facility failed to ensure necessary care and services were provided for one of three sampled residents (Resident 1), who repeatedly refused food, medications, oral care, and hygiene services by failing to:Ensure a white film on the resident's tongue was assessed and treated.Ensure the resident's refusal of food, medications, oral care, and hygiene services were assessed, and care- planned with interventions.Ensure the resident's dentures were properly identified and accessible for use.During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of toxic encephalopathy (disease of the brain that alters brain function or structure), pulmonary cryptococcosis (a fungal infection of the lungs with symptoms ranging from mild cough and chest pain to respiratory failure), Atrial fibrillation (A-fib: an irregular and often very rapid heart rhythm, can lead to blood clots in the heart).During a record review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated 6/4/2026, the MDS indicated Resident 1 had intact cognition (ability to think, remember and reason for daily decision making). Resident 1 was dependent on staff for eating, sitting up, lying to sitting on side of bed, chair/bed to chair transfer, repositioning, oral hygiene, toileting, shower bathe, upper and lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 1's Medication Administration Record (MAR), dated June 2026, the MAR indicated Resident 1 refused prescribed HIV (HIV- is a virus that attacks the body's immune system) and A-fib medications for 8 consecutive days starting 6/2/2026 through 6/9/2026. The review of the electronic medical record (EMR) revealed that the physician was aware of the medication refusals; however, no new physician orders, assessments, care plan revisions, referrals, or additional interventions were identified related to the ongoing refusals.During a review of Resident 1's Care Plan, the Care Plan did not indicate interventions to ensure dentures were properly stored, labeled, and made accessible to the resident to promote oral intake and oral hygiene.During a concurrent observation and interview on 6/9/2026 at 10:57 AM with Resident 1, in Resident 1's room, Resident 1 was observed lying in bed in his room, A white film was observed on Resident 1's tongue. Resident 1 stated he was sad and felt lonely. Resident 1 stated he wished he had a family member nearby and reported having no appetite. Resident 1 stated he had not worn his dentures since admission and felt very weak. Resident 1 further stated it was too much effort to try and do things and had a lot of pain all over his body. Resident 1 kept grimacing, groaning, and guarding his body during the interview. During an interview on 6/9/2026 at 11:31 AM, with certified nursing assistant (CNA 1), CNA 1 stated Resident 1 was very depressed and frequently refused to eat, be repositioned, and be changed. CNA 1 also stated she reported to the Charge Nurse that Resident 1 was looking worse.During a concurrent observation and interview on 6/9/2026 at 12:10 PM with the Treatment Nurse in Resident 1's room, the Treatment Nurse stated staff had not reported Resident 1's refusals of care in the morning. The Treatment Nurse further verified Resident 1's tongue had a white film and acknowledged Resident 1 required oral care and mouth cleaning.During a concurrent observation and interview on 6/9/2026 at 1:06 PM with CNA 2 in Resident 1's room, CNA 2 stated she was unaware Resident 1 had dentures and verified that an unlabeled plastic bag was under Resident 1's bed, which contained Resident 1's dentures. Staff were unaware the dentures were in the bag and unable to confirm how long the dentures had remained there.During an interview on 6/9/2026 at 1:28 PM with the Director of Nursing (DON), the DON acknowledged Resident 1 had arrived in the facility in poor condition and despite the physician had been made aware of Resident 1's refusal of care, medications, and assessments, no new interventions were identified or implemented to address Resident 1's continued refusals.During an interview on 6/9/2026 at 1:30 PM with the Administrator, the Administrator stated if Resident 1 continued to refuse his HIV medications, as well as other vital medications, his (Resident 1's) condition could worsen.During a review of the facility policy and procedures (P&P) titled Behavioral Health Services dated 1/2026, indicated the facility staff shall offer behavioral health services which includes necessary care for person-centered care and reflects resident's goals, preferences and choices, and maximizes the resident's dignity, autonomy, privacy, socialization, independence, and safety. When a resident is identified by the interdisciplinary team as requiring more intensive behavioral health services the team will make reasonable attempts to provide for and /or change such services. The types of services needed are clearly identified and care planned with strategies to obtain such services, and based on the individual assessment.

Based on observation, interview, and record review the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs for three of three sampled residents (Resident 21, Resident 37, and Resident 50) as evidenced by:Failing to create and implement a care plan for being Out on Pass ([NAME], taking a short, approved, temporary leave from the facility) for Resident 21 and Resident 50.Failing to create and implement a care plan for Resident 37's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device).These failures had the potential for Resident 21, Resident 37 and Resident 50 to receive inadequate care and/or supervision which could have affected the residents' quality of care and caused the residents' harm.Findings: 1. During a review of Resident 21's admission Record, the admission Record indicated the facility admitted the resident on 9/24/2025 with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), dementia (a progressive state of decline in mental abilities), and hypertension (HTN, high blood pressure). During a review of Resident 21's Order Recap Report, the Order Recap Report indicated the resident had a physician order dated 10/5/2025 that indicated the resident could go out on pass for therapeutic services (services aimed at healing, fixing, or managing a health issue) for four hours with family. During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool) dated 12/26/2025, the MDS indicated the resident had moderately impaired cognition (a slight decline in thinking and memory). The MDS indicated Resident 21 was independent with eating, oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 21's Release of Responsibility for Leave of Absence form, the form indicated the resident went out on pass on 1/17/2026, 1/20/2026, 1/29/2026, 2/2/2026, 2/9/2026, 2/14/2026, 2/21/2026, 2/26/26, 3/2/2025, 3/3/2026, 3/8/2026, 3/9/2026, 3/10/2026, and 3/15/2026. During an observation on 3/16/2026 at 11:50 AM, Resident 21's room was observed with the resident's bed made and call light laying on top of the bed. Resident 21 was not observed in the room. During an interview on 3/16/2026 at 12:30 PM with Licensed Vocational Nurse 5 (LVN 5), LVN 5 was assigned to take care of Resident 21. LVN 5 stated Resident 21 was out of the facility. LVN 5 stated Resident 21 usually went out of the facility with her granddaughter. During a concurrent interview and record review on 3/16/2026 at 1:35 PM with LVN 5, Resident 21's Care Plan Report was reviewed. LVN 5 stated Resident 21 did not have a care plan for being out of the facility on pass. LVN 5 stated Resident 21 should have had a care plan for being out on pass because the resident frequently went out of the facility with family. LVN 5 stated a care plan containing a plan of how to care for residents. LVN 5 stated the care plan guided the nursing staff on what to do and how to treat a resident's condition. LVN 5 stated a care plan for being out on pass had to have interventions on checking a resident's vital signs before they left the facility, verifying the resident was going out on pass with immediate family members, educating the resident and/or family on physician orders, and educating the resident and/or family on what to do in case of an emergency. LVN 5 stated that without a care plan for being out on pass, there was a potential Resident 21 would not be aware of what to do in case of an emergency while being out of the facility. During a concurrent interview and record review on 3/16/2026 at 2:20 PM with Registered Nurse 1 (RN 1), Resident 21's Care Plan Report was reviewed. RN 1 stated Resident 21 did not have a care plan for being out on pass. RN 1 stated Resident 21 should have had a care plan for being out on pass because the resident was frequently out on pass with her granddaughter. RN 1 stated the care plan was an outline of a resident's plan of care. RN 1 stated a care plan contained interventions that a resident was to receive for an identified concern or problem. RN 1 stated an out on pass care plan for Resident 21 should have contained interventions that prompted staff to review the resident's physician orders for being out on pass, to educate the resident and family about the expected return time, to educate the resident and family on what to do if the resident was returning to the facility late, to educate the resident on medication, and to educate the resident and family on what to do in case of an emergency. RN 1 stated Resident 21 potentially could have had a medical emergency if there was no care plan for being out on pass. During a concurrent interview and record review on 3/16/2026 at 3:08 PM with the Director of Nursing (DON), Resident 21's Care Plan Report was reviewed. The DON stated Resident 21 did not have a care plan for being out on pass. The DON stated Resident 21 should have had a care plan for being out on pass because the resident went out on pass with family almost every week. The DON stated a care plan was a resident specific plan of care that guided nursing staff on how to care for a resident's needs. The DON stated Resident 21's care plan for being out on pass should have had interventions that included the resident's physician order for being out on pass, educating the resident and family on the process for signing out of the facility, educating the resident and family on the facility's policy for being out on pass, and educating the resident and family on what to do in case of an emergency. The DON stated that without a care plan for being out on pass there was potential for the facility staff (in general) to not know the whereabouts of the Resident 21. The DON stated that without a care plan for being out on pass there was potential for Resident 21 to have a change of condition and not know what to do in case of an emergency. During an interview on 3/18/2026 at 10:02 AM with Resident 21, Resident 21 stated that she returned to the facility on 3/17/2026 after spending time outside with her granddaughter. Resident 21 stated that that staff (in general) had not informed her (Resident 21) of any time limitation when leaving the facility. Resident 21 stated no further education was provided to her or her granddaughter regarding expected return times. Resident 21 stated that when she would leave the facility, she did not take her prescribed medications with her, as neither she nor her granddaughter had access to them. Resident 21 stated that staff did not provide her medications for use while out of the facility and that she had not received instructions regarding medication administration during the time she was out on pass. During a review of Resident 50's admission Record, the admission Record indicated the facility initially admitted the resident on 4/5/2023, and readmitted on [DATE] with diagnoses that included necrotizing fasciitis( diabetes mellitus (a rare but extremely serious bacterial infection that spreads rapidly under the skin, destroying tissue, fat, and muscle), unspecified open wound left lower leg, muscle weakness(generalized),bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)unspecified, and schizophrenia(a mental illness that is characterized by disturbances in thought), unspecified. During a review of Resident 50's Order Summary Report dated 9/3/2024, the Order Summary Report indicated the resident could go OOP, not to exceed 4 hours for therapeutic purposes. During a review of Resident 50's Minimum Data Set (MDS, a resident assessment tool) dated 12/16/2025, the MDS indicated the resident was cognitively intact (ability to think, understand, and reason). The MDS indicated Resident 50 was independent for upper body dressing, putting on and/or taking off footwear, and had the ability to walk at least 150 feet. During a review of Resident 50's Wandering/Elopement Risk Evaluation dated 3/16/2026, the Wandering/Elopement Risk Evaluation indicated the resident had the ability to walk or self-propel off the premise without assistance. During an observation on 3/16/2026 at 10:29AM, Resident 50 was not in his room. During an interview on 3/16/2026 at 1:07PM, with Resident 50 in his room, Resident 50 stated he would go out on pass from the facility every day. During a concurrent interview and record review on 3/17/2026 at 10:47 AM, with Licensed Vocational Nurse (LVN) 1, Resident 50's Order Summary Report and complete Care Plan Report were reviewed. LVN 1 confirmed there was no care plan for Resident 50 for being out on pass from the facility. LVN 1 stated Resident 50 should have had a care plan in place for safety and education that would have been included in the interventions, and to ensure the interventions were being met. LVN 1 stated if there was no care plan the facility would not have known that the residents' needs were being met. During a concurrent interview and record review on 3/17/2026 at 2:55 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans dated 1/2026, was reviewed. The DON stated any licensed nurse or members of the interdisciplinary team (IDT, a collaborative group of diverse health care professionals from different fields who work together) could create a care plan. The DON stated a care plan was a way of communicating a plan of care for Resident 50 among staff by having interventions in place. The DON stated Resident 50 should have had a care plan for being out on pass from the facility as part of his psychosocial (the interaction between a person's emotional/mental health and their social environment) needs being met. The DON stated without a care plan facility staff would not know how to have cared for the resident. The DON stated having a care plan in place was part of facility policy. During a review of the facility's Policy and Procedure (P&P) titled Out On Pass Therapeutic Leave dated 1/2025, the P&P indicated This facility ensures that resident and/or their representatives, as applicable, are aware of the risks associated with leaving the facility and are provided with necessary information and support to make informed decisions prior to leaving. The interdisciplinary team completes a care plan for residents who choose to exercise their right for therapeutic leave, consistent with the resident's goals for care, and does not use therapeutic leave as a means of discharging the resident against their wishes or stated goals. During a review of the facility's P&P titled Develop-Implement Comprehensive Care Plans dated 1/2026, the P&P indicated The facility develops a person-centered comprehensive care plan that is culturally competent and trauma-informed, developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs.The comprehensive care plan describes: The services that are to be furnished are to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Any Services that are not provided due to the resident's exercise of right to refuse treatment.Based on the comprehensive assessment. Facility staff shall work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices, and goals during their stay at the facility. The facility establishes, documents, and implements the care and services provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences. 2. During a review of Resident 37's admission Record, the admission Record indicated the facility initially admitted the resident on 2/21/2023, and readmitted on [DATE] with diagnoses that included 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 caused by a blocked blood vessel in the brain) affecting the right dominant (stronger more skillful) side and left non-dominant (less used) side, dysarthria (a motor speech disorder that weakens control of the muscles used for speaking), facial weakness, dysphagia (difficulty swallowing), and muscle weakness. During a review of Resident 37's Order Summary Report dated 10/20/2025, the Order Summary Report indicated LALM with bolsters (raised, air-filled sides) for skin maintenance. During a review of Resident 37's Physician Progress Note dated 1/13/2026, the Physician Progress Note indicated Resident 37 was bedbound, and nodded to simple questions. During a review of Resident 37's Minimum Data Set (MDS, a resident assessment tool) dated 2/7/2026, the MDS indicated the resident had severe cognitive impairment (impaired ability to think, understand, and reason). The MDS indicated the resident had unclear speech and sometimes understood others and sometimes made self-understood. The MDS indicated Resident 37 was dependent on the staff (helper does all of the effort) for eating, oral (mouth) hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on and/or taking off footwear lying. The MDS indicated Resident 37 was at risk of developing pressure ulcers/injuries (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). The MDS indicated Resident 37 utilized a pressure reducing device for bed and was on a turning/repositioning program. During a concurrent interview and record review on 3/19/2026 at 11:46 AM, with Registered Nurse (RN) 1, Resident 37's Order Summary Report and Complete Care Plan Report were reviewed. RN 1 confirmed there was no care plan for Resident 37's use of a LALM for skin integrity. RN 1 stated the resident should have had a care plan for the LALM. RN 1 stated the interventions for the LALM would have included how to manage the LALM's maintenance and function, placing the LALM at the correct settings according to the medical doctor's orders. RN 1 stated care plans created an outline on how to care for the resident, and any licensed nurse could have created a care plan. RN 1 stated not having had a care plan for the LALM would not have aligned with the medical doctor's orders. During a concurrent interview and record review on 3/19/2026 at 11:57 AM, with the Director of Nursing (DON), Resident 37's Complete Care Plan Report was reviewed. The DON confirmed there was no care plan for the use of the LALM for skin integrity. The DON stated a care plan for the LALM should have been created to include interventions that would have included interventions to prevent pressure injuries and mattress settings. The DON stated any licensed nurse could have created a care plan and a care plan was a plan of care for Resident 37. During a review of the facility's policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans dated 1/2026, the P&P indicated Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs with seven days after the completion of the comprehensive assessment. The P&P indicated The comprehensive care plan describes the services that are to be furnished are to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated The interdisciplinary team, including the physician, a registered nurse, the resident or the resident's representative and other staff determined by the resident's needs will develop the care plan with corresponding interventions for care in accordance with professional standards of practice. The P&P indicated Care plans shall include the discipline providing care or services, measurable objectives, and timeframes to evaluate the resident's progress toward his/her goal(s).

Based on observations, interviews, and record reviews, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) prevention care consistent with professional standards of practice and per physician's orders for two of three sampled residents (Resident 12 and Resident 37) on Low Air Loss Mattresses (LALM, a specialized medical support surface designed to prevent and treat skin breakdown and pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence]). By failing to ensure the LALM's were set at the appropriate level. This failure had the potential for Resident 12 and Resident 37 to develop skin breakdown and/or pressure ulcers. Findings: During a review of Resident 12's admission record, the admission record indicated the facility re-admitted the resident on 5/4/2025 with diagnoses that included dementia (a progressive state of decline in mental abilities), reduced mobility, the need for assistance with personal care, contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right ankle, and flexion deformity (a condition where a joint becomes stiff and stuck in a bent position) of the left and right hip. During a review of Resident 12's Order Summary Report, the Order Summary Report indicated the resident had an active physician's order dated 12/1/2025 for a LALM for skin management. During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 1/20/2026, the MDS indicated the resident had severely impaired cognition (a profound decline in mental abilities such as memory, reasoning, and awareness that significantly hinders daily functioning and independence). The MDS indicated Resident 12 was dependent on help for oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 12 was at risk of developing pressure ulcers. The MDS indicated Resident 12 utilized a pressure reducing device for bed. During a review of Resident 12's Care Plan Report dated 1/26/2026, the Care Plan Report indicated the resident required the use of a LALM to relieve pressure and support the maintenance of skin integrity. The Care Plan Report indicated Resident 12 was at high risk of developing pressure ulcers which necessitated special pressure-reducing care. The Care Plan Report indicated a goal for Resident 12 was to have a reduced risk of the development of pressure injuries. The Care Plan Report indicated interventions that included ensuring Resident 12's LALM was in place, plugged in, and functioning properly. During a concurrent observation and interview on 3/16/2026 at 10:42 AM, with Licensed Vocational Nurse 3 (LVN 3), in Resident 12's room, Resident 12's was observed on a Serene Air LALM. Resident 12's LALM was observed to be off and deflated. LVN 3 stated Resident 12's LALM should have been turned on and placed on the second setting. LVN 3 stated he did not know how long Resident 12's LALM was turned off. LVN 3 stated the LALM had to be turned on to function properly. LVN 3 stated Resident 12 was on a LALM for skin management. LVN 3 stated Resident 12 was at risk of developing pressure ulcers. LVN 3 stated there was a potential for Resident 12 to develop skin breakdown (damage to the skin and underlying tissue, ranging from red, irritated skin to deep, open wounds/bedsores) if the LALM was not turned on and not functioning. Resident 12's LALM was observed to inflate after LVN 3 turned the resident's LALM on. During an interview on 3/19/2026 at 7:51 AM with Treatment Nurse 1 (TN 1), TN 1 stated Resident 12 was at a high risk of developing pressure ulcers. TN 1 stated Resident 12 was on a LALM to help maintain the resident's skin integrity. TN 1 stated because Resident 12's LALM was off for an unknown period of time, there was potential for Resident 12 to develop skin breakdown or a pressure ulcer. TN 1 stated Resident 12's LALM had to be turned on to ensure the LALM was functioning properly. During an interview on 3/19/2026 10:03 AM with the Director of Nursing (DON), the DON stated Resident 12 was using a LALM for skin maintenance. The DON stated Resident 12 was at high risk of developing pressure ulcers. The DON stated she did not know how long Resident 12's LALM was turned off. The DON stated Resident 12's LALM had to be turned on to function. The DON stated there was potential for Resident 12 to experience skin breakdown if the resident's LALM was off and not functioning for a long period of time. During a review of Resident 37's admission Record, the admission Record indicated the facility initially admitted the resident on 2/21/2023, and readmitted on [DATE] with diagnoses that included 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 caused by a blocked blood vessel in the brain) affecting the right dominant (stronger more skillful) side and left non-dominant (less used) side, dysarthria (a motor speech disorder that weakens control of the muscles used for speaking), facial weakness, dysphagia (difficulty swallowing), and muscle weakness (generalized). During a review of Resident 37's Order Summary Report dated 10/20/2025, the Order Summary Report indicated an active order for LALM with bolsters (raised, air-filled sides) for skin maintenance. During a review of Resident 37's Physician Progress Note dated 1/13/2026, the Physician Progress Note indicated Resident 37 was bedbound, and nodded to simple questions. During a review of Resident 37's Minimum Data Set (MDS, a resident assessment tool) dated 2/7/2026, the MDS indicated the resident had severe cognitive impairment (impaired ability to think, understand, and reason). The MDS indicated the resident had unclear speech and sometimes understood others and sometimes made self-understood. The MDS indicated Resident 37 was dependent on the staff (helper does all of the effort) for eating, oral (mouth) hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on and/or taking off footwear lying. The MDS indicated Resident 37 was at risk of developing pressure ulcers/injuries (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). The MDS indicated Resident 37 utilized a pressure reducing device for bed and was on a turning/repositioning program. During a review of Resident 37's Weights and Vitals Summary, the Weights and Vitals Summary indicated the resident weighed 97 pounds (lbs., a unit of weight) on 3/2/2026. During an observation in Resident 37' room on 3/16/206 at 12:06PM, Resident 37 was observed lying in bed, and awake. Resident 37's LALM was observed to be on and set to a range of 105-140 pounds. During a concurrent observation and interview on 3/17/2026 at 2:03 PM, with Treatment Nurse (TN)1, in Resident 37's room, Resident 37 was observed on a microAir 65 LALM with settings set between 105 and 140 lbs. TN1 confirmed Resident 37's LALM settings were set at 105 to 140 lbs. TN1 stated the LALM settings were based on a residents' weight (in general). TN1 verified Resident 37's weight in the medical record and stated Resident 37 weight was 97 lbs. on 3/2/2026. TN1 stated Resident 37's LALM was not at the correct setting and should have been set at the range from 70 to 105 lbs. TN1 stated if the LALM was at the wrong setting it would place Resident 37 at risk for skin issues, skin breakdown and would not be doing its (LALM's) therapeutic intervention by not distributing pressure correctly. During a concurrent interview and record review on 3/17/2026 at 3:01 PM, with the Director of Nursing (DON), the user manual titled MicroAir MA65 Alternating Pressure On-Demand Low Air Loss System dated 2011, was reviewed. The DON stated a LALM was set based on resident weight. The DON stated a LALM was used for the prevention of skin injuries. The DON stated Resident 37's LALM should have been at the setting with the range of 70 to 105 lbs. according to his weight of 97lbs, not at the weight setting range of 105 and 140lbs. The DON stated the incorrect setting put Resident 37 at risk for a pressure injury and was not providing the therapeutic benefit of the LALM. During a review of the LALM manufacturer guidelines titled Serene Air User's Manual dated 2019, the manufacturer guidelines indicated Press On to turn on the unit.The power switch on the side of pump must be turned on.General Operation: Switch on the main power switch found from the side of the pump and press the on button on the control panel to turn on the power. During a review of the user manual titled microAir MA65 Alternating Pressure On-Demand Low Air Loss System dated 2011, the user manual indicated .provides a guide to the caregiver to set approximate comfort pressure level depending on the patient weight. During a review of the facility's policy and procedure (P&P) titled, Low Air Loss Mattresses dated 1/2026, the P&P indicated Low Air Loss Mattresses: Designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown. The P&P indicated Low air loss mattress therapy maintains peripheral circulation by distributing the patient's weight over several low-pressure mattress sections. The P&P indicated For.settings and care, the facility shall follow the manufacturers' guidelines.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for one of five sampled residents (Resident 81) by failing to ensure Resident 81's bed was not left in a high position. This failure had the potential to increase Resident 81's risk for falls and injury such as broken bones. Findings:During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted Resident 8 on 4/14/2023 and readmitted Resident 8 on 3/12/2026 with diagnoses that included acute systolic congestive heart failure (a sudden, severe weakening of the heart's main pumping chamber meaning it cannot squeeze hard enough to push blood out to the body), muscle weakness, anemia (a condition where the body does not have enough healthy red blood cells), morbid obesity due to excess calories (a chronic condition where excessive calorie intake leads to extreme weight gain, typically 100 or more pounds over ideal weight), hemiplegia (paralysis - the loss of voluntary muscle function in part or most of the body, making it impossible to move affected areas) and hemiparesis (weakness) followed unspecified cerebrovascular disease (stroke or blood vessel issue in the brain occurred, but the specific cause is not detailed) affecting left non-dominant side, type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on supplemental oxygen (person's lungs cannot take in enough oxygen from the air to keep their blood oxygen levels healthy requiring a machine or tank to provide extra oxygen) and dementia (a progressive state of decline in mental abilities). During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool) dated 12/24/2025, the MDS indicated Resident 8 usually had the ability to understand others and usually had the ability to make herself (Resident 8) understood. The MDS indicated Resident 8 was dependent (helper does all of the effort and resident does none of the effort to complete the activity) for toileting, shower/bathing, upper/lower body dressing, putting on/taking off footwear (shoes and socks), personal hygiene (combing hair, applying makeup, washing/drying face and hands), transferring from bed to chair, and getting in/out of a tub/shower. The MDS indicated Resident 8 needed substantial/maximal assistance (helper does more than half of the effort) for rolling left and right in bed, sitting on the side of the bed to lying flat on the bed, and going from lying on the back to sitting on the side of the bed. During a review of Resident 8's Fall Risk Evaluation, dated 3/12/2026, the Fall Risk Evaluation indicated Resident 8 was at high risk for fall. During a review of Resident 8's Care Plan Report dated 3/13/2026, the Care Plan Report indicated Resident 8 was at risk for falls related to gait (a person's particular manner or style of walking)/balance problems, history of falls, poor safety awareness. The Care Plan Report indicated the goal was to minimize the risks of falls and injuries. During a review of Resident 8's Care Plan Report dated 3/13/2026, the Care Plan Report indicated Resident 8 was at risk for falls related to gait/balance, incontinence (the involuntary or accidental leakage of urine or poop due to a loss of bladder or bowel control), unaware of safety needs. The Care Plan Report indicated interventions to keep the furniture locked in position and to avoid repositioning furniture. During a review of Resident 8's History and Physical (H&P) dated 3/14/20226, the H&P indicated Resident 8 had decisional capacity (a person's ability to understand, reason through, and make a specific medical or personal decision at a particular time). The H&P indicated Resident 8 was taking Eliquis (a prescription blood thinner). During an observation on 3/16/2026 at 11:05 AM in the hallway outside of Resident 8's room, a star (sticker) was observed next to Resident 8's name on the wall outside of Resident 8's room indicating Resident 8 was a high risk for fall. Licensed Vocational Nurse 1 (LVN 1) was observed exiting Resident 8's room. During a concurrent observation and interview on 3/16/2026 at 11:06 AM with Resident 8 in Resident 8's room, Resident 8's bed was observed to be set to a high position. Resident 8 stated she (Resident 8) did not put the bed in high position. During a concurrent observation and interview on 3/16/2026 at 11:08 AM with Certified Nurse Assistant 5 (CNA 5) and LVN 1, in Resident 8's room, Resident 8's bed was observed to be set to a high position. CNA 5 stated Resident 8's bed was in a high position since Resident 8 had therapy at 10:30 AM. LVN 1 stated he (LVN1) went into Resident 8's room to give Resident 8's roommate pain relief medication. LVN 1 stated he (LVN 1) should have lowered Resident 8's bed to a low position after giving Resident 8's roommate pain medication because Resident 8 was a high fall risk. During an interview on 3/17/2026 at 8:31 AM with Registered Nurse 1 (RN 1), RN 1 stated Resident 8 was a high fall risk, and the facility should have placed Resident 8's bed in a low position to prevent injury from a potential fall. RN 1 stated LVN 1 should have lowered Resident 8's bed on 3/16/2026 when LVN 1 was in the room when Resident 8's bed was set in a high position. During an observation on 3/17/2026 at 2:54 PM, in Resident 8's room, Resident 8's bed was observed to be in a raised (high) position. During a concurrent observation and interview on 3/17/2026 at 3:10 PM, in Resident 8's room, with the Director of Nursing (DON), Resident 8's bed was observed to be in a high position. The DON stated Resident 8's bed was slightly high. During a concurrent interview and record review on 3/17/2026 at 3:14 PM with the DON, the facility's Free of Accident Hazards/supervision/devices policy and procedure (P&P) dated 1/2025 was reviewed. The DON stated Resident 8 was at risk for fall and a factor that could result in Resident 8 having a fall was an incorrect bed height. The DON stated the P&P indicated factors that may result in resident falls but were not limited to incorrect bed height and/or width. During a review of the facility's P&P titled, Falling Star Program, dated 5/2022, indicated Residents identified with history of fall prior to admission and residents with a fall/multiple falls in the facility shall participate in the falling star program. The P&P indicated The Falling Star Program champion (DON) shall ensure that the program is implemented, monitored & sustained. During a review of the facility's P&P titled, Fall Management Program, dated 1/2025, the P&P indicated The facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls and to provide an environment which remains as free from accident hazards as possible. The P&P indicated Avoidable Accident: An accident which occurred because the facility failed to:identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or Evaluate and analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; and/or Implement interventions, including adequate supervision and assistive devices (any tools, equipment, or software designed to help people with disabilities or age-related challenges live more independently), consistent with a resident's needs, goals, care plan, and current professional standards of practice to eliminate the risk, if possible, and, if not, reduce the risk of on occident; and/or Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. During a review of the facility's P&P titled, Fall Management Program, dated 1/2025, the P&P indicated a definition of Hazards: Elements of the resident (in general) environment that have the potential to cause injury or illness. The P&P indicated a definition of Risk: To any external factor, facility characteristic (e.g., staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident. The P&P indicated The facility educates employees at the time of hire, annually and as indicated on the facility policy Fall Management, included interventions to reduce injury and [NAME] related accidents.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in accordance with professional standards to ensure food service safety by failing to: -Discard of expired chlorine (a powerful chemical cleaner/disinfectant used to kill germs) test strips (small, paper-based tools used primarily in commercial settings to measure the concentration of sanitizing chemicals in the final rinse cycle) used to monitor the chlorine chemical level in the facility' s dishwasher. -Discard of expired food items. -Properly labeled food items with a use by date (the last day a product should be consumed). -Label nine of ten drums of water containers. These failures had the potential to result in foodborne illness (food poisoning-illness from eating contaminated food containing bacteria[germs), and salmonella (a type of bacteria that causes a food-poisoning illness) which could lead to medical complications.Findings: During a concurrent observation and interview on 3/16/2026 at 8:49AM with the Dietary Supervisor inside the kitchen, the following were observed: 1. One open bottle of chlorine test paper strips with an expiration date of 11/2025. 2. One opened container of pickle relish not indicating a use by or expiration date. 3. One opened container of cherries not indicating a use by or expiration date. 4.One opened bottle of caramel sauce that had a use by date of 12/17/2025 on the label and an opened date of 3/8/2026 marked on the bottle. 5.One turkey sandwich that had a use by date of 3/14/2026 marked on the label. 6.One opened bag of tortillas that had a use by date of 2/28/2026. 7. One opened plastic bag of chicken that had a use by date of 3/9/2026. 8.One opened plastic bag of gelatin that had a use by date of 2/25/2026. 9.One opened plastic bag of white bread with an open date of 3/8/2026 and no use by date. During a concurrent interview of the kitchen with the DS on 3/16/2026 at 8:49AM, the DS stated that using expired chlorine test strip to check the level of the chemical ran the risk of having an inaccurate reading and could cause cross contamination (the transfer of harmful bacteria from one substance or object to another), and food borne illnesses. The DS stated the staff (in general) would not know if the dishwasher was sanitizing (lowering the number of germs on surfaces or objects to safe levels to prevent the spread of infection, often accomplished by using chemicals or heat) the dishes properly and residents (in general) could become ill. The DS stated residents (in general) could get sick if the residents (in general) would eat expired food items. The DS stated food items that were opened and not labeled with an expiration date or use by date, should have been discarded for safe practice. The DS stated without a label indicating an expiration date or use by date, kitchen staff (in general) would not know how long the food was good for. The DS stated the first kitchen staff member (unidentified) who opened the food item including himself should have checked for: the expiration date, the use by date, and should have labeled the food item with an open date and a use by date. The DS stated expired chicken could contain salmonella and could cause food poisoning. The DS stated expired food items should have been thrown away, residents may get sick and get food poisoning. During an interview on 3/18/2026 at 2:34 PM, with the Director of Nursing (DON), the DON stated if expired chemical test strips were used for the dishwasher there would be an incorrect reading, which would potentially result in bacteria (germs) not to be killed on everything that was being washed in the dishwasher. The DON stated residents (in general) could have gotten sick if they (residents) were served and ate expired food and could develop food poisoning. The DON stated it was the expectation that kitchen staff (in general) would check the expiration date for food items prior to use. The DON stated if residents (in general) were served chicken that was beyond the use by date, they could get sick, gotten food poisoning, and could have diarrhea since chicken contained salmonella and the facility had immune compromised (weakened immune system) residents. The DON stated it was not up to the residents to check the expiration date of their food. During a review of the facility's policy and procedure (P&P) titled, Washing and Sanitizing-Dietary dated 1/2026, the P&P indicated Improper test strips yield inaccurate results when testing for chemical sanitation. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage dated 1/2026, the P&P indicated .staff must inspect.ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated. The P&P indicated . removing foods not safe for consumption, .and rotating supplies. The P&P indicated .labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded During a review of the facility's policy and procedure (P&P) titled, Food and Nutritional Services Equipment and Supplies dated 1/2026, the P&P indicated Spoiled or contaminated food shall not be stored or served. During an observation on 3/18 /2026 at 8:25 AM at facility's parking lot storage shelves, there were ten drums of water containers. One drum was labeled with Treatment date 12/12/2025 and nine drums were not labeled. During a concurrent observation and interview on 3/18 /2026 at 9 AM, with Maintenance Supervisor (MS), at the facility's parking lot storage shelves, ten drums of water were on the shelves. The MS stated the ten emergency water drums were designated potable water for staff (in general) and residents' (in general) consumption for drinking and kitchen use for food preparation and cooking. The MS stated the water was treated once a year to stay potable. The MS stated one drum was labeled with treatment date indicating it was a potable supply. The MS stated the facility did not label nine drums with treatment date to indicate water inside the drums were potable. The MS stated the nine drums should have been labeled to identify if the water was safe for consumption. The MS stated unlabeled drums could be consumed and potentially expose residents (in general) and staff (in general) to harmful bacteria. During a concurrent interview and record review on 3/18 /2026 at 9:13 AM with the MS, the facility's Emergency Water Supply log was reviewed. The MS stated the log indicated ten total drums were treated and stored on 12/12/2025 however the log did not identify each individual drum to ensure correlation between the documented treated water drums and the actual drums observed. The MS stated the drums one to ten should have been individually logged with treatment date and drums two to ten observed should have been individually labeled with treatment date to ensure the ten drums were potable emergency water supply. During an interview on 3/18/2026 at 3:05 PM, with the Infection Preventions (IP), the IP stated emergency potable water supplies were available to all residents (in general) and staff (in general). The IP stated emergency water supplies were intended for drinking water, cooking, and food preparation as needed. The IP stated that unlabeled emergency water containers did not ensure the water was safe for consumption and, if distributed, could potentially expose residents (in general) and staff (in general) to microorganisms, which may result in symptoms such as diarrhea, nausea, vomiting and stomach pain. During a concurrent interview and review on 3/19/2026 at 9:26 PM with the DON, photos of unlabeled potable water drum supplies were reviewed. The DON stated emergency potable water supplies were for drinking water and food preparation. The DON stated potable water supplies were free from bacteria and safe for consumption. The DON stated the water supply should be labeled in a way it indicated safe potable water supply. The DON stated the photos indicated one drum was labeled and nine drums were not labeled. The DON stated it would be unsafe to distribute water from unlabeled emergency water drums for consumption. The DON stated if water was provided from unlabeled containers, residents and staff may potentially consume contaminated water, leading to symptoms of stomach pain, diarrhea and vomiting. During a review of the facility's policy and procedure (P&P) titled Maintenance Services-Water Supply, last reviewed on 1/2026, the P&P indicated the purpose is to ensure a continuous, safe and potable water supply for resident care, sanitation, and facility operations in compliance with regulatory standards.

Based on interview and record review the facility failed to ensure the Interdisciplinary Team (IDT, a collaborative group of healthcare professionals-including nurses, physicians, therapists, social workers, and dietitians-who work together to create and implement personalized care plans) and public patient representative (a trained advocate who acts for long-term care residents lacking decision-making capacity and family, ensuring their wishes or best interests are represented in medical decisions) convened (to come and bring together for a meeting) when one of five sampled residents (Resident 42) did not have the capacity to (the ability to use and understand information to make a decision and communicate any decision made) to provide an informed consent (voluntary agreement to accept treatment after receiving education regarding the risks, benefits, and alternatives to the treatment) for the treatment of Quetiapine Fumarate (Seroquel, a medication used to treat the symptoms of schizophrenia, a mental illness that is characterized by disturbances in thought). This failure had the potential to result for Resident 42 to receive unnecessary psychotropic (medication that affects mood, thoughts, behaviors, or perceptions) which could cause adverse side effects (an undesired, harmful, or unexpected reaction to a medication).Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility re-admitted the resident from the General Acute Care Hospital (GACH) on [DATE] with diagnoses that included hepatic encephalopathy (brain dysfunction caused by advanced liver disease or failure), schizophrenia, dementia (a progressive state of decline in mental abilities), and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality). The admission Record indicated Resident 42 was self-responsible and under the IDT. During a review of Resident 42's Psychotherapeutic Drug Informed Consent Form dated [DATE], the Psychotherapeutic Drug Consent Form indicated a signature to verify the consent for Seroquel 25 milligrams (a unit of mass) three times a day for psychosis could not be obtained from the resident. The Psychotherapeutic Drug Informed Consent Form indicated the Assistant Director of Nursing (ADON) signed and confirmed that Resident 42 gave consent to treatment with Seroquel 25 mg three times a day for psychosis. During a review of Resident 42's History and Physical (H&P) dated [DATE], the H&P indicated the resident was not decisional. During a review of Resident 42's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated [DATE] for Seroquel 25 mg one tablet by mouth three times a day for psychosis manifested by aggressive behavior as evidenced by striking out at staff. During a review of Resident 42's Medication Administration Record (MAR) dated [DATE] to [DATE], the MAR indicated the resident received nine doses of Seroquel 25 mg. During a review of Resident 42's Medication Administration Record (MAR) dated [DATE] to [DATE], the MAR indicated the resident received 84 doses of Seroquel 25 mg. During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated the resident had severely impaired cognition (a profound decline in mental abilities such as memory, reasoning, and awareness that significantly hinders daily functioning and independence). The MDS indicated Resident 42 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completed activity) for eating and oral hygiene. The MDS indicated Resident 42 required partial/moderate assistance (helper does less than half the effort) for upper body dressing. The MDS indicated Resident 42 was dependent on help for showering/bathing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 42 was taking antipsychotic (medication used to treat psychosis) medication. During a review of Resident 42's Medication Administration Record (MAR) dated [DATE] to [DATE], the MAR indicated the resident received 54 doses of Seroquel 25 mg. During a review of Resident 42's IDT Progress Notes for Behavior Management dated [DATE] at 1:05 PM, the IDT Progress Notes for Behavior Management indicated the Psychiatric Nurse Practitioner (PNP) evaluated the resident and did a comprehensive review of the resident's current medication regimen. The IDT Progress Note for Behavior Management indicated the decision was made to persist with the current medication regimen as it appeared to be successfully managing the resident's symptoms and improving the resident's overall well-being. The IDT Progress Note for Behavior Management indicated the care team would continue monitoring Resident 42's progress and reassess the resident as needed in future follow-ups. During a concurrent interview and record review on [DATE] at 11:25 AM with Licensed Vocational Nurse 3 (LVN 3), Resident 42's Psychotherapeutic Drug Informed Consent Form dated [DATE] was reviewed. LVN 3 stated Resident 42 was oriented only to self and did not have the capacity to make decisions. LVN 3 stated Resident 42 had a physician order for Seroquel 25 mg three times a day. LVN 3 stated Resident 42 did not sign the Psychotherapeutic Drug Informed Consent Form dated [DATE], and indicated the form was signed by a licensed nurse (unidentified). LVN 3 stated that in the event a resident did not have the capacity to make decisions, the decision was handled by the IDT. LVN 3 stated the ADON and Social Services Director (SSD) were part of the IDT. During an interview on [DATE] at 9:39 AM with the Social Services Director (SSD), the SSD stated she (the SSD) was part of the IDT. The SSD stated she (SSD) was familiar with Resident 42. The SSD stated Resident 42 was confused and oriented only to self. The SSD stated Resident 42 did not have any family. The SSD stated Resident 42 did not have the capacity to make decisions. The SSD stated that when a resident (in general) did not have the capacity to make decisions, the decision was determined by the IDT. The SSD stated that in addition to the IDT the facility could also contact the patient representative hotline to help make decisions for Resident 42. The SSD stated the patient representative hotline was not contacted to discuss Resident 42 taking Seroquel. The SSD stated she (SSD) was not sure if Resident 42 had an IDT for behavioral management when he (Resident 42) returned from the GACH on [DATE]. During a concurrent interview and record review on [DATE] at 11:50 AM with the ADON, Resident 42's Psychotherapeutic Drug Informed Consent Form dated [DATE] and IDT Progress Note for Behavioral Management dated [DATE] were reviewed. The ADON stated she (the ADON) signed Resident 42's Psychotherapeutic Drug Informed Consent Form dated [DATE] for Seroquel 25 mg three times a day for psychosis. The ADON stated Resident 42 could not sign the Psychotherapeutic Drug Informed Consent Form because the resident did not have the capacity to make decisions. The ADON stated that when a resident (in general) did not have family, did not have a responsible party, and did not have the capacity to make decisions, the IDT could step in to help make decisions for the resident (in general). The ADON stated an IDT for behavioral management was not done when Resident 42 was re-admitted to the facility on [DATE]. The ADON stated an IDT for behavioral management should have been done to discuss Resident 42's change in capacity before she (the ADON) signed the resident's consent form for Seroquel. The ADON stated that the patient representative should have also been contacted for Resident 42. The ADON stated there was a potential for Resident 42 to experience unnecessary adverse side effects from psychotropic medication if the IDT and patient representative did not discuss if the resident should be on Seroquel. During an interview on [DATE] at 12:09 PM with the Director of Nursing (DON), the DON stated Resident 42 did not have the capacity to make decisions because the resident was confused and oriented only to self. The DON stated Resident 42 did not have any family. The DON stated Resident 42 was taking Seroquel 25 mg three times a day for psychosis. The DON stated consent was needed from Resident 42 to receive Seroquel but stated that because Resident 42 did not have the capacity to provide consent, the IDT should have reviewed the resident's medication and treatment options. The DON stated that when Resident 42 returned from the GACH on [DATE] the resident should have had an IDT for behavioral management to discuss Resident 42's lack of capacity before Resident 42 started taking Seroquel. The DON stated that the patient representative could have also been contacted to help make decisions for Resident 42. The DON stated there was a potential for Resident 42 to receive medication that was not needed if the IDT did not meet to discuss the resident taking Seroquel. During a review of the facility's Policy and Procedure (P&P) titled Dignity and Respect Psychoactive Medications dated 1/2026, the P&P indicated Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative shall be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. The resident's medical record shall include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternative that he or she preferred. The facility has written consent form which may serve as evidence of a resident's consent to psychotropic medication; and may have other documented evidence of the resident's consent or decline to treatment. During a review of the facility's P&P titled Informed Consent dated 1/2026, the P&P indicated In cases where the resident does not have the capacity to make decisions and there is no surrogate decision maker, the interdisciplinary team will: Review the physician's documentation of the resident and pertinent health information in the medical record. Review the medication intervention as outlined by the physician or designated licensed health professional. In collaboration with the primary care physician and Ombudsman: Discuss the resident desires, if known, through past conversations, interviews and discussions with family and friends. Review the type of medical intervention. Discuss the impact to the resident if the intervention was withheld. Discuss if there are any alternative interventions that could be discussed with the physician or licensed healthcare professional. Reach a decision and obtain physician orders if pertinent. The interdisciplinary team (IDT) will develop individualized care plans for the resident including resident condition, goals, and interventions, non-pharmacological interventions prior to administration, and target behaviors. The IDT will reevaluate the resident's condition at least once in every quarter for any changes in the resident's physical, mental, emotional and psychosocial well-being. During a review of the California Department of Aging Website dated 1/2026, the California Department of Aging Website indicated The Office of the Long-Term Care Patient Representative (OLTCPR) provides trained public representatives for specified long-term care residents who may need medical treatment but lack decision-making capacity and have no legally authorized surrogate.Under California Health and Safety Code S 1418.8, skilled nursing and intermediate care facilities may convene an interdisciplinary team (IDT) to make medical decisions for these residents. As of [DATE], facilities are required to include patient representatives on the IDT. If the facility cannot find a suitable person-such as a friend or family member-OLTCPR provides a trained public patient representative to help ensure the resident's rights, preferences, and dignity are supported in medical decision-making. Retrieved from: https://aging.ca.gov/providers_and_partners/office_of_the_long-term_care_patient_representative/

Based on observation, interview, and record review the facility failed to ensure one of one sampled residents (Resident 12) was free from physical restraint (any physical, chemical, or mechanical device or method used to limit a patient's movement or restrict their freedom of movement, typically to prevent harm to themselves or others) as evidenced by placing Resident 12's bed against the wall without an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the resident's Responsible Party (RP, a specific individual or entity legally accountable for making healthcare decisions if the resident is unable to). This failure had the potential to affect Resident 12's dignity and result in the entrapment (an event in which a resident is caught, trapped, or entangled in the space) of the resident.Findings:During a review of Resident 12's admission Record, the admission Record indicated the facility re-admitted the resident on 5/4/2025 with diagnoses that included dementia (a progressive state of decline in mental abilities), reduced mobility, the need for assistance with personal care, contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right ankle, and flexion deformity (a condition where a joint becomes stiff and stuck in a bent position) of the left and right hip. During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 1/20/2026, the MDS indicated the resident had severely impaired cognition (a profound decline in mental abilities such as memory, reasoning, and awareness that significantly hinders daily functioning and independence). The MDS indicated Resident 12 was dependent on help for oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 12 did not use restraints. During a review of Resident 12's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 1/26/2026 that indicated the resident may have the bed against the wall for safety every shift. During a review of Resident 12's Care Plan Report dated 2/10/2026, the Care Plan Report indicated the resident was at risk for falls related to confusion, incontinence (involuntary loss of control over bladder (urinary) or bowel (fecal) functions), poor communication/comprehension, and being unaware of safety needs. The Care Plan Report indicated a goal to minimize Resident 12's risk of injury from falls. The Care Plan Report indicated interventions that included keeping Resident 12's bed low with the bed against the wall for safety. During a concurrent observation and interview on 3/16/2026 at 10:42 AM, with Licensed Vocational Nurse 3 (LVN 3), in Resident 12's room, Resident 12's was observed lying in bed with a bed alarm (a tool that alerts caregivers when a person sits up or leaves their bed) and the right side of the bed against the wall. LVN 3 stated Resident 12's bed was against the wall to prevent the resident from falling out of bed. LVN 3 stated the bed against the wall could be considered a restraint, but indicated the facility had consent from Resident 12's RP to place the resident's bed against the wall. During an interview and record review on 3/18/2026 at 10:01 AM with Registered Nurse 1 (RN 1), Resident 12's informed consents (in general) were reviewed. RN 1 stated there was no informed consent for Resident 12's bed being against the wall from the resident's RP. RN 1 stated Resident 12 had a physician order for the bed to be against the wall for safety. RN 1 stated that Resident 12's bed was against the wall because the resident was at risk of falling. RN 1 stated Resident 12 was not alert or oriented (lacked awareness of their surroundings, current time, and/or identity) and had fallen out of bed in the past. RN 1 stated informed consent for the bed to be against the wall should have been obtained from Resident 12's RP because it could potentially limit the resident's movement. During a telephone interview on 3/19/2026 at 8:13 AM with RP 1, RP 1 stated she was responsible for making decisions for Resident 12. RP 1 stated she (RP1) was not informed that Resident 12's bed was placed against the wall prior to 3/18/2026. RP 1 stated she (RP1) was not informed of the reasoning, risks, or benefits of having Resident 12's bed against the wall prior to 3/18/2026. During an interview on 3/19/2026 at 10:04 AM with the Director of Nursing (DON), the DON stated Resident 12's bed was against the wall for safety because the resident was at risk of falls. The DON stated Resident 9 would occasionally slide around in bed. The DON stated the nursing staff did not want to risk the resident falling off the bed. The DON stated the facility did not have an informed consent from Resident 12's RP for the bed being against the wall. The DON stated the RP should have been informed of the risk and benefits that involved having Resident 12's bed pushed against the wall. The DON stated informed consent should have been obtained for a bed against the wall because it could potentially restrict Resident 12's movement. During a review of the facility's Policy & Procedure (P&P) dated 1/2026, the P&P indicated The following practices shall be considered a physical restraint including, but not limited to placing a chair or bed close enough to a wall that the resident is prevented from risking out of the chair or voluntarily getting out of bed.Physical restraints may increase the risk of one or more of the following.Accidents such as falls, strangulation, or entrapment. Psychosocial impact related to the use of physical restraints may include one ore more of the following.loss of dignity, self-respect, and identity.feelings of imprisonment or restriction of freedom of movement.The licensed nurse shall obtain a physician's order for the use and specific type of restraint.Residents, or the resident representatives, may refuse the use of a restraint, even when medically warranted to treat a medical symptoms. During a review of the facility's P&P dated 1/2026, the P&P indicated It is the responsibility of the prescribing physician, or approved licensed healthcare provider, to personally examine and obtain a written informed consent, whereby applicable and indicated by state and federal regulations, from a resident or their representative for the use of physical restraints.

Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) for one of five sampled residents (Resident 81) was accurately completed. This failure had the potential to result in a delay in the necessary care and treatment for Resident 81.Findings:During a review of Resident 81's admission Record, the admission Record indicated the facility admitted Resident 81 on 2/9/2017 and readmitted Resident 81 on 11/5/2025 with diagnoses that included other reduced mobility, muscle weakness, dementia (a progressive state of decline in mental abilities), hemiplegia (paralysis - the loss of voluntary muscle function in part or most of the body, making it impossible to move affected areas) and hemiparesis (weakness) followed unspecified cerebrovascular disease (stroke or blood vessel issue in the brain occurred, but the specific cause is not detailed) affecting left non-dominant side and major depressive disorder, recurrent, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 81's History and Physical (H&P) dated 1/29/2026, the H&P indicated Resident 81 could make her (Resident 81) needs known but could not make medical decisions. During a review of Resident 81's MDS dated [DATE], the MDS indicated Resident 81 usually could make herself (Resident 81) understood and usually had the ability to understand others. The MDS indicated the facility did not check the box for Depression under Section I - Active Diagnosis. During a review of Resident 81's Order Summary Report dated 3/19/2026, the Order Summary Report indicated an order for Escitalopram Oxalate (a prescription antidepressant that helps treat depression and anxiety) 5 mg (milligrams - metric unit of measurement, used for medication dosage and/or amount) - Give 1 tablet by mouth one time a day for Depressive d/o (disorder - disruption of normal, healthy functioning in the body) m/b (manifested by - shown by) verbalization (putting into words) sadness. During a concurrent interview and record review on 3/19/2026 at 8:47 AM with the MDS Licensed Vocational Nurse (MDS 1), Resident 81's admission Record was reviewed. MDS1 stated Resident 81's admission Record indicated Resident 81 had a diagnosis of major depressive disorder. MDS 1 stated Resident 81 had a diagnosis of major depressive disorder. During a concurrent interview and record review on 3/19/2026 at 8:47 AM with MDS 1, Resident 81's MDS dated [DATE] was reviewed. MDS1 stated Resident 81's MDS indicated the facility did not check the box for depression in Section I. MDS 1 stated the MDS was not accurate because the diagnosis of depression was missing. MDS 1 stated the MDS should be accurate so the facility could appropriately create a care plan for Resident 81. During a concurrent interview and record review on 3/19/2026 at 9:05 AM with the Assistant Director of Nursing (ADON), Resident 81's MDS dated [DATE] was reviewed. The ADON stated the MDS indicated the facility did not check the box for depression in Section I. The ADON stated the MDS was not accurate because the diagnosis of depression was missing. The ADON stated the MDS should be accurate so the facility could appropriately create a care plan for Resident 81. During a concurrent interview and record review on 3/19/2026 at 9:52 AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Accuracy of Assessments, dated 1/2026 was reviewed. The DON stated the MDS needed to be accurate because the facility used the MDS for Resident 81's care planning. The DON stated the P&P indicated Accuracy of Assessments P&P indicated the P&P's intent was to ensure each resident (in general) receives an accurate assessment, reflective of the resident's (in general) status at the time of the assessment by staff qualified to assess relevant care areas and are knowledgeable about the resident's (in general) status, needs, strengths, and areas of decline. The Accuracy of Assessments P&P indicated a guideline of the assessment included the following: 2. The determination of appropriate participation of health professionals must be based on the physical, mental, and psychosocial (the interaction between a person's internal emotional/mental state and their external social environment) condition of each resident (in general). 5. The assessment must represent an accurate picture of the resident's status during the observation period of the MDS. During a concurrent interview and record review on 3/19/2026 at 9:52 AM with the DON, the facility's P&P titled Resident Assessment, dated 1/2026 was reviewed. The Resident Assessment P&P indicated the MDS must minimally include a resident's (in general) mood and behavior patterns, psychosocial well-being, and disease diagnosis and health conditions. The DON stated the MDS needed to be accurate because the facility used the MDS for Resident 81's care planning.

Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 9) received assistance from the Restorative Nursing Assistants (RNAs) during meals as part of RNA feeding program (a specialized program that focuses on maintaining, improving, and encouraging a resident's functional independence during meals). This failure had potential for Resident 9 to have a decline in meal intake and experience weight loss.Findings: During a review of Resident 9's admission Record, the admission Record indicated the facility re-admitted the resident on 2/10/2026 with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), urinary tract infection (UTI, an infection in the bladder/urinary tract), pneumonitis (inflammation of the lung tissue), and benign prostatic hyperplasia (BPH, enlargement of the prostate gland).During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool) dated 2/17/2026, the MDS indicated the resident had moderate cognitive impairment (a slight decline in thinking and memory). The MDS indicated Resident 9 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating. The MDS indicated Resident 9 was on a mechanically altered diet (moist, soft-textured foods that are ground, minced, or chopped to require minimal chewing).During a review of Resident 9's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 3/12/2026 that indicated the resident was to be on the RNA feeding program for loss of appetite.During a concurrent observation and interview on 3/17/2026 at 12:40 PM with Certified Nursing Assistant 3 (CNA 3), in Resident 9's room, CNA 3 was observed setting up the meal tray for Resident 9 then leaving the resident to eat independently. CNA 3 stated Resident 9 was independent with feeding and could eat on his own.During an observation on 3/18/2026 at 8:10 AM, in Resident 9's Room, the resident was observed sitting up in bed with a breakfast meal tray in front of him on a bedside table. Resident 9 was observed attempting to feed himself. Resident 9 stated I don't like this food; I don't want to eat it. There were no staff observed at Resident 9's bedside.During an interview on 3/18/2026 at 8:22 AM with CNA 4, CNA 4 stated she was assigned to Resident 9. CNA 4 stated she was not assisting Resident 9 to eat because the resident was able to eat on his own and was independent with feeding. CNA 4 stated she did not know if Resident 9 was a part of the RNA feeding program.During a concurrent interview and record review on 3/18/2026 at 2:12 PM with the Director of Rehabilitation (DOR), Resident 9's physician orders were reviewed. The DOR stated Resident 9 had physician orders to be on the RNA feeding program. The DOR stated that Resident 9 was placed on the RNA feeding program because he (Resident 9) wasn't eating and had a loss of appetite. The DOR stated he (DOR) was responsible for informing the RNAs of the residents who were placed on the feeding program. The DOR stated he had not informed the RNAs that Resident 9 was to be on the feeding program. The DOR stated because Resident 9 was supposed to be on the RNA feeding program, the expectation was that the RNAs would be sitting at the resident's bedside, assisting the resident during meals, and encouraging the resident to eat. The DOR stated there was a potential for Resident 9 to not eat if the resident was not encouraged or assisted by staff during meals.During a telephone interview on 3/19/2026 at 8:03 AM with the Registered Dietitian (RD), the RD stated Resident 9 was placed on the RNA feeding program by the weight variance committee (a specialized team that reviews patients with significant and unexpected weight loss that implements interventions to manage and reverse declining health in residents). The RD stated the weight variance committee felt Resident 9 would consume more food during meals with RNA supervision. The RD stated the purpose of RNA supervision during meals was to assist, re-orient, and cue Resident 9 to continue eating. The RD stated if RNA supervision was not provided to Resident 9 during meals the resident could potentially not be able to improve with meal intake which could lead to additional weight loss.During an interview on 3/19/2026 at 9:53 AM with the Director of Nursing (DON), the DON stated Resident 9 was placed on the RNA feeding program for loss of appetite. The DON stated Resident 9 should have been assisted by the nursing staff during meals. The DON stated the purpose of the RNA program was to provide encouragement and guidance to Resident 9 during meals so Resident 9 would be motivated to eat more. The DON stated if RNA supervision was not provided to Resident 9 during meals, the resident would not be encouraged to eat as much.During a review of the facility's Policy and Procedure (P&P) titled Restorative Feeding Program dated 1/2026, the P&P indicated The facility provides and each resident shall receive restorative feeding care as needed to help promote optimal independence with eating.A resident may participate in both Restorative and Rehabilitation Dining Program if appropriate. The goal is to reinforce and improve the residents' self-feeding and swallowing techniques as established by the therapy team.The RNA will provide cueing and assistance in the use of adaptive feeding techniques and equipment as instructed by the Occupational Therapist or Speech Therapist.Feeding status: moderate to supervised assist for self-feeding; supervised for use of swallowing techniques.Restorative Diet Aide: Responsible for the transport of RDP residents to the designated dining area. Responsible for implementing feeding program/plan as developed/per recommendation of OTR and/or SLP. Documenting progress on flow sheet and weekly summaries. Informing Dining Program Coordinator and/or Occupational Therapist, Speech - Language Pathologist of significant change in resident's status.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 4 (LVN 4) verified medication dosage prior to medication administration for one of seven sampled residents (Resident 31). As a result, Resident 31 received vitamin C (ascorbic acid, a nutrient crucial for immune function and wound healing) at a dose much higher than the dose prescribed. Placing residents at risk for medication errors and negative adverse effects. Findings: During a review of Resident 31's medication orders, the medication orders indicated an active order dated 2/18/2026 at 2:40 PM for ascorbic acid (vitamin C) 250 mg by mouth one time a day. During a medication administration observation on 3/18/2026 at 9:31 AM, LVN 4 was observed preparing medications for Resident 31. LVN 4 prepared 9 medications and 1 of those 9 medications was a tablet of vitamin C 500 milligrams (mg, a unit to measure mass). During concurrent observation and interview on 3/18/2026 at 11:06 AM, LVN 4 was asked to show the vitamin C bottles in the medication cart. LVN 4 looked and stated there was 1 bottle of vitamin C 500 mg; and confirmed there was no bottle of vitamin C 250 mg in the medication cart. During a concurrent review of Resident 31's medication orders, LVN 4 stated Resident 31's order was for Vitamin C 250 mg and there was no vitamin C 250 mg in the med cart. During a concurrent interview, LVN 4 stated he should have cut the 500 mg tablet in half or check the central supply closet for vitamin C 250mg. LVN 4 further stated he would contact the resident's physician and notify the physician the wrong dose given to Resident 31. During a concurrent observation of the facility's over the counter (OTC) medications supply closet and interview on 3/18/2026 at 2:48 PM, the director of nursing (DON) stated the facility did not have vitamin C 250 mg in stock; the facility had Vitamin C 500 mg. DON stated during medication administration, the practice was to check against the order for the correct medication and dosage. During a review of the facility policy and procedures, Administering Medications (January 2025), the policy indicated . Medications must be administered in accordance with the orders. The licensed nurse must check the label three times to verify the right resident, right medication, right dosage, right time, . before giving the medication.

Based on observation, interview, and record review, the facility failed to follow infection control practices for one of five sampled residents (Resident 67) reviewed for infection control by failing to: -Ensure staff (in general) did not store the trash and soiled (dirty) linen carts inside shower room [ROOM NUMBER]. -Ensure staff (in general) cleaned shower room [ROOM NUMBER] after the Social Services Assistant (SSA) removed the trash and soiled linen carts before Certified Nursing Assistant 2 (CNA2) bathed Resident 67 on 3/17/2026 at 9:06 AM. This failure placed Resident 67 at risk of infection. Findings:During a review of Resident 1's admission Record, the admission Recorded indicated the facility admitted Resident 67 on 3/3/2009 and readmitted the resident on 6/23/2015 with diagnoses including right elbow contracture (a permanent tightening or shortening of muscles, tendons, skin, or tissues, usually replacing flexible tissue with inelastic, fiber-like tissue) and dysphagia (difficulty swallowing). During a review of Resident 67's History and Physical (H&P) dated 12/31/2025, the H&P indicated the resident did not have the capacity to make medical decisions. During a review of Resident 67's Minimum Data Set (MDS, a resident assessment tool) dated 2/24/2026, the MDS indicated Resident 67 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 67 was dependent on mobility and activities of daily living (ADLs, activities such as bathing, lower body dressing and toileting a person performs daily). During an observation on 3/17/2026 at 9:06 AM in shower room [ROOM NUMBER], the SSA took the trash and soiled linen carts out from shower room [ROOM NUMBER]. The surveyor observed CNA 2 wheeled in Resident 67 directly for a bath before shower room [ROOM NUMBER] was cleaned. During an observation on 3/17/2026 at 9:16 AM, Resident 67 completed her (Resident 67) bath in shower room [ROOM NUMBER]. CNA 2 wheeled Resident 67 back to Resident 67's room. Following Resident 67's exit, the surveyor observed housekeeping staff (unidentified) entered shower room [ROOM NUMBER] to clean shower room [ROOM NUMBER]. During an interview on 3/17/2026 at 9:21 AM with CNA 1, CNA 1 stated the trash, and soiled linen carts should not be stored in the shower room. CNA 1 stated that the trash and soiled linen carts needed to be in the hallway. During an interview on 3/17/2026 at 10:41 AM with CNA 2, CNA 2 stated she (CNA2) took Resident 67 inside shower room [ROOM NUMBER] and did not consider infection control practices at that time. CNA 2 stated if she (CNA2) had to do it all over again, she (CNA2) would bring Resident 67 back into the room and would have called the environmental service to clean shower room [ROOM NUMBER] before Resident 67's bath. During a concurrent interview and record review on 3/18/2026 at 3:05 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Shower -tub room Cleaning, dated 7/2026 was reviewed. The DON stated the P&P indicated to assure all bathing areas were maintained in a clean and orderly fashion between and during resident bathing. The DON stated soiled linens should not be stored in the shower rooms. The DON stated that the facility did not follow infection control practices when shower room [ROOM NUMBER] was not cleaned and disinfected prior to Resident 67's bath. During a concurrent interview and record review on 3/18/2026 at 3:05 PM with the Infection Preventionist (IP), the facility's P&P titled Infection Prevention and Control Program, dated 7/2025 was reviewed. The IP stated the P&P indicated the facility established and maintained an Infection Control Program to provide safe and comfortable to help prevent infections. The IP stated that trash and soiled linen carts should be kept in the hallways and not stored in the shower rooms. The IP stated the shower room should be decontaminated if trash and soiled carts were stored inside the shower rooms. The IP stated CNA 2 should have ensured the shower room was clean before Resident 67 was given a bath. The IP stated that the facility failed to maintain a clean environment when shower room [ROOM NUMBER] was not disinfected prior to Resident 67's bath, creating the potential for cross contamination and possible infection [NAME] to Resident 67. During a review of the facility's P&P titled Shower-Tub Room cleaning, last reviewed on 1/2026, the P&P indicated that it is the responsibility of each CNA assisting residents with bathing and showering to keep the room clean and free of clutter.

Based on observation, interview, and record review, the facility failed to meet the requirement for no more than four residents per room for one of 38 resident residential rooms (room [ROOM NUMBER]).This failure had the potential to result in inadequate space to provide necessary care, safe nursing care, and privacy for the residents in room [ROOM NUMBER].Findings:During a review of the facility's room waiver request letter dated 3/16/2026, the room waiver request letter indicated room [ROOM NUMBER] did not meet the 4 bed per room regulation.Room NumberRoom SizeNumber of Beds218543.98 sq ft6 The room waiver request letter indicated the rooms had no projections or other obstructions that would interfere with the free movement of wheelchairs and/or sitting devices. The room waiver request letter indicated that the rooms had enough space to provide for each resident's care, dignity, and privacy. The room waiver request letter indicated the rooms were in accordance with the special needs of the residents and would not have an adverse effect on the residents' health and safety. The room waiver request letter indicated the rooms would not impede the ability of any resident in the rooms to attain his/her highest practicable well-being. The room wavier letter indicated all measures would be taken to assure the comfort of each resident. During multiple room observations conducted in room [ROOM NUMBER] from 3/16/2026 to 3/19/2026, nursing staff (in general) were observed with adequate space to provide care to the residents in room [ROOM NUMBER]. Each resident in room [ROOM NUMBER] was observed to have curtains for privacy, working call lights, a dresser, television, and a bedside table. During an interview on 3/19/2026 at 8:47 AM with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated he (LVN5) was assigned to care for the residents in room [ROOM NUMBER]. LVN 5 stated he (LVN5) had no concerns with the amount of space in room [ROOM NUMBER]. LVN 5 stated some residents in room [ROOM NUMBER] had wheelchairs which were easy to maneuver in and out of the room. LVN 5 stated the space in room [ROOM NUMBER] did not prevent him from providing quality care to the residents in the room. During an interview on 3/19/2026 at 9:04 AM with Resident 16, in room [ROOM NUMBER], Resident 16 stated he (Resident 16) did not have any issues or complaints about the amount of space in his room. Resident 16 stated his CNAs (in general) were able to change him and help move him without any problems. Resident 16 stated he (Resident 16) was happy with the amount of space he (Resident 16) had in room [ROOM NUMBER].The Department is recommending continuation of the room wavier request.

Based on observation, interview, and record review the facility failed to ensure 16 of 38 resident rooms (rooms 101, 102, 103, 104, 110, 111, 112, 113, 214, 215, 216, 217, 219, 220, 221, and 222) met the requirement that each resident must have at least 80 square feet of useable living space in multiple resident rooms.This failure had the potential to result in the inadequate space necessary to provide safe nursing care and privacy for residents.Findings:During a review of the facility's room waiver request letter dated 3/16/2026, the room waiver letter indicated the facility requested a room variance for 16 resident rooms (rooms 101, 102, 103,104, 111, 112, 113, 214, 215, 216, 217, 219, 220, 221, 222, and 238). The room waiver letter indicated the following rooms had less than 80 square feet per bed:Room NumberFloor Area (square feet)Capacity101236.12 sq ft3102228.90 sq ft3103237.45 sq ft3104231.92 sq ft3110230.84 sq ft3111230.84 sq ft3112228.46 sq ft3113228.35 sq ft3214229.59 sq ft3215228.53 sq ft3216229.16 sq ft3217229.01 sq ft3219228.89 sq ft3220228.53 sq ft3221229.81 sq ft3222227.76 sq ft3 The room waiver request letter indicated the rooms had no projections or other obstructions that would interfere with the free movement of wheelchairs and/or sitting devices. The room waiver request letter indicated that the rooms had enough space to provide for each resident's care, dignity, and privacy. The room waiver request letter indicated the rooms were in accordance with the special needs of the residents and would not have an adverse effect on the residents' health and safety. The room waiver request letter indicated the rooms would not impede the ability of any resident in the rooms to attain his/her highest practicable well-being. The room wavier letter indicated all measures would be taken to assure the comfort of each resident. During an initial tour observation of the facility on 3/16/2026 from 9:30 AM to 11:30 AM, nursing staff (in general) were observed with adequate space to provide the care for the residents in each facility room. The residents were observed with the ability to move freely in the residents' rooms and throughout the facility. During an interview on 3/19/2026 at 8:59 AM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated he was assigned to care for the residents in rooms 101, 102, 103, and 104. LVN 4 stated he did not have any concerns about the space in the rooms. LVN 4 stated he did not feel crowded when passing medication to the residents. LVN 4 stated he could easily maneuver around the rooms when caring for residents. During a concurrent observation and interview on 3/19/2026 at 9 AM with Resident 66, in room [ROOM NUMBER], Resident 66 was observed lying in bed with a wheelchair, bedside table, oxygen concentrator (a medical device that filters nitrogen from ambient air to deliver concentrated, medical-grade oxygen to residents with respiratory conditions), and dresser at bedside. Resident 66 stated she (Resident 66) did not have any concerns regarding the space in the room. Resident 66 stated the Certified Nursing Assistants (CNAs) in general could easily provide care and maneuver the wheelchair in her room. Resident 66 stated she was quite happy with the space in room [ROOM NUMBER] because she could keep all her belongings and necessities nearby. During a concurrent observation and interview on 3/19/2026 at 9:13 AM with CNA 5, in room [ROOM NUMBER], CNA 5 was observed assisting a resident in a wheelchair back to bed. CNA 5 stated she had no complaints about the space in room [ROOM NUMBER]. CNA 5 stated she was able to move a wheelchair or shower chair in room [ROOM NUMBER] easily. CNA 5 stated the space in room [ROOM NUMBER] did not prevent her from being able to provide quality care to the residents.The Department is recommending continuation of the room waiver request.

Based on observation, interview, and record review, the facility failed to develop a Comprehensive Care Plan (CP- a personalized document that outlines a resident's needs, goals, and the specific services required to achieve them, ensuring consistent and holistic care) for one of three sampled residents (Resident 1), to address Resident 1's Urinary Tract Infection (UTI- infection that happens when bacteria enter the urethra, and infect the urinary tract) after returning from the hospital to the facility.This failure placed Resident 1 at risk for recurrent hospitalizations, which the resident experienced six times from 11/2/2025 through 1/10/2026.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnosis metabolic encephalopathy (brain dysfunction caused by diseases or toxins in the body) and readmitted to the facility on [DATE] with diagnosis of UTI.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 10/25/2025, the MDS indicated Resident 1 had moderate to severe cognitive (ability to think, remember and reason) skills for daily decision making. The MDS indicated Resident 1 was independent (Resident completes the activity by themself with no assistance from a helper) for eating, personal hygiene, oral hygiene, roll left and right, sit to lying, and lying to sitting on side of bed. The MDS indicated Resident 1 required maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting and showering, and partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for upper body dressing, lower body dressing, putting on taking off footwear, sit to stand, chair and bed transfers, and required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for personal hygiene. The MDS indicated Resident 1 was frequently incontinent (seven or more episodes of urinary incontinence, but at least one episode of continent voiding).During a review of Resident 1's Medical Administration Record (MAR) dated 1/8/2026, indicated Ciprofloxacin (medication to treat UTI) 500 milligram (mg-unit of mass) give one tablet by mouth in the morning for UTI for seven days.During a review of Resident 1's medical record, no Care Plan interventions were found that addressed Resident 1's UTI to include problem statement, goals, monitoring parameters, comfort measures, or physician notification requirements. During a concurrent interview and record review interview on 1/14/2026 at 1:15 PM with the Minimum Data Set (MDS) nurse, the MDS nurse stated she was working on updating Resident 1's CP, which had not been updated since 10/16/2025. The MDS nurse stated that the CP should be updated quarterly and upon each resident's admission or readmission. The MDS nurse further explained that since Resident 1 has had frequent hospitalizations, she intended to update the CP upon his next admission.During an interview on 1/14/2026 at 1:30 PM with the Director of Nursing (DON), the DON acknowledged Resident 1 did not have a CP addressing the UTI following hospital return. The DON stated a Comprehensive Care Plan should have been initiated for Resident 1's UTI diagnosis to include interventions, goals, and failure to develop and implement the CP placed Resident 1 at risk for continued decline and recurrent hospitalizations.During a review of the facility's policy and procedure titled Comprehensive Care Plans- Timing, dated 1/2025, indicated the facility's interdisciplinary team is responsible for the review and revision of the comprehensive care plan after each assessment and completed within seven das and no more than 21 days after admission.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 2) had the call light within reach.This failure resulted in Resident 2's inability to call staff for assistance, since she was unable to reach the call light.During a review of Resident 2's admission Record, dated 7/3/25, indicated Resident 2 was admitted to the facility on [DATE], with a diagnoses including; hemiplegia (muscle weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting the left dominant side, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and atrial fibrillation (Afib-irregular heart beat which affects the blood pumping mechanism of the heart). During a review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool) indicated Resident 2 was dependent on staff for Activities of Daily Living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 2's Care Plan for risk for falls dated 4/10/25 indicated and intervention of Call light is within reach and encourage the resident to use it for assistance as needed. During an observation with concurrent interview on 7/2/25 at 10:10 am in Resident 2's room, with Resident 2, the resident's call light was observed behind on the floor behind the head of the bed on the left side - out of reach. Resident 2 stated if she could find the call light she would use it to call for assistance. During an observation with concurrent interview on 7/2/25 at 1:41 pm in Resident 2's room with CNA 2, the resident's call light was observed attached to the fitted sheet on the left side of the resident out of reach again. CNA 2 verifies and states the resident cannot reach the call light and repositions it on across the residents left arm within reach of the resident's right side. During a review of the facility's policy and procedures titled, Fall Management Program reviewed March 2025, indicated implement intervention, including adequate supervision and assistive devices, consistent with a resident's needs, goals and care plan and current professional standards of practice in order to eliminate the risk. During a review of the facility's policy and procedures titled, Resident Call System reviewed January 2025, indicated When the resident is sitting in his/her chair or confined to his/her bed, be sure to provide resident with call light access.

Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was provided with the ordered oxygen therapy. This failure resulted in Resident 1 being left without ordered oxygen therapy after personal hygiene care by Certified Nursing Assistant (CNA) and experiencing a temporary desaturation (decrease in the oxygen level of the blood). During a review of Resident 1's admission Record, dated 7/3/25, indicated the resident was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and sleep disturbances), HTN and muscle weakness. During a review of Resident 1's History & Physical, dated 12/20/24 indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's MDS dated [DATE], indicated the resident had severely impaired cognition (the mental process of thinking, learning, and perception). The MDS further indicated Resident 1 was completely dependent on staff for dressing, toilet use, personal hygiene, and bed mobility.During a review of Resident 1's Order Summary Report dated 7/3/25 indicated an order for routine oxygen 2-4 liters per minute via nasal cannula (a medical device used to deliver supplemental oxygen to a patient through small prongs inserted into the nostrils).During record review with Resident 1's Health Status Note dated 6/29/25 at 12:20 pm, the note indicated While attending another resident, another charge nurse was informed Resident 1's oxygen tubing was off. Upon assessment there was no distress, no shortness of breath, but when resident's oxygen level was checked it was 77% (normal level is 95%-100%), then the LVN placed the oxygen back on and the oxygen saturation rose to 95%. During an interview with Licensed Vocational Nurse (LVN) 1 on 7/3/25 at 3:03 pm, LVN 1 verified there was an incident where Resident 1 desaturated to 77%, a few days before, when Certified Nursing Assistant (CNA) 1, was providing care to the resident and had removed the nasal cannula temporarily to reposition the resident forgetting to put it back on. Once the oxygen was back on the oxygen level went up and he called the doctor to have the order for oxygen changed to as needed to routine. During an interview with CNA 1 on 7/3/25 at 3:16 pm, CNA 1 stated she had repositioned Resident 1 and removed the oxygen tubing so it would not pull on her and then forgot to put it back. During a review of the facility's policy and procedures titled Oxygen Therapy, reviewed March 2025, indicated this procedure is to provide guidelines for the administration of oxygen. Oxygen therapy is administered by way of. nasal cannula. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose.

Based on interview and record review, the facility failed to ensure medical records were accurately documented and complete for one of three sampled residents (Resident 2). Resident 2 had a history of depression not a current diagnosis of depression, as indicated on Resident 2's face sheet. This deficient practice had the potential to cause errors in medical treatment, plan of care, and delivery of necessary care and services. Findings: A review of the face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including dementia (a progressive state of decline in mental abilities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of the Psychiatrist Progress Note dated 8/23/2024, the Psychiatrist Progress Note indicated Resident 2 had a treatment plan that included no psychiatric medication at that time and was encouraged to participate in group activities. A review of the history and physical dated 10/23/2024 indicated Resident 2 was alert and oriented times one (being aware and knows their own name, but may not be aware of their location, time, or the current situation) at baseline and usually answers yes/no with a history of dementia and nonverbal. In addition, Resident 2's past medical history diagnosis included history of cerebrovascular accident (CVA- stroke, loss of blood flow to a part of the brain). A review of the Minimum Data Set Assessment (MDS, an resident assessment tool) dated 3/3/2025, indicated Resident 2 was severely cognitively impaired (problems with a person's ability to think, remember, use judgement, and make decisions). Further review of the MDS did not indicate an active diagnosis of Major Depressive Disorder, Recurrent, Unspecified. During a concurrent interview and record review on 4/4/2025 at 9:40 AM, the Director of Nursing (DON) stated, after review of Resident 2's History and Physical, that the diagnosis of depression was part of the resident's history and was not a current exhibiting symptom. After review of the MDS, the DON stated the diagnosis of depression was not indicated where active diagnoses were listed. During an interview on 4/4/2025 at 11:30 AM, after review of the Psychiatrist Progress Notes dated 8/5/2024, the DON stated the psychiatrist indicated the single depression episode for Resident 2 was based on assessment of the resident. The Progress Note further indicated Resident 2 did not need antidepressant medication at this time. The DON stated the diagnosis of recurrent depression was a typo error and should read 'unspecified depression' as clarified by the psychiatrist. The DON stated the MDS was not coded with diagnosis of Major Depressive Disorder, Recurrent, Unspecified due to Resident 2 not being prescribed any antidepressant medication and solely having a history of depression. During an interview on 4/4/2025 at 3:20 PM, the Administrator (ADM) and DON stated that it was important to document the diagnosis accurately to ensure proper assessment and proper care of Resident 2's needs. A review of the facility's policy and procedure titled, Documentation Policy, dated July 2019 indicated the policy of the facility was to document relevant findings in the clinical record.

Based on observation, interview and record review, the facility failed to ensure 11 of 20 sampled residents (Resident 1, 8, 10, 11, 32, 37, 50, 54, 66, 95, and 99), were free of significant medication error. The facility failed to: -Ensure Resident 50 was administered Eliquis (apixaban, an anticoagulant, a blood thinner), Norvasc (amlodipine, a medication used to treat high blood pressure), and aspirin for myocardial infarction (MI, also known as a heart attack, occurs when blood flow to the heart is blocked) prophylactically (PPX, measures designed to preserve health), in accordance with the physician's orders for eleven days during February 2025. -Ensure Residents 10, 54, 95 and 99 were administered Eliquis in accordance with physician's orders and facility's policy and procedures titled, Medication Administration - General Guidelines to minimize the risk of adverse consequences (an undesired effect of a drug) including an increased risk of bleeding. -Ensure Resident 1 was administered Depakote (valproic acid, a medication used to control seizures [a sudden, uncontrolled burst of electrical activity in the brain that can cause temporary changes in behavior, movement, sensation, or awareness]) on 2/20, 2/22, 2/23, and 2/25/2025 at 9 a.m., and 1 p.m., as ordered and not within 39 minutes to less than two hours of the next scheduled dose. -Ensure Resident 37 was administered Keppra (levetiracetam a medication used to control seizures) on 2/20, 2/22, 2/23, 2/24, and 2/25/2025 at 9 a.m., and 5 p.m. daily as ordered. -Ensure Residents 8, 11, 32 and 66 were administered medications in accordance with physician orders and facility's policy and procedures titled, Medication Administration - General Guidelines to minimize the risk of adverse consequences which could lead to a deterioration in the resident's condition, hospitalization , harm, or death. These deficient practices resulted in: -Residents 10, 50, 54, 95 and 99 were at increased risk of bleeding, including serious bleeding that can be fatal and increased risk of uncontrolled blood pressure, that could lead to stroke, heart attack, hospitalization , or death -Residents 1 and 37 was placed at high risk for hepatotoxicity (liver toxicity, a condition that occurs when the liver is damaged by harmful substances, such as medications, toxins, or chemicals, which can lead to impaired liver function and, in severe cases, liver failure). -Residents 8, 11, 32, and 66 were placed at risk for uncontrolled blood glucose (a type of sugar) levels. On 2/26/2025 at 4:42 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM) and Director of Nursing (DON), regarding the facility's failure to identify and ensure Resident 1, 8, 10, 11, 32, 37, 50, 54, 66, 95, and 99, who were at increased risk of bleeding, toxicity or hyperglycemia (increased blood sugar) were free of significant medication error and received necessary care and services in accordance with professional standards of practice. On 2/27/2025 at 4:18 PM, while onsite at the facility, the IJ was removed in the presence of the ADM and DON, after the ADM submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: The Licensed Nurse completed change in condition assessments on 2/26/25 and reported the medication errors for each resident effected with the related medications. The residents would be monitored every shift for adverse reactions. Effected residents were monitored by the DON. Licensed Nurses would be re-educated by the DON before their next Med Pass or on or before 3/15/25 on the standard of practice and facility policy and procedure for administering medications and in accordance with the physician's ordered time to reduce the risk of medication error, serious injury, harm and or death. The DON evaluated the resident medication administration assignments, including evaluation of residents on antiseizure, anticoagulants, hypertensive and anticonvulsant medications, including gastrostomy tubes, dialysis, blood pressure parameter checks, diabetics with insulin administration, controlled pain medications and seizure protocol on 2/26/25. The DON contacted the pharmacy consultant and requested an additional medication cart on 2/26/25, which was verified. The cart would be delivered on 2/26/25. The DON redistributed the resident assignment to ensure the load over four medication carts on 2/26/25. The Interdisciplinary Team met on 2/26/25 and developed and implemented a plan of care to closely monitor effected residents for adverse effects related to receiving medications at the wrong time resulting in a medication error on 2/25/25. The Medical Records staff generated an audit of all in house residents medication administration records including the time of administration for all shifts, identifying any residents who were effected by the medication error. A copy of the audit was provided to the DON for review on 2/27/25. All licensed nurses in the oncoming shifts were prioritized with re-education with the objective to achieve 100% of the licensed nurses before the start of their shift beginning 2/27/25. The Director of Staff Development / designee would complete a medication pass observation skill competency with LVN 1 and 2 prior to the start of their shift. Cross Reference F759 Findings: a. A review of the Admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (a stroke that occurs when blood flow to the brain is blocked) affecting left non-dominant side, hypertension (high blood pressure), cardiomegaly (a condition where the heart is larger than normal), and atrial fibrillation (AF, abnormal heartbeat). During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool) dated 9/26/24, the MDS indicated Resident 50's cognitive skills (mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making was moderately impaired. Resident 50's MDS indicated the resident required setup for eating and oral hygiene, required substantial assistance for personal hygiene and was dependent on staff physical assistance. During a review of Resident 50's History and physical (H&P) dated 2/29/2024, the H&P indicated Resident 50 had the capacity to understand and make decisions. During a review of Resident 50's Order Summary Report, the Order Summary Report indicated Resident 50's orders included: -Apixaban (Eliquis, an anticoagulant, a blood thinner) 5 (five) milligrams (mg - unit of measure of weight) give one tablet by mouth every 12 hours, scheduled at 9 a.m., and 9 p.m., for AF, order date 4/26/2023. -Amlodipine (Norvasc, a medication used to treat high blood pressure) 5 mg, give one tablet by mouth one time a day, scheduled at 9 a.m., for hypertension, hold if systolic blood pressure (SBP, when the heart beats, top number) is less than 110 millimeters of mercury [mm Hg]), (mmHg - unit of measure), order date 8/28/2024. -Aspirin Enteric Coated (EC) 81 mg, give one tablet by mouth one time a day, scheduled at 9 a.m., for myocardial infarction (MI, also known as a heart attack, occurs when blood flow to the heart is blocked) prophylactically (PPX, measures designed to preserve health), order date 6/17/2020. During a review of Resident 50's, Care Plans, the care plans for Resident 50 indicated the following: -Black Box Warning (is a serious warning given by the Food and Drug Administration [FDA] for drugs or drug classes that may cause serious harm or death) for use of Apixaban (Eliquis), dated 3/27/2020. Resident 50's care plan goal indicated; the resident will not experience side effects/ interactions with the use of Apixaban (Eliquis). -Anticoagulant therapy, Apixaban for atrial fibrillation, at risk for active bleeding, revised 2/6/2025. Resident 50's care plan intervention indicated give Apixaban 5 mg by mouth every 12 hours for AF. Resident/family/caregiver teaching to include the following: take/give medication at the same time each day. -Hypertension (HTN) related to lifestyle and stroke, dated 3/27/2020. The interventions included instructions to give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a sudden drop in blood pressure when standing) and increased heart rate (tachycardia) and effectiveness. -Risk for repeat Cardiovascular Accident (CVA) as resident had a CVA prior to admission, date revised 2/6/2025, and goal indicated to minimize risk with interventions. Interventions indicated, administer medication(s) as ordered. -Risk for adverse reaction related to polypharmacy (the simultaneous use of multiple drugs by a single patient, for one or more conditions), revision date 2/6/2025. Resident 50's care plan interventions included to review resident's medications with MD/Consultant pharmacist for proper dosing, timing and frequency of administrations. During a concurrent observation and interview on 2/25/2025 at 10:17 a.m., with a Licensed Vocational Nurse (LVN) 3 on Station 2 at Medication Cart (MedCart) 2, LVN 3 stated she was preparing the morning medications for Resident 50 that was scheduled for 9 a.m. During a medication pass observation on 2/25/2025 at 10:20 a.m., with LVN 3, LVN 3 prepared and administered Resident 50's morning medications, scheduled for 9 a.m., administration that included Apixaban 5 mg, one tablet, Amlodipine 5 mg, one tablet, and Aspirin Enteric Coated (EC) 81 mg, one tablet. During an interview on 2/25/2025 at 10:32 a.m., Resident 50 stated she usually gets her medications late, but she knew the nurses were very busy. During an interview on 2/25/2025 at 10:38 a.m., LVN 3 stated she had 17 more residents to administer morning medications to that were scheduled for 9 a.m LVN 3 stated the supervisor and Director of Nursing (DON) was made aware of the heavy load, which included four of her 32 residents received medications through a gastrostomy tube (GT - a tube inserted through the belly that brings nutrition, fluids, and medications directly to the stomach), which takes more time and that she was not able to pass medications to all of residents on time. During an earlier interview on 2/25/2025 at 10:11 a.m., with LVN 1, on Station 2, at MedCart 3, LVN 1 stated he had 12 more residents to pass medications scheduled for 9 a.m., out of a total of 27 residents, and usually finished passing morning medications each day around 11:30 a.m. LVN 1 stated he notified a Registered Nurse Supervisor. LVN 1 stated, It can be overwhelming, especially when you are trying to give the best care, not rush residents, and not make mistakes. During an interview on 2/25/2025 at 1:32 p.m., the DON stated licensed nurses should administer medications within an hour of the scheduled administration time or up to an hour after the scheduled administration time. The DON stated the resident's physician must be notified if resident's medications would be administered outside of the time frame and then following the physician's instructions, if it was okay to administer the medication. During a record review of Resident 50's Medication Administration Audit Report, Resident 50's Medication Audit Report was reviewed between 2/1 to 2/25/2025. The Medication Administration Audit Report indicated Resident 50 was administered apixaban, amlodipine, and aspirin late and for apixaban less than 12 hours from the next scheduled dose as follow on: -2/2/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 3:09 p.m. (six hours and nine minutes late). -2/2/2025 apixaban 5 mg scheduled for administration at 9 p.m., was administered at 8:33 p.m., five hours and 24 minutes after the last dose was given at 3:09 p.m., instead of the ordered 12 hours between doses. -2/4/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 10:57 a.m. (one hour and 57 minutes late). -2/8/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 10:35 a.m. (one hour and 35 minutes late). -2/9/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 1:55 p.m. (four hours and 55 minutes late). -2/9/2025 apixaban 5 mg scheduled for administration at 9 p.m., was administered at 8:17 p.m., six hours and 22 minutes after the last dose was given at 1:55 p.m., instead of the ordered 12 hours between doses. -2/12/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 10:58 a.m. (one hour and 58 minutes late). -2/13/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 11:08 p.m. (two hours and eight minute late). -2/16/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 1:02 p.m. (four hours and two minutes late). -2/16/2025 apixaban 5 mg scheduled for administration at 9 p.m., was administered at 8:43 p.m., seven hours and 41 minutes after the last dose was given at 1:02 p.m., instead of the ordered 12 hours between doses. -2/21/2025 apixaban, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 10:33 a.m. (one hour and 33 minutes late). -2/22/2025 apixaban 5 mg scheduled for administration at 9 a.m., was documented administered at 6:03 p.m. (nine hours and three minutes late). -2/22/2025 apixaban 5 mg scheduled for administration at 9 p.m., was documented administered at 8:51 p.m. two hours and 48 minutes after the last dose was given at 6:03 p.m., instead of the ordered 12 hours between doses. -2/23/2025 apixaban, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 11:10 a.m. (two hours and 10 minutes late) -2/22/2025 apixaban 5 mg scheduled for administration at 9 p.m., was documented administered at 9:22 p.m., ten hours and 22 minutes after the last dose was given at 11:10 a.m., instead of the ordered 12 hours between doses. b. A review of Resident 10's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including Type II diabetes (DM, a condition that occurs when the body does not use insulin properly, leading to high blood sugar levels), hypertension (high blood pressure), myocardial infarction (MI), and AF. During a review of Resident 10's, MDS dated [DATE], the MDS indicated Resident 10's cognitive skills for daily decision-making was moderately impaired. During a review of Resident 10's Order Summary Report, the Order Summary Report indicated Resident 10 had orders for: -Eliquis 2.5 mg, to give one tablet by mouth two times a day scheduled at 9 a.m. and 5 p.m., for AF, with an order date of 3/27/2024. -Eliquis: Monitor for signs and symptoms of bleeding (abnormal or unexplained bruising, petechiae (tiny spots of bleeding under the skin), internal bleeding, nosebleeds, bleeding gums, abnormal bleeding) by (+) Yes or (-) No. Notify MD if (+) every shift (Day shift, Evening Shift, and Night Shift), order date 11/10/2023. -Metformin 500 mg, one tablet by mouth four times a day for DM, give with food, order date 11/2/2023 During a review of Resident 10's, Care Plans, the care plans indicated: -Resident 10 had High Risk for Bleeding, Bruising, and/or Skin Discoloration related to anticoagulant therapy, Eliquis, dated 12/1/2022. Resident 10's care plan goal indicated, the resident will remain free of abnormal bleeding or bruising, and the care plan intervention indicated, administer medications as ordered and monitor for side effects. Observe / record / report to MD as needed, abnormal or unexplained bruising. -Resident 10 had a Black Box Warning for use of Metformin (Glucophage) for diabetes mellitus (DM), revised 2/8/2025. Resident 10's care plan goal indicated the resident will not experience side effect/ interactions with the use of Metformin, and the care plan interventions included, Black Box Warning, post marketing cases of metformin-associated lactic acidosis (lactic acid build up in the bloodstream) have resulted in death, hypothermia (body loses heat faster than it can produce heat), hypotension (low blood pressure), and resistant bradyarrhythmia (an irregular heartbeat that's slower than normal). The onset of metformin-associated lactic acidosis is often subtle, accompanied only by myalgias (muscle pain), respiratory distress (difficulty to breath), somnolence (drowsiness), and abdominal pain. During a review of Resident 10's Nursing Progress Notes dated 2/24/2025 at 8:46 a.m., Resident 10's progress notes indicated, On monitoring for discoloration to right wrist. Resident still noted with discoloration in affected wrist. During a record review of Resident 10's Medication Administration Audit Report, Resident 10's Medication Audit Report was reviewed between 2/1/2025 to 2/25/2025, the Medication Administration Audit Report indicated resident was administered apixaban less than 8 hours from the next scheduled dose as follow on: -2/17/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 11:12 a.m. (two hours and 12 minutes late). -2/24/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 2:29 p.m. (five hours and 29 minutes late). -2/24/2025 apixaban 2.5 mg scheduled for administration at 5 p.m., was administered at 5:17 p.m., two hours and 48 minutes after the last dose was given at 2:29 p.m., instead of the ordered eight hours between doses. -2/25/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 1:34 p.m. (four hours and 34 minutes late). -2/17/2025 metformin 500 mg, scheduled for administration at 7:30 a.m., to be given with food was documented administered at 11:10 a.m. (over three hours late). -2/18/2025 metformin 500 mg, scheduled for administration at 7:30 a.m., to be given with food was documented administered at 10:09 a.m. (over two hours late). -2/17/2025 metformin 500 mg, scheduled for administration at 7:30 a.m., to be given with food was documented administered at 9:57 a.m. (two hours late). -2/20/2025 metformin, scheduled for administration at 5:30 p.m., to be given with food was documented administered at 7:39 p.m. (two hours late). -2/24/2025 metformin, scheduled for administration at 7:30 a.m., to be given with food was documented administered at 2:28 p.m. (almost seven hours late). -2/17/2025 metformin, scheduled for administration at 5:30 p.m., to be given with food was documented administered at 5:17 p.m. (less than three hours since last administration of 2:38 p.m.). c. During a review of Resident 54's Admission Record, the Admission Record indicated Resident 54 was admitted to the facility on [DATE] with diagnoses that included repeated falls, cardiomegaly, hypertension, and atrial flutter (a condition in which the heart's upper chambers [atria] beat too quickly) During a review of Resident 54's, MDS dated [DATE], the MDS indicated Resident 54's cognitive skills for daily decision-making was severely impaired. A review of Resident 54's H&P dated 6/22/2024 indicated, She has been in ED (emergency department) three times in three days following falls at her SNF (a previous skilled nursing facility). First visit on 6/15/2024 after a witnessed fall while getting up from bed and tempted to use her walker and fell . Resident 54's H&P indicated the resident had persistent atrial fibrillation and was on anticoagulant therapy, Fall Risk Precautions, and did not have medical decision making capacity. During a review of Resident 54's Order Summary Report for February 2025, the Order Summary Report indicated Resident 54 had an order for Eliquis 2.5 mg, to give one tablet by mouth two times a day scheduled at 9 a.m., and 5 p.m., for AF / atrial flutter. During a review of Resident 54's Care Plans revised 1/5/2025, the care plans indicated Resident 54: -was at risk for falls related to gait/balance problems, at risk for fall due to history of repeated falls prior to admission to facility. The most recent fall was on 12/25/2024. -has Black Box Warning for use of apixaban (Eliquis): atrial fibrillation, resident's care plan goal revised 10/14/2024 indicated Resident 54 will not experience side effects/interactions with the use of apixaban (Eliquis). During a record review of Resident 54's Medication Administration Audit Report, Resident 54's Medication Audit Report was reviewed between 2/1/2025 to 2/25/2025, the Medication Administration Audit Report indicated resident was administered apixaban less than 8 hours from the next scheduled dose as follows on: -2/17/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 11:48 a.m. (two hours and 48 minutes late). -2/17/2025 apixaban 2.5 mg scheduled for administration at 5 p.m., was administered at 5:42 p.m., five hours and 54 minutes after the last dose was given at 11:48 a.m., instead of the ordered eight hours between doses. -2/18/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 11:40 a.m. (two hours and 40 minutes late). -2/18/2025 apixaban 2.5 mg scheduled for administration at 5 p.m., was administered at 5:14 p.m., five hours and 54 minutes after the last dose was given at 11:40 a.m., instead of the ordered eight hours between doses. -2/20/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 12:03 p.m. (three hours and three minutes late). During an interview on 2/25/2025 at 3:06 PM with DON, the DON provided a list of 23 residents which included Residents 8, 10, 11, 32, 54, 66, 95, 99. Eleven of the 23 residents were on Station 2, MedCart 2 and 12 of the 23 residents were on Station 2, MedCart 3, that were administered morning medications scheduled for 9 a.m., over 60 minutes pass the scheduled administration time, close to the next scheduled dose, and/ or not in accordance with the physician's orders between 2/17/2025 - 2/25/2025. The DON stated there was no documentation that the physician was called prior to LVN 1 and LVN 2 administering medications late to residents on Station 2 MedCart 2, and to residents on Station 2 MedCart 3 on 2/25/2025. The DON stated the physician should have been called before administering medications late to residents and they were working to notify the physicians now. d. During a review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including seizures (a sudden, uncontrolled burst of electrical activity in the brain that can cause temporary changes in behavior, movement, sensation, or awareness), cerebral palsy (a brain disorder that affects a person's ability to move and maintain balance and posture), and cerebral infarction (stroke, death of brain tissue caused by a lack of blood flow) due to occlusion or stenosis of right middle cerebral artery (a narrowing or blockage of the blood vessel that supplies blood to the brain). During a review of Resident 1's, MDS dated [DATE], the MDS indicated Resident 1's cognitive skills (mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making was intact. Resident 1's MDS indicated the resident required set up for eating, moderate assistance for oral hygiene and was dependent on staff for physical assistance. During a review of Resident 1's, H&P dated 1/29/23 the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated Resident 1 had an order for Depakote (valproic acid) Solution 250 milligrams (mg - unit of measure of weight) per 5 (five) milliliters (ml - unit of measure of volume) 250 mg/5 ml, to give 5 ml by mouth three times a day, scheduled at 9 a.m., 1 p.m., and 5 p.m., for seizure, order date 2/23/2023. During a review of Resident 1's, Care Plan revised 2/7/2025, the care plan indicated Resident 1 had a Black Box Warning (a serious warning given by the Food and Drug Administration (FDA) for drugs or drug classes that may cause serious harm or death) for use of Depakote (valproic acid), indication for seizures, care plan goal indicated the resident will not experience side effects/interactions (when one drug alters the effectiveness of another drug) with the use of Depakote. Resident 1's care plan intervention indicated, Black Box Warning .monitor resident closely . Hepatic failure resulting in fatalities has occurred in patients receiving valproate .Severe or fatal hepatotoxicity may be preceded by nonspecific symptoms such as malaise (a general feeling of being unwell), weakness, lethargy (lack of energy), facial edema (swelling), and vomiting. In patients with epilepsy (a neurological condition that causes unprovoked, recurrent seizures [is a sudden rush of abnormal electrical activity in your brain]), a loss of seizure control may also occur. During a record review on 2/27/25 at 1:30 p.m., with the Director of Nursing (DON), Resident 1's Medication Administration Audit Report was reviewed for 2/17/2025 to 2/26/2025, the Medication Administration Audit Report indicated the following: -Resident 1's scheduled 9 a.m. dose of valproic acid was given at 1:37 p.m., on 2/20/2025, which was four hours and 37 minutes later than scheduled and dose. The valproic acid ordered for 1 p.m. was given at 2:16 p.m. on 2/20/2025, which was 39 minutes after the last dose was given at 1:37 p.m. -Resident 1's scheduled 9 a.m. dose of valproic acid was given at 10:58 a.m., on 2/22/2025, which was one hour and 58 minutes later than scheduled dose and the valproic acid ordered for 1 p.m. was given at 12:12 p.m. on 2/22/2025, which was one hour and 14 minutes after the last dose was given at 10:58 a.m. -Resident 1's scheduled 9 a.m. dose of valproic acid was given at 11:21 a.m., on 2/23/2025, which was two hours and 21 minutes later than scheduled and the valproic acid ordered for 1 p.m. was given at 12:54 p.m. on 2/23/2025, which was one hour and 33 minutes after the last dose was given at 11:21 a.m. -Resident 1's scheduled 9 a.m. dose of valproic acid was given at 12:33 p.m., on 2/25/2025, which was three hours and 33 minutes later than scheduled and the valproic acid ordered for 1 p.m. was given at 2:28 p.m. on 2/25/2025, which was one hour and 55 minutes after the last dose was given at 12:33 p.m. During an interview on 2/27/2025 at 1:38 p.m., the DON stated giving a seizure medication 40 minutes after the first dose or close to the next scheduled dose was not acceptable. The DON stated this would be considered double dosing and could cause Resident 1 to experience adverse reactions (unwanted or harmful effect that can occur when taking a drug or undergoing a medical procedure) and could cause Resident 1 to reach toxic levels of the valproic acid, could trigger a seizure or lead the resident becoming hospitalized for uncontrolled seizures or death. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2012, the P&P indicated the facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Medications were administered in accordance with written orders of the prescriber. Medications were administered within (60 minutes) of scheduled time, except before or after meal orders, which are administered (based on mealtimes). e. During a review of Resident 37's Admission Record, the Admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including seizures and traumatic subdural hemorrhage (a brain injury that occurs when blood builds up between the brain and the skull) with loss of consciousness of unspecified duration During a review of Resident 37's MDS dated [DATE], the MDS indicated Resident 37's cognitive skills for daily decision-making was moderately impaired. Resident 37's MDS indicated the resident required set up for eating and was dependent on staff for physical assistance with oral hygiene, bathing, and dressing, During a review of Resident 37's, H&P dated 3/31/22, the H&P indicated Resident 37 can make needs known but cannot make medical decisions. During a review of Resident 37's Order Summary Report, the Order Summary Report for February 2025 indicated Resident 37 had an order for Keppra (levetiracetam) 500 mg, to give one tablet by mouth two times a day, scheduled at 9 a.m. and 5 p.m., for seizures. During a review of Resident 37's, Care Plan revised 2/7/2025, the care plan indicated Resident 37 had a seizure disorder and the care plan intervention indicated to give seizure medication as ordered by doctor, to monitor and document side effects and effectiveness. During a record review, Resident 37's Medication Administration Audit Report was reviewed for 2/17/2025 to 2/26/2025, the Medication Administration Audit Report indicated the following: -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 2:12 p.m., on 2/20/2025, which was five hours and 12 minutes later than scheduled and the levetiracetam ordered for 5 p.m. was given at 5:47 p.m. on 2/20/2025, which was three hours 35 minutes after the last dose was given at 2:12 p.m. -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 11:01 a.m., on 2/22/2025, two hours later than scheduled. -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 11:24 a.m., on 2/23/2025, two hours and 24 minutes later than scheduled. -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 12:11 p.m., on 2/24/2025, over three hours later than scheduled. -Resident 37's scheduled 5 p.m. dose of levetiracetam was given at 10:54 p.m., on 2/24/2025, almost six hours later than scheduled. -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 12:06 p.m., on 2/25/2025, which was three hours and six minutes later than scheduled and the levetiracetam ordered for 5 p.m. was given at 5:29 p.m. on 2/20/2025, which was four hours 23 minutes after the last dose was given at 12:06 p.m. During an interview on 2/26/2025 at 1:37 p.m., with the facility's Pharmacist Consultant (PC) stated the facility was supposed to have a process in place to have another nurse help to ensure medication administration did not run into the noon or next medication administration time if residents had medications scheduled for two or three times a day. The PC stated he suggested to the facility's Assistant Director of Nursing (ADON) and the DON several months ago, having another nurse to assist with medication pass to prevent late medication administration. The PC stated when medications were administered over three hours late, that was not acceptable practice. The PC stated it was important to give apixaban as ordered because of the pharmacokinetics (the movement of drug into, though, and out of the body) of the medication to maintain therapeutic effects (the response(s) after a treatment of any kind, the results of which were judged to be useful or favorable). The PC stat

Based on interview, and record review, the facility failed to revise (update) the care plan for 3 sampled residents (Resident 82, 84, and 1) by: -Failing to update the elopement (the act of leaving a facility unsupervised and without prior authorization) / wandering care plan quarterly (every 3 months) as per the facility's policy for Resident 82. -Failing to update the activities care plan quarterly to reflect Resident 84's activity preferences. -Failing to update and revise a Pressure Ulcer (damage to the layers of the skin caused by prolonged pressure on a part of the body) Care Plan to meet the individual needs for Resident 1 with a ischium (a bone in the pelvis that forms the lower and back part of the hip bone) pressure ulcer. This deficient practice had the potential to affect the provision of necessary care, treatment, and services for Resident's 82, 84, and 1. Findings: a. A review Resident 82's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain's function was impaired due to an imbalance in the body's metabolism), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities). A review of the history and physical (H&P) completed on 6/4/2024 indicated Resident 82 did not have the capacity to understand or make decisions. A review of the quarterly Minimum Data Set (MDS - a resident assessment tool) dated 12/6/2024, indicated Resident 82 had moderate cognitive impairment a decline in thinking and memory that makes it hard to complete complex tasks) and did not indicate that wandering behavior was exhibited. A review of Resident 82's Wandering/Elopement Risk evaluation dated on 6/18/2024, indicated the resident wandered aimlessly (randomly) without purpose and had no history of elopement. A review of Resident 82's Wandering/Elopement Risk evaluation dated 12/6/2024, indicated the resident did not wander aimlessly without purpose and had no history of elopement. A review of Resident 82's Devices/Physical Restraint assessment dated [DATE], indicated that a Wander guard device was needed to alert staff if Resident 82 attempted to get out and was close to the exit door. A review of the Physician's Order dated 6/3/2024, indicated use of a Wander guard to alert staff when Resident 82 attempted to get out and was close to the exit door. It indicated to monitor placement of the Wander guard on every shift. A review of Resident 82's elopement/wandering care plan last revised on 6/18/2024, indicated interventions that included a Wander guard alarm (wearable bracelet designed to alert caregivers when a resident or patient at risk of wandering approaches a monitored door or exits a designated safe area) to be always worn due to poor safety awareness, assist in reorientation from opening doors, and provide diversional activities. It further indicated that the resident would not elope/wander out of the facility every shift and will accept redirection when observed near exits thru next review date. b. A review of Resident 84's face sheet, indicated resident was admitted on [DATE] with diagnoses including congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic kidney disease (CKD- a condition in which the kidneys are damaged and cannot function properly over a long period of time), and atrial fibrillation (an irregular and rapid heart rhythm). A review of Resident 84's H&P dated on 7/24/2024, indicated that resident had a lack of capacity. A review of Resident 84's MDS dated [DATE], indicated the resident had no cognitive impairment. The MDS further indicated that it was somewhat important for the resident to do their favorite activities and have books, newspapers, and magazines to read. A review of the Resident 84's quarterly Activity Participation Review assessment dated [DATE], indicated the resident was in the room visit sensory stimulation (the use of various stimuli to activate the senses, such as sight, smell, hearing, touch, and taste) program and would participate in group activity when she was able, and that the resident enjoyed her headphones and refused invitation to group activities and special events. It further indicated the interventions / approaches were partially effective in attaining goals and the approaches have been revised. A review of Resident 84's activities care plan last revised on 10/4/2024, indicated interventions that included assisting the resident to and from the activity area in the morning, afternoon, and special events, provide self-directed activity materials such as reading, music, and memory games. The care plan did not mention that resident was in the sensory stimulation program or that resident enjoyed wearing headphones as indicated in Resident 84's Activity Participation Review Assessment. During a concurrent interview and record review on 2/27/2025 at 9:35 AM with the Activities Director (AD), the AD stated that he reviewed and revises the activities care plan quarterly. The AD stated that it was important to review and revise the care plans so that they know what the resident's activity preferences were and to ensure the activities were appropriate for each resident. The AD stated Resident 84's care plan should have been updated to reflect their current interests. The AD further stated that if the care plans were not updated or revised then they would not be resident centered. During an interview on 2/27/2025 at 1:39 PM, the Director of Nursing (DON) stated resident care plans should be updated on a quarterly and when there was a change of condition. The DON stated it was important for the care plans to be updated to ensure the interventions were being implemented, effective, and that the resident's goals were met. A review of the facility's policy and procedure (P&P) titled, Activities, revised 3/2023 indicated resident's individualized activities of interest shall be noted in the assessment, identified in the plan of care, and updated as necessary to reflect the changes in the resident's preferences. A review of the facility's P&P titled, Comprehensive Care Plans-Timing, revised on 3/2023, indicated the interdisciplinary team reviews and revises the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessment. 50296 c. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs), cerebral palsy (a movement disorder that affects posture and balance), and lumbar spina bifida (a birth defect where the spinal cord does not fully close during fetal development). A review of Resident 1's MDS dated [DATE] indicated the resident was alert and oriented and had good recall. The MDS indicated Resident 1 had impairment on one side of the resident's upper extremity and on both sides of the resident's lower extremity. During a concurrent observation in Resident 1's room and interview on 2/24/25 at 9:26 am, Resident 1 was lying in bed, siderails up x 2, the call light was within reach. Resident 1 stated she was on an alternating pressure bed (bed with an air mattress that changes pressure points) because she had a wound on the left hip and the mattress was used to prevent more pressure ulcers (Stage I: red, warm to touch, stays red when pushed down on, Stage II: break in top layer of skin, Stage III crater-like appearance damage to top layers and fat layers, Stage IV: damage to all layers of skin, including muscle, bone may be visible) . The mattress was set at 3, 20 min alternating pressure. Resident 1 stated the pressure ulcer dressing was changed daily. During a concurrent interview and record review on 2/25/25 at 1:24 PM with the Treatment Nurse (TN), Resident 1's Pressure Ulcer Care Plan dated 10/4/24 was reviewed. The Pressure Ulcer Care Plan indicated the last revision was dated 10/4/24. The TN confirmed the care plan was not revised. The TN stated the care plan was a guide and if not revised then facility staff would not know if the care plan was effective. During a concurrent interview and record review on 2/25/24 at 1:28 PM, with the Minimum Data Set Nurse (MDSN), Resident 1's Pressure Ulcer Care Plan dated 10/4/24 was reviewed. Resident 1's Pressure Ulcer Care Plan indicated last revision date was 10/4/24. The MDSN stated Care plans had to be revised every three months. The MDSN confirmed there was no way to know if the interventions were effective if interventions were not revised. The MDSN stated the risk to the Resident 1 would be ineffective wound healing. During an interview on 2/27/25 at 1:29 PM, the DON stated the care plans had to be updated and reviewed quarterly, if no changes were needed then the same goals and interventions would continue. The DON stated if the care plan was not working the treatments/care plans had to be revised. The DON stated facility staff were not assessing the care plans. The DON stated the interventions were not updated which made it seem like nothing was being done. A review of the facility's P&P titled, Skin Assessment, dated 3/23 indicated quarterly assessments would be completed using the standardized assessment tool in accordance with the RAI guidelines for completion. A review of the facility's P&P titled, Comprehensive Care Plans-Timing, dated 3/23 indicated the interdisciplinary team was to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments.

Based on interview and record review, the facility failed to protect the resident's right to be free from abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1), who had diagnoses of mood affective disorder (a condition that affects a persons emotions) and unspecified psychosis (a condition that makes people lose contact with reality, seeing and hearing things that other people cannot, and believing things that are not true). The facility failed to: -Ensure a complete and adequate comprehensive assessment on 5/29/2024 and 7/24/2024, including cognitive patterns, mood, behaviors, and active diagnoses. -Review and reassess the Mood Impairment care plan interventions quarterly and on a regular basis, per the Abuse Prevention, Agitated or Combative Residents policy. -Develop a comprehensive person-centered care plan for the medical diagnosis psychosis (a mental disorder condition characterized by a disconnection from reality, seeing and hearing things that other people cannot, and believing things that are not true). -Supervise or monitor Resident 2, per the Depression care plan and the facility policy titled, Abuse Prevention, when on 8/25/2024 around 10 PM, Resident 2 was verbally abusive to staff, exhibiting a decline in mood and coping skills. As a result, on 8/25/2024 at around 11:15 PM, a charge nurse yelled for help as Resident 2 pulled the curtain back when the nurse provided care to Resident 2's roommate (Resident 1). Resident 2 continued to scream and yell inappropriately to the charge nurse and Resident 1, then threw a cup of juice which hit Resident 1. Resident 1 stated he was fearful and felt unprotected by being attacked by Resident 2. On 8/26/2024, Resident 2 was transferred to the General Acute Care Hospital (GACH) due to physical and verbal aggression, manifested by abusive behavior, inappropriate behavior, throwing objects, and for psychiatric evaluation. Findings: A review of Resident 2's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, unspecified depression (a disease that causes low mood or loss of interest in activities, disrupts sleep patterns, and irritability), mood affective disorder (a condition that affects a persons emotions), and unspecified psychosis (a condition that makes people lose contact with reality, seeing and hearing things that other people cannot, and believing things that are not true). A review of the Psychology Assessment (an evaluation by a mental health professional who studies behavior, knowledge, and mind), dated 4/16/2024 indicated, Resident 2 spoke about his former roommate and an incident that caused him frustration. The assessment goal was to provide a space for Resident 2 to process emotion in order for him to feel calmer. A review of the At Risk for Mood Impairment care plan dated 4/18/2024, indicated Resident 2 was short tempered, easily annoyed, screamed and cursed at others. The goal indicted for Resident 2 not to exhibit a decline in mood and demonstrate coping skills. The care plan interventions indicated a psychological referral and treatment as indicated and to observe for and note decline or improvement since previous mood assessment. Further review indicated this care plan was not reviewed or revised quarterly, last update was 8/29/2024 (after the incident). According to a review of the Progress Note dated 4/21/2024, Resident 2 was being monitored due to an episode of verbal aggression towards his roommate indicating a decline in mood, per the Mood Impairment care plan. The Progress Note dated 4/24/2024 indicated Resident 2 was transferred to the GACH for evaluation of verbally aggressive behavior. A review of Resident 2's Psychiatric Intake Note dated 4/30/2024 indicated Resident 2 was very irritable, increasingly agitated, and dismissive. The note indicated the resident refused for the interview and conversations to continue, and refused taking the prescribed medication Zoloft (a medication that treats depression, anxiety). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 5/29/2024 indicated Resident 2's cognitive skills for daily decision making were not assessed and remained blank. The MDS indicated Resident 2 had no symptoms of feeling down and no symptoms of little interest or pleasure in doing things, no hallucinations or delusions and no physical / verbal behaviors directed towards others. The MDS indicated Resident 2 did not reject evaluation of care, which was a discrepancy compared to the Psychiatric Intake Noted dated 4/30/2024. Further review of the MDS indicated the resident's active diagnoses remained blank, and did not have a psychotic disorder. The MDS indicated Resident 2 did not experience social isolation and never felt lonely or isolated from those around him. A review of the History of Depression care plan revised on 6/2/2024 indicated Resident 2 was not on any pharmacological intervention. The care plan interventions indicated to monitor / document / report anxiety, verbalizing negative statements, risk for harming others, increased anger, agitation, feels threatened by others or thoughts of harming someone. A review of the Psychiatrist Progress Note dated 6/10/2024 indicated to refer Resident 2 to psychotherapy, encourage group participation and no psychotropic medications at this time. A review of the Psychiatrist Progress Noted dated 7/19/2024 indicated to refer Resident 2 to psychotherapy, encourage group participation and resident refused any psychotropic medication. Further review of the medical record indicated there was no referral completed for Resident 2 to receive psychotherapy after 6/10/2024. According to a review of the MDS dated [DATE], Resident 2's cognitive patterns had no acute change in mental status from the resident's baseline, no symptoms of feeling down and no symptoms of little interest or pleasure in doing things. The MDS indicated Resident 2 did not feel lonely or isolated and that the resident's cognitive skills for daily decision making were not assessed (remained blank). A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE] with diagnosis including quadriplegia (injury or disease affecting the spinal cord and brain that causes loss of feeling and function of limbs), muscle weakness, and unspecified disorder of muscle. The medical record indicated Resident 1's cognition was intact (ability to think, remember, use judgement, and make decisions). A review of the Progress Note dated 8/25/2024 indicated at around 10 PM, the charge nurse reported that Resident 2 (bed A) was verbally aggressive to staff. The Registered Nurse checked on Resident 2 and requested the resident calm down, but Resident 2 continued to be verbally aggressive to staff and the doctor was informed. The Progress Note indicated at around 11:15 PM, a charge nurse yelled for help as Resident 2 pulled the curtain back when the nurse provided care to Resident 2's roommate (Resident 1). Resident 2 continued to scream and yell inappropriately to charge nurse and Resident 1, then threw a cup of juice which hit Resident 1. A review of the Progress Note dated 8/26/2024 indicated Resident 2 was transferred to the GACH due to physical and verbal aggression, manifested by abusive behavior, inappropriate behavior, throwing objects, and for psychiatric evaluation. During an interview on 9/4/2024 at 9:43 AM, Resident 1 stated his roommate (Resident 2) was verbally and physically abusive towards him (on 8/25/2024). Resident 1 stated Resident 2 threw items at him hitting him on his arm and right side of his head. Resident 1 stated he was fearful and felt unprotected, as this incident with Resident 2 triggered a prior abuse experience from a different facility. During an interview on 9/4/2024 at 11:17 AM, the facility administrator (ADM) stated Resident 2 was verbally abusive towards staff throughout his stay in the facility. The ADM stated Resident 2 was referred for psychological and psychiatric evaluations with no significant outcomes that showed changes in Resident 2's behavior. During an interview on 9/4/2024 at 12:11 PM, Certified Nursing Assistant (CNA) 2 stated, that on 8/25/2024 around 11 AM, I was assisting a resident in the next room, and I heard Resident 2 screaming. I went to Resident 2's room to check. Resident 2 was verbally abusive cursing at Resident 1, and started throwing things. CNA 2 stated she remained with Resident 1, called for help, and Resident 2 continued being verbally abusive towards staff and Resident 1, throwing cups of juice and pillows hitting Resident 1. On 9/4/2024 at 12:29 PM, during a telephone interview, Licensed Vocational Nurse (LVN) 1 stated that on 8/25/2024 at around 11:15 AM, I witnessed Resident 2 throwing juice containers and pillows at Resident 1 and LVN 1. Resident 2 was verbally abusive and throwing things while LVN 1 was assisting Resident 1. Resident 1 had to be removed from room to ensure Resident 1's safety. During an interview on 9/5/2024 at 2:15 PM, the Director of Nursing (DON) stated Resident 2 had been refusing medications since April 2024, was verbally aggressive, dismissive, and uncooperative with care planning. The DON stated since Resident 2 did not exhibit any behaviors of psychosis that at psychosis care plan was not required. During an interview on 9/5/2024 at 2:31 PM, the MDS Coordinator stated she could not explain Resident 2's inadequate MDS assessment, including the resident's daily decision making and active diagnoses remaining blank. The MDS Coordinator stated the importance of a complete and accurate MDS assessment was to obtain the baseline assessment, prevent decline, and improve outcomes. The MDS Coordinator stated she would review and update the MDS for Resident 2. The MDS Coordinator stated the care plan for Psychosis was supposed to be developed and the importance of having the care plan was to get a resident's baseline, prevent decline, improve outcome of behavior and psychosocial wellbeing for the resident and other residents. A review of the facility's Policy and Procedure titled, Behavioral Health Services, dated March 2023, indicated the facility provides behavioral health care and services which include necessary care and services for person-centered care and reflects the resident's goals for care while maximizing the resident's dignity, autonomy, socialization, independence, choice, and safety. The interdisciplinary team including the resident, their family, or the resident representative ensures residents individualized behavioral health needs are met, through the Resident Assessment Instrument (RAI) process. A review of the facility's Policy and Procedure titled, Abuse Prevention Agitated or Combative Residents, dated March 2023, indicated each resident had the right to be free from mistreatment, neglect, and misappropriation of property. This included the facility's identification of residents' whose personal histories render them at risk for abusing other residents that would trigger abusive behavior, and reassessment of the interventions on a regular basis. The policy indicated the facility takes reasonable precautions, including providing adequate supervision, when the risk of resident-to-resident altercation was identified. A review of the facility's policy and procedure titled, Develop-Implement Comprehensive Care Plans, reviewed 3/2023 indicated the facility developed person-centered comprehensive care plans that were culturally competent and trauma-informed, developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, and mental and psychosocial needs. The policy indicated care plans shall include the discipline providing care or services, measurable, objectives and timeframes in order to evaluate the resident's progress towards his/her goals(s). The policy did not indicate the federal requirement to review, revise or update the care plan on a quarterly basis.

Based on interview, and record review, the facility failed to assure that services being provided meet professional standards of practice for two of three sampled residents (Resident 1 and Resident 2). For Resident 1, the facility failed to: a. Evaluate and analyze hazards and risks for Resident 1 who is had multiple falls. b. Monitor for the effectiveness and modify interventions for a resident who is a non-compliant. As a result, on 3/13/2024, Resident 1 had a fall from his wheelchair when attempted to transfer himself to his bed and was found on the floor. Resident 1 was transferred to GACH 1 via 911 and sustained a right ankle fracture. For Resident 2, who had severely impaired vision, the facility failed to: c. Complete an accurate Fall Risk Assessment on 9/4/2024. d. Evaluate and implement individualized, resident-centered interventions to reduce the risk of fall for Resident 2. As a result, on 3/16/2024, Resident 2 had a fall from her bed when she turned abruptly (in a sudden and unexpected way) to her left side and was found on the floor. Resident 2 was transferred to GACH 2 via 911 and sustained rib (a curved bone in a person's chest) fractures. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility originally admitted the resident on 11/29/2022, and readmitted on [DATE], with diagnoses including fall, cachexia (loss of body weight and muscle), and muscle weakness. A review of Resident 1's History and Physical dated 12/15/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Situation-Background-Assessment and Recommendation (SBAR - a written communication tool that helps provide important information) Communication Form dated 1/2/2024, indicated the resident was found sitting on the bathroom floor with a skin tear at his right elbow. The SBAR indicated Resident 1 stated he hit the right side of his head. As a result, a 72- hour neuro-check was initiated. A review of Resident 1's Post Fall Evaluation/Interdisciplinary Team Review (IDT- a group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) dated 1/2/2024 at 3:57 PM, indicated Resident 1 had unsteady gait and generalized muscle weakness related to the aging process. The IDT Review indicated Resident 1 continued to perform activities beyond his ability and was not compliant with the requirement to call for assistance when using the toilet, despite being educated to do so. A review of Resident 1's Care Plan initiated on 1/2/2024, and resolved on 3/13/2024, indicated that Resident 1 had an actual fall due to poor balance and unsteady gait. The care plan goal for the resident was to resume usual activities minimizing the risk of injury until the next review date. The care plan interventions indicated to check Resident 1's range of motion, encourage the resident to use the bell to call for assistance, keep call lights with reach at all times, monitor/document/report as needed for 72 hours any signs/symptoms of pain, bruises, change in mental status, sleepiness, inability to maintain posture, neuro-checks for 72 hours as ordered, and to start Resident 1 on RNA ambulation (walking with Restorative Nursing Assistant-Assist residents with exercise to improve or maintain mobility and independence) for strength and mobility three times a week. A review of Resident 1's Physician's Progress Notes dated 2/1/2024, indicated the resident was non-compliant with care, did not call for assistance and wants to be independent beyond capacity. The notes indicated Resident 1 had recurrent (happening again) falls, and a diagnosis of osteoporosis (a disease that weakens your bones) which placed him at increased risk for recurrent fracture. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/1/2024, indicated the resident had moderately impaired cognition (decisions poor, cues/supervision required) and required maximum assistance (helper does more than half the effort) with showering. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, personal hygiene, dressing upper and lower body, sit to stand (the ability to come to standing position from sitting in a chair, wheelchair and or on the side of the bed), chair/bed to chair transfer (the ability to transfer to and from a bed to chair or wheelchair), and toilet transfer (the ability to get on and off a toilet or commode). A review of Resident 1's SBAR Communication Form dated 3/5/2024, indicated Resident 1 had an assisted fall (when a staff member was with the patient and attempted to minimize the impact of the fall) and was found on the floor with a skin tear at his right elbow and forearm. A review of Resident 1's Fall Risk Evaluation after fall, dated 3/6/2024, indicated a total score of 10. The fall risk evaluation form indicated that if the total score was 10 or greater, the resident should be considered at high risk for potential falls. The form indicated Resident 1 was oriented to person, place, and time, had one to two falls within the last three months, had adequate vision, had balance problem while standing/walking, and had 1-2 predisposing conditions (conditions and activities that can lead to the development of disease). A review of the Physical Therapy (PT) Evaluation and Plan of Treatment dated 3/6/2024, indicated Resident 1 was presented to therapy due to repeated falls in the facility with the most recent occurring on 3/5/2024. The PT evaluation form indicated Resident 1 had soreness to the right shoulder and left hip, the X-ray was negative for fracture and had decreased strength and safety awareness. A review of Resident 1's Post Fall Evaluation/IDT Review dated 3/7/2024 at 12:21 PM, indicated the lost his balance while standing up and using urinal and was assisted to the floor by Certified Nursing Assistant (CNA) staff. The IDT Review indicated Resident 1 had episodes of confusion and forgetfulness and required partial to moderate assistance (helper does less than half the effort) with transfers from his bed to his wheelchair and vice versa (with the order changed). The IDT Review indicated the facility would place a floor mat on the left side of the bed to minimize injury in case of a fall. A review of Resident 1's Care Plan initiated on 3/10/2024, indicated the resident had an assisted fall due to loss of balance while using urinal. The care plan goal for the resident was to resume usual activities minimizing the risk of injury until the next review date. The care plan interventions indicated to assess for pain every shift and medicate as needed, check Resident 1's range of motion, encourage the resident to use the bell to call for assistance, keep call lights with reach at all times, monitor/document/report as needed for 72 hours any signs/symptoms of pain, bruises, change in mental status, sleepiness, inability to maintain posture, place a floor mat on left side of the bed to minimize injury in case of fall reoccurrence and to provide skilled PT and Occupational Therapy (OT-therapy that focuses on helping people do all the things that they want and need to do in their daily lives). A review of Resident 1's Physical Therapy Treatment Encounter Notes dated 3/12/2024, indicated the resident reported pain in his left knee, had difficulty standing due to pain and required moderate verbal and tactile (using the sense of touch) cues (signals) to facilitate proper posture and movement during the treatment. A review of Resident 1's Care Plans initiated before 3/13/2024, did not indicate any care plans developed for Resident 1 regarding his non-compliance with care and calling staff for assistance. A review of Resident 1's SBAR Communication Form dated 3/13/2024, indicated the resident fell from his wheelchair, was heard calling for help. The CNA went inside the resident's room and found Resident 1 on the floor mat, on the left side of his bed. The SBAR form further indicated Resident 1's ankle looked dislocated, and he was transferred to GACH 1 for further evaluation. The SBAR form indicated Resident 1 was trying to transfer himself into his bed without staff assistance and he was non-compliant and not using the call light for assistance. A review of Resident 1's Fall Risk Evaluation after fall, dated 3/13/2024, indicated a total score of 11, and that 10 or greater, the resident should be considered at high risk for potential falls. The form indicated Resident 1 was oriented to person, place, and time, had three or more falls within the last three months, had adequate vision, had balance problem while standing/walking, required use of assistive devices and had 1-2 predisposing conditions. A review of Resident 1's Rehabilitation Screening Form dated 3/13/2024, indicated the resident had a history of falls in the past years with the most recent fall on 3/5/2024. The form indicated Resident 1 was currently on skilled therapy. A review of Resident 1's Post Fall Evaluation/IDT Review dated 3/13/2024 at 4:10 PM, indicated the resident had possible dislocated right ankle, had difficulty walking, osteoporosis, and generalized muscular weakness, and that the fall was due to Resident 1 trying to be independent beyond his ability. The evaluation indicated the resident was non-compliant with calling for staff assistance when help is needed. Per Resident 1's statement, he attempted to transfer himself from his wheelchair to his bed, lost his balance, and he landed on top of the floor mat at the left side of his bed. The IDT Review indicated that 911 was called and Resident 1 was transferred to emergency room (ER) for further evaluation and treatment of the right ankle. A review of Resident 1's ankle X-ray from GACH 1 resulted 3/13/2024, indicated an acute (new) moderately displaced fracture of distal right fibula (bone on the outside of the ankle). A review of Resident 1's GACH 1 Discharge Summary dated 3/16/2024, indicated Resident 1 sustained an ankle fracture that was reduced (push or pull the ends of the fractured bone until they line up) in the ER. The discharge summary indicated Resident 1 and his family refused Open Reduction Internal Fixation surgery (ORIF- a surgical procedure for repairing fractured bone) and requested a non-operative management (not involving surgery). The discharge summary indicated Resident 1 had a long cast, would be discharged back to his Skilled Nursing A review of the Physician's Orders dated 3/16/2024, indicated to place tab alarm in his bed and wheelchair to alert staff when the resident was trying to get up from his bed and wheelchair unassisted. The order further stated to monitor the placement of the alarms and their function during every shift. A review of Resident 1's Admission Summary notes dated 3/17/2024 at 4:34 AM, indicated the resident was readmitted from GACH 1 to the facility on [DATE] at 5:33 PM. During an interview on 3/28/2024 at 12:22 PM, Restorative Nursing Assistant 1 (RNA 1) stated, The resident (Resident 1) was alert but if you told him not to do something, he would do it. Resident 1 was able to walk with assistance. When he fell for the first time this year, we educated him to use the call light for assistance, but he would say that he wanted to go to the toilet by himself. RNA 1 stated, On 3/13/2024, when Resident 1 fell , I was present in the facility. The CNA took him to the toilet, brought him back near his bed, and asked him if he wanted to be transferred to his bed. Resident 1 replied that he did not want to be transferred to his bed. RNA 1 stated, I was sitting on the hallway in front of the resident's room when I heard a scream. I went inside the room and found him (Resident 1) on the floor. RNA 1 stated Resident 1 attempted to transfer himself from his wheelchair to his bed and he fell . During an interview on 3/28/2024 at 12:43 PM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was alert and oriented, but was not compliant with his care, and did not use his call light for assistance, thinking he could do it all. LVN 1 stated Resident 1 required assistance with his transfers, as he had three falls in 2024. LVN 1 stated, On 3/13/2024, I was assigned to Resident 1 and around 2:50 PM, the CNA had just taken him to the restroom. Resident 1 stayed on his wheelchair, and he tried to get into his bed without assistance. LVN 1 stated Resident 1 did not have a pad alarm on his wheelchair. During an interview on 3/28/2024 at 1:06 PM, Registered Nurse Supervisor 1 (RN 1) stated, On 3/13/2024, I was present in the facility when Resident 1's fall occurred, as I was passing by the resident's room. I saw that one of the CNAs was inside the bathroom with Resident 1. After I left, the CNA came to me and reported that Resident 1 had fallen. RN 1 stated, The resident fell in less than 5 minutes after I left his room. RN 1 stated Resident 1 did not have a tab alarm on his wheelchair, and if there was a tab alarm it would have alerted the staff to assist him. RN 1 stated that when she went to assess the resident, she observed that Resident 1's right foot appeared to be dislocated. RN 1 stated, When I asked the resident why he did not call for help, he replied I just want to do it myself. During a concurrent interview and record review on 3/28/2024 at 4:15 PM, with the Director of Nursing (DON), Resident 1's care plans were reviewed. The DON stated, Resident 1 was non-compliant and for non-compliant residents, we keep educating them. We provide CNAs they are already familiar with. Resident 1 used to go to the bathroom on his own. The DON stated staff did not initiate a care plan for Resident 1's non-compliance with appropriate interventions. The DON stated there was no documentation that Resident 1's family member was informed about the non-compliance to use the call light for assistance. The DON stated Resident 1's family member was not present at any of the IDT meetings and that the resident was able to use the call light, but only used it whenever he wanted to. The DON stated Resident 1 had dementia. During a telephone interview on 3/28/2024 at 5:40 PM, RN 2 stated when Resident 1 used the call light and if we did not get to him immediately, he would become inpatient and get up on his own. During an interview on 3/29/2024 at 1:42 PM, the Director of Rehab (DOR) stated Resident 1 required assistance with transferring, as he was at high risk for falls. The DOR stated Resident 1 did not have strength in his legs, and he required constant reminders to call for help. In his mind, he thought he could get up on his own. However, his legs did not have the strength for him to get up on his own. The DOR stated Resident 1 did not have a bed alarm or chair alarm and a chair alarm would be a good intervention for Resident 1 which would alarm the staff before he tried to get up on his own. During an interview on 3/29/2024 at 4:08 PM, the DON stated the Falling Star Program (a fall prevention program, that focuses on promoting a safe environment and anticipating the patient's needs to prevent a fall ) included residents with falls within the last three months. The DON stated In the falling star program, we monitor residents closely. In addition to low beds, we have safety devises such as tab alarms, rooms close to the nurses' station, and frequent visual monitoring of the residents. The DON stated Resident 1 was part of the falling star program, but he did not have a tab alarm as part of his fall prevention interventions. The DON stated, The resident was alert and oriented. We don't place a tab alarm for residents who are alert and oriented. The DON stated, I included a tab alarm as a person-centered care plan intervention for Resident 1 after his fall on 3/13/2024, when he came back from hospital on 3/16/2024. 2. A review of Resident 2's Admission Record indicated the facility readmitted the resident on 4/29/2022, with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading), low vision right eye, blindness left eye, glaucoma (a chronic, progressive eye disease caused by damage to the optic nerve, which leads to visual field loss), and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). A review of Resident 2's Care Plan initiated on 4/29/2022, indicated the resident had severely impaired visual function related to glaucoma and blindness. The goal for the resident was to use appropriate visual devices to promote participation in Activities of Daily Living (ADLs- activities related to personal care) and other activities. The care plan interventions included to explain surroundings to the resident, keep belongings within her reach and re-orient placement, always provide safety, provide assistance with needs as needed, call light within reach at all times, identify/record factors affecting visual function and to arrange consultation with eye care practitioner as required. A review of Resident 2's History and Physical dated 11/18/2023, indicated the resident had the capacity to understand and make decisions. A review of the SBAR Communication Form dated 7/21/2023, indicated Resident 2 had an alleged unwitnessed fall. The resident stated she fell on the floor next to her wheelchair while ambulating to the restroom. Resident 2 stated that she bumped into the wheelchair, and she fell on the floor. Resident 2 complained of pain at her right leg. The SBAR form further indicated Resident 2 was assessed for injuries and no bruising, discoloration, bleeding, lacerations (cut), or deformities (not the normal shape) were noted to site. A review of Resident 2's Care Plan initiated on 7/21/2023, and revised on 2/8/2024, indicated an alleged fall in the resident's room, but she got up without staff assistance. The care plan goal was to resume usual activities minimizing the risk of injury until the next review date. The care plan interventions indicated to check Resident 2's range of motion, encourage the resident to use the bell to call for assistance, keep call lights within reach at all times, monitor / document / report as needed for 72 hours any signs/symptoms of pain, bruises, change in mental status, sleepiness, inability to maintain posture, neuro-checks for 72 hours as ordered, and pharmacy consult to evaluate medications. A review of Resident 2's Fall Risk Evaluation after fall, dated 7/21/2023, indicated a total score of three (3). The fall risk evaluation form indicated that if the total score was 10 or greater, the resident should be considered at high risk for potential falls. The form indicated Resident 2 did not have any falls within the last three months, was legally blind, had normal gait/balance, and did not have any predisposing conditions (conditions and activities that can lead to the development of disease) such as arthritis (swelling and tenderness of one or more joints), and osteoporosis. A review of Resident 2's Post Fall Evaluation / IDT Review form dated 7/21/2023, indicated Resident 2 alleged the wheelchair was in her way while ambulating to the restroom. A review of the Rehabilitation Joint Mobility Screening Form dated 7/21/2023 at 2:50 PM, indicated that skilled PT and OT therapy was not recommended for Resident 2. The screening form indicated the recommendation was for RNA/ Functional Maintenance program (clinical programs that can be designed to maintain a resident's functional status). A review of Resident 2's Fall Risk Evaluation dated 9/4/2023, indicated a total score of 10. The fall risk evaluation form indicated that if the total score is 10 or greater, the resident should be considered at high risk for potential falls. The form indicated Resident 2 did not have any falls within the last three months, required regular assist with elimination (getting grid of waste from body), was legally blind, had balance problem while standing/walking, had decreased muscular coordination and required use of assistive devices (i.e., cane, wheelchair, walker, or furniture) and did not have predisposing conditions such as arthritis, and osteoporosis. The Fall Risk Evaluation note indicated the resident did not have any falls in the last quarter. A review of Resident 2's History and Physical dated 11/18/2023, indicated the resident had the capacity to understand and make decisions. A review of the SBAR Communication Form dated 3/16/2024, indicated Resident 2 had a fall because she abruptly turned while in bed, was found sitting on the floor beside her bed and complained of pain to left side of her body, rib, hip, and left lower leg. The form indicated the resident was transferred to the hospital due to pain to the left side of her body. A review of the Physician's Orders dated 3/16/2024 at 12:33 PM, indicated to transfer Resident 2 to GACH 2 status post fall due to lower back and left side of the body pain via 911. A review of Resident 2's GACH 2 Computed Tomography (CT- a medical imaging technique used to obtain detailed internal images of the body) of the chest and abdomen report resulted 3/16/2024 at 1:11 PM, indicated the resident had multiple (more than one) fractures of the left 3rd through 9th ribs. A review of the Physician's Orders dated 3/17/2024, indicated to place bilateral floor mats when Resident 2 was in bed to minimize injury in case of fall reoccurrence. A review of Resident 2's Fall Risk Evaluation after fall, dated 3/16/2024, indicated a total score of 5 and that if the total score was 10 or greater, the resident should be considered at high risk for potential falls. The form indicated Resident 2 did not have any falls within the last three months, was legally blind, had normal gait/balance and did not have predisposing conditions such as arthritis, and osteoporosis. A review of Resident 2's Post Fall Evaluation / IDT Review form dated 3/16/2024, indicated the resident had a fall on 3/16/2024, because she abruptly turned to her left side while lying on her bed and ended up on the floor. The IDT review indicated Resident 2 was able to move in and out of bed and ambulate to the toilet on her own and her last fall was on 7/28/2023. The IDT review indicated the resident had history of non-compliance with calling for assistance and wanting to be independent beyond her ability. The IDT review further indicated Resident 2 complained of pain to the left side of her body and was transferred to ER for evaluation. The IDT review further indicated that bilateral (both sides) floor mats were placed at Resident 2`s bedside to minimize the injury in case of fall recurrence. A review of Resident 2's fall care plan initiated on 3/28/2024, after her fall on 3/16/2024, indicated that the resident is at risk for falls related to incontinence, visual problems, history of fall and she gets up to use the bathroom without calling for assistance. The care plan indicated the risk factors as blindness, lower extremities (legs) weakness, and poor transfer balance. The care plan also indicated that the resident had behavior of trying to be independent beyond her ability and was not calling for assistance. The care plan interventions are to orient resident with surroundings, re-educate regarding calling for assistance when needed, remind to use the call light, re-orient placement of call light, room change to be closer to station two for easy visual monitoring, and placement of tab alarm in bed to alert staff when resident is trying to get up unassisted. During an interview on 3/29/2024 at 11:50 AM, RN 3 stated that on 3/16/2024, she was working in the facility. RN 3 stated, It was noon, when the guy who delivers laundry for the residents, started yelling that Resident 2 was on the floor. We went in the room, and Resident 2 was sitting on the floor next to her bed crying. RN 3 stated LVN 1 asked Resident 2 what happened, she stated she was laying on the left side of the bed and fell on the floor when she abruptly turned. RN 3 stated We offered Resident 2 pain medication and asked her where she was feeling pain. At first, she said her lower back, and later stated left hip, leg, and left upper body. RN 3 stated Resident 2's fall on 3/16/2024, was preventable. If a staff member had told Resident 2 that she was not at the center of her bed, she might not have fallen. RN 3 stated staff are required to be more cautious about how residents are laying down on their beds specially for Resident 2 who was blind. RN 2 further stated that Resident 2 required frequent visual checks by staff for safety. During a concurrent interview and record review, on 3/29/2024 at 12:10 PM, with RN 3, Resident 2's Fall Risk Evaluations were reviewed. RN 3 stated fall risk evaluation dated 3/16/2024, with a total score of 5 indicated Resident 2 did not have any falls within the last three months which was incorrect because Resident 2 fell on [DATE] (the same date). RN 3 stated this fall risk assessment indicated Resident 2 did not have any predisposing conditions, which was not correct because Resident 2 had diagnosis of arthritis. RN 3 further stated the fall risk evaluation dated 9/4/2023, indicated Resident 2 did not have any falls within the last three months which was incorrect because Resident 2 fell on [DATE]. RN 3 stated this fall risk assessment indicated Resident 2 did not have any predisposing conditions, which was incorrect because Resident 2 had diagnoses of arthritis. RN 3 stated when the fall risk assessment was completed inaccurately, the assessment value was also incorrect. RN 3 stated Resident 2 was not considered a high risk for fall based on the incorrect fall risk assessments. Therefore, appropriate interventions were not implemented to prevent her fall. RN 3 stated, High risk for fall residents are placed close to the nursing station. If the resident is able to ambulate, we need to put the tab alarm on their bed or wheelchair, so when they move, the alarm goes off. RN 3 stated Resident 2 did not have a tab alarm for her bed or wheelchair. RN 3 stated prior to Resident 2's fall on 3/16/2024, it was required that a floor mat was placed next to her bed. A floor mat would have potentially reduced the extend of her injuries. During a concurrent interview and record review, on 3/29/2024 at 12:20 PM, with RN 3, Resident 2's care plans were reviewed. RN 3 stated Resident 2's care plan for fall was initiated on 7/21/2023 and revised on 2/8/2024. RN 3 stated Resident 2 did not have the necessary person - centered interventions for a person who was blind in the care plan. RN 3 stated one of the interventions that could be added for Resident 2 was the placement of a commode at her bedside or a tab alarm on her bed and performing frequent visual checks by the staff. RN 3 stated the potential outcome of not developing a person-centered care plan for a high risk for fall resident was fall and injury which was what happened to Resident 2 on 3/16/2024. During a concurrent interview and record review on 3/29/2024 at 12:41 PM, with LVN 2, Resident 2's fall risk Assessments were reviewed. LVN 2 stated, On 3/16/2024, after Resident 2's fall, I completed the fall risk assessment. I did not enter any falls for the last three months even though Resident 2 had just fallen. Resident 2 had diagnoses of arthritis which was not included in this assessment. LVN 2 stated if a resident was determined to be at high risk for fall, the facility places them in the Falling Star program. LVN 2 stated Resident 2 was high risk for fall because she was blind. However, she was not placed in the falling star program because she did not have any falls prior to this incident. LVN 2 stated there was no floor mats on the floor next to Resident 2's bed. During an interview on 3/29/2024 at 2:19 PM, CNA 1 stated Resident 2 was very stubborn because she was used to always doing stuff on her own. She did not want to ask for help. CNA 1 stated Resident 2 had visual impairments and used to walk without a walker. CNA 1 stated Resident 2 used to go to the bathroom without calling for help. She did not want to be supervised by the staff, and on 3/17/2024, I was assigned to Resident 2. We performed her morning routine. When I came back from lunch, I was told that she fell . CNA 1 stated there was no floor mats at Resident 2's bedside. During an interview on 3/29/2024 at 4:08 PM, the DON stated Resident 2's care plan for fall initiated on 7/21/2023, was not revised quarterly and the licensed staff were required to revise each resident's care plan quarterly or when there was a change of condition to evaluate the effectiveness of the care plan interventions. The DON stated Resident 2 was blind but very independent. The DON stated Resident 2's fall care plan did not indicate person-centered interventions for a blind resident. The DON stated the potential outcome was insufficient care. The DON stated she included floor mat in Resident 2's care plan intervention after her fall on 3/17/2024. The DON stated Resident 2's fall risk assessments dated 7/21/2023, 9/4/2023, and 3/16/2024 were completed incorrectly. A review of the facility's policy and procedure titled, Post Fall Evaluation, revised 3/2023, indicated the purpose of this procedure was to provide guidelines for identifying the cause (s) associated with resident falls. Documentation: the following should be recorded in the resident's medical record, appropriate interventions taken to reduce the potential for future falls. A review of the facility's policy and procedure titled, Fall Management Program, revised 3/2023, indicated the facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accident hazards as possible. Avoidable Accident: an accident which occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or evaluate and analyze the hazards and risk and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards and risks as much as possible; and/or implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not reduce the risk of an accident; and/or monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. Residents at risk for falling shall have a care plan that identifies individual risk factors and person-centered interventions, based on the risk factors. The facility nursing staff and/or the interdisciplinary team shall update the resident's plan of care accordingly to reduce the risk for further occurrences of a fall and/or to reduce the risk (s) for significant injury related to falling.

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 3), who was a high risk for falls, had a history of multiple falls, and impairment to both lower extremities, received care and services to prevent accidents and falls by failing to: -Revise / update Resident 3's Risk for Falls care plan after the resident had a fall on 8/3/2023 and 9/17/2023. -Implement the Interdisciplinary Team (IDT, group of health care professionals with various areas of expertise who work together toward the goals of their clients) recommendations for Resident 3 to utilize a Geriatric Chair (Geri chair, a large, padded chair with a wheeled base that can recline. The chair is supportive and designed to assist residents with limited mobility and provide more substantial support and comfort than a traditional wheelchair) when up out of bed to prevent falls. -Collaborate with the Rehabilitation staff in Resident 3's Post Fall / IDT review on 9/17/2023, for an individualized plan of care. As a result, on 11/7/2023, Resident 3 had an unwitnessed fall from a wheelchair and was found on the floor. Resident 3 was transferred to the General Acute Care Hospital (GACH) 1 via 911 and sustained a nasal fracture, a hematoma to the forehead and a laceration to the nose. Findings: A review of Resident 3's Admission Record indicated the facility readmitted the resident on 6/23/2015 with diagnoses including hemiplegia (paralysis of one side of the body), contracture (a fixed tightening of muscle, tendons, ligaments, or skin, causes a deformity and prevents normal movement of the associated body part) of muscle of the right hand, contracture of the right elbow, difficulty in walking, cognitive (ability to think, understand, and reason) impairment, and glaucoma (a chronic, progressive eye disease caused by damage to the optic nerve, which leads to visual field loss). A review of Resident 3's History and Physical dated 4/26/2022, indicated the resident did not have the capacity to understand and make decisions due to a cognitive impairment. A review of the Resident 3's Situation, Background, Assessment, and Recommendation (SBAR) / Change of Condition (COC) documentation dated 8/3/2023, indicated Resident 3 was found in activities lying on the floor. The SBAR indicated a skin assessment was done without any injury noted. The SBAR indicated Resident 3 was able to move all extremities without discomfort. The SBAR further indicated Resident 3 was assisted to sit back in the wheelchair and taken back to bed. A review of Resident 3's Post Fall Evaluation / IDT Review documentation dated 8/3/2023 indicated Resident 3 had a fall on 8/3/2023 at 3:10 PM and slid out of the chair while in activities. The IDT Review indicated Resident 3 did not have any complaints of pain and the Range of Motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) remained at baseline for the resident. The IDT Review indicated Resident 3 was to have frequent monitoring while in the wheelchair, physical therapy was to screen the resident, and activities was to provide one-to-one (1:1) room visits as needed. The IDT Review further indicated the facility would continue with the plan of care for risk for falls. The IDT Review indicated The Director of Nursing (DON), Dietary Supervisor (DS), Activities, and Rehab Therapy were present for the IDT meeting. According to a review of the Actual Fall care plan initiated on 8/3/2023 and resolved on 10/17/2023, Resident 3 was found lying on the floor next to her wheelchair. The care plan interventions indicated to check Resident 3's ROM, to continue interventions on the at-risk care plan, encourage the resident to use the bell for assistance, keep the call lights within reach at all times, determine and address causative factors of the fall, monitor/document/report as needed for 72 hours any signs/symptoms of pain, bruises, change in mental status, sleepiness, inability to maintain posture, neuro-checks for 72 hours as ordered, provide 1:1 activities if bed bound, a physical therapy consult for strength and mobility. The care plan did not indicate interventions to have frequent monitoring while in the wheelchair as indicated in the IDT Review documentation dated 8/3/2023 at 4:32 PM. A review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/14/2023, indicated the resident had severely impaired cognitive skills (never/rarely made decisions) for daily decision making. The MDS indicated Resident 3 required total dependence and one-person physical assistance for eating and toilet use. The MDS indicated Resident 3 required extensive assistance and two-person physical assistance for bed mobility and transferring. The MDS indicated Resident 3 required extensive assistance and one-person physical assistance for dressing and personal hygiene. The MDS indicated Resident 3 was not steady and was only able to stabilize with staff assistance for surface-to-surface transfers (transfer between bed and chair or wheelchair). The MDS indicated Resident 3 had impairment to one side of their upper extremities (shoulder, elbow, wrist, hand); and impairment to both lower extremities (hip, knee, ankle, foot). The MDS indicated Resident 3 utilized a wheelchair and was always incontinent (having no or insufficient voluntary control over urination or defecation) of bowel and urine. A review of Resident 3's Order Listing Report dated 9/1/2023 - 2/23/2024, did not indicate a Geri chair was ordered for the resident after the fall on 9/17/2023. A review of Resident 3's Fall Risk Evaluation dated 9/17/2023 indicated the resident was a high risk for falls due to being disoriented (confused and unable to think clearly), regularly incontinent, having poor vision status (with or without glasses), required use of assistive devices (i.e., cane, wheelchair, walker, or furniture), and 1-2 predisposing diseases. According to a review of the SBAR / COC documentation dated 9/17/2023, Resident 3 slid from the wheelchair onto the floor. The SBAR indicated Resident 3 showed no signs of pain and was able to move the lower extremities and left arm. A review of Resident 3's Post Fall Evaluation/IDT Review dated 9/17/2023 at 6:16 PM, indicated Resident 3 was noted with an unwitnessed fall/slide to the floor from the wheelchair and was noted without injury. The IDT Review indicated the IDT recommended a Geri chair for Resident 3 when the resident was up in the wheelchair. The IDT Review indicated Resident 3 was not appropriate for restraints because the resident was totally dependent with activities of daily living. The IDT Review indicated the Assistant Director of Nursing (ADON), Social Services Director (SSD), DS, and Administrator were part of the IDT, and the plan of care was to continue. The IDT Review did not indicate the Rehab or Therapy was part of the IDT. A review of Resident 3's Actual Fall care plan initiated on 9/17/2023 and resolved on 11/8/2023, indicated a goal for Resident 3 to resume usual activities minimizing the risk of injury until the next review date. The care plan interventions indicated to check Resident 3's range of motion, continue interventions on the at-risk care plan, encourage the resident to use the bell to call for assistance, keep call lights with reach at all times, monitor/document/report as needed for 72 hours any signs/symptoms of pain, bruises, change in mental status, sleepiness, inability to maintain posture, neuro-checks for 72 hours as ordered, and to use extended footrest while up in wheelchair for support/safety. The care plan did not indicate interventions to use a Geri chair for Resident 3 when the resident was up in the wheelchair as indicated in the IDT Review dated 9/17/2023 at 6:16 PM. A review of Resident 3's Progress Notes dated 9/17/2023 - 11/7/2023 did not indicate there was documentation Resident 3 was assessed by staff or physical therapy for the appropriateness of use of a Geri chair. The Progress Notes reviewed did not indicate documentation Resident 3 was utilizing a Geri chair. A review of Resident 3's Rehabilitation Screening Form dated 9/18/2023 indicated the resident had a history of falls in the past years with the most recent fall on 9/17/2023. The form indicated Resident 3 slipped out of the wheelchair, was currently on skilled rehabilitation, but did not indicate the IDT recommendations for a Geri chair. A review of the Physical Therapy Treatment Encounter Notes dated 9/20/2023 - 11/8/2023, did not indicate documentation Resident 3 was assessed for the appropriateness of use of a Geri chair. The Physical Therapy Treatment Encounter Notes did not indicate documentation Resident 3 was utilizing a Geri chair. According to a review of the IDT Progress Notes dated 9/25/2023 at 10:12 AM, due to Resident 3's recent fall, the resident was added to the falling star program for 3 months and then would be reevaluated. The note indicated Resident 3 was to have a yellow wrist band placed and a red star by name identifier on the door. The note indicated safety devices were to be noted in place and the plan of care was to continue. A review of Resident 3's Physical Therapy Recert, Progress Report & Updated Treatment dated 8/31/2023 -9/26/2023, did not indicate documentation of Resident 3 utilizing a Geri chair. A review of Resident 3's IDT Progress Note dated 10/17/2023 at 2:45 PM, indicated the resident had a fall on 9/17/2023, was alert and oriented x1 (oriented to either person, place, time, or event) with a diagnosis of hemiplegia, abnormal posture, and mild cognitive impairment of unknown etiology. The progress note indicated Resident 3 had poor safety awareness at times and needed to be redirected. The note indicated Resident 3 was noted as maximum assistance with Activities of Daily Living (ADLs) and transfers, would remain on the falling star program and will be reassessed at the 3-month mark from the most recent fall. The note indicated the plan of care was to be noted as ongoing per the MD orders. A review of Resident 3's Physical Therapy Recert, Progress Report & Updated Treatment dated 9/27/2023 -10/23/2023, did not indicate documentation of Resident 3 utilizing a Geri chair. A review of Resident 3's SBAR / COC documentation dated 11/7/2023 at 1:22 PM, indicated the resident had an unwitnessed fall from her wheelchair in the hallway. The SBAR indicated at around 12:58 PM, Registered Nurse (RN) was notified by Certified Nursing Assistant (CNA) that Resident 3 was on the floor in the hallway. The SBAR indicated Resident 3 was noted with a hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space, usually caused by a broken blood vessel that was damaged by surgery or an injury) to the forehead, a skin tear to the nose and lip with bright red blood. The SBAR indicated Resident 3 had a pain level of 5 out of 10 and was given Tylenol (pain reliever medication) 650 milligrams (mg). The SBAR indicated Resident 3 was assisted back in bed by physical therapy and the treatment nurse, 911 was called, and the resident's physician and the responsible party (RP) were notified. The SBAR indicated at 1:19 PM Resident 3 left the facility to General Acute Care Hospital (GACH) 1. A review of Resident 3's Emergency Documentation from GACH 1 dated 11/7/2023 at 1:44 PM, indicated the resident was brought into the emergency room (ER) by ambulance after being found down at their nursing home. The documentation indicated Resident 3 was eating breakfast in the wheelchair, next thing, staff found the resident on the floor conscious. The documentation indicated Resident 3 was noted to have a hematoma to the forehead and 0.5 centimeters (cm) nasal bridge laceration (a deep cut or tear in skin or flesh). The documentation indicated Resident 3 had a Computed Tomography (CT, a medical imaging technique used to obtain detailed internal images of the body) of the cervical spine (neck), CT of the head, and the maxillofacial (bones of the face) completed. According to a review of Resident 3's CT of the head imaging result dated 11/7/2023, the images of the brain demonstrated there was central frontal and superior nasal (area at the front of the face) soft tissue swelling and hematoma. The result further indicated a focal (focal fracture occurs from a force applied to a small area of the body) comminuted (comminuted fracture occurs when a bone breaks into three or more pieces) and right nasal fracture. A review of Resident 3's CT of the maxillofacial imaging result dated 11/7/2023 at 2:12 PM, indicated frontal and superior nasal soft tissue swelling with focal comminuted nasal bone fracture with foreshortening of the fracture fragments. A review of Resident 3's Emergency Documentation from GACH 1 dated 11/7/2023, indicated the resident had a laceration repair procedure. The documentation indicated Resident's laceration to their nasal bridge measured 1 cm in length. The documentation indicated the laceration was irrigated (flushing of a body part with a stream of liquid) with saline and the skin was closed with derma bond (a sterile, liquid skin adhesive that holds wound edges together). A review of Resident 3's Emergency Documentation from GACH 1 dated 11/7/2023 at 6:11 PM, indicated the resident was cleared by the trauma physician (a physician responsible for treating bone fractures, cuts, internal injuries, burns, and shock) and had physician orders to be discharged back to the nursing facility. A review of Resident 3's Physical Therapy Recert, Progress Report & Updated Treatment dated 10/24/2023 -11/19/2023, did not indicate documentation of Resident 3 utilizing a Geri chair. A review of Resident 3's Health Status Note dated 11/8/2023 at 12:08 AM, indicated the resident's discharge diagnosis was blunt trauma (injury of the body by forceful impact, falls, or physical attack with a dull object), contusion (bruise) of the lip, nasal fracture, nasal laceration, and traumatic hematoma of the forehead. The note indicated Resident 3 had left and right peri-orbital (area around the eyes) area bruises that were a bluish color, nasal area laceration, and glabella (the area of skin between the eyebrows and above the nose) area swelling. A review of Resident 3's Health Status Note dated 11/8/2023 at 5:09 AM, indicated Resident returned to the facility around midnight. During an interview on 2/22/2024 at 11:01 AM, RN 1 stated she was working the day Resident 3 fell on [DATE] and was found face down on the floor. RN 1 stated Resident 3 was bleeding, had a laceration on their nose bridge and had a hematoma on their forehead. RN 1 stated 911 was called and Resident 3 was transferred out to GACH 1. RN 1 stated Resident 3 came back to the facility the next day. RN 1 stated Resident 3 was sitting in their wheelchair and fell out of their wheelchair face down. RN 1 stated Resident 3 can be impulsive and will try to get up on their own. During an interview on 2/22/2024 at 11:30 AM, CNA 2 stated she was working the 7 AM - 3 PM shift on 11/7/2024 when Resident 3 fell . CNA 2 stated Resident 3 was sitting in a wheelchair, states she left the resident for a few minutes and when she came back, she found the resident on the floor. CNA 2 stated Resident 3 was bleeding and had a bump on her forehead. CNA 2 stated when Resident 3 fell , the resident was in a wheelchair. CNA 2 stated, Now she is put in a Geri chair when out of bed, so the resident doesn't fall. On 2/22/2024 at 12:43 PM, during an interview, the Director of Rehab (DOR) stated he assisted Resident 3 back to bed when the resident fell on [DATE]. The DOR stated he was part of the IDT meeting after the fall on 11/7/2023 and indicated the recommendation was for the Resident to utilize a Geri chair when out of bed. The DOR stated Resident 3 was being seen by physical therapy prior to the fall on 11/7/2023, but he was not part of the IDT after Resident 3's fall on 9/17/2023. The DOR stated rehab should be part of the post fall IDT and was usually part of the post fall IDT to help make recommendations. During a concurrent interview and record review on 2/23/2024 at 9:45 AM, Resident 3's risk for falls care plan initiated 2/13/2016 and Resident 3's Post Fall Evaluation/IDT Review dated 9/17/2023 at 6:16 PM were reviewed with RN 1. RN 1 stated the Post Fall Evaluation/IDT Review dated 9/17/2023 indicated recommendations for Resident 3 to utilize a Geri chair when out of bed. RN 1 stated Resident 3 was in a wheelchair when she fell on [DATE]. RN 1 stated Resident 3's risk for falls care plan did not indicate it was revised after the resident's fall on 9/17/2023 to include the IDT recommendation for the resident to use a Geri chair when out of bed. RN 1 stated the care plan interventions were either dated 2/13/2016 or were initiated after Resident 3's fall on 11/7/2023. RN 1 stated the purpose of the IDT meeting was for staff to collaborate and make recommendations to help prevent Resident 3 from future falls. RN 1 stated the recommendations from the IDT meeting should have been added to the care plan because the care plan acts as a guide for the care Resident 3 was to receive. During a concurrent interview and record review on 2/23/2024 at 9:57 AM, Resident 3's SBARs, Post Fall/IDT Reviews, and care plan was reviewed with the DON. The DON stated she was aware of Resident's fall on 11/7/2023. The DON stated the IDT consists of rehab, dietary, and nursing, they analyze the fall and put interventions together. The DON stated Rehab was part of the IDT post fall. The DON stated rehab was usually done for the resident post fall. The DON stated the care plan was the resident's plan for their care; if the care plan was not updated interventions will not be implemented. On 2/23/2024 at 2:37 PM, during a concurrent interview and record review, Resident 3's risk for falls care plan initiated 2/13/2016 and Resident 3's Post Fall Evaluation/IDT Review dated 8/3/2023, 9/17/2023, and 11/7/2023 were reviewed with the Assistant Director of Nursing (ADON). The ADON stated the Post Fall Evaluation/IDT review documentation indicated Resident 3 fell from a wheelchair three times. The ADON stated the Post Fall Evaluation/IDT review documentation dated 9/17/2023 indicated recommendations for Resident 3 to use a Geri-chair when out of bed, but the recommendation were not carried over to the risk for falls care plan initiated on 2/13/2016. The ADON stated the risks for falls care plan initiated on 2/13/2016 was not updated after Resident 3 had a fall on 8/2/2023 or 9/17/2023. The ADON stated the risk for falls care plan should have been reviewed, revised, and updated after each fall and should have included the recommendations from the Post Fall Evaluation/IDT Review. The ADON stated Resident 3 should have been in a Geri-chair when out of bed because it would have helped prevent Resident 3 from falling. A review of the facility's policy and procedure titled, Comprehensive Care Plans-Timing, revised 3/2023 indicated the comprehensive care plan was completed by the Interdisciplinary Team that includes but was not limited to: the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, to the extent practicable, the participation of the resident and the resident's representative, if applicable, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. The policy indicated the interdisciplinary team reviews and revises the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments. A review of the facility's policy and procedure titled, Develop-Implement Comprehensive Care Plans, revised 3/2023 indicated the facility develops a person-centered comprehensive care plans that are culturally competent and trauma informed, developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. The interdisciplinary team develops the care plan with corresponding interventions for care that is in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. The facility must establish, document and implement the care and services to be provided to each resident to assist in attaining and maintaining his or her highest practicable quality of life. Care Plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences. A review of the facility's policy and procedure titled, Post Fall Evaluation, revised 3/2023, indicated the purpose of this procedure was to provide guidelines for identifying the cause (s) associated with resident falls. Documentation: the following should be recorded in the resident's medical record, appropriate interventions taken to reduce the potential for future falls. A review of the facility's policy and procedure titled, Fall Management Program, revised 3/2023 indicated the facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accident hazards as possible. Avoidable Accident: an accident which occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or evaluate and analyze the hazards and risk and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards and risks as much as possible; and/or implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not reduce the risk of an accident; and/or monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. Assistance Device or Assistive Device: Any item (e.g., fixtures such as handrails, grab bars, and mechanical devices / equipment such as stand-alone or overhead transfer lifts, canes, wheelchairs, and walkers etc.) that is used by, or in the care of a resident to promote, supplement, or enhance the resident's function and/or safety. Residents at risk for falling shall have a care plan that identifies individual risk factors and person-centered interventions, based on the risk factors. The facility nursing staff and/or the interdisciplinary team shall update the resident's plan of care accordingly to reduce the risk for further occurrences of a fall and/or to reduce the risk (s) for significant injury related to falling.

Based on interview and record review the facility failed to follow its fall management program for one of two sampled residents (Resident 1) who was identified as high risk for fall by failing to: 1. Identify hazards and risks of Resident 1 unwitnessed falls on 11/28/2022, 11/29/2022, and 12/2/2022. 2. Ensure revision of the Fall Risk care plan for Resident 1 after the unwitnessed on 11/28/2022 and 11/29/2022. 3. Identify and develop new interventions related to the resident's specific risks and causes to try to prevent further falls after each unwitnessed fall on 11/28/2022 and 11/29/2022. These deficient practices resulted in Resident 1's transfer to a General Acute Care Hospital (GACH) via Emergency Medical Services (EMS) on 12/2/2022 for further evaluation and treatment due to fall. Resident 1 sustained a bilateral (two sides/both) nasal bone fractures (a break, usually in a bone) and abdominal wall contusion (caused by a direct blow to the body that can cause damage to the surface of the skin and to deeper tissue). Findings: A review of Resident 1's Admission Record (Face sheet) dated 10/21/2022, indicated the facility originally admitted Resident 1 on 4/22/2021 and was readmitted on [DATE] with diagnoses including osteoarthritis (occurs when the cartilage that cushions the ends of bones in your joints gradually deteriorates), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), generalized muscle weakness, lack of coordination (poor muscle control that causes clumsy voluntary movements), morbid obesity (if the body weight is more than 80 to 100 pounds above the ideal body weight), and glaucoma (increase in eye pressure that can cause vision loss and blindness by damaging a nerve in the back of the eye). A review of Resident 1's Minimum Date Set (MDS-a standardized assessment care screening tool), dated 11/3/2022, indicated Resident 1 had moderate mental impairment (mild mental disability to make decisions for activities of daily living). The MDS further indicated Resident 1 was dependent and required one-to-two-person physical assist for bed, surface transfer, locomotion (movement) on/off the unit, dressing, toilet use, and personal hygiene. Resident 1 could not walk, had impairment on both sides of the lower extremities (legs), and used a wheelchair (WC) for mobility. A review of Resident 1's Risk for Fall related to deconditioning, gait (walking)/balance problems, incontinence (loss of bladder control) and history of falls at home care plan dated 10/21/2022, indicated, the goals included Resident 1 will be free of falls and that the resident will be free of minor injury through the review date. The risk for fall care plan intervention indicated, to anticipate and meet resident's needs, place call light within reach and encourage the resident to use if for assistance as needed. The resident needs prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what do if a fall occurs, and encourage and remind to always keep bed in lower position when in bed . A review of Resident 1's care plan titled Risk for Falls and Injuries due to Decline in Functional Status, Diagnoses of Parkinson, and History of Falls initiated on 10/21/2022, indicated the goals included Resident 1 will not have falls and will have no injuries through review date of 12/6/2022. The interventions indicated to educate resident/responsible party for fall preventions, encourage resident to call for assistance in ambulation, wait for assistance to arrive, evaluate possible, medical, physical, cognitive, and psychiatric conditions and report if exhibits decline . keep environment free from obstruction all times and always keep personal items within reach of resident. A review of the Resident 1's History and Physical (H&P), dated 10/23/2022, indicated Resident 1 had no capacity to understand and make decisions. A review of Resident 1's Progress Notes completed by Licensed Vocational Nurse 1 (LVN 1) dated 11/28/2022 at 5:01 PM, indicated Certified Nurse Attendant (CNA) and charge nurse found Resident 1 on the floor next to a bed lying on left side. The note indicated Resident 1 was assessed, vital signs (body temperature, blood pressure, pulse and breathing rate) were within normal limits. The note further indicated No complaints of pain or discomfort noted at present time. The noted indicated the Registered Nurse (RN), the Medical Doctor (MD), and hospice (special care to people who are near the end of life) notified . A review of a Fall Risk assessment dated [DATE], indicated Resident 1 had a fall in the last month and was a high risk for falls. A review of Resident 1's Change of Condition progress notes dated 11/29/2022 at 2:25 AM, completed by RN 1, indicated Resident 1 had unwitnessed fall and was found on the floor on the left side of the bed on 11/29/2022. Resident 1 had a LAL (low air loss - a mattress designed to prevent and treat pressure wounds) for wound management which makes it easy for resident to slip off the bed and that this condition (fall) had occurred before. Resident 1 had small skin abrasion to right hand, left hand, and left elbow. A review of Resident 1's Health Status Notes dated 11/29/2022 at 2:26 AM, indicated Patient (Resident 1) fell yesterday (11/28/2022) and found again today at the side of her bed with a little abrasion to the left arm and right arm. Dressing applied.' A review of Resident 1's Health Status Notes dated 11/29/2022 at 2:30 AM, indicated Resident 1 was repositioned to the center of the bed by unnamed facility staff at 1 AM. The note indicated Resident 1 kept gravitating towards the edge of the bed. The health status note further indicated the CNA Resident 1 was found lying on the left side of the bed at 2:25 AM. Resident 1 had an abrasion to the left elbow, which was cleansed with NS (Normal Saline- sterile salt solution used cleaning and for fluid replacement) and covered with a dry dressing. A review of a Fall Risk assessment dated [DATE], indicated Resident 1 had a fall in the last month and had a fall in the last 2 to 6 months. The Fall Risk Assessment indicated resident was on a low air loss mattress and listed as a high risk for falls. A review of Resident 1's Health Status Note dated 11/30/2022 at 2:28 PM, indicated Resident 1 monitored for s/p (status post) fall . Resident 1 c/o (complained of) 2/10 (numerical pain assessment where zero as no pain and 10 as severe pain) knees pain managed with routine medication. A review of Resident 1's Progress Notes dated 12/2/2022 at 7:03 PM, completed by RN 2, indicated Resident 1 was found on the floor by the CNA when making rounds. The note further indicated Resident 1 hit her face on the floor, was bleeding through her nose, and had sustained a skin tear of the right arm. The note indicated Resident 1 was transferred to emergency room by EMS. A review of Los Angeles City Fire Department (LAFD) Medical Record dated 12/2/2022, indicated, LAPD responded emergency to a convalescent home for a female (Resident 1), who had a ground level fall by rolling off her bed. The medical record indicated upon LAFD arrival, the patient (Resident 1) was alert and oriented times three. Resident 1 had a loss of consciousness about one to two minutes per the roommate. Resident 1 was non-ambulatory and bedbound, was on blood thinners (medication to make blood thinner) and denied any neck or back pain. A head-to-toe examination was completed, and Resident 1 had some bleeding to her nose, and a minor abrasion to her right knee. A review of Resident 1's GACH Emergency Department (ED) Notes dated 12/2/2022, indicated Resident 1 was brought in by ambulance for unwitnessed fall from bed at convalescent home, patient (Resident 1) is agitated and confused, multiple abrasions, bruising and swelling noted to nasal bridge. The ED note indicated Resident 1 fell off her bed with blunt (injury of the body by forceful impact, falls, or physical attack) facial trauma and was admitted for further evaluation and treatment. Diagnosis includes nasal fracture and open knee wound. A review of Resident 1's GACH Trauma History and Physical dated 12/2/2022 at 9:26 PM, indicated Resident 1 was brought to GACH ED as a tier 2 trauma Code (Potentially Life Threatening-a Level of trauma evaluation for a patient who meets mechanism of injury criteria (the sequence of events that results in a particular injury or injuries) with stable vital signs pre-hospital and upon arrival) and complained of pain around her nose and bridge of nose. A review of Resident 1's GACH History and Physical dated 12/3/2022 at 8:57 AM, indicated Resident 1 had a Computerized Tomography (CT-scan combined series of X-ray images taken from different angles around the body), indicated Resident 1 had bilateral nasal bone fractures and abdominal wall contusion. A review of Resident 1's care plan titled Risk for Falls and Injuries due to Decline in Functional Status, Diagnoses of Parkinson, and History of Falls initiated on 10/21/2022 and revised on 12/6/2022. The care plan did not indicate if the facility revised/updated the goals/interventions following Resident 1's falls on 11/28/2022, 11/29/2022, and 12/2/2022. On 12/21/2022 at 11:21 AM, during an interview, LVN 1 stated she was informed by a (unidentified) CNA on 11/28/2022 that she (CNA) found Resident 1 on the floor and that the registered nurse completed/recorded the vital signs (blood pressure, pulse, respirations, and temperature) for Resident 1. LVN 1 stated Resident 1 had no complaints of pain, had no obvious injuries, and was placed back in bed. LVN 1 stated, when I arrived in the room, the resident (Resident 1) was on the floor on the left side. LVN 1 stated Resident 1 had a habit of turning and was unsure if there were floor mats on the floor for Resident 1. LVN 1 stated she was not aware if the facility had updated Resident 1's care plan following the fall. On 1/6/2023 at 11:45 AM, during an interview and concurrent record review, Resident 1's plan of care was reviewed. The Director of Nursing (DON) stated Resident 1 had multiple falls in the facility, and the first fall was on 11/28/2022, the second was on 11/29/2022 and the third fall was on 12/2/2022. The DON stated that on 12/02/2022, Resident 1 was found next to her bed, was bleeding from her nose, and was transported to the GACH on 12/02/2022. The DON stated that when a resident falls in the facility, the facility licensed staff assesses the resident, completes a fall risk assessment, completes/updates the care plan specific to the resident, and conducts an interdisciplinary team (IDT) (a team that comprises of professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) meeting. The DON further stated a resident specific care plan should have been updated for each fall incident. The DON stated that an IDT should be completed and conducted to identify the cause and to prevent further falls for Resident 1. A review of facility's policy and procedures titled Fall Management Program dated 2/25/2018, indicated following a resident's fall, the licensed nurse will complete an incident report and a fall risk assessment as soon as possible. The licensed nurse will review the circumstances of the fall, review the plan of care, implement new interventions as appropriate and revise the plan as indicated . IV. Post-Fall . The IDT of health professionals will meet within 72 hours of a fall. The IDT will review and document: i. Summary of event following a fall, ii. Root cause analysis; . iv. Interventions to prevent future falls.

Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program to identify, report, and investigate the presence of cockroaches (small insects that cause spread of bacterial infection) in the facility's kitchen for 89 of 89 residents in the facility. This deficient practice caused an increased risk for vector-borne diseases (disease that result from an infection transmitted to human by insects such as cockroaches, mosquitos, ticks, and fleas) for 89 out of 89 residents. On 1/6/20 at 5:38 p.m., the Los Angeles County Environmental Health Department Inspector (performs inspections of various licensed health care facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections) informed the Department regarding closure of the facility's kitchen due to active infestation of live brown banded cockroaches in the facility's kitchen. The inspector additionally observed 25 dead cockroaches and heavy fecal spotting around the drain board panels attached to the wall, and around the fire extinguisher case and the wall. During a kitchen inspection on 1/6/20 at 7:45 p.m., live and dead cockroaches were observed in the dishwashing and food prep areas, on the sink and warming table. During a kitchen inspection on 1/6/20 at 8:05 p.m., five active adult cockroaches, one juvenile cockroach, and three dead cockroaches were observed under the dishwashing sink area, two active adult and one juvenile cockroaches were under the table adjacent to the stove, two active adult and one juvenile cockroaches were under the steam warmer tables, and two cockroach eggs and multiple non-active adult and juvenile cockroaches were observed under the steam warmer tables. A review of article from the Department of Public Health, County of Los Angeles titled, Effective management of cockroach infestation (retrieved 1/13/20 at publichealth.lacounty.gov > Vector_Management) indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of an article from WebMD retrieved 2/5/20 at webMD.com, the symptoms of food borne illness include diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. When those conditions persist, they can lead to dehydration and may require hospitalization . On 1/6/20 at 10:05 p.m., an Immediate Jeopardy was declared (IJ-a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident) and the facility's on duty Registered Nurse Supervisor (RN 1) was notified of the situation. On 1/10/20 (four days later) at 4:35 p.m., the IJ was removed in the presence of the Administrator after the facility submitted an acceptable plan of action (POA) and the surveyor verified the POA was implemented, as follows: 1. The Director of Nursing (DON) office was immediately identified as a temporary kitchen to prepare food for residents. 2. All opened food items inside the kitchen were immediately discarded. New food items were ordered as per menu dictates. 3. All kitchen items and equipment were removed and thoroughly cleaned. These items will be thoroughly cleaned before use. 4. The facility increased the use of pest control service which treated/sprayed entire kitchen on 1/7, 1/8 and 1/9/20. 5. Residents were observed for any signs and symptoms of food borne illness. 6. Infection Control Preventionist (ICP) will receive training / in services by Infection Control Nurse Consultant related to infection control practices, sanitation rounds, tracking and trending of infections. 7. ICP will begin a tracking log for any issues arising from infestation in the facility and report to the Quality Assessment and Assurance Program (QAPI) Committee for trend analysis. Findings: A review of the facility's census report, dated 1/6/20, indicated there were 89 residents residing in the facility. On 1/6/20 at 5:38 p.m., the California Department of Public Health received a report from the Los Angeles County Environmental Health Department Inspector regarding closure of the facility's kitchen. A review of the email communication report dated 1/6/20 at 5:38 p.m. indicated during the kitchen inspection on 1/6/20, the inspector observed live brown banded cockroaches (2 nymphs (baby), 1 juvenile, and 4 adults) in the facility's kitchen in between a wall panel and the wall above the drain board at the dish washing area, in between the wall and the fire extinguisher case next to the dish washing area. Brown banded cockroaches are known to carry disease-producing organisms, such as bacteria, parasitic worms, and other kinds of human pathogens. These cockroaches also spread different forms of gastroenteritis (food poisoning, diarrhea, and other illnesses). They carry a number of allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma. There were cockroaches observed in the cavity underneath drain board panel attachment to the wall, cockroaches walking on the floor next to the stove, and 25 dead cockroaches on the shelves around the plate warming equipment, across the stove. The inspector additionally observed heavy fecal spotting around the drain board panels attached to the wall, and around the fire extinguisher case and the wall. The inspector also reported the facility had closed kitchen at 4:30 p.m. During a kitchen inspection by the inspector on 1/6/20 at 7:45 p.m., live and dead cockroaches were observed in the dishwashing and food prep areas, on the sink and warming table. During a kitchen inspection by the inspector on 1/6/20 at 8:05 p.m., five active adult cockroaches, one juvenile cockroach, and three dead cockroaches were observed under the dishwashing sink area, two active adult and one juvenile cockroaches were under the table adjacent to the stove, two active adult and one juvenile cockroaches were under the steam warmer tables, and two cockroach eggs and multiple non-active adult and juvenile cockroaches were observed under the steam warmer tables. A review of article from the Department of Public Health, County of Los Angeles titled, Effective management of cockroach infestation (retrieved 1/13/20 at publichealth.lacounty.gov > Vector_Management) indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of an article from WebMD retrieved 2/5/20 at webMD.com, the symptoms of food borne illness include diarrhea, vomiting, headaches, fever, confusion, loss of appetite, abdominal cramping and pain. When those conditions persist, they can lead to dehydration and may require hospitalization . A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated 7/2019, (retrieved 1/13/20 at https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html) indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches found in health-care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (carrier that transfers an infectious organism from one host to another). During an interview, on 1/6/20 at 8:20 p.m., the facility cook (Cook 1) stated there were active and dead adult and juvenile cockroaches under the dishwashing sink area, in the steam warming tables, food prepping table next to stove, and cockroach eggs under the steam warming table. Cook 1 stated cockroaches can contaminate food and spread disease to residents. During an interview, on 1/6/20 at 8:25 p.m. the Dietary Supervisor (DS) stated she could see active and dead adult and juvenile cockroaches under dishwashing sink area, steam warming tables, food prepping table next to stove, and two cockroach eggs under the steam warming table. The DS stated cockroaches can cause cross contamination of food and spread disease to residents. During an interview, on 1/6/20 at 9:20 p.m. the Dietary Supervisor (DS) stated she noticed cockroaches in the kitchen before, a couple of times a month in the past year. The DS stated she informed the Administrator and Maintenance Supervisor when the cockroaches were observed. During an interview on 1/7/20 at 9:45 a.m., Licensed Vocational Nurse 1 (LVN 1) stated she used apple sauce from the facility kitchen to mix with medication for Resident 7. LVN 1 stated she was not supposed to provide apple sauce from the kitchen to the residents during the cockroach infestation and kitchen closure. During an interview, on 1/7/20 at 10:18 a.m., the Dietary Supervisor stated apple sauce in non-disposable containers from the kitchen was used this morning to mix with the medications. The DS stated staff should not have given applesauce from kitchen to residents due to possible contamination of applesauce and containers. During an interview, on 1/7/20 at 11:05 a.m., the Director of Nursing (DON) stated the staff should not have used applesauce from kitchen in non-disposable containers, but should have used individual applesauce cups for medication needs. During an interview, on 1/8/20 at 2:09 p.m., the Infection Control Prevention Nurse (ICP) stated she did not track infection control issues in the kitchen and did not track pests or vector borne illnesses. The ICP stated she was not trained to track pest infestations and vector borne diseases and was not trained to do all the duties of Infection Control Preventionist. She stated she did not have a monitoring system for pest infestations and vector borne illnesses. During an interview, on 1/8/20 at 2:15 p.m., the Administrator stated the ICP was trained to track [MEDICAL CONDITION] and bacterial infections, but not pest infestations and vector borne diseases. The Administrator stated the facility did not have an effective and complete infection control program. During an interview, on 1/9/20 at 9:45 a.m., the Administrator stated the Maintenance Supervisor (MS) and other staff have mentioned cockroaches during stand up meetings. The Administrator stated the kitchen had an ongoing cockroach problem and interventions so far have been ineffective to maintain a pest free kitchen environment. The Administrator stated the Infection Control issues of cockroaches in the kitchen was not brought up during Quality Assessment and Assurance Program (QAPI) or Interdisciplinary Team (IDT) meetings. The Administrator stated cockroach infestation problem should have been brought up in the QAPI meeting. Admin stated if we did more proactive complete and thorough deep cleaning and infection control, the cockroach infestation would not have been as bad. During an interview, on 1/9/20 at 10:24 a.m., the Registered Dietitian (RD) stated it was part of her responsibility to review the Pest Control service reports for infestation. The RD stated she conducted a kitchen audit in (MONTH) and (MONTH) 2019, but did not look at any other months. The RD stated there was a current cockroach infestation and pest infestation can lead to food contamination and lead to food borne illnesses. The RD stated she should have conducted QAPI for infection control in regards to cockroaches in the kitchen. The RD stated, The times I was involved in QAPI and IDT, issues of roaches were never brought up during the meetings. During an interview, on 1/10/20 at 10:17 a.m., the DS stated it was part of her responsibility to do daily rounds to inspect kitchen for sanitary conditions and pest infestation. The DS stated any kind of pest infestation could potentially contaminate food and lead to foodborne illnesses. During an interview, on 1/10/20 at 10:19 a.m., the Administrator stated there was an oversight in not doing a proper kitchen inspection and audit, which contributed to the cockroach infestation in the kitchen. The Administrator stated cockroach infestation could potentially contaminate food preparation and lead to food borne illness, cockroaches carry disease. During an interview, on 1/10/20 at 2:06 p.m., the ICP stated she should have tracked all infestation issues at the facility. The ICP stated the facility failed to keep the kitchen free of pest infestation (cockroach), and infestation can contaminate food and kitchen equipment, and cause foodborne illness. The ICP stated she should have tracked and documented pest infestation in order to make recommendations and to determine root cause of the infestations. A review of the facility's current policy titled, QAA Program-Role of the Infection Control Coordinator, revised 7/1/15, indicated the Infection Control Coordinator works to integrate the Quality Assessment and Assurance Program standards into infection control practices. The duties of the Infection Control Coordinator includes but not limited to reviewing pest control, reviewing techniques in maintenance of equipment, and ensure facility is maintained in a sanitary environment. A review of the (YEAR) U.S. Food and Drug Administration Food Code 6-202.15 indicated, insects and rodents are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. Food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings; closed, tight fitting windows and solid self-closing tight fitting doors. In addition, Food code 4-402.11 indicated, the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic microorganisms that are transmissible through food. Effective measures must be taken to eliminate their presence in food establishments. Ensure that fixed equipment is installed in a way that: allows accessibility for cleaning on all sides, above, and underneath the units or minimizes the need for cleaning due to closely abutted surfaces; ensures that equipment that is subject to moisture is sealed; prevents the harborage of insects and rodents and provides accessibility for the monitoring of pests. A review of the facility's current policy titled, Infection Prevention and Control Program, revised 1/1/17, indicated the facility must establish an infection prevention and control program under which it identifies, investigates, controls, and prevents infections in the facility. The duties and responsibilities of the ICP within the infection control committee included but not limited to review of pest control, food handling practices, waste disposal, help monitor and assess facility wide environmental infection control practices, and provide guidance for maintaining the facility in a sanitary condition.

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program to prevent the infestation of cockroaches (small insects that cause spread of bacterial infection) in the facility's kitchen for 89 of 89 residents in the facility by failing to: 1. Maintain an ongoing pest control service twice a month to ensure the kitchen was kept free of insects and other pests as indicated in the facility's pest control contract. 2. Evaluate and follow-up the findings from the pest control service reports to verify pests were removed as indicated in the facility's policy on pest control program. These deficient practices caused an increased risk to the 89 residents out of 89 residents for vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches, mosquitos, ticks, and fleas). On 1/6/20 at 5:38 p.m., the Department Inspector (performs inspections of various licensed health care facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections) informed the Department regarding closure of the facility's kitchen due to active infestation of live brown banded cockroaches in the facility's kitchen. The inspector additionally observed 25 dead cockroaches and heavy fecal spotting (stool) around the drain board panels attached to the wall, and around the fire extinguisher case and the wall. On 1/6/20 at 7:45 p.m., live and dead cockroaches were observed by the Department Inspector in the dishwashing and food prep areas, on the sink and warming table. During a kitchen inspection, on 1/6/20 at 8:05 p.m., five active adult cockroaches, one juvenile cockroach, and three dead cockroaches were observed by the Department Inspector under the dishwashing sink area, two active adult and one juvenile cockroaches were under the table adjacent to the stove, two active adult and one juvenile cockroaches were under the steam warmer tables, and two cockroach eggs and multiple non-active adult and juvenile cockroaches were observed under the steam warmer tables. A review of article from the Department of Public Health, County of Los Angeles titled, Effective management of cockroach infestation (retrieved 1/13/20 at publichealth.lacounty.gov/eh/docs/specializedvencor_management) indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of an article from WebMD retrieved 2/5/20 at webMD.com, the symptoms of food borne illness include diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. When those conditions persist, they can lead to dehydration (when your body loses more fluid than you drink) and may require hospitalization . On 1/6/20 at 10:05 p.m., an Immediate Jeopardy (IJ-a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident) was declared and the facility's on duty Registered Nurse Supervisor (RN 1) was notified of the situation. On 1/10/20 (four days later) at 4:35 p.m., the IJ was removed as confirmed by an onsite verification by the Department Inspector, in the presence of the Administrator after the facility submitted an acceptable plan of action (POA) and the inspector verified the POA was implemented, as follows: 1. The Director of Nursing (DON) office was immediately identified as a temporary kitchen to prepare food for residents. 2. All opened food items inside the kitchen were immediately discarded. New food items ordered as per menu dictates. 3. All kitchen items and equipment were removed and thoroughly cleaned. These items will be thoroughly cleaned before use. 4. The facility increased the use of pest control service which treated/sprayed the entire kitchen on 1/7, 1/8 and 1/9/20. 5. The kitchen was deep cleaned, cracks, crevices, and penetrations were sealed on 1/7, 1/8 and 1/9/20. 6. The Maintenance Supervisor/Administrator/designee will monitor for signs of infestation through daily room rounds. 8. The Registered Dietician will perform kitchen sanitation rounds monthly. 9. Dietary Supervisor will perform sanitation rounds daily and report any infection control issues during stand up meeting. 10. In-services will be conducted by the Director of Nursing/designee including the importance of timely reporting of infestations. Findings: A review of the facility's census report, dated 1/6/20, indicated there were 89 residents residing in the facility. On 1/6/20 at 5:38 p.m., the California Department of Public Health received a report from the Los Angeles County Environmental Health Department Inspector regarding closure of the facility's kitchen. A review of the email communication report dated 1/6/20 at 5:38 p.m. indicated during the kitchen inspection on 1/6/20, the inspector observed live brown banded cockroaches (2 nymphs (baby), 1 juvenile, and 4 adults) in the facility's kitchen in between a wall panel and the wall above the drain board at the dish washing area, in between the wall and the fire extinguisher case next to the dish washing area. Brown banded cockroaches are known to carry disease-producing organisms, such as bacteria, parasitic worms, and other kinds of human pathogens. These cockroaches also spread different forms of gastroenteritis (food poisoning, dysentery, diarrhea, and other illnesses). They carry a number of allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma. There were cockroaches observed in the cavity underneath drain board panel attachment to the wall, cockroaches walking on the floor next to the stove, and 25 dead cockroaches on the shelves around the plate warming equipment, across the stove. The inspector additionally observed heavy fecal spotting around the drain board panels attached to the wall, and around the fire extinguisher case and the wall. The inspector also reported the facility had closed the kitchen at 4:30 p.m. During the kitchen inspection by the inspector, on 1/6/20 at 7:45 p.m., live and dead cockroaches were observed in the dishwashing and food prep areas, on the sink and warming table. During a kitchen inspection by the inspector, on 1/6/20 at 8:05 p.m., five active adult cockroaches, one juvenile cockroach, and three dead cockroaches were observed under the dishwashing sink area, two active adult and one juvenile cockroaches were under the table adjacent to the stove, two active adult and one juvenile cockroaches were under the steam warmer tables, and two cockroach eggs and multiple non-active adult and juvenile cockroaches were observed under the steam warmer tables. A review of article from the Department of Public Health, County of Los Angeles titled, Effective management of cockroach infestation (retrieved 1/13/20 at publichealth.lacounty.gov > Vector_Management) indicated the cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of an article from WebMD retrieved 2/5/20 at webMD.com, the symptoms of food borne illness include diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. When those conditions persist, they can lead to dehydration (when your body loses more fluid than you drink) and may require hospitalization . During an interview on 1/6/20 at 8:20 p.m., the facility cook (Cook 1) stated there were active and dead adult and juvenile cockroaches under the dishwashing sink area, on the steam warming tables, on the food prepping table next to stove, and there were cockroach eggs under the steam warming table. Cook 1 stated cockroaches can contaminate food and spread disease to the residents. During an interview on 1/6/20 at 8:23 p.m. the Dietary Supervisor (DS) stated there were active and dead adult and juvenile cockroaches under dishwashing sink area, on the steam warming tables, on the food prepping table next to stove, and two cockroach eggs under the steam warming table. The DS stated cockroaches can cause cross contamination of food and spread disease to the residents. During an interview on 1/6/20 at 9:20 p.m., the Maintenance Supervisor (MS) stated he performs maintenance for kitchen, but not pest control. The MS stated he saw cockroaches in the kitchen two months ago, but did not inform the kitchen staff or Administrator about the cockroach problem. During an interview on 1/6/20 at 9:20 p.m. the Dietary Supervisor (DS) stated she noticed cockroaches in the kitchen before, a couple of times a month in the past year. The DS stated she informed the Administrator and Maintenance Supervisor when the cockroaches were observed. A review of the Pest Control contract, dated 3/16/17, indicated the frequency of service to the facility was semi-monthly (twice a month). The contract indicated the treatment included, but not limited to insecticide, cockroach gel bait, and pyrocide (pesticides - any substance used to kill, repel, or control pests). A review of the Pest Control customer service report indicated semi-monthly services were provided for 11/8/19 and 11/27/19. The service reports further indicated the facility was serviced once (not twice per the contract) for the months of January, February, March, May, June, July, August, September, and (MONTH) of 2019. The service report indicated there was no service provided to the facility for (MONTH) and (MONTH) of 2019. The Pest Control service report dated 1/22/19, 2/21/19, and 3/25/19, indicated cockroaches noted during service. The service report dated 5/14/19 indicated a recommendation to clean in and around drains frequently to help prevent pest breeding sites. The Pest Control service report dated 11/18/19 indicated cockroaches noted during service underneath dishwasher and rinse sink. During an interview, on 1/9/20 at 9:45 a.m., the Administrator stated the MS and other staff have mentioned cockroaches during stand up meetings. The Administrator stated the kitchen had an ongoing cockroach problem and interventions so far have been ineffective to maintain a pest free kitchen environment. The Administrator stated the Infection Control issues of cockroaches in the kitchen was not brought up during Quality Assessment and Assurance Program (QAPI) or the Interdisciplinary Team (IDT) meeting. The Administrator stated cockroach infestation problem should have been brought up in the QAPI meeting. The Administrator stated if we did more proactive complete and thorough deep cleaning and infection control, the cockroach infestation would not have been as bad. During an interview, on 1/9/20 at 10:24 a.m., the Registered Dietitian (RD) stated it was part of her responsibility to review the Pest Control service reports for infestation. The RD stated she conducted a kitchen audit in (MONTH) and October, 2019, but did not look at any other months other than (MONTH) and (MONTH) 2019. The RD stated there was a current cockroach infestation. She stated pest infestation can lead to food contamination and lead to food borne illnesses. The RD stated she should have conducted QAPI for infection control in regards to cockroaches in the kitchen. The RD stated, The times I was involved in QAPI and IDT, issues of roaches were never brought up during the meetings. During an interview, on 1/9/20 at 2:45 p.m. the Administrator stated the Pest Control Service did not come treat /spray the kitchen in (MONTH) and (MONTH) of 2019. The Administrator stated she did not have the service report documentation for (MONTH) and (MONTH) 2019. During an interview, on 1/10/20 at 10:19 a.m. the Administrator stated there was an oversight in not doing a proper kitchen inspection and audit, which contributed to the cockroach infestation in the kitchen. The Administrator stated cockroach infestation could potentially contaminate food preparation and lead to food borne illness, cockroaches carry disease. A review of the (YEAR) U.S. Food and Drug Administration Food Code 4-402.11 indicated, the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic microorganisms (bacteria, viruses that can produce disease) that are transmissible through food. Effective measures must be taken to eliminate their presence in food establishments. A review of the facility's current policy for Pest Control, revised 11/1/17, indicated the facility maintains an ongoing pest control program to ensure the building and grounds were kept free of insects, rodents, and other pests. The Administrator arranges for a pest control company to visit and inspect the facility at least once a year. The pest control company will carry out inspection, evaluation, submit, and carry out actions needed to rid the facility and its grounds of any environmental pests. The pest control company submits an additional report to the Administrator after the follow up inspection, verifying that all environmental pests were removed. The policy indicated the pest control service provider will provide additional consultation and pest-control services as needed.

Based on observation, interview and record review the facility failed to provide emergency care to Resident 15, who was non responsive by failing to: 1. Immediately assess the resident's level of consciousness (any measure of arousal other than normal) when there was no responds to verbal and tactile (touch) stimulation, 2. Ensure the airway was patent (open and clear), 3. To activate the emergency response system by contacting other staff members and emergency personnel (911) to assist one of 19 sampled residents (15). Additonally, the facility also failed to reassess and manage the pain of one of 19 sampled residents (Resident 18) after she sustained a fall, which resulted in a right [MEDICAL CONDITION] and required surgery. This deficient practice resulted in delay in services and treatment which led to Resident 15 being transferred to the General Acute Care Hospital (GACH), where she was diagnosed with [REDACTED]. The resident expired three days later due to poor prognosis (the prospect of survival is very low) from the massive [MEDICATION NAME] hemorrhage when taken off the ventilator. Resident 18 suffered with increased pain scale level of 8 out of 10 (0 being no pain and 10 being the worst pain) after the fall for over five hours until the transfer to the GACH for re-evaluation. Findings: a. On February 28, 2017 at 3:45 p.m., Resident 15 was observed propelling backwards in the wheelchair. Her left arm was contracted and her left leg appeared to be weak. When approached, Resident 15 started crying stating she wanted to go live with her son. On [DATE] at 7:15 a.m., during an observation a Certified Nursing Assistant (CNA 1) was standing outside the doorway of Resident 15's room. There was no staff in the room, and the resident was observed lying in bed with her eyes closed. On the same day at 8:10 a.m., a medication pass observation was started with Licensed Vocational Nurse (LVN 1) in Resident 15's room. The resident was making very loud snoring sounds and her eyes were closed while sitting upright at a 45 degree angle in bed. LVN 1 also heard the resident making the loud sound. CNA 1, shook Resident 15 and called out her name, but the resident did not respond. On the same day, [DATE], at 8:15 a.m., CNA 1 stated Resident 15 usually did not snore. At the same time, Resident 15's roommate was calling her name, but Resident 15 was not responding. Even though CNA 1 found Resident 15 not responding to verbal and tactile stimulation, she did not call other staff members for assistance in the emergency situation. On the same day at 8:45 a.m., RN supervisor (RN 1) took the resident's blood pressure which was measured ,[DATE] millimeter per mercury (mmHg). The resident was making loud snoring sounds and was not responding to verbal or tactile stimulation. RN 1 was observed leaving the resident without first maintaining an open airway for the resident and calling other staff members for assistance. The staff called the doctor and an order was obtained to transfer the resident to the GACH via a regular transport ambulance. On the same day at 8:55 a.m., while Resident 15 was still not responding to verbal stimuli, LVN 2 measured the oxygen saturation level (the amount of oxygen in the blood) which was 83 percent (%) (normal oxygen saturation level to be between 95 - 100 %). At 8:57 a.m., even though the resident was not responding, CNA 1 was observed placing a spoon full of water to the resident's lips to get resident to drink water. CNA 1 stated she wanted to see if drinking a little water would make the resident wake up. CNA 1 stated the resident was always up early in the mornings but when she arrived at 7 a.m. the resident was not waking up. During the same observation at 9 a.m., a non-rebreather (a device used in medicine to assist in the delivery of oxygen therapy) was placed on the resident's face and the oxygen saturation level was increased to 98 %. The resident's blood pressure was ,[DATE] mmHg, heart rate 88 beats per minute, oxygen saturation was 98 % and her blood sugar was 285 milligrams per deciliter. During an observation on [DATE], the paramedics arrived at the facility at 9:10 a.m., and transferred the resident to the GACH. A review of a transport ambulance company run report sheet indicated on [DATE] at 7:40 a.m., they were called to pick up Resident 15 with a scheduled pick up time of 9 a.m. However, the run sheet indicated the call was canceled at 9:04 a.m., because the facility called 911. A review of Resident 15's nurse's progress notes entry made by RN 1, dated [DATE] at 7:30 a.m., indicated a call was placed for an ambulance with pick up time for 9 a.m. The notes indicated the oxygen saturation was 83 % and 911 was called because Resident 15 was non-responsive with low oxygen saturation levels. The notes at 7:40 a.m., indicated At 7 a.m., received resident in bed sleeping. Patient noted weak than usual and non-verbal at this time. Assessment done. There was no documented evidence of what type of assessments was done and what the findings were when the resident was not responding but making loud snoring sounds. Two hours later, the same notes by RN 1 at 9:32 a.m., indicated the MD was notified of Resident 15's condition and an order was given to transfer the resident to the GACH due to generalized weakness. During an interview on [DATE] at 3:20 p.m., LVN 3 stated around 6:30 a.m. on the same day Resident 15 told her she was not feeling good and did not look good. Even though the resident told LVN 3 she was not feeling well, there was no documentation of a nurse's assessment to describe the resident's condition and the interventions of notifying the charge nurse and calling the doctor for orders. On [DATE] at 8:14 a.m., during an interview with RN 1, she stated on [DATE] at 7:30 a.m., Resident 15 was not responding to voice command, which was not normal. There was no documentation in the resident's records regarding the resident's level of consciousness. On [DATE] at 8:53 a.m., in an interview with the Director of Staff Development (DSD) she stated the CNAs are taught to report all changes of condition to the charge nurses. DSD further stated the staff are taught when a resident does not respond, even when they have normal vital signs, it is an emergency and they had to call 911. On [DATE] at 7:36 a.m., during an interview with RN 1, she stated an assessment of the resident consisted of vital signs and checking the eyes to see if pupils are reactive to light. RN 1 showed how to check pupillary reaction to light by keeping the eye open and holding one finger in front of patient's face to see if their eyes are able to follow the movement of the finger. RN 1 stated around 7:30 a.m. on [DATE] Resident 15 was not able to follow the finger movements. She further stated a penlight (a small flashlight shaped like a fountain pen) was not used to assess the pupillary reaction to light. There was no documentation of these findings in the resident's clinical records. According to the https://www.americannursetoday.com/evaluating-the-neurologic-status-of-unconscious-patients/ a journal of American Nurses Association ([DATE] Vol. 4 No. 4) indicated when assessing the type of neurological exam depends on whether the patient can follow commands. If not, assess the pupils, eye opening, motor response and some of the cranial nerves (the cranial nerves are 12 pairs of nerves with some that bring information from the sense organs to the brain; some nerves control muscles; other cranial nerves are connected to glands or internal organs such as the heart and lungs To give top priority to assessing the ABC (airway, breathing, and ) by asking yourself; is the airway patent and if so, is the patient able to maintain it. To determine if the patient is unconscious and unable to follow commands, use the Glasgow Coma Scale (GCS, the most common scoring system used to describe the level of consciousness) to test eye opening, best motor response, and best verbal response. An unconscious patient is likely to open her eyes only in response to pain, if at all. Pupil evaluation includes assessment of pupil size, shape, and equality before and after exposure to light. Normally, pupils are equal in size and about 2 to 6 millimeter (mm) in diameter, but they may be as large as 9 mm. Also, the pupils may be pinpoint, small, large, or dilated. Normal pupil shape is round; variations include irregular, keyhole and ovoid. To assess the patient's pupils, hold both eyelids open and shine a light into the eyes. The pupils should constrict immediately and equally bilaterally; after you remove the light, they should immediately dilate back to baseline. Fixed and dilated pupils are a sign that warrant immediate physician notification. Establish your patient's baseline early and make sure you know how to differentiate normal and abnormal neurological findings. During an interview with Resident 15's roommate (RSR 27) on [DATE] at 8:39 a.m., stated she saw the resident vomiting on [DATE] during the night time. RSR 27 stated she heard Resident 15 tell the nurse the next day at 5:30 a.m., on [DATE] that she was not feeling good. RSR 27 stated she called Resident 15 by name but when she did not see or hear a response from her, she shook the legs but there was still no response. RSR 27 further stated nursing staff came in the room after they heard her yelling Resident 15's name and tried waking her up but she was not responding anymore. In an interview with RN 1 on [DATE] at 11 a.m., stated she did not document a full assessment of Resident 15 not responding but she knew in the nursing world, if it was not documented that meant it was not done. Review of the GACH emergency records, dated [DATE] indicated Resident 15's initial arrival to the emergency department was on the same day at 9:34 a.m. The notes indicated the resident was brought in by the rescue team for altered mental status (a disruption in how the brain works that causes a change in behavior) last seen normal 12 hours ago but this morning the resident was not responding at all. A review of the CAT scan (a scan which makes use of computer-processed allowing the user to see inside the object without cutting) results from the GACH revealed Resident 15 suffered subarachnoid hemorrhage, [MEDICATION NAME] hemorrhage, intraventricular hemorrhage (a bleeding into the brain's ventricular system) and a ruptured middle cerebral artery bifurcation aneurysm (mid brain bleed) on the left side of brain. Review of the history of present illness for Resident 15 from the GACH notes, dated [DATE] indicated the last documented well-known time the resident was seen was at 8 p.m., the night before but she was found less responsive this morning. The notes indicated the resident had a stroke (damage to the brain from interruption of its blood supply) and it was too late for any interventions (action taken to improve a situation). A review of Resident 15's admission records indicated the resident was initially admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. A review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE] indicated the resident was cognitively intact. According to the MDS assessment Resident 15 only required oversight for eating and extensive assistance on dressing, mobilizing and transferring from bed to chair. A resident care plan, dated [DATE] indicated Resident 15 required extensive staff's assistance for mobility and set up assistance for meals from the CNAs. A review of Resident 15's roommate medical records indicate an initial admitted [DATE] with the [DIAGNOSES REDACTED]. A review of the Resident 15's roommate Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE] indicated the resident had the ability to understand others, usually able to make self -understood by communicating, is able to see and hear adequately. Review of the facility's policy and procedure dated [DATE] titled Change of Condition Notification, indicated an acute change of condition is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. The clinically important means a deviation , without intervention, may result in complications or death. The policy further indicated if the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital. A review of the facility's undated policy and procedure titled Resident Examination and Assessment, indicated the purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. The policy further listed some of the supplies necessary for performing the assessment by using a pen light to assess the pupils equal, regular, reactive to light. To report other information in accordance with facility policy and professional standards of practice. b. On [DATE] at 12:35 p.m., the investigation of an Entity-Reported Incident (ERI) regarding Resident 18's injury of unknown origin was initiated. A review of the investigation report, dated February 26, 2017 and revised [DATE] indicated at 2:30 p.m., Resident 18's caregiver said goodbye, I'm leaving and am going to sleep. The report indicated at 2:55 p.m. bed alarm was heard from the resident's room and three staff members went to answer the alarm. The report indicated Resident 18 was found on the floor in front of doorway. The resident complained of pain to the right hip and [MEDICATION NAME] (pain medication) was given for pain. A review of Resident 18's diagnostic laboratories and radiology result, dated February 26, 2017 at 7:16 p.m. indicated right [MEDICAL CONDITION] with complaint of pain. A review of the emergency transfer communication form, dated February 26, 2017 at 8:15 p.m., indicated Resident 18 had right hip pain with facial grimace. The form indicated the resident's pain rating scale was 8 out of 10 (0 being no pain and 10 being the worst pain), responded to verbal stimuli, was alert oriented x 1, confused and spoke no English. A review of the admission records indicated Resident 18 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. to perform everyday activities), diabetes (high blood sugar) and muscle weakness. A review of Resident 18's history and physical, dated February 25, 2017 indicated the resident did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated February 26, 2017 showed Resident 18 had been admitted 5 days prior to the fall. The resident's problem areas were cognitive loss which was severely impaired, activities of daily living ranged from extensive assistance to total dependence with one to two people assist. The functional status was assessed as not steady but only able to stabilize with staff assistance and used walker and a cane. The pain assessment interview indicated pain was frequently present with verbal descriptor scale being moderate. On [DATE] at 12:35 p.m., during an interview with the Director of Nursing (DON) stated Resident 18 required surgery at the General Acute Care Hospital (GACH) because of the fall. On [DATE] at 9 a.m., during an interview with a Certified Nursing Assitant (CNA 2) who was assigned to Resident 18 the day of the fall indicated (February 26, 2017) stated the family asked her to put the resident back to bed at 2:30 p.m. CNA 2 stated when the resident was put to bed the family removed the nonskid socks and replaced it with a warmer slippery socks. CNA 2 stated she last saw the resident at 2:45 p.m. On [DATE] at 9:50 a.m., during an interview with a Licensed Vocational Nurse (LVN 4) who was the charge nurse assigned to Resident 18 the day of the fall (February 26, 2017) stated at 2 p.m., she gave the resident her medications. LVN 4 stated at 2:30 p.m., the resident's family said they were leaving and when she checked the resident was asleep, the alarm was on and the call light was in place. LVN 4 stated at 2:50 p.m., she saw Resident 18 lying on her side by the door and the resident complained of pain in the right hip. LVN 4 stated she gave the resident [MEDICATION NAME] at 3:10 p.m. On [DATE] at 10 a.m., during an interview with Registered Nurse (RN 2) assigned to Resident 18 the day of the fall (February 26, 2017) stated she saw Resident 18 on the floor and she was complaining of pain. On [DATE] at 9:25 a.m., during an interview with Resident 18's family member stated she had a care giver who notified the staff on the day of the fall (February 26, 2017) that she was leaving. When the care giver came back to the facility she stated the resident kept complaining of her leg hurting really bad. Resident 18's family member stated she arrived at the facility on the same day at 6:45 p.m., and the paramedics arrived around 7 to 7:30 p.m., after I asked them to call 911 because the resident was in a lot of pain. On [DATE] at 10:27 a.m., during another interview with RN Supervisor 2, she indicated the reason for the delay in care was because the X-ray technician had a four hour window to come. RN 2 stated she checked on Resident 18 after the pain medication was given which was at 3:10 p.m., but did not document it. RN 2 stated there was no pain assessment documented in the chart. On [DATE] at 11 a.m., during another interview with LVN 4 stated she confirmed Resident 18's pain level was not reassess because her shift ended before the reassessment time. LVN 4 stated she told the on coming staff. On [DATE] at 11:15 a.m., during another interview with the DON she confirmed there was no reassessment of pain level done after [MEDICATION NAME] was given at 3 p.m. The DON also stipulated that there was no additional pain assessment done from 3:10 p.m. to 8:15 p.m. DON stated there was no documentation to show the doctor was notified of the delay for X-ray and that Resident 18's pain level was still an issue. The DON indicated Resident 18 did not have a pain assessment record. A review of Resident 18's care plans failed to indicated there was plan to address the resident's actual or potential for pain. A review of Resident 18's physician order, dated February 21, 2017 indicated the resident received a [MEDICATION NAME] for pain at 9 a.m. During an interview and record review Resident 18's Medication Administration Record [REDACTED]. The resident's MAR failed to show additional pain medication administered before the resident was transported via ambulance at 8:15 p.m., with a pain scale level of 8 out of 10. The DON and RN Supervisor 2 were unable to produce a pain assessment record in the resident's chart. There was no pain level reassessment documentation after giving the [MEDICATION NAME] per facility policy. A review of the facility's policy and procedure which was revised on [DATE] tiled, Pain Management indicated the facility staff is responsible for helping the residents maintain their highest level of well-being while working to manage the resident's pain. The licensed nurse will develop a care plan for pain management. Nurses will complete the pain flow sheet for residents receiving pain medication as needed to evaluate the effectiveness of the medication regime. The licensed nurse will assess the resident for pain and document results on the Medication Administration Record [REDACTED]. If new onset of pain or pain has not been relieved with current medication the licensed nurse will notify the attending physical for a review of medication. The nursing staff will implement timely interventions to reduce the increase in severity of pain. Pain assessment will be maintained in the resident's medical record. Document the explanation to the resident and responsible party of how the pain scale works. A review of the Facility's policy revised on [DATE], Medication Administration indicated when a as needed (PRN) medication is given the result or effectiveness of the medication will be charted by the responsible Nurse on the back of the MAR indicated [REDACTED]