Every finding on record at University Park Healthcare Center

Based on observation, interview, and record review, the facility failed to protect the resident's right to remain free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), when on 6/18/2026 at 8:45AM Resident 2 hit Resident 1 on his (Resident 1) head with an overhead table (an adjustable table designed to roll over a bed and provide a flat and stable surface). This failure resulted in Resident 1 who was bedbound (unable to leave one's bed), feeling scared and being subjected to physical abuse by Resident 2 (who had history of abusing other residents [Resident 3]) while under the care and supervision of the facility on 6/18/2026 at 8:45AM. The facility called 911 (emergency services number) and transferred Resident 1 to a general acute care hospital (GACH). Resident 1 sustained a blunt trauma (occurs when an external force impacts your body without piercing the skin), a closed head injury (brain is damaged without any object penetrating the skull), and scalp laceration (a deep cut or tear of the flesh). Cross reference F607 and F609Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/13/2026 with diagnoses including muscle weakness and muscle wasting and atrophy (the thinning, shrinking, or loss of muscle tissue). During a review of Resident 1's History and Physical (H&P- medical assessment of a resident's medical condition) dated 3/16/2026, the H&P indicated Resident 1 did not have the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/1/2026, the MDS indicated Resident 1 had the ability to understand others and required maximal assistance (helper does more than half the effort) for oral hygiene showers and toileting hygiene. During a review of Resident 1's Change of Condition (a sudden clinically important change from a patient's baseline in physical, cognitive [mental], behavioral, or functional domains) form dated 6/18/2026 8:45 AM, the Change of Condition SBAR (Situation, Background, Assessment Recommendation - a tool to share patient information in a clear, complete, concise and structured format; improving communication efficiency and accuracy) form indicated a voice (unidentified) of a scream was heard from Resident 1's room. The Change of Condition SBAR form indicated Resident 1 alleged that Resident 2 hit Resident 1's head with the overhead table. The Change of Condition SBAR form indicated Resident 1 was noted with bleeding and a laceration of approximately three inches (a unit of length) to the left side of the skull, and Resident 1 reported 3/10 pain (0 means no pain and 10 means having the worst pain). The Change of Condition SBAR form indicated the facility called 911 and Resident 1 was transferred to the GACH for further evaluation. During a review of Resident 1's Emergency Department (ED GACH notes) dated 6/18/2026 9:43 AM, the ED notes indicated Resident 1 was bedbound and presented to the ED with a blunt trauma. The ED notes indicated Resident 1 was struck in the head at the facility and had a head laceration that measured three centimeters in length. The ED notes indicated Resident 1's skin laceration was heavily contaminated (dirty) and was irrigated (watered) with extensive amounts of saline (cleaning solution) and repaired with two staples. The ED notes indicated Resident 1's diagnoses were blunt trauma, scalp laceration, and closed head injury. The ED note indicated Resident 1 needed to follow up on 6/28/2026 for the removal of the staples. During a review of Resident 1's Intradisciplinary Team (IDT -group of diverse health care professionals from different fields) notes dated 6/19/2026 11:18 AM, the IDT notes indicated Resident 1 had poor memory and was bedbound. The IDT notes indicated on 6/18/2026 at 8:45 AM, staff (unidentified) heard that a resident (unidentified) screamed from Resident 1's room. The IDT notes indicated Resident 1 alleged Resident 2 hit Resident 1 with an overhead table. The IDT notes indicated Resident 2 claimed he (Resident 2) hit Resident 1 on Resident 1's head with the overhead table. The IDT notes indicated Resident 2 was placed under direct supervision until the local police arrived at the facility. During a Review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/15/2026 with diagnoses including schizoaffective disorder (mental disorder), insomnia (is a common sleep disorder that can make it hard to fall asleep or stay asleep), and anxiety (nervousness). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to understand others and was cognitively intact (able to independently make decisions regarding tasks of daily life). During a review of Resident 2's H&P dated 5/21/2026, the H&P indicated Resident 2 lacked capacity to make medical decisions. During a review of Resident 2's Care Plan Report dated 5/29/2026, the Care Plan Report indicated Resident 2 had potential to demonstrate verbal and physical abusive behaviors. The Care Plan Report indicated the nursing interventions were for the licensed nursing staff (in general) to intervene when Resident 2 became agitated before the agitation escalated. During a review of Resident 2's Change of Condition SBAR dated 6/15/2026 at 9:24 AM, the Change of Condition SBAR indicated Resident 2 was irritated and called Resident 3 names (unidentified names), threatened to beat Resident 3, and spit at Resident 3. The Change of Condition SBAR indicated Resident 2's spit landed on Resident 3's shirt. The Change of Condition SBAR indicated Resident 2 was verbally aggressive towards the staff (unidentified, [derogatory]) and with Resident 3. The Change of Condition SBAR indicated the facility moved Resident 2 to a different room (Resident 1's room) to avoid future issues. During a review of Resident 2's Care Plan Report dated 6/15/2026, the Care Plan Report indicated Resident 2 had aggressive behavior related to anger resulting in spitting that landed on resident's (Resident 3) shirt. The Care Plan Report indicated interventions to change rooms and for licensed nursing staff (in general) to assess and anticipate resident's needs such as comfort level. During a review of Resident 2's Behavior Related Incidents form dated 6/18/2026 8:45AM, Behavior Related Incidents form indicated Resident 2 hit stated he (Resident 2) pushed the overhead table and hit Resident 1 on the head. The Behavior Related Incidents form indicated that approximately 11 AM the local police arrived at the facility and took Resident 2 on a 5150-hold (involuntary 72-hour psychiatric [relating to mental illness or its treatment] hold) related to increased aggression towards others. During an observation and interview on 7/1/2026 2:32 PM with Resident 1 inside Resident 1's room, Resident 1 had staples on his left side of the head. Resident 1 stated he (Resident 1) was afraid on 6/18/2026 when Resident 2 was irritated and hit him (Resident 1) on the head with an overhead table. During an interview and a record review on 7/2/2026 at 12:23PM with the Director of Nursing (DON), Resident 2's 72 Hour Monitoring (refers to a structured observation and assessment window of three days used to track a patient's condition, safety, and response to treatment) form dated 6/15/2026 7:26 PM was reviewed. The DON stated the facility moved Resident 2 to Resident 1's room on 6/15/2026 because Resident 1 was verbally aggressive and spit at Resident 3 and required to be monitored for 72 hours every shift. The DON stated Resident 2 required supervision to prevent further abuse of other residents (in general). The DON stated Resident 2 required close supervision for aggressiveness and for spitting at Resident 3. The DON did not respond to the surveyor's question when asked if the staff (in general) provided supervision for Resident 2 to prevent him (Resident 2) from hitting Resident 1 on 6/18/2026 at 8:45AM. The DON stated Resident 2 was last monitored on 6/17/2026 at 11:40 PM according to Resident 2's 72 Hour Monitoring forms. The DON stated Resident 2's monitoring should have ended on 6/18/2026 7-3 shift. During a review of the facility's Abuse Prevention Program policy and procedure (P&P) dated 1/15/2026, the P&P indicated the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation (means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion). The P&P indicated that as part of the resident abuse prevention, the administration will protect the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.

Based on observation, interview, and record review, the facility failed to implement its policies and procedures (P&P) titled Abuse Prevention Program with a reviewed date of 1/15/2026 and P&P titled Resident-to-Resident Altercations with a reviewed date of 1/15/2026, for three of three sampled residents (Resident 1, Resident 2, and Resident 3) by failing to: 1. Protect Resident 1 (who was bedbound) from physical abuse on 6/18/2026 at 8:45AM when Resident 2 (who was supposed to be on 72 hours monitoring for verbal aggression and spitting at Resident 3 on 6/15/2026) hit Resident 1 on his (Resident 1) head with an overhead table (an adjustable table designed to roll over a bed and provide a flat and stable surface), and caused a head laceration (a deep cut or tear of the flesh), and bleeding to Resident 1. 2. Ensure the Director of Nursing (DON), Administrator 1 (ADM1), and Licensed Vocational Nurse 1 (LVN1) reported to the Ombudsman, the California Department of Public Health (CDPH), and to the local police on 6/15/2026 at 9:30 AM when Resident 2 (who had a diagnosis of schizophrenia) threatened Resident 3 to beat him up (Resident 3) up and spit at Resident 3. 3. Ensure the facility investigated the physical and verbal abuse allegations between Resident 2 and Resident 3 on 6/15/2026. 4. Protect Resident 3 from verbal and physical abuse from Resident 2 on 6/15/2026. 5. Ensure all the facility's staff were able to identify all types of abuse. As a result, Resident 1 and Resident 3 were not protected from abuse from Resident 2, Resident 1 was taken to the hospital on 6/18/2026 via emergency services and was found with blunt trauma (external forces on your body injure you), closed head injury (brain is damaged without any object penetrating the skull), scalp lacerations (open cut). Resident 1 and Resident 3's allegations of physical and verbal abuse were not investigated and not reported to the Ombudsman, local police, and to CDPH, and placed other unidentified residents at potential for further abuse. Cross Reference F600 and F609Findings:During a Review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/13/2026 with diagnoses that included muscle weakness, muscle wasting, schizophrenia (mental disorder which leads to hallucinations, irrational thoughts, and behaviors), and wedge compression fracture of the fourth lumbar vertebra (the fourth bone in the lower back (the L4) cracked and collapsed in the front, making it shaped like a wedge rather than a square). During a review of Resident 1's Readmit H&P [history and physical] dated 3/16/2026, the H&P indicated Resident 1 did not have the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 4/1/2026, the MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from facility staff for toileting, showering, and upper body dressing. The MDS indicated Resident 1 was dependent on facility staff for personal hygiene and lower body dressing. During a review of Resident 1's situation background assessment and recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) dated 6/18/2026 at 7AM, the SBAR indicated a resident (unidentified) to resident altercation that resulted in an open wound to Resident 1's head. The SBAR indicated that around 8:45 AM, a voice was heard from Resident 1's room and Resident 1 alleged that Resident 2 hit Resident 1's head with the overhead table. The SBAR indicated Resident 1 was bleeding with a laceration of approximately three inches to the left side of the skull. The SBAR indicated Resident 1 reported 3/10 pain and the facility called 911 and was transferred to the general acute care hospital (GACH) for further evaluation. During a review of Resident 1's GACH record ER dated 6/18/2026, the GACH ER record indicated Resident 1 was diagnosed with blunt trauma, closed head injury, scalp lacerations. During a review of Resident 2's admission record, the admission record indicated the facility admitted the resident on 4/15/2026 with diagnoses that included homelessness, schizoaffective disorder (a mix of psychosis [hallucinations or delusions] and extreme mood swings), and parkinsonism (any condition that causes a specific group of movement problems, like slowed motion, rigid muscles, shaking [tremors], and balance issues). During a review of Resident 2's Care Plan Report dated 4/21/2026, the care plan indicated a focus of [Resident 1] has behavior: intermittent episodes of yelling, agitation, restlessness, and attention seeking. Refusing to take PRN [whenever necessary] anti-anxiety as offered. The care plan report indicated the facility was to ensure Resident 2 had a psychiatric consult and was monitored closely to prevent harm to self and others. During a review of Resident 2's MDS dated [DATE], the MDS indicated the resident was cognitively intact. During a review of Resident 2's H&P dated 5/21/2026, the H&P indicated Resident 2 lacked the capacity to make decisions. During a review of Resident 2's Care Plan Report initiated on 5/29/2026, the care plan report indicated The resident has potential to demonstrate [verbally/physically] abusive behaviors r/t ineffective coping skills, poor impulse control, history of homelessness. The facility staff was to Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later, when the resident became agitated. During a review of Resident 2's SBAR dated 6/15/2026 at 9:24 AM, the SBAR indicated Resident 2 was irritated and called Resident 3 names (unidentified), threated to beat Resident 3, and spitted at Resident 3. The SBAR indicated Resident 2's spit landed on Resident 3's shirt. The SBAR indicated Resident 2 was verbally aggressive towards the staff (unidentified, [derogatory]) and with Resident 3. The SBAR indicated the facility moved Resident 2 to a different room [Resident 1's room] to avoid future issues. During a review of Resident 2's 72 Hour Monitoring note dated 6/15/2026 at 7:26 PM, the note indicated that on 6/15/2026 the resident was placed on 72-hour monitoring, due to a Room change due to verbal aggression & spitting on roommate. The 72-hour monitoring start indicated the monitoring was to end on 6/18/2026 at 7:26 PM. During a review of Resident 2's 72 Hour Monitoring note dated 6/17/2026 at 8:45 AM, the note indicated 72-hour monitoring continued due to a Room change due to verbal aggression & spitting on roommate. During a review of Resident 2's 72-hour monitoring notes, there was no note documenting the final 11 hours of the monitoring ordered to end on 6/18/2026 at 7:26 PM. During a review of Resident 2's INC-Behavior Related Incidents note dated 6/18/2026 at 9 AM, the note indicated At around 08:45AM a voice was heard of a scream coming from room [ROOM NUMBER]. Upon arrival to the room, resident's roommate [Resident 1] alleged that [Resident 2] hits him with the overhead table. Upon interviewing [Resident 2], he said he pushed the overheard table which hits [Resident 2] on the head. [Local law enforcement] was called, CDPH, and Ombudsman was notified. An order was received to transfer resident to 1 [GACH] for psych eval r/t increased aggression towards others. Resident was also placed on 72-hours 1:1 monitoring until he is transferred to the hospital. At about 10:00AM, resident moved closer to the exit door, as he remained on 1:1 monitoring. When resident noticed a slight distraction on the floor, he ran out of the facility and staff members went after him. Outside of the facility, resident made several attempts to go on the road as staffs continued to stop him for safety precaution as we continue to awaits police arrival. In the process, resident hits two staff members. The note indicated the resident was taken to a psychiatric hospital During a review of Resident 2's Progress Notes dated 6/18/2026 at 11:26AM, the Progress Notes indicated Resident 2 was transferred to a psychiatric urgent care on a 5150 hold (an emergency, involuntary 72-hour psychiatric hold) by the local police related to increased aggression towards others. During a review of Resident 3's admission record, the admission record indicated the facility admitted the resident on 7/23/2025 and readmitted the resident on 5/23/2026, with diagnoses that included schizophrenia and anxiety disorder. During a review of Resident 3's H&P dated 5/26/2026, the H&P indicated the resident did not have the capacity to understand or make decisions. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 required substantial/maximal assistance from facility staff for eating, toileting, and personal hygiene. During an interview on 7/2/2026 at 9:30AM with the Director of Nursing (DON) and Licensed Vocational Nurse (LVN1), the DON and LVN1 stated that spitting was not a form of abuse. LVN1 stated spitting was gross and disrespectful but there was no need to report as an abuse when Resident 2 spit at Resident 3. The DON stated she (DON) did not report the incident between Resident 2 and Resident 3 to the Ombudsman (an independent, government-funded advocate who protects the rights of residents), local police, or to CDPH because spitting and name calling (derogatory) was not considered abuse. During an interview on 7/2/2026 at 9:45 AM with LVN 1, LVN1 used Google to search for spitting and stated that the Google search indicated a resident spitting at another resident was considered a form a physical abuse. The DON stated the physical abuse between Resident 2 and Resident 3 should have been reported and investigated. During an interview on 7/2/2026 at 11:20 AM with the administrator (ADM 2), ADM2 stated the expectation was for the staff to be able to identify the types of abuse and act accordingly. ADM2 stated all staff were mandated reporters and needed to report abuse within two hours. During an interview and a record review on 7/2/2026 at 12:23PM with the Director of Nursing (DON), Resident 2's 72 Hour Monitoring (refers to a structured observation and assessment window of three days used to track a patient's condition, safety, and response to treatment) form dated 6/15/2026 7:26 PM was reviewed. The DON stated the facility moved Resident 2 to Resident 1's room on 6/15/2026 because Resident 1 was verbally aggressive and spit at Resident 3 and required to be monitored for 72 hours every shift. The DON stated Resident 2 required supervision to prevent further abuse of other residents (in general). The DON stated Resident 2 required close supervision for aggressiveness and for spitting at Resident 3. The DON did not respond to the surveyor's question when asked if the staff (in general) provided supervision for Resident 2 to prevent him (Resident 2) from hitting Resident 1 on 6/18/2026 at 8:45AM. The DON stated Resident 2 was last monitored on 6/17/2026 at 11:40 PM according to Resident 2's 72 Hour Monitoring forms. The DON stated Resident 2's monitoring should have ended on 6/18/2026 7-3 shift. During a review of the facility's P&P titled Abuse Prevention Program with a reviewed date of 1/15/2026, the P&P indicated that facility residents had the right to be free from abuse. The P&P indicated facility administration was to protect resident from abuse from anyone. The P&P indicated the facility was to Identify and assess all possible incidents of abuse. During a review of the facility's P&P titled Resident-to-Resident Altercations with a review date of 1/15/2026, the P&P indicated All altercations. including those that may represent resident-to-resident abuse, shall be investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. The policy indicated that if two residents were involved in an altercation, facility staff was to report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy.

Based on interview and record review, the facility failed to report and investigate an allegation of physical and verbal abuse to the California Department of Public Health (CDPH), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and the local police department, within two hours for two of three sampled residents (Resident 2 and Resident 3) by failing to: -Ensure the Director of Nursing (DON), Administrator 1 (ADM1), and Licensed Vocational Nurse 1 (LVN1) reported to the Ombudsman, CDPH, and to the local police on 6/15/2026 at 9:30 AM when Resident 2 (who had a diagnosis of schizophrenia) threatened Resident 3 to beat him up (Resident 3) up, was verbally aggressive, and spit at Resident 3. -Ensure the facility investigated the physical and verbal abuse allegations between Resident 2 and Resident 3 on 6/15/2026. -Ensure all the facility's staff were able to identify all types of abuse. These failures resulted in not reporting and not investigating and had the potential for Resident 3 to be at risk for further abuse.Cross Reference F600 and F607Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 4/15/2026 with diagnoses that included homelessness, schizoaffective disorder (a mix of psychosis [hallucinations or delusions] and extreme mood swings), and parkinsonism (any condition that causes a specific group of movement problems, like slowed motion, rigid muscles, shaking [tremors], and balance issues). During a review of Resident 2's Care Plan Report dated 4/21/2026, the care plan indicated a focus of [Resident 1] has behavior: intermittent episodes of yelling, agitation, restlessness, and attention seeking. Refusing to take PRN [whenever necessary] anti-anxiety as offered. The care plan report indicated the facility was to ensure Resident 2 had a psychiatric consult and was monitored closely to prevent harm to self and others. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 5/5/2026, the MDS indicated the resident was cognitively intact (alert). During a review of Resident 2's History and Physical (H&P) dated 5/21/2026, the H&P indicated Resident 2 lacked the capacity to make decisions. During a review of Resident 2's Care Plan Report initiated on 5/29/2026, the Care Plan Report indicated The resident has potential to demonstrate [verbally/physically] abusive behaviors r/t [related to] ineffective coping skills, poor impulse control, history of homelessness. The facility staff was to Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later, when the resident became agitated. During a review of Resident 2's Situation, Background, Assessment Recommendation (SBAR- a tool to share patient information in a clear, complete, concise and structured format; improving communication efficiency and accuracy) dated 6/15/2026 at 9:24 AM, the SBAR indicated Resident 2 was irritated and called Resident 3 names (unidentified), threatened to beat Resident 3, and spitted at Resident 3. The SBAR indicated Resident 2's spit landed on Resident 3's shirt. The SBAR indicated Resident 2 was verbally aggressive towards the staff (unidentified, [derogatory]) and with Resident 3. The SBAR indicated the facility moved Resident 2 to a different room [Resident 1's room] to avoid future issues. During a review of Resident 2's 72 Hour Monitoring note dated 6/15/2026 at 7:26 PM, the note indicated that on 6/15/2026 the resident was placed on 72-hour monitoring, due to a Room change due to verbal aggression & spitting on roommate. The 72-hour monitoring start indicated the monitoring was to end on 6/18/2026 at 7:26 PM. During a review of Resident 2's 72 Hour Monitoring note dated 6/17/2026 at 8:45 AM, the note indicated 72-hour monitoring continued due to a Room change due to verbal aggression & spitting on roommate. During a review of Resident 2's 72-hour monitoring notes, there was no note documenting the final 11 hours of the monitoring ordered to end on 6/18/2026 at 7:26 PM. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 7/23/2025 and readmitted the resident on 5/23/2026, with diagnoses that included schizophrenia and anxiety disorder. During a review of Resident 3's H&P dated 5/26/2026, the H&P indicated the resident did not have the capacity to understand or make decisions. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 required substantial/maximal assistance from facility staff for eating, toileting, and personal hygiene. During an interview on 7/2/2026 at 9:30AM with the DON and LVN1, the DON and LVN1 stated that spitting was not a form of abuse. LVN1 stated spitting was gross and disrespectful but there was no need to report as an abuse when Resident 2 spit at Resident 3. The DON stated she (DON) did not report the incident between Resident 2 and Resident 3 to the Ombudsman (an independent, government-funded advocate who protects the rights of residents), local police, or to CDPH because spitting and name calling (derogatory) was not considered abuse. During an interview on 7/2/2026 at 9:45 AM with LVN 1, LVN1 used Google to search for spitting and stated that the Google search indicated a resident spitting at another resident was considered a form a physical abuse. The DON stated the physical abuse between Resident 2 and Resident 3 should have been reported and investigated. During an interview on 7/2/2026 at 11:20 AM with Administrator 2 (ADM 2), ADM2 stated the expectation was for the staff (in general) to be able to identify the types of abuse and act accordingly. ADM2 stated all staff (in general) were mandated reporters and needed to report abuse within two hours. During an interview and a record review on 7/2/2026 at 12:23PM with the DON, Resident 2's 72 Hour Monitoring (refers to a structured observation and assessment window of three days used to track a patient's condition, safety, and response to treatment) form dated 6/15/2026 7:26 PM was reviewed. The DON stated the facility moved Resident 2 to Resident 1's room on 6/15/2026 because Resident 1 was verbally aggressive and spit at Resident 3 and required to be monitored for 72 hours every shift. The DON stated Resident 2 required supervision to prevent further abuse of other residents (in general). The DON stated Resident 2 required close supervision for aggressiveness and for spitting at Resident 3. The DON did not respond to the surveyor's question when asked if the staff (in general) provided supervision for Resident 2 to prevent him (Resident 2) from hitting Resident 1 on 6/18/2026 at 8:45AM. The DON stated Resident 2 was last monitored on 6/17/2026 at 11:40 PM according to Resident 2's 72 Hour Monitoring forms. The DON stated Resident 2's monitoring should have ended on 6/18/2026 7-3 shift. During a review of the facility's P&P titled Abuse Prevention Program with a reviewed date of 1/15/2026, the P&P indicated that facility residents had the right to be free from abuse. The policy indicated to investigate and report any allegations of abuse within timeframes as required by federal requirements.

Based on interview and record review, for one of six sampled residents (Resident 1), the facility failed to ensure:Two staff members assisted to transfer Resident 1 from a car onto a wheelchair (WC) on 6/2/2026 at approximately 4 PM to prevent falls.Resident 1's Family Member (FM 1), was trained on how to assist, and safely use and safely transfer Resident 1 in and out of a wheelchair (WC) according to the facility's policy and procedures (P&P) titled Assistive Devices and Equipment dated 1/15/2026.The facility was aware Resident 1 had a history of falls and was at risk accidents and falls. As a result, on 6/2/2026 at approximately 4 PM, Resident 1 slid off the WC and fell to the ground when certified nursing assistant (CNA 1) and FM 1 were transferring Resident 1 from a car onto a WC placing Resident 1 at increased for injury, hospitalization and deathFindings: During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses of dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), cerebral infarction (disruption of blood flow to the brain due to problematic vessels that cause lack of blood supply and oxygen to the brain), muscle weakness, abnormal posture, neuralgia (a sharp, severe, and often burning pain that follows the path of a nerve, caused by nerve irritation, damage, or disease), and readmitted on [DATE] with mood dysregulation disorder (a mental health condition characterized by severe, chronic irritability and frequent, intense temper outbursts that are way out of proportion to the situation) and anxiety (Persistent feeling of dread or panic that can interfere with daily life). During a record review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated 4/15/2026, The MDS indicated Resident 1 had moderate impaired cognition (ability to think, remember and reason for daily decision making). 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, shower/bathe, upper and lower body dressing, putting on/taking off footwear, and toilet transfer. Resident 1 required 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 eating, oral hygiene, personal hygiene, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed transfer. The MDS indicated Resident 1 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) from staff to roll left and right. During a record review of Resident 1's Care Plan (CP) titled Risk for accidents/falls .) dated 4/21/2025, the CP indicated, staff will assist (Resident 1) with all transfers as needed, eliminate potential hazards, and provide safety instruction to resident/family regarding transfers when appropriate to reduce the risk of falls and injury daily. During a record review of Resident 1's Care Plan (CP) At risk for complications due to alteration in musculoskeletal status dated 4/22/2026, the CP indicated, Staff will assist (Resident 1) with the use of supportive devices and educate family/caregivers on safety measures that need to be taken in order to reduce risk of falls. During a record review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 1 was moderate risk for falls due to disoriented level of consciousness, history of 1-2 falls in the past three months, being chair bound, decreased muscular coordination, balance problem while walking and standing, and taking narcotics (medications to treat severe pain), psychotropics (Drugs/medications that affect a person's mental state), and sedatives (medications that slows brain activity to induce calmness, relaxation, or sleep). During a record review of Resident 1's Fall Incident, dated 6/2/2026, the Fall Incident (report) indicated Resident 1 had a witnessed fall on 6/2/2026 at around 4 PM during returning from out on pass (an admitted resident has temporary, authorized permission to leave the facility for a few hours or days without being officially discharged ) with FM 1. A facility staff assisted Resident 1 to get on the WC, however, the resident slid off the WC. During a record review of Resident 1's Radiology Report dated 6/2/2026, the Radiology Report indicated Resident 1 had no evidence of fracture or dislocation to Resident 1' s bilateral hips. During a phone interview on 6/16/2026 at 9:30 AM with FM 1, FM 1 stated that on 6/2/2026 at approximately 4 PM, Resident 1 and FM 1 returned to the facility from out of pass (OOP) and was greeted by two staff members. FM 1 stated that FM 1 and Resident 1 were outside in a car at the facility entrance. FM 1 stated that CNA 1 and FM 1 assisted to transfer Resident 1 from the car into the WC instead of two trained facility staff members. FM 1 stated that Resident 1 was not properly positioned in the WC and slid from the WC to the ground. FM 1 stated that the facility had not instructed or educated FM 1 on how to properly perform surface transfer the resident. FM 1 stated the incident occurred outside of the facility at the entrance, and that multiple staff members came out to offer assistance but the staff seemed more preoccupied with how Resident 1 fell versus trying to get the resident up off the ground and assess the resident for injuries. FM 1 stated FM 1 attempted to report the incident to Registered Nurse Supervisor (RNS) and also requested RNS of the incident report. FM 1 stated that RNS declined FM 1's request of Resident 1's incident report because RNS had already received a report from a facility staff regarding the incident and that RNS would complete the incident report for Resident 1. FM 1 stated FM 1 was not provided with Resident 1's fall incident report or further information regarding the reporting process. FM 1 stated FM 1 felt the facility staff were trying to cover up Resident 1's fall incident. During a phone interview on 6/16/2026 at 12:15 PM with RNS, RNS stated Resident 1 was at risk for falls. RNS stated that on 6/2/2026 at approximately 4 PM, FM 1 requested assistance to get Resident 1 out of a vehicle when FM 1 and Resident 1 returned to the facility. RNS stated RNS directed CNA 1 and CNA 2 to assist Resident 1 transfer from the car into a WC as resident 1 required a 2 person assist. RNS stated that CNA 1 transferred Resident 1 from the car to a WC. RNS stated that after CNA 1 and CNA 2 transferred Resident 1 to bed, FM 1 reported to RNS that Resident 1 fell during the transfer from the car into a WC. RNS stated that both CNA 1 and CNA 2 denied that Resident 1 fell because Resident 1 did not make contact with the ground. RNS stated that FM 1 insisted that Resident 1 made contact with the ground when being transferred from the car into a WC. RNS stated RNS informed Resident 1's physician of the alleged fall, and the physician ordered an X-ray (Radiograph: type of medical imaging that creates pictures of bones and soft tissue). RNS further stated Resident 1 was probably not seated correctly in the WC and acknowledged that Resident 1 had poor posture and physical limitations, of which the CNAs were aware of. RNS stated RNS would complete an incident report after receiving information from staff regarding Resident 1 fall incident. During a phone interview on 6/16/2026 at 12:08 PM with CNA 2, CNA 2 stated that on 6/2/2026 at approximately 4 PM, RNS asked CNA 2 to help assist CNA 1 to transfer Resident 1 from the vehicle outside the facility into a WC and then bring the resident inside the facility. CNA 2 stated CNA 2 went outside to assist CNA 1 and noticed Resident 1 was hitting CNA1 because that's how Resident 1 typically does to staff and he was aware of it. CNA 2 stated he did not help CNA 1 get Resident 1 out of the car because CNA1 and Resident 1's FM 1 were already getting Resident 1 out of the car. CNA 2 stated that FM 1 assisted CNA 1 to transfer Resident 1 onto the WC and then Resident 1 slid off the WC. CNA 2 stated that the WC did not have footrests. CNA 2 stated Resident 1 is heavy and requires 2 staff assist with surface transfers. During a phone interview on 6/16/2026 at 12:39 PM with CNA 1, CNA1 stated that on 6/2/2026 at approximately 3:45 PM, CNA 1 stated that RNS asked CNA 1 to go and assist transfer Resident 1 from the car onto a WC who had just returned from an appointment CNA 1 stated Resident 1 is very aggressive, hits and yells at staff. CNA 1 stated that on 6/2/2026 at approximately 43;45 PM, while CNA 1 attempted to get Resident 1 out of the vehicle, Resident 1 began to hit CNA 1 and that FM 1 was able to calm the resident down. CNA 1 stated that Resident 1 did not fall to the ground but instead slid forward off the WC and that CNA 2 reached to catch Resident 1 before the resident touched the ground. CNA 1 stated that CNA 2 intervened and caught Resident 1 before the resident made contact with the ground. CNA 1 stated that Resident 1 frequently slides during transfers CNA 1 stated that the facility has not provided CNA 1 with recent in-service training on how to perform resident surface transfer. CNA 1 stated that Resident 1 was not optimally seated in the WC while still outside the facility by main entrance. CNA 1 further stated that if two facility staff members had completed Resident 1's transfer from the car to a WC, then CNA 1 and CNA 2 may have been able to position the resident correctly and potentially prevent Resident 1 from sliding off the WC and falling. CNA 1 stated that Resident 1's transfer may not have been performed correctly due to involving FM 1. CNA 1 stated had if CNA 2 had assisted CNA 1 to transfer Resident 1 from the car onto the WC, then Resident 1's transfer could have been completed safely. During an interview on 6/16/2026 at 12:51 PM with the Director of Nursing (DON), the DON stated that on 6/2/2026 at approximately 4:30 PM, DON was walking in the facility when DON observed a group of staff and FM 1 near Resident 1's room. The DON stated FM 1 reported to DON that Resident 1 had slid off the WC asCNA1 turned the WC toward the entrance of the facility. The DON indicated that Resident 1's buttocks may not have been fully positioned on the wheelchair, and that the incident of the resident sliding off a WC is still considered a fall. The DON further stated that Resident 1's WC did not have footrests. The DON stated Resident 1 is a high risk for fall due to dementia and contractures (the permanent tightening or shortening of muscles, tendons, skin, or other soft tissues). The DON stated Resident 1 requires two staff members for surface transfers. The DON stated that fall prevention measures include ensuring that the resident is properly seated in the WC and to exercise caution when maneuvering the WC. The DON acknowledged and stated that Resident 1's WC was faulty/were stuck and could not be put down for Resident 1 to rest his legs and stated that the resident sliding off the WC and falling incident could have been prevented had Resident 1 been properly seated/positioned in the WC and the WC had functional footrests. The DON stated, This failure placed Resident 1 at risk for falls and injury. During a review of the facility's policy and procedures (P&P) titled Assistive Devices and Equipment dated 1/15/2026, the P& P indicated, 4. Staff and volunteers are trained and demonstrate competency on the use of devices and equipment prior to assisting or supervising residents.5. Resident Family and visitors are trained on the safe use of equipment and devices.C. Defective or worn devices are discarded or repaired. During a review of the facility's P&P titled Fall-Clinical Protocol reviewed 1/15/2026, the P&P indicated the following: Assessment and Recognition1. The physician will help identify individuals with a history of falls and risk factors for falling.a. Staff will ask the resident and the caregiver or family about a history of falling.b. The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days).c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause.6. Falls should be categorized as: .c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor.

Based on observation, interview, and record review, the facility failed to accurately account for four doses of controlled medications (medications with a high risk for abuse or diversion [any use other than that intended by the prescriber]) affecting Resident 18, Resident 29, and Resident 61 in one of two inspected medication carts (Medication Cart 1). This deficient practice increased the risk of diversion (illegal transfer/use) of controlled medications and the risk that Resident 18, Resident 29, and Resident 61 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.Findings: During an observation and concurrent interview of Medication Cart 1 on 4/1/2026 at 11:11 AM with Licensed Vocational Nurse 2 (LVN 2) the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): -Resident 18's Narcotic and Hypnotic Record for lorazepam (a medication used to treat mental illness) 0.5 milligrams (mg - a unit of measure for mass) indicated there were 25 doses left; however, the medication card contained 24 doses. -Resident 29's Narcotic and Hypnotic Record for clonazepam (a medication used to treat mental illness) 0.5 mg indicated there were 19 doses left; however, the medication card contained 18 doses. -Resident 29's Narcotic and Hypnotic Record for phenobarbital (a medication used to treat seizures) 64.8 mg indicated there were 25 doses left; however, the medication card contained 24 doses. -Resident 61's Narcotic and Hypnotic Record for hydrocodone/apap (a medication used to treat pain) 5/325 mg indicated there were 50 doses left; however, the medication card contained 49 doses. During a concurrent interview on 4/1/2026 at 11:11 AM with LVN 2, LVN 2 stated she (LVN2) administered all of the missing controlled medications for Resident 18, Resident 29 and Resident 61 on 4/1/2026 but failed to sign the corresponding Narcotic and Hypnotic Records because she (LVN2) was distracted by other tasks. LVN 2 stated she (LVN2) was required to sign the Narcotic and Hypnotic Record immediately after the dose was administered. LVN 2 stated that ensured accountability of the controlled medications was maintained and helped to prevent medications from being administered too often to residents (in general) which could lead to medical complications. A review of the facility's policy Controlled Substances, revised April 2019, indicated Upon administration, the nurse administering the medication is responsible for recording. time of administration. quantity of the medication remaining; and signature of nurse administering medications.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Five errors out of 27 opportunities contributed to an overall error rate of 18.52 % affecting three of four residents observed for medication administration (Resident 17, Resident 20, and Resident 98). The errors noted were as follows: a. Incorrect drug (senna/docusate - a medication used to stimulate a bowel movement) administered to Resident 98. b. Incorrect drug (senna/docusate) administered to Resident 17.-Failure to administer metformin (a medication used to treat high blood sugar) with food per the physician order for Resident 17. c. Incorrect formulation of multivitamins (multivitamins with minerals - a supplement) administered to Resident 20.-Incorrect strength of lidocaine patch (a medication used to treat pain) administered to Resident 20. The deficient practice of failing to administer medications in accordance with the physician's orders or professional standards increased the risk that Resident 17, Resident 20, and Resident 98 could experience medical complications possibly resulting in hospitalization.Findings: a. During an observation of medication administration on 4/1/2026 at 8:04 AM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 was observed preparing the following medication for Resident 98:-One tablet of senna/docusate 8.6/50 milligrams (mg - a unit of measure for mass). During an observation on 4/1/2026 at 8:08 AM, Resident 98 was observed taking the senna/docusate tablet along with other medications by mouth with water. During a review of Resident 98's admission Record dated 4/2/2026, the admission Record indicated the facility admitted Resident 98 on 5/26/2024 and most recently readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right-side weakness and paralysis following a stroke.) During a review of Resident 98's History and Physical (H&P, a record of a physician's comprehensive medical assessment) dated 3/14/2026, the H&P indicated Resident 98 had the capacity to understand and make medical decisions. During a review of Resident 98's Order Summary Report (a monthly summary report of all active physician orders) dated 3/30/2026, the Order Summary Report indicated Resident 98's attending physician prescribed the following: -Senna 8.6 mg tablet by mouth two times daily for constipation During an interview on 4/1/2026 at 8:45 AM with LVN 2, LVN 2 stated she (LVN2) administered the incorrect formulation of senna to Resident 98. LVN 2 stated she (LVN2) administered a combination product containing both senna and docusate rather than the senna alone as indicated on the physician's order. LVN 2 stated she (LVN2) failed to check the label of the product against the physician's order prior to administering the medication. LVN 2 stated failing to ensure she (LVN2) was administering the right medication to the resident could result in major health complications possibly resulting in hospitalization. b. During an observation of medication administration on 4/1/2026 at 8:26 AM with LVN 2, LVN 2 was observed preparing the following medications for Resident 17:-One tablet of senna/docusate 8.6/50 mg.-One tablet of metformin 1000 mg. During an observation on 4/1/2026 at 8:40 AM, Resident 17 was observed taking the metformin tablet by mouth with water along with other medications and refusing the senna/docusate tablet. During a review of Resident 17's admission Record dated 4/2/26, the admission Record indicated the facility admitted Resident 17 on 2/14/2026 with diagnoses including type 2 diabetes (a medical condition characterized by poor blood sugar control). During a review of Resident 17's H&P dated 2/17/2026, the H&P indicated Resident 17 had the capacity to understand and make medical decisions. During a review of Resident 17's Order Summary Report dated 3/30/26, the Order Summary Report indicated Resident 98's attending physician prescribed the following: -Senna 8.6 mg to give two tablets by mouth two times a day for bowel management.-Metformin 1000 mg by mouth two times a day at 7:15 AM and 5:00 PM with meals. During an interview on 4/1/2026 at 8:45 AM with LVN 2, LVN 2 stated she (LVN2) administered the incorrect formulation of senna to Resident 17. LVN 2 stated she (LVN2) administered a combination product containing both senna and docusate rather than the senna alone as indicated on the physician's order. LVN 2 stated she (LVN2) failed to check the label of the product against the physician's order prior to administering the medication. LVN 2 stated failing to ensure she (LVN2) was administering the right medication to the resident could result in major health complications possibly resulting in hospitalization. During an interview on 4/1/2026 at 10:15 AM with LVN 2, LVN 2 stated she (LVN2) failed to administer Resident 17's metformin with a meal as required by the physician order. LVN 2 stated most residents (in general) usually completed their breakfast between 7AM and 8AM, but she (LVN2) did not know exactly when Resident 17 completed her (Resident 17) breakfast. LVN 2 stated the metformin was not given to Resident 17 with her breakfast and it was also given at the wrong time as it was scheduled for 7:15 AM and given around 8:40 AM. LVN 2 stated this may cause Resident 17 to have an upset stomach, possibly leading to a decline in her quality of life. c. During an observation of medication administration on 4/1/2026 at 8:51 AM with LVN 3, LVN 3 was observed preparing the following medication for Resident 20:-One tablet of multivitamins w/ minerals.-One lidocaine 5% patch. During an observation on 4/1/2026 at 9 AM, Resident 20 was observed taking the multivitamin with minerals tablet by mouth with water and LVN 3 was observed applying the lidocaine 5% patch to the middle of Resident 20's upper back. During a review of Resident 20's admission Record dated 4/2/26, the admission Record indicated the facility admitted Resident 20 on 2/25/2026 with diagnoses including spondylosis without myelopathy or radiculopathy, cervical region (an age-related degeneration of the spine's vertebrae, discs, and joints often causing stiffness and pain in the upper back/neck region). During a review of Resident 20's H&P dated 2/27/2026, the H&P indicated Resident 20 did not have the capacity to understand and make medical decisions. During a review of Resident 20's Order Summary Report dated 3/30/2026, the Order Summary Report indicated Resident 20's attending physician prescribed the following: -Lidocaine 1.8 % patch to apply topically to skin one time a day for arthritis (the inflammation of one or more joints, causing pain, swelling, stiffness, and reduced mobility) pain.-One multivitamin tablet (formulation without minerals) by mouth one time a day for supplement. During an interview on 4/1/2026 at 10:22 AM with LVN 3, LVN 3 stated he (LVN3) administered the wrong formulation of multivitamins to Resident 20. LVN 3 stated he (LVN3) administered the formulation with minerals whereas the order specifies the version without. LVN 3 stated he (LVN3) also administered the wrong dose of lidocaine patches to Resident 20. LVN 3 stated Resident 20's order for lidocaine patch was 1.8 % and he (LVN3) administered a 5 % patch. LVN 3 stated the lidocaine 5 % patch was a prescription product, and he (LVN3) accidentally administered it from a different resident's (unidentified) supply. LVN 3 stated he (LVN3) failed to check the prescription label before obtaining the lidocaine patch. LVN 3 stated he (LVN3) also failed to check the strength of the lidocaine patch versus Resident 20's order. LVN 3 stated he (LVN3) failed to check the formulation of the multivitamins versus Resident 20's order. LVN 3 stated administering the wrong formulation, wrong strength, or wrong resident's medications could cause medical complications which could possibly be life threatening. During a review the facility's policy Administering Medications, revised April 2019, indicated Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medications. Medications ordered for a particular resident may not be administered to another resident.

Based on observation, interview, and record review, the facility failed to ensure to follow the standardized (consistent) recipes for lunch menu on 3/31/2026 by failing to: 1.Ensure 14 residents (unidentified) on pureed diet (foods that do not require chewing and are easily swallowed and should be smooth and pureed to the consistency of pudding) received bread texture in a form that met their needs and in accordance with the international Dysphagia Diet Initiative (IDDSI- a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) when the texture of the pureed bread was lumpy, dry, not smooth and had small pieces of bread crust present requiring chewing before swallowing. 2.Follow food production recipes for the renal (related to the kidneys) diet. Two residents (unidentified) on renal diet received chicken nuggets and rice instead of turkey patty with gravy and pasta with margarine per menu. These deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake, and increased choking risk for the residents (unidentified) on the pureed diet. Findings: During an observation of the tray line (tray line- a system of food preparation, in which trays move along an assembly line) service for lunch on 3/31/2026 at 12:06 PM the pureed bread looked lumpy, dry, and not smooth while in a pan on the steam table (a table with slots to hold food containers which are kept hot by steam circulating beneath them). During a concurrent observation and interview with [NAME] on 3/31/2026 at 12:10PM, Cook1 stated the pureed bread was made with blended whole wheat bread. During a concurrent interview and taste test (sampling the flavor and texture of the prepared meal) of the pureed bread on 3/31/2026 at 12:45PM with the Dietary Supervisor (DS) the pureed bread was grainy, dry, and not smooth requiring chewing before swallowing. The pureed bread was stuck to the spoon and during tasting it was stuck on the roof of the mouth and not easy to swallow. During the same taste test on 3/31/2026 at 12:45PM, the DS stated the bread was not smooth, was chewy, and sticky. The DS stated the pureed bread needed to be blended longer and should be moist. The DS stated when the pureed texture was not prepared right it could be a risk for choking for the residents (unidentified) who were on a pureed diet. During an interview on 3/31/2026 at 12:45PM with the Registered Dietitian (RD), the RD stated the pureed bread was not smooth because the cook (unidentified) used a whole wheat bread to make it. The RD stated the pureed bread is grainy and requires some chewing. The RD stated puree texture should not need chewing and must be smooth. During an interview on 3/31/2026 at 1PM with Cook1, Cook1 stated the pureed bread was not smooth and was lumpy because [NAME] 1 used whole wheat bread. [NAME] 1 stated [NAME] 1 should have blended the bread longer and added more liquid to make it smoother. Puree texture that was not smooth could cause problems with residents (in general) who have difficulty chewing and swallowing. During a review of the facility recipe titled Pureed (IDDSI Level 4)Breads, cakes, cookies, pancakes and other bread products (dated 2025) the recipe indicated, puree bread on low speed adding milk gradually.the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated that Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test. 2.During a review of the facility lunch menu on 3/31/2026 indicated that the following items would be served for the Renal Diet (a diet aimed at keeping levels of fluids, electrolytes, and minerals balanced in the body in individuals with kidney disease or dialysis):-Turkey Pattie with gravy three ounces (oz); wheat pasta with margarine 1/2 cup; Italian green beans 1/2 cup; 1 slice of garlic bread; sugar cookies; beverage. During an observation on 3/31/2026 at 12:06PM of the tray line service for lunch residents (unidentified) who were on renal diet the cook (Cook1) served chicken nuggets (a small piece of chicken meat-either minced or whole muscle-that is breaded or battered, then deep-fried or baked and is often a frozen food item) and white rice instead of the items on the menu. During an interview on 3/31/2026 at 1PM with Cook1, Cook1 stated they (unidentified kitchen staff) served chicken nuggets because they did not have turkey Pattie and chose chicken nuggets because most residents (unidentified) preferred them as an alternative to the regular menu. Cook1 stated he (Cook1) forgot that whole wheat pasta was on the menu. Cook1 stated he (Cook1) made a mistake and did not follow the menu to prepare the items for renal diet. Cook1 stated he (Cook1) did not inform the DS or the RD when the ingredients were missing and was substituting chicken nuggets and rice for the turkey patties and whole wheat pasta. During a concurrent interview on 3/31/2026 at 1 PM with the DS and the RD, the DS stated they had ground turkey meat and cooks (in general) could follow the recipe to prepare turkey patty as indicated on the menu. The RD stated staff (kitchen staff in general) should inform the RD and the DS when ingredients were missing to make proper adjustment on the menu to serve similar foods keeping in mind the preference for residents who were on a renal diet. The DS stated renal diet was ordered by doctors and it was important to follow to make sure the right food was served to residents on this diet. The DS stated when residents did not get what was on the menu they (residents) could get upset and refuse to eat. During a review of the facility's cooks spreadsheet titled Spring Menus (page 2) for week1 Tuesday (dated 3/31/2026), the spreadsheet indicated to serve Renal diets: Turkey patty with gravy; wheat pasta with margarine; Italian green beans, garlic bread; dessert and beverage During a review of facility's Policy and Procedure (P & P) titled Therapeutic and Liberalized Diet policy (revised 1/15/2026) the p & p indicated, therapeutic diets shall be provided when indicated based on physician orders, clinical condition and interdisciplinary team recommendations. Liberalized Diet Policy- the facility supports least restrictive diets to enhance quality of life and promote intake, Registered Dietitian will evaluate need for liberalization, resident preference will be considered. During a review of facility policy and procedures (p & p) titled, Menu Planning (dated 2023), the p & p indicated, The menus are planned to meet nutritional needs of residents in accordance with established national guidelines.Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation.

Based on observation, interview, and record review the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1.One scoop was stored inside bulk rice container, and the handle was in contact with the food. 2.Bulk food (flour, rice, oatmeal) was stored inside trash bags that were not food grade (refers to materials that are safe for direct contact with food, free from harmful substances, and designed to prevent contamination). These deficient practices had the potential to result in cross contamination of food (transfer of harmful bacteria and chemicals from one place to another) that could lead to foodborne illness (food poisoning) in 79 out of 81 residents (unidentified) who received food from the facility.Findings:1. During an observation on 3/31/2026 at 9 AM inside the kitchen, one of the bulk dry food storage bins containing rice, the scoop was stored on the food, and the handle of the scoop was touching the rice. During a concurrent observation and interview on 3/31/2026 at 9 AM with the Dietary Supervisor (DS), the DS stated the scoop should not be inside the bin and on the food because the handle was not clean and could contaminate the food. The DS stated all the scoops were hanging on a holder inside the bins. During a review of the 2022 U.S. Food and Drug Administration Food Code titled In-Use utensils, Between-Use Storage Code 3-304.12 indicated, During pauses in Food operation or dispensing, Food preparation and dispensing utensils shall be stored: (E) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour or cinnamon. 2.During an observation on 3/31/2026 at 9 AM inside the kitchen, bulk food (oatmeal, rice and flour) was stored in large bins that were lined with plastic bags. During a concurrent observation and interview on 3/31/2026 at 9 AM with the DS, the DS stated the plastic liners inside the bins were regular trash bags and were not food grade. The DS stated the kitchen staff (in general) used the same bags for trash, and they were stored in the chemical room. The DS stated he (DS) would remove the bulk food and store it directly inside the plastic bins that were easy to clean and sanitize after use. The DS stated plastic trash bags could cause chemical contamination of food. During a review of facility's policy and procedures (p & p) titled Storage of Food and Supplies (dated 2023), the p & p indicted, Dry bulk foods (flour, sugar, dry beans, food thickener, spices, etc.)should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized. If using plastic bags for dry bulk food storage, food grade bags must be used. Scoops should not be left in the containers. Do not add more product to a bin container until it is empty and sanitized. Bins/containers are to be labeled, covered and dated. If lining bins use food grade bags. During a review of the 2022 U.S. Food and Drug Administration Food Code titled Characteristics code 4-102.11, the code indicated, The safety and quality of food can be adversely affected through single service and single use articles that are not constructed of acceptable materials. The migration of components of those materials to food they contact could result in chemical contamination and illness to the consumer. In addition, the use of unacceptable materials could adversely affect the quality of the food because of odors, tastes, and colors transferred to the food.

Based on observation, interview, and record review the facility failed to update and revise the tube feeding (TF, a form of nutrition that is delivered into the digestive system as a liquid) care plan (a plan of care that summarizes a resident's health conditions, current treatments, and specific care and services facility staff (in general) need to provide a resident to promote healing and prevent a worsening of a condition) for one out of one sampled resident (Resident 5) after a new TF order was received on 3/27/2026. This failure had the potential for Resident 5 to receive care that was not in alignment with the resident's needs.Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 8/20/2025 with diagnoses that included, adult failure to thrive (a syndrome common in older adults that is characterized by unintentional weight loss, decreased appetite, poor nutrition, and physical inactivity), dysphagia (difficulty swallowing), and gastrostomy (g-tube, a surgical opening fitted with a device to allow nutrients to be administered directly to the stomach). During a review of Resident 5's Care Plan Report dated 9/9/2025, the Care Plan Report indicated the resident was on tube feeding related to dysphagia. The Care Plan Report indicated a goal for Resident 5 was to maintain adequate nutritional and hydration status as evidenced by having stable weight and no signs or symptoms of malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets) or dehydration (a condition caused by the loss of too much fluid from the body). The Care Plan Report included an intervention that indicated the resident was to receive Jevity 1.5 (a type of high calorie TF formula) at 55 milliliters (a metric unit of volume) per hour (ml/hr) for 20 hours. During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 3/7/2026, the MDS indicated the resident had severe cognitive impairment (a significant decline in the ability to think, understand, and reason). The MDS indicated Resident 5 was dependent on staff for help with oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 5 had a feeding tube. During a review of Resident 5's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 3/27/2026 for Glucerna 1.2 via the g-tube at 70 ml/hr for 20 hours for a total of 1400 ml. During a concurrent interview and record review on 4/2/2026 at 1:04 PM with Registered Nurse 1 (RN 1), Resident 5's Care Plan Report dated 9/9/2025 and physician order dated 3/27/2026 were reviewed. RN 1 stated Resident 5 was on tube feeding. RN 1 stated Resident 5 had physician orders to be on Glucerna 1.2 at 70 ml/hr. RN 1 stated Resident 5 had a care plan for tube feeding which indicated the resident was on Jevity 1.5 at 55 ml/hr. RN 1 stated Resident 5's tube feeding care plan had to be revised and updated to include the resident's current physician orders for Glucerna 1.2. RN 1 stated Resident 5's care plan had to reflect the resident's current plan of care. RN 1 stated the purpose of a care plan was to guide the staff (in general) on how to provide care for Resident 5. RN 1 stated Resident 5's care plan listed interventions that staff were to follow when caring for Resident 5. RN 1 stated there was potential for the staff (in general) not to be updated on Resident 5's current plan of care which could affect the care received. During a concurrent interview and record review on 4/3/2026 at 8:20 AM with the Director of Nursing (DON), Resident 5's Care Plan Report dated 9/9/2025 and physician order dated 3/27/2026 were reviewed. The DON stated Resident 5 was on tube feeding and had physician orders for Glucerna 1.2 at 70 ml/hr. The DON stated Resident 5's care plan for tube feeding indicated the resident was on Jevity 1.5 at 55 ml/hr. The DON stated Resident 5's tube feeding care plan was not updated when the resident received new physician orders for Glucerna 1.2 at 70 ml/hr on 3/27/2026. The DON stated Resident 5's care plan should have been revised and updated when new physician orders were received. The DON stated the care plan had to reflect Resident 5's current plan of care. The DON stated the care plan indicated the kind of care the resident was to receive at the facility. The DON stated if the care plan was not updated there was potential for Resident 5 to receive care that was not in alignment with the resident's needs. During a review of the facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated 1/15/2026, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change.

Based on interview and record review the facility failed to ensure the Dialysis (process of removing waste products and excess fluid from the body) Communication Record was completed for one of two sampled residents (Resident 1) who received dialysis treatment every Monday, Wednesday, and Friday. This failure had the potential to place Resident 1 at risk for a delay in detecting and treating complications related to dialysis such as infection, bleeding, and hypotension (low blood pressure).Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility re-admitted the resident on 11/12/2024 with diagnoses that included End Stage Renal Disease (ESRD, irreversible kidney failure) and dependence on renal dialysis. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 3/1/2026, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 1 required set-up or clean-up assistance (helper sets up or cleans up) with eating and oral hygiene. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with upper body dressing and personal hygiene. The MDS indicated Resident 1 required partial/moderate assistance from staff (helper does less than half the effort) with toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 was receiving dialysis treatment. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 3/2/2026 for dialysis every Monday, Wednesday, and Friday at the dialysis center. During a review of the facility's undated Dialysis Communication Record form, the Dialysis Communication Record form indicated it was to be completed by a licensed nurse at the facility before (pre) dialysis, completed by the dialysis center during dialysis, and completed by a licensed nurse at the facility after (post) dialysis. During a review of Resident 1's Dialysis Communication Records dated 3/9/2026 - 4/1/2026, the Dialysis Communication Records indicated the post dialysis assessment was not completed for Resident 1 on 3/11/2026, 3/16/2026, and 3/20/2026. The Dialysis Communication Records dated 3/11/2026, 3/16/2026, and 3/20/2026 indicated there was no documentation under the post dialysis assessment section regarding Resident 1's cognitive status, vital signs, dialysis access site, or breathing patterns. There were no Dialysis Communication Records for Resident 1 dated 3/23/2026, 3/25/2026, 3/27/2026, and 3/30/2026. During a concurrent interview and record review on 4/02/2026 at 9:52 AM with Registered Nurse 2 (RN 2), Resident 1's Dialysis Communication Records dated 3/9/2026 - 4/1/2026 were reviewed. RN 2 stated the Dialysis Communication Record was a form that accompanied the resident to and from dialysis. RN 2 stated the licensed nurses were responsible for filling out and completing the Dialysis Communication Record pre and post dialysis. RN 2 stated a Dialysis Communication Record had to be completed every time Resident 1 went to dialysis. RN 2 confirmed by stating the Dialysis Communication Record for Resident 1 was not completed by a licensed nurse post dialysis on 3/11/2026, 3/16/2026, and 3/20/2026. RN 2 stated there was no Dialysis Communication Record for Resident 1 on 3/23/2026, 3/25/2026, 3/27/2026, and 3/30/2026. RN 2 stated the Dialysis Communication Record for Resident 1 should have been completed by a licensed nurse post dialysis on 3/11/2026, 3/16/2026, and 3/20/2026. RN 2 stated the Dialysis Communication Record should have been completed by the facility and the dialysis center on 3/23/2026, 3/25/2026, 3/27/2026, and 3/30/2026. RN 2 stated the purpose of the Dialysis Communication Record was to monitor Resident 1 throughout the dialysis process. RN 2 stated the Dialysis Communication Record ensured that from the facility to the dialysis center and back to the facility, Resident 1 remained stable. RN 2 stated the Dialysis Communication Record would help to identify if Resident 1 had a change of condition during the dialysis process. RN 2 stated if the Dialysis Communication Record was not completed there was potential for Resident 1 to have a change of condition that was not identified and treated promptly. During a concurrent interview and record review on 4/03/2026 at 8:15 AM with the Director of Nursing (DON), Resident 1's Dialysis Communication Records dated 3/9/2026 - 4/1/2026 were reviewed. The DON confirmed by stating the post dialysis assessments on the Dialysis Communication Records were not completed for Resident 1 on 3/11/2026, 3/16/2026, and 3/20/2026. The DON stated the Dialysis Communication Record was not completed on 3/23/2026, 3/25/2026, 3/27/2026, and 3/30/2026. The DON stated the Dialysis Communication Record had to be completed before, during, and after Resident 1 had dialysis. The DON stated the Dialysis Communication Record had to be completed with every dialysis session. The DON stated the Dialysis Communication Record was an assessment used to ensure residents were stable. The DON stated the Dialysis Communication Record ensured the licensed nurses monitored the residents' vitals and dialysis site for any changes. The DON stated if the Dialysis Communication Record was not completed pre, during, and post dialysis, Resident 1 could potentially have had a change of condition that was not monitored and treated. During a review of the facility's Policy and Procedure (P&P) titled Hemodialysis Access Care dated 1/15/2026, the P&P indicated The general medical nurse should document in the resident's medical record every shift as follows: Location of catheter, condition of dressing (interventions if needed), if dialysis was done during shift, any part of report from dialysis nurse post-dialysis being given, observations post-dialysis.

Based on interviews and record reviews the facility failed to ensure one of five sampled residents (Resident 3) was free from chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom of movement of a patient or in some cases to sedate the patient) by failing to: Ensure Resident 3's physician order dated 4/1/2026 for Haloperidol (Haldol, a type of medication used to treat the symptoms of schizophrenia [a mental illness that affects thoughts, mood, and behavior]) 10 milligrams (mg: unit of measurement) at bedtime specified resident specific behavior manifestations (observable actions, reactions, and physical, visible expressions of an underlying psychological state, emotional condition, or physiological disorder). This failure had the potential for Resident 3 to become over-medicated, restrict mobility, and experience adverse side effects (unexpected or harmful consequences of medication) of Haldol such as dizziness, sedation (a decrease in awareness), blurred vision, and constipation (infrequent bowel movements).Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 9/19/2023 with diagnoses that included mood affective disorder (a mental health condition involving long-term emotional disturbances), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety (a mental health condition characterized by feelings of fear, dread and uneasiness that interfere with daily activities). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 2/25/2026, the MDS indicated the resident had severely impaired cognition (a significant decline in the ability to think, understand, and reason). The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) from facility staff with eating and oral hygiene. The MDS indicated Resident 3 was dependent on facility staff for help with toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 3 was taking antipsychotic medication (medication used to treat schizophrenia). During a review of Resident 3's Psychotherapeutic Drug Informed Consent Form dated 3/26/2026, the Psychotherapeutic Drug Informed Consent Form indicated informed consent (voluntary agreement to accept treatment and/or procedure after receiving education regarding the risks, benefits, and alternatives offered) was received from the resident's surrogate decision maker (a person authorized to make healthcare decisions for someone else who has become incapacitated) for Haldol 10 milligrams (mg, and unit of mass) at bedtime for schizophrenia manifested by auditory hallucinations (hearing voices or noises that don't exist in reality). During a review of Resident 3's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 4/1/2026 for Haldol 10 mg at bedtime for responding to internal stimuli related to schizoaffective disorder. During a review of Resident 3's Medication Administration Record (MAR) dated 3/27/2026 - 3/31/2026, the MAR indicated Resident 3 received five doses of Haldol 10 mg at bedtime for manifestations of responding to internal stimuli related to schizoaffective disorder. The MAR indicated Resident 3 had three instances of responding to internal stimuli on the evening shift on 3/31/2026. During a concurrent interview and record review on 4/02/2026 at 11:03 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 3's physician orders dated 3/27/2026 and 4/1/2026 were reviewed. LVN 1 stated Resident 3 had schizophrenia. LVN 1 stated Resident 3 was taking Haldol for responding to internal stimuli. LVN 1 stated there were physician orders to monitor Resident 3 for behaviors of responding to internal stimuli. LVN 1 stated she (LVN 1) was not sure what responding to internal stimuli meant. LVN 1 stated it would have been easier to monitor Resident 3 for more specific behavior like yelling or talking to herself (Resident 3). During a concurrent interview and record review on 4/2/2026 at 12:58 PM with Registered Nurse 1 (RN 1), Resident 3's physician orders dated 3/27/2026 and 4/1/2026 were reviewed. RN 1 stated Resident 3 was on Haldol for schizophrenia and responding to internal stimuli. RN 1 stated responding to internal stimuli referred to how Resident 3 was responding internally to environmental factors. RN 1 stated that the nurses (in general) were supposed to monitor how Resident 3 responded internally to environmental factors, such as noise levels. RN 1 stated the nurses (in general) were supposed to adjust Resident 3's environment based on how the resident responded internally to environmental factors. RN 1 stated the nurses (in general) were not monitoring for specific behavior. RN 1 stated responding to internal stimuli was not a specific behavior. During a concurrent interview and record review on 4/2/2026 at 1:09 PM with RN 2, Resident 3's physician orders dated 3/27/2026 and 4/1/2026 were reviewed. RN 2 stated Resident 3 had physician orders for Haldol 10 mg for schizophrenia manifested by responding to internal stimuli. RN 2 stated responding to internal stimuli referred to Resident 3 having auditory or visual hallucinations. RN 2 stated responding to internal stimuli was a broad manifestation which could cover all of Resident 3's behavioral symptoms. RN 2 stated that if the physician order for Haldol had a manifestation that was more specific, it would be easier to monitor Resident 3 for that specific behavior. RN 2 stated there was a potential that the licensed nurses would interpret the manifestation of responding to internal stimuli differently which could lead to the resident's behaviors not being monitored accurately. During a concurrent interview and record review on 4/3/2026 at 8:31 AM with the Director of Nursing (DON), Resident 3's physician orders dated 3/27/2026 and 4/1/2026 were reviewed. The DON stated Resident 3 had physician orders for Haldol 10 mg for schizophrenia manifested by responding to internal stimuli. The DON stated the manifestation for responding to internal stimuli was not specific enough to be monitored. The DON stated there was a potential for the licensed nurses to have different interpretations of responding to internal stimuli. The DON stated she (the DON), had difficulty explaining what responding to internal stimuli meant. The DON stated the behavior manifestation for Resident 3's Haldol order should have been a more specific behavior such as an auditory hallucination. The DON stated there was a potential for Resident 3 to become overmedicated and experience side effects of Haldol if the resident's behaviors were not interpreted or monitored accurately. During a review of the facility's Policy and Procedure (P&P) titled Antipsychotic Medication Use dated 1/15/2026, the P&P indicated Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications.

Based on observation and interview the facility failed to ensure one of one sampled resident (Resident 1) was made aware of pre-appointment instructions for a Computed Tomography (CT, an imaging procedure used to create detailed images of internal body structures) angiogram (a procedure that uses dye to visualize blood throw through arteries or veins) and cardiac echocardiogram (cardiac echo, an ultrasound test that creates images of the heart's structure) as scheduled on 3/30/2026 at 10 AM as per physician's orders dated 2/18/2026. As a result, Resident 1 could not have the CT angiogram done on 3/30/26, placing the resident at risk for a delay in care and treatment.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility re-admitted the resident on 11/12/2024 with diagnoses that included End Stage Renal Disease (ESRD, irreversible kidney failure), dependence on renal dialysis (process of removing waste products and excess fluid from the body), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (mild or partial weakness or loss of strength on one side of the body), hypertension (high blood pressure), and hepatic failure (loss of liver function). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 3/1/2026, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 1 required set-up or clean-up assistance (helper sets up or cleans up) with eating and oral hygiene. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with upper body dressing and personal hygiene. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 received dialysis treatment. During a review of Resident 1's Order Summary Sheet, the Order Summary Sheet indicated the resident had a physician order dated 2/18/2026 for an appointment to have a CT angiogram and cardiac echo on 3/30/2026 at 10 AM. The physician order indicated that dialysis for Resident 1 had to be scheduled within four to five hours after the appointment. The physician order indicated Resident 1 had to fast (have no food or drink) for four hours before the appointment. The physician order indicated Resident 1 could not have caffeine 24 hours before the appointment. During an interview on 3/31/2026 at 10:20 AM with Resident 1, Resident 1 stated he (Resident 1) was supposed to have a CT angiogram on 3/30/2026 and fast before the CT angiogram. Resident 1 stated he (Resident 1) was supposed to go to the appointment for the CT angiogram before dialysis and stated the nurses (in general) did not communicate any information or instructions about the CT angiogram appointment to him (Resident 1). Resident 1 stated he (Resident 1) went to the appointment for the CT angiogram after having dialysis on 3/30/2026. Resident 1 stated he (Resident 1) ate food before going to the appointment for the CT angiogram. Resident 1 stated he (Resident 1) could not have the CT angiogram done because he (Resident 1) ate food and had dialysis before the appointment. Resident 1 stated the appointment for the CT angiogram had to be rescheduled to 4/15/2026. Resident 1 stated he (Resident 1) was frustrated because the CT angiogram could not be done on 3/30/2026. During an interview on 4/2/2026 at 12 PM with the Social Services Director (SSD), the SSD stated Resident 1 had an appointment on 3/30/2026 for a CT angiogram and cardiac echo. The SSD stated Resident 1 was supposed to fast for four hours before the appointment and go to dialysis after the appointment. The SSD stated that on the day of the appointment Resident 1 went to dialysis before the appointment. The SSD stated that on 3/30/2026 at 9:30 AM, she (the SSD) received a call that Resident 1 could not have the CT angiogram and cardiac eco because the resident had already eaten and had dialysis. The SSD stated that on 3/27/2026 she (the SSD) posted a communication on the facility's care communication board as a reminder that Resident 1 had an appointment on 3/30/2026. The SSD stated instructions on fasting and attending dialysis after Resident 1's appointment was also included as part of the resident's physician order dated 2/18/2026. The SSD stated that she (the SSD) and Registered Nurse 2 (RN 2) were responsible for communicating the appointment instructions and information to Resident 1. The SSD confirmed by stating the instructions to fast and have dialysis after the appointment were not communicated to Resident 1. The SSD stated Resident 1's dialysis was supposed to be rescheduled for a later time on 3/30/2026 but stated that it was not done. The SSD stated Resident 1's appointment for a CT angiogram and cardiac echo had to be rescheduled for 4/15/2026. During an interview on 4/2/2026 at 1:15 PM with RN 2, RN 2 stated Resident 1 had physician orders for a CT angiogram and cardiac echo appointment on 3/30/2026. RN 2 stated Resident 1 was supposed to be fasting prior to the CT angiogram appointment. RN 2 stated Resident 1 was supposed to have the CT angiogram and cardiac echo done prior to going to dialysis. RN 2 stated that on 3/30/2026 Resident 1 went to dialysis before the resident's appointment for the CT angiogram. RN 2 stated she (RN 2) was informed that Resident 1 could not have the CT angiogram and cardiac echo done because the resident had eaten, so the resident returned to the facility. RN 2 stated she (RN 2) and the SSD were responsible for communicating with Resident 1 the need for fasting and going to the appointment before dialysis. RN 2 confirmed by stating the appointment and dialysis instructions were not communicated to Resident 1. RN 2 stated relaying the instructions for Resident 1's appointment got missed. RN 2 stated Resident 1's dialysis was supposed to be rescheduled for a later time on 3/30/2026 but stated that it was not done. RN 2 stated Resident 1's appointment for a CT angiogram and cardiac echo had to be rescheduled for 4/15/2026. During an interview on 4/3/2026 at 8:24 AM with the Director of Nursing (DON), the DON stated Resident 1 had a physician order for a CT angiogram and cardiac echo appointment on 3/30/2026. The DON stated Resident 1's physician order indicated the resident had to fast for four hours before the appointment and was to have dialysis after the appointment. The DON stated the SSD, and the RN supervisors were responsible for communicating the appointment instructions with Resident 1. The DON stated Resident 1 did not have the CT angiogram and cardiac echo on 3/20/2026 as scheduled because the appointment instructions were not communicated with the resident. In addition, the DON stated Resident 1's dialysis on 3/30/2025 was not scheduled for later in the day. The DON stated it was important for facility staff to communicate with residents regarding appointments and care plans. The DON stated that without communication important details could be missed. The DON stated there was a potential for Resident 1 to have a delay in care and treatment because the resident missed the CT angiogram and cardiac echo appointment. During a review of the facility's Policy and Procedure (P&P) titled Referrals, Social Services dated 1/15/2026, the P&P indicated Social services personnel shall coordinate most resident referrals with outside agencies. Social services shall coordinate most resident referrals. Exceptions might include emergency or specialized services that are arranged directly by a physician or the nursing staff.Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.Social services will help arrange transportation to outside agencies, clinical appointments, etc., as appropriate. During a review of the facility's P&P titled Use of Outside Resources dated 1/15/2026, the P&P indicated The facility recognizes the importance of utilizing outside resources to provide comprehensive care and support to residents. The facility will determine if outside resources are necessary to meet the needs of residents. Resident's medical condition, functional status, psychosocial needs, and preferences will be taken into consideration by the Interdisciplinary team when identifying the need for outside resources.The facility will comply with all applicable laws, regulations, and guidelines related to the use of outside resources.

Based on observation, interview, and record review, the facility failed to ensure that call light (a device with a button or touch pad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) was within reach for one of six sampled residents (Resident 68). This deficient practice had the potential to result in staff delay in meeting Resident 68's needs for activities of daily living (ADLS, activities a person performs daily such as bathing, dressing, and toileting), prolonged distress and increased risk of falls for Resident 68.Findings: During a review of Resident 68's admission Record, the record indicated the facility originally admitted Resident 68 on 2/7/2025 and readmitted the resident on 3/13/2026, with diagnoses that included spondyloarthropathy (a chronic autoimmune disease that causes pain and stiffness of the joints) of the spine, dementia (a progressive state of decline in mental abilities) and major depression disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 68's Fall Risk assessment dated [DATE], the assessment indicated the resident was at moderate risk for falls. During a review of Resident 68's Minimum Data Set (MDS, a resident assessment tool), dated 2/4/2026, the MDS indicated the resident required maximum assistance (helper does more than half the effort) from staff in completing ADLS. During a review of Resident 68's care plan revised on 3/22/2026, the care plan indicated Call light with easy reach and answer promptly. During an interview on 3/31/2026 at 10:49 a.m., Resident 68 stated she was unable to get up or reposition herself to a sitting position without assistance. Resident 68 stated she relied on using the call light to call for help and asked where the call light was because she (Resident 68) could not find the call light after staff had changed her bed linens earlier that day (3/31/26). During a concurrent observation and interview on 3/31/2026 at 11:01 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 68's room, the cord for Resident 68's call light was observed to be clipped to the bedsheet at the head of the bed. The call light was dangling off the left side of the bed. CNA 1 stated the call light was not within Resident 68's reach. CNA 1 stated the call light should have been within reach so the resident could press the call light to call for help. During an interview on 4/2/2026 at 9:38 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated it was not acceptable for call lights to be out of residents reach. LVN 4 stated residents with limited mobility would try to reach for the call light or move without assistance, which could lead to falls. During an interview on 4/3/2026 at 8:27 a.m. with the Registered Nurse Supervisor (RN), RN 2 stated call lights should be clipped on the bed within residents reach. RN 2 stated it can be stressful for residents when they cannot reach the call light to call for help. During a concurrent interview and record review the facility's policy and procedure (P&P) titled, Answering the Call Light, dated January 2026 on 4/3/26 at 8:31 a.m. with the Director of Nursing (DON), the DON reviewed the policy and stated it was not acceptable for call lights to be out of reach when residents needed to use the call lights. The DON stated the P&P was not followed. During a review of the facility's P&P titled, Answering the Call Light, dated January 2026, the P&P indicated, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to: Store unopened insulin lispro (a medication used to control blood sugar) in the refrigerator per the manufacturer's requirements in one of two inspected medication carts (Medication Cart 2.)Store gabapentin solution (a medication used to treat pain) in the refrigerator per the manufacturer's requirements in one of two inspected medication carts (Medication Cart 1). The deficient practice of failing to store medications in the refrigerator according to the manufacturer's requirements, increased the risk that residents could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.Findings: During a concurrent observation and interview on 4/1/2026 at 11:01 AM of Medication Cart 2 with the Licensed Vocational Nurse (LVN 4), one unopened insulin lispro pen was found stored at room temperature without a labeled open date. The insulin lispro pen product labeling indicated unopened insulin lispro pens had to be stored in the refrigerator. LVN 4 stated the lispro stored in the cart was unopened and should have been stored in the refrigerator. LVN 4 stated if insulin was stored at the wrong temperature, it could affect the potency of the medication which could lead to a loss of blood sugar control and other medical complications. During a concurrent observation and interview on 4/1/2026 at 11:11 AM of Medication Cart 1 with LVN 2, one prescription bottle of gabapentin solution 250 milligrams (mg - a unit of measure for mass) per 5 milliliters (ml - a unit of measure for volume) was found stored at room temperature. The gabapentin solution product and pharmacy labeling indicated the gabapentin solution had to be stored in the refrigerator. LVN 2 stated the gabapentin solution was stored in the cart at room temperature. LVN 2 stated, per the pharmacy label, gabapentin solution had to be stored in the refrigerator. LVN 2 stated she did not know how long the gabapentin solution had been stored at room temperature. LVN 2 stated failing to store gabapentin solution in the refrigerator could cause the medication not to work as well leading to seizures, increased pain, or other medical complications. A review of the facility's policy Storage of Medications, revised November 2020, indicated The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured locations.

Based on interview and record review, the facility failed to notify the resident's physician timely for one of three sampled residents (Resident 1). The facility failed to notify Resident 1's physician when Resident 1 had been refusing to take Depakote (medication used to treat including mental and mood conditions). This deficient practice had the potential for Resident 1's symptoms of paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) manifested by delusions (having false or unrealistic beliefs) to worsen.During a review of the admission Record indicated the facility admitted Resident 1 on 11/7/24 with diagnoses including paranoid schizophrenia, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and muscle weakness.During a review of the Physician Order dated 12/4/24 at 4:29 p.m., indicated physician's order to give Resident 1 Depakote tablet 125 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) delayed release by mouth for schizophrenia two times a day.During a review of Resident 1's care plan initiated on 12/4/24 and revised on 3/23/25 indicated Resident 1 was on Depakote 125 mg. two times a day for paranoid schizophrenia. The care plan goal indicated Resident 1 will not have side effects from the medication for three months. Interventions included assess daily for behavior manifested, notify the physician if the medication can be reduced, monitor the behavior and report monthly to the physician/psychiatrist to assist to assure lowest possible therapeutic dose.During a review of the Minimum data set (MDS, resident assessment tool) dated 11/4/25 indicated Resident 1 was cognitively intact. Resident 1 needed set-up assistance (helper sets up or cleans up, resident completes activity) with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 1/26 indicated Resident 1 refused to take the Depakote 125 mg. orally the following dates and time.1/1/26 - refused at 9 a.m. and 5 p.m.1/2/26 - refused at 9 a.m.1/3/26 - refused at 9 a.m.1/4/26 - refused at 9 a.m.1/5/26 - refused 9 a.m.1/6/26 - refused at 9 a.m. and 5 p.m.1/7/26 - refused at 9 a.m. and 5 p.m.1/8/26 - refused at 9 a.m. and 5 p.m.1/9/26 - refused at 9 a.m.1/10/26 - refused at 9 a.m.1/11/26 - refused at 9 a.m.1/12/26 - refused at 9 a.m. and 5 p.m.1/13/26 - refused at 9 a.m. and 5 p.m.1/14/26 - refused at 9 a.m.1/15/26 - refused at 9 a.m.1/16/26 - refused at 9 a.m. and 5 p.m.1/17/26 - refused at 9 a.m.1/18/26 - refused at 9 a.m. and 5 p.m.1/19/26 - refused at 9 a.m. and 5 p.m.1/20/26 - refused at 9 a.m. and 5 p.m.1/21/26 - refused at 9 a.m. and 5 p.m.1/22/26 - refused at 9 a.m.1/24/26 to 1/30/26 - refused at 9 a.m. and 5 p.m. During a review of the Change of Condition dated 1/30/26 at 1:51 p.m., indicated Resident 1 continued to refuse taking her medications, including laboratory tests. The COC indicated Resident 1's primary physician was notified. During an interview on 2/5/26 at 11:17 a.m. licensed vocational nurse (LVN 1) stated Resident 1 had been refusing her medications including Depakote. LVN 1 stated when Resident 1 refuses her medication, Resident 1 will be offered the medication two times and when she continues to refuse the medication, the physician should be notified. During a review and concurrent interview on 2/5/26 at 11:58 a.m., Resident 1's MAR for 1/26 was reviewed with the registered nurse supervisor (RNS 1). RNS 1 stated Resident 1 had been refusing to take the Depakote sometimes in the morning. RNS 1 stated Depakote is for Resident 1's delusion and when she does not take the Depakote, Resident 1's delusions will not be controlled. RNS 1 stated the change of condition was created on 1/30/26 and Resident 1's primary physician was notified on 1/30/26. During a review and concurrent interview on 2/5/26 at 12:55 p.m., the director of nursing (DON) stated when Resident 1 refuses to take the Depakote, the refusal to take the Depakote . will exacerbate her condition. DON stated she was unable to find any other documentation that the primary physician or psychiatrist were notified before 1/30/26. During a review of the facility's policy and procedures titled Change in a Resident's Condition or Status reviewed on 1/15/26 indicated the facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition and or status. The same Policy indicated the nurse will notify the resident's attending physician or physician on call when there has been refusal of treatment or medications two or more consecutive times.

Cross Reference F686Based on interview, and record review, the facility failed to ensure physician orders were implemented on 11/29/2025 and 12/1/2025 for five out of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5), who required daily treatment for wound (a physical injury to the body, like a cut or tear in the skin) management to maintain the highest practicable physical well-being.This failure resulted in lack of daily wound treatment for:a. Resident 1's stoma (a surgically created opening in the body, usually on the abdomen, that connects an internal organ (like the bowel or urinary system) to the outside, allowing waste (urine or feces) to exit into a collection bag), left ischium (the curved bone forming the base of each half of the pelvis), perineal area (the diamond-shaped region of skin and muscle between the anus and the genitals, extending from the pubic bone to the tailbone), scrotum, and sacrococcyx (lower part of the spine and tail bone). b. Resident 2's prevention of wound injuryc. Resident 3's bilateral extremitiesd. Resident 4's left arm caste. Resident 5's left foot, left plantar, right heel, right ischium, right lateral foot stumpplacing the residents at risk for delayed wound healing and further skin breakdown. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of quadriplegia (The complete inability to move due to sever disability frailty caused by another medical condition without physical injury or damage to the spinal cord), colostomy (a surgical procedure where a surgeon creates an opening in the abdominal wall so that stool can leave the body through he abdomen instead of the rectum) status, and open wound of left buttock. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 11/1/2025, indicated Resident 1 had intact cognition (the mental ability to think, remember and reason) for decisions of daily living, and 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 eating. The MDS indicated Resident 1 was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for toileting, lower body dressing, putting on/off footwear, and showering, rolling left and right, sit to lying, lying to sitting on side of bed, and transferring to the shower. The MDS indicated Resident 1 was at risk of developing pressure injuries (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure). A review of Resident 1's Order Summary, dated 6/17/2025, indicated for Resident 1, to cleanse with normal saline (NS- a mixture of sodium chloride and water that is used to clean wounds), pat dry apply skin prep around stoma, apply colostomy bag everyday shift for colostomy management. Apply Santyl collagenase (is a prescription medication used to remove dead or damaged tissue from chronic skin ulcers and severe burns. This process helps promote the formation of healthy new tissue and wound healing) ointment to left ischium and perineal area to scrotum, topically every day for surgical wound for 30 days, cleanse with NS, apply collagen pellets, apply calcium alginate and cover with DD. Apply Zinc Oxide to Sacro-coccyx topically everyday shift for healed wound management. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities) and difficulty in walking. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had moderate impaired cognition (ability to think, remember and reason) for decisions of daily living, 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 eating, 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 oral hygiene, and maximal assistance for toileting, showering, upper and lower body dressing, putting on taking off footwear, personal hygiene, rolling left and right, sit to lying, lying to sitting on side of bed, and chair transfer. The MDS indicated Resident 2 was at risk of developing pressure injuries. A review of Resident 2's Order Summary, dated 6/4/2025, indicated to monitor functionality of low air loss mattress (LAL, a bed that alternates pressure to help heal and prevent pressure injuries) every shift for skin management. A review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of contractures (the permanent tightening and shortening of muscles, tendons, skin, or other tissues around a joint, making it stiff, difficult to bend or straighten, and restricting normal movement, often caused by injury, nerve damage, inactivity, scarring ) to arms and ankle, and muscle weakness. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had intact cognition for daily decision making. The MDS indicated Resident 3 required set up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, oral hygiene, 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 toileting, showering, upper body dressing, rolling left and right, sit to lying and lying to sitting on side of bed. The MDS indicated Resident 3 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 putting on taking off footwear, lower body dressing and personal hygiene. The MDS indicated Resident 3 was at risk of developing pressure injuries. A review of Resident 3's Order Summary, dated 11/7/2024, indicated to apply A/D ointment to bilateral extremities and as barrier cream every shift for skin maintenance. A review of Resident 4's admission Record, the indicated Resident 4 was admitted to the facility on [DATE] with diagnosis of hemiplegia (loss of ability to move one one side of the body) and hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or nerves connected to the affected muscles). A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had moderate impaired cognition for daily decision making. The MDS indicated Resident 4 required set up assistance for eating, maximal assistance for oral hygiene, toileting, showering, upper body dressing, putting on taking off footwear, personal hygiene, partial assistance to roll left and right, sit to lying, lying to sitting on side of bed, and dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for lower body dressing. The MDS indicated Resident 4 was at risk of developing pressure injuries. A review of Resident 4's Order Summary, dated 10/20/2025, indicated to monitor skin integrity under cast (left arm) every day and evening shift. A review of Resident 5's admission Record, indicated Resident 5 was admitted to the facility on [DATE] with diagnoses of pressure injury to left buttock and open wound left foot. A review of Resident 5's MDS, dated [DATE], indicated Resident 5 had severely impaired cognition for daily decision making. The MDS indicated Resident 5 was dependent on staff for oral hygiene, toileting, showering, upper and lower body dressing, putting on taking off footwear, personal hygiene, rolling left and right, sit to lying, lying to sitting on side of bed. The MDS indicated Resident 5 was at risk of developing pressure injuries. A review of Resident 5's Order Summary, dated 11/6/2025, indicated cleanse gastrostomy site with NS and apply dry dressing daily every shift. Apply Santyl ointment to left foot, left plantar, right heel, right ischium, right lateral foot stump, topically every day for 30 days. Monitor functionality of LAL mattress every shift for wound management, and provide catheter care (A catheter which is inserted into the bladder, via the urethra or abdomen and remains in place to drain urine) every shift. A review of the Treatment Administration Record (TAR), dated 11/29/2025 and 12/1/2025, the TAR indicated physician-ordered daily wound care was not provided on scheduled days for Residents 1, 2, 3, 4, and 5. During an interview on 12/15/2025 at 1:27 PM with the Treatment Nurse (TN), the TN stated he is the only full time TN at the facility, and was scheduled to work on 12/1/2025 but was unable to attend his shift. The TN verified treatments provided to residents on 11/29/2025 and 12/1/2025 on the electronic medical record and stated Residents 1, 2, 3, 4, and 5 had not been provided treatment on those days per physician's order. The TN stated there was no documentation indicating treatment was completed, refused, or held. During an interview on 12/15/2025 at 1:58 PM with the Registered Nurse Supervisor (RNS), the RNS stated he worked on 12/1/2025 and was aware there was no assigned treatment nurse during the shift. The RNS stated he did not provide the ordered treatments, did not reassign another licensed nurse to complete treatments, nor was informed of residents who didn't receive treatment. The RNS also verified that treatments for residents on 11/29/2025 was not provided by the treatment nurse assigned that day. The RNS stated the treatment nurse on 11/29/2025 did not report the missed treatments to anyone, including the physician. During an interview on 12/15/2025 at 2:15 PM with the Director of Nursing (DON), the DON stated the facility failed to assign a treatment nurse on 12/1/2025 which resulted in Residents 1, 2, 3, 4, and 5 not receiving treatment as ordered per physician. The DON stated she assigned herself to provide treatment on 12/1/2025 because she could not find anyone to provide treatment despite having licensed nurses in the facility that day. The DON stated she did not prioritize residents who required extensive treatment, or had more complicated wounds, hoping she could provide treatment to all residents with physician orders, but failed to complete treatments for at least five residents. The DON stated it is important to follow physician's orders to ensure residents are being provided with the necessary treatment and services to treat resident's diagnosis based on the clinical judgment of the ordering physician. The DON stated this failure placed residents at risk for deteriorating skin integrity. A review of the facility policy and procedures (P&P) titled Medication and Treatment Orders dated 7/2016, indicated, Medications and treatments shall be administered only upon the written order of a person licensed and authorized to prescribe such medications and treatments. A review of the facility P&P titled Competency of Nursing Staff dated 11/2025, indicated, Licensed nurses will demonstrate competencies deemed necessary to care for the needs of residents as identified through resident assessments and described in the plans of care. The staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as skin and wound care.

Cross Reference F684 Based on interview, and record review, the facility failed to ensure physician orders were implemented on 11/29/2025 and 12/1/2025 for five out of five sampled residents (Resident 1, Resident 2, Resident 3, and Resident 5), who required daily treatment for wound (a physical injury to the body, like a cut or tear in the skin) management to prevent the development of and or deterioration of pressure injuries (Pressure sore/ulcer-is localized damage to skin and underlying tissues from intense or prolonged pressure, often over bony areas like hips, heels, or tailbone, due to reduced blood flow, exacerbated by friction, shear, and moisture).This failure resulted in lack of daily wound treatment for:a. Resident 1's stoma (a surgically created opening in the body, usually on the abdomen, that connects an internal organ (like the bowel or urinary system) to the outside, allowing waste (urine or feces) to exit into a collection bag), left ischium (the curved bone forming the base of each half of the pelvis), perineal area (the diamond-shaped region of skin and muscle between the anus and the genitals, extending from the pubic bone to the tailbone), scrotum, and Sacro-coccyx (lower part of the spine and tail bone). b. Resident 2's prevention of wound injuryc. Resident 3's bilateral extremitiesd. Resident 5's left foot, left plantar, right heel, right ischium, right lateral foot stumpplacing the residents at risk for delayed wound healing and further skin breakdown.Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of quadriplegia (The complete inability to move due to sever disability frailty caused by another medical condition without physical injury or damage to the spinal cord), colostomy (a surgical procedure where a surgeon creates an opening in the abdominal wall so that stool can leave the body through he abdomen instead of the rectum) status, and open wound of left buttock. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 11/1/2025, indicated Resident 1 had intact cognition (the mental ability to think, remember and reason) for decisions of daily living, and 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 eating. The MDS indicated Resident 1 was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for toileting, lower body dressing, putting on/off footwear, and showering, rolling left and right, sit to lying, lying to sitting on side of bed, and transferring to the shower. The MDS indicated Resident 1 was at risk of developing pressure injuries (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure). A review of Resident 1's Order Summary, dated 6/17/2025, indicated for Resident 1, to cleanse with normal saline (NS- a mixture of sodium chloride and water that is used to clean wounds), pat dry apply skin prep around stoma, apply colostomy bag everyday shift for colostomy management. Apply Santyl collagenase (is a prescription medication used to remove dead or damaged tissue from chronic skin ulcers and severe burns. This process helps promote the formation of healthy new tissue and wound healing) ointment to left ischium and perineal area to scrotum, topically every day for surgical wound for 30 days, cleanse with NS, apply collagen pellets, apply calcium alginate and cover with DD. Apply Zinc Oxide to Sacro-coccyx topically everyday shift for healed wound management. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities) and difficulty in walking. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had moderate impaired cognition (ability to think, remember and reason) for decisions of daily living, 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 eating, 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 oral hygiene, and maximal assistance for toileting, showering, upper and lower body dressing, putting on taking off footwear, personal hygiene, rolling left and right, sit to lying, lying to sitting on side of bed, and chair transfer. The MDS indicated Resident 2 was at risk of developing pressure injuries. A review of Resident 2's Order Summary, dated 6/4/2025, indicated to monitor functionality of low air loss mattress (LAL, a bed that alternates pressure to help heal and prevent pressure injuries) every shift for skin management. A review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of contractures (the permanent tightening and shortening of muscles, tendons, skin, or other tissues around a joint, making it stiff, difficult to bend or straighten, and restricting normal movement, often caused by injury, nerve damage, inactivity, scarring ) to arms and ankle, and muscle weakness. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had intact cognition for daily decision making. The MDS indicated Resident 3 required set up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, oral hygiene, 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 toileting, showering, upper body dressing, rolling left and right, sit to lying and lying to sitting on side of bed. The MDS indicated Resident 3 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 putting on taking off footwear, lower body dressing and personal hygiene. The MDS indicated Resident 3 was at risk of developing pressure injuries. A review of Resident 3's Order Summary, dated 11/7/2024, indicated to apply A/D ointment to bilateral extremities and as barrier cream every shift for skin maintenance. A review of Resident 5's admission Record, indicated Resident 5 was admitted to the facility on [DATE] with diagnoses of pressure injury to left buttock and open wound left foot. A review of Resident 5's MDS, dated [DATE], indicated Resident 5 had severely impaired cognition for daily decision making. The MDS indicated Resident 5 was dependent on staff for oral hygiene, toileting, showering, upper and lower body dressing, putting on taking off footwear, personal hygiene, rolling left and right, sit to lying, lying to sitting on side of bed. The MDS indicated Resident 5 was at risk of developing pressure injuries. A review of Resident 5's Order Summary, dated 11/6/2025, indicated cleanse gastrostomy site with NS and apply dry dressing daily every shift. Apply Santyl ointment to left foot, left plantar, right heel, right ischium, right lateral foot stump, topically every day for 30 days. Monitor functionality of LAL mattress every shift for wound management A review of the Treatment Administration Record (TAR), dated 11/29/2025 and 12/1/2025, the TAR indicated physician-ordered daily wound care was not provided on scheduled days for Residents 1, 2, 3, and 5. During an interview on 12/15/2025 at 1:27 PM with the Treatment Nurse (TN), the TN stated he is the only full time TN at the facility, and was scheduled to work on 12/1/2025 but was unable to attend his shift. The TN verified treatments provided to residents on 11/29/2025 and 12/1/2025 on the electronic medical record and stated Residents 1, 2, 3, and 5 had not been provided treatment on those days per physician's order. The TN stated there was no documentation indicating treatment was completed, refused, or held. During an interview on 12/15/2025 at 1:58 PM with the Registered Nurse Supervisor (RNS), the RNS stated he worked on 12/1/2025 and was aware there was no assigned treatment nurse during the shift. The RNS stated he did not provide the ordered treatments, did not reassign another licensed nurse to complete treatments, nor was informed of residents who didn't receive treatment. The RNS also verified that treatments for residents on 11/29/2025 was not provided by the treatment nurse assigned that day. The RNS stated the treatment nurse on 11/29/2025 did not report the missed treatments to anyone, including the physician. During an interview on 12/15/2025 at 2:15 PM with the Director of Nursing (DON), the DON stated the facility failed to assign a treatment nurse on 12/1/2025 which resulted in Residents 1, 2, 3, 4, and 5 not receiving treatment as ordered per physician. The DON stated she assigned herself to provide treatment on 12/1/2025 because she could not find anyone to provide treatment despite having licensed nurses in the facility that day. The DON stated she did not prioritize residents who required extensive treatment, or had more complicated wounds, hoping she could provide treatment to all residents with physician orders, but failed to complete treatments for at least five residents. The DON stated it is important to follow physician's orders to ensure residents are being provided with the necessary treatment and services to treat resident's diagnosis based on the clinical judgment of the ordering physician. The DON stated this failure placed residents at risk for deteriorating skin integrity. A review of the facility policy and procedures (P&P) titled Medication and Treatment Orders dated 7/2016, indicated, Medications and treatments shall be administered only upon the written order of a person licensed and authorized to prescribe such medications and treatments. A review of the facility P&P titled Pressure Ulcers/Skin Breakdown-Clinical protocol last reviewed 11/25/2025, indicated, Treatment Management -1. The physician will order wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc) and application of tropical agents.

Based on interview and record review, the facility failed to ensure the discharge summary and plan policy was followed by failing to have the post-discharge plan filled out completely and signed for one of three sampled residents (Resident 1). This failure resulted in Resident 1's post-discharge plan not being completed or signed accordingly. During a review of Resident 1's admission Record, dated 11/20/25 indicated the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) anxiety disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem) , anemia (a condition where the body does not have enough healthy red blood cells), peripheral venous insufficiency (occurs when the walls and/or valves in the veins are not working effectively, making it difficult for blood to return to the heart).During a review of Resident 1's History and Physical (H&P) dated 5/14/25 indicated the resident had capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 5/17/25 indicated Resident 1 had moderate cognitive (learning, reasoning, thinking, understanding) impairment, and required supervision /touching assistance for Activities of Daily Living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a concurrent interview and record review on 11/18/25 at 3:22 pm with Registered Nurse Supervisor (RNS) 1, Resident 1's Post Discharge Plan of Care was reviewed. RNS 1 verified the document was incomplete: it did not indicate who the plan was developed with, equipment needs, special observations, special training/instructions or post-discharge goals. It was also missing the completed by and accepted by names and dates. RNS 1 stated he was unsure who filled out the document but thinks it was the night shift RN because that is how it is typically done, also the resident should have signed.During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan reviewed 4/17/25, the P&P indicated When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment.The post-discharge plan will be developed by the care planning/interdisciplinary (IDT) team with the assistance of the resident and his or her family and will include:. a description of the resident's stated discharge goals, the degree of caregiver/support person availability. how the IDT will support the resident or representative in the transition to post-discharge care. the resident/representative will be involved in the post-discharge planning process.

Based on interview and record review the facility failed to accurately assess for wandering behaviors for one of three sampled residents (Resident 1).This failure resulted in inaccurate Minimum Data Set (MDS- resident assessment tool) and had the potential to affect the residents care and services. During a review of Resident 1's admission Record, dated 11/20/25 indicated the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) anxiety disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem) , anemia (a condition where the body does not have enough healthy red blood cells), peripheral venous insufficiency (occurs when the walls and/or valves in the veins are not working effectively, making it difficult for blood to return to the heart).During a review of Resident 1's History and Physical (H&P) dated 5/14/25 indicated the resident had capacity to understand and make decisions.During a review of Resident 1's Health Status note dated 5/16/25 indicated Resident 1 was on monitoring for behavior of wandering. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 5/17/25 indicated Resident 1 had moderate cognitive (learning, reasoning, thinking, understanding) impairment, and required supervision /touching assistance for Activities of Daily Living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The same MDS further indicated the resident did not have any wandering behaviors.During a concurrent interview and record review on 11/18/25 at 3:41 pm with Director of Nursing (DON) Resident 1's health status note dated 5/16/25 and MDS section for behaviors dated 5/17/25 were reviewed. The health status note indicated the resident was on monitoring for behavior of wandering and the MDS indicated the resident had no behaviors of wandering. The DON confirmed the there was a discrepancy in the assessment and stated she was not aware but the resident was new so those behaviors are not uncommon. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements reviewed 1/16/25 indicated The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.During a review of the facility's P&P titled, Resident Assessment reviewed 1/16/25 indicated, a comprehensive assessment of every resident's needs is made. includes a. completion of the Minimum Data Set (MDS). The interdisciplinary team uses the MDS form currently mandated by federal and state regulation to conduct the resident assessment. All members of the care team, including licensed and unlicensed staff members, are asked to participate in the resident assessment process.

Based on interview and record review, the facility failed to: 1. Supervise and monitor the whereabouts of one of three sampled residents (Resident 2). Resident 2 had a history of inappropriate sexual behaviors, pulling off his pants, self-pleasuring throughout the day, and rubbing his genitals (genitalia- refers to reproductive organs/private parts) in the presence of residents residing in the facility according to Resident 2's care plan (CP) on (Resident 2) has altered behavior manifested by (m/b) invading roommate's space and episode of sexual inappropriate behavior (rubbing his crotch). 2. Protect one of three sampled residents (Resident 1) from sexual abuse (non-consensual sexual contact of any type or sexual harassment) by Resident 2 (Resident 1's roommate). On 10/29/2025 at 8:33AM, a Certified Nursing Assistant (CNA-unknown) informed Social Service Assistant (SSA) that Resident 2 had inappropriately attempted to touched Resident 1's leg according to Resident 2's care plan (CP) on (Resident 2) has altered behavior manifested by (m/b) invading roommate's space and episode of sexual inappropriate behavior (rubbing his crotch). 3. Develop/create a care plan upon admission that addressed Resident 2's inappropriate sexual behavior according to the facility policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered dated 1/16/2025,. 4. Conduct an Interdisciplinary Team (IDT- a collaborative group of diverse health care professionals from different fields who work together) to develop a plan of care and interventions when on 10/2/2025 Resident 2 was noted with inappropriate sexual behavior according to the facility policy and procedures (P&P) titled, Care Planning - Interdisciplinary Team dated 1/16/2025. These deficient practices had increased potential for: 1. Resident-to-resident verbal and or physical altercation, and injury between Resident 2 and other residents in the facility. 2. Resident 2 to continue invading Resident 1's and the residents' personal space. 3. Resident 1 and other resident in the facility to suffer emotional or psychological distress, and/or emotional discomfort, fear to Resident 1 and other residents in the facility. A review of Resident 1's admission Record, indicated the facility admitted Resident 1 on 6/13/2023 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the body), unspecified dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body)and hemiparesis (partial weakness on one side of the body, affecting the arm, leg and sometimes the face) following cerebral infarction( a stroke caused by a blocked blood vessel in the brain) affecting left non-dominant(less used) side and muscle weakness (generalized). A review of Resident 1's History and Physical (H&P) dated 8/22/2025, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/1/2025, indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired (significant problems with thinking and memory). The MDS indicated Resident 1 had lower extremity (hip, knee, ankle, foot) impairment (loss of anatomical function). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene (practices and habits that maintain cleanliness and health of the body), showering/bathing, dressing, and personal hygiene. The MDS indicated Resident 1 was dependent on staff to go from sitting to lying position and from lying position to a sitting position on the side of the bed and rolling left to right. The MDS indicated Resident 1 did not walk. A review of Resident 2's admission Record, indicated the facility admitted Resident 2 on 9/16/2025 with diagnoses including other encephalopathy ( a general disturbance in brain function), psychotic disturbance(a state where a person loses touch with reality and has a hard time distinguishing it from reality) and mood disturbance (a mental health condition where a person's emotions are affected in a severe and prolonged way, going beyond normal ups and downs). A review of Resident 2's General Acute Care Hospital (GACH) 1 Discharge Summary provided to Skilled Nursing Facility (SNF) 2 by GACH 1 indicated that on 09/08/2025, SNF 1 placed Resident 2 on a 5150 (a temporary, 72-hour involuntary psychiatric hold) for danger to others. The GACH Discharge Summary indicated SNF 1 documented that Resident 2, has been sexually inappropriate, including episodes of pulling his pants down, attempting to engage in sexual activity with his male roommate, and frequently touching himself or self-pleasuring throughout the day. GACH 1 Discharge Summary indicated Resident 2 had a history of poor impulse control (acting without thinking about the consequences, driven by a desire for immediate gratification), poor judgement and sexually inappropriate behaviors that placed Resident 2 at a remained risk of harming others. A review of Resident 2's H&P dated 9/17/2025, indicated Resident 2 did not have capacity to understand and make decisions. The H&P indicated, Patient (Resident 2) was placed on 5150 hold for danger to others on 09/08/2025. Patient was a previous resident at SNF 1. He (Resident 2) has been sexually inappropriate, including episodes of pulling his pants down, attempting to engage in sexual activity with his male roommate, and frequently touching himself or self-pleasuring throughout the day. A review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was able to walk 50 feet on their own. The MDS indicated Resident 2 was independent and able to complete all activities by himself with or without assistive device, and with no assistance from a helper. The MDS indicated Resident 2 had no impairment in both upper and lower extremities. A review of Resident 2's Initial Psychiatric Evaluation dated 9/21/2025, indicated staff had reported Resident 2 had history of sexual inappropriateness. A review of Resident 2's care plan (CP) on Resident noted with inappropriate behavior of pulling off his pant in the hallway. initiated on 10/2/2025, CP the goal indicated, Resident will maintain appropriate behavior through review date. The CP interventions included to, Provide a safe environment. Teach resident safe practice (masturbation [stimulation of the genitals for sexual pleasure]). Transfer to the hospital for psych (psychiatry) evaluation . A review of Resident 2's Change of Condition (COC) Situation Background Assessment Recommendation (SBAR) document dated 10/2/2025 at 8 AM, indicated that on 10/2/2025 at 7:30AM, (Resident 2) was noted with inappropriate behavior of pulling off his pant in the hallway. The COC SBAR indicated a Please review and triage the attached HS802 physician was notified who gave an order to transfer Resident 2 to GACH 2 for psych evaluation. A review of Resident 2's CP on (Resident 2) has altered behavior manifested by (m/b) invading roommate's space and episode of sexual inappropriate behavior (rubbing his crotch) in the activity room initiated 10/29/2025, the CP goal indicated, Resident will demonstrate coping mechanisms. The CP interventions indicated, Continue to monitor behavior, provide redirection as needed, and ensure environmental safety. Document any recurrent or escalating behaviors. Psychiatry to evaluation for medication adjustment or behavioral intervention. A review of Resident 2's COC SBAR dated 10/29/2025 at 1:23PM, indicated that on 10/29/2025 at 1:23PM, (Resident 2) was noted approaching and invading his roommate's (Resident 1) personal space and episode of displaying behavior that was sexually inappropriate in nature (rubbing his crotch) in the activity room. The COC SBAR indicated Resident 2's attending physician was notified and referral to psychiatry will be made for further evaluation . A review of Resident 2's IDT Review record dated 10/29/2025 at 2:04PM, indicated, Behavior Concern: Risk of Resident-to-Resident Altercation or Injury Invading another resident's personal space may trigger verbal or physical aggression from peers, potentially leading to injury to self or others. Risk of Emotional or Psychological Distress to Others Sexually inappropriate or intrusive behaviors may cause emotional discomfort, fear, or distress to roommates or other residents. Risk of Escalation of Inappropriate Behavior. A review of Resident 2's Social Service Note dated 10/29/2025 at 8:33AM, indicated SSA (Social Service Assistant) was informed that morning by staff (unidentified) that Resident 2 was exhibiting inappropriate behavior toward fellow roommate (unidentified). Resident 2 is observed doing inappropriate behavior to himself in his room by staff daily but this issue that occurred or happened this morning was wrong. During an interview on 11/10/2025 at 9:47AM, SSA stated that on 10/29/2025 a Certified Nurse Assistant (SSA could not remember CNA's name) informed SSA that she (CNA) saw Resident 2 being inappropriate with Resident 1 while Resident 1 was in bed and that Resident 2 was trying to touch Resident 1's leg. SSA stated the facility staff had witnessed Resident 2 having inappropriate behavior of masturbating (stimulate own genitals for sexual pleasure), and CNA would find Resident 2 being overly sexual with himself, touching himself inappropriately. SSA stated Resident 2's curtains should have been pulled for privacy, to have shown dignity. SSA stated Resident 2 should not have masturbated to where he exposed himself to others. SSA stated masturbation needed to be done in private and must not touch any resident including Resident 1 who cannot defend himself. SSA stated she immediately requested for a room change from Registered Nurse (RN) 1 immediately requested for due to the inappropriate behavior of Resident 2 towards Resident 1. SSA stated the facility should have ensured Resident 2 had to have roommates that were more alert (vigilant) and who could be able to speak up for themselves if they needed help. During an interview on 11/10/2025, at 10:29 AM Licensed Vocational Nurse (LVN)1 stated a CNA (unable to recall the name) witnessed Resident 2's one hand underneath Resident 1's blanket, and Resident 2's other hand was down Resident 2's own pants while masturbating. LVN 1 stated the incident between Resident 2 on Resident 1 happened inside Resident 1 and Resident 2's room and that the incident is considered sexual abuse. LVN 1 stated she notified RN 1 of the incident between Resident 1 and Resident 2 and did not know if anyone else was notified. LVN 1 stated any incidents of sexual abuse were reportable to the state and that she herself did not report to the state California Department of Public Health (CDPH). During an interview and record review on11/10/2025 at 11:02 AM, with RN1stated Resident 2's Care Plan Report initiated on 10/29/2025 was reviewed. RN 1 stated the Care Plan Report indicated Resident 2 had a behavior of inappropriate sexual behavior (rubbing his crotch[genitals]) in the activity room while other residents were present and invading roommate's space. RN 1 stated the care plan report interventions included to monitor Resident 2's behavior and environmental safety (steps to protect people) and document any recurrent (repeated)or escalating (actions that get worse) behaviors. RN 1 stated, we (facility) had a vague inclination of what may or may not end up happening in the future and we had to be vaguer in the care plans with what we monitored, until we were more familiar with (Resident 2's) behaviors. RN 1 stated Resident 2 walks around by himself in the facility unescorted and unmonitored. RN1 stated Resident 2 had a lot of history of sexually inappropriate behavior when Resident 2's admission paperwork was reviewed. RN 1 stated that on 10/29/2025, around 10AM Resident 2 was moved to a room with residents who were alert. RN 1 stated that on 10/29/2025 at around 7AM to 8AM, a CNA (unidentified) reported (unidentified staff) the incident between Resident 1 and Resident 2. RN1 stated, I don't remember who that would have been on that day (10/29/2025) reported Resident 2 was walking around in Resident 1's spaces rubbing his crotch. RN 1 stated Resident 1 would not have been able to tell us anything; (Resident 1) is not alert. RN 1 stated she spoke to the Director of Nursing (DON) on 10/29/2025 and a registered nurse consultant (a registered nurse with extensive experience who provides expert advice). During an interview and record review on11/10/2025 at 12:26 PM, with Licensed Vocational Nurse (LVN) 2, Resident 2' Care Plan Report initiated 10/2/2025 and medical record were reviewed. LVN 2 stated, the Care Plan Report indicated Resident 2 was noted with inappropriate behavior of pulling off his pants in the hallway. LVN 2 stated the care plan report interventions included to teach resident safe practice (masturbation). LVN 2 stated the care plan report interventions were not specific, they do not indicate what the safe practices are needed. LVN 2 stated there was no care plan before 10/2/22025, that addressed Resident 2's inappropriate sexual behavior. and that a care plan should have been based on the hospital (GACH) records from 9/16/2025 (prior to admission). LVN 2 stated care plans have interventions to intervene before a behavior happens, to manage a behavior. LVN 2 stated an interdisciplinary team (meeting should have been done to identify concerns in Resident 2, to have been able to come up with a plan for Resident 2. LVN 2 stated an IDT was not done for the incident on 10/2/2025, for Resident 2 removing his pants in the hallway, that made sure the interventions are appropriate, realistic, and interventions had to be resident specific. LVN 2 stated if incidents happen and IDTs are not done, interventions are not created It would be a risk of an incident such as an altercation of some kind, abuse such as sexual assault, or sexual abuse. During an interview on 11/10/2025 at 3:36 PM the DON stated that she (DON), reviews preadmission records to make sure that the facility can take care of the residents, that we had the proper standards for resident care. The DON stated, we were trying to find a better placement for Resident 2 since he had some issues and things that he did. The DON stated there was no IDT conducted for incident on 10/2/2025, when Resident 2 pulled off his pants in the hallway and that Resident 2's behavior was inappropriate. The DON stated and IDT could have been done. The DON stated that interventions on Resident 2's care plan should have been more detailed. During a concurrent interview and record review on 11/10/2025 at 4:44 PM with the Administrator (ADM), Resident 2's GACH, dated 9/16/2025 medical records was were reviewed. The ADM stated when Resident 2 exposed himself it was not an appropriate behavior. The ADM stated if Resident 2 had exposed himself daily, we might have placed Resident 2 on a 1:1 (one staff member is providing focused, one -on-one attention to a single resident at a time), spoken to the Resident 2's doctor and Resident 2's conservator (a person given the legal authority to manage the personal care of another individual[the conservatee] who, is unable to manage their own affairs). The ADM stated Resident 2's conservator and the medical doctor would have determined if sending Resident 2 to a different level of care was applicable. The ADM stated that if he knew of Resident 2's history of exposing himself and masturbating in front of other people, he would have been more vigilant from the beginning. The ADM stated the DON was responsible for screening residents prior to admission and was responsible for clinical oversight (a supervisor ensuring that patient care is safe and followed proper rules and methods). The ADM confirmed that none of the staff had reported any allegation of abuse of Resident 2 trying to touch Resident 1 inappropriately. A review of policy and procedures (P&P) titled, Abuse Prevention Program dated 1/16/2025, indicated, Our residents have the right to be free from abuse . This includes but is not limited to . sexual abuse. As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to .other residents. A review of the facility P&P titled, Care Plans, Comprehensive Person-Centered dated 1/16/2025, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated, The comprehensive, person-centered care plan will; incorporate identified problem areas; incorporate risk factors associated with identified problems; reflect treatment goals, timetables and objectives in measurable outcomes; reflect current recognized standards of practice for problem areas and conditions. The P&P indicated, Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just only symptoms and triggers. The P&P indicated, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). A review of the facility P&P titled, Care Planning - Interdisciplinary Team dated 1/16/2025, indicated, Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS).

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for two of eight sampled residents (Resident 9 and Resident 42), who was subjected to Resident 392's physical aggression, who had diagnoses of schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior). The facility failed to: -Implement the facility's policy and procedure titled, Abuse Prevention Program, dated 1/16/2025 to protect residents from abuse by anyone including other residents. -Develop a resident specific schizoaffective disorder bipolar type care plan for Resident 392, with interventions to monitor behavior. As a result, on 2/9/2025 at 8:24 pm, Resident 392 hit Resident 42 in the room they shared. On 2/10/2025, Resident 392 hit Resident 9 (his new roommate) above his right eye while Resident 9 was lying in bed. Resident 392 was transferred to the General Acute Care Hospital (GACH) on 2/10/2025 for altered mental status (a noticeable change in someone's mental state, like being confused, disoriented, not acting like themselves, or having difficulty thinking clearly) and agitation. This deficient practice caused an increased risk for Resident 42's psychological harm and Resident 9 sustained a scratch on his neck and remained angry and upset days after the incident. Findings: A review of the GACH Therapy record dated 1/28/2025, indicated Resident 392 was combative, agitated (a feeling of extreme restlessness, tension, or irritability), and required a sitter for monitoring behavior. A review of Resident 392's GACH Consultation record dated 1/29/2025, indicated the resident had an altered mental state (a noticeable change in someone's mental function, like being confused, disoriented, unusually sleepy, or acting strangely), and had aggressive behavior that required antipsychotic medication (generally used to treat the symptoms of psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality]). The GACH Consultation record indicated Resident 392 had poor attention, was confused, had impoverished thought content (issues with thinking often associated with schizophrenia [a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions]), dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), severe depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), and poor judgement and insight (a person is unable to recognize changes in their own behavior and emotions). A review of Resident 392's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a change in how your brain works due to an underlying condition), schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior), and unspecified dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning). A review of the Physician's Order Summary Report dated 2/7/2025, indicated Resident 392 had an order for Zyprexa (medication used to treat schizophrenia) 5 milligrams (mg- metric unit of measurement) by mouth two times a day for schizoaffective disorder. The physician's order summary report indicated to monitor behavior of wide mood swings every shift for use of Zyprexa (an antipsychotic medication that can treat several mental health conditions like schizophrenia) starting 2/8/2025. A review of Resident 392's History and Physical (H&P) dated 2/8/2025, indicated the resident was not competent to understand his medical condition and bill of rights. The H&P indicated Resident 392 had a diagnosis of anxiety. According to a review of the Progress Note documented by Registered Nurse (RN) 1, dated 2/9/2025 at 8:24 pm, Resident 392 hit Resident 42 in the room they shared on 2/9/2025. The progress note indicated Resident 392 had a small scratch on his face and the facility moved Resident 392 to Resident 9's room on the same day. A review of Resident 392's care plan dated 2/9/2025 indicated the resident was involved in a physical altercation with a resident (Resident 42). The care plan goal was for Resident 392 to verbalize understanding and the need to control his behavior. The care plan intervention indicated to identify Resident 392's behavior and intervene and monitor for signs of psychological distress (when someone is experiencing a lot of negative emotions or mental discomfort that interferes with their daily life). The care plan also indicated that social services would do daily wellness checks for 72 hours and the facility would be attentive/responsive to Resident 392's behavior and would remove and identify behavior triggers (something that brings on or worsens symptoms). A review of Resident 392's Minimum Data Set (MDS - a resident assessment tool), dated 2/10/2025, indicated the resident's preferred language was non-English, and needed or wanted an interpreter for communication with a doctor or health care staff. The MDS indicated Resident 392 sometimes was able to make himself understood and sometimes able to understand others. The MDS indicated Resident 392 was unable to respond when asked about his health literacy, was inattentive (not able to pay attention), and had issues with sleep and trouble concentrating. A review of Resident 392's Psychiatric Consultation Note dated 2/10/2025, indicated a Psychiatric Mental Health Nurse Practitioner (NP) - a registered nurse who specializes in mental health care) saw Resident 392, but did not indicate the time the resident was seen. The note indicated the NP used a translator during his assessment of Resident 392 and that the resident was anxious, uncooperative, and avoiding eye contact. The consultation note indicated Resident 392 stared blankly at the NP when asked about his altercation with Resident 42. The note indicated Resident 392 was disorganized, irritable, and agitated. The note indicated Resident 392 had poor insight, impaired judgement, poor concentration and limited attention span with a diagnosis of schizoaffective disorder and bipolar type. According to a review of the Interdisciplinary Team (IDT - a group of people with different areas of expertise, like doctors, therapists, and social workers, who work together to solve a problem by combining their unique knowledge and skills to achieve the best possible outcome, especially when dealing with complex situations) Review notes dated 2/10/2025, Resident 392 had periods of confusion and struck his roommate (Resident 42) on 2/9/2025. The IDT notes indicated the facility would monitor Resident 392's behavior and refer him for a psychiatric evaluation (a mental health assessment that helps identify and treat mental health conditions). The notes indicated the SSD would perform wellness visits for 72 hours, the facility would encourage Resident 392 to attend activities of his choice, encourage Resident 392 to verbalize his feelings, and continue the care plan developed on 2/9/2025. The IDT also indicated Resident 392's primary language was English, which was a discrepancy compared to the MDS. A review of the Change of Condition (COC) Situation, Background, Assessment, Recommendation - SBAR) form dated 2/10/2025 at 7 pm, indicated Resident 392 was having a physical confrontation with his new roommate (Resident 9) on 2/10/2025. The COC SBAR form indicated a Certified Nursing Assistant (CNA) separated the residents and the facility placed Resident 392 on visual monitoring for the safety of other residents. The COC SBAR form indicated Resident 392 was transferred to the hospital at 7:30 pm on 2/10/2025 for altered mental status (a noticeable change in someone's mental state, like being confused, disoriented, not acting like themselves, or having difficulty thinking clearly) and agitation. A review of Resident 42's Admission Record indicated the facility admitted the resident on 9/4/2024 with diagnoses including schizophrenia, lack of coordination (not being able to move different parts of your body smoothly together), muscle weakness, low back pain. A review of the MDS, dated [DATE], indicated Resident 42 was able to make himself understood and had the ability to understand others. According to a review of Resident 42's investigation report titled, Resident to Resident Altercation, a CNA standing near Resident 42's room heard a loud disturbance at approximately 7:15 pm on 2/9/2025. The investigation report indicated the CNA intervened right away. Resident 42 reported he was in his wheelchair when Resident 392 approached him and struck him. The investigation report indicated Resident 392 was moved to another room on the opposite end of the building and Resident 42 did not sustain any injury. The investigation report indicated Resident 392 had a superficial scratch on the left side of his jaw. During an interview on 2/10/2025 at 9:37 am with Resident 42 in his room, Resident 42 stated he was done talking about the incident with his former roommate, Resident 392 who had hit him. Resident 42 stated he did not want to talk to anyone anymore. A review of Resident 9's Admission Record indicated the facility admitted Resident 9 on 6/6/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness, and history of traumatic brain injury (brain damage caused by an external force, such as a blow to the head or an object penetrating the brain). A review of Resident 9's MDS, dated [DATE], indicated Resident 9 was able to make himself understood and had the ability to understand others. A review of the Resident 9's investigation report titled, Resident on Resident Altercation, indicated on 2/10/2025 a CNA heard a loud voice from Resident 9's room and immediately responded. The CNA observed Resident 392 holding Resident 9's necklace and was striking Resident 9 in the face. The investigation report indicated Resident 392 had an order to transfer to a hospital on 2/10/2025 and was waiting for transportation. During an interview on 2/11/2025 at 10:44 am, in Resident 9's room, Resident 9 stated that his roommate, Resident 392, pulled the necklace from Resident 9's neck and punched him over his right eye on 2/10/2025. Resident 9 stated he was angry and upset that Resident 392 hit him and that he would be upset if Resident 392 returned to the facility. Resident 9 used curse words when talking about Resident 392, that he would hurt Resident 392 after what Resident 392 did to him, and that the attack was unprovoked. Resident 9's face was red, and his voice elevated when describing what happened. During a concurrent observation and interview on 2/13/2025 at 8:59 am, in Resident 9's room, Resident 9 was irritable. Resident 9 stated he remained upset regarding the incident when Resident 392 hit him. Resident 9 stated Resident 392 hit him without provocation (something happened for no reason). During an interview on 2/13/2025 at 10:10 am in Resident 42's room, Resident 42 stated that Resident 392 was acting weird, would go between the curtain and the window that was next to Resident 42's bed on 2/9/2025. Resident 42 stated Resident 392 was on the right side of his bed, then Resident 392 hit Resident 42 without warning. Resident 42 then stated he no longer wanted to talk about what happened since he had already spoken about it with others. During an interview on 2/14/2025 at 11:49 am, CNA 11 stated she heard a sound from Resident 9's and Resident 392's room on 2/10/2025. CNA 11 stated she witnessed Resident 392 pulling Resident 9's necklace and stated she separated the residents right away. On 2/14/2025 at 11:55 am during an interview with the Director of Nursing (DON) and the facility Administrator (ADM), the DON and ADM stated they made arrangements for Resident 392 to be transferred to the hospital and while waiting for the ambulance, Resident 392 hit his roommate, Resident 9. The ADM stated the facility had a care plan (the physical altercation care plan with Resident 42) and a sitter was not needed. During an interview on 2/14/2025 at 2:24 pm, Registered Nurse Consultant 1 (RNC 1), stated the diagnosis of schizoaffective disorder for Zyprexa was not present on Resident 392's admission record, and the facility should have clarified with the Medical Doctor (MD). RNC 1 stated once clarified they would have assessed Resident 392 and created a care plan for schizoaffective disorder on admission. RNC 1 stated since the facility did not verify the diagnosis of schizoaffective disorder, there was no care plan in place for the resident and the interventions may not have been appropriate for Resident 392. The RNC 1 stated the facility staff should have verified the diagnosis to make sure the treatment Resident 392 received was appropriate. The RNC 1 stated there was a risk of Resident 392 to decline in behaviors since there was no schizoaffective care plan developed in accordance with facility policy and the facility may not be able to manage the resident's changes of behavior. During an interview on 2/14/2025 at 2:42 PM, regarding Resident 392 not having a care plan for schizoaffective disorder RNC 1 stated the care plan was important because it guided the staff to follow the interventions for the resident's care needs and to re-evaluate for effectiveness. During an interview on 2/14/2025 at 2:59 pm, when asked about Resident 392 receiving Zyprexa for schizoaffective disorder dated 2/7/2025, but the admission record did not have the diagnosis of schizoaffective disorder indicated until 2/14/2025, the DON stated the facility staff should have verified the diagnosis with the MD. The DON stated once verified, the facility staff should have developed a care plan for schizoaffective disorder to better care for Resident 392. The DON stated since there was no care plan in place, this affected how the staff cared for Resident 392. When asked about the consequences of not managing Resident 392's behavior, the DON declined to answer. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 1/16/2025, indicated the residents have a right to be free from abuse and the facility would protect residents from abuse by anyone including other residents. The P&P indicated the facility would implement measures to address factors that may lead to abusive situations. A review of the facility's P&P titled, Care Planning - Interdisciplinary Team (IDT), dated 1/16/2025, indicated the IDT would be responsible for developing an individualized comprehensive care plan for each individual. A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 1/16/2025, indicated the IDT and the resident and his/her family or legal representative would develop and implement a person-centered care plan for each resident. The P&P indicated the care plan would have measurable objectives and timeframes, describe the services to be furnished to help the resident maintain their highest practicable level in regard to physical, mental, and psychosocial well-being. The P&P indicated the care plan would have goals, timetables, objectives, interventions, and desired/measurable outcomes. The P&P indicated the care plan would include problem areas and risk factors associated with identified problems. The P&P indicated the care plan would help in preventing or reducing a resident's decline, identify problem areas, and develop interventions that the facility targeted and was meaningful to the resident. The P&P indicated the facility would revise the care plan when a resident's condition changes.

Based on interview and record review, the facility failed to ensure one sampled resident (Resident 77), who had diagnoses pneumonia (an infection / inflammation in the lungs that causes inflammation, leads to the accumulation of fluid and pus in the lungs, making it difficult to breathe) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), received necessary care and services in accordance with professional standards of practice by failing to: -Implement the Speech Therapy at Risk for Aspiration care plan interventions dated [DATE], for Resident 77 to receive oral pharyngeal stimulation and exercises (a series of movements designed to strengthen the muscles in the mouth and throat). -Develop a comprehensive, person-centered care plan to include the Physician's Order, for Resident 77 to receive oxygen at two liters per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath related to COPD and include the oxygen use in the comprehensive assessment. -Ensure Resident 77's vital signs documented by the Licensed Vocational Nurse (LVN 4) were accurate on ,d+[DATE], ,d+[DATE] and [DATE]. -Implement the facility's policy and procedure (P&P) titled Routine Resident Checks as there was no routine resident check at least once per each 8-hour shift for Resident 77. The last skilled nursing assessment was documented on [DATE] at 1:45 PM. As a result, Resident 77 was found unresponsive in his room on [DATE] at 7:32 AM by LVN 3. Cardiopulmonary Resuscitation (CPR, consisting of chest compressions, combined with artificial ventilation [breathing], or mouth-to-mouth in an effort to manually preserve the brain) was initiated and Emergency Medical Services (EMS - immediate medical assistance via ambulance) was called. At 8:08 AM Resident 77 was pronounced dead by the paramedics. Findings: A review of Resident 77's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including pneumonia, COPD, bacteremia (condition where bacteria are present in the bloodstream, an abnormal infection in the blood), and dysphagia. A review of Resident 77's History and Physical (H&P) dated [DATE] indicated the resident was not competent to understand his medical condition. A review of the Physician's Orders for Life-Sustaining Treatment (POLST, provides seriously ill patients more control over their end-of-life care) dated [DATE], indicated Resident 77 was a 'Full Code' (a medical term that indicates a patient's wish to receive all possible life-saving measures in the event of a cardiac or respiratory arrest). The POLST was signed by the Attending Physician and Resident 77's responsible party (RP 1). A review of the Physician's Order dated [DATE] indicated Resident 77 to receive oxygen at two liters per minute via nasal cannula, as needed for shortness of breath related to COPD. According to a review of Resident 77's Speech Therapy (ST) care plan dated [DATE], the resident was at risk for aspiration (the accidental inhalation of foreign substances, such as food, liquid, or vomit, into the lungs). The care plan interventions indicated for Resident 77 to receive oral pharyngeal stimulation and exercises (a series of movements designed to strengthen the muscles in the mouth and throat), safe swallowing strategies, and patient and caregiver education. A review of Resident 77's Pneumonia Care Plan dated [DATE] indicated the goal was for the resident's pneumonia to be resolved without any complications. The care plan interventions indicated to elevate the head of the bed for comfort and lung expansion. The care plan did not indicate Oxygen Use interventions for the physician ordered oxygen at two liters per minute as needed. A review of the Acute Respiratory Failure with Hypoxia (low oxygen in the blood) care plan dated [DATE], indicated the goal for Resident 77 was to not have complications related to shortness of breath (SOB). The care plan interventions indicated to encourage sustained deep breaths using an incentive spirometer (a medical device used to help patients improve their lung function with deep inhale and exhale) and asking the resident to yawn. The care plan did not indicate Oxygen Use interventions for the physician ordered oxygen at two liters per minute as needed. A review of the medical record indicated Resident 77 did not have an Oxygen Use care plan with person-centered interventions. A review of the Dysphagia Care Plan dated [DATE], indicated staff interventions to provide Resident 77 with a healthy heart, pureed texture, honey consistency diet as ordered, and a ST evaluation and treatment as ordered. According to a review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE], Resident 77 had severe cognitive impairment (problems with a person's ability to think, remember, use judgement, and make decisions) and was dependent on facility staff with showering and transfers. The MDS indicated Resident 77 had diagnoses of pneumonia, septicemia (blood poisoning, especially that caused by bacteria or their toxins), hypertension (HTN, high blood pressure), COPD, respiratory failure (a condition where the lungs cannot adequately exchange oxygen), and dysphagia. The MDS did not indicate that Resident 77 was on oxygen therapy. A review of the Medication Administration Record (MAR) dated [DATE] indicated Resident 77's vital signs during the 3 PM -11:30 PM shift was noted as Blood Pressure (BP): ,d+[DATE], Temperature (Temp): 97.1, Pulse: 72, Respirations (Resp): 18, and Oxygen Saturation (O2 Sats): 97. All within normal limits. A review of the MAR dated [DATE] indicated Resident 77 vital signs during the 11 PM - 7:30 AM shift were Blood Pressure (BP): ,d+[DATE], Temperature (Temp): 97.1, Pulse: 72, Respirations (Resp): 18, and Oxygen Saturation (O2 Sats): 97, exactly the same as the prior shift (3 PM - 11:30 PM). All within normal limits. A review of the MAR dated [DATE] indicated Resident 77's vital signs during the 3 PM - 11:30 PM was noted as BP: ,d+[DATE], Temp: 97.8, Pulse: 74, Resp: 18, O2 Sats: 98. A review of the MAR dated [DATE] for the 11 PM - 7:30 AM shift for Resident 77, were exactly the same as the shift prior (3 PM - 11:30 PM). All within normal limits. A review of the Medication Administration Record (MAR) dated [DATE] indicated Resident 77's vital signs during the 3 PM -11:30 PM shift was noted as BP: ,d+[DATE], Temp: 97.1, Pulse: 72, Resp: 18, O2 Sats: 96. A review of the MAR dated [DATE] indicated Resident 77 vital signs during the 11 PM- 7:30 AM shift were exactly the same as the prior shift (3 PM - 11:30 PM). All within normal limits. The MAR's for Resident 77 dated ,d+[DATE], ,d+[DATE] and [DATE] during the 11 PM - 7:30 AM shift were documented by the same LVN (LVN 4). A review of the Medication Administration Record (MAR) dated ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE] indicated Resident's 341, 32, 62, 21, and 19 (five additional residents) vital signs during 11 PM - 7:30 AM shift were exactly the same as the prior shift (3 PM - 11:30 PM). All within normal limits and all documented by the same LVN (LVN 4). According to a review of the Nurses Note dated [DATE] at 1:45 PM, Resident 77 was alert and able to follow directions. Resident 77's breathing was regular, had normal breath sounds, and had no cough. The nurses note indicated vital signs were within normal limits and the resident had no pain or discomfort. This was the last nursing note documented for Resident 77 (excluding the vital signs) as there was no nursing notes during the 3 PM - 11:30 PM shift, nor the 11 PM - 7:30 AM shift (approximately 16 hours), A review of the Change of Condition (COC) report, dated on [DATE] at 7:32 AM indicated Resident 77 was found unresponsive in his room by LVN 3. The COC indicated further assessment by LVN 3 included Resident 77 had no pulse, was not breathing, and vital signs were unobtainable. Cardiopulmonary Resuscitation (CPR) was initiated, and EMS was called. A review of the Paramedic Care Report dated [DATE] at 7:38 AM indicated EMS arrived on site with Resident 77 laying in the bed without a pulse and apneic (a condition where breathing stops or is severely reduced). The report indicated the last know well time for Resident 77 was approximately one hour prior to arrival and CPR was initiated. The Paramedic Report indicated EMS administered Resident 77, 15 liters of oxygen per minute via bag valve mask and three rounds of epinephrine (also known as adrenaline, plays an important role in your body's fight-or-flight response, a medication to treat many life-threatening conditions). The Paramedic Report indicated Resident 77 was in asystole (a medical condition where the heart stops to produce electrical activity and contractions, the heart no longer pumps blood throughout the body) and remained in asystole for the duration of CPR. The Paramedic Report indicated Resident 77 had a severe distress level, pupils were fixed and dilated and Resident 77's time of death was 8:08 AM. During an interview on [DATE] on 12:45 PM with the Medical Director (MD, who was also Resident 77's physician), the MD stated he believed that an assessment for Resident 77 should have been conducted every shift and that it was another form of communication. The last skilled nursing assessment was documented on [DATE] at 1:45 PM (two shifts missing documentation prior to Resident 77's death). The MD stated when there was no documentation staff would not know the resident's condition or needs and would not understand the trends of the resident's condition. During a concurrent interview and record review on [DATE] at 1:57 PM, with the Director of Nursing (DON), Resident's 77's MARs were reviewed. The DON stated that she could not consider the vital sign documentation for Resident 77 and the additional five residents as falsification (the act of deliberately lying about or misrepresenting something) of records. The DON stated and agreed the vital sign records for Resident 77 for ,d+[DATE], ,d+[DATE] and [DATE] on the 3 PM-11:30 PM and 11 PM-7:30 AM shift were exactly the same. The DON stated and agreed the vital sign records for Residents 341, 32, 62, 21, and 19 (five additional residents) during the 11 PM - 7:30 AM shift were exactly the same as the prior shift (3 PM - 11:30 PM). The DON stated the Nursing Note documentation was required by the LVN to be done daily and did not need to be completed for each shift. The DON stated she did not have a policy that stated this specifically and could not provide a policy that showed how often documentation needed to be done for Resident 77. A review of the facility's policy and procedure (P&P) titled, Routine Resident Checks, indicated that nursing staff shall make routine resident checks at least once per 8-hour shift. It further stated the nursing supervisor or charge nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. This P&P indicated a discrepancy with the DON's statement regarding documentation. During a telephone interview on [DATE] at 2:47 PM, LVN 4 stated he worked the 11 PM -7:30 AM shift on ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE] and documented the vital signs for Resident 77 (including the vital signs for the additional five residents). LVN 4 stated he could not explain how the vital signs on ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE] from his shift were exactly the same as the prior shift 3 PM -11:30 PM. During an interview on [DATE] at 11:24 AM, Registered Nurse (RN) 1 stated he received Resident 77 upon admission on [DATE] receiving oxygen via nasal cannula at two liters per minute (LPM). RN 1 stated there was no need to continue Resident 77 on oxygen and there was no need for an incentive spirometer because the resident did not have any respiratory issues. RN 1 stated he placed Resident 77's head of bed up and instructed Resident 77 to take deep breaths, but there was no documentation indicating this. During an interview on [DATE] at 1:42 PM, CNA 5 stated Resident 77's meal card indicated he had swallowing issues and to feed with small bites. CNA 5 stated she was not informed regarding any speech therapy recommendations required for Resident 77 and that she did not document the interventions that she completed with the resident. CNA 5 stated that it was important to document because if it was not documented it means it was not done. During an interview on [DATE] at 2:35 PM, the DON stated Resident 77 was on oxygen as needed at the General Acute Care Hospital (GACH). The DON stated the Acute Respiratory Failure care plan and the Pneumonia care plan was not required to include the as needed (PRN) order of oxygen use for Resident 77. During an interview on [DATE] at 2:26 PM the Minimum Data Set Nurse (MDSN) stated Resident 77 had an as needed (PRN) order for oxygen and a care plan should have been initiated. The MDSN stated and confirmed Resident 77's comprehensive assessment (MDS dated [DATE]) did not include the oxygen use but should have been included. During an interview with the Administrator (ADM) on [DATE] at 8:30 AM, the ADM stated that LVN 4 was suspended as of [DATE] pending the facility's internal investigation. When asked the reason of LVN 4's suspension, the ADM stated it was for charting and documentation. During a concurrent interview, the DON stated that an in-service meeting was done with staff on [DATE] regarding accurate documentation of resident vital signs. During a telephone interview on [DATE] at 10:05 AM, the Speech Therapist stated Resident 77 was assessed upon admission due to the dysphagia diagnosis. The ST stated she saw Resident 77 during mealtimes with the CNAs and she gave the CNAs her recommendations to have the head of bed in an upright posture, observe any coughing, and to report any issues to the ST, but this was not documented. The ST stated sometimes Resident 77 would feed himself and sometimes he would need feeding. During a telephone interview on [DATE] at 12:13 PM, the MD stated, in his opinion Resident 77 could have aspirated. The Medical Director stated Resident 77 had some cognitive decline which may have contributed to the aspiration. A review of the facility's P&P titled, Charting and Documentation, reviewed on [DATE], indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (IDT) regarding the resident's condition. The P&P indicated that documentation in the medical record would be objective, complete, and accurate. A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, reviewed on [DATE], indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to provide therapy services for two of eight sampled residents (Residents 48 and 6) who had limited range of motion (ROM, full movement potential of a joint [where two bones meet]) by failing to: -Provide Occupational Therapy (OT, rehabilitative profession aimed to increase or maintain a person's capability to participate in everyday life activities) evaluation after identifying a decline in Resident 48's range of motion in the left shoulder, left elbow, left wrist, and left hand during the OT Joint Mobility Screen (JMS, brief assessment of a resident's ROM) dated 8/22/2024. -Provide OT Evaluation and treatment for Resident 48 prior to the application of a left resting hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for one to six (1-6) hours in accordance with professional standards of practice on 8/22/2024. -Provide Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment from 8/2024 to 2/2025 (over five months) to Resident 48 for passive range of motion (PROM, movement at a given joint with full assistance from another person) to left upper extremity (UE, shoulder, elbow, wrist, hand/fingers) in all planes (all possible joint movements) five (5) times a week in accordance with the physician's order dated 8/22/2024 . -Provide RNA treatment from 8/2024 to 2/2025 (over five months) for the application of a left resting hand splint for 1-6 hours as tolerated five times a week in accordance with the physician's order dated 8/22/2024. -Report Resident 48's refusals and missed RNA treatments on 9/2024, 10/2024, 12/2024, 1/2025, and 2/2025 to the Charge Nurse and Therapy staff in accordance with the facility's job description titled, Restorative Nursing Assistant/CNA. -Provide Resident 48 with a nursing assessment after Restorative Nursing Aide (RNA 3) reported Resident 48's refusals to participate in RNA throughout 11/2024 in accordance with facility policy and procedure. -Provide an appropriate RNA order for Resident 6 who wore left ankle foot orthotics (AFO, an orthotic device designed to correct or address problems with the ankle and foot) for no more than four (4) hours as established by physical therapy (PT, a profession aimed in restoration, maintenance, and promotion of optimal physical function). -Ensure Resident 6 did not have a delay in the start of RNA services for PROM with both lower extremities (LE, hip, knee, ankle, foot) five times a week and application of left AFO five times a week ordered on 2/4/2025 to start on 2/5/2025. These failures resulted in Resident 48's worsening contracture (loss of motion of a joint) of the left hand from 9/2024 to 1/2025 (over four months) into a fisted position with the left thumb positioned under the left index finger and over the middle finger. This fisted position resulted in the development of Resident 48's Stage IV pressure injury (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the left middle finger, which was identified on 1/15/2025. These failures had the potential for Resident 6 to be injured due to the application of the left AFO. Findings: a. A review of Resident 48's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left non-dominant side and muscle weakness. A review of Resident 48's Care Plan initiated on 9/15/2022 indicated the resident had the potential for limitations in joint mobility related to decreased physical mobility, history of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), osteoporosis (weak and brittle bones) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). The care plan goal indicated Resident 48 would have no further loss of ROM daily for three months. The care plan interventions indicated to monitor for pain or stiffness, position resident to prevent further contractures with pillow or splint as needed, RNA to perform PROM to left UE (LUE) in all places as tolerated 5 times a week, RNA to apply left resting hand splint for 1-6 hours or as tolerated 5 times a week. A review of Resident 48's Care Plan initiated on 9/15/2022 indicated the resident was at risk for complications due to alteration in musculoskeletal status related to diagnosis of hemiplegia and hemiparesis, osteoarthritis of knee and hip, osteoporosis, advanced age, contractures, joint pain. The care plan goal indicated complications related to fracture (broken bone), such as contracture formation, and immobility would be minimized. The care plan interventions included to assist the resident with the use of supportive devices (splints) as recommended; monitor/document/report to medical doctor (MD) as needed signs and symptoms or complications related to arthritis (swelling and tenderness of a joint causing pain and stiffness): joint pain, joint stiffness, swelling, decline in mobility, decline in self-care ability, contracture formation/joint shape changes, pain after exercises. A review of Resident 48's OT Joint Mobility Screening (JMS) dated 2/14/2024 indicated the resident had full range of motion in both wrists, both hand/fingers, both elbows, and both shoulders. The JMS indicated Resident 48 did not have minimal to severe loss of UE passive ROM and did not have a diagnosis or condition that placed Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation and RNA program was not recommended. A review of Resident 48's OT JMS dated 6/1/2024, indicated the resident had full range of motion in both wrists, both hand/fingers, both elbows, and both shoulders. The JMS indicated Resident 48 did not have minimal to severe loss of UE passive ROM and did not have a diagnosis or condition that placed Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation and RNA program was not recommended. A review of Resident 48's OT JMS dated 8/22/2024, indicated the resident had full range of motion in the right wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had moderate loss (26-50 percent (%) loss) of range of motion in the left wrist, left hand/fingers, and left shoulder and minimal loss (less than 25% loss) range of motion in the left elbow. The JMS indicated Resident 48 had minimal to severe loss of UE passive ROM and had a diagnosis or condition that placed Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was not recommended, and RNA program was recommended. The comments indicated PROM left UE, left resting hand splint, [right]UE AAROM. According to a review of the Physician's Order Summary Report (OSR) dated 8/22/2024, Resident 48 was to receive RNA services, perform PROM LUE in all planes as tolerated, frequency five times a week. The OSR indicated the RNA to apply left resting hand splint for 1-6 hours or as tolerated, frequency 5 times a week. A review of Resident 48's 8/2024 RNA Daily Survey Report (DSR), the DSR indicated Resident 48 did not complete RNA treatment (RNA entry was blank or not available) to perform PROM LUE in all planes as tolerated, 5 times a week on the following days: 8/30/24. During a review of Resident 48's 8/2024 RNA DSR, the DSR indicated Resident 48 refused RNA treatment to perform PROM LUE in all planes as tolerated, 5 times a week on 8/26/24. Resident 48 did not complete RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on 8/30/24. The DSR indicated Resident 48 refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on 8/26/24. During a review of Resident 48's OT JMS dated 9/1/24, the JMS indicated Resident 48 had full range of motion in the right wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had moderate loss of motion in the left wrist, left hand/fingers, and left shoulder and minimal loss of motion in the left elbow. The JMS indicated Resident 48 had minimal to severe loss of UE passive ROM and had a diagnosis or condition that put Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was not recommended. During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/24, the MDS indicated Resident 48 had severe cognitive impairments. The MDS indicated Resident 48 did not exhibit any behavior for rejection of care that was necessary to achieve health and well-being. The MDS also indicated Resident 48 required substantial/maximal assistance from staff for oral hygiene, bathing, dressing, personal hygiene, sit to stand, and bed to chair transfers. The MDS indicated Resident 48 had functional range of motion impairments on one side of the upper extremity and impairments on one side of the lower extremity. During a review of Resident 48's 9/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to perform PROM LUE in all planes as tolerated, 5 times a week on the following days: 9/2, 9/4, 9/5, 9/11, 9/17, 9/18, 9/24, 9/25, and 9/30/2024. During a review of Resident 48's 9/2024 RNA DSR, the DSR indicated Resident 48 refused RNA treatment to perform PROM LUE in all planes as tolerated, 5 times a week on 9/13/24. The DSR indicated Resident 48 did not complete RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 9/2 - 9/5, 9/11, 9/13, 9/16, 9/17, 9/18, 9/20, 9/24 - 9/27 and 9/30/2024. According to a review of Resident 48's 10/2024 RNA DSR, Resident 48 did not complete RNA treatment to perform PROM LUE in all planes as tolerated, 5 times a week on the following days: 10/1, 10/2, 10/4, 10/8, 10/11, 10/14, 10/18, 10/21, 10/22, 10/25, 10/28 and 10/31/2024. The DSR indicated Resident 48 did not refuse RNA treatment to perform PROM LUE in all planes as tolerated, five times a week. During a review of Resident 48's 10/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 10/1, 10/4, 10/8, 10/11, 10/14, 10/18, 10/21, 10/22, 10/25, 10/28 and 10/31/2024. The DSR indicated Resident 48 refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 10/7, 10/15, 10/17, 10/23 and 10/24/2024. During a review of Resident 48's RNA Weekly Summary (WS) dated 10/1/24, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM, PROM, and splint application. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's RNA WS dated 10/8/24, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM, PROM, and splint application for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's RNA WS dated 10/22/24 an 10/30/2024 the WS indicated Resident 48 completed RNA treatment for AAROM and PROM. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's 11/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 11/4, 11/7, 11/13, 11/21 and 11/25/2024 and refused RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 11/1/24, 11/8/24, 11/11/24, 11/12/24, 11/15/24, 11/19/24, 11/20/24, 11/22/24, 11/26 - 11/29/24 During a review of Resident 48's 11/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 11/1/24, 11/4/24, 11/6/24, 11/7/24, 11/13/24, 11/15/24, 11/20/24, 11/21/24, 11/25/24, 11/26/24, 11/27/24 and refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 11/8/24, 11/11/24, 11/12/24, 11/14/24, 11/19/24, 11/22/24, 11/28/24, 11/29/24. According to a review of Resident 48's RNA WS dated 11/1/24, Resident 48 completed RNA treatment 5 times in the last week for AAROM and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's RNA WS dated 11/8/24 and 11/15/2024, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM of both lower extremities, PROM of LUE, and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. The WS indicated refuse in comments. The WS was reviewed and co-signed by an unidentified nursing staff. During a review of Resident 48's RNA WS dated 11/22/2024 and 11/29/2024, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM of both lower extremities and PROM of LUE. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. The WS indicated refuse in comments. The WS was reviewed and co-signed by an unidentified nursing staff. During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48 had severe cognitive impairments. The MDS indicated Resident 48 did not exhibit any behavior for rejection of care that was necessary to achieve health and well-being. The MDS also indicated Resident 48 required substantial/maximal assistance from staff for oral hygiene, bathing, dressing, personal hygiene, sit to stand, and bed to chair transfers. The MDS indicated Resident 48 had functional limitations in range of motion impairments on one side of the upper extremity and impairments on one side of the lower extremity. During a review of Resident 48's OT JMS dated 12/3/24, the JMS indicated Resident 48 had full range of motion in the right wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had moderate loss of motion in the left wrist, left hand/fingers, and left shoulder and minimal loss of motion in the left elbow. The JMS indicated Resident 48 did not have minimal to severe loss of UE passive ROM and had a diagnosis or condition that put Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was not recommended, and an RNA program was recommended. During a review of Resident 48's 12/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 12/3 - 12/5/24, 12/9/24, 12/10/24, 12/18/24 and refused RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 12/2/24, 12/6/24, 12/16/24, 12/24/24. During a review of Resident 48's 12/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 12/3 - 12/5/24, 12/9/24, 12/10/24, 12/18/24 and refused RNA treatment RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 12/2/24, 12/6/24, 12/11 - 12/13/24, 12/16/24, 12/17/24, 12/19/24, 12/23/24, 12/24/24, 12/26/24, 12/27/24, 12/31/24. According to a review of Resident 48's RNA WS dated 12/3/24, Resident 48 completed RNA treatment 5 times in the last week for AAROM and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's RNA WS dated 12/9/24, 12/16/24 and 12/23/24 the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM, PROM, and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's 1/2025 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 1/3/25, 1/6/25, 1/8/25, 1/9/25, 1/13/25, 1/17/25, 1/20/25, 1/24/25, 1/27/25, 1/28/25, 1/30/25, 1/31/25 and did not refuse RNA treatment to perform PROM LUE in all planes as tolerated, five times a week. During a review of Resident 48's 1/2025 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 1/1/25, 1/3/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/13/25, 1/15/25, 1/20/25, 1/27/25, 1/28/25, 1/30/25, 1/31/25 and refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 1/2/25, 1/14/25. During a review of Resident 48's RNA WS dated 1/2/25 and 1/9/25, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM, PROM, and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's Change of Condition (COC) dated 1/15/25, the COC indicated Resident 48 had a contracture related pressure injury Stage 4 to inferior left middle finger. The COC indicated Resident 48 had pain to left hand middle finger when moved due to contracture. The COC indicated Resident 48 had a Stage 4 pressure wound 1 centimeter (cm) in length, 1.2 cm in width, and 0.3 cm in depth. The COC indicated Resident 48 was in pain when the affected hand was moved. The COC also indicated a CNA informed charge nurse that Resident 48's left hand appeared different than normal and upon assessment of left hand, observed the hand with existing contracture with thumb between middle finger and index finger. The COC indicated per resident facial grimacing and body language, the wound site was painful when moved or manipulated. The COC indicated Wound Consultant Specialist (WCS) visited resident same day and assessed site with measurement of 1 cm x 1 cm x 0.3 cm and classified the wound as Stage 4 with new orders for wound treatment. During a review of Resident 48's WCS's visit note dated 1/15/25, the WCS visit note indicated Resident 48 had a contracture related Stage 4 pressure wound on inferior left middle finger. The visit note indicated WCS performed a procedure to remove devitalized necrotic (dead tissue) subcutaneous (beneath the skin) tissue and muscle tissue to promote healing and a topical spray solution was provided for anesthesia. According to a review of Resident 48's RNA WS dated 1/16/25 and 1/23/25, Resident 48 completed RNA treatment five times in the last week for AAROM, PROM, and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's OT JMS dated 1/28/25, the JMS indicated Resident 48 had full range of motion in the right wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had moderate loss of motion in the left wrist, left hand/fingers, and left shoulder and minimal loss of motion in the left elbow. The JMS indicated Resident 48 did not have minimal to severe loss of UE passive ROM and did not have a diagnosis or condition that put Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was not recommended, and an RNA program was recommended. During a review of Resident 48's 2/2025 RNA DSR, the DSR indicated Resident 48 missed RNA treatment to perform PROM LUE in all planes as tolerated, 5 times a week on the following days: 2/3/25, 2/4/25, 2/6/25, 2/7/25 and did not refuse RNA treatment to perform PROM LUE in all planes as tolerated, five times a week. During a review of Resident 48's 2/2025 RNA DSR, the DSR indicated Resident 48 missed RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 2/3/25, 2/4/25, 2/7/25 and refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 2/10/25, 2/11/25. During a review of Resident 48's RNA WS dated 2/4/25, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. The WS indicated Resident 48 complained of pain during ROM exercises. During a review of Resident 48's OT JMS dated 2/13/25, the JMS indicated Resident 48 had full range of motion in the right wrist, left wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had minimal loss of range of motion in the left shoulder, moderate loss of range of motion in the left elbow, and severe loss (more than 50% loss) of range of motion in the left hand/fingers. The JMS indicated Resident 48 had minimal to severe loss of UE passive ROM and had a diagnosis or condition that put Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was recommended, and an RNA program was not recommended. During an observation and interview on 2/10/25 at 1:15 p.m. in Resident 48's room, Resident 48 was sitting up in bed. Resident 48 was able to move the right arm up and down to about shoulder level. Resident 48 was able to lift the left arm up a little, the left wrist was straight, and the left hand was fully bent in a fisted position. The left thumb was opposed across the palm underneath the second finger and the tip of the thumb was above the third middle finger. Resident 48 stated the left hand was no good and stated she could not really move the lower extremities. Resident 48's hip and knees were bent and rotated towards the right side. Resident 48 was not wearing any splints on the upper extremities. During an observation on 2/11/25 at 8:24 a.m. in Resident 48's room, Resident 48 was laying in the bed and the left hand was in a fisted position with the thumb opposed and inside the palm. Resident 48 was not wearing any splints on the upper extremities. During an interview on 2/11/25 at 8:35 a.m., Restorative Nursing Aide (RNA 1) stated he was an RNA and central supply, which included ordering and stacking up supplies. RNA 1 stated on Mondays, he completed RNA treatments for residents in bed A, Tuesdays he completed RNA treatments for residents in bed B, Wednesdays he completed RNA treatments for resident in bed C, and then goes back to residents in bed A on Thursdays, bed B Fridays, and bed C on Saturdays. During an observation on 2/11/25 at 1:53 p.m., Resident 48 was lying on a geriatric chair (a large, padded chair designed to help persons with limited mobility) in the hallway outside Resident 48's room and Resident 48's eyes were closed. Resident 48 was not wearing any splints on the upper extremities. On 2/12/25 at 8:50 a.m. during an observation in Resident 48's room, Resident 48 was laying in bed. Resident 48's right knee was bent, and left ankle crossed over the right ankle. Resident 48 was able to move the right arm to move the gown, the left elbow was bent about halfway and left hand was in a fist. RNA 1 asked Resident 48 to move and straighten the right knee and Resident 48 was able to straighten the right knee. Resident 48 did not want to complete exercises with RNA 1. During an interview on 2/12/25 at 9 a.m., RNA 1 stated when Resident 48 agreed to RNA treatment, RNA 1 performed ROM on BUE and BLE and wore a hand roll, a soft one with a cushion. RNA 1 stated the hand roll was in the laundry. RNA 1 stated he also put on boots for both feet. RNA 1 stated on the right side, he did AROM, and on the left side, both he and Resident 48 moved the arms and legs. RNA 1 stated when Resident 48 refused, he would tell the charge nurse and therapy department. RNA 1 stated Resident 48 refused about two times a week. RNA 1 stated if Resident 48 refused, he would document that Resident 48 refused RNA. During an observation and interview on 2/12/25 at 12:55 p.m. in Resident 48's room, Resident 48 was laying in bed. Resident 48's left wrist was straight and able to move the left arm a little. Resident 48 stated the left hand was hard to move. Resident 48 tried to open the left fingers a little and observed minimal movement in the left fingers, but Resident 48 was not able to open the left hand. Resident 48 stated the left arm was paralyzed. During a record review and concurrent interview on 2/12/25 at 1:32 p.m. in the therapy gym, the Director of Rehabilitation (DOR) reviewed Resident 48's therapy records and stated there were no Occupational Therapy records for Resident 48 since 2022 when the new company started. The DOR stated Resident 48 had not received any skilled OT evaluations or treatments in 2022, 2023, 2024, or 2025. During an interview on 2/12/25 at 1:39 p.m., Licensed Vocational Nurse (LVN 6) stated she was Resident 48's charge nurse. LVN 6 stated she had never received any reports from RNA staff about Resident 48 refusing RNA treatment. LVN 6 stated Resident 48 usually did not refuse and had never received any reports about Resident 48 refusing any kind of care. LVN 6 stated Resident 48's left hand was contracted so it was especially important to perform hand hygiene and nail care, because there could be germs inside the hands. During an interview on 2/12/25 at 2:05 p.m., Certified Nursing Assistant (CNA 3) stated Resident 48's left hand was in a fist now and stated it was about 2 to 3 months when Resident 48's left hand started to be in a fist. CNA 3 stated it was harder to clean the left hand now because it was in a fist. CNA 3 stated Resident 48 could now barely open the fingers (CNA 3 demonstrated a clawed hand) and stated Resident 48 either would not let staff open her fingers more than that or Resident 48 could not open the hand more than that. CNA 3 stated she could not remember the last time she saw Resident 48 wear a hand splint with RNA. During an interview and concurrent record review on 2/12/25 at 2:17 p.m., the Wound Treatment Nurse (LVN 5) stated Resident 48 currently had a contracture related pressure injury on the left middle finger. LVN 5 stated when he first assessed Resident 48 on 1/15/25, the thumb was contracted and underneath the second finger and the thumbnail was digging into the right side of the third middle finger between the large knuckle and middle joint. LVN 5 stated Resident 48's hand was in a fisted position and when LVN 5 opened the thumb out, there was an open wound with slough (layer of dead tissue on surface of wound). LVN 5 stated the Wound Consultant Specialist (WCS) was present and assessed the wound as a Stage 4. LVN 5 stated there were Stages 1 through 4 (4 being worse). LVN 5 stated because Resident 48's hand was in a fist and it was contracted, it put Resident 48 at high risk to develop the wound. LVN 5 stated when LVN 5 completed the wound treatments, Resident 48 could not open the left hand fully. LVN 5 stated Resident 48 was in pain when LVN 5 tried to open the hand. LVN 5 stated to prevent the wound from developing, staff should constantly check Resident 48's hand, keep the thumb from touching the other fingers, and keep the fingernails trimmed. LVN 5 stated a wound was not a condition a resident should have, because when a resident had a wound, there was a risk of infection, risk for further skin breakdown, and it was painful. LVN 5 stated he should have informed the therapy department and included therapy in the wound interdisciplinary team (IDT) because the wound was contracture related and therapy could have offered an alternative other than the splint that Resident 48 had and may have accepted. LVN 5 stated for residents that refuse any type of intervention including RNA and splints, the facility should complete a COC assessment, notify the primary MD, document the refusals and update the care plan. LVN 5 reviewed Resident 48's care plans and stated there were no care plans regarding Resident 48 refusing RNA or splints. During an interview and record review on 2/12/25 at 3:21 p.m., Occupational Therapist (OT 2) stated for residents with contracture, including hand contracture, OT would treat the resident for ROM, assess to see if the resident would benefit from a splint and determine the splint that would work best for that specific resident, monitor and establish splint wear time, and establish an RNA program for splinting and ROM to prevent the contracture from getting worse. OT 2 stated contractures should be prevented because contractures were painful, limit ROM, and limit independence in activities of daily living. OT 2 stated contractures also put residents at risk for skin breakdown, especially if a finger was digging into the palm. OT 2 stated if a resident refused RNA, the facility could train Certified Nursing Assistants (CNA) and RNAs to monitor the resident, reposition the resident if there were redness and make sure nails were trimmed. OT 2 stated if a resident refused to wear splints during RNA, OT could reassess the resident and assess the splint, ask RNA about the splint, and maybe order another type of splint, add a finger separator, try a carrot (finger or hand apparatus shaped like a carrot to position the finger away from palm) or hand rolls. OT 2 stated it would be helpful to have the IDT discuss the resident together. OT 2 stated for example, if Resident 48 had a hand contracture in a fist and you put a carrot inside the palm, the carrot would keep the thumb apart and not touch that part of the finger. OT 2 stated Resident 48 refusing RNA ROM or splinting, and developing a wound because of a hand contracture was something OT would want to be informed about so that OT could assess and see if there were any possible interventions. OT 2 stated OT 2 did not have any knowledge of Resident 48 developing a wound in the left finger due to a fisted position. During an interview on 2/12/25 at 3:37 p.m., DOR stated she attended all the RNA meetings and stated RNAs did not report anything regarding Resident 48 continually refusing to wear the left hand splint. DOR stated to therapy's knowledge, Resident 48 had been wearing the left resting hand splint as ordered with RNA. During an interview on 2/12/25 at 3:40 p.m., Certified Nursing Assistant (CNA 2) stated Resident 48 could only open one hand and the other hand was in a fist. CNA 2 stated she tried to open the left hand, but Resident 48 told her she did not like it. During an interview on 2/12/25 at 3:45 p.m., Licensed Vocational Nurse (LVN 2) observed Resident 48 in the room and stated Resident 48's left hand was in a fist. LVN 2 stated Resident 48 would benefit from something inside her hand to help Resident 48. LVN 2 stated Resident 48 sometimes refused care, but not really. LVN 2 stated if you take time with Resident 48, the resident will do the care. During an interview and concurrent record review on 2/13/25 at 8:24 a.m. with RNA 1, Resident 48's RNA DSR was reviewed. RNA 1 confirmed his initials on the RNA DSR in 9/2024, 10/2024, 11/2024, 12/2024, 1/2025, and 2/2025. RNA 1 stated if the DSR indicated a number, it meant Resident 48 completed RNA that day and the number was how long RNA took to complete RNA as a whole. RNA 1 stated if the box was blank, it meant no RNA was completed that day. RNA 1 stated RR indicated Resident 48 refused RNA that day. RNA 1 stated NA was not applicable and it could mean Resident 48 was not in the facility or Resident 48 was in the activity room and meant Resident 48 did not complete the RNA treatment that day. RNA 1 confirmed Resident 48 put on the left resting hand splint 2 times total in 11[TRUNCATED]

Based on interview and record review, the facility failed to protect the resident ' s right to be free from neglect (the failure to provide healthcare services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of four sampled residents (Resident 1). On 9/4/2024, Resident 1, who was cognitively impaired (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was left unattended with his body partially uncovered, while lying and crawling on the floor of the facility hallway for approximately 59 minutes. This deficient practice resulted in Resident 1 being subjected to neglect while under the care of the facility. On 9/4/2024, Certified Nursing Assistant (CNA) 2, Licensed Vocational Nurse (LVN) 3, Staff 10, CNA 9, Staff 11, Staff 12, Staff 13, Registered Nurse Supervisor (RNS) 2, and Staff 14 watched and allowed Resident 1 to crawl and lay on the floor with Resident 1 ' s body partially uncovered without providing assistance, comfort, and safety to Resident 1. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 1 ' s severely impaired cognition (ability to think and make decisions), an individual subjected to neglect has lifetime psychological (mental or emotional) effects including feelings of embarrassment and humiliation. Findings: During a review of the General Acute Care Hospital (GACH) narrative notes dated 8/21/2024 indicated, Resident 1 was confused (not in possession of all one's mental faculties) and had a diagnosis of dementia (a chronic condition that causes a decline in cognitive function, such as thinking, learning, and remembering, to the point that it interferes with daily life). During a record review of the admission record (Face sheet) indicated the Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), hypertension (elevated blood pressure), and conversion disorder with seizures (also known as functional neurological system disorder, is a psychiatric condition that can cause seizures [a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness] as a physical symptom of a mental health issue). During a review of Resident ' s 1 care plan initiated on 9/4/2024, with a focus on Resident with behavior of crawling out bed, indicated the following interventions: Be attentive and responsive to resident's behavior and provide constant supervision that clothing and footwear is clean and appropriate. During a review of Resident ' s 1 Nursing Notes with an effective date of 9/4/2024 at 8:30 pm which was documented on 9/5/2024 at 4:18 pm, indicated LVN 2 was notified about the newly admitted resident (Resident 1) and was in the room at 8 pm. The same note indicated Resident 1 went to the nursing station with unsteady gait (a walking pattern that is abnormal, uncoordinated, or lacks balance) at 9 pm and that the CNA 1 assisted Resident 1 back to the room. During a review of Resident ' s 1 Nursing Notes with an effective date of 9/4/2024 at 10:40 pm which was documented on 9/5/2024 at 3:56 pm by the RNS 2 indicated, Resident 1 was received to the facility at 6:40 pm and re-oriented to his room. Frequent visual checks are needed due to Resident 1 getting up unassisted. The same note indicated all nursing care was rendered and to continue with the same plan of care. During an interview with LVN 2 on 9/16/2024 at 3:10 pm, LVN 2 stated that she was assigned with Resident 1 for the 11 pm to 7 am shift between 9/4/2024 and 9/5/2024. LVN 2 stated that during shift change, the off going LVN stated that Resident 1 likes to get on the floor in the hallway. LVN 2 stated she found Resident 1 sitting on the floor in the hallway and that Resident 1 was helped up and taken back to his room. During an interview with CNA 1 on 9/16/2024 at 2:48 pm, CNA 1 stated that Resident 1 was mostly sitting on the floor and appeared confused. CNA 1 stated that Resident 1 consistently stared at the ceiling and did not make eye contact when asked questions and instead would only mumble incoherently. CNA 1 stated that at 2:30 am while doing rounds, found Resident 1 unresponsive. CNA 1 stated that she immediately called an LVN to the room to assess further. During a concurrent record review of the facility ' s surveillance video footage on 9/19/2024 at 11:09 am with the Administrator, the Administrator stated that both himself and the Director of Nursing (DON) were both newly hired in the facility (four days ago). The video footage indicated that on (time stamp): 1. 9/4/2024 at 10 pm observed Resident 1 ' s hands are seen in the door frame (floor level) of his room. 2. 9/4/2024 between 10:00:10 pm to 10:04 pm, Resident 1 came out of the room crawling, and lying on the floor of the hallway. 3. 9/4/2024 at 10:05 pm, Resident 1 came in video frame outside the hallway sleeping on the floor, belly down with his face on the floor. Resident 1 had a gown which was hanging and dragging on the floor. Gown tied on the neck area. Resident 1 had his upper body exposed and had an incontinence brief that was around his knees and had his private parts exposed in the back. 4. 9/4/2024 at 10:06 pm, Resident 1 turned to his left side (still on the floor) while a female (CNA 2) and male (LVN 3) were observed at nurses ' station talking to each other. Female nurse in navy blue scrubs (CNA2) noted walking from station to other side of the hall wall, within eyesight of Resident 1. 5. 9/4/2024 at 10:07 pm Resident 1 lying on his back with arms stretched out in the hallway floor close to nurses ' station (within eyesight of Resident 1). 6. 9/4/2024 at 10:08 pm Resident 1 tries to get up but then lands on left side of his body. Attempts to get up then gets into fetal position. Another male resident dressed in black (unidentified - Resident 88) with roll aider (walker) observed walking towards resident and (at 10:09 pm) hops over resident (still lying on the floor) while lifting his walker while CNA 2, Staff 11, Staff 12, and Staff 13 were present (within eyesight of Resident 1) and not paying attention to the Resident 1. 7. 9/4/2024 at 10:09 pm LVN in burgundy scrubs (Staff 10) seen working on the medicine cart (a movable piece of equipment used in healthcare settings to transport, store, and dispense medical supplies and medications) [within eyesight of Resident 1] with resident still lying on the floor. 8. 9/4/2024 Between 10:09 pm and 10:14 pm Resident 1 still lying down in the hallway. 9. 9/4/2024 at 10:14 pm LVN in burgundy scrubs (Staff 10) walks away from cart then returns. Moved to the nursing station placing Resident 1 in view of her sight. 10. 9/4/2024 at 10:14 pm, Resident 1 seen crawling back in his room with legs still in hallway and then turns to go back to the hallway in crawling. 11. 9/4/2024 at 10:15 pm, female nurse [CNA] in navy blue scrubs (CNA2) walks over with linen looks at resident then continues to the other side of the hallway. Nurse [CNA] in white scrub (CNA 9) walks over, looks at resident, then continues to other side of the hallway. 12. 9/4/2024 at 10:16 pm, nurse [CNA] in blue scrubs walks (CNA2) in hallway [within eyesight of Resident 1] and ignores Resident 1. Resident 1 lying on the floor. 13. 9/4/2024 at 10:17 pm to 10:19 pm, Resident 1 still lying down in the middle of the hallway with exposed back. 14. 9/4/2024 at 10:20 pm, a female resident (unidentified, Resident 89) who had walked up to the nursing station and was observed saying something to (CNA2) in blue scrubs and pointing at Resident 1 who was turning restlessly on the floor. The (CNA 2) then turned to look at Resident 1 then looked back ahead towards nursing station. 16 seconds later, (CNA2) turns back to look at resident over the shoulder then looks back ahead. Resident still lying on floor in hallway. The same (CNA 2) looks over shoulder again to look at Resident 1. 15. 9/4/2024 at 10:22:35 Resident 1 seen crawling further towards nurse station in hallway then falls to his left side. (CNA2) in blue scrubs (CNA2) turns to look at Resident 1 at 10:22:41 pm, then walks away. 16. 9/4/2024 at 10:23 pm. (CNA2) in blue scrubs comes back in frame and ignores Resident1 who is still lying on the floor with CNA 2 ' s eyesight. 17. 9/4/2024 at 10:23:20 pm, Resident 1 seen crawling towards nursing station and gets within approximately 4 feet of CNA 2 in blue scrubs. Just then the nurse in white scrubs (CNA9) appears in frame and looks at Resident 1. Female nurse in blue scrubs (CNA2) turns towards Resident 1 who was now almost at her feet, then stands on other side of the medication cart, placing resident to her right side, now about 5-6 feet away. Resident 1 continues to wiggle and crawl on the floor. 18. 9/4/2024 at 10:23 pm, female nurse in blue scrubs (CNA2) starts chatting with another staff in blue scrubs with a mask sitting in the nurse ' s station (Staff 11). Resident 1 lying on the floor and looking at the two nurses in the station. 19. 9/4/2024 at 10:24 pm, Resident sits up facing the two staff (CNA2 and Staff 11) at the station who were observed speaking with each other and not paying attention to the Resident 1. 20. 9/4/2024 at 10:24:33 pm, Resident 1 lies down while facing the LVNs and CNA2 looks at resident then continues to chart. Resident 1 at this point sits up against the wall on the floor. 21. 9/4/2024 10:25 pm, nurse in white scrubs (CNA9) and female nurse in peach scrubs (Staff 12) walks in the hallway in full view of Resident 1 struggling on the floor. The two staff look at Resident 1 and left. 22. 9/4/2024 at 10:26 pm, a nurse in blue scrubs (CNA2) looks at Resident 1 again (lying down on the floor), turns to her coworker (Another female nurse in burgundy scrubs, Staff 13) and starts to walk away (Resident 1 was within eyesight). 23. 9/4/2024 at 10:26:36 male nurse in blue scrubs (LVN 3) comes to join the two staff (CNA 2 and Staff 11) in the station. Resident 1 still lying on the floor. 24. 9/4/2024 at 10:27:15 pm, the female nurse in blue (CNA2) and the one in white (CNA9) walk past approximately 2 feet from resident. Female resident dressed in white dress with green palm trees (Unidentified, Resident 90) struggles to walk between Resident 1 and medicine cart while pushing her wheelchair. 25. 9/4/2024 at 10:28 pm, Resident 1 attempted to sit up, lean against the wall, then slips back to the ground mostly starting with his head as though it was heavy. Female nurse in burgundy (Staff 13) observed going to room close to resident. Still no help offered. 26. 9/4/2024 at 10:32:10 pm, Resident 1 crawls back in room, female nurse (CNA 9) in burgundy (Staff 13) observed coming in frame at the medication cart in station 2. CNA9 in white scrubs observed walking past the resident ' s room, pause, then go into the next room. 27. 9/4/2024 at 10:33 to 10:51 pm, Resident 1 continues to be restlessly turning back and forth and crawling on the floor. 28. 9/4/2024 at 10:51 pm, Resident 1 comes back in hallway and the male nurse in blue scrubs (LVN3) as well as the female in burgundy (Staff 10) assist resident up back to room. 29. 9/4/2024 at 10:58:40 pm, Resident 1 came out of the room and laid on his belly down. 30. 9/4/2024 at 11:01 pm, female nurse in gray pants and black top scrubs (Staff 14) walks past Resident 1 with no offer for assistance. 31. 9/4/2024 at 11:03:52 pm, male nurse in burgundy (Registered Nurse Supervisor, RNS2) looks directly at Resident 1, while Resident 1 points at him. RNS 2 looks away with no offer for help. Several nurses (LVNs, RNS, and CNA) walked past Resident 1. 32. 9/4/2024 at 11:05:18 pm, Resident 1 pulls off his gown completely with his diaper still around his knees. Female nurse (Staff 14) that appeared to have been starting her shift gazed at resident with hand under her chin. 33. 9/4/2024 at 11:06:38 pm, male nurse in burgundy (RNS2) speak with Resident 1, then walks away leaving him on the floor. Resident 1 crawled next to medicine cart at nurse ' s station. Female nurse in light blue scrubs (Staff 14) speaks with him for a while then walks away. 34. 9/4/2024 at 11:06:38 pm was the last entry footage seen then skips to 9/5/2024 at 12 midnight. 35. 9/5/2024 at 12 midnight. Resident 1 was no longer seen in the hallway. During a review of the facility ' s surveillance video footage on 9/4/2024 at 11:15 am with the Administrator, the Administrator stated, it is always the same two nurses not helping the resident. During a concurrent interview and record review of the video surveillance with CNA 2 on 9/19/2024 at 3:32 pm, CNA 2 verified that she was one of the nurses who was dressed in blue scrubs and talking to another nurse while the Resident was lying down on the floor close to the nurses ' station. She stated that she was not assigned with Resident 1 but had observed Resident 1 come out in the hallway on several occasions lying down on the floor. She stated that she had helped the assigned nurses bring the resident to his room on one occasion. CNA 2 stated that Resident 1 appeared to be uncomfortable and possibly looking for attention when he crawled to the nurse ' s station. She stated that the residents ' dignity was not preserved. The potential of not helping could result in injury to the resident as well as embarrassment from being exposed. During a concurrent interview and record review of the video footage with CNA 3 on 9/19/2024 at 3:49 pm, CNA 3 stated that she was assigned with Resident 1 and admitted that Resident 1 consistently came out of his room crawling and lying in the hallway. CNA 3 started crying when she saw the footage and stated that she felt bad for Resident 1. She stated that she could have helped him more but was assigned to several other residents and it was impossible to assist him every time. During an interview with the administrator on 9/19/2024 at 5:09 pm, the Administrator admitted that the nurses did see Resident 1 on lying on the floor and crawling while he was exposed multiple times and did not help him. He stated that the nurses should have helped him off the floor. The Administrator stated that his (Resident 1) dignity was not preserved. The Administrator stated that Resident 1 may have benefited from having a 1:1 sitter (a patient care intervention where a staff member is always present with a resident) as a potential intervention he kept coming back out. During a concurrent interview and record review on 9/19/2024 at 5:22 pm, with the Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled Abuse and Neglect - Clinical Protocol, dated 8/15/2024 was reviewed. The P&P indicated under treatment/management that the facility management and staff will institute measures to address the needs of the residents in order to reduce the possibility of abuse and neglect. The same P&P indicated, The physician and staff will address appropriately causes of problematic resident behavior where possible, such as mania (a mental and behavioral disorder that involves a period of abnormally elevated energy, arousal, and affect) psychosis (a severe form of mania that can involve a break from reality), and medication side effects. The same P&P indicated the Medical Director will advise facility management and staff to safeguard the basic needs functionally, medically, and psychosocial (looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and mental wellness and their ability to function) are met thereby preventing or treating conditions that affect function and quality of life are addressed appropriately. The DON stated that the staff in the facility did not know if lying and crawling in the hallway while exposed was Resident 1 ' s baseline behavior (normal behavior for Resident 1). A copy of the facility ' s surveillance video footages for 9/4/2024 and 9/520/24 was requested on 9/19/2024 but was not provided. On 9/20/2024 the facility Administrator informed the Department that the facility ' s surveillance video footages for 9/4/2024 and 9/5/2024 requested was mistakenly deleted and can no longer provide the footages to the Department. During a review of the facility ' s P&P titled Dignity, reviewed 8/15/2024, the P & P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The same P&P indicated: Staff are expected to treat cognitively impaired residents with dignity and sensitivity, for example: a. addressing the underlying motives or root causes for behavior; and b. not challenging or contradicting the resident's beliefs or statements.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, may have grandiose delusions [strong beliefs of things that are untrue]) and history of wandering was provided with the necessary behavioral health care as indicated in the comprehensive assessment. The facility failed to: -Monitor Resident 1 for schizophrenic behavior each shift, per the Physician's Order. - Evaluate the care plan interventions for their effectiveness and update or revise the interventions based on resident's behavior and needs. -Develop an appropriate care plan for Resident 1's Wandering, and provide supervision, including the frequency. -Anticipate Resident 1's needs and intervene when the resident gets agitated before agitation escalates, per the Potential to Demonstrate verbally / physically Abusive Behaviors care plan related to schizophrenia. As a result, on 6/14/2024, Resident 1 wandered the facility, entered Resident 2's room, and after being told to leave the room, Resident 1 hit Resident 2 in the face causing Resident 2's lip to bleed. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident on 5/22/2024, with diagnoses including anxiety disorder (a condition with excessive worry and fear that interferes with daily activities), and schizophrenia. A review of Resident 1's Admission / Readmission Data Tool dated 5/22/2024, indicated the resident was independently mobile, paced (walk at a steady and consistent speed, especially back and forth and as an expression of one's anxiety), wandered (to walk around slowly in a relaxed way or without any clear purpose or direction), and tried to leave the facility. The form indicated Resident 1 had a history of wandering and was not readily accepting nursing home placement. A review of Resident 1's At Risk of Elopement (leaves the facility, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decision to leave) care plan initiated on 5/22/2024, indicated the resident was a wanderer due to his impaired (weakened) safety awareness. The care plan interventions indicated to distract Resident 1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, to identify types of wandering such as purposeful, aimless (without purpose and direction), or escapist wandering (the state of having wandering and imaginative thoughts in order to escape from reality), and to provide structured activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. A review of the Physician's Orders dated 5/22/2024, indicated to administer haloperidol (Haldol - a medication used to treat certain mental / mood disorders such as schizophrenia) oral tablet one milligram, three times a day for schizophrenia manifested by constant pacing. A further review of the physician's orders dated 5/22/2024, indicated to monitor Resident 1's schizophrenic behavior during each shift. A review of Resident 1's History and Physical (H&P) dated 5/23/2024, indicated the resident did not have medical decision-making capacity. According to a review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/25/2024, Resident 1's cognitive skills (ability to think, remember, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 1 had schizophrenia diagnosis and was taking antipsychotic medication (the main class of drugs used to treat psychosis [a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality] and other mental and emotional conditions. The MDS further indicated Resident 1's current behavior, care rejection or wandering was worse when compared to prior assessment. A review of Resident 1's Potential to Demonstrate verbally / physically Abusive Behaviors care plan dated 5/30/2024 indicated this was related to psychosis (a collection of symptoms that affect the mind, with some loss of contact with reality), schizophrenia, ineffective coping skills and poor impulse control (lacking the ability to maintain self-control). The care plan interventions indicated to access and anticipate Resident 1's needs, evaluate for side effect of the medications, give the resident as many choices as possible about care and activity, and to intervene when the resident gets agitated before agitation escalates. A review of the Situation Background Assessment and Recommendation Form (SBAR) dated 6/14/2024, indicated Resident 1 displayed physical aggression towards another resident (Resident 2), and that per Certified Nursing Assistant 1's (CNA 1) report, Resident 1 swung at Resident 2 and struck Resident 2 in the mouth. The SBAR indicated Resident 2 was subjected to physical aggression by Resident 1, and fell . Upon assessment, Resident 2 had discoloration on the inside of his lower lip. The SBAR form indicated Resident 2 asked Resident 1 to leave the room, Resident 1 swung at him and struck him in the lip. Resident 1's physician was informed of the incident and a new order was made to transfer Resident 1 to the emergency room (ER) for psychiatric evaluation. A review of Resident 2's Skin Observation Tool dated 6/14/2024, indicated a cut measuring less than one centimeter (a metric unit of length) on Resident 2's upper lip. A review of Resident 1's Medication Administration Record (MAR) for the month of June 2024, indicated the resident did not display any schizophrenic behavior, such as constant pacing. During an observation on 7/3/2024 at 8:10 AM, Resident 1 was observed walking in the hallway with his walker. Resident 1 appeared confused, did not answer any questions, and continued walking. During a concurrent observation and interview on 7/3/2024 at 9 AM, inside Resident 2's room, Resident 2 was observed sitting on his wheelchair next to his bed. Upon observation, there were no visible injuries or wound to Resident 2's lip. Resident 2 stated, About 2 weeks ago Resident 1 entered my previous room. Resident 1 always walks in the hallways and sometimes entered my previous room. He does not understand. I told him to leave the room. He began swinging his arms and he left the room. The police came and talked to me. Resident 2 stated, I did not press charges against Resident 1. This was the first time that Resident 1 was swinging his arms at me. He did not mean to hit me. His arm might have accidentally struck me on the face. During an interview on 7/3/2024 at 10:57 AM, CNA 1 stated, I was not assigned to either Resident 1 nor Resident 2. I heard commotion in the hallway. I saw Resident 1 swinging his arms and striking Resident 2 on his shoulders. I called for help, and I tried to separate them. I noticed Resident 2 was bleeding at the mouth. CNA 1 stated Resident 2 told her that Resident 1 hit his mouth. CNA 1 stated she always sees Resident 1 walking in the hallways. During a concurrent interview and record review on 7/3/2024 at 2:30 PM, with MDS Coordinator (MDSC), Resident 1's care plans were reviewed. The MDSC stated she revised Resident 1's at risk for elopement care plan today (7/3/2024) because Resident 1 was only wandering in the hallways and not attempting to exit the facility. The MDSC stated Resident 1's risk for elopement care plan did not have any interventions to monitor the resident. The MDSC stated Resident 1 was a wanderer, he sometimes entered other residents rooms and staff were required to perform frequent visual monitoring for him to prevent him from exiting the facility or entering other residents rooms. During a concurrent interview and record review on 7/3/2024 at 2:45 PM, with the facility's Director of Nursing (DON), Resident 1's care plans were reviewed. The DON stated Resident 1's risk for wandering care plan initiated on 5/22/2024, did not include any individualized person-centered interventions for the resident, indicating how and how often staff were monitoring Resident 1. The DON stated Resident 1 was always wandering in the hallways and he needed to be monitored closely by staff. The DON stated Resident 1's care plan intervention of distracting the resident from wandering by offering structured activities was not effective and staff were required to evaluate care plan interventions for their effectiveness and update or revise the interventions based on resident's behavior and needs. The DON stated the potential outcome of not developing a person-centered care plan with effective interventions for a resident who was constantly wandering and pacing was safety issues and harm to other residents. During a concurrent interview and record review on 7/3/2024 at 2:55 PM, with the DON, Resident 1's MAR for June 2024 was reviewed. The DON stated based on licensed staff documentation, it appears that Resident 1 did not display any schizophrenic behavior such as constant pacing during the month of June. The DON stated this documentation was inaccurate because Resident 1 was constantly wandering and pacing. The DON stated licensed staff were required to monitor and document Resident 1's conduct, condition, and behavior and this was an inaccurate reflection of the resident's true condition. A review of the facility policy and procedure titled,Wandering and Elopement, revised March 2019, indicated the facility would identify residents who were at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility policy and procedure titled, Abuse and Neglect-Clinical Protocol, revised March 2018, indicated the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The physician and staff will address appropriate causes of problematic resident behavior where possible, such as mania (extremely elevated and excitable mood usually associated with bipolar disorder), psychosis, and medication side effects. A review of the facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised December 2016, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial (the interrelation of social factors and individual thought and behavior) and functional needs was developed and implemented for each resident. The comprehensive person-centered care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents were ongoing and care plans were revised as information about the residents and the residents' condition change.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID -19 (Coronavirus disease 2019, a severe respiratory illness and infectious disease caused by a virus and spread from person to person during close contact and through the air) in accordance with the Center for Disease Control and Prevention (CDC) guideline titled, The Respiratory Protection Information Trusted Source, and the facility's policy titled, Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents, for five of five sampled residents (Resident 71, Resident 33, Resident 14, Resident 52, and Resident 18 ) out of a total of 82 residents in facility census and four of five staff in the facility by failing to: -Ensure Resident 71, a COVID-19 positive resident, was not in the hallway unmasked. -Ensure Resident 33 a close contact of Resident 71 (COVID-19 positive and roommate) was not observed in the room and hallway unmasked. -Ensure Certified Nursing Assistant (CNA) 1 and Restorative Nurse Assistant (RNA) 1 donned full Personal Protective Equipment (PPE, gown, gloves, or eye protection) prior to entering Resident 14's (a COVID-19 positive resident) room to provide care. CNA 1 was not fit tested for a mask and RNA 1 was fit tested but wearing the wrong mask. -Ensure Resident 5 and Resident 290 (COVID-19 negative, roommates / close contacts of Resident 14) were not observed unmasked in room and in hallway. -Provide isolation carts and signage at the entrance of two COVID-19 positive rooms (Resident 14's room and Resident 71's room). -Ensure confirmed COVID-19 residents (Resident 18 and Resident 52), including their roommate / close contact (Resident 39, a non COVID-19) wear well-fitting masks indoors, when not in their room, for the duration of their isolation period. All were observed in hallway with no mask. -Ensure re-use (over multiple days) and extended use (over multiple residents) of gowns were not allowed. CNA 3 and CNA 5 were observed wearing re-usable gowns in six resident rooms, with no bins for doffing the gowns. On 1/22/2024 at 1:22 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 facility's Administrator and Director of Nursing (DON) for the facility's failure to implement measures to prevent the transmission of COVID-19 infection, which threatened the health and safety of the residents and staff. As a result, on 1/23/2024, Resident 5, Resident 39 and Resident 66 were newly infected with COVID-19 and three additional staff members (Maintenance Staff, Licensed Vocational Nurse (LVN) 1 and a CNA 10) were infected with COVID-19. These deficient practices had the potential to result in the spread of COVID-19, placing 82 residents and staff in the facility at risk of infection with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. On 1/24/2024 at 2:45 PM, the IJ was lifted after the facility submitted an acceptable Plan of Action (POA). The survey team verified and confirmed on-site the implementation of the immediate removal plan through observation, interview, and record review. The IJ situation was removed in the presence of the Administrator, the DON. The accepted removal plan included the following actions: -On 1/22/2024 the Infection Preventionist (IP) nurse provided a mask for Resident 71. Facility Interdisciplinary Team (IDT) met with Resident 71, to discuss facility implementation of masking and limiting exposure. The facility will offer mask to COVID positive residents inside their room and in the hallway. Residents are advised to limit going outside their rooms. Assigned CNAs are to supervise them in the halfway and/or activity designee to supervise them in the patio. -On 1/22/2024 room changes were done Resident 71 was moved to room [ROOM NUMBER] A for isolation. -On 1/22/24 Facility IDT met with resident to discuss facility implementation of masking and limiting exposure. -On 1/22/2024 a one on one in-service was provided to IP nurse and DON by IP consultant regarding masking, PPE donning and doffing and proper PPE. -On 1/23/2024 IP consultant in-service DON and IP regarding resident masking and limiting exposure to COVID, co-horting, N95 fit testing, proper signage, isolation carts, trash bins, and linen bins. -On 1/22/2024 an in-service was provided by IP consultant together with the IP to staff regarding masking. PPE donning and doffing and proper PPE. 52 out of 102 staff was able to be in-serviced in person. Facility will continue to in-service until 100% of the staff are captured. -On 1/23/2024 A text notification was sent by IP nurse to the employees who are not currently in the facility in person regarding proper masking. PPE donning and doffing and proper PPE, an attestation will be provided by the staff and will be given back to IP nurse. IP nurse will also include a post-test and will be given back to IP nurse. -On 1/23/2024 one on one in-service was provided to RNA 1 by IP consultant to wear proper N9S fit tested mask and proper PPE donning including gown. gloves or eye protection. On 1/22/24 IP fit tested CNA I for N95, on 1/23/24 one on one in- service was provided to CNA regarding proper PPE donning including gown, gloves or eye protection. -On 1/23/2024 IP nurse ensured all 102 staff are N95 fit tested ; 5 staff were found with no N95 fit test record and all 5 were fit tested on [DATE] for N95; IP nurse has an N95 employee log. IP will ensure fit testing for N95 is done upon hire, annually and as needed. -On 1/22/2024 IDT met with 17 residents who tested positive and exposed to COVID-19 discussed facility implementation of masking and limiting exposure to the facility. -On 1/22/2024 IDT met with all 82 residents to discuss implementation of masking and limiting exposure to the facility. -On 1/22/2024 the facility did a room change to the resident who are positive COVID-19 and established a COVID-19 co-[NAME]. Room change was done to isolate COVID-19 positive residents limiting exposure. Exposed residents remained in a non-isolated room. Residents who have potential for non-compliance with masking, limiting exposure and co-[NAME] was met by the IDT and care plan.continue monitoring for 10 days and tested on the first day, third day and fifth day. -Assigned CNA for all shift for COVID-19 positive residents will monitor the co-[NAME] and ensure residents in the room have mask all the time inside the room and hallway. Assigned CNAs will be doing their patient care. An in-service was provided by the Director of Staff Development (DSD) to the assigned CNA. -On 1/23/2024 LVN 1 was provided a one-on-one in-service by the IP consultant on proper PPE use, including doffing and donning. LVN 1 has been verified to have fit test for N95 is done on 1/22/24. -Facility will identify more residents during bi-weekly testing, Tuesdays, and Fridays to ensure no others are affected by the deficient practice. Staff will be testing prior to starting shift to ensure no others are affected by the deficient practice. Last test date for COVID-19 of residents was on 1/23/24. if result comes out positive, resident will be monitored for symptoms and put on co-[NAME] or isolation for 10 days. IDT will meet with residents to discuss implementation of masking and are advised to limit going out in the hallway. For staff found to be positive will be removed from the schedule and can come back on the fifth day with a negative COVID-19 test or 10 days. -On 1/22/2024 IP nurse provided all COVID-19 positive rooms with isolation carts and signage. IP and or designee could be supervisor or charge nurse will conduct 2 hours to the COVID-19 positive rooms to ensure proper isolation carts, trash bins, and linen bins are in place daily. -On 1/22/2024 Resident 52, Resident 18 and Resident 39 were provided masks by the IP nurse. On 1/22/2024 facility IDT met with Resident 52, 18, and 39 to discuss implementation of masking and limiting exposure to the facility. -The facility will no longer use re-usable gowns and will only use disposable gowns. -Charge nurse is to ensure a proper fit tested N95 mask at the start of the shift for all staff. Station will have a roster of staff with their proper N95. Facility door monitor will refer every staff will enter the facility to the charge nurse to check for proper fit tested mask. -IP Nurse will do a random check spot check for staff who goes to the COVID-19 positive room and will do a verbal re-education every two hours five times a week until cleared from COVID-19 outbreak. -Quality Assurance and Performance Improvement (QAPI) is initiated by IP, DON and/or designee regarding employee fit testing for N95 and presented to medical director and QA committee. QAPI will be presented to the next QA meeting on 2/2024. -QAPI is initiated by IP, DON and/or designee regarding masking. PPE donning and doffing, and proper PPE and presented to medical director and QA committee QAPI will be presented to the next QA meeting on 2/2024. Findings: a. A review of Resident 71's admission record indicated the facility admitted the resident on 3/31//2023 with diagnoses including but not limited to cancer of the larynx (part of the throat that contains the vocal cords), diabetes mellitus (a disease that result in too much sugar in the blood) and difficulty walking. A review of Resident 71's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 12/28/2023 indicated the resident's cognition (decisions poor, cues/supervision required) was intact, and required substantial assistance (helper does more than half the effort) with personal hygiene, dressing, and transfer. A review of the Change of Condition- Situation Background Assessment and Response (SBAR) form dated 1/20/2024 indicated Resident 71 tested positive for COVID-19. A review of Resident 71's COVID-19 care plan, initiated 1/20/2024, indicated the resident was positive for COVID-19. The care plan indicated the goal was for signs and symptoms of worsening respiratory illness will be identified and intervention started as soon as possible. The care plan further indicated the interventions included to educate resident on hand hygiene, benefits of wearing mask or covering mouth and social distancing. The interventions also included to place the resident on contact and droplet isolation with eye protection and keep door closed at all times. A review of Resident 71's January 2024 Medication Administration Record indicated the facility was to follow Novel Respiratory Precaution (interventions in place to prevent the transmission of a newly identified respiratory pathogen that include cleaning hands when entering room and when leaving the room. Wearing a disposable gown, eye protection [goggles or face shield], fit-tested respirator [N95 or higher] and gloves) every shift for Active COVID-19 infection for 10 days and to monitor for available PPE and signage with a start date of 1/20/2024. During an observation on 1/22/2024 at 9:02 AM, Resident 71's roommate was observed sitting in the hallway in a wheelchair without a mask. Resident 71's room was observed to have contact and droplet precaution isolation signs posted and there was no isolation cart observed. During a concurrent interview and observation on 1/22/2024 at 9:06 AM in the hallway outside of Resident 71's room, Licensed Vocational Nurse 1 (LVN 1) stated, the residents in Resident 71's room did not have COVID-19 despite the isolation signs present. LVN 1 stated if a resident was COVID-19 positive there would be an isolation cart outside of the room. During an observation, on 1/22/2024 at 9:36 AM, Resident 71 was outside of his room, unmasked. During a concurrent interview, while speaking with resident, Certified Nursing Assistant 1 (CNA 1) approached Resident 71 and stated you have to wear your mask because you have COVID-19. Resident 71 stated he was tested last Friday, and no one told him he was positive for COVID-19. During an interview on 1/22/2024 at 9:38 AM, CNA 1 stated Resident 71 has COVID-19. CNA 1 stated, I just found out this morning. CNA 1 stated Resident 71's roommates do not have COVID-19. b. A review of Resident 33's Admission Record indicated the facility readmitted the resident on 4/8/2022 with diagnoses including kidney failure (damage to kidneys that happens slowly over a long period of time, can cause wastes to build up in the body), major depressive disorder (characterized by a persistent feeling of sadness or a lack of interest in outside stimuli) and bilateral below the knee amputations. A review of Resident 33's MDS dated [DATE] indicated the resident's cognition was intact, the resident could understand others and make himself understood. The MDS also indicated the resident was dependent upon staff for personal hygiene, dressing and showering. A review of the facility census, dated 1/21/2024, indicated Resident 33 and Resident 71 were roommates. During an observation on 1/22/2024 at 9:31 AM, Resident 33 was observed in the hallway. During an observation on 1/22/2024 at 9:44 AM, Resident 33 was observed in hallways wearing no face mask. During a concurrent interview, Resident 33 stated he was Resident 71's roommate. Resident 33 he was tested sometime last week and does not have COVID-19 and doesn't have symptoms. Resident 33 further stated his roommate has COVID-19. States the facility has not talked to him about what is going on, or if he has COVID-19. During an interview on 1/22/2024 at 9:45 AM, the Infection Preventionist (IP) stated Resident 71 currently had COVID-19 and his roommate Resident 33 did not. The IP stated the facility did not separate COVID-19 positive residents from their COVID-19 negative roommates. The IP stated COVID-19 positive residents were allowed to walk through the hallway masked when walking outside to smoke. COVID-19 positive residents were not allowed to linger in the hallways unmasked and the exposed residents were educated to wear a mask while outside of their rooms. When informed, Resident 33 was observed in the hallway unmasked for 15 minutes, the IP stated she was unable to confine residents in their room or ensure they are masked when they are alert and oriented and non-compliant. When asked could staff offer the residents a mask when they saw non-compliance, the IP stated maybe they should do that. c. A review of Resident 14's Admission Record indicated the facility readmitted the resident on 12/12/2023 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), Type II diabetes and acute kidney failure. A review of Resident 14's MDS dated [DATE] indicated the cognition was intact and required moderate to maximal assistance with toileting hygiene, dressing and bathing. It also indicated the resident did not attempt to stand or transfer. The MDS also indicated the resident received continuous oxygen therapy. A review of Resident 14's Change of Condition- SBAR form dated 1/20/2024 indicated Resident 14 was positive for COVID-19 and was placed on novel respiratory isolation. on 1/20/2024. A review of Resident 14's COVID-19 care plan, initiated 1/20/2024 indicated the interventions were to place the resident on contact and droplet isolation with eye protection and keep door closed at all times. During an observation on 1/22/2024 at 10:30 AM, Restorative Nurse Aide 1 (RNA 1) was observed entering Resident 14's room with transmission-based precaution signage for Novel respiratory virus. There was no isolation cart observed at entrance to room. RNA 1 donned a KN95 mask (a mask made to filter at least 95% of particles of size down to 3 microns in diameter), RNA 1 did not don gown, face shield/goggles or gloves prior to entering room. During an interview on 1/22/2024 at 10:33 AM, RNA 1 stated she was not wearing a gown, or goggles. RNA 1 stated she should have donned personal protective equipment (PPE) prior to entering Resident 14's room, she did not see the signage and there was no isolation cart at entrance to door. RNA 1 stated she was wearing KN95 mask because she had difficulty breathing with N95 mask. RNA 1 also stated for COVID-19 positive room she should be wearing a N95 mask. During an observation on 1/22/2024 at 10:42 AM, CNA 1 was observed entering Resident 14's room wearing a KN95 mask. CNA 1 did not don a gown, gloves, or face shield/goggles prior to entering Resident 14's room. CNA was observed assisting Resident 14's roommate with care. During an observation on 1/22/2024 at 10:45 AM, Resident 14's roommate (Resident 5), was observed ambulating in hallways and entered Resident 14's room. Resident 5 was not wearing a mask. During a concurrent interview Resident 5 stated he was fine. During an interview on 1/22/2024 at 11 AM, CNA 1 stated Resident 14 and Resident 14's roommates (Resident 5 and Resident 290) did not have COVID-19. CNA 1 stated the room had signage for COVID-19, but the residents in the room did not have COVID-19. CNA 1 further stated the sign was just to inform everyone to be careful. CNA 1 stated for COVID-19 positive room she should be wearing full PPE that included N95 mask, a gown, gloves, and face shield/goggles. CNA 1 was observed wearing KN95 mask. CNA 1 stated she was wearing a KN95 mask that she bought herself and brought in from home. During an interview on 1/22/2024 at 12:58 PM, the IP stated the facility staff fit testing records were reviewed. The IP stated staff should wear proper personal protective equipment (PPE) when entering COVID-19 positive rooms. The IP stated proper PPE consists of gown, gloves, eye protection and N95 mask. The IP stated CNA 1's fit test (a test to verify that a respirator is both comfortable and provides the wearer with the expected protection) was not completed. The IP also stated RNA 1 was fit tested on [DATE] and was to wear a Honeywell N95 mask. The IP stated the fit test was performed to make sure the staff was safe, and the staff was not able to breathe in any infectious agents in the air. The IP further stated it was important to have the right mask to protect one from receiving or passing infectious agents to the residents. A review of Resident 5's laboratory report, dated 1/23/2024, indicated the resident was infected with COVID-19. A review of the Center for Disease Control and Prevention (CDC) guideline titled, The Respiratory Protection Information Trusted Source, indicated that users are required to be fit tested to confirm the fit of any respirator that forms a tight seal on your face before using it in the workplace. Fit testing is important to ensure the expected level of protection is provided by minimizing the total amount of contaminant leakage into the facepiece through the seal. It also indicated that one should be fit tested yearly to ensure that N95 mask fits properly (https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3fittest.html#:~:text=You%20should%20be%20fit%20tested ,type%2Fbrand%2C%20or%20size). d. A review of the facility's census, dated 1/21/2024, indicated Resident 52, Resident 18 and Resident 39 were roommates. A review of Resident 52's admission record indicated the facility readmitted the resident on 4/1/2023 with diagnoses including endocarditis, hepatitis (inflammation of the liver that can affect its function) and venous insufficiency (leg veins don't allow blood to flow back up to the heart). A review of Resident 52's Change of Condition- SBAR form, dated 1/20/2024, indicated Resident 52 was positive for COVID-19 and was placed on novel respiratory isolation. A review of Resident 18's admission record indicated the facility admitted the resident on 10/12/2023 with diagnoses including high blood pressure, schizoaffective disorder bipolar type (condition in which one experience psychotic symptoms, such as hallucinations or delusions, as well as episodes of mania and sometimes depression). A review of Resident 18's Change of Condition- SBAR form, dated 1/21/2024, indicated Resident 18 was positive for COVID-19 and was placed on novel respiratory isolation. A review of Resident 39's admission record indicated the facility readmitted the resident on 11/29/2023 with diagnoses including dementia, diabetes and chronic hepatitis. A review of Resident 39's weekly nursing progress note, dated 1/22/2024, indicated the resident had no significant changes in the resident's condition. During an observation on 1/22/2024 at 9:14 AM, Resident 39 was observed sitting in the hallway in a wheelchair not wearing a mask. During a concurrent interview, Resident 39 stated he did not have COVID-19 and did not know if his roommates had COVID-19. Resident 39 stated the facility staff did not educate him on isolation precautions. During an observation on 1/22/2024 at 10:20 AM, Resident 52 was not in the room. Resident 52 was observed in the hallway self-propelling himself in a wheelchair from the hallway back into Resident 52's room. Resident 52 was wearing an N95 respirator mask under the chin and the N95 respirator mask was not over the resident's nose and mouth. A review of Resident 39's Laboratory Report, dated 1/23/2024, indicated the resident tested positive for COVID-19. e. During a concurrent interview and observation on 1/22/2024 at 10:19 AM, inside Resident 86's room, CNA 3 was observed wearing a reusable gown and gloves. CNA 3 was not wearing eye protection. During a concurrent interview, when asked where the reusable gown was disposed, CNA 3 opened a plastic trash liner bag for the surveyor to dispose of the reusable gown. During an observation on 1/22/2024 at 12:38 PM, Restorative Nursing Aide (RNA 1) was wearing an N95 and donned a gown and gloves prior to entering Resident 71's room, a COVID-positive resident. RNA 1 did not wear any eye protection prior to entering Resident 71's room or while in Resident 71's room. During an observation and interview on 1/22/2024 at 1 PM, reusable gowns were observed in the PPE cart outside of Resident 23's room. CNA 5 observed Resident 23's room and confirmed there was no closed bin to put the used and dirty reusable PPE gowns inside the resident's room. CNA 5 proceeded to grab an empty plastic bag from the PPE cart and put the dirty reusable gown inside the plastic bag and stated CNA 5 would put the bag into the soiled linen bin in the nearest bathroom. CNA 5 stated the covered trash can inside the resident's room was only for trash and not for soiled reusable gowns. f. A review of Resident 66's admission record indicated the facility admitted the resident on 1/23/2023 and the resident did not have a history of COVID-19. A review of Resident 66's MDS, dated [DATE], indicated the resident's cognition was intact and the resident required supervision with toileting hygiene and dressing and required set up assistance with transferring and standing. A review of the color-coded facility map, dated 1/23/2024, indicated Resident 66 was not in a COVID-19 positive room. A review of Resident 66's lab result, dated 1/23/2024 indicated Resident 66 was infected with COVID-19. During a phone interview on 1/22/2024 at 10:37 AM, the facility's public health nurse (PHN) stated the IP was instructed to room the COVID-19 positive residents separate from the COVID negative residents because there was an increased possibility of spreading COVID-19. During an interview on 1/22/2024 at 1:53 PM, the IP stated she should have moved the COVID-19 positive residents together. She stated exposed and COVID-19 positive residents in the hallways not wearing mask and commingling with the other residents increased the risk of the other residents become infected with COVID-19. During an interview on 1/25/2024 at 4:31 PM, the Director of Nursing (DON) stated COVID-19 positive residents should not be in the hallway and should be quarantined in their room. The DON stated a possible outcome would be increased transmission of COVID-19 among the residents. A review of the facility line list, dated 1/29/2024 indicated three additional staff members tested positive for COVID-19 (Maintenance staff, LVN 1 and a CNA 10) During an interview on 1/31/2024 at 12:34 PM, the Public Health Nurse (PHN) stated there were three additional staff members infected with COVID-19. A review of facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents, revised 7/2020, under the section Resident Placement and Cohorting, indicated resident was suspected COVID-19 are placed in a private room, moved to a dedicated unit, or cohorted with another resident who was suspected to have COVID-19 pending the results of SARS Cov-2 testing. Residents with confirmed COVID-19 are separated from residents who do not have confirmed COVID-19 or have an unknown status. Residents with known or suspected COVID-19 are cared for using all recommended PPE, including an in N95 or higher-level respirator or face mask if respirators are not available), eye protection, gloves and gown.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 66), who had diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally) and had a history of multiple falls, received the care, treatment and services in accordance with professional standards of practice by failing to: -Provide the correct level of assistance for transfers and ambulation, on 7/19/2023, 8/18/2023 and 9/20/2023, per the comprehensive assessment. -Revise and implement the Fall Care Plan to include different fall interventions needed with specific levels of assistance -Complete / Update a fall risk assessment after each fall As a result of this deficient practice, on 12/8/2023, Resident 66 had an unwitnessed fall, hit the back of her head which required transfer to general acute hospital 2 (GACH 2). At GACH 2, Resident 66 had a one-inch laceration treated with staples and hematoma (bruise) on the back of her head, as well as skin tears to her abdomen and back. Findings: A review of Resident 66's admission record indicated the facility admitted the resident on 1/23/2023 with diagnoses including Huntington's Disease (a genetic disease that damages the brain and affects one movement, cognition and mental health), schizophrenia (a serious mental disorder in which people interpret reality abnormally) and anxiety (a mental health condition with feeling of worry, anxiety, or fear interfering with one's daily activities). A review of Resident 66's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/1/2023, indicated the resident's cognition was intact and the resident required supervision (helper provides verbal cues and /or touch /steadying and or contact guard assistance [have one or two hands on the body but provides no other assistance to perform the functional tasks] as resident completes the activity. Assistance may be provided throughout the activity or intermittently) with walking 10 to 150 feet and assistance with transfer. A review of the At Risk for Injury and Falls care plan, revised 4/10/2023, indicated Resident 66 used psychotropic medication (drug taken to exert an effect on the chemical makeup of the brain and nervous system), had poor safety awareness, Huntington's disease, unsteady gait and had impulsive behavior. The care plan interventions included to assist with all transfers as needed, keep bed in lowest position and to maintain safe environment free of hazards. The care plan did not indicate interventions for Resident 66's ambulation. According to a review of the nurse's note, dated 7/11/2023, Resident 66 had a witnessed fall in the hallway and hit the back of her head. The Nurses Note indicated Resident 66 sustained a laceration to the back of her head with bleeding noted. A review of Physician's Order Summary Report dated 7/11/2023 indicated Resident 66 received: - cleanse the resident's occipital (back of head) laceration with normal saline, pat dry and cover with a dry dressing for seven days and - provide the resident with a chest x-ray and skull x-ray after a fall A review of Resident 66's Change of Condition - SBAR form, dated 7/19/2023, indicated the resident had a fall and two staff members assisted the resident to stand and escorted the resident back to bed. A review of Resident 66's Change of Condition - SBAR form, dated 7/28/2023, indicated the resident had a witnessed fall. The form indicated resident was seen on the floor in a sitting position in the hallway. It also indicated the resident was non-compliant with fall precautions provided. The resident was offered a helmet and wheelchair both of which she refused. According to a review of Resident 66's Change of Condition - SBAR form, dated 8/18/2023, the resident had a fall with head and hand injury, as the resident attempted to ambulate (walk) without assistance or supervision. A review of the nurse's note, dated 8/18/2023, indicated Resident 66 returned to the facility from GACH 1, as the resident's imaging results were negative and did not show hemorrhage (an escape of blood from a ruptured blood vessel), or fracture (broken bone) related to fall. A review of the resident's medical chart indicated there was no updated fall risk assessment completed after the 8/18/2023 fall and there was no care plan for Resident 66's non-compliance. A review of Resident 66's Change of Condition - SBAR form, dated 9/20/2023, indicated the resident fell while walking in the hallway. It indicated the resident had a rapid jerking movement and fell backwards hitting her head. It indicated the resident had on her helmet during the fall. A review of the resident's medical chart indicated a fall risk assessment was not completed after the 9/20/2023 fall. According to a review of Resident 66's Change of Condition - SBAR form, dated 12/8/2023, the resident had an unwitnessed fall in her room and the resident was not using an assistive device for ambulation or transferring. A review of the Emergency Services Patient Care Report, dated 12/8/2023, indicated the resident was transferred from the facility to a GACH for the chief complaint of a blunt head injury. The Patient Care Report indicated Resident 66 fell prior to emergency services arrival and hit the back of her head. The Emergency Services Patient Care Report indicated Resident 66 had a one-inch laceration and hematoma (bruise) on the back of her head as well as skin tears to her abdomen and back. A review of the Emergency Department (ED) Physician's Note, dated 12/8/2023, indicated Resident 66 came to the ED with a posterior head laceration after a trip and fall. It indicated while at the facility, the resident lost her balance and hit the back of her head with resultant bleeding. The ED Physician Note indicated Resident 66 received five staples for an occiput (back part of the head) laceration was repaired at bedside without complication. A review of Resident 66's Order Summary Report, indicated on 12/15/2023, the physician ordered the facility to monitor the stapled scalp site for any bleeding, pain or any sign of infection. During an interview on 1/25/2024 at 10:56 AM, Licensed Vocational Nurse 5 (LVN 5) stated that on 12/8/2023 Resident 66 fell in her room. Resident 66 split the back of her head open and there was profuse bleeding. During a concurrent review of Resident 66's care plans related to falls and the medical chart, LVN 5 stated and confirmed Resident 66's care plans were last updated on 7/31/2023. LVN 5 stated that Resident 66's Risk for Fall Care Plan should have been updated (on 8/18/2023 and 9/20/2023) after each fall to reflect new interventions, in order to prevent the resident from repeated falls. Upon further review of the resident's medical chart, LVN 5 stated and confirmed Resident 66's last fall risk assessment was completed on 7/19/2023. LVN 5 stated after Resident 66 fell , a fall risk assessment should have been completed to assess the causes of the fall and generate new interventions to prevent further falls. During an interview on 1/25/2024 at 1:55 PM, the MDS Coordinator (MDSC) stated that on 12/8/2023, Resident 66 had an unwitnessed fall and was transferred via 911 after the fall. The MDSC stated and confirmed Resident 66's fall care plan was last updated on 7/31/2023 and should have been updated after the resident fell on [DATE] and 9/20/2023. The MDSC stated the care plan was to be updated to implement new interventions to prevent further falls. During an interview on 1/25/2024 at 4:37 PM, the Director of Nursing (DON) stated after Resident 66 fell on [DATE], the fall care plan should have been updated on 8/18/2023 and 9/20/2023. A review of the facility's policy and procedure titled, Fall Risk Assessment, dated 3/2018, indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, dated 3/2018, indicated the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on interview and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1), who was identified as exhibiting wandering (walking from place to place without any purpose) behavior and verbalized feelings of being afraid inside the facility, by failing to implement the Wandering and Elopements, [an act or instance of a resident leaves the facility independently without notifying anyone] policy to include in Resident 1's care plan strategies and interventions to maintain resident's safety. These deficient practices resulted in Resident 1 eloping from the facility on 7/18/2023. Resident 1 had not been found. Findings: A record review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 7/13/2023 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), malnutrition (lack of proper nutrition), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A record review of Resident 1's At Risk for Injury/Accidents and Falls care plan dated 7/13/2023, indicated Resident 1 was at risk for injury and falls related to psychotropic medication (medications that affects how the brain works and causes changes in mood, awareness, thought, feelings, or behavior). Resident 1 interventions included to assist resident with all transfers, call light within reach and answer promptly, maintain environment safe and hazard free, remind resident request assistance. A record review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 7/18/2023, indicated Resident 1 was cognitively intact and able to make needs known. The same MDS indicated Resident 1 required supervision with bed mobility, transfers, eating and toilet use. Resident 1 required limited one-person physical assistance with dressing and personal hygiene. A record review of Resident 1's Progress Notes dated 7/15/2023 at 8:10 AM, indicated Resident 1 was outside in the smoking area. Resident states, I am fine, I don't feel safe in there Resident 1 was paranoid (unreasonably anxious, suspicious and mistrustful) about going into the building. Resident 1 was unable to state why she did not want to get into her assigned bed. Nurse kept trying to encourage Resident 1 to go inside the facility. Behavior was endorsed to oncoming nurse. A record review of Resident 1's Progress notes dated 7/16/2023 indicated Resident 1 refused the medication Lithium [Oral Capsule 600 MG (Lithium Carbonate) Give 1 capsule by mouth one time a day for Mood Disorder m/b rapid cycling of mood] (a medication used to treat mood disorder). A record review of Resident 1's Progress Notes dated 7/18/2023 at 6:28PM, indicated at approximately 3:30 PM on 7/18/2023, Licensed Vocational Nurse 3 (LVN 3) made rounds and was informed Resident 1 was in the smoking patio. LVN 3 was passing medications around 4:50PM. A staff member received a phone call for Resident 1. LVN 3 did not see Resident 1 in the room or in the bathroom. LVN 3 asked another nursing staff to assist in looking for the resident. Staff was unable to locate Resident 1 on 7/18/2023. Administrator, Director of Nurses, Medical Doctor notified at 5 PM. A thorough search was conducted throughout the facility. Police Department was called to file a missing person report. During an interview with LVN 1, on 7/20/2023 at 2 PM, LVN 1 stated when she worked the night shift on 7/15/2023, she could not locate Resident 1. LVN 1 stated she instructed other nurses to look for the resident. LVN 1 further stated, when Resident 1 was found and asked to come back into the building, Resident 1 was very paranoid and did not want to go back inside the building. LVN 1 stated, Resident 1 stated she does not feel safe inside the building. LVN 1 further stated, Resident 1 refused to go back into her room the whole night. During an interview with the Administrator (ADMIN), on 7/20/2023 at 2:30PM, ADMIN stated she was not aware that on 7/15/2023 Resident 1 verbalized not feeling safe in the facility and exhibiting behaviors of paranoia. The ADMIN further stated a care plan, Interdisciplinary Team (IDT means a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a patient) for Resident 1's wandering and change of condition should have been initiated. The ADMIN further stated the facility did not initiate and or implement any of the intervention mentioned. During an interview with Director of Nurses (DON), on 7/20/2023 at 2:40 PM, the DON confirmed and stated Resident 1 left the faciity on [DATE]. The DON further stated Resident 1 had left previous facilities against medical advice. DON stated, Resident 1 was not reassessed for wandering and or elopement after Resident 1 verbalized not feeling safe in the facility and not wanting to be here. During a telephone interview with the facility's Medical Director (MD), on 7/21/2023 at 8:21 AM, MD stated he was not aware Resident 1 was missing from the facility. The MD stated the Resident's psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness.) should have been notified regarding when Resident 1 reported feeling unsafe in the facility and the psychiatrist should have been notified regarding the refusal of the medication lithium. Medical Director stated the facility needed to initiate a change of condition for Resident 1 on 7/15/2023. A review of the facility's policy and procedures (P & P) titled, Wandering and Elopements, dated March 2019 indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain a resident's safety.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from physical abuse when Resident 1, with a history of physical aggression, hit Resident 2 on the left eye. This deficient practice resulted in Resident 2 sustaining a bruise (blood or bleeding under the skin due to trauma) under/around the left eye. Findings: A review of Resident 1's admission record indicated the facility admitted Resident 1 on 9/7/2022 and readmitted Resident 1 on 2/13/2023 with diagnoses that included extended spectrum beta lactamase (ESBL - chemicals produced by germs like certain bacteria) resistance, difficulty in walking, anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as a fuel), schizoaffective disorder (a serious mental disorder in which people interpret reality abnormally), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 2/16/2023, indicated Resident 1's cognitive skills (the mental core skills to think, read, learn, remember, reason, and pay attention) for daily decision making was severely impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions). A review of Resident 1's physician order summary dated 1/17/2023, indicated staff to monitor Resident 1 for schizoaffective disorder manifested by persistent delusion (having false or unrealistic beliefs or opinions) that people are out to harm her and hold her against her will and for physical aggressive behavior every shift for the use of Abilify (a medication to treat schizophrenia), and monitor anxiety manifested by restlessness. The physician order summary further indicated Resident 1 was on: -Abilify Tablet five milligrams (mg - unit dose measurement) give one tablet two times a day for aggressive behavior related to bipolar disorder, -Lorazepam (medication used to treat anxiety disorders) tablet one mg give one tablet by mouth every 24 hours as needed for anxiety related to bipolar disorder effective 1/16/2023: and -Risperidone (medication used to treat certain mental/mood disorders) tablet one mg, give one tablet by mouth two times a day for schizophrenia effective 1/16/2023. A review of Resident 1's Medication Administration Record (MAR) for the month of 2/2023, indicated to monitor Resident 1 for schizoaffective disorder manifested by persistent delusion of people out to harm her and hold her against her will and monitor behaviors of physical aggressive behavior every shift for use of Abilify. The MAR further indicated the facility did not administer Abilify or Risperidone to Resident 1 on 2/6/2023 and 2/7/2023. A review of Resident 1's care plan for physically aggressive to staff and throwing ice in the room dated 10/24/2022, indicated the goals included Resident 1, will demonstrate effective coping skills through review date. Interventions included to analyze key times, place, circumstances, triggers and what de-escalates behavior and document for Resident 1. The interventions also included to assess, and address contributing sensory deficits (shortages), assess and anticipate resident's needs such as food, thirst, toileting needs, comfort level, body positioning, pain etc. The interventions included to provide Resident 1 with physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . intervene before agitation escalates, and guide away from source of distress. A review of Resident 1's care plan for behavior of hitting staff dated 10/25/2022, indicated the goals included Resident 1 will demonstrate positive coping mechanisms. The interventions included staff to be attentive and responsive to resident's behavior, check for unmet needs, identify and remove triggers for the behavior, and if possible, minimize changes to resident's environment. A review of Resident 1's care plan for potential demonstrate abusive behaviors dated 9/21/2022, indicated the goals included Resident 1 will demonstrate effective coping mechanism. The interventions included to monitor/document observed behavior and attempted interventions in behavior log. A review of Resident 1's Psychiatry (a branch of medicine that deals with mental, emotional, or behavioral disorders) consult note dated 10/28/2022, indicated Resident 1 was anxious, perplexed and internally preoccupied (lost in thought), not with cognitive impairment, and denied any psychiatry complaints. The plan of care included to continue to monitor Resident 1's symptoms and behavior. A review of Resident 1's Psychiatry consult note dated 11/10/2022, indicated Resident 1 is anxious and the plan was to continue current management, continue to monitor symptoms and behavior. A review of Resident 1's progress note documented by Licensed Vocational Nurse 1 (LVN 1) dated 2/7/2023 at 6:47 PM, indicated Resident 2 was noted with bruising on 2/7/2023 at approximately 6:30 PM. The progress note indicated Resident 2 said Resident 1 hit her because Resident 2 called Resident 1 the N word. The progress note further indicated Resident 1 had no injuries and a Nurse Practitioner (NP - a registered nurse who has additional education and training to diagnose and treat disease) was notified at 6:54 PM on 2/7/2023. The NP ordered to monitor Resident 2's behavior for 72 hours and to make sure resident took her routine medications as ordered. A review of Resident 2's admission record indicated the facility admitted Resident 2 on 1/12/2023 with diagnoses including metabolic encephalopathy (an alteration in consciousness caused by diffuse or global brain dysfunction), peripheral vascular angioplasty (a procedure to help blood flow), dysphagia (difficulty with swallowing), depression (group of conditions associated with the elevation or lowering of a person's mood), anxiety disorder, and embolism (a blocked artery typically from a blood clot) and thrombosis (the formation of a blood clot), of arteries (blood vessel) of the lower extremities. A review of Resident 2's History and Physical dated 1/24/2023, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE], indicated Resident 2's cognition was intact. The MDS indicated Resident 2 required one person assist with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 2' progress note documented by LVN 1 dated 2/7/2023 at 6:47 PM, indicated at approximately 6:30 PM on 2/7/2023, . Resident 2 was assessed and noted with bruising on the left cheek. Resident 2 denied pain or tenderness, and no changes in level of orientation. Resident 2 was offered ice pack for the left cheek but refused. On 2/23/2023 at 4:45 PM, during an interview, LVN 1 stated she was on duty on 2/7/2023 and remembered the incident between Residents 1 and 2. LVN 1 stated another nurse told her to go and look at Resident 2's face because Resident 2 had a black eye. LVN 1 stated Resident 1 (Resident 2's roommate) had a history of aggressive behavior and mental illness and nobody saw her hit Resident 2. LVN 1 stated she notified the facility's Acting Administrator (ADM-Abuse coordinator) who told her (LVN 1) not to report until we (facility) can confirm what happened. On 2/28/2023 at 1:30 PM, during an interview, the Social Services Director (SSD) stated Resident 1 had a history of mental illness, was confused most of time, was aggressive at times, and was verbally and physically abuse. The SSD stated Resident 2 told her we (Residents 1 and 2) hit each other. The SSD stated, that would be considered a resident to resident abuse. The SSD stated she contacted and informed the psychiatrists of what had happened between Residents 1 and 2. The SSD stated Resident 1 was sent to a hospital for higher level of care and Resident 2 told SSD that she was okay. On 2/28/2023 at 3:13PM, during an interview, the Director of Nursing (DON) stated, I was informed that Resident 2 had discoloration under the left eye The DON stated Resident 2 was unable to say how her (Resident 2's) left eye got decolorization. The DON stated Resident 2 stated denied pain or blurred (unclear) vision. On 3/2/2023 at 12:45 PM, during an interview, Resident 2's Responsible Party (RP) stated, when I spoke with Resident 2 about the bruising (left eye), her (Resident 2) exact words were, that woman (Resident 1) beat me, and her voice sounded funny, like she had just come from the dentist. RP 1 stated the SSD contacted and told her there is nothing wrong with her (Resident 2) mouth .The next day I called and spoke with the SSD who told me Resident 2 has bruising around her eye. We (facility) are doing an investigation and it may be possible that it (bruising) was caused by medication. FM 1 stated, I received a call a few days later (unsure who called) and they told me, they found out that Resident 2 and Resident 1 got into a fight. RP stated, I asked Resident 2 what happened, and she (Resident 2) said that woman (Resident 1) beat me. RP stated Resident 2 was at a General Acute Care Hospital (GACH) for an unrelated medical concern and did not want Resident 2 to return to the facility. RP stated she was upset with the care at the facility and the aforementioned incident between Resident 1 and Resident 2. On 3/2/2023 at 3:45 PM, during an interview, the ADM stated she was the facility's acting Administrator on 2/7/2023. The ADM stated she remembered Resident 2 and that Resident 2 had decolorization around the left eye. On 3/3/2023 at 12:15 PM, during a follow up interview and concurrent record review with the DON, Resident 2's nursing progress notes were reviewed. The DON stated the nursing progress notes indicated Resident 2 said Resident 1 hit Resident 2. The DON stated the aforementioned incident should be considered as a resident to resident abuse. The DON stated resident to resident abuse should be reported to the authorities (CDPH). A review of the facility's policy and procedures titled Abuse Prevention Program dated December 2016, indicated our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary, seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms . As part of the resident abuse prevention the administration will: Protect residents rom abuse by anyone including, but not necessary limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors or any other individual . Identify and assess all possible incidents of abuse . Investigate and report any allegations of abuse within timeframes as required by federal requirements . Protect residents during abuse investigations.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for two of seven residents at risk of elopement by failing to: 1. Supervise the whereabouts of Resident 1. Resident 1 had history of elopement (leaving the facility unsupervised), to prevent further elopement. 2. The alarm system was functional for two of two exit doors (Door 1 [front door] and Door 2 [side door]). 3. Resident 1's wander (aimless, slow, or pointless movements, meandering, or repetitive locomotion that exposes the individual to harm; it is frequently incongruent with boundaries, limits, or obstacles) guard bracelet/band (or anklet, a device worn by a resident which trigger an alarm when the resident attempts to go through the door equipped with the alarm system) was checked for placement every shift and daily for proper functioning as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. The maintenance staff conducted weekly checks to ensure the wander guard alarm system (a system that does not startle a patient but alerts the caregiver that the patient is on the move/wandering) was functioning. 5. Resident 7's wander guard bracelet/anklet was attached on Resident 1 and not on Resident 7's wheelchair (w/c). As a result: 1. Resident 1 again eloped from the facility on 10/14/2022 at 11:05 p.m. The law enforcement found Resident 1, 14.3 miles from the facility in a parking lot confused and agitated (feelings of irritability or severe restlessness) on 10/20/2022. Resident 1 did not receive her necessary medications for six days. Resident 1 was transferred to a general acute care hospital (GACH) for medical evaluation on 10/20/2022. Resident 1 did not receive necessary medications for six days. 2. Resident 7 eloped from the facility on 11/5/2022 at 6:00 a.m. The Administrator (Adm) found Resident 7, 0.8 miles from the facility in a local restaurant parking lot, sitting in a wheelchair (w/c) and begging for change on 11/6/2022 at 10:30 a.m. Resident 7 did not receive his necessary between 11/5/2022 at 6:00 a.m. and 11/6/2022 10:30 a.m. Resident 7 did not receive necessary medications for 1 day. These deficient practices also had the potential for Residents 1 and 7 to be exposed to extreme weather conditions, injury, unsafe physical environment, inability to access nutrition and hydration, and death. On 10/18/2022, at 5:48 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the facility's Administrator because of the seriousness related to: 1. Resident 1's successfully eloping from the facility. 2. The facility's failure to have an effective system in place to protect residents from elopement. 3. The facility's lack of knowledge that the wander guard alarm system was not functional. 4. The facility had six of seven residents identified at risk for elopement and did not have wander guard bracelets. 5. The maintenance staff not checking daily if the wander guard alarm system was functional. 6. The licensed nurses not checking daily or accurately recording for the residents' wander guard bracelet placement and failure to check daily if the wander guard alarm system was functional. On 10/20/2022, at 3 p.m., the SSA removed the IJ in the presence of the Administrator, after the facility provided an acceptable IJ Removal Plan (interventions to correct the deficient practice) and the survey team confirmed implementation of the IJ corrective actions through observation, interview, and record review while onsite. The IJ removal plan included the following: 1. On 10/19/2022, the Administrator provided 1:1 (two parties come into direct contact) in-service to the Maintenance Supervisor (MS) regarding using the preventative maintenance tracking log, repair log, communication process of repair needs including door alarms. 2. A maintenance log will be kept at the Nurses' Stations and the Administrator and/or the Director of Nursing (DON) designee to check the log daily. 3. The MS or designee to report any items needing repair during daily stand-up meetings. 4. The Administrator and DSD (Director of Staff Development) designee started training all staff on elopement policy and procedures. 5. The facility assessed and identified 12 ambulatory residents identified at risk for elopement and would place wander guard alarm bracelets (triggers alarms and can lock monitored doors to prevent the resident leaving unattended) on them. 6. The charge nurse (CN) to monitor the wander guard alarm placement on residents every shift for placement and document in the residents' electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Cross Reference F689 Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 6/21/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's admission Evaluation of Elopement Risk Tool, dated 6/21/2022, indicated the resident would pace, wander, and try to get out of the door. Resident 1 was assessed at risk for elopement. A review of Resident 1's Care Plan for resident at risk for elopement initiated on 6/22/2022, indicated the interventions to distract Resident 1 from wandering by offering pleasant diversions. The interventions also included to structure activities, food conversation, television or book and identify pattern of wandering. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 6/28/2022, indicated Resident 1's cognition (ability to think, learn and process information to make decisions) was severely impaired. Resident 1 had behavioral problems including verbal and physical abuse. The MDS indicated Resident 1 was restless and was on multiple [CONDITION(S)] medications (any drug that affects behavior, mood, thoughts, or perception). Resident 1 did not use any device (such as wheelchair or walker) for mobility/walking. Resident 1 needed supervision with dressed, eating, and toileting use. Resident 1 was assessed at risk for elopement. A review of Resident 1's nursing Progress Note dated 7/4/2022, indicated on 7/4/2022 at 4:30 p.m., Resident 1 had eloped, and the staff drove around the facility, found Resident 1 nearby and brought the resident back to the facility. Resident 1 was placed on one-to-one (1:1 -a sitter who remains with a resident at all times) for 72 hours. There was no documented evidence if Resident 1 was wearing the wander guard bracelet/anklet or if the wander guard alarm was triggered. There was no documented evidence that interdisciplinary team (IDT, a group of healthcare workers from different disciplines coordinating the resident's care) investigated Resident 1's elopement, the use of the wander guard, and the wander alarm system to prevent further elopement by Resident 1 and or any resident at risk for elopement. A review of Resident 1's nursing Progress Note dated 7/5/2022, indicated Resident 1 was on 72-hour monitoring for elopement and frequent visual checks done. A review of Resident 1's nursing Progress Note dated 7/6/2022 to 7/7/2022, had no documented evidence of Resident 1's whereabouts. A review of Resident 1's Quarterly Risk Data Collection Tool, dated 9/22/2022, indicated under Elopement Risk Assessment, Resident 1 was independently mobile and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's MAR for the month of 10/2022, indicated Resident 1 to receive [MEDICATION(S)] tablet 1 MG by mouth every 8 hours as needed for anxiety M/B (manifested by) restlessness and nonstop pacing. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Residents 1's MAR for the month of 10/2022, indicated 10 (meaning other) for the following scheduled medications to be administered at 9:00 a.m. from 10/15/2022 up to 10/16/2022 for Resident 1: - [MEDICATION(S)] Sulfate Tablet 325 (65 Fe [Iron supplement]) MG give 1 tablet by mouth one time a day. -Vitamin D3 2000 IU (international units- unit dose measurement) one time a day . A review of Resident 1's MAR for the month of 10/2022, did not indicate the reason(s) why left blank for the following medications scheduled to be administered at 9:00 a.m. from 10/17/2022 up to 10/20/2022 for Resident 1: - [MEDICATION(S)] Sulfate Tablet 325 (65 Fe) MG give 1 tablet by mouth one time a day. -Vitamin D3 2000 IU (international units- unit dose measurement) one time a day . A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 10/1/2022, 10/3/2022, 10/9/2022, 10/12/2022; and 10/13/2022. A review of Resident 1's MAR for 10/2022, under checking the wander guard alarm for placement every shift, indicated N (No) on the 3:00 p.m. to 11:00p.m. shift on: 10/9/2022, 10/12/2022; and 10/13/2022. A review of Resident 1's MAR for 10/2022, regarding checking the wander guard alarm for placement every shift, indicated N (No) on the 11:00 p.m. to 7:00 a.m. shift on: 10/1/2022, 10/4/2022, 10/7/2022, 10/11/2022, 10/12/2022; and 10/13/2022. Also, on further review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's nursing Progress Notes dated 10/15/2022, indicated on 10/14/2022, at 11:40 p.m., Resident 1 was not in the facility, staff search around the facility and were unable to locate the resident. Staff notified law enforcement that Resident 1 had eloped. The local law enforcement arrived at the facility on 10/15/2022 at 1:20 p.m. and filed a missing person report. The progress note did not address the wander guard and if the alarm went off. A review of Resident 1's nursing Progress Notes dated 10/17/2022, indicated housekeeping found a wandering alarm bracelet under Residents 1's bed. On 10/18/2022, a review of the facility's list of residents with wander guards indicated seven residents were at risk for elopement. A review of Resident 1's nursing Progress Notes dated 10/20/2022, timed at 1:54 p.m., indicated law enforcement brought back Resident 1 to the facility. On 10/18/2022 at 11:15 a.m., during an interview, the Maintenance Supervisor 1 (MS 1) confirmed and stated the Administrator told him on 10/17/2022, that the facility's Door 2 wander guard alarm system was not functional. The MS 1 stated both him and the Social Services Designee (SSD) check the facility's wander guard door alarm system weekly by placing a device by the exit Door 1 and Door 2 to test if the wander guard alarm was functioning. On 10/18/2022 at 11:25 p.m., during an interview and record review with the MS 1, the facility's Weekly Log of Monitoring Device (used to indicate the doors with wander alarms were checked for functionality weekly) from 1/6/2022 to 10/2022 was reviewed. The columns on the log for the Door Monitor Working Yes/No and Action Taken to Correct, were left blank from 1/6/2022 up to 10/2022. MS 1 stated, I did not put anything (document). I am sorry but I checked the door. When, asked if MS 1 should have known that Door 2 was not functional after testing, MS 1 stated, Maybe I don't know and was unable to explain why the wander alarm system was not checked if functioning. On 10/18/2022 at 11:31 a.m., during an interview, the SSD stated she tests the wander guard alarm system by holding a wander guard bracelet next to the exit doors to trigger the alarm system before the wander guard bracelet is applied on a resident. The SSD stated she and MS 1 check the wander guard alarm system weekly. The SSD was unable to explain why the columns on the log for the Door Monitor Working Yes/No and Action Taken to Correct, were blank since the month of 1/2022. On 10/19/2022 at 9:45 a.m., during an interview, Charge Nurse 1 (CN 1) confirmed that she was on duty on 10/14/2022 on the 3:00 p.m. to 11:00 p.m. shift. CN 1 stated Resident 1 kept walking around and pacing and last saw Resident 1 in the hallway at around 10:50 p.m. on 10/14/2022. CN 1 stated she could not remember if Resident 1 had the wander guard alarm bracelet on 10/14/2022 before Resident 1 eloped from the facility. CN 1 stated she did not give Resident 1Ativan (medication for anxiety) because Resident 1 paces a lot and does not become aggressive. On 10/19/2022 at 1:49 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated she reported to work on 10/14/2022, at 11:00 p.m. CNA 1 stated when making rounds, she noticed Resident 1 was not in her room or in the hallway at 11:05 p.m. CNA 1 stated she continued to look for Resident 1 and notified CN 1 and CN 2 sometime between 11:05 p.m. and 11:20 p.m. that Resident 1 was missing. On 10/20/2022 at 1:53 p.m., during an observation, the law enforcement accompanied and returned Resident 1 to the facility. The law enforcement officer who accompanied Resident 1, stated Resident 1 was located in the City of Monterey park in a parking lot approximately 14.3 miles from the facility. Resident 1 was confused and agitated. A review of Google Map search by the surveyor, indicated Resident 1 was located approximately 14.3 miles from the facility. On 10/20/2022 at 1:53 p.m., upon Resident 1's return to the facility and during a concurrent observation and interview with Resident 1 in the presence of the Administrator, Resident 1 appeared disheveled (very untidy), and the resident's hair was unkempt hair. Resident 1 had black dirt-like substance underneath the fingernails, all over the hands, the face, clothes, and shoes. Resident 1 was observed without a wander guard alarm anklet/bracelet. Resident 1 refused to answer questions, attempted to jump out of the wheelchair while smoking a cigarette and swung in the direction of the surveyor and the Administrator. The Administrator stated Resident 1 will be transported to a hospital for medical evaluation. On 10/20/2022 at 2:21 p.m., during an interview, the Administrator stated the device to test the wander guard alarm bracelet was stored inside a locked medication cart and that the licensed nurses should know where to find it. The Administrator stated licensed nurses should check if the residents' wander guard alarm bracelet are functional and that MS 1 should check if the wander guard alarm system is working. The Administrator stated the facility did not have a policy on the wander guard alarm system. On 10/21/2022 at 11:53 a.m., during an interview, CN 2 stated she worked on 10/14/2022 from 11:00 p.m. to 7:00 a.m. CN 2 stated CNA 1 informed her at around 11:45 p.m. that Resident 1 was missing. CN 2 stated she instructed CNA 1 to continue searching around the facility for Resident 1 and later joined the search but could not locate Resident 1. CN 2 stated she notified the police at around at 1:00 a.m. (on 10/15/2022). The police arrived at the facility at 1:20 a.m. to file missing person report. CN 2 stated she last saw Resident 1 on 10/13/2022 night but could not recall if Resident 1 was wearing a wander guard alarm bracelet. CN 2 stated she did not use the device to test the residents' wander guard alarm bracelets. 2. A review of Resident 7's Admission Record indicated the admitted Resident 7 on 9/14/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 7's admission Evaluation of Elopement Risk Tool, dated 9/15/2022, indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 7's Care Plan regarding Resident 7 at risk for elopement initiated on 9/15/2022, indicated interventions included to check wander alarm bracelet for proper functioning and placement on the left wrist every shift every shift (7 a.m. to 3 p.m.; 3 p.m. to 11 p.m.; and 11 p.m. to 7 a.m.). A review of Resident 7's Minimum Data Set, dated dated dated [DATE], indicated Resident 7's cognition was intact. Resident 7 did require a mobility device (such as wheelchair or walker) when walking. Resident 7 had behavioral problems including verbal and physical abuse, wandering and was on multiple [CONDITION(S)] (affect the mind) medications. A review of Resident 7's Care Plan revised on 10/18/2022 for the resident's elopement risk included the intervention's resident removes his wander alarm bracelet when placed on wrists and ankles, bracelet placed on wheelchair instead. Check wander alarm bracelet for proper functioning and placement every shift. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 7's MAR for 11/2022, under check wandering alarm placement on w/c every shift, was left blank for: The 11 p.m. to 7 a.m. shift on 11/3/2022. It indicated Y (Yes) for the 11 p.m. to 7 a.m. shift on 11/4/2022. A review of Resident 7's MAR for 11/2022, under check wandering alarm every shift for proper functioning was left blank for the 11 p.m. to 7 a.m. shift on 11/3/2022. A review of Resident 7's MAR for the month of 11/2022, indicated Resident 17 was on the following scheduled medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - FerrouSul ([MEDICATION(S)] Sulfate) Tablet 325 (65 Fe) MG give 1 tablet by mouth one time a day for supplement. - Propanalol HCI (Medication to treat/control high blood pressure) Tablet 10 MG give 1 tablet by mouth one time a day for hypertension ([CONDITION(S)]- High blood pressure) . - Senna (Sennosides- medication to prevent constipation) Capsule give 2 capsules by mouth at bedtime for bowel movement. - Vitamin D3 ([MEDICATION(S)]) Tablet 25 mcg (micrograms- unit dose measurement) give 1 tablet by mouth one time a day for supplement. - [MEDICATION(S)] (Medication to treat/control seizures/ mental illness) Tablet Delayed Release 500 MG give 1 tablet by mouth tow times a day for [CONDITION(S)]. - [MEDICATION(S)] (medication to treat mental illness) Tablet 7.5 MG give 3 tablets by mouth two times a day for [CONDITION(S)] (a serious mental disorder in which people interpret reality abnormally). - Acetaminophen (medication for mild pain) Tablet give 650 mg by mouth every 4 hours as needed for mild pain . - [MEDICATION(S)] Sulfate Aerosol Powder Breath Activated (medications to treat/control SOB [shortness of breath] or wheezing) 2 puff inhale (breath in) orally (by mouth) every 6 hours as needed for SOB or wheezing related to Chronic Obstructive Pulmonary Disease ([CONDITION(S)] - a condition involving [MEDICATION(S)] of the airways and difficulty or discomfort in breathing). A review of resident 7's MAR for the month of 10/2022, did not indicate the reason(s) why left blank for the following medications scheduled to be administered at 9:00 a.m., 5:00 p.m., and or 9:00 p.m. from 11/5/2022 up to 11/6/2022 for Resident 7: - FerrouSul ([MEDICATION(S)] Sulfate) Tablet 325 (65 Fe) MG give 1 tablet by mouth one time a day for supplement. - Propanalol HCI Tablet 10 MG give 1 tablet by mouth one time a day for hypertension ([CONDITION(S)]- High blood pressure) . - Senna Capsule give 2 capsules by mouth at bedtime for bowel movement. - Vitamin D3 ([MEDICATION(S)]) Tablet 25 mcg give 1 tablet by mouth one time a day for supplement. - [MEDICATION(S)] Tablet Delayed Release 500 MG give 1 tablet by mouth tow times a day for [CONDITION(S)]. - [MEDICATION(S)] Tablet 7.5 MG give 3 tablets by mouth two times a day for [CONDITION(S)] (serious mental illness). A review of Resident 7's nursing Progress Note dated 11/5/2022, indicated at 6:00 a.m., Resident 7 was not in the facility and had eloped. Staff drove around the facility, did not find resident and notified law enforcement who arrived on 11/5/2022 at 7:00 a.m. and issued a silver alert (activated when an elderly, developmentally, or cognitively impaired person has gone missing and is determined to be at risk). The note further added no door alarm sounded. A review of Resident 7's nursing Progress Note dated 11/6/2022, indicated at 10:30 a.m. The resident was found by the Adm, returned to the facility and law enforcement was notified. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/8/2022 at 9:30 a.m., during an interview with the Adm and concurrent observation of a wander alarm bracelet in her hand that had been cut. The Adm stated she found it on Resident 7's w/c in the facility and cut it off. She went on to say Resident 7 told her he switched w/c with someone because he wanted to check on his mother who lives in another state. The Adm was asked why the bracelet was placed on the w/c and stated the bracelet needed to be placed somewhere it could not be removed because Resident 7 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Adm further added Resident 7 was unable to ambulate (walk) so she thought the w/c would be a good place for the bracelet. On 11/8/2022 at 9:56 a.m. during an observation of Resident 7 sitting in his w/c at the nursing station the wander alarm bracelet was noted on his left wrist. On 11/8/2022 at 1:45 p.m. during an interview, CN 3 stated she uses a handheld device (used to test the residents' wander alarm bracelet and the exit doors wander guard alarm system if functional) which is located in Medication Cart 1 in Nursing Station 1. CN 3 confirmed and further stated Resident 7's wander guard alarm bracelet was attached at the back of Resident 7's w/c before Resident 7 eloped. On 11/8/2022 at 2:15 p.m. CN 3 confirmed Resident 7 was ambulatory (walk) with assistance and had observed Resident 1 transfer (move) himself independently from bed to w/c. CN 3 stated she had also observed Resident 1 ambulate down the hall while pushing and holding onto his w/c. CN 3 further stated, everyone knows he is a wanderer, but he is always in the w/c, and we would just re direct him. CN 3 stated, responded I don't know. That is a good question when was asked if the facility was aware that Resident 7 was able to transfer to and from the w/c unassisted and what could stop Resident 1 from getting into a different w/c. CN 3 added she did not hear any alarms go off when Resident 7 eloped on 10/5/2022 at 6:00 a.m. On 11/8/2022 at 2:46 p.m. during an interview with the assistant Director of Rehabilitation (ADOR) and concurrent review of Physical Therapy Evaluation Plan of Treatment dated 10/5/2022 the ADOR confirmed Resident 7 was able to transfer from bed to chair with contact guard (minimal to no assistance) stand unassisted and ambulate with a walker 30-50 feet. A review of the facility's policy and procedures (P&P) titled, Safety and Supervision of Residents, revised on 7/2017, indicated resident supervision is a core of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents' assessed needs and identified hazards in the environment. The P&P under individualize, resident-centered approach to safety, further indicated the following: 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; . d. Ensuring that interventions are implemented . 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring interventions are implemented correctly and consistently, b. Evaluating the effectiveness of interventions; . A review of the facility's policy and procedures titled, Abuse and Neglect-Protocol revised 3/2018, indicated Neglect . means the failure of the facility, its employees or service providers to provide goods and services to a resident that is necessary to avoid physical harm, pain, mental anguish or emotional distress. A review of the facility's policy and procedures tiled, Emergency Procedure-Missing Resident revised on 8/2018, indicated residents at risk for wandering and or elopement will be monitored, and staff will take necessary precautions to ensure their safety. A review of the facility's policy and procedures titled, Wandering Elopement, revised 3/2019, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on observation, interview, and record review, for two of seven residents (Residents 1 and 7) at risk of elopement, the facility failed to: 1. Provide a hazard free environment for Residents 1 and 7. 2. Supervise the whereabouts of Resident 1. Resident 1 had history of elopement (leaving the facility unsupervised), to prevent further elopement. 3. The alarm system was functional for two of two exit doors (Door 1 [front door] and Door 2 [side door]). 4. Resident 1 ' s wander (aimless, slow, or pointless movements, meandering, or repetitive locomotion that exposes the individual to harm; it is frequently incongruent with boundaries, limits, or obstacles) guard bracelet/band (or anklet, a device worn by a resident which trigger an alarm when the resident attempts to go through the door equipped with the alarm system) was checked for placement every shift and daily for proper functioning as per physician ' s order. Resident 1 had initially eloped from the facility on 7/4/2022. 5. The maintenance staff conducted weekly checks to ensure the wander guard alarm system (a system that does not startle a patient but alerts the caregiver that the patient is on the move/wandering) was functioning. 6. Resident 7's wander guard bracelet/anklet was attached on Resident 1 and not on Resident 7's wheelchair (w/c). As a result: 1. Resident 1 again eloped from the facility on 10/14/2022 at 11:05 p.m. The law enforcement found Resident 1, 14.3 miles from the facility in a parking lot confused and agitated (feelings of irritability or severe restlessness) on 10/20/2022. Resident 1 did not receive her necessary medications for six days. Resident 1 was transferred to a general acute care hospital (GACH) for medical evaluation on 10/20/2022. Resident 1 did not receive necessary medications for six days. 2. Resident 7 eloped from the facility on 11/5/2022 at 6:00 a.m. The Administrator (Adm) found Resident 7, 0.8 miles from the facility in a local restaurant parking lot, sitting in a wheelchair (w/c) and begging for change on 11/6/2022 at 10:30 a.m. Resident 7 did not receive his necessary between 11/5/2022 at 6:00 a.m. and 11/6/2022 10:30 a.m. Resident 7 did not receive necessary medications for 1 day. These deficient practices also had the potential for Residents 1 and 7 to be exposed to extreme weather conditions, injury, unsafe physical environment, inability to access nutrition and hydration, and death. On 10/18/2022, at 5:48 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the facility ' s Administrator because of the seriousness related to: 1. Resident 1 ' s successfully eloping from the facility. 2. The facility ' s failure to have an effective system in place to protect residents from elopement. 3. The facility ' s lack of knowledge that the wander guard alarm system was not functional. 4. The facility had six of seven residents identified at risk for elopement and did not have wander guard bracelets. 5. The maintenance staff not checking weekly if the wander guard alarm system was functional. 6. The licensed nurses not checking daily or accurately recording for the residents ' wander guard bracelet placement and failure to check daily if the wander guard alarm system was functional. On 10/20/2022, at 3 p.m., the SSA removed the IJ in the presence of the Administrator, after the facility provided an acceptable IJ Removal Plan (interventions to correct the deficient practice) and the survey team confirmed implementation of the IJ corrective actions through observation, interview, and record review while onsite. The IJ removal plan included the following: 1. On 10/19/2022, the Administrator provided 1:1 (two parties come into direct contact) in-service to the Maintenance Supervisor (MS) regarding using the preventative maintenance tracking log, repair log, communication process of repair needs including door alarms. 2. A maintenance log will be kept at the Nurses ' Stations and the Administrator and/or the Director of Nursing (DON) designee to check the log daily. 3. The MS or designee to report any items needing repair during daily stand-up meetings. 4. The Administrator and DSD (Director of Staff Development) designee started training all staff on elopement policy and procedures. 5. The facility assessed and identified 12 ambulatory residents identified at risk for elopement and would place wander guard alarm bracelets (triggers alarms and can lock monitored doors to prevent the resident leaving unattended) on them. 6. The charge nurse (CN) to monitor the wander guard alarm placement on residents every shift for placement and document in the residents ' electronic medication administration record (eMAR- electronic Medication Administration Record). Cross Reference F600 Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 6/21/2022 with diagnoses including [CONDITION(S)] (any brain disease that alters brain function or structure), unsteady on feet (difficulty walking and standing), anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and [CONDITION(S)] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). A review of Resident 1 ' s admission Evaluation of Elopement Risk Tool, dated 6/21/2022, indicated the resident would pace, wander, and try to get out of the door. Resident 1 was assessed at risk for elopement. A review of Resident 1 ' s Care Plan for resident at risk for elopement initiated on 6/22/2022, indicated the interventions to distract Resident 1 from wandering by offering pleasant diversions. The interventions also included to structure activities, food conversation, television or book and identify pattern of wandering. A review of the Physician ' s Orders for Resident 1 dated 6/23/2022, indicated to place a wander guard alarm bracelet (anklet) to the resident ' s left ankle and to check the bracelet/anklet daily if functioning and check the bracelet/anklet for placement every shift (7:00 a.m. to 3:00 p.m.; 3:00 p.m. to 11:00 p.m.; and 11:00 p.m. to 7:00 a.m.). A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 6/28/2022, indicated Resident 1's cognition (ability to think, learn and process information to make decisions) was severely impaired. Resident 1 had behavioral problems including verbal and physical abuse. The MDS indicated Resident 1 was restless and was on multiple [CONDITION(S)] medications (any drug that affects behavior, mood, thoughts, or perception). Resident 1 did not use any device (such as wheelchair or walker) for mobility/walking. Resident 1 needed supervision with dressed, eating, and toileting use. Resident 1 was assessed at risk for elopement. A review of Resident 1 ' s nursing Progress Note dated 7/4/2022, indicated on 7/4/2022 at 4:30 p.m., Resident 1 had eloped, and the staff drove around the facility, found Resident 1 nearby and brought the resident back to the facility. Resident 1 was placed on one-to-one (1:1 -a sitter who remains with a resident at all times) for 72 hours. There was no documented evidence if Resident 1 was wearing the wander guard bracelet/anklet or if the wander guard alarm was triggered. There was no documented evidence that interdisciplinary team (IDT, a group of healthcare workers from different disciplines coordinating the resident ' s care) investigated Resident 1 ' s elopement, the use of the wander guard, and the wander alarm system to prevent further elopement by Resident 1 and or any resident at risk for elopement. A review of Resident 1 ' s nursing Progress Note dated 7/5/2022, indicated Resident 1 was on 72-hour monitoring for elopement and frequent visual checks done. A review of Resident 1 ' s nursing Progress Note dated 7/6/2022 to 7/7/2022, had no documented evidence of Resident 1 ' s whereabouts. A review of Resident 1 ' s Quarterly Risk Data Collection Tool, dated 9/22/2022, indicated under Elopement Risk Assessment, Resident 1 was independently mobile and had a history of elopement, wandering, and getting lost. A review of Resident 1 ' s Medication Administration Record (MAR) for the month of 10/2022, indicated Resident 1 to receive [MEDICATION(S)] ([MEDICATION(S)] - medication to treat anxiety) 2 MG/ML (Milligrams per Milliliter - unit dose measurement) inject 1 mg intramuscularly (IM- Into muscle) every 8 hours as needed (PRN) for severe agitation if [MEDICATION(S)] PO (by mouth) ineffective. The MAR indicated Resident 1 received [MEDICATION(S)] 1 MG IM one time on 10/7/2022 at 3:17 p.m. A review of Resident 1 ' s MAR for the month of 10/2022, indicated Resident 1 to receive [MEDICATION(S)] tablet 1 MG by mouth every 8 hours as needed for anxiety M/B (manifested by) restlessness and nonstop pacing. The MAR indicated Resident 1 was not administered [MEDICATION(S)] 1 mg by mouth between 10/1/2022 up to 10/20/2022. A review f Residents 1 ' s MAR for the month of 10/2022, indicated 10 (meaning other) for the following scheduled medications to be administered at 9:00 a.m. from 10/15/2022 up to 10/16/2022 for Resident 1: - [MEDICATION(S)] Sulfate Tablet 325 (65 Fe [Iron supplement]) MG give 1 tablet by mouth one time a day. -Vitamin D3 2000 IU (international units- unit dose measurement) one time a day . A review of Resident 1 ' s MAR for the month of 10/2022, did not indicate the reason(s) why left blank for the following medications scheduled to be administered at 9:00 a.m. from 10/17/2022 up to 10/20/2022 for Resident 1: - [MEDICATION(S)] Sulfate Tablet 325 (65 Fe) MG give 1 tablet by mouth one time a day. -Vitamin D3 2000 IU (international units- unit dose measurement) one time a day . A review of Resident 1 ' s MAR for 10/2022, under checking the wander guard alarm for placement every shift, indicated N (No) on the 7:00 a.m., to 3;00 p.m. shift on: 10/1/2022, 10/3/2022, 10/9/2022, 10/12/2022; and 10/13/2022. A review of Resident 1 ' s MAR for 10/2022, under checking the wander guard alarm for placement every shift, indicated N (No) on the 3:00 p.m. to 11:00p.m. shift on: 10/9/2022, 10/12/2022; and 10/13/2022. A review of Resident 1 ' s MAR for 10/2022, regarding checking for the wander guard alarm for placement every shift, indicated N (No) on the 11:00 p.m. to 7:00 a.m. shift on: 10/1/2022, 10/4/2022, 10/7/2022, 10/11/2022, 10/12/2022; and 10/13/2022. Also, on further review of Resident 1 ' s MAR dated 10/2022, did not have any documented explanation or implemented interventions, that indicated why Resident 1 did not have a wander guard bracelet/anklet in place. A review of Resident 1 ' s nursing Progress Notes dated 10/15/2022, indicated on 10/14/2022, at 11:40 p.m., Resident 1 was not in the facility, staff search around the facility and were unable to locate the resident. Staff notified law enforcement that Resident 1 had eloped. The law enforcement arrived at the facility on 10/15/2022 at 1:20 p.m. and filed a missing person report. The progress note did not address the wander guard and if the alarm went off. A review of Resident 1 ' s nursing Progress Notes dated 10/17/2022, indicated a wandering alarm bracelet was found under Residents 1 ' s bed by housekeeping. On 10/18/2022, a review of the facility ' s list of residents with wander guards indicated seven residents were at risk for elopement. A review of Resident 1 ' s nursing Progress Notes dated 10/20/2022, timed at 1:54 p.m., indicated law enforcement brought back Resident 1 to the facility. On 10/18/2022 at 11:15 a.m., during an interview, the Maintenance Supervisor 1 (MS 1) confirmed and stated the Administrator told him on 10/17/2022, that the facility ' s Door 2 wander guard alarm system was not functional. The MS 1 stated both him and the Social Services Designee (SSD) check the facility ' s wander guard door alarm system weekly by placing a device by the exit Door 1 and Door 2 to test if the wander guard alarm was functioning. On 10/18/2022 at 11:25 p.m., during an interview and record review with the MS 1, the facility ' s Weekly Log of Monitoring Device (used to indicate the doors with wander alarms were checked for functionality weekly) from 1/6/2022 to 10/2022 was reviewed. The columns on the log for the Door Monitor Working Yes/No and Action Taken to Correct, were left blank from 1/6/2022 up to 10/2022. MS 1 stated, I did not put anything (document). I am sorry but I checked the door. When, asked if MS 1 should have known that Door 2 was not functional after testing, MS 1 stated, Maybe I don ' t know and was unable to explain why the wander alarm system was not checked if functioning. On 10/18/2022 at 11:31 a.m., during an interview, the SSD stated she tests the wander guard alarm system by holding a wander guard bracelet next to the exit doors to trigger the alarm system before the wander guard bracelet is applied on a resident. The SSD stated she and MS 1 check the wander guard alarm system weekly. The SSD was unable to explain why the columns on the log for the Door Monitor Working Yes/No and Action Taken to Correct, were blank since 1/2022. On 10/19/2022 at 9:45 a.m., during an interview, Charge Nurse 1 (CN 1) confirmed that she was on duty on 10/14/2022 on the 3:00 p.m. to 11:00 p.m. shift. CN 1 stated Resident 1 kept walking around and pacing and last saw Resident 1 in the hallway at around 10:50 p.m. on 10/14/2022. CN 1 stated she could not remember if Resident 1 had the wander guard alarm bracelet on 10/14/2022 before Resident 1 eloped from the facility. CN 1 stated she did not give Resident 1Ativan (medication for anxiety) because Resident 1 paces a lot and does not become aggressive. On 10/19/2022 at 1:49 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated she reported to work on 10/14/2022, at 11:00 p.m. CNA 1 stated when making rounds, she noticed Resident 1 was not in her room or in the hallway at 11:05 p.m. CNA 1 stated she continued to look for Resident 1 and notified CN 1 and CN 2 sometime between 11:05 p.m. and 11:20 p.m. that Resident 1 was missing. On 10/20/2022 at 1:53 p.m., during an observation, the law enforcement accompanied and returned Resident 1 to the facility. The law enforcement officer who accompanied Resident 1, stated Resident 1 was located in the City of Monterey park in a parking lot approximately 14.3 miles from the facility. Resident 1 was confused and agitated. A review of Google Map search by the surveyor, indicated Resident 1 was located approximately 14.3 miles from the facility. On 10/20/2022 at 1:53 p.m., during an observation in the presence of the Administrator, Resident 1 ' s appeared disheveled (very untidy), and the resident ' s hair was unkempt hair. Resident 1 had black dirt-like substance underneath the fingernails, all over the hands, the face, clothes, and shoes. Resident 1 was observed without a wander guard alarm anklet/bracelet. Resident 1 refused to answer questions, attempted to jump out of the wheelchair while smoking a cigarette and swung in the direction of the surveyor and the Administrator. The Administrator stated Resident 1 will be transported to a hospital for medical evaluation. On 10/20/2022 at 2:21 p.m., during an interview, the Administrator stated the device to test the wander guard alarm bracelet was stored inside a locked medication cart and that the licensed nurses should know where to find it. The Administrator stated licensed nurses and MS 1 should check if the residents ' wander guard alarm bracelet is functional once a shift. The Administrator stated the facility did not have a policy on the wander guard alarm system. On 10/21/2022 at 11:53 a.m., during an interview, CN 2 stated she worked on 10/14/2022 from 11:00 p.m. to 7:00 a.m. CN 2 stated CNA 1 informed her at around 11:45 p.m. that Resident 1 was missing. CN 2 stated she instructed CNA 1 to continue searching around the facility for Resident 1 and later joined the search but could not locate Resident 1. CN 2 stated she notified the police at around at 1:00 a.m. (on 10/15/2022). The police arrived at the facility at 1:20 a.m. to file missing person report. CN 2 stated she last saw Resident 1 on 10/13/2022 night but could not recall if Resident 1 was wearing a wander guard alarm bracelet. CN 2 stated she did not use the device to test the residents ' wander guard alarm bracelets. 2. A review of Resident 7 ' s Admission Record indicated the admitted Resident 7 on 9/14/2022 with diagnoses including [CONDITION(S)] (any brain disease that alters brain function or structure), anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), closed fracture of upper end of left tibia with routine healing (a break in the shinbone) that involves the knee joint), fracture to base of skull with routine healing, [CONDITION(S)] (skin infection) of left lower leg, [CONDITION(S)] disorder ( a mental disorder characterized by alternating periods of elation and depression) and [CONDITION(S)] disorders ( a condition where symptoms of both psychotic and mood disorders are present together during one episode (or within a two week period of each other- psychotic symptoms and mood symptoms) and alcohol dependance. A review of Resident 7 ' s admission Evaluation of Elopement Risk Tool, dated 9/15/2022, indicated the resident had a history of elopement/wandering. Resident 7 was assessed at risk for elopement. A review of Resident 7 ' s Care Plan regarding Resident 7 at risk for elopement initiated on 9/15/2022, indicated interventions included to check wander alarm bracelet for proper functioning and placement on the left wrist every shift every shift (7 a.m. to 3 p.m.; 3 p.m. to 11 p.m.; and 11 p.m. to 7 a.m.). A review of Resident 7's Minimum Data Set, dated dated dated [DATE], indicated Resident 7's cognition was intact. Resident 7 did require a mobility device (such as wheelchair or walker) when walking. Resident 7 had behavioral problems including verbal and physical abuse, wandering and was on multiple [CONDITION(S)] (affect the mind) medications. A review of Resident 7 ' s Care Plan revised on 10/18/2022 for the resident ' s elopement risk included the intervention ' s resident removes his wander alarm bracelet when placed on wrists and ankles, bracelet placed on wheelchair instead. Check wander alarm bracelet for proper functioning and placement every shift. A review of the Physician ' s Orders for Resident 7 dated 10/18/2022, indicated to place a wander guard alarm bracelet on wheelchair every shift. A review of the Physician ' s Orders for Resident 7 dated 10/19/2022, indicated to check wander alarm bracelet every shift for proper functioning. A review of Resident 7 ' s MAR for 11/2022, under check wandering alarm placement on w/c every shift, was left blank for: The 11 p.m. to 7 a.m. shift on 11/3/2022. It indicated Y (Yes) for the 11 p.m. to 7 a.m. shift on 11/4/2022. A review of Resident 7 ' s MAR for 11/2022, under check wandering alarm every shift for proper functioning was left blank for the 11 p.m. to 7 a.m. shift on 11/3/2022. A review of Resident 7 ' s MAR for the month of 11/2022, indicated Resident 17 was on the following scheduled medications: - FerrouSul ([MEDICATION(S)] Sulfate) Tablet 325 (65 Fe) MG give 1 tablet by mouth one time a day for supplement. - Propanalol HCI (Medication to treat/control high blood pressure) Tablet 10 MG give 1 tablet by mouth one time a day for hypertension ([CONDITION(S)]- High blood pressure) . - Senna (Sennosides- medication to prevent constipation) Capsule give 2 capsules by mouth at bedtime for bowel movement. - Vitamin D3 ([MEDICATION(S)]) Tablet 25 mcg (micrograms- unit dose measurement) give 1 tablet by mouth one time a day for supplement. - [MEDICATION(S)] (Medication to treat/control seizures/ mental illness) Tablet Delayed Release 500 MG give 1 tablet by mouth tow times a day for [CONDITION(S)]. - [MEDICATION(S)] (medication to treat mental illness) Tablet 7.5 MG give 3 tablets by mouth two times a day for [CONDITION(S)] (a serious mental disorder in which people interpret reality abnormally). - Acetaminophen (medication for mild pain) Tablet give 650 mg by mouth every 4 hours as needed for mild pain . - [MEDICATION(S)] Sulfate Aerosol Powder Breath Activated (medications to treat/control SOB [shortness of breath] or wheezing) 2 puff inhale (breath in) orally (by mouth) every 6 hours as needed for SOB or wheezing related to Chronic Obstructive Pulmonary Disease ([CONDITION(S)] - a condition involving [MEDICATION(S)] of the airways and difficulty or discomfort in breathing). A review of resident 7's MAR for the month of 10/2022, did not indicate the reason(s) why left blank for the following medications scheduled to be administered at 9:00 a.m., 5:00 p.m., and or 9:00 p.m. from 11/5/2022 up to 11/6/2022 for Resident 7: - FerrouSul ([MEDICATION(S)] Sulfate) Tablet 325 (65 Fe) MG give 1 tablet by mouth one time a day for supplement. - Propanalol HCI Tablet 10 MG give 1 tablet by mouth one time a day for hypertension ([CONDITION(S)]- High blood pressure) . - Senna Capsule give 2 capsules by mouth at bedtime for bowel movement. - Vitamin D3 ([MEDICATION(S)]) Tablet 25 mcg give 1 tablet by mouth one time a day for supplement. - [MEDICATION(S)] Tablet Delayed Release 500 MG give 1 tablet by mouth tow times a day for [CONDITION(S)]. - [MEDICATION(S)] Tablet 7.5 MG give 3 tablets by mouth two times a day for [CONDITION(S)] (serious mental illness). A review of Resident 7 ' s nursing Progress Note dated 11/5/2022, indicated at 6:00 a.m., Resident 7 was not in the facility and had eloped. Staff drove around the facility, did not find resident and notified law enforcement who arrived on 11/5/2022 at 7:00 a.m. and issued a silver alert (activated when an elderly, developmentally, or cognitively impaired person has gone missing and is determined to be at risk). The note further added no door alarm sounded. A review of Resident 7 ' s nursing Progress Note dated 11/6/2022, indicated at 10:30 a.m. The resident was found by the Adm, returned to the facility and law enforcement was notified. A review of the Physician ' s Orders for Resident 7 dated 11/6/2022, indicated to place a wander guard alarm bracelet to left wrist. On 11/8/2022 at 9:30 a.m., during an interview with the Adm and concurrent observation of a wander alarm bracelet in her hand that had been cut. The Adm stated she found it on Resident 7 ' s w/c in the facility and cut it off. She went on to say Resident 7 told her he switched w/c with someone because he wanted to check on his mother who lives in another state. The Adm was asked why the bracelet was placed on the w/c and stated the bracelet needed to be placed somewhere it could not be removed because Resident 7 had a history of removing the bracelet when it was placed on his person. The Adm further added Resident 7 was unable to ambulate (walk) so she thought the w/c would be a good place for the bracelet. On 11/8/2022 at 9:56 a.m. during an observation of Resident 7 sitting in his w/c at the nursing station the wander alarm bracelet was noted on his left wrist. On 11/8/2022 at 1:45 p.m. during an interview, CN 3 stated she uses a handheld device (used to test the residents' wander alarm bracelet and the exit doors wander guard alarm system if functional) which is located in Medication Cart 1 in Nursing Station 1. CN 3 confirmed and further stated Resident 7's wander guard alarm bracelet was attached at the back of Resident 7's w/c before Resident 7 eloped. On 11/8/2022 at 2:15 p.m. CN 3 confirmed Resident 7 was ambulatory (walk) with assistance and had observed Resident 1 transfer (move) himself independently from bed to w/c. CN 3 stated she had also observed Resident 1 ambulate down the hall while pushing and holding onto his w/c. CN 3 further stated, everyone knows he is a wanderer, but he is always in the w/c, and we would just re direct him. CN 3 stated, responded I don ' t know. That is a good question when was asked if the facility was aware that Resident 7 was able to transfer to and from the w/c unassisted and what could stop Resident 1 from getting into a different w/c. CN 3 added she did not hear any alarms go off when Resident 7 eloped on 10/5/2022 at 6:00 a.m. On 11/8/2022 at 2:46 p.m. during an interview with the assistant Director of Rehabilitation (ADOR) and concurrent review of Physical Therapy Evaluation Plan of Treatment dated 10/5/2022 the ADOR confirmed Resident 7 was able to transfer from bed to chair with contact guard (minimal to no assistance) stand unassisted and ambulate with a walker 30-50 feet. A review of the facility ' s policy and procedures (P&P) titled, Safety and Supervision of Residents, revised on 7/2017, indicated resident supervision is a core of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents ' assessed needs and identified hazards in the environment. The P&P under individualize, resident-centered approach to safety, further indicated the following: 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; . d. Ensuring that interventions are implemented . 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring interventions are implemented correctly and consistently, b. Evaluating the effectiveness of interventions; . A review of the facility ' s policy and procedures (P&P) tiled, Emergency Procedure-Missing Resident revised on 8/2018, indicated residents at risk for wandering and or elopement will be monitored, and staff will take necessary precautions to ensure their safety. The P&P did not indicate how residents at risk for wandering will be monitored. The P&P further indicated . If the search is unsuccessful after a period of 10 minutes, call the police to report the resident missing. A review of the facility ' s policy and procedures (P&P) titled, Wandering Elopement, revised 3/2019, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on interview and record review, the facility failed to ensure staff used appropriate assistive device(s) during transfer for one of three sampled residents (Resident 1), who was had history of multiple falls and was unable to stand, by not: 1. Implementing its policy on Using a Mechanical Lifting Machine, the Lift manufacturer's guidelines. 2. Evaluating Resident 1's physical ability to safely use the correct lift machine, a Hoyer Lift (assistive medical devices which apply specially-designed slings and pads under the resident to safely lift the resident from a bed to a chair or wheelchair) instead of a Sit-to-Stand Lift (often referred to as Sara Lifts, Lift Ups, Stand Assist, or Stand Up Lifts). They are used to assist mobility patients when they are unable to transition from a sitting position to a standing position on their own. They help mobility patients transfer from standing to sitting safely. Sit-to-Stand devices, work for patients that still have some muscular strength, but not enough strength to safely change positions by themselves. These assisting mobility devices help weight-bearing patients to maintain greater independence and achieve safer transfers.to transfer between surfaces. 3. Training Certified Nursing Assistants including CNAs 2 and 5 on different lift devices for Resident 1's safety during surface transfer. 4. Instructing CNAs 2, and 5 on safe transfer of Resident 1 using the Hoyer Lift. As a result, on 3/5/2022 at 8:10 am, when CNAs 2 and 5 used a Sit-to-Stand Lift machine to transfer Resident 1 from bed to chair, Resident 1 fell on his left arm. On 3/6/2022 at 3 am, Resident 1 complained of severe pain on the left shoulder, received [MEDICATION(S)] (controlled pain medication), X-rays taken showed a broken left shoulder requiring transfer to General Acute Care Hospital 1 (GACH 1) where the fracture was ruled out and was diagnosed with a contusion (deep bruise) of the left shoulder. Findings: A review of Resident 1's Admission Record indicated the facility initially admitted Resident 1 on 10/10/2019 and was readmitted on [DATE] with diagnoses including [CONDITION(S)], cognitive (the mental action or process of acquiring knowledge and understanding through thought, experiences, and senses) communication deficit [CONDITION(S)] of both knee (a [CONDITION(S)] joint disease where the tissues in the knee joint break down overtime and can cause pain and stiffness), abnormal posture, and muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue). A review of Resident 1's Actual Fall Care Plan, indicated Resident 1 fell on [DATE] (unwitnessed fall), on 3/10/2020 (when reaching for an item from the floor), and on 9/14/2021 (in the therapy room). A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 1/4/2022, indicated Resident 1 was able to remember and make decisions and required extensive to total assistance with bed mobility, transfers from and to bed/chair, dressing, eating, toilet use, and personal hygiene. Resident 1 had impairment to arms and legs and used a wheelchair for mobility, was unable to move from a seated position to a standing position, and was unable to walk, turn around, and moving on and off toilet. A review of Resident 1's Physical Therapy (PT) treatment dated on 3/4/2022, 3/5/2022, and 3/7/2022, indicated the resident was a high fall risk and had poor sitting balance and was unable to stand. A review of Resident 1's nursing Progress Notes, dated 3/6/2022 and timed at 8:10 am, indicated CNA 5 assisted CNA 2 transferring Resident 1 onto a chair using a standup (sit-to-stand) lifting device. Resident 1's feet slid sideways to the right from the lifting device board causing the resident's body weight to rest on the resident's left arm. A review of Resident 1's Pain Assessment record dated 3/6/2022 timed at 8:30 am., indicated Resident 1 received a scheduled and or PRN (as necessary) unnamed pain medication for mild left shoulder pain 2/10 (pain rating scale from zero to 10, zero indicating no pai and 10 the worst possible pain), and or offered and declined. A review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation - communication technique between the health care team) form, dated 3/6/2022 timed at 3:00 am, indicated Resident 1 complained of new onset of pain on the left shoulder and left wrist and rated his pain at 8/10. The physician was notified and ordered X-rays. A review of the Physician's Order for Resident 1 dated 3/6/2022 timed at 3:40 am., indicated to administer [MEDICATION(S)] (combination medication used to relieve moderate to severe pain. It contains an opioid pain reliever [[MEDICATION(S)]] and a non-opioid pain reliever [acetaminophen]) 5-325 milligrams (mg) orally one time for mild shoulder pain and as needed. A review of Resident 1's IDT (Interdisciplinary Team- a team of professionals who plan, coordinate, and deliver personalized health care) notes dated 3/7/2022 at 8:50 AM., indicated that on 3/6/2022 at approximately 2:30 am., Resident 1 reported that he fell from a lift chair on 3/5/2022 during transfer on the day shift. The IDT notes further indicated Resident 1 complained of left shoulder pain/wrist/forearm and the resident was noted with left wrist swelling per nurse skin assessment. Pain medication given as ordered. Stat (now) X-ray ordered. A review of the facility's in-services lesson plan, titled, Resident handling, staff lifting and moving of residents, dated 3/7/2022, indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Staff shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: . resident's mobility (degree of dependency), Resident's size, and weight-bearing ability . Safe lifting and movement of residents is part of an overall facility employee health and safety program, which involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies. A review of Resident 1's Fall Care Plan, dated 3/7/2022, indicated Resident 1 fell on [DATE]. The Interventions included a left shoulder immobilizer (designed to hold the arm against the body) in place as ordered, X-ray result of acute nondisplaced (pieces of bones do not move out of alignment) humeral head fracture and transferring Resident 1 to GACH 1. A review of GACH 1 X-ray report dated 3/7/2022, indicated Resident 1 had no evidence of fracture to the left shoulder. A review of GACH 1 Follow These Instructions at Home notes, dated 3/7/2022 and timed at 2:44 pm, indicated Resident 1 had a contusion (deep bruise) because of a [MEDICATION(S)] injury to tissues and muscle fibers under the skin. Resident 1 to rest, apply pressure, raise the injured area, and use a sling on the left shoulder. During a concurrent interview and record review, during a concurrent, on 6/7/2022, at 1:30 pm, Resident 1's care plans were reviewed. The MDS nurse stated and confirmed she was unable to find any care plan(s) in Resident 1's medical chart related to the lift devices used to transfer Resident 1 before the resident fell on [DATE]. During an interview on 6/10/2022, at 2:50 pm, CNA 3 stated she has provided care to Resident 1 and that the Sit-to-Stand Lift should not be used on the resident because the resident is unable to stand. CNA 3 stated the facility trained her on lift devices. During a concurrent interview with the MDS Nurse and record review on 6/10/2022, at 3:20 pm, the in-service training records for CNAs and licensed nurses were reviewed. The MDS nurse stated she was unable to locate nor provide any documentation that facility staff were trained on different lift devices. During an interview on 6/10/2022, at 4:40 pm, the physical therapist assistant (PTA) stated the staff should use a Hoyer Lift and not a Sit-to-Stand Lift. During a telephone interview on 6/15/2022, at 9:45 AM, restorative nursing assistant 2 (RNA 2) stated, Resident 1 is unable to stand, requires two-person physical assist and a Hoyer lift to transfer Resident 1. RNA 2 also stated that before Resident 1 fell on [DATE], the facility staff used the sit to stand lift machine to transfer Resident 1 between surfaces. RNA 2 stated she cannot recall when the facility started using to use the Hoyer lift to transfer Resident 1 between surfaces. During a telephone interview on 6/15/2022, at 10:10 am, CNA 2 stated she and CNA 5 were using and had used the Sit-to-Stand Lift machine before 3/5/2022 to transfer Resident 1 to a chair. CNA 2 stated Resident 1 was able to stand at the time, but his legs were weak. On 3/5/2022, Resident 1 bent his knees, she grabbed the resident's pants so that the resident could sit on the chair, but Resident 1 rested his weight on his arm. CNA 2 stated she did not consider the resident fell because she grabbed Resident 1's pants breaking the fall to the floor. CNA 2 stated the facility trained on all lift devices. During a telephone interview on 6/16/2022, at 9:28 am, the Director of Nursing (DON) stated residents that cannot stand, are unable to walk, and are dependent on staff for transfers should be transferred using the Hoyer Lift and not the Sit-to-Stand Lift. During a telephone interview on 6/23/2022, at 11:16 am, the DON stated, Resident 1's fall incident was preventable if the facility staff did not use appropriate lift machine. During a telephone interview on 7/01/2022, at 10:09 am, the director of staff development (DSD) stated she started working at the facility 3/10/2022. The DSD stated the DON is responsible to in-services staff when she was not working. The DSD also stated she was unable to provide in-service documentation on falls and or lifting devices prior Resident 1 falling on 3/5/2022 because she gave them to the previous DON. During a telephone interview on 7/01/2022, at 1:20 PM, the Administrator (ADMIN) stated, the previous infection control preventionist 2 (IPN 2) doubled as the DSD. The ADMIN also confirmed IPN 2 provided the in-service, Resident handling, staff lifting and moving of residents on 3/7/2022. The ADMIN was not able to provide training records on lifting devices and or fall prior Resident 1's falling on 3/5/2022. A review of the lift manufacturer's guide, Care Stand Operations revised on 10/2016, indicated under assessment: 1. The Stand lift devise is specifically designed for assisting residents to a standing position. 2. Because the Stand lift is an assistive device, it should only be used with residents that can bear the requisite amount of weight as determined by your facility. 3. It also requires that patients possess more advanced motor and cognitive skills. 4. It is important to first determine the appropriateness of this piece of equipment for a particular patient. A review of the facility's Policy and Procedures (P&P) titled, Lifting Machine, Using a Mechanical, revised date 7/2017, indicated before using a lifting device: 1. To assess the resident's current condition, including: a. Physical. 2. Can a resident assist with the transfer? 3. Is the resident's weight and medical condition appropriate for the use of a lift? A review of the facility's P&P titled, Fall Risk Assessment, revised on 3/2018, indicated staff's assessment shall be used to identify underlying medical conditions that may increase the risk of injury from falls. The policy also indicated that staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. A review of the facility's P&P titled, Falls and Fall Risk, Managing, revised on 3/2018, indicated a Fall is defined as: Unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. A review of the facility's P&P titled, CNA role undated, indicated a CNA's role includes proper lifting and transitioning residents from wheelchair to bed, bed to chair, and helping residents, sit, stand, and walk.

Based on observation, interview, and record review, the facility failed to identify and evaluate accident risks and provide a safe environment to prevent accidents for one of two sampled residents (Resident 1). For Resident 1, who was diagnosed with [CONDITION(S)] (paralysis of, cannot move, one side of the body) following a cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), muscle wasting, had history of falls and was a fall risk, the facility failed to: 1. Provide a floor mat at the bedside to prevent injury from fall, in accordance with Resident 1's plan of care. 2. Develop a revised, person-centered plan of care after Resident 1 had an actual fall on 5/8/2020, to prevent injury. As a result, on 5/3/2021, at 7:25 AM, Resident 1 had a second fall, requiring a transfer to General Acute Care Hospital (GACH) 1 where Resident 1 was diagnosed with chronic left [CONDITION(S)] (a partial dislocation), and a laceration (cut/tear) on the right forehead requiring suture placement. Findings: A review of the Admission Record (Face Sheet) indicated Resident 1 was [AGE] year-old female when admitted to the facility on [DATE] with diagnoses including, [CONDITION(S)] and [CONDITION(S)] (weakness on one side of the body that can affect the arms, legs, and facial muscles) affecting the left non-dominant side, muscle wasting, atrophy (wasting / thinning or loss of muscle tissue) and unsteadiness on feet. A review of Resident 1's Progress Notes dated 5/11/2020, indicated on 5/8/2020 Resident 1 was found with half her body on the floor and the other half on the bed. The progress note indicated Resident 1 stated she was trying to change positions from her bed and slid onto the floor. Resident 1 was transferred to GACH (General Acute Care Hospital) 2 and found to have a left hip contusion (blood or bleeding under the skin due to trauma of any kind) and left wrist sprain (stretched or torn ligament, ligaments are tissues that connect bones at a joint). Resident 1 was readmitted to the facility on [DATE] with a splint on the left arm. A review of Resident 1's Interdisciplinary Team Notes (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient), dated 5/11/2020, indicated recommendations were to place Resident 1's bed in the lowest position with a floor mat by bedside, provide safety education, encourage to request for assistance with reposition and bed mobility and explain and discuss risks of injuries related to falls. According to a review of the quarterly Minimum Data Set (MDS - an assessment and care planning tool) dated 3/11/2021, Resident 1 was assessed with moderate mental impairment (significantly sub average intellectual ability). The MDS indicated Resident 1 required extensive assistance with two people assist with transfers, bed mobility, and toilet use, and one person assist with dressing, eating and personal hygiene. A review of Resident 1's Care Plan on Actual Fall related to resident getting out of bed unassisted, dated 3/15/2021, indicated the goal was for the resident not to have a major injury from fall. The interventions included for Resident 1's bed to be in a low position with a floor mat in place, safety education with patient and encourage to request for assistance with repositioning and bed mobility. The care plan did not indicate Resident 1 had an actual fall. A review of Resident 1's Care Plan for At Risk for Injury/Accidents and Falls related to resident on [CONDITION(S)] medication (any drug that affects behavior, mood, thoughts, or perception), unsteady gait, poor safety awareness and history of falls, was dated 3/15/2021. The goal indicated Resident 1 was to have no major injury should a fall incident occur in the next three months. The care plan interventions included assisting with all transfers as needed, call light within reach and answer promptly, eliminate potential hazards such as uneven surfaces, debris or water on the floor, and use of rubber-soled healed shoes or nonskid slippers. A review of Resident 1's care plan for antipsychotic medication (class of medication used to manage [CONDITION(S)]) [MEDICATION(S)] (prescription drug used to treat mood disorders) related to [CONDITION(S)] (chronic mental health condition characterized primarily by symptoms of [CONDITION(S)] (mental illness that affects how a person thinks, feels, and behaves, such as hallucinations or delusions, and symptoms of a mood disorder, such as [CONDITION(S)] and depression) manifested by hearing voices, revised on 3/15/2021, indicated the interventions included observing Resident 1 closely for side effects of sedation, drowsiness, blurred vision and to monitor for cognitive behavior (decreased mental status) and akathisia (inability to sit still). According to the Nurse's Drug Guide 2020, the side effects for [MEDICATION(S)] were restlessness, dizziness, feeling unsteady and having trouble keeping your balance. A review of a Fall Risk Assessment, dated 3/31/2021 (15 days after the fall risk care plan was initiated), indicated Resident 1 had no falls in the past 6 months, was taking [CONDITION(S)] medication (affects behavior, mood, thoughts, or perception) more than three times per week and had incontinence for bowel and bladder (the loss of control). A review of Resident 1's Nursing Notes, dated 5/3/2021, indicated Resident 1 had a fall (second fall) and was found yelling and lying on the floor close to her roommates' bed, on the right side. Resident 1 was noted to have blood on the right side of her forehead, and pressure to the resident's head was applied. The nursing notes indicated emergency services was called, and paramedics arrived at 7:38 AM. Resident 1 was transferred to GACH 1 for further evaluation. A review of GACH 1 History and Physical (H&P) dated 5/3/2021, indicated Resident 1 was admitted to the GACH on 5/3/2021 after rolling off her bed falling on the right side of body, injuring the hip and lateral (side) head injury. Resident 1 denied losing consciousness during the event and felt immediate left sided hip pain following the event. A review of Resident 1's final Orthopedic Consult (branch of surgery concerned with conditions involving the musculoskeletal system) notes, dated 5/3/2021, indicated no acute surgical intervention indicated for chronic left [CONDITION(S)] (a partial dislocation). Left knee arthritis and rigidity with no acute intervention indicated. Place patient in a knee immobilizer (immobilizes the knee joint and prevents it from moving) and follow up with orthopedics in one to two weeks. According to a review of Resident 1's Nursing Notes dated 5/6/2021, Resident 1 was readmitted to the facility with a knee immobilizer in place to left knee. Resident 1 was noted to have bed in the lowest position with call light in place. On 5/13/2021 at 10:55 AM, Resident 1 was observed in her room and noted to have a left knee immobilizer and a laceration to the right side of her head with sutures in place. During an interview on 5/13/2021 at 11:18 AM, Licensed Vocational Nurse (LVN) 1 stated a Certified Nursing Attendant (CNA) came and informed her that Resident 1 was on the floor. LVN 1 evaluated the resident and noted there was blood on the floor and informed the nurse to call 911 and call the doctor. LVN 1 applied pressure to the wound and stayed with resident until paramedics arrived. The paramedics moved Resident 1 from the floor to the gurney and Resident 1 was taken to the hospital. LVN 1 stated no floor mat was in place at the time of the fall. During an interview on 6/17/2021 at 1 PM, the DON stated that she was not sure why Resident 1 did not have a floor mat at her bedside at the time of the fall. The DON stated that there had not been a change in the plan of care since the last time Resident 1 fell out of bed on 5/8/2020. On 10/13/2021 at 12:35 PM, during an interview with the DON, when asked about the At Risk for injury/accidents and falls care plan intervention of rubber-soled heeled shoes or nonskid slippers, the DON stated this intervention did not apply for Resident 1 and were not provided to Resident 1. The DON stated the interventions should have been removed from the care plan since it did not apply to Resident 1 since she was bed bound. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated December 2016, indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet resident's physical, psychosocial and function needs was developed and implemented for each resident. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. A review of the facility's policy and procedure titled, Falls-Clinical Protocol, dated March 2018, indicated if underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason was identified for its continuation.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was diagnosed with [REDACTED]. As a result on 11/2/2020, after three incidents of unsafe wandering, Resident 1 entered Resident 2's room and punched Resident 2 on the left side of the face. Resident 2 screamed for help and felt afraid of Resident 1. On 11/4/2020, Resident 1 was transferred to the General Acute Care Hospital (GACH) for evaluation. Findings: A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Care Plan, dated 9/30/2020, indicated Resident 1 was at risk for elopement (leaving the facility unsupervised) and wandering, with impaired safety awareness. The care plan interventions indicated to distract resident from wandering by offering pleasant diversion or structured activities and Wander Guard (a bracelet and monitoring device that helps prevent a resident from leaving a facility unattended) as ordered. Further review indicated the care plan was not updated or modified after 9/30/2020. A review of the Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 10/8/2020, indicated Resident 1 had severe cognitive (mental) impairment, and was at risk for elopement due to wandering behavior. A review of the Progress Note, dated 10/23/2020, indicated Resident 1 was observed urinating in another room, the resident continued going into other resident's rooms, and required frequent re-orienting to his room. The Progress Note indicated Resident 1 constantly noted heading towards the exit doors, had to be reoriented and told not to head in that direction multiple times per shift. Resident 1 was noted heading towards the door twice every 10 minutes throughout shift and had to be constantly reminded. A review of Resident 1's Progress Notes, dated 10/29/2020, indicated resident noted walking into another residents room, and started punching the privacy curtain. Resident wandered the halls throughout the shift, entering other residents room. The progress note indicated Resident 1 was noted taking food from other residents, laying down in other residents beds, and constantly walking towards the exit doors. Resident 1 was less reactive to re-direction, and started mumbling words under his breath after he was told not to do something. A review of Resident 1's Progress Notes, dated 10/31/2020, indicated resident was observed with aggressive behavior towards staff members and other residents. Resident 1 threw a table at a staff member, knocked over items in the dining room, and was arguing with other residents. A review of the Los Angeles Police Department Investigative Report, dated 11/2/2020, indicated Resident 1 entered Resident 2's room and attempted to take Resident 2's television. When Resident 2 told Resident 1 no, Resident 1 pretend to spit at Resident 2. When Resident 2 told Resident 1 no again, Resident 1 punched Resident 2 on the left side of the face. A review of Resident 2's Progress Note, dated 11/2/2020 indicated Resident 2 was assessed by Licensed Vocational Nurse (LVN) 1 and noted to have red discoloration under the left eye. A review of Resident 1's Progress Notes, dated 11/3/2020, indicated resident was seen going into another residents room, started yelling and trying to grab at another resident. Resident 1 then attempted to shove the writer, while being helped out the room. Resident 1 then tried going into a different room, and grabbing towards another resident. Resident 1 then stated, I'm not the one to f--- with, I'm from a gang, don't f--- with me. Resident 1 then tried going back inside the first room, and kept taunting and calling out the other resident. A review of the Progress Notes, dated 11/4/2020, indicated the physician ordered to transfer Resident 1 to the GACH for evaluation due to uncontolled behavior related to [MEDICAL CONDITION]. During an observation of Resident 2 on 11/12/2020 at 11:40 a.m., Resident 2's bed was closest to the window and had a television on the left side of the bed. During a concurrent interview, Resident 2 stated she was watching the television when Resident 1 came near her bed on 11/2/2020. Resident 2 stated she informed Resident 1 that he was in the wrong room. Resident 2 stated Resident 1 attempted to grab the television but could not. Resident 2 stated Resident 1 proceeded to spit at her and hit her in the left eye. Resident 2 stated she obtained a mark in her left eye and her face and head were in pain. Resident 2 stated she started screaming for help and the nurses came into the room and assisted Resident 1 out of the room. During an interview with Resident 2 on 11/12/2020 at 12 p.m., Resident 2 stated Resident 1 always comes in and out of other resident rooms and nobody watched Resident 1. Resident 2 stated the incident left her with half of nose that was swollen and left side of the face swollen. Resident 2 stated she took a pain medication to relieve her pain. Resident 2 stated she sleeps during the day so she can stay awake during the night because she was afraid Resident 1 would come and hurt her during the night. Resident 2 stated she was scared of Resident 1. During an interview with the Social Worker (SW) on 11/12/2020 at 12:25 p.m., the SW stated and confirmed that Resident 1 went inside Resident 2's room and hit Resident 2 on 11/2/2020. The SW stated an ophthalmologist (eye doctor) was consulted to come and assess Resident 2's eyes as a result of the incident. The SW stated Resident 1 had shown aggressive behavior at another facility before. The SW stated Resident 1 paced and walked around the facility. During an interview, on 11/12/2020 at 12:45 p.m., Resident 3 stated, He's a very tall slender man who wanders up and down the hallway. Resident 3 stated, Familiar with him (Resident 1) because he comes to my room when I was in another room and stands and look over me. Resident 3 stated Resident 1's normal behavior was to come into her room uninvited but did not stay long. During an interview, on 11/12/2020 at 1:46 p.m., when asked what was done after Resident 1's incident on 11/2/2020, the Administrator stated it was reported to the mental health staff, who visited the resident on 11/3/2020, but did not take him. The Administrator did not indicate the care plan was updated or modified. The Administrator stated Resident 1 was transferred to the GACH for evaluation on 11/4/2020, two days after hitting Resident 2. During an interview, on 11/12/2020 at 2:15 p.m., Resident 4 stated Resident 1 comes into his room at night uninvited. Resident 4 stated he would wake up at night and see Resident 1 hovering on top of him, which scared him. Resident 4 stated he did not sleep during the night because of Resident 1's actions and therefore attempts to sleep during the day. Resident 4 stated he spoke to the Administrator regarding this concern. During an interview with the Minimum Data Set Licensed Vocational Nurse (MDS LVN) on 11/12/2020 at 2:42 p.m., MDS LVN stated Resident 1 wears a Wander Guard. MDS LVN stated Wander Guard assessment was done every shift for Resident 1 and this was an active order with care plan in place. During a concurrent interview and record review with MDS LVN, Resident 1's Medication Administration Record [REDACTED]. A review of the facility's policy titled, Wandering and Elopements, undated, indicated the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintain the least restrictive environment for residents. The policy indicated if identified at risk for wandering, elopement, other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on interview and record review, the facility failed to notify the physician when one of two sampled residents (Resident 1) developed fever (elevated body temperature), as indicated in the facility's policy and plan of care. On [DATE] at 1:28 p.m., Resident 1 developed a fever of 100.5 degrees Fahrenheit (°F - normal range from 97 °F to 99 °F) and the change of condition was not reported to Resident 1's attending physician for medical interventions, including finding out the source of the fever (possible infection) through laboratory tests, frequent checks of the resident's temperature, pharmaceutical and non-pharmaceutical interventions. As a result, on [DATE], at 9:29 a.m., Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where he was found with an elevated body temperature of 106.3 °F and hemodynamically unstable (abnormal or unstable blood pressure, which can cause inadequate blood flow to organs). Resident 1 expired on [DATE] at 11:23 p.m. Cross Reference: F755 Findings: A review of Resident 1's Admission Record (Face Sheet) indicated a readmitted d on [DATE] with [DIAGNOSES REDACTED]. vessel) with left [MEDICAL CONDITION] (weakness on one side of the body). A review of Resident 1's physician's orders [REDACTED]. A review of the Care Plan developed on [DATE] indicated Resident 1 had a risk of dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake). The care plan interventions included to observe for contributing factors (such as elevated temperature (fever)) and notify the physician as needed. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated [DATE], indicated Resident 1's cognition (mental processes involved in gaining knowledge and comprehension) was moderately impaired (decision poor, supervision required). Resident 1 needed limited assistance with one-person physical assist with activities of daily living (ADLs - such as transfers, toileting, and personal hygiene). A review of Resident 1's physician's orders [REDACTED].°F, and to notify the physician. A review of the facility's contact line listing (surveillance, tracing of an infection) for COVID-19 (Coronavirus disease 2019, a highly contagious [MEDICAL CONDITION] infection that is spread from person-to-person causing respiratory complications requiring in many cases hospitalization and may result in death) dated [DATE], indicated Resident 1 was tested for COVID-19. A review of Resident 1's Change of Condition/SBAR (Situation - Background - Assessment - Recommendation) form dated [DATE] indicated Resident 1's temperature was 98.8 °F, the blood pressure at ,[DATE] millimeters of mercury (mmHg - unit of measure , the normal adult blood pressure is below ,[DATE] mmHg), and had pain but was unable to rate the pain. A review of Resident 1's Vital Signs log (measurement of the body's most basic functions such as respiratory and cardiac rate, blood pressure, and body temperature) indicated that on [DATE] at 1:28 p.m., Resident 1's temperature was 100.5 °F, on [DATE] at 9 p.m., the temperature was 99.2 °F, on [DATE] at 8:22 a.m., the temperature was 104 °F. A review of Resident 1's COVID-19 test result dated [DATE] indicated Resident 1 was positive for COVID-19. A review of Resident 1's Medication Administration Record [REDACTED]. A review of Resident 1's medical record indicated no change of condition was conducted on [DATE] after the elevated temperature were identified. There was no documentation the physician was informed. A review of Resident 1's Change of Condition / SBAR form dated [DATE] indicated Resident 1 had a body temperature of 104 °F, was shaking and was possibly having [MEDICAL CONDITION]. Resident 1 was transferred to GACH 1 for high body temperature of 104 °F. A review of Resident 1's Nursing Notes dated [DATE] indicated Resident 1 was transferred to GACH 1 for high temperature, altered mental status and shortness of breath via paramedics (emergency medical team). A review of the Paramedics' Report dated [DATE], indicated Resident 1 was lying in bed shaking and able to follow commands. Facility staff stated (to paramedics) Resident 1 had a fever and was shaking all morning. The resident was not given any medication for fever. Resident 1 was transported to the GACH 1 at 9:29 a.m. for fever. A review of GACH 1's Emergency Department (ED) Documentation dated [DATE], indicated Resident 1 arrived at the ED from the facility with reports of chills starting Friday ([DATE]), with a high fever of 106.3 °F, and was hemodynamically unstable requiring vasopressors (medicines that constrict (narrow) blood vessels, increasing the blood pressure. They are used in the treatment of [REDACTED]. Resident 1 was hypotensive (low blood pressure), hypoxic (deprived of adequate oxygen supply) and was intubated (a tube is inserted into the windpipe (trachea) for ventilation (breathing) and airway protection). Resident 1 had a heart rate of 110 beats per minute, respiration rate of 18 breaths per minute, blood pressure of ,[DATE] mmHg. Resident 1was admitted to the cardiac care unit for further management. A review of GACH 1 Death Summary indicated Resident 1 was febrile (with fever) 101.7 °F, maxed (revceived maximum number) on four vasopressors, increasing blood pressure. Resident 1 with no urine elimination (anuria), worsening acidosis (buildup of acid in the bloodstream due to kidneys and lungs failure). Resident 1 was extubated (the tube to the airway was removed) on [DATE] and was placed on comfort care measures. Resident 1 expired on [DATE] at 11:23 p.m. During an interview on [DATE] at 3:45 p.m., the Director of Nursing (DON) stated Resident 1 had a body temperature of 100.5 °F on [DATE] and confirmed the physician was not notified and Resident 1 was not given medication for fever and no other interventions such as cooling measures were provided. During an interview on [DATE] at 7:30 a.m., LVN 3 stated she was taking care of Resident 1 on [DATE]. LVN 3 stated she was not informed of Resident 1's temperature of 100.5 °F on [DATE]. LVN 3 stated she did not give [MEDICATION NAME] to Resident 1 or notified the physician because she did not know Resident 1's temperature was 100.5 °F. On [DATE] at 3:15 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated on [DATE], she took Resident 1's temperature at around 1:30 p.m. and it was 100.5 °F. CNA 1 stated she informed Registered Nurse 1 (RN 1) and RN 1 told her he would take care of it. On [DATE] at 2 p.m., during an interview, RN 1 stated he was the RN Supervisor on [DATE] morning shift (7 a.m. to 3 p.m.) and CNA 1 did not inform him of Resident 1's elevated temperature. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, revised on [DATE], indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting), or impacts more than one area of the resident's health status. The nurse will record in the resident's medical record information relative to changes in the resident's medica/mental condition or status.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and modify interventions when necessary for one of three sampled residents (Resident 5). For Resident 5, who was assessed as requiring extensive assistance for transfer, the certified nurse assistant 3 (CNA 3) solely transferred Resident 5 to the wheelchair causing pain to the resident's shoulder and the facility failed to develop a resident specific care plan to address the resident's identified risk in mobility. This deficient practice resulted in Resident 5 sustaining a [MEDICAL CONDITION] humerus neck (broken shoulder), experiencing pain, and required acute care hospital visit. Findings: A review of the Face Sheet indicated Resident 5, [AGE] years of age, was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 12/5/17, indicated Resident 5's Brief Interview for Mental Status (BIMS) was three, which indicated severe cognitive impairment. The MDS indicated the resident required extensive assistance from two or more persons physical assist for transfer to or from bed, chair, wheelchair, and standing position. A review of Resident 5's care plan initiated 5/11/17 and revised on 12/11/17, titled, Self Care Deficit indicated the goal was for the resident to be out of bed daily. A care plan intervention included to assist the resident with transfers and mobility as needed (PRN). According to a review of Resident 5's care plan initiated 6/14/17 and revised on 12/11/17, titled, At Risk for Complications due to Alteration in Musculoskeletal status indicated the goal was for the resident to achieve highest level of mobility possible daily. The care plan intervention indicated to anticipate and meet the resident's needs and to assess resident for pain. A review of the care plan initiated 6/14/17, titled, Further decline in functional mobility indicated the goal was Resident 5's discomfort would remain at an acceptable level to the resident through the review date. The care plan intervention indicated to avoid pulling / pushing extremities, educate the resident and care givers on joint conservation techniques, and to handle resident gently during care. A review Resident 5's Progress Notes, dated 12/14/17, indicated at 9:45 a.m., CNA 3 called Licensed Vocation Nurse 1 (LVN 1) into Resident 5's room. LVN 1 saw Resident 5 in the wheel chair and complained of pain on the left arm and shoulder. The note indicated the resident stated she hurt her hand while being transferred from a shower chair to a wheel chair, but was unable to explain in detail what had happened. The resident was medicated with Tylenol two tablets for pain rated 5 out of 10 (10 being the worst possible pain). According to the note, CNA 3 indicated the resident was being transferred from a shower chair to a wheelchair via a stand-up machine, but the machine stopped working during the process of transferring. Restorative Nursing Assistant 1 (RNA 1) and CNA 3 helped Resident 5 from the stand-up machine to the wheelchair. A review of Resident 5's Progress Notes, dated 12/14/17, at 2 p.m., indicated Resident 5 was noted with purple discoloration on the first three fingers of left hand. A review of Resident 5's Progress Notes (discharge summary), dated 12/15/17, at 11:30 a.m. indicated X-ray results revealed a fracture with left humeral neck (broken left shoulder). The notes indicated the doctor was called and ordered to transfer Resident 5 to an acute care hospital. During an interview, on 12/29/17, at 2:50 p.m., Registered Nurse 1 (RN 1) stated CNA 3 was transferring Resident 5 from the shower chair to a wheelchair using an EZ lift machine (stand-up machine) and the machine stopped after lifting Resident 5 up, CNA 3 then called RNA 1 for help to get Resident 5 to wheelchair. RN 1 stated the resident complained of pain to her shoulder after being placed in wheelchair. RN 1 stated an X-ray was ordered and revealed a fracture to the left shoulder. RN 1 stated both CNA 3 and RNA 1 were terminated. On 12/29/17, at 3:30 p.m., during an interview with CNA 4, she stated she received in-service about how to operate the machine and was instructed to have two staff when transferring a resident with the stand-up machine. During an interview, on 1/17/18, at 3:45 p.m., Visitor 1 stated the same incident happened once before in (MONTH) (YEAR) with Resident 5, that the stand-up machine stopped working after Resident 5 was being lifted. A review of the facility's policy and procedure (undated) titled, Safe Lifting and Movement of Residents, indicated this facility used appropriate techniques and devices to lift and move residents. the policy indicated resident safety would be incorporated into goals and decisions regarding the safe lifting and moving of residents.

Based on interview and record review, the facility failed to ensure a resident fed by a gastrostomy tube (GT - a tube surgically inserted into the stomach through the skin and the stomach wall to provide nutrition and medication) received appropriate treatment when the GT was pulled out for Resident 1. Resident 1 had a GT surgically placed for the first time on [DATE], at a general acute care hospital (GACH 1) but on [DATE], at 6:15 a.m., 10 days after the procedure, the GT became dislodged and Registered Nurse 1 (RN 1) inserted a new GT without a physician's order and against the facility's policy and procedure. By 7 a.m., RN 1 resumed the feeding through the GT. On the same day, around 2 p.m., when the resident arrived to an outpatient [MEDICAL TREATMENT] center for his routine [MEDICAL TREATMENT] treatment, was noted with altered level of consciousness and the resident was transferred to GACH 2 via paramedic. The resident was found to have the GT tip outside the stomach, developed peritonitis (inflammation of the membrane which lines the inside of the abdomen and all of the internal organs), intra-abdominal abscess (collection of pus) [MEDICAL CONDITION] (potentially life-threatening complication of an infection). On [DATE], Resident 1 required an exploratory laparotomy (surgical incision into the abdominal cavity through the flank or, more generally, through any part of the abdominal wall), replacement of the GT and drainage of the fluid/abscess collection. On [DATE], Resident 1 required a computed tomography (CT) guided peritoneal abscess drainage followed by a wound VAC (vacuum assisted closure -VAC negative pressure wound therapy). On [DATE], GACH 2 transferred the resident to another skilled nursing facility for continued care with intravenous (IV) antibiotic and wound VAC; however, upon arrival to the facility the resident was transferred via paramedics to GACH 3 due to shortness of breath, where Resident 1 expired on [DATE]. Findings: On [DATE], at 8:15 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1's GT that was pulled out on [DATE], and replaced in order to complete the feeding. On the same day while at [MEDICAL TREATMENT], Resident 1 became less responsive and was transferred to a GACH. On [DATE], a review of Resident 1's clinical record revealed the resident was initially admitted to the facility from GACH 1 on [DATE], with [DIAGNOSES REDACTED]. According to the clinical record from the transferring hospital (GACH 1) where the resident stayed from [DATE] to [DATE], the resident underwent [REDACTED]. The Minimum Data Set (MDS - a standardized assessment and care planning tool) dated [DATE], indicated the resident was severely impaired in his cognitive skills (never/rarely made decisions), had communication deficit, required extensive to total assistance with all of his activities of daily living (ADLs)and received nutrition only through the GT. Upon admission on [DATE], the attending physician ordered the feeding formula [MEDICATION NAME] Renal at 75 cubic centimeters (cc) per hour to provide 1200 cc, 1200 kilocalories (kcal) in 16 hours per day, by the way of a feeding pump. The physician ordered to flush the GT with 370 cc of water every shift. All medications were ordered to be administered through the GT. The physician also ordered [MEDICAL TREATMENT] treatment three times a week, on Tuesdays, Thursdays and Saturdays, at an outpatient [MEDICAL TREATMENT] center beginning at 4:30 p.m. The physician's orders did not include orders to reinsert/replace the GT if pulled out or became dislodged. According to the 11 p.m. to 7 a.m. shift nursing note and a Change of Condition Assessment form dated [DATE], RN 1 documented the resident's GT was pulled out, found on the floor at 6:15 a.m. and the GT site was slightly bleeding. The GT was reinserted, the resident tolerated the procedure, a dressing was applied, the GT was patent and the feeding was resumed. RN 1 further documented he called the attending physician at 6:45 a.m. and left a message. According to the nursing nurse, on [DATE], timed at 3 p.m., the resident went to [MEDICAL TREATMENT] in stable condition. The nursing note entry dated [DATE], timed at 3:20 p.m., indicated the [MEDICAL TREATMENT] center transferred the resident to a hospital (GACH 2) due to unresponsiveness. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. A review of the clinical record from GACH 2 revealed the resident arrived to the emergency department on [DATE], at 2:15 p.m., with altered mental status. On the same day, an x-ray result shows right lower low pneumonia. On [DATE], a CT - radiologic study of the abdomen and pelvis with contrast indicated the GT was outside of the antrum (initial portion) of the stomach and there was some small loculated (divided into small cavities or compartments) fluid collections near the tip of the GT and multiple small pockets of free intraperitoneal (within the peritoneal cavity) gas. On the same day, [DATE], due to peritonitis and dislodgement of the GT, the resident underwent [REDACTED]. On [DATE], due to continued intraperitoneal fluid collection and the resident not being a candidate for another laparotomy, he underwent a CT-guided fluid and peritoneal abscess drainage followed by a wound VAC (the edges of the wound are made airtight with foam and a dressing, and a tube is placed in the wound, connecting to a canister that creates a vacuum. Infectious materials and other fluids are then sucked out of the wound). On [DATE], the resident was transferred to another skilled nursing facility for continued care with IV antibiotics and wound VAC. A review of the receiving skilled nursing facility documentation revealed the resident was unable to be admitted to the facility on [DATE], because he arrived in an unstable condition. Paramedics were required to transfer the resident to a nearby hospital (GACH 3) due to shortness of breath where the resident expired on [DATE]. According to the Certificate of Death, the date of death was [DATE], at 1:55 p.m., with the cause of death indicating cardiopulmonary arrest,[MEDICAL CONDITION] and pneumonia. On [DATE] at 11:20 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1), who was the medication nurse on [DATE], 7 a.m. to 3 p.m. shift, stated he gave the resident the medications via GT and he checked the GT for placement and residual. LVN 1 also stated the resident was, "Okay" when he left for [MEDICAL TREATMENT]. On [DATE], at 11:30 a.m., during an interview, RN 1 confirmed he replaced the resident's GT using a house supplied GT (Corflo brand) size 16 French to prevent closing of the stoma. RN 1 stated, "He checked patency and air and was okay." RN 1 also indicated there was no problem with the GT placement. RN 1 further stated he called the physician and left a message, however, the physician did not return the call. A review of the personnel file revealed RN 1 was hired on [DATE], with the last enteral feeding competency check done on [DATE]. According to the facility's policy and procedure on Gastrointestinal Tube Change and Reinsertion dated ,[DATE], gastrointestinal tubes will be changed/reinserted, per physician's order, in residents with established tracks in order to maintain patency for nutritional maintenance. The procedures indicated to obtain a physician's order. The policy further noted that it was recommended that a new GT (less than four weeks old) not to be reinserted by facility licensed nurses. PEG tubes should not be removed/replaced by a licensed nurse at the facility. Citation # [DATE]-F 483.25(g)(2)(A) A resident who is fed by a naso-[MEDICAL CONDITION] or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, it possible, normal eating skills.On [DATE], at 8:15 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1's gastrostomy tube (GT - a tube surgically inserted into the stomach through the skin and the stomach wall to provide nutrition and medication) that was pulled out on [DATE], and replaced in order to complete the feeding. On the same day while at the [MEDICAL TREATMENT] center, Resident 1 became less responsive and was transferred to a general acute care hospital (GACH). Based on interview and record review, the facility failed to ensure Resident 1, who was fed by a GT which had been inserted for the first time on [DATE], received the appropriate treatment and services to prevent complications by failing to:Implement the facility ' s policy and procedure that indicated to insert the GT only as per physician ' s order, not to reinsert a new GT (less than four weeks old) and not to replace a PEG (percutaneous (procedure performed through the skin) endoscopic gastrostomy) tube. On [DATE], at 6:15 a.m., after the resident ' s GT was pulled out and 10 days after the GT surgical insertion, Registered Nurse 1 (RN 1), without a physician ' s order, reinserted a new GT and resumed the feeding formula. On the same day, around 2 p.m., the resident developed an altered level of consciousness and required transfer to GACH 2 via paramedics. The resident was found to have the GT tip outside the stomach, developed peritonitis (inflammation of the membrane which lines the inside of the abdomen and all of the internal organs), had an intra-abdominal abscess (collection of pus) [MEDICAL CONDITION] (potentially life-threatening complication of an infection). The resident remained in GACH 2 until [DATE], where he twice required drainage of abdominal abscess. On [DATE], the resident was transferred to a skilled nursing facility; however, he could not be admitted because he was short of breath upon arrival. Paramedics then transferred the resident to GACH 2 where he expired on [DATE]. On [DATE], a review of Resident 1's clinical record revealed the resident was initially admitted to the facility from GACH 1 on [DATE], with [DIAGNOSES REDACTED].According to the clinical record from the transferring hospital (GACH 1), where the resident stayed from [DATE] to [DATE], the resident required on [DATE], a placement of a PEG tube due to difficulty with swallowing. The Minimum Data Set (MDS - a standardized assessment and care planning tool) dated [DATE], indicated the resident was severely impaired in his cognitive skills (never/rarely made decisions), had communication deficit, required extensive to total assistance with all of his activities of daily living and received nutrition only through the GT. Upon admission on [DATE], the attending physician ordered the feeding formula [MEDICATION NAME] Renal at 75 cubic centimeters (cc) per hour to provide 1200 cc, 1200 kilocalories (kcal) in 16 hours per day, by the way of a feeding pump. The physician ordered to flush the GT with 370 cc of water every six hours. All medications were ordered to be administered through the GT.The physician also ordered [MEDICAL TREATMENT] treatment three times a week, on Tuesdays, Thursdays and Saturdays, at an outpatient [MEDICAL TREATMENT] center beginning at 4:30 p.m. The physician's order did not include orders to reinsert or replace the GT if it was pulled out or became dislodged.According to the 11 p.m. to 7 a.m. shift nursing note and a Change of Condition Assessment form dated [DATE], RN 1 documented the resident's GT was pulled out, found on the floor at 6:15 a.m. and the GT site was slightly bleeding. The GT was reinserted, the resident tolerated the procedure, a dressing was applied, the GT was patent and the feeding was resumed. RN 1 further documented he called the attending physician at 6:45 a.m. and left a message. According to the nursing note, on [DATE], timed at 3 p.m., the resident went to [MEDICAL TREATMENT] in stable condition.The nursing note entry dated [DATE], timed at 3:20 p.m., indicated the [MEDICAL TREATMENT] center transferred the resident to a hospital (GACH 2) due to unresponsiveness.A review of the clinical record from GACH 2 revealed the resident arrived to the emergency department on [DATE], at 2:15 p.m., with altered mental status. At the same time, the x-ray result shows right lower lobe pneumonia. On [DATE], a computed tomography (CT) of the abdomen and pelvis with contrast indicated the GT was outside of the antrum (initial portion) of the stomach. There was some small loculated (divided into small cavities or compartments) fluid collections near the tip of the GT and multiple small pockets of free intraperitoneal (within the peritoneal cavity) gas. On the same day, due to peritonitis and dislodgement of the GT, the resident underwent [REDACTED]. He required drainage of intraperitoneal abscess and tube feeds, a gastrorrhaphy (suture of the stomach) and a new GT.On [DATE], due to continued intraperitoneal fluid collection and the resident not being a candidate for another laparotomy, he underwent a CT-guided fluid and peritoneal abscess drainage followed by a wound VAC (vacuum assisted closure). The edges of the wound are made airtight with foam and a dressing, and a tube attached to a vacuum is placed in the wound. Infectious materials and other fluids are then sucked out of the wound.On [DATE], the resident was transferred to another skilled nursing facility for continued care with IV antibiotics and wound VAC. A review of the receiving skilled nursing facility documentation revealed the resident was unable to be admitted to the facility on [DATE], because he arrived in an unstable condition. Paramedics were required to transfer the resident to a nearby hospital (GACH 3) due to shortness of breath where the resident expired on [DATE]. According to the Certificate of Death, the resident expired on [DATE], at 1:55 p.m., with the cause of death indicating cardiopulmonary arrest,[MEDICAL CONDITION] and pneumonia.On [DATE] at 11:20 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1), who was the medication nurse on [DATE], 7 a.m. to 3 p.m. shift, stated he gave the resident the medications via GT and he checked the GT for placement and residual. LVN 1 also stated the resident was, "Okay", when he left for [MEDICAL TREATMENT].On [DATE], at 11:30 a.m., during an interview, RN 1 confirmed he replaced the resident's GT using a house supplied GT (Corflo brand) size 16 French to prevent closing of the stoma. RN 1 stated, " He checked patency and air and was okay. " RN 1 also indicated there was no problem with the GT placement. RN 1 further stated he called the physician and left a message, however, the physician did not return the call.A review of the personnel file revealed RN 1 was hired on [DATE], with the last enteral feeding competency check done on [DATE].According to the facility's policy and procedure on Gastrointestinal Tube Change and Reinsertion dated ,[DATE], gastrointestinal tubes will be changed and reinserted, per physician's order, in residents with established tracks in order to maintain patency for nutritional maintenance. The procedures indicated to obtain a physician's order. The policy further noted it was recommended a new GT (less than four weeks old) not to be reinserted by facility licensed nurses and PEG tubes should not be removed or replaced by a licensed nurse at the facility. The facility failed to ensure Resident 1, who was fed by a GT which had been inserted for the first time on [DATE], received the appropriate treatment and services to prevent complications by failing to:Implement the facility ' s policy and procedure that indicated to insert the GT only as per physician ' s order, not to reinsert a new GT (less than four weeks old) and not to replace a PEG (percutaneous (procedure performed through the skin) endoscopic gastrostomy) tube. On [DATE], at 6:15 a.m., after the resident ' s GT was pulled out and 10 days after the GT surgical insertion, Registered Nurse 1 (RN 1), without a physician ' s order, reinserted a new GT and resumed the feeding formula. On the same day, around 2 p.m., the resident developed an altered level of consciousness and required transfer to GACH 2 via paramedics. The resident was found to have the GT tip outside the stomach, developed peritonitis (inflammation of the membrane which lines the inside of the abdomen and all of the internal organs), had an intra-abdominal abscess (collection of pus) [MEDICAL CONDITION] (potentially life-threatening complication of an infection). The resident remained in GACH 2 until [DATE], where he twice required drainage of abdominal abscess. On [DATE], the resident was transferred to a skilled nursing facility; however, he could not be admitted because he was short of breath upon arrival. Paramedics then transferred the resident to GACH 2 where he expired on [DATE].The above violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.