Every finding on record at Valley Healthcare Center

Based on interview and record review, the facility failed to:Follow their policy and procedure (P&P) titled, WanderGaurd [sic](device used as safety protocol used to assist staff in monitoring people at risk for wandering near exits) Policy and Procedure for one of three sampled residents (Resident 1) when Respiratory Therapist (RT) responded to Resident 1's wanderguard alarm but did not check outside the surrounding area to ensure Resident 1 did not exit the facility premises.Ensure the every 30-minute monitoring log were completed for one of three sampled residents (Resident 1) with a history of elopement (occurs when a resident leaves the facility without authorization and/or any necessary supervision).These failures resulted in Resident 1 leaving the facility unaccompanied, missing for approximately 15 hours, exposing Resident 1 to environmental dangers, and was found by the police department approximately 0.9 miles from the facility, lying on the ground deceased .Findings:During a review of the admission Record (AR), the AR indicated Resident 1 was [AGE] year-old, was admitted to the facility on [DATE] with diagnosis of muscle weakness, lack of coordination, unsteadiness on feet, difficulty in walking, Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities).During a review of the facility's 5-day Report Investigation (RI) dated [DATE], the RI indicated, Resident 1 Elopement [DATE] 10:22 am per tv recording. reached up and turned the wander guard alarm off; immediately went out the door. (Resident 1) went directly to the locked gate and was able to open it and relocked the gate. When noted, missing 12 noon. (Resident 1) was found by the bpd (Police Department) . at 1:00 am [DATE].currently awaiting the coroner's report for reason of death.During a review of the annual Minimum Data Set (MDS-resident assessment tool) dated [DATE], the MDS indicated Resident 1 had a BIMS (brief interview for mental status-cognitive screening) Summary Score of 9 (score of 8-12 means moderate impairment) and functional abilities: no functional limitations in upper and lower extremity range of motion, uses wheelchair for mobility.During a review of Resident 1's annual WANDERING RISK SCALE (WRS) assessment, dated [DATE], the assessment indicated Resident 1 cannot follow instructions, has a history of wandering, diagnosis of dementia, and has wandered in the past month. Resident 1's assessment score13 (11 - above Hight Risk to Wander).During a review of Resident 1's Progress Notes PN, dated [DATE] (first elopement), the PN indicated, At routine rounds, resident (Resident 1) was noted to be absent from assigned location. The resident's (Resident 1) WanderGuard device was discovered at bedside, indicating the resident had exited without tracking device in place. The PN dated [DATE] (second elopement attempt) indicated, Resident 1 was seen leaving the facility. The PN dated [DATE] (third elopement attempt) indicated Front office staff noted alarm in the front going off. Resident (Resident 1) was walking his wheelchair out the door.During a review of Resident 1's Progress Notes (PN), dated [DATE] at 2:46 p.m., the PN indicated, 12 noon >[sic] visual monitoring check resident (Resident 1) not in his room or activities. This nurse check back patio, his bathroom and other places he usually goes. Code green (a facility response process to make staff aware of a missing resident) activated to check every room in the Facility. Police was phoned.During a review of Resident 1's PN, dated [DATE] at 6:55 p.m. the PN indicated, Resident still not at the facility, contacts on file called. who stated none of the family members have any information about him. All ERs (emergency room) were called and was not found in of [sic] of them.During a review of Resident 1's PN, dated [DATE] at 4 a.m., the PN indicated, Received call from (police department) around 0105 (1:05 a.m.), (police department) stated that they have found (Resident 1) deceased . Per (police department). 'Looks like he just layed [sic] down and passed away' (police department) stated they called here because Resident (1) had a wrist bracelet with our information on it.1.During an interview on [DATE] at 12:45 p.m. with Administrator, Administrator stated on [DATE] at 10:22 a.m., Resident 1 was seen on the facility surveillance camera of the front lobby leaving the facility. Administrator stated Resident 1 turned off the main entrance wanderguard alarm system, opened the front door, exited in his wheelchair, opened the outdoor gate, and left the facility perimeter unaccompanied. Administrator stated Resident 1 was found deceased by the police department on [DATE] at 1 a.m. (approximately 15 hours after Resident 1 left the facility) approximately 0.9 miles from the facility. During an interview on [DATE] at 1:39 p.m. with Administrator, Administrator stated on [DATE] at 10:22 a.m. Administrator stated RT was seen in the facility surveillance camera responding to the wanderguard alarm system. Administrator stated RT was seen walking to the front lobby and turning off the wanderguard alarm system. Administrator stated RT did not go outside the facility to look around to ensure no residents had exited the premises. Administrator stated when the wanderguard alarm system goes off, it was the staff responsibility to turned off the alarm system and look in the surrounding area including outside to look to see if there is any resident around. make sure they [residents] didn't go out.During an interview on [DATE] at 2:06 p.m. with RT, RT stated on [DATE] at approximately 10:30 a.m. he heard an alarm going off in the front lobby. RT stated he went to the front lobby, did not see any residents, turned off the alarm, and resumed working. RT stated he thought the alarm malfunctioned since there were no residents in the front lobby. RT stated he did not go outside to check the surrounding area to ensure no residents had already left the facility.During an interview on [DATE] at 2:26 p.m. with Certified Nursing Assistant (CNA 2), CNA 2 stated on [DATE] between 10 a.m. to 10:30 a.m. she was busy and did not hear the wanderguard alarm system go off. CNA 2 stated when responding to the alarm system, it was the responsibility of the staff to check all exit doors including checking outside the facility to make sure there is no one outside.During an interview on [DATE] at 2:44 p.m. with CNA 4, CNA 4 stated on [DATE] between 10 a.m. to 10:30 a.m. while she was in the shower room, she heard the wanderguard alarm system go off but was busy giving showers and did not respond to the alarm. CNA 4 stated when responding to the alarm system, it was important to check all surroundings including outside to ensure no residents had left the facility.During a review of the facility P&P titled, WanderGaurd [sic] Policy and Procedure adopted date [DATE], the P&P indicated, 3. Alarm Testing and response. Alarm Response: If the alarm sounds, staff immediately stop what they are doing and check to doors to ensure the residents have not left the safe area.2. During a review of Resident 1's Care Plan (CP) , dated [DATE], the CP indicated, (Resident 1) is at high risk for further attempts to wander/elope out of facility AEB(as evidenced by): Ambulates independently, exit seeking behaviors, propels wheelchair independently, verbalizes desire to leave the facility, episodes of wandering out off facility/elopement. Interventions dated [DATE] included: Frequent monitoring and diversion from exits.Provide consistent reminders to the resident that he/she needs to stay in the facility unless they are accompanied by a staff or family members. Revised intervention dated [DATE] included: Monitor resident's whereabouts q (every) 30 minutes.During a record review of Resident 1's 30 MINUTES MONITORING Log, dated [DATE] through [DATE], the log indicated the following: On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: room, dining room, back patio, sleeping in room, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: room, hallway, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: hallway, back patio, backyard, sleeping in room, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: hallway, dining room, back patio, restroom, and sleeping in room, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: activities, dining, hallway, in room, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: hallway, in room, in bed, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: hallway, backyard, dining area, sleeping in room, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: dining, used restroom, in room, sleeping in bed, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: room, dining area, backyard patio, sleeping in room, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: hallway, backyard, dining room, and sleeping in room, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: in room, dining, in hallway, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: dining, hallway, back patio, sleeping in room, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: backyard, dining, hallway, sleeping in bed, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: hallway, dining hall, back patio, sleeping in bed, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: hallway, eating dinner in dining, watching tv in dining, back patio, sleeping in bed, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: outside, dining room dinner, in room, however CNAs did not document the times the observations were made.On [DATE] Night shift between 10:30 p.m. to 6 a.m. CNAS documented Resident 1's whereabouts, however no CNA signature was documented.On [DATE] Night shift between 10:30 p.m. to 6 a.m. CNAS documented Resident 1's whereabouts, however no CNA signature was documented.On [DATE] Night shift between 10:30 p.m. to 6 a.m. CNAS documented Resident 1's whereabouts, however no CNA signature was documented.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: hallway, back patio, watching tv, dining area, sleeping room, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs were documenting Resident 1 was in the following areas: hallway, dining area, back patio, sleeping in bed, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: hallway, dining area, watching tv, back patio, sleeping room, however CNAs did not document the times the observations were made.On [DATE] PM shift between 2:30 p.m. to 11 p.m. CNAs documented Resident 1 was in the following areas: hallway, dining area, back patio, talking to roommates, sleeping in room, however CNAs did not document the times the observations were made.On [DATE] Night shift between 10:30 p.m. to 6 a.m. CNAs did not document Resident 1's whereabouts.On [DATE] AM shift between 6:30 a.m. to 2 p.m. CNA (CNA 1) documented at 9:30 a.m. Resident 1 was last seen in bedroom. No additional documentation on Resident 1's whereabouts after [DATE] at 9:30 a.m.During a concurrent interview and record review on [DATE] at 10:33 a.m. with Director of Nurses (DON), Resident 1's CP was reviewed. DON stated Resident 1 has a history of elopement. DON stated Resident 1 had first eloped on [DATE] (was missing for approximately 8 hours) and attempted to elope on [DATE] and [DATE]. On [DATE] Resident 1 was reassessed for WRS. DON stated Resident 1 remained a high risk for elopement and remained on every 30 minutes monitoring.During a concurrent interview and record review on [DATE] at 4 p.m. with DON, Resident 1's every 30 minutes monitoring log was reviewed from [DATE] through [DATE]. DON confirmed the 30 minutes monitoring log had missing documentation including, time, Resident 1's whereabouts and CNA signatures. DON stated Resident 1's whereabouts should have been monitored every 30 minutes, and the log should have been completed including time, and staff signatures.During an interview on [DATE] at 2:33 p.m. with CNA 3, CNA 3 stated Resident 1 was able to communicate his needs. CNA 3 stated Resident 1 was on every 30 minutes monitoring because He (Resident 1) tries to leave all the time. Sometimes he goes to the door, he has stuff packed and he tries to leave.During an interview on [DATE] at 3 p.m. with CNA 5, CNA 5 stated Resident 1 was high risk for elopement and required every 30 monitoring. CNA 5 stated, We keep an eye on him because he tries to leave.During an interview on [DATE] at 3:34 p.m. with CNA 1, CNA 1 stated she was assigned to Resident 1 on [DATE] on the day Resident 1 went missing. CNA 1 stated Resident 1 was on every 30 minutes monitoring due to he always tries to leave. CNA 1 stated she last documented seeing Resident 1 in his bedroom at 9:30 a.m. CNA 1 stated at 11 a.m. she was passing lunch tray, got to Resident 1's room and noted Resident 1 was not in his room. CNA 1 stated she did not see or document Resident 1's whereabouts at 10 a.m. or 10:30 a.m. During a review of The Weather Channel's monthly weather (TWCMW), dated [DATE], the TWCMW indicated the highest temperature on [DATE] was 101 degrees Fahrenheit (F), and lowest 75 degrees F.During a review of the Police report dated [DATE] at 3:17 p.m., the report indicated, On Saturday, [DATE].at approximately 12 p.m. (Resident 1 name) left the facility and went missing. On Sunday, [DATE], at approximately 12:38 a.m. (officer name) responded.at the top of the bridge on the east side of the roadway, for a man down. During a review of Resident 1's Death Certificate dated [DATE], the certificate indicated Resident 1's probable cause of death was Myocardial Infarction (heart attack-happens when blood flow to the heart drops or stops).During a review of the facility's policy and procedure (P&P) titled, Wandering & Elopement, dated11/17, the P&P indicated, The Facility will identify residents at risk for elopement and minimize any possible injury because of elopement.During a review of the facility's P &P titled, Elopement Risk Reduction Approaches, dated 11/17, the P&P indicated, I. Planning. D. Ensure that residents are able to move about freely, are monitored and remain safe.During a review of the facility's P&P titled, Care Planning, dated [DATE], the P&P indicated, II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representatives), resident's Attending Physician, and IDT work to help the resident move toward resident specific goals that address the resident's medical, nursing, mental and psychological needs. A comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychological needs.

Based on observation, interview, and record review, the facility failed to provide a safe environment for two of three sampled residents with high risk for elopement (Resident 2 and Resident 3) when the south hallway alarm was not activated. This failure had the potential for Resident 2 and Resident 3 to elope.During an observation and interview on 7/6/25 at 1:54 p.m. with Licensed Vocational Nurse (LVN) in the facility's south hallway, the exit alarm did not alarmed when door was opened. LVN stated the exit alarm can only be turned off by a key and should be on at all times.During an interview on 7/6/26 at 2:40 p.m. with Administrator (Admin), Admin stated the exit door alarms should not be turned off.During an interview on 7/14/26 at 1:53 p.m. with Central Supply (CS), CS stated she disarms the exit alarm when she goes outside. CS stated she disarmed it on 7/6/26.During a review of the facility's P&P titled, Safety Committee - Composition and Duties, dated 11/1/17, the P&P indicated, Purpose To promote the quality of resident care and safety by monitoring safety practices. Procedure. Duties and Responsibilities may consist of, but are not limited to the following. B. Maintain Facility grounds in a manner to allow for the safety of residents. Identify unsafe work practices. G. Ensure that appropriate safety equipment and protective equipment is on hand and used as instructed.

Based on observation, interview, and record review the facility failed to ensure physician orders (PO) were followed for one of three sampled Residents (Resident 2) when Resident 2's Wanderguard band (system designed to help alert staff when residents wearing Wanderguard band are trying to exit facility) was used against manufactures instructions for proper usage. This failure had the potential for Resident 2 to leave the facility without staff being aware. During an observation on 7/6/26 at 2:14 p.m. in Resident 2's room. Resident 2 had the wanderguard wristband on her right ankle. During a review of Resident 2's PO, dated 11/4/25, the PO indicated, MONITOR PLACEMENT OF WANDEGURARD (RIGHT WRIST) QSHIFT (every shift). During a concurrent interview and record reviewed on 7/14/26 at 2:08 p.m. with Director of Nursing (DON), the Wanderguard Manufacture Instructions (WMI) were reviewed. The WMI indicated, Placement. Your Resident Wristband Transmitter may be placed on resident in several ways. Some key points to remember when placing wristband are: Place wristband wrist height, approximately three (3) feet off the ground. DON stated she is not sure why it was moved to Resident 2's ankle. DON stated it is important to follow manufacturer's instructions. DON reviewed Resident 1's and confirmed the wanderguard should be placed on Resident 1's right wrist. During a review of the facility's P&P titled, Physician Orders, dated 5/1/19, the P&P indicated, Purpose This will ensure that all physician orders are complete and accurate. Procedure. VIII. Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order.

Based on observation, interview, and record review, the facility failed to accurately assess, develop, and implement interventions as well as implement the facility's policy and procedures (P&P) for one of 22 Residents (Resident 3) when: Resident 3 had nine falls with injuries between admission date (9/5/25) to hospitalization (12/1/25). These failures resulted in Resident 3 having two hospitalizations (11/3/25 & 12/1/25) with multiple injuries including skin tears, a fracture (broken bone) in the neck of left femur (top part of leg bone is broken), which required surgical intervention, and need for rehabilitation (action of restoring someone to health or normal life through training and therapy after illness).Resident 3 was not accurately assessed for skin conditions based on shower sheets and Braden scale (assess a resident's risk of developing pressure injury/sore/ulcer - [serious wound extending through the skin often presenting as a deep crater]) resulting in a facility acquired stage III pressure injury.Findings: During a review of Resident 3's admission RECORD (AR), dated 1/26/26, the AR indicated, Resident 3 was admitted on [DATE] with diagnosis of muscle weakness, unspecified dementia (relating to the mental processes of thinking, knowing, learning, and understanding), depression, anxiety disorder, lack of coordination and history of falling. During a review of Resident's 3 Brief Interview of Mental Status (BIMS - screening tool to assess cognitive function from scale 0-15 [intact 13-5, moderate 7-12, and severe 0-6]) dated 9/8/25, Resident 3's BIMS score was 6 (severe cognitive decline). During a review of Resident 3's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 9/6/25 the MDS section GG (Resident assessment tool to assess functional abilities and goals) indicated, Resident 3 required: A. Eating - Setup clean-up assistance B. Oral hygiene - Supervision or touching assistance (helper provides verbal cues and/or touching resident to complete activity) C. Toileting hygiene - Partial/moderate assistance (helper does less than half the effort) D. Shower/bathe self - Dependent (helper does all the effort) E. Upper body dressing- Supervision or Touching assistance F. Lower body dressing - Partial/moderate assistance (helper does less than half the effort) G. Put on/taking off footwear-Partial/moderate assistance H. Personal Hygiene - Partial/moderate assistance 1.During an observation on 1/26/26 at 9:23 a.m., in Resident 3's room, Resident 3 was lying flat in bed on a low pressure air mattress (mattress used to prevent wounds), holding two stuff animals, oriented to self, unable to identify how to call for assistance, and confused. During a concurrent interview and record review on 1/29/26 at 2:17 p.m. with Director of Nursing (DON), Resident 3's Interdisciplinary Team [IDT - group of professionals working together to achieve common focused patient goals] Fall, was reviewed. The following IDT dated 9/8/25-12/1/25 indicated: A. The IDT dated 9/8/25 indicated, Resident 3 had a fall on 9/7/25 at midnight. DON stated Resident 3 was found in the bathroom putting her pants back on and laying on the floor. DON stated interventions were to not leave Resident 3 unattended in bathroom and there were no other interventions initiated. B. The IDT dated 9/9/25 indicated, Resident 3 had a fall on 9/8/25 at 7:15 p.m. DON stated Resident 3 had been getting out of bed and fell on her left side. DON stated interventions were to put a fall mat on left side of bed and there were no other interventions initiated. C. The IDT dated 9/11/25 indicated, Resident 3 had a fall on 9/10/25 at 8:10 a.m. DON stated Resident was found in her room, on her bottom on floor to the left side of the bed. DON stated interventions were to replace fall mat was with landing strips (a non slip material on the floor to assist with prevention of the fall) on left side and there were no other interventions initiated. DON stated Resident 3 acquired a skin tear on her left upper arm from the fall. D. The IDT dated 10/7/25 indicated, Resident 3 had a fall on 10/6/25 at 7 a.m. DON stated Resident 3 was found on her bottom in her room. DON stated interventions were to schedule a neurology (specialist of the brain) consult and had an appointment for December but was unable to go. DON stated there were no other interventions for Resident 3's fall. E. The IDT dated 10/8/25 indicated, Resident 3 had a fall on 10/7/25 at 2:20 a.m. DON stated Resident 3 acquired skin tears on her left and right elbow from the fall. DON stated new interventions were to keep overhead light on at all times during the night shift and there were no other interventions initiated. F. The IDT dated 11/3/25 indicated, Resident 3 had a fall on 11/3/25 at 10 a.m. DON stated Resident 3 was in her wheelchair and bent forward and fell to floor near the dining room. DON stated Resident 3 was sent to the emergency department but had no injuries. DON stated interventions were to have orthostatic blood pressures (the measurement of blood pressure [force of blood pushing against the wall of arteries] while sitting, standing and lying) monitoring weekly and there were no other interventions initiated. G. The IDT dated 11/5/25 indicated, Resident 3 had a fall on 11/4/25 at 4:30 a.m. DON stated Resident 3 was found in the hallway outside of her room and found on her knees. DON stated interventions were a referral to a psychiatrist (medical practitioner specializing in the diagnosis of mental illness) to review her medications. DON stated Resident 3 was seen the same day by the psychiatrist with no changes to her medications. DON stated there were no other (new) interventions initiated and nothing was changed regarding Resident 3's falls. H. The IDT dated 11/13/25 indicated, Resident 3 had a fall on 11/12/25 at 4 a.m. DON stated Resident 3 was found on her left side on her bottom, on the floor in her room. DON stated interventions were to place Resident 3 in a room closer to the nurses station and there were no other interventions initiated. I. The IDT dated 12/1/25 indicated, Resident 3 had a fall on 12/1/25 at 4:06 a.m. in Resident 3's room. DON stated Resident 3 had a lot of falls in the previous two months (9), and she did not like that Resident 3 was falling all the time. DON stated she had recommended Resident 3 to have a 1:1 (provides a dedicated staff member dedicated for one resident for complex medical needs) in the past (unspecified dates) to prevent further falls, but it was not approved (did not indicate who declined). There was no new intervention added after this fall. During a concurrent interview and record review on 1/29/26 at 3:10 p.m. with DON, Resident 3's Bowel and Bladder Program Screener (B&B - restorative nursing program designed to improve continence [the ability to control movement of the bowels and bladder] through scheduled toileting), dated 9/5/25 at 6:33 p.m. was reviewed. The B&B indicated, Resident 3 was a good candidate for retraining (learning a skill so job can be done differently). DON stated Resident 3 had a B&B score of 19 which would indicate a need for bowel and bladder training. DON stated a B&B retraining with care plans was not done and they should have been done to address Resident 3's falls. During a review of Resident 3's Change of Condition Evaluation (COC) dated 12/1/25 at 3:31 a.m., the COC indicated, Writer [not identified] was called to residents' [Resident 3] room by aide. Nurse found resident [3] sitting on floor on L [left] side of bed. ROM (range of motion) unable to complete d/t [due to] resident [3] not following instructions. C/o [complained of] hip pain at this time. Resident [3] unable to say why she wanted to get up. During a review of Resident 3's Acute Rehab Facility's admission H&P (AH&P-History and Physical), dated 12/6/25, the AH&P indicated, Resident 3 was female with medical history of. anxiety disorder, major depressive disorder. dementia, and wheelchair-bound over the past several months due to imbalance. The [Resident 3] is currently living at [Skilled Nursing Facility (SNF)] for the last four months. The [Resident 3] arrived to [Acute Hospital] after sustaining a ground-level fall. ED [emergency department] work up revealed a left femoral [thigh] fracture. The [Resident 3] is alert and oriented to name and DOB [DATE of birth ] . On 12/2/25, the patient underwent open reduction and internal fixation [surgical procedure used to treat severe, displaced bone fracture that cannot heal properly with casting alone and secure them using metal plates, screws, or rods] of left femoral neck fracture. Resident 3 required acute rehabilitation for 18 days (12/5/26-12/23/26) before being able to be safely discharged back to the facility.

Based on observation, interview, and record review, the facility failed to ensure a call system was available and functional for the residents in two of two sampled shower rooms. This failure had the potential to put the residents at risk for falls. Findings:During a concurrent observation and interview on 1/27/26 at 2:08 p.m. with Maintenance Supervisor (MS) in the shower room in station 3, the shower room did not have a call system present. MS stated there was no call system available for residents using the toilet and the shower in the shower room in station 3. MS stated there should have been an alternative call system provided for the residents using the toilet and the shower in the shower rooms.During a concurrent observation and interview on 1/27/26 at 2:15 p.m. with MS in the shower room in station 2, there was a black wireless call button with a bell logo hanging on the hand rail next to the toilet. MS pressed the black wireless call button. MS went to the nurses station 1 but there was no alarm heard from the shower room in station 2. MS stated there should have been an alarm heard at the nurses station 1 alerting the staff somebody needed assistance in the shower room in station 2. MS stated he would replace the black wireless call button in the shower rooms, but the black wireless call buttons would go missing. MS stated there should have been a functional call system available for the residents using the toilet and the shower in the shower rooms.During an interview on 1/28/26 at 12:44 p.m. with Director of Nursing (DON), DON stated the facility had two shower rooms (station 2 and station 3). DON stated the call system had not been working in the shower rooms and it had been an ongoing issue in the facility. DON stated there should have been an alternative call system available for the residents. DON stated Resident 85 and Resident 14 were using the toilet in the shower room in station 3. DON stated Resident 85 and Resident 14 were at risk for falls. DON stated if there was no call system in the shower rooms, it would put the residents at risk for accidents and falls.During a review of Resident 85's Morse Fall Scale (MFS), dated 12/9/25, the MFS indicated, Resident 85 had a score of 55 (score of 45 and higher means high risk for falls).During a review of Resident 14's Minimum Data Set (MDS - an assessment tool), dated 12/31/25, the MDS indicated, Resident 14 had a BIMS (Brief Interview for Mental Status) score of 6 (score of 0-7 means severe cognitive impairment).During a review of Resident 14's MFS, dated 12/31/25, the MFS indicated, Resident 14 had a score of 60.During an interview on 1/28/26 at 1:26 p.m. with Resident 14, Resident 14 stated he was able to control his bladder and would independently use the toilet in the shower room in station 3. Resident 14 stated there was no call system in the shower room.During a review of the facility's policy and procedure (P&P) titled, Communication - Call System, dated 11/1/17, the P&P indicated, Purpose To provide a mechanism for residents to promptly communicate with nursing staff. The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. Should the primary call system become inoperable for any reason, the Facility shall provide a bell for each resident room. Call bells located within resident bathrooms are considered emergency calls due to the potential for falls and injury and must be answered promptly.

Based on observation, interview, and record review, the facility failed to provide a safe, sanitary and homelike environment for nine out of 22 residents (Resident 2, Resident 17, Resident 21, Resident 45, Resident 54, Resident 55, Resident 63, Resident 65, and Resident 72). This failure had the potential to increase risk for falls, effect resident dignity, and result in low self-esteem.Findings: During a concurrent observation and interview on 1/27/26 at 8:45 a.m. with Administrator and Maintenance Supervisor (MS) the following was found:1.Resident 2's room had a large 10 inch (in.) by 10 in. area of unpainted plaster located on the wall.2. The north wing shower room had a 12 in. by 12 in. area in the shower stall of slimy black textured dots on the ceiling. MS stated it was mold.3. Residents 17's room had a plastic container that held what appeared to be electrical or phone wires detached from the north wall of the room and exposed the contents. The wall under where the windows are located had a 16 in. by 16 in. area of loosened wall that moves with slight touch. Administrator stated it was possibly water damage.4. Residents 21's room had an air conditioning unit with a large ventilation tubing measuring approximately 12 in. in diameter running through the room window. The tubing was not secured and air from the outside was coming into the room.5. Residents 45's room had a large area about 13 in. by 13 in. of unpainted wall plaster. Next to the area of unpainted wall plaster was three large 20 in. scratches into the wall exposing the plaster.6. Resident 54's room had missing flooring approximately 15 in. in length upon entry into the room and missing flooring approximately 15 in. length prior to entering the restroom.7. Residents 55's room had missing blinds to the windows and a large 12 in. circular hole to the wall beneath the windows that cold air can be felt coming through.8. Residents 63's room had a 15 in. by 15 in. area on the wall in the middle of the room with unpainted plaster.9. Residents 65's room had a 40 in. by 40 in. area on the wall of exposed unpainted plaster. Approximately two feet away from the center window in the room is an area of missing flooring approximately 10 in. by 10 in. in measurement.10. Residents 72's room had a wall that was broken into pieces in a circular pattern approximately 12 in. in diameter. Above the circular broken wall was 24 in. scratches into the wall exposing the plaster. The floor beneath Res 72's bed had a 10 in. piece of flooring missing.Administrator stated the room findings, Needs to be addressed.During a review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, dated 11/1/17, the P&P indicated, Purpose . To provide residents with a safe, clean, comfortable and home like environment. The Facility provides residents with safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk.Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following . Cleanliness and order . comfortable levels of ventilation.

Based on interview and record review the facility failed to implement their policy and procedure (P&P) titled DISHWASHING, when a facility dishwasher failed to reach the mandatory temperature to sanitize resident dishware and/or failed to document the temperature the dishwasher was reaching to ensure sanitation. This failure had the potential for a foodborne illness outbreak to occur resulting in harm up to and including death.Findings:During a concurrent interview and record review on 1/27/26 at 8:19 a.m. with Kitchen Supervisor (KS), the facility DISH MACHINE TEMPERATURE LOG (DMTL), was reviewed. KS stated the facility dish machine needs to reach a temperature of at least 120 degrees Fahrenheit (a unit of measurement) to sanitize resident dishware. KS stated the facility dish machine did not reach the temperature it should have to ensure sanitation of dishware on the following dates:June 30th there was no recorded temperature for the facility dish machine at dinner serviceAugust 28th there was no recorded temperature for the facility dish machine at dinner service. August 31st the facility dish machine was recorded to be at 100 degrees Fahrenheit at lunch service. August 31st there was no recorded temperature for the facility dish machine at dinner serviceOctober 17th, 21st, 22nd, 23rd, 28th and 29th 2025 the dish machine temperature was recorded to be at 100 degrees Fahrenheit for lunch serviceNovember 15th to the 30th 2025 (15 days total) the dish machine temperature was recorded to be at 100 degrees Fahrenheit for breakfast serviceKS stated he should have been made aware the facility dish machine was not reaching temperature, but he was not. KS stated if he was contacted about the facility dish machine not reaching temperature, he would have the dish machine serviced to fix the issue.During a review of the facility's Dish Machine Temperature Log (DMTL) dated 2023, the DMTL indicated, Please record wash and rinse temperatures . before each meal . Wash temperatures must be at least 120 (degrees Fahrenheit).During a review of the facility's policy and procedure (P&P) titled, DISHWASHING, undated, the P&P indicated, All dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order. A temperature log . will be kept and maintained by the dishwashers to assure that the dish machine is working correctly. This log will be completed each meal prior to any dishwashing. If you cannot achieve the temperature, alert . Director or cook who will alert the Maintenance Department and stop washing dishes.

Based on interview and record review the facility failed to have Certified Nursing Assistant (CNA)'s who have successfully completed either a nurse aide training or a competency evaluation program (is a structured and regulated process that measures an individual's knowledge, skills, and behaviors against establish job requirement) for three of three CNA's (CNA 1, CNA 2, and CNA 3). This failure resulted in CNA 1, CNA 2, and CNA 3 not be evaluated to determine if they were competent to provide resident care services.Findings:During a concurrent interview and record review on 1/28/26 at 10:07 a.m. with Director of Staff Development (DSD), CNA 1's personnel file (PF) was reviewed. DSD stated CNA 1 did not have the competency evaluation worksheet for onboarding completed. DSD stated CNA 1 did not have the competency evaluation for: hand hygiene, universal precaution (a set of infection control practices that require treating all human blood and certain body fluids for infection), isolation technique (method used to separate a specific component, organism, or variable from a mixed, contaminated, complex environment), and applying and removing Protected Personnel Equipment (PPE- a gear worn to minimize exposure) completed.During a concurrent interview and record review on 1/28/26 at 10:10 a.m. with DSD, CNA 2's PF was reviewed. DSD stated CNA 2 did not have the competency evaluation worksheet for onboarding completed. DSD stated CNA 2 did not have the competency evaluation for: hand hygiene, universal precaution, isolation technique, and applying and removing PPE completed.During a concurrent interview and record review on 1/28/26 at 10:15 a.m. with DSD, CNA 3's PF was reviewed. DSD stated CNA 3 did not have the competency evaluation worksheet for onboarding completed. DSD stated CNA 3 did not have the competency evaluation for: hand hygiene, universal precaution, isolation technique, and applying and removing PPE completed.During a review of the facility's policy and procedure (P&P) titled All Departments - New Employee Orientation, [undated], the P&P indicated, all newly hired employees receive a comprehensive New Employee Orientation prior to assuming independent job responsibilities.No employee may work independently until required orientation components are completed.Director of Staff Development (DSD) .Coordinates and conducts orientation .Maintains orientation and competency records .Maintains employee personnel file.E. Competency and Supervision .Competency validation required prior to independent work. During a review of the facility's P&P titled Job Description, undated, the P&P indicated, Title: Director of Staff Development (DSD).Implement and oversee the facility's in-service training program, ensuring compliance with state and federal training regulations. Provide hands-on training, skill validation, and competency assessment for all nursing staff.

Based on interview and record review, the facility failed to:Follow their policy and procedure (P&P) titled Drug Disposition when two controlled medications were not accounted for on the facility's medication disposition form (document used to record the secure destruction or disposal of expired, discontinued or unwanted medication). This failure had the potential for abuse of controlled (highly, abusive) medication.Authenticate the medication for one of one sampled resident (Resident 56). This failure had the potential for Resident 56 to receive an unknown medication and not being monitored for side effects. Findings: During a concurrent interview and record review on [DATE] at 10:15 a.m. with Director of Nursing (DON), the controlled medications disposition forms undated, were reviewed. DON stated Ativan (benzodiazepine medication used to treat anxiety) oral concentration 2 milligrams (mg/milliliter [ml]) unopened 30 ml container, and lorazepam (benzodiazepine) 2 mg/ml with 7 ml left in container were not recorded on the medication disposition form. DON stated the process is when a controlled medication is discontinued or resident is discharged two licensed nurses will document the controlled medication on the medication disposition form with their signatures. DON stated the medication disposition form will include the medication name, prescription number, and signature of two licensed nurses. DON stated this process was not done for Ativan and lorazepam, and should have been done. During a review of the facility's (P&P) titled, Drug Disposition undated, the P&P indicated, Drugs discontinued by a physician order and outdated drugs that cannot be returned to the pharmacy for credit, can be returned for pharmacy proper disposal, are to be properly marked and disposed of in accordance with California's Medical Waste Management Act. Documentation of disposal is to be maintained. 3. Discontinued or outdated controlled drugs are to be delivered to the Director of Nursing for storage in an appropriately locked and secured storage area separate from other discontinued drugs until disposed properly according to policy and procedure. 4. Controlled drugs to be disposed and witnessed per facility policy. 5. All drugs disposed of or returned to the pharmacy for credit are to be entered onto an appropriate medication disposition record. 6. Information that must be entered into the records include a). RX Number b). Pharmacy Name c). Drug Name and Strength d). Quantity of Doses Remaining e). Resident's Name f). Date of Disposal. 7. Controlled drugs must be prepared for disposal by a registered nurse employed by the facility and a witness. Disposition of records for controlled drugs must include the information listed above and the signatures of both the nurse and the witness. 2.During a concurrent interview and record review on [DATE] at 2:30 p.m. with Infection Prevention Nurse (IP), Resident 56's Electronic Medical Record (EMR), [undated] was reviewed. The EMR indicated Resident 56 came back from hospital on [DATE] and there was no order for Cresemba (antifungal medication). IP stated the medication was brought in by family [unspecified]. IP stated the medication Cresemba was not sent to the pharmacy to validate the medication. During an interview on [DATE] at 4:23 p.m. with DON, the DON stated Cresemba was not verified with pharmacy. DON stated the facility staff [not specific] copied the order from the medication bottle on to the facility EMR without validating with pharmacy and dispensed it to Resident 56.

Based on observation, interview, and record review, the facility failed to provide the correct amount of ingredients to a meal per the facility recipe for three of 22 residents (Resident 21, Resident 51, Resident 80). This failure had the potential for Resident 21, Resident 51, and Resident 80's nutritional and caloric intake to be inaccurate and result in unwanted weight loss or gain. Findings:During a concurrent observation and interview on 1/28/26 at 11:32 a.m. with Facility [NAME] (FC) 1 in the facility kitchen, FC was observed making five quesadillas as a substitute meal for Resident 21, Resident 51, and Resident 80. FC 1 was observed using his hands to grab cheese and dispense unmeasured amounts onto a tortilla. FC 1 stated he had not measured how much cheese was used for the quesadillas and did not know what the facility recipe required as far as amount. During a review of the facility document titled RECIPE: CHEESE QUESADILLA (RCQ), dated 2025, the RCQ indicated, Add 1/2 cup cheese per tortilla.

Based on observation, interview, and record review the facility failed to:Label and date opened food items. Maintain a clean refrigerator per policy and procedure (P&P) REFRIGERATOR AND FREEZER. Accurately document the temperature of the facility dry food storage area. These failures had the potential to cause food to spoil and cause foodborne illness.Findings:1.During a concurrent observation and interview on 1/26/26 at 8:02 a.m. with Certified Dietary Manager (CDM) in the facility kitchen, the following food items were observed to have no open date or label:One pound (lb.) container of paprika, One lb. container of ground thyme, One lb. container of ground rosemary, One lb. container of sesame seeds, One lb. container of ground cumin, One lb. container of lemon pepper seasoning, One lb. container of dill weed, One lb. container of bay leaves, and Three pink 32-ounce containers with whitish thick liquid substance found in the walk-in refrigerator. There was no indication of what the liquid was.CDM stated per the facility, process food items should have an 'open and used by' date, as well as a label to indicate what the food item is. CDM stated the spice food items observed did not have an open or use by date. CDM stated the three 32-ounce pink pitchers of thick liquid were a drink made for residents, and that should have been labeled to indicate what it was and dated when it was made.During a review of the facility's P&P titled, Dry Storage, [undated], the P&P indicated, Dry food items which have been opened, such as . spices . will be tightly closed, labeled and dated.2. During a concurrent observation and interview on 1/27/26 at 8:40 a.m. with CDM in the facility kitchen, the facility pastry refrigerator was observed. The pastry refrigerator had three levels of shelving that could not be observed due to a buildup of ice of about 1 to 1.5 inches. On the top shelf there was a 7.62 kilogram (kg) box of French fries, on the middle shelf a box of raw cookie dough (weight not specified), and on the bottom shelf a 7.62 kg box of French fires. The very top of the inside of the refrigerator was covered in about 2 inches of ice. CDM stated the facility pastry refrigerator needed to be defrosted (become free of accumulated ice) and cleaned. CDM stated she was not sure when the last time the facility pastry refrigerator was cleaned. During a review of the facility's P&P titled, REFRIGERATOR AND FREEZER, dated 2023, the P&P indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. Refrigerator and freezer should be on a weekly cleaning schedule. Remove all items and clean shelves. Wipe with sanitizer. Periodically inspect shelves and replace if coating is chipped away exposing metal shelves.3. During a concurrent interview and record review on 1/28/26 at 10:09 a.m. with Dietary Aide (DA) 1, the facility's DRY STORAGE TEMP (Temperature) LOG (DSTL), dated 1/2026 was reviewed. DA 1 stated she placed the temperature entries for the log on 1/7/26, 1/8/26, 1/9/26, 1/10/26, 1/11/26, 1/13/26, 1/14/26, 1/15/26, 1/16/26, 1/17/26, 1/18/26, 1/20/26, 1/22/26, 1/23/26, 1/25/26, 1/26/26, 1/27/26 and 1/28/26 and that they were all measured at 62 degrees Fahrenheit. DA 1 stated she documented the entries incorrectly as she did not read the thermometer in the dry storage room to get the reading but was looking at the setting of an air conditioner located in the dry storage room. DA 1 was unable to state what the actual temperature of the dry storage room was.During a review of the facility's P&P titled, CORRECTIVE ACTION WHEN FOOD IN THE STORE ROOM REACHES ABOVE 85 (degrees Fahrenheit), dated 2023, the P&P indicated, When temperature within the emergency or food storage room becomes higher than 85 (degrees Fahrenheit), corrective action must take place to ensure food has not become compromised. PROCEDURE . The Dry Food Storage Temperature Log . will be started to monitor storage unit temperatures.

Based on observation, interview, and record review, the facility failed to ensure medications were stored at proper temperature. This failure had the potential for medication to be ineffective or harmful to residents and staff.Findings:During a concurrent observation and interview on 1/27/26 at 2:01 p.m. with Infection Prevention Nurse (IP) in the facility medication room, three boxes of Prevnar 20-valent Conjugate Vaccine (pneumococcal (flu) vaccine) was stored in the facility freezer temperature at 20 degrees. IP stated the pharmacist stated to store the extra boxes in the freezer. IP stated the box of Prevnar indicated Do not freeze, and the medication should be discarded and not stored in the freezer.During a review of Prevnar's Instructions for Use (IFU) [undated], the IFU's indicated, After shipping, Prevnar 20 may arrive at temperatures between 36 degrees F (Fahrenheit) to 77 degrees F. Upon receipt, store refrigerated at 36 degrees F to 46 degrees F. Do not freeze, Discard if the vaccine has been frozen.During a review of the facility's policy and procedure (P&P) titled , Drug Storage and Labeling undated, the P&P indicated, Policy: Drugs and biologicals will be stored in a safe, secure and orderly fashion, and will be accessible only to licensed nursing or pharmacy personnel. 8. Drugs that are stored at room temperature will be stored in an area no warmer than 86 degrees F. 9. Drugs stored under refrigeration will be stored between 36 degrees F & 46 degrees F.

Based on interview and record review, the facility failed to ensure three of 22 sampled residents (Resident 98, Resident 97, and Resident 35) had staff with skills (specific abilities to perform their job) and competency (knowledge, skills, abilities, and behaviors) to provide care and services when: 1.Registered Nurses (RN 1, RN 2, RN 3, RN 4, RN 5, and Director of Nursing [DON]) were not competent to provide TPN (total parenteral nutrition - is a method of delivering all essential nutrients-such as protein, carbohydrates, fats, vitamins, and minerals-directly into the bloodstream through an PICC ( a long, this, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) line for two of two sampled residents (Resident 98 and Resident 97). This failure had the potential for TPN associated negative outcomes up to and including death. 2. Certified Nursing Assistants (CNA 1, CNA 2, and CNA 3) were not competent to provide direct care to residents that included: hand hygiene, bed making, infection control measures, clean and dirty linen handling, Activities of a Daily Living (ADLs -everyday task people do to live independently which includes bathing, dressing, eating, using the toilet, and moving around), razor disposal, cleaning/storing bed pans and urinals, feeding residents. This failure had the potential for all residents to be exposed to negligent care and compromised safety. 3. Five of Five sampled RN's (RN 1, RN 2, RN3, RN 4, and RN 5) were not competent to provide Dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to perform these functions naturally) Catheter Care (an access point created surgically for patients undergoing dialysis). This failure had the potential for Dialysis Catheter Care negative outcomes such as infection, up to and including death to occur. Findings: 1. During a review of Resident 98's admission RECORD (AR), dated 1/29/26, the AR indicated, Resident 98 was admitted to the facility on [DATE] with diagnosis of muscle weakness, need for assistance with personal care, colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body), mild protein-calorie malnutrition (a nutritional state from insufficient protein and energy, showing subtle signs like fatigue, recurrent infections, or losing some weight/muscle/fat), electrolyte and fluid imbalance (a condition where the body's water levels and essential minerals like sodium, potassium, calcium, and magnesium are too high or too low, disrupting normal, vital functions), and disorder of plasma-protein metabolism (a condition in which is characterized by the faulty production, processing, or regulation of proteins in the blood). During a review of Resident 98's Physicians Order Sheet (POS), dated 1/23/26, the POS indicated, Resident 98 was to be placed on TPN at 50 ml (milliliter) an hour (hr) for one hour then increase to 100 ml/hr for 14 hours then decrease back to 50 ml/hr for one hour then stop. Repeat every night. 500 ml 20% (percent) lipid (fatty compounds that perform a variety of functions in your body) four times a week (Monday, Wednesday, Friday, and Sunday) infused separately, one time a day. During a review of Resident 98's Care Plan Report (CP), dated 1/26/26, the CP indicated, Resident 98 has nutritional problems or potential for nutritional problems related to taking TPN. The interventions listed on the CP indicated to provide TPN as ordered by the physician. During a review of Resident 98's IV MAR (Intravenous Medication administration record) (IVMAR), dated January 2026, the IVMAR indicated, Resident 98 received TPN on 1/24/26, 1/25/26, 1/27/26, and 1/28/26. During a concurrent interview and record review on 1/28/26 at 2:48 p.m. with Director of Nursing (DON), the facility staff competencies were reviewed. DON stated five RN's (RN 1, RN 2, RN 3, RN 4, RN 5) and DON provided Resident 98 with IV TPN. DON stated there were no competency test or assessments done on the facility RNs including herself (DON) to show that they are competent in providing TPN care. DON stated RN 1 had previous experience with TPN and verbally instructed the other RNs on how to provide TPN to Resident 98. DON stated there was no documented proof that RN 1 provided appropriate competency training on TPN to the RN's. During an interview on 1/28/26 at 3:03 p.m. with RN 1, RN 1 stated, he taught RN 2, RN 3, RN 4, RN 5, and DON how to provide TPN to Resident 98. RN 1 stated he had no documented proof that he provided the TPN education. RN 1 stated the experience he had with providing TPN was when he was out of the country in 2022 and had a patient (resident) that required it. RN 1 stated he had no other experience with giving TPN to residents or educating other staff on how to safely provide TPN. During a review of Resident 97's Care Plan (CP), dated 11/17/25, the CP indicated, Administer TPN daily X 24 Hours. Access PICC line for S/SX [signs and symptoms] of infection infiltration. During a review of Residents 97's POS, dated 12/7/25, the POS indicated, MIX EACH BAG WITH 10ml [milliliters] INFUVITE [ daily multivitamin maintenance supplement ] (BLUE AND WHITE), THEN INFUSE 1 IV BAG VIA IV PUMP AS FOLLOWING: 77 ML/HR X 24 HOURS/DAY, (1560ML CLINIMIX 5%-20%, 250ML INTRALIPIDS 20%, 5ML STERILE WATER) ELECTROYLTES: 1ML TRACE ELEMENTS. EVERY 24 HOURS FOR TPN. During a review of Resident 97's IVMAR, dated 11/25, the IVMAR indicated, Resident 97 received the TPN on the following days; 11/16/25, 11/17/25, 11/18/25, 11/19/25, 11/21/25, 11/22/25,11/23/25,11/25/25,11/26/25, 11/27/25,11/28/25,11/29/25.11/30/25. During a review of Resident 97's IVMAR, dated 12/25, the IV MAR indicated, Resident 97 received the TPN on the following days;12/1/25, 12/2/25, 12/3/25,12/4/25,12/5/25,12/6/25,12/7/25,12/8/25,12/9/25,12/10/25,12/11/25,12/12/25,12/13/25,12/14/25,12/15/25,12/16/25,12/17/25,12/18/25,12/19/25,12/20/25,12/21/25,12/22/25,12/23/25,12/24/25,12/26/25,12/27/25,12/28/25,12/29/25,12/30/25. During an interview on 1/29/26 at 9.44 a.m., with DON, DON stated there was no training for PICC Line or TPN prior to Resident 97's receiving TPN. During a review of the facility's policy and procedure (P&P) titled Total Parenteral Nutrition, dated 11/1/17, the P&P indicated, Registered nurses completes all pre administration checks. 3. Central lines assessed using strict aseptic techniques. 4. TPN administered via infusion pump only. 5. Monitor lab values blood glucose intake/output, and vital signs. 6 Manage complications per provided orders. 7. Discontinued of TPN is performed by an RN only.Forms: RN TPN Competency Checklist. During a review of the facility's policy and procedure (P&P) titled, Staff Competency Policy and Procedure, dated 11/1/17, the P&P indicated, Purpose . To ensure that all staff at (facility) demonstrate and maintain the knowledge, skills, abilities, and professional behaviors necessary to safely and effectively perform their assigned job duties, in compliance with federal, state, and local regulations, and to promote quality resident care. All staff are competent prior to independently performing assigned duties. Competency: The demonstrated ability to safely and effectively perform assigned job duties . NURSING SERVICES . IV therapy (RN only, if applicable) . TPN management. 2. During a concurrent interview and record review on 1/28/26 at 10:07 a.m. with Director of Staff Development (DSD), CNA 1's personnel file (PF) was reviewed. DSD stated CNA 1 did not have the competency evaluation worksheet for onboarding completed. DSD stated CNA 1 did not have the competency evaluation for: hand hygiene, universal precaution (a set of infection control practices that require treating all human blood and certain body fluids for infection), isolation technique (method used to separate a specific component, organism, or variable from a mixed, contaminated, complex environment), and applying and removing Protected Personnel Equipment (PPE- a gear worn to minimize exposure) completed. During a concurrent interview and record review on 1/28/26 at 10:10 a.m. with DSD, CNA 2's PF was reviewed. DSD stated CNA 2 did not have the competency evaluation worksheet for onboarding completed. DSD stated CNA 2 did not have the competency evaluation for: hand hygiene, universal precaution, isolation technique, and applying and removing PPE completed. During a concurrent interview and record review on 1/28/26 at 10:15 a.m. with DSD, CNA 3's PF was reviewed. DSD stated CNA 3 did not have the competency evaluation worksheet for onboarding completed. DSD stated CNA 3 did not have the competency evaluation for: hand hygiene, universal precaution, isolation technique, and applying and removing PPE completed. During a review of the facility's policy and procedure (P&P) titled All Departments - New Employee Orientation, [undated], the P&P indicated, all newly hired employees receive a comprehensive New Employee Orientation prior to assuming independent job responsibilities.No employee may work independently until required orientation components are completed.Director of Staff Development (DSD) .Coordinates and conducts orientation .Maintains orientation and competency records .Maintains employee personnel file.E. Competency and Supervision .Competency validation required prior to independent work. During a review of the facility's P&P titled Job Description, undated, the P&P indicated, Title: Director of Staff Development (DSD).Implement and oversee the facility's in-service training program, ensuring compliance with state and federal training regulations. Provide hands-on training, skill validation, and competency assessment for all nursing staff. 3.During a review of Resident 35's AR, dated 1/19/26, the AR indicated, Resident 35 had a diagnosis of, DEPENDENCE ON RENAL [Kidneys] DIALYSIS.END STAGE RENAL DISEASE [also known as renal failure-the final, irreversible phase of kidney failure where dialysis is required]. During a review of Resident 35's POS, dated 4/30/25, the POS indicated, (Dialysis catheter) Site: Right Femoral [thigh region] MONITOR FOR ANY S/S [sign and symptoms] OF INFECTION AT ACCESS SITE. Right Femoral MONTIOR FOR ANY ITCHING AT ACCESS SITE . During a review of Resident 35's CP, dated 1/20/26, the CP indicated, Potential for complications related to hemodialysis [a life-sustaining treatment for kidney failure that uses a machine and a specialized filter (dialyzer) to remove waste, toxins, and excess fluid from the blood ] for diagnosis of Chronic [persistent for long time or constantly recurring illness] Renal Failure. Check shunt [catheter] site for s/s of infection, pain or bleeding daily and PRN [as needed]. During an interview on 1/29/26 at 3:07 p.m. with Treatment Nurse (TN), TN 1 stated, I have not had any training on dialysis catheter care. During an interview on 1/29/26 at 3:11 p.m. with RN 1, RN 1 stated I have not had any training on dialysis catheter care. During an interview on 1/29/25 at 4:22 p.m. with DON, DON stated she does not have complete documentation that the staff was trained on dialysis catheter care. During a review of the facility's P&P titled All Departments - New Employee Orientation, [undated], the P&P indicated, Competency and Supervision .Competency validation required prior to independent work. During a review of the facility's P&P titled Job Description, [undated], the P&P indicated, Job Titled: Director of Nursing Services.Evaluate all Registered Nurse in the facility including Supervisory and Charge Nurse and Staff Development.

Based on observation, interview, and record review, the facility failed to give one of 22 sampled residents (Resident 35) oxygen per the physicians' orders. This failure had the potential for hypoxia (insufficient oxygen reaching body tissues to maintain normal function causing shortness of breath, confusion, rapid heart rate, bluish skin, and other negative outcomes up to and including death).Findings:During a review of Resident 1's admission RECORD (AR), dated 1/29/26, the AR indicated, Resident 35 was admitted to the facility on [DATE] with diagnosis of muscle weakness, need for assistance with personal care, hypertensive heart disease (damage to the heart muscle, valves, or blood vessels caused by long-term high blood pressure [measures the pressure your blood is pushing when the heart beats] with heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs), acute (severe, sudden) on chronic (persistent long lasting condition) combined systolic (blood pressure when the heart is at work) and diastolic (blood pressure when the heart is at rest) heart failure. During a review of Resident 35's Physician order sheet (POS), dated 1/25/26, the POS indicated, Resident 35 was ordered by the physician to be on oxygen two liters (a unit of measurement) via nasal cannula (nc - a lightweight, flexible tube worn around the ears inserted into the nostrils to deliver supplemental oxygen) as needed for shortness of breath.During a concurrent observation and interview on 1/26/26 at 8:48 a.m. with Treatment Nurse (TN), in Resident 35's room, Resident 35 was observed lying in bed with oxygen being delivered via nc. TN observed the oxygen setting and stated it was at 1 liter not two liters of oxygen as ordered for her shortness of breath. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 11/1/17, the P&P indicated, Purpose . To prevent or reverse hypoxemia and provide oxygen to the tissues. A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include . oxygen flow rate . procedure . check the physician's order . Turn on the oxygen at the prescribed rate.

Based on observation, interview, and record review, the facility failed to provide the individualized activities services for one of 22 sampled residents (Resident 97). This failure had the potential for Resident 97 to have diminished functional needs to promote maximum participation in activities. Findings:During an observation on 1/26/26 at 9:15 a.m. in Resident 97's room, Resident 97 was lying in bed staring at the walls. During an interview on 1/26/26 at 2:39 p.m. with Family Member (FM) 1, FM 1 stated, Resident 97 is in bed all the time. FM 1 stated he had requested activities to be provided to Resident 97 in the room because FM 1 feels that Resident 97 is depressed. During a review of Resident's 97's admission RECORD (AR), dated 11/15/25, the AR indicated, Resident 97 had muscle weakness, lack of coordination, and assistance with personal care.During a review of Resident 97's Care Plan (CP) Activities, [undated], the CP indicated, Resident 97 goal is, express satisfaction with type of activities and level of activity involvement when asked.During a concurrent interview and record review on 1/26/26 at 9:26 a.m. with Activities Director (AD), Resident 97's IN ROOM VISITS ACTIVTY RECORD (IRVAR) was reviewed, the IRVAR indicated, on 1/1/26 transfer to the hospital1/2/26 transfer to the hospital1/4/26 family visit1/5/26 slept1/7/26 Not Applicable1/9/26 family visit1/11/26 family visit1/19/26 Not Applicable1/21/26 CNA attending to him1/23/26 Not Applicable1/25/23 Family Visit1/27/26 SleptAD stated that Resident 97's activities is for one hour on Monday's, Wednesday's and Fridays. AD can't verify that staff attempted other times to involve Resident 97 in activities when family was present during the hour, when Resident 97 was sleeping, or when Resident 97 was being attended by a Certified Nursing Assistant (CNA). AD could not identify what Not Applicable meant. AD had no other log that attempted Resident 97 in activities or what activities were being presented to Resident 97 for participation. During a review of the facility's policy and procedure (P&P) titled, Room Visit Program, dated 4/1/21, the P&P indicated, The Facility will provide recreational opportunities for residents who are not physically able to or choose not to leave their room. Residents who prefer not to, or cannot, participate will be visited in their room on a regular scheduled basis.Room activities may include games, discussions, arts and crafts, and sensory stimulations, reading or educational programs, or adapted exercise.Activity staff will maintain a record of the activities provided for each resident when visited in the room.activities staff will document the activity the level of participation and response to the approach will be recorded.

Based on observation, interview and record review, the facility failed to follow their policy and procedure (P&P) on:1. Out on Pass for one of three sampled residents (Resident 64) when Resident 64 was going out on pass without a physician order, and Resident 64 was not assessed by a licensed nurse prior to leaving out on pass and after coming back to the facility. These failures had the potential to jeopardize Resident 64's safety and had the potential for Resident 64 to receive delay in care. 2. Wound Management for one of two sampled residents (Resident 35) when Resident 35's gastrostomy tube (GT - small, soft tube placed through the skin directly into the stomach to deliver food, liquids, and medicine) site was not being treated as ordered by the physician and there was no care plan developed to manage Resident 35's skin irritation around the GT site. These failures had the potential to result in further skin breakdown.Findings:1. During a review of Resident 64's Minimum Data Set (MDS - an assessment tool), dated 10/1/25, the MDS indicated on section C (Cognitive Patterns), Resident 64 had a BIMS (Brief Interview for Mental Status) score of 13 (score of 13-15 means cognitively intact). The MDS indicated on section GG (Functional Abilities), Resident 64 had functional limitation in range of motion (limit to which a part of the body can be moved around a joint) on one side for both upper and lower extremities, was wheelchair-bound, was unable to walk, required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes the activity) with transferring to and from a bed to a chair or wheelchair, and required set up assistance (helper only assists prior to or following the activity) with wheeling himself using his wheelchair.During a review of Resident 64's MD [Medical Doctor] Progress Note (MDPN), dated 12/15/25, the MDPN indicated, patient has a history of: Need for assistance with personal care, generalized muscle weakness. Comments: Supervision and care 24 hours.During a review of Resident 64's Social Services Note (SSN), dated 1/9/26, the SSN indicated, [Resident 64] purchased a vehicle and is leaving the facility with out [sic] a MD out on pass.During a review of Resident 64's Order Summary Report (OSR), dated 1/21/26, the OSR indicated, Resident 64 did not have a physician order to go out on pass.During a review of Resident 64's RELEASE OF RESPONSIBILITY FOR LEAVE OF ABSENCE (RRLA - log for residents to sign when going out on pass and coming back to the facility), dated January 2026, the RRLA indicated:a. On 1/2/26, Resident 64 signed out on pass and did not sign when he came back to the facility.b. On 1/5/26, Resident 64 signed out on pass and did not sign when he came back to the facility.c. On 1/6/26, Resident 64 signed out on pass and did not sign when he came back to the facility.d. On 1/9/26, Resident 64 signed out on pass and did not sign when he came back to the facility.e. On 1/13/26, Resident 64 signed out on pass and did not sign when he came back to the facility.f. On 1/14/26, Resident 64 signed out on pass and did not sign when he came back to the facility.g. On 1/19/26, Resident 64 signed out on pass and did not sign when he came back to the facility.During a concurrent observation and interview on 1/20/26 at 2:35 p.m. with Resident 64 in Resident 64's room, Resident 64 had dry dressing wrapped around his right foot. Resident 64 stated he had all his toes amputated (surgically removed) on his right foot and his surgical wound on his right foot was still healing. Resident 64 stated he had been going out of the facility and had been driving his car.During an interview on 1/20/26 at 2:51 p.m. with Social Services Director (SSD), SSD stated Resident 64 had been seen using a mind-altering drug (marijuana) in the facility and had been driving his car. SSD stated Resident 64 had almost hit several cars in the parking lot. SSD stated when Resident 64 would go out on pass, he would not notify the licensed nurses, and the licensed nurses would not be able to notify the doctor until they found out during their rounds that Resident 64 had gone out.During an interview on 1/20/26 at 3:30 p.m. with Director of Nursing (DON), DON stated Resident 64 had said Resident 64 was driving his car. DON stated Resident 64 would leave out on pass anytime without telling the staff. DON stated the facility don't know how to monitor Resident 64 of his whereabouts. DON stated there was a concern for Resident 64's safety when he would go out and drive his car because of his mind-altering drug (marijuana) use and unresolved surgical wound on his right foot. DON stated Resident 64 did not have a physician order to go out on pass. DON stated Resident 64 should have had an authorization from the physician prior to going out on pass.During a concurrent interview and record review on 1/20/26 at 4 p.m. with DON, Resident 64's Nurses Note (NN), dated 1/13/26, was reviewed. The NN (written at 7:56 p.m.) indicated, Morning nurse reported to pm [evening shift] nurse that resident signed out around 2:35pm [sic] to go on pass out of facility during nurse rounds resident was seen heading out facility, during med [medication] pass resident have not returned back to facility. The NN (written at 9 p.m.) indicated, Resident returned back to facility. DON stated Resident 64 was not assessed prior to leaving the facility and coming back to the facility. DON stated the licensed nurses should have assessed Resident 64 when coming back to the facility for injuries and changes in mental status because the facility was aware Resident 64 was also using a mind-altering drug (marijuana).During a concurrent interview and record review on 1/26/26 at 11 a.m. with DON, the facility's P&P titled, Out on Pass, dated 11/1/17, was reviewed. The P&P indicated, It is the policy of the Facility to meet residents' physical and psychosocial needs to go out on pass. The Facility will make reasonable efforts to ensure the resident safety and uphold resident rights. If the Attending Physician and Psychiatrist (if applicable) determine that the resident may participate in activities outside the Facility, the Attending Physician will write/give an order for a pass on the physician order sheet. Prior to the resident leaving on pass, a Licensed Nurse will assess the resident's physical and mental status. When the resident returns to the Facility, a Licensed Nurse will re-assess the resident to determine the resident's condition and any medication returned after going out on pass, if applicable. The resident/responsible person will verbally notify a Licensed Nurse prior to going out on pass and will sign out and back in on Form A - Resident Out on Pass Log. DON stated the P&P was not followed. 2. During a review of Resident 35's Nurses admission Record (NAR), dated 1/19/26, the NAR indicated, G tube [GT] with skin irritation.During a concurrent interview and record review on 1/27/26 at 3:22 p.m. with Treatment Nurse (TN), Resident 35's Order Summary Report (OSR), dated 1/27/26, was reviewed. The OSR indicated, Cleanse GT site with NS [normal saline (used to clean wounds)], pat dry then apply zinc oxide [medicated cream used for wound treatment] to peri wound [skin surrounding a wound], cover with T-Drain sponge [white dry dressing, pre-cut absorbent pad used to keep the GT insertion site dry] then secure with tape Q [every] shift. Order Date. 01/19/2026. Resident 35's Treatment Administration Record (TAR), dated January 2026, was reviewed. The TAR indicated, the treatment order started on 1/19/26 for Resident 35's GT site was being done every day and evening shift. TN stated the OSR was not followed. TN stated the treatment order for Resident 35's GT site should have been done three times a day (every day, evening, and night shift) as ordered by the physician on 1/19/26. TN stated Resident 35's skin irritation around the GT site would get worse if the physician order was not followed. The OSR indicated, there was no physician order to monitor Resident 35's GT site as needed. TN stated there was no order to monitor Resident 35's GT site as needed if the dressing needed to be changed.During a concurrent observation and interview on 1/28/26 at 11:39 a.m. with TN in Resident 35's room, Resident 35's dressing on her GT site was black and did not cover the GT insertion site. Resident 35's GT site had redness and was leaking yellow liquid from the GT insertion site. TN stated Resident 35's dressing on her GT site was wet because there was GT formula (specially designed liquid, high-nutrient food meant to provide all necessary nutrition directly into the stomach) leaking from the GT insertion site. TN stated the moisture around the GT site was causing irritation and redness on Resident 35's skin. TN stated Resident 35's GT site should have been monitored as needed to keep the GT site clean and dry. During an interview on 1/28/26 at 11:50 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated she saw Resident 35 on 1/28/26 around 10:30 a.m. and the dressing on Resident 35's GT site was black and did not cover the GT site. CNA 4 stated she did not notify TN or any licensed nurse about Resident 35's GT site. CNA 4 stated she should have notified the TN or any licensed nurse to change the dressing on Resident 35's GT site.During a concurrent interview and record review on 1/28/26 at 12:44 p.m. with DON, Resident 35's Care Plans (CP), dated 1/28/26, was reviewed. The CP indicated there was no care plan developed to address Resident 35's skin irritation on her GT site. DON stated Resident 35's skin irritation on her GT site was caused by the GT formula leaking from the GT insertion site. DON stated there should have been a care plan to monitor if the dressing on Resident 35's GT site needs to be changed to prevent further skin breakdown. DON stated CNA 1 should have notified a licensed nurse when the dressing on Resident 35's GT site needed to be changed.During a concurrent interview and record review on 1/28/26 at 12:44 p.m. with DON, the facility's P&P titled, Wound Management, dated 11/1/17, was reviewed. The P&P indicated, Purpose To provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers. A Licensed Nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. A Licensed Nurse will develop a Care Plan for the resident based on recommendations from Dietary, Rehabilitation and the Attending Physician. Per Attending Physician order, the Nursing Staff will initiate treatment and utilize interventions for pressure redistribution and wound management. DON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to develop and implement a care plan for three of 22 sampled residents (Resident 9, Resident 56, and Resident 64): Resident 64's use of mind altering substances (Marijuana) substance while driving vehicle. This failure had the potential to put Resident 64, other residents, staff, and visitors at risk for accidents. 2. Resident 9's continued behavior of non-compliance. This failure had the potential for unmet care needs. 3. Resident 56 was on anti-viral medication. This failure had the potential for unmet care needs. Findings: 1. During a review of Resident 64's Minimum Data Set (MDS – an assessment tool), dated 10/1/25, the MDS indicated on section C (Cognitive Patterns), Resident 64 had a BIMS (Brief Interview for Mental Status) score of 13 (score of 13-15 means cognitively intact). The MDS indicated on section GG (Functional Abilities), Resident 64 had functional limitation in range of motion (limit to which a part of the body can be moved around a joint) on one side for both upper and lower extremities, was wheelchair-bound, was unable to walk, required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes the activity) with transferring to and from a bed to a chair or wheelchair, and required set up assistance (helper only assists prior to or following the activity) with wheeling himself using his wheelchair. During a review of Resident 64's MD [Medical Doctor] Progress Note (MDPN), dated 12/15/25, the MDPN indicated, patient [Resident 64] has a history of: Need for assistance with personal care, generalized muscle weakness. Comments: Supervision and care 24 hours. During a review of Resident 64's Behavior Note (BN), dated 1/12/26, the BN indicated, Resident [64] was seen sitting on his bed in his room preparing a marijuana cigar. During a review of Resident 64's BN, dated 1/20/26, the BN indicated, was reported by nursing that [Resident 64] was in his car all night, blocked entrance way and way [sic] playing loud music. Was asked to move car but refused till [sic] staff informed him it will be towed. During a concurrent observation and interview on 1/20/26 at 2:35 p.m. with Resident 64 in Resident 64's room, Resident 64 had dry dressing wrapped around his right foot. Resident 64 stated he had been going out of the facility and had been driving his car despite having amputation (surgically removed) of his right foot and smoking marijuana. During an interview on 1/20/26 at 2:51 p.m. with Social Services Director (SSD), SSD stated Resident 64 had been seen using marijuana in the facility and had been driving his car. SSD stated Resident 64 had almost hit several cars in the parking lot. During an interview on 1/20/26 at 3:30 p.m. with Director of Nursing (DON), DON stated Resident 64 had said he was driving his car. DON stated Resident 64 had been found to have marijuana on his bedside table. DON stated there was a concern for Resident 64's safety when he would go out and drive his car because of his substance use and unresolved surgical wound on his right foot. During a concurrent interview and record review on 1/20/26 at 3:45 p.m. with DON, Resident 1's Care Plan (CP), dated 1/20/26, was reviewed. There was no care plan developed to address Resident 64's use of illegal substance and driving his car. DON stated the facility don't know how to keep Resident 64 safe when driving his car. DON stated there should have been a care plan developed for Resident 64 to ensure his safety when using a mind altering substance and when driving his car. During a concurrent interview and record review on 1/26/26 at 11 a.m. with DON, the facility's policy and procedure (P&P) titled, Care Planning, dated 11/1/17, was reviewed. The P&P indicated, Purpose To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs. DON stated P&P was not followed. 2. During a review of Resident 9's Medical Record (MR), [undated], the MR indicated Resident 9 went out with ex-wife on 5/6/25 and returned on 5/9/25. During a concurrent interview and record review on 1/29/26 at 3:10 p.m. with SSD, Resident 9's Care Plan, was reviewed. SSD was unable to provide evidence a care plan was developed and implemented for Resident 9's leaving facility without informing the staff. SSD stated there was no care plan written for non-compliance. 3. During a concurrent interview and record review on 1/29/26 at 2:30 p.m. with Infection Prevention Nurse (IP), Resident 56's Care Plan, was reviewed. IP was unable to provide evidence a care plan was developed and implemented for Resident 56's medication Cresemba (medication for fungal infection). During a review of Resident 56's Physician Orders (PO), dated 1/23/26, the PO indicated, Cresemba 186 milligram was started on 1/23/26 two capsules once time a day. During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 11/1/2017, the P&P indicated, To ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. Procedure. II. B. Any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment.

Based on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting, for one of 22 sampled residents (Resident 3) when the facility did not report to the California Department of Public Health (CDPH) Resident 3's fall with injury (fracture [broken bone] of left leg) with subsequent hospitalization, need for surgical intervention, and rehabilitation. This failure resulted in the facility not reporting to CDPH and resulted in a lack of investigation. Findings:During a review of Resident 3's admission RECORD (AR), dated 1/26/26, the AR indicated, Resident 3 was admitted on [DATE] with diagnosis of muscle weakness, unspecified dementia (cognitive decline), depression, anxiety disorder, lack of coordination and history of falling.During a review of Resident 3's Change of Condition Evaluation (COC), dated 12/1/15, the COC indicated, at 3:31 a.m. Writer was called to residents' room by aide. Nurse found resident [3] sitting on floor on L [left] side of bed. ROM (range of motion) unable to complete d/t [due to] resident [3] not following instructions. C/o [complained of] hip pain at this time. Resident [3] unable to say why she wanted to get up.During a review of Resident 3's :admission H&P (AHP), dated 12/6/25, the AHP indicated, on 12/1/25 Resident 3 had a fall at the facility that resulted in left leg fracture. On 12/2/25 Resident 3 had surgery to correct the left leg fracture. During a concurrent interview and record review on 1/29/26 at 12:03 p.m. with Director of Nursing (DON), Resident 3's electronic health record (EHR) was reviewed. DON stated Resident 3 had a fall on 12/1/25 and was sent to acute hospital (12/1 thru 12/5/25) status post fall and pain in left hip. DON stated she was not aware of Resident 3's left leg fracture (12/1/25) until she reviewed the EHR today (1/29/26). DON stated she did not follow up on Resident 3's fall and report the incident as she had been unaware of Resident 3's fall with a fracture.During an interview on 1/29/26 at 2:17 p.m., with DON, DON stated Resident 3's fall with a femoral fracture was an unusual occurrence and should have been reported to the CDPH according to their policy.During a review of the facility's P&P titled, Unusual Occurrence Reporting, dated November 2017, the P&P indicated, Purpose. To ensure that timely reports are made to designated agencies as required by state and federal law. 1. The facility reports the following events by phone and in writing to the appropriate Sate or Federal agencies . III. Unusual occurrence are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing.

Based on interview and record review the facility failed to have clear clinical justification to provide Zyprexa (a medication used to treat psychosis [mental state where you lose touch with reality, experiencing things that aren't real or hold strong false beliefs]) to one of 22 residents (Resident 82). This failure had the potential cause medication induced harm.Findings:During a review of Resident 82's admission RECORD (AR), dated 1/29/26, the AR indicated, Resident 82 was admitted to the facility on [DATE] with diagnosis of need for assistance with personal care, anxiety disorder (a mental health condition marked by excessive, persistent, and uncontrollable worry or fear), unspecified psychosis, and muscle weakness. During a review of Resident 82's Physician Order Sheet (POS), dated 1/6/26, the POS indicated, Resident 82 was to be on Zyprexa 5 mg (milligram) by mouth at bedtime for psychosis manifested by lack of motivation and trouble thinking. During a review of Resident 82's MEDICATION ADMINISTRATION RECORD (MAR), dated January 2026, the MAR indicated, Resident 82 received Zyprexa 5 mg at 9 p.m. on 1/6/26 to 1/28/26 (22 days). Under the section Monitor for number of episodes of lack of motivation and trouble thinking every shift, Resident 82 had no documented behavior episodes for the month of January 2026. During a concurrent interview and record review on 1/29/26 at 9:37 a.m. with Social Services Director (SSD), Resident 82's Electronic Health Record (EHR) was reviewed. SSD stated Resident 82 was admitted to the facility on [DATE] with a prescription for Zyprexa 5 mg. SSD stated on 7/29/24 Resident 82's order for Zyprexa was ordered to be discontinued as it was no longer needed. SSD stated Resident 82 went to the acute hospital on 1/4/26 and returned to the facility on 1/6/26 and the acute hospital may have mistakenly restarted Resident 82's Zyprexa 5 mg. SSD stated at the facility Resident 82's Zyprexa 5 mg was continued per the hospital order but there was no IDT (Interdisciplinary team - a team of professionals that meet to discuss resident safety, treatment, and goals) to discuss if the Zyprexa order should have been continued and if there was clinical justification for Resident 82 to take the Zyprexa. SSD stated there were no alternative treatments trialed prior to placing Resident 82 back on Zyprexa (the IDT would have discussed this) nor was a care plan (a written, personalized roadmap for a person's health, safety, and daily support needs, created by doctors, caregivers, and the individual) created.During an interview on 1/29/26 at 10:36 a.m. with Director of Nursing (DON), DON stated, the IDT did not meet for Resident 82 new order of Zyprexa 5 mg. DON stated the IDT should have met to discuss the appropriateness of the new order for Zyprexa and see if there was clinical justification. During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management, dated 11/1/17, the P&P indicated, Purpose . To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life. To ensure the resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed condition(s). To ensure non-pharmacological interventions are considered and used when indicated, instead of, or in addition to, medication. To ensure clinically significant adverse consequences are minimized. The IDT, in consultation with the Consulting Pharmacist and the resident's Attending Physician . will discuss the psychotherapeutic medications at least quarterly, or as needed. Interdisciplinary Team (IDT) Responsibility . The care plan will reflect an individualized team approach emphasizing person-centered interventions with measurable goals, timetables and specific interventions. The resident's Care Plan will include the reason(s) for the drug and describe the behaviors the drug was prescribed to treat. The IDT note will include: reasons for the drug, manifestations for the drug, an analysis of the residents response to the drug and response to psychiatric consult or recommendations . new non-drug interventions and reasons for continuing same dose, decreasing dose and/or increasing dose.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on Change of Condition Notification, for one of three sampled residents (Resident 53). This failure resulted in Resident 53 having unmet care needs for high blood pressure (force of blood pushing when your heart beat) and heart rate (the number of times when the hear beats per minute) which could result in damage to the heart, kidneys, brain, and result in heart attack.Findings:During a review of Resident 53's ADMISISON RECORD (AR), dated 12/9/25, the AR indicated, Resident 53 has a diagnosis of Atrial Fibrillation (AFib - is a common heart arrhythmia [abnormal heart beat] characterized by an irregular and often rapid heart rate and effect blood pressure) and Hypertensive heart disease without heart failure (structural and functional changes in the heart). During a review of Resident 53's Minimal Data Sheet (MDS - Resident assessment Tool), dated 12/12/25, the MDS indicated, Resident 53's Brief Interview for Mental Status (BIMS - cognition assessment tool, 15-point scale: 13-15 cognitively intact, 8-12 moderate impairment ) score was 12.During an interview on 1/26/26 at 8:13 a.m. with Resident 53, Resident 53 stated she was considering going to the hospital a few days ago (unspecified date) because staff did not give her medication for AFib . Resident 53 stated she feels ill when she does not receive her AFib medication. Resident 53 stated it makes her feel scared when her heart rapidly beats and she doesn't know why the facility did not have her medication.During a review of Resident 53's Orders, dated 12/9/25, the Orders indicated, Resident 53 was prescribed Apixaban [blood thinner used to reduce the risk of blood clots in residents with AFib]) Oral Tablet 2.5 mg [milligram] give 1 tablet by mouth two times a day for A-Fib.During a review of Resident 53'3 Medication Administration Record (MAR), dated 1/1/26 -1/31/26, the MAR indicated, Monitor Vital Signs (assessment of blood pressure, heart rate, and breathing) Daily. The MAR indicated on 1/2/26 the vital signs indicated, Blood pressure (b/p) was 162/100 (normal is 120/60), Heart rate (HR) was 145 (normal is 60-100).During a concurrent interview and record review on 1/29/26 at 10:26 a.m. with Infectious Prevention Nurse (IP), Resident 53's medical record was reviewed. Resident 53's b/p on 1/2/25 at 9:07 a.m. was 147/100, and at 10:15 a.m. b/p was 148/100 with a HR of 145. IP stated the nurse should have rechecked Resident 53's vital signs but saw no documentation indicating that it was done. IP stated the facility practice is to re-check abnormal vital signs. During a concurrent interview and record review on 1/29/26 at 10:33 a.m. with IP, Resident 53's Progress notes (PN), were reviewed. Resident 53's PN indicated, Resident 53 was going to be sent to the hospital by the facility for high blood pressure but was not. Resident 53's hospital transfer got cancelled. IP stated the staff should have checked her vital signs and notified the physician but did not.During a review of the facility P&P titled, Vital Signs (VS), dated 11/1/17, the P&P indicated, Report abnormal or out of range vital signs promptly . the licensed nurse will assess the resident and notify the physician.notification interventions must be documented.During a review of the facility P&P titled, Change of Condition Notification (COC) dated 11/1/17, the P&P indicated, The licensed nurse will notify the residents attending physician when there is a.an accident involving the resident which.has the potential for requiring a physician intervention.a significant change in the residence physical mental or psychosocial status.clinical complicated.the licensed nurse will assess the residents change of condition and document the observation and symptoms.

Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Pressure Ulcer (or injury is localized damage to the skin and underlying soft tissue usually over a bony prominence) Prevention for one of three sampled residents (Resident 1) when: 1. Resident 1 was not assessed for risk for developing pressure injuries upon admission. 2. Physician was not notified to obtain treatment for Resident 1's left heel redness. 3. A care plan (resident centered health document designed to facilitate communication among members of the care team with the resident) was not developed to address Resident 1's left heel redness. 4. Interdisciplinary team (Team members from different disciplines working collaboratively with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting was not conducted to address Resident 1's left heel redness. These failures resulted in Resident 1 sustaining a facility acquired Stage 3 (Full-thickness loss of skin, in which adipose [fat] is visible) pressure injury to the left heel. Findings: During a review of Resident 1's Admission Record (AR) the AR indicated, Resident 1 was admitted on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (occurs as a result of disrupted blood flow to the brain and you may become paralyzed on one side of the body, or lose control of certain muscles), muscle weakness, and reduce mobility. During a review of Resident 1's Nursing Admission Screening/History (NASH) dated 3/14/24, the NASH indicated Resident 1 was alert and oriented to person, place, time, and situation and Resident 1's cognition (mental action or process) was intact. The NASH indicated, Skin . Face . Dryness . (no other documented skin issues). During a review of Resident 1's admission Minimum Data Set (MDS-an assessment tool) dated 3/20/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) a score of 12 (a score of 8 to 12 indicates moderately impaired cognition). The MDS indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), sit to lying (the ability to move from sitting on side of bed to lying flat on the bed), and sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), and Resident 1 was dependent (helper does all the effort) for chair/bed to chair transfers (the ability to transfer to and from bed to a chair or wheelchair). 1. During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk (Braden-a medical instrument used to measure residents' risk of developing pressure injuries) dated 3/14/24, the document was noted blank. During a concurrent interview and record review on 4/24/24 at 1:30 p.m. with Director of Nursing (DON), Resident 1's Braden Scale for Predicting Pressure Sore Risk dated 3/14/24, was reviewed. DON confirmed Resident 1 was admitted on [DATE]. DON reviewed Resident 1's Braden Scale for Predicting Pressure Sore Risk dated 3/14/24, and DON stated the Braden Scale for Predicting Pressure Sore Risk was not completed. 2. During a review of Resident 1's Skin Observation Tool, (SOT) dated 3/15/24, the SOT indicated redness to Resident 1's left heel (one day after the admission). During a review of Resident 1's Treatment Administration Record, dated 3/2024, the TAR indicated no documented treatment for Resident 1 left heel redness. During a concurrent interview and record review on 4/24/24 at 1:30 p.m. with DON, Resident 1's SOT dated 3/15/24 was reviewed. The SOT indicated Resident 1 left heel redness. DON reviewed Resident 1's medical record and stated the physician was not notified to obtain treatment for Resident 1's left heel redness. 3. During a review of Resident 1's Skin Observation Tool, (SOT) dated 3/15/24, the SOT indicated redness to Resident 1's left heel (one day after the admission). During a concurrent interview and record review on 4/24/24 at 1:30 p.m. with DON, Resident 1's SOT dated 3/15/24 was reviewed. DON confirmed the SOT indicated Resident 1's left heel redness. DON reviewed Resident 1's care plans and stated there was no care plan developed to address Resident 1's left heel redness. During a review of Resident 1's Wound Weekly Observation Tool (WWOT) dated 4/4/24 (20 days after the admission), the WWOT indicated, Resident 1 had a SDTI (suspected deep tissue injury-intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [small bubble on the skin filled with serum]) to the left heel. The WWOT indicated the SDTI was intact, measuring 20 mm (millimeters-unit of measure) in length by 20 mm in width. During a review of Resident 1's WWOT dated 4/10/24, the WWOT indicated Resident 1's SDTI to the left heel worsened to a Stage 3 pressure injury measuring 25 mm in length by 25 mm in width and 1 cm (centimeter-unit of measure) in depth. The WWOT indicated slough (yellow, tan, white, or stringy material noted in the wound) and necrotic (dead skin tissue-brown, black, leather, scab-like) tissue. During a concurrent observation and interview on 4/17/24 at 12:39 p.m. with Resident 1, in Resident 1 room, Resident 1 had his left foot elevated on a pillow. Resident 1 stated he was not admitted to the facility with pressure injury to the left heel. Resident 1 stated two weeks ago (4/4/24) a wound care provider took something off the bottom of his left foot, he stated the wound care provider came in today and scrapped and scrapped at my left foot again. Resident 1 stated, I was ready to go home but they won't let me go because of the wound [left heel]. During an interview on 4/24/24 12:32 p.m. with Treatment Nurse (TN), TN stated the facility process for new admitted resident identified with wounds was for the treatment nurse to measure the wounds, contact the physician to obtain treatment orders, develop a care plan, perform weekly wound assessment with the wound specialist, and update the treatment order and care plan as needed. During an interview on 5/15/24, at 11:25 a.m. with DON, DON confirmed Resident 1's SDTI to the left heel was now a Stage 3. 4. During a concurrent interview and record review on 5/20/24 at 11:56 a.m. with DON, Resident 1's medical record was reviewed. There was no IDT meeting noted to address Resident 1's left heel redness. DON stated Resident 1 did not have an IDT meeting to address Resident 1's left heel redness on the month of March 2024. During a review of facility's P&P titled, Pressure Ulcer Prevention, revised 11/1/17, the P&P indicated, Purpose To identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure ulcers and minimize complications. Policy: The facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development. Procedure I. Risk Identification and Assessment: A. The Licensed Nurse will complete a Braden Scale Assessment upon admission and quarterly to identify residents at risk for skin breakdown. B. Licensed Nurse will conduct a skin assessment for a resident upon admission, readmission, weekly and as needed. a. If the resident is identified as having wound upon admission, findings will be documented on the Resident Admission Assessment . and a Wound Monitoring Record . will be implemented. c. A Wound Monitoring Record will be implemented for each identified wound. II. Plan of Care: A. The Licenses Nurse will develop a Care Plan specific to the resident's risk factors such as moisture control, pressure reduction, positioning, mobility, and nutrition in consultation with the following: i. Attending Physician ii. Interdisciplinary Team (IDT)- Skin Committee iii. Registered Dietician iv. Director of Rehabilitation Services B. Nursing Staff will monitor interventions for effectiveness and resident tolerance. C. The Care Plan will be revised as indicated. III. Ongoing Monitoring: .C. The Licensed Nurse will document effectiveness of pressure ulcer prevention techniques in the resident's medical record on a weekly basis.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurses (LVN) 2 and LVN 4 performed skin assessment through direct observations, licensed nurses developed a care plan for the condition of the feet, licensed nurses notified the attending physician regarding the condition of the feet, Certified Nursing Assistant (CNA) 2 reported to the licensed nurses the condition of the feet, CNAs documented their observations of the condition of the feet using the facility's Comprehensive Certified Nursing Assistant Shower Review Form (CCNASRF), and the podiatrist provided appropriate medical foot care and treatment for two of two sampled residents (Resident 15 and Resident 36). This failure resulted in pain, discomfort, and neglect (state of not receiving enough care or attention) of Resident 15 and Resident 36's skin and foot care. Findings: During a review of Resident 15's Admission Record (AR), the AR indicated, Resident 15 is an [AGE] year old male, admitted on [DATE] and readmitted on [DATE] after recent hospitalization , with diagnosis including, Chronic Obstructive Pulmonary Disease (COPD- lung disease that causes airflow blockage and breathing-related problems), Type 2 Diabetes Mellitus (DM-characterized by high blood sugar) with Polyneuropathy (a complication of diabetes mellitus characterized by progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and development of foot ulcers), and Hemiplegia (one-sided paralysis)/hemiparesis (loss of strength in the arm, leg, and face on one side of the body) affecting the left dominant side. During a concurrent observation and interview on 3/25/24 at 9:48 a.m. with Resident 15, in Resident 15's room, Resident 15 was lying in bed, awake and conversant, with the lower portion of the body covered with a blanket. Resident 15 was unable to move the left side of his body, and complained of pain on the left knee. During a concurrent observation and interview on 3/25/24 at 9:50 a.m. with CNA 1, in Resident 15's room, CNA 1 pulled Resident 15's blankets off to look at the left knee. Resident 15 had foot drop (inability to lift the forefoot due to weakness of the muscles of the foot for movement) on his left foot. CNA 1 removed the socks and exposed both feet. Resident 15 had pain and discomfort when the left foot was touched. The left foot had an appearance of a small wound on the forefoot of the left 3rd medial phalanx (bone of the toe), redness and swelling of the left foot and five toes, dry and scaly skin on the foot, toes, and blackish discoloration in-between the toes. There was yellowish/blackish discoloration on the 4th toe nail; long and yellowish discoloration of the 2nd, 3rd, and 5th toenails; thick, hard, deformed left big toenail with upward growth of the nail and fungus-like appearance: discolored, thickened, and crumbled at the edge. Resident 15's right foot and toes also had dry, scaly, flaky skin, yellowish discoloration and long toenails on the right 2nd, 3rd, and 4th toes, and the right big toenail was thick, yellowish in color, deformed with toenail growth upward, and fungus-like appearance. CNA 1 stated,It looks like the feet have not been cleaned. I will call his nurse. During an interview on 3/25/24 at 9:52 a.m. with Treatment Nurse (TN) 1and Licensed Vocational Nurse (LVN) 1, TN 1 stated, I have not seen the resident's feet. The cart nurses (referring to the nurses passing medications) do the weekly assessments of the residents. LVN 1 stated, I also have not seen the resident's foot. TN 1 stated, The feet have not been properly showered and cleaned. The right lower extremity has redness and dry skin. The right big toe is thick and has fungus-like appearance. Resident 15 needs podiatry (treatment of disorders of the foot, ankle and lower limb) care, but podiatry is not covered by insurance. Podiatrist comes to the facility every three months. During an interview on 3/25/24 at 10:11 a.m. with CNA 2, CNA 2 stated she noticed Resident 15 had flaky skin on both lower extremities. CNA 2 stated she noticed the feet were red, but she did not check in between the toes. CNA 2 stated she did not document her observations regarding Resident's feet on the person figure on the shower form, and she did not report her observation to the nurse. During an interview on 3/25/24 at 10:12 a.m. with Resident 15, Resident 15 stated it was about two to three months ago when his feet were cleansed. During a concurrent observation and interview on 3/25/24 at 10:13 a.m. with Director of Nursing (DON), in Resident 15's room, DON came to evaluate Resident 15's lower extremities. DON stated, [Resident 15] had bilateral lower extremities redness, scattered. The skin was dry and with scabs on the shin, possible rash, and with unopened wound on the left lateral area of the left lower leg. The left foot has foot drop, with some redness and swelling. The nails were large, hypertrophic (thickening, excessive growth in cells/tissues), joints were getting contracted (hardening of muscles, tissues leading to deformity/rigidity of joints). The left 3rd toe, metatarsal (five long bones in the midfoot) had dry scab. [Resident 15] needs hygiene, definitely needs attention from wound care, and needs podiatry care. DON continued to evaluate Resident 15's right foot and stated, There is redness, swelling, and dryness on the toes. The nails are large on the right big toe, 3rd, 4th, and 5th toenails. There are no wounds observed in between the toes. The left foot is worse than the right foot. DON stated the social worker is responsible for arranging podiatry visits for the residents. DON stated in the past, [Resident 15] had been seen by the podiatrist, but in looking at his feet, it's not recent. During a concurrent observation and interview on 3/25/24 at 11 a.m. with TN 1, in Resident 15's room, TN 1 measured the thickness and the length of the toenails for both feet. The following were the toenail measurements for both feet: Left Foot Toenails: Big toenail: Length 1.4-centimeter (cm) Thickness 1.8 cm. 2nd toenail: Length 0.5 cm Thickness 1 cm 3rd toenail: Length 0.5 cm Thickness 1 cm 4th toenail: Length 1.7 cm Thickness 1 cm 5th toenail: Length 1 cm Thickness 0.7 cm Right Foot Toenails: Big toenail: Length 1.3 cm Thickness 2 cm 2nd toenail: Length 0.7 cm Thickness 0.5 cm 3rd toenail: Length 1.9 cm Thickness 0.6 cm 4th toenail: Length 1.9 cm Thickness 1 cm 5th toenail: Length 1 cm Thickness 1 cm During a concurrent interview and record review on 3/25/24 at 11:21 a.m. with Social Worker (SW), Resident 15's Podiatric Evaluation and Treatment Form (PETF), dated 3/20/24, was reviewed. The PETF indicated, Chief Complaint: pain, edema (fluid retendtion in the body tissues). Skin: Check mark for Atrophy (decrease in size of tissue), Hydration, and Growth. Nails: Right and Left 1,2,3,4,5. Check mark for hypertrophic, yellow, brittle, thick subungual (under the fingernail/toenail) debris. With Pain: Check mark for pain. Edema: +2 (measurement of edema in tissue). Loss of protective sensation: Left. Check mark for: No other significant changes. Check mark for: Nails debrided (removal of infected, damaged or dead tissue) to patient's tolerance only. PETF physician' signature was blank. SW stated Podiatry comes every 45-60 days and they see all the residents. SW stated the podiatrist was last here on 3/20/24 and saw [Resident 15]. SW looked at Resident 15's feet and stated podiatrist did not provide aggressive treatment for Resident 15's feet nor made any recommendations based on the documented podiatrist notes. SW verified the podiatrist did not sign the PETF dated 3/20/24. SW was unable to find other podiatrist PETF documentation on previous visits in the chart. During a review of Resident 15's Shower Schedule, dated 3/5/24, 3/12/24, 3/19/24, and 3/22/24. the shower schedule indicated, Resident 15 is scheduled every Tuesdays and Fridays. During a concurrent interview and record review on 3/25/24 at 2:18 p.m. with TN 1, Resident 15's Skin Monitoring: Comprehensive Certified Nursing Assistant Shower Review Form (CCNASRF), dated 3/5/24, 3/19/24, and 3/22/24, were reviewed. The CCNASRF indicated, On 3/5/24, Resident 15 had completed shower and needed his toenails cut. No visual observation was documented on the person figure on the shower review form. On 3/19/22, [Resident 15] refused to shower. CNA 2 documented Resident 15 needed his toenails cut. No documentation of CNA 2's skin observation on the person figure of the shower review form. On 3/22/24, Resident 15 had full shower, but refused to have lotion applied on the legs due to pain. No documentation of CNA 2's skin observation on the person figure of the shower review form. TN 1 verified the findings and stated the CNAs must document their skin observation on the shower form. During a concurrent interview and record review on 3/25/24 at 2:30 p.m. with TN 1, Resident 15's Care Plan, dated 2/29/24 to 3/25/24, were reviewed. TN 1 was unable to find care plans for skin integrity, and problems with feet and toenails, and stated there were no care plans written. During a concurrent interview and record review on 3/25/24 at 2:40 p.m. with TN1 , Resident 15's Weekly Assessments, dated 1/10/24 to 3/22/24, were reviewed. The weekly assessments indicated the following: 1/10/24 Licensed Vocational Nurse (LVN) 2 documented toenails clean, no foot problem. No skin assessment performed. 1/16/24 LVN 2 documented toenails clean, no foot problem. No skin assessment performed. 1/22/24 LVN 2 documented no foot problem. No skin assessment performed. 2/4/24 LVN 3 documented no foot problem, no skin issue, toenails clean. 2/16/22 LVN 4 documented left lower leg front, no skin issues, toenails clean, no skin issues. 2/22/24 LVN 2 documented left lower leg no skin issues, fingernails/toenails clean, no foot problem. 3/10/24 LVN 2 documented left lower leg no skin issue, fingernails/toenails clean, foot problem, none. 3/16/24 LVN 4 documented fingernails/toenails clean, foot problems none, weekly assessment not completed. 3/22/24 LVN 2 documented foot problem none, fingernails/toenails clean. TN verified the above findings and stated the documentations were copied and pasted. During a concurrent observation, interview, and record review on 3/26/24 at 2:30 p.m. with Physician 2 and LVN 1, in Resident 15's room, Physician 2 examined Resident 15's feet. Physician 2 stated Resident 15 needs to be seen by another Podiatrist. Physician 2 verified Resident 15 has left foot edema and needs proper foot care. LVN 1 verified Resident 15 was on aspirin (medication with blood thinning properties). Physician 2 spoke with LVN 1 and verbally ordered to stop aspirin for two weeks due to presence of petechiae (pinpoint, round spots that form on the skin) on both lower extremities. A review of Physician's Progress Notes, dated 3/26/24, indicated Physician 2 did not document his evaluation of Resident 15's feet. During an interview on 3/27/24 at 2:59 p.m. with LVN 2, LVN 2 stated she reviews the Treatment Assessment Record (TAR) if there is any order for skin and wound issues, and if there is none, she documents no skin issues on her weekly assessment. During an interview on 3/27/24 at 4:32 p.m. with LVN 4, LVN 4 stated the weekly assessment is done whenever he passes his medications. The certified nursing assistants look at the residents' bodies when they give showers, and they notify the nurses of their observations. LVN 4 stated that's how he records his weekly assessment. LVN 4 stated, It is impossible to do head-to toe assessments for all residents. I just copy and paste. They are the same findings. During a review on 3/27/24 at 10 a.m. with Minimum Data Set (MDS-resident assessment tool) Coordinator (MDSC) 1, Resident 15's Nursing Progress Notes, dated 3/1/24-3/22/24, were reviewed. MDSC 1 was unable to find documentation the attending physician was notified of Resident 15's skin and feet condition: red rash to bilateral lower extremities, edema, dry, flaky skin, yellowish discoloration, thick, hard, upward growth of nails on the left and right big toes, and unopened wound to the 3rd phalanx of the left foot, scabs on both shins, and unopened wound on the left lateral aspect of the lower extremity. MDSC 1 stated the only physician notification documented regarding Resident 15's skin and foot condition was on 3/25/24 at 4 p.m. 39356 During a review of Resident 36's Order Summary Report (OSR) [undated}, the OSR indicated, Resident 36 was admitted on [DATE]. During an interview on 3/25/24 at 10:39 a.m. with TN 1, TN 1 stated she had put in a progress note regarding Resident 36 needing podiatry care and a physician order was initiated but Resident 36 has not received any podiatry care. During a review of Nurses Notes (NN) dated 12/26/23 at 10 a.m., the NN indicated, Assessment and recommendation for podiatry consultation for resident [36], focusing on the concern of thickened toe nails. This condition is causing discomfort, unable to provide regular nail care. During a review of Order Details (OD) dated 12/28/23, the OD indicated, Podiatry Care every 60-61 days as needed. During a concurrent observation and interview on 3/25/24 at 10:50 a.m. with DON, TN 1 and Resident 36, in Resident 36's Room, Resident was lying in his bed, awake and alert, with a blanket covering his feet. TN 1 exposed Resident 36's feet, and DON and TN 1 examined the feet of Resident 36. DON stated Resident 36's has a hypertrophied nail on right big toe growing upward, third toe nail has black on it and looks like dried blood. DON stated, left foot all toes have long nails, and both feet are dry and flaky. TN 1 measured the length of the toenails and stated the large toe is approximately 2 cm in thickness and measures in length 1.7 cm from the skin. DON stated Resident 36 is in need of podiatry care and these needs have not been met. Resident 36 stated his feet and toes had been hurting him. During a concurrent interview and record review on 3/25/24 at 11:22 a.m. with DON, Resident 36's Podiatric Evaluation and Treatment (PET) dated 9/8/23 was reviewed. DON stated Resident 36 last podiatry treatment had been completed on 9/8/23. During a review of the facility's policy and procedure (P&P) titled, Grooming Care of the Fingernails and Toenails, dated 11/1/17, the P&P indicated, XVlll. Report any changes in the color of the skin around the nail or nail bed to the attending physician. XlX. Document procedure in the resident's medical record and update resident's care plan as needed. During a review of the facility's P&P titled, Showering a Resident, dated 11/1/17, the P&P indicated, XVl. Report any broken skin, bruises, rashes, cut, skin discoloration or reddened areas to the charge nurse. XVll. Update the resident's care plan.

Based on interview and record review, the facility failed to: 1. Accurately assess and document the pressure ulcers (according to the National Pressure Ulcer Advisory Panel [NPUAP] a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with a shear), noted upon admission for one of four sampled residents (Resident 1). 2. Notify the Medical Doctor (MD) and obtain treatment orders for one of four sampled residents' (Resident 1) pressure ulcers. 3. Develop and implement a care plan (a tool used to follow a plan of action for a resident issues) for one of four sampled residents' (Resident 1) pressure ulcers. These failures resulted in Resident 1 ' s untreated pressure ulcers and had the potential for worsening of Resident 1's pressure ulcers. Findings: During an interview on 5/26/22, at 3:40 PM, with Family Member (FM) 1, FM 1 stated, Resident 1 was sent to the acute hospital on 5/20/22, due to her [CONDITION(S)] (Urinary tract infection - bladder infection). FM 1 stated the acute hospital noted Resident 1 with pressure ulcers to the sacrum (triangular bony area located in the lower back) and deep tissue injuries (an injury to the tissue caused by prolonged pressure to the area which results in unblanchable reddened, maroon, or purple areas of intact, non-intact, or blood-filled blisters) to the right and left heel. FM 1 stated Resident 1 was complaining of pain to her right and left heel at the acute hospital. During a review of Resident 1 ' s ADMISSION RECORD (AR), re-admitted [DATE], the AR indicated, Resident 1 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1 ' s BRADEN SCALE [a tool used to assess a residents risk for skin breakdown] FOR PREDICTING PRESSURE SORE RISK (BSPS), dated 2/10/22, the BSPS indicated, Resident 1 had a score of 15 (a score of 15 to 18 is a mild risk, 13 to 14 is a moderate risk, 10 to 12 is a high risk, and any score less than 9 is considered a severe risk) which indicated Resident 1 was a mild risk for pressure ulcer. During a review of Resident 1 ' s Nurse Admission Record (NAR), dated 4/4/22, the NAR indicated, Resident 1 was readmitted to the facility on [DATE], with a Stage 2 pressure ulcer (partial thickness skin loss with exposed dermis [skin], the wound is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) to her sacrum, and an unstageable pressure ulcer (not able to identify the severity of ulcer) to her right heel, and a wound (no identification of what type) to her left heel. During a review of Resident 1 ' s Minimum Data Set (MDS - an assessment tool), dated 4/10/22, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 15 (a score of 13 to 15 means resident is cognitively [mental process that involves knowledge and comprehension] intact, 8 to 12 suggest moderate impairment, 0 to 7 suggest severe impairment). Resident 1 was incontinent (unable to voluntarily control) of bowel and bladder. Resident 1 was totally dependent and required one person assistance for toilet use, needed extensive one person assistance for bed mobility, eating, dressing and personal hygiene. Resident 1 required extensive two persons assistance for transfers between surfaces. The MDS did not indicate Resident 1 had pressure ulcers to the sacrum and right and left heel on admission. 1. During an interview on 6/13/22, at 11:31 AM, with Director of Nursing (DON), DON stated, she reviewed Resident 1 ' s complete clinical record (progress notes, nursing notes, assessments, treatment records, medication records, MD notes from 4/4/22 to 5/20/22) and stated there were no skin assessments and the nurses' notes did not indicate Resident 1 had pressure ulcers to her sacrum and right and left heel (from date of admission 4/4/22 to date of discharge 5/20/22). During a concurrent interview and record review on 6/13/22, at 12:06 PM, with Wound Nurse (WN), Resident 1 ' s complete clinical record (progress notes, nursing notes, assessments, treatment records, medication records, MD notes from 4/4/22 to 5/20/22) was reviewed. WN stated she had been working at the facility for about a year. WN stated she did not recall providing any type of skin assessments to Resident 1. WN stated there were no nursing progress notes to reflect any assessments to the pressure ulcers of Resident 1 ' s sacrum and right and left heel. During an interview on 7/8/22, at 2:34 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 was sent to the acute hospital and she was the nurse who completed the body sheet assessment (a tool used to convey information regarding a residents physical body status) for Resident 1 prior to sending Resident 1 to the acute hospital on 5/20/22 due to [CONDITION(S)]. LVN 1 stated Resident 1 had, at least a Stage 1 pressure ulcer [non-blanchable redness of intact skin] to her sacrum and to right and left heel (from date of admission 4/4/22 to date of discharge 5/20/22). During a review of Resident 1 ' s Discharge Body Sheet (DBS), dated 5/20/22, the DBS indicated, Resident 1 had been assessed on the day of discharge (5/20/22) to the acute hospital with: a. Multiple skin discolorations (locations not defined nor measurements taken). b. Stage 1 and redness to sacrum area (no measurements taken). c. Wound/redness to both heels (no measurements or description). d. Discoloration to below the left back of knee (no measurements or description). The DBS indicated Resident 1 was sent to the acute hospital (5/20/22) for [CONDITION(S)] ([CONDITION(S)])/collapse. During a review of Resident 1 ' s Acute Hospital Record Clinical Photos (ACRCP), dated 5/21/22, the ACRCP indicated, Resident 1 was admitted to the acute hospital with the following skin/wound conditions: a. Skin conditions/wound to Resident 1 ' s left forearm and left posterior forearm (no measurements or details). b. Skin conditions/wound to Resident 1 ' s right and left lower extremities (no measurements or details). c. Skin conditions/wound to Resident 1 ' s bilateral feet (no measurements or details). d. Skin conditions/wound to Resident 1 ' s coccyx (tailbone)/buttocks (no measurements or details). e. Skin conditions/wound to Resident 1 ' s left leg (no measurements or details). f. Skin condition/wound to Resident 1 ' s right face/neck (no measurements or details). g. Skin condition/wound to Resident 1 ' s left neck (no measurements or details). h. Skin condition/wounds to Resident 1 ' s right arm (no measurements, details or number of wounds noted). i. Skin condition/wounds to Resident 1 ' s chest (no measurements or details). j. Skin condition/wound to Resident 1 ' s left heel (no measurements or details). k. Skin condition/wounds to Resident 1 ' s right heel (no measurements or details). During an interview on 7/8/22, at 3:01 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she had noticed pressure ulcers with Resident 1 all the time (from date of admission 4/4/22 to date of discharge 5/20/22). CNA 1 stated Resident 1 was very frail. CNA 1 stated she noticed Resident 1 ' s sacrum had pressure ulcer and redness. CNA 1 stated the facility did not have a wound nurse at that time (cannot remember the date), so she was not sure if [Resident 1] received wound treatment. CNA 1 stated she reported the pressure ulcers and skin issues to the licensed nurses' all the time (could not identify which nurses). CNA 1 stated everyone (nurses and CNAs) knew about Resident 1 ' s pressure ulcers, it was no secret, CNAs and licensed nurses all knew. During a review of the facility ' s policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, undated, the P&P indicated, The nurse shall assess and document/report the following . Full assessment of pressure sore including location, site, length, width and depth, presence of exudates [mass of cells and fluids that seep out of wounds] or necrotic [dead] tissue. During a review of the facility ' s policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, the P&P indicated, All services provided to the resident . or any changes to the resident ' s medical, physical or psychosocial condition, shall be documented in the residents medical record. Documentation of procedures and treatment will include care specific details, including . The assessment data and/or any unusual findings obtained during the procedure/treatment . 2. During an interview on 6/13/22, at 11:31 AM, with DON, DON stated, she reviewed Resident 1 ' s clinical records (progress notes, nursing notes, assessments, treatment records, medication records, MD notes from 4/4/22 to 5/20/22) and noted there was no notification to the MD regarding Resident 1 ' s pressure ulcers or wound treatment orders in place (from date of admission 4/4/22 to date of discharge 5/20/22). During a concurrent interview and record review on 6/13/22, at 12:06 PM, with WN, WN stated, there was no evidence the facility provided pressure ulcer treatment to Resident 1's sacrum and left and right heel from 4/4/22- 5/20/22 (more than six weeks). WN stated she had been working at the facility for about a year. WN stated she did not recall providing any type of wound treatment to Resident 1. During an interview on 6/30/22, at 2:22 PM, with Registered Nurse (RN) 1, RN 1 stated, she was the nurse who performed the re-admission initial body assessment for Resident 1 on 4/4/22. RN 1 stated Resident 1 was noted with pressure ulcers to the sacrum and right and left heel upon admission, but she may have gotten busy and not informed the MD of Resident 1 ' s pressure ulcers or obtain wound treatment orders. During an interview on 7/8/22, at 2:34 PM, with LVN 1, LVN 1 stated if Resident 1 was not on treatments for wounds she (Resident 1) should have been. LVN 1 stated she was not sure if the MD or WN was aware of Resident 1 ' s pressure ulcers. LVN 1 stated she had never reported the pressure ulcers of Resident 1 to the MD. During a review of the facility ' s policy and procedure (P&P) titled, Guideline for Notifying Physicians of Clinical Problems, undated, the P&P indicated, These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner. The charge nurse or supervisor should contact the Attending Physician at any time if they feel a clinical situation requires immediate discussion and management. During a review of the facility ' s policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, undated, the P&P indicated, The physician will help the staff define the type and characteristics of an ulceration [wound]. The physician will authorize pertinent orders related to wound treatments . The physician will help identify medical interventions related to wound management . During resident visits, the physician will evaluate and document the progress of wound healing . The physician will help the staff review and modify the care plan as appropriate. 3. During a concurrent interview and record review on 6/13/22, at 11:31 AM, with DON, DON stated, she reviewed Resident 1 ' s clinical record and stated there were no care plans developed for Resident 1 ' s pressure ulcers to the sacrum and right and left heel (from date of admission 4/4/22 to date of discharge 5/20/22). During a review of the facility ' s policy and procedure (P&P) titled, Care Plan, dated 8/2006, the P&P indicated, The care plan shall be used in developing the resident ' s daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident.

Based on interview and record review, the facility failed to: 1. Identify and report a fall for one of three sampled residents (Resident 1) 2. Follow the facility's policy and procedure (P&P) titled, Assessment and Management of Residents Falls, for three of three sampled residents (Resident 1, Resident 2, and Resident 3) 3. Develop and implement an effective risk for fall care plan (CP) for one of three sampled residents (Resident 1) These failures had the potential to result in future falls for Resident 2 and Resident 3, and resulted in Resident 1 sustaining a femur (thighbone) fracture (break in the bone) and pain which went unnoticed for six days. Findings: 1. During an interview on 1/5/22, at 10:38 AM, with Resident 1, Resident 1 stated, a certified nursing assistant (CNA) 1 was helping him transfer to the wheelchair the morning of 12/27/21. Resident 1 stated, his right leg got weak and stiff, and he grabbed the wheelchair and fell to the ground. Resident 1 stated, he was in pain, and he hollered, and screamed Get some help! Resident 1 stated, CNA 1 and two another staff members helped him to his wheelchair. Resident 1 stated, he must now wear a brace and cannot walk on his right leg for a while. During an interview on 1/5/22, at 1:45 PM, with Director of Nursing (DON), DON stated, she became aware of Resident 1's fall on Sunday (1/2/22). DON stated, she was informed Resident 1 had a discoloration to right leg, Resident 1's physician ordered an x-ray, and the next day we found out about the fracture. DON stated, during the investigation she found on 12/27/21, Resident 1 was eased to the floor by CNA 1. DON stated, Licensed Vocational Nurse (LVN) 1 and CNA 1 assisted Resident 1 back bed. DON stated, I told them so many times even though you ease the patient to the ground that is still considered a fall. As long as the patient touches the ground it is a fall. During an interview on 1/8/22, at 12:39 AM, with CNA 1, CNA 1 stated, she was assisting Resident 1 to the wheelchair, she stated he felt weak, so she assisted him to the floor. CNA 1 stated, she went and got LVN 1 and a CNA to help. During an interview on 1/8/22, at 12:46 AM, with LVN 1, LVN 1 stated, she does not recall assisting Resident 1 to the wheelchair or helping him up off the floor, she stated the fall that the CNA was talking about was two weeks ago. During a review of Resident 1's Progress Notes (PN), dated 12/27/21, at 6 AM, the PN indicated, @0600 while LN (Licensed Nurse) [LVN 1] was doing medication round CNA mentioned that resident had slip a bit from his wheelchair. When asked if he had a fall CNA denied and CNA said they just need help with transfer and got another CNA. Upon doing blood check and giving mornin (Draft)g [sic] med on resident @0630, resident did not mention any fall to LN [LVN 1] as he was already in wheelchair. During a review of the facility provided document titled, Conclusion of Self Report Resident Fall with Injury, undated, the document indicated, On 1/2/22, resident was noted to have a skin discoloration on his right leg. Investigation was initiated. On 12/27/21, resident (Resident 1) lost his balance during transfer from bed to wheelchair and was carefully assisted down to the floor by the CNA (CNA 1). The CNA (CNA 1) then asked for assistance from charge nurse (LVN 1) and another CNA to transfer him back to bed. Resident was sent to hospital per MD (Medical Doctor) orders on 1/3/22. 2. During a concurrent interview and record review, on 1/5/22, at 1:45 PM, with DON, DON reviewed Resident 1's medical record (MR). DON confirmed, there was no documentation of Resident 1's fall. DON reviewed Resident 2's MR. DON confirmed Resident 2 had a fall on 12/9/21. DON confirmed Resident 2 did not have a fall risk assessment completed, or an updated care plan for the fall on 12/9/21. DON reviewed Resident 3's MR. DON confirmed Resident 3 had a fall on 12/16/21 and 12/21/21. DON confirmed Resident 3 did not have a fall risk assessment completed for 12/16/21 or 12/21/21. DON stated, her expectation of nurses is to identify type of fall; witnessed or unwitnessed. She stated, if unwitnessed start neurological (relating to the anatomy, functions, and organic disorders of nerves and the nervous system) checks, assess resident, notify physician and responsible party, 72-hour alert charting to monitor for delay injuries, fall assessment, update care plan, and increased visual monitoring. During a review of the facility's P&P) titled, Assessment and Management of Residents Falls, undated, the P&P indicated, The staff will evaluate and document falls that occur while the individual is in the facility, for example, when and where they happen, any observations of the events, etc. 3. During a concurrent interview and record review, on 1/25/22, at 11:15 AM, with DON, DON reviewed Resident 1's Minimum Data Set (MDS- an assessment tool), dated 10/14/21. DON confirmed Resident 1 needed extensive assistance to transfer and was a two person assist. DON reviewed Resident 1's CP with the focus on risk for falls, initiated 11/22/19. DON confirmed, the CP did not contain documentation of Resident 1 needing two persons assist with transfers. DON reviewed Resident 1's CP with the focus on limited physical mobility, initiated 12/4/19. DON confirmed, the CP did not contain documentation of Resident 1 needing two persons assist with transfers. DON stated, it should have been care planned. DON stated, CNA 1 should have had two persons to transfer Resident 1. DON stated, with two persons assist Resident 1's fall on 12/27/21 with fracture could have been prevented. During a review of the facility's P&P) titled, Assessment and Management of Residents Falls, undated, the P&P indicated, It is the policy of [facility name] to prevent falls among resident as humanly possible and provide interventions that may address resident's specific risks and causes of residents falls.

Based on observation, interview, and record review, the facility failed to provide a safe environment for one of four residents (Resident 1). This failure resulted in Resident 1's elopement (departing a health care facility unsupervised and undetected) through the bedroom window and return to facility with facial injuries. Findings: During a review of Resident 1's ADMISSION RECORD, (AR), the AR indicated, Resident 1 was admitted on [DATE]. During a review of Resident 1's Minimum Data Set (MDS - Comprehensive assessment of Resident's functional abilities), dated 12/29/21, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS-determines Resident's cognition to determine interventions) was three (BIMS of zero-three indicates severe cognitive impairment.) During a review of Resident 1's ELOPEMENT/WANDERING RISK WORKSHEET (EWRW), dated 1/8/22, the EWRW indicated, CLINICAL CONDITION PREDISPOSING DISEASE: DEMENTIA [brain disorder than can affect memory, though process and decision making], ORGANIC BRAIN SYNDROME [memory, thinking, perception and attention disorder], ALZHEIMER'S DISEASE [progressive mental deterioration], MENTAL ILLNESS, T.B.I. [Traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head) ]. The EWRW also indicated, Resident 1 was ambulatory(able to walk)/WC (wheel chair), intermittent confusion, purposeful exit seeking, had 1-2 elopement episodes for the last 6 months, was at risk for elopement. The EWRW plan indicated, PLAN: CONSIDER ANY PATTERN OF EXIT SEEKING, NEED T ALTER RESIDENT SCHEDULE, TREATMENT, MEDICATIONS, OR ENVIRONMENT TO MANAGE BEHAVIOR wander safety management bracelet [band placed on arm or leg that would activate an alarm if resident attempted to exit the facility through the door] as monitoring device. During a review of Resident 1's EWRW, dated 1/28/22, The EWRW indicated, PLAN: CONSIDER ANY PATTERN OF EXIT SEEKING, NEED TO ALTER RESIDENT SCHEDULE, TREATMENT, MEDICATIONS, OR ENVIRONMENT TO MANAGE BEHAVIOR wander safety management bracelet bracelet as monitoring device, Q [EVERY] 15 MIN [minute] MONITORING, [MEDICATION(S)] [used to treat anxiety] routine and prn (as needed) per md [Medical Doctor] orders. During a concurrent observation and interview on 1/28/22, at 3:50 PM with Maintenance Supervisor (MS), in Resident 1's room (Room X -Room Resident 1 eloped from on 1/28/22), MS stated he was told Resident 1 had left through the bathroom window on 1/28/22. Resident 1's bathroom window was observed to not have a functioning window latch (latch is turned to lock or unlock the window) or window crank (turning the handle on the crank causes a control arm to move, pushing the window open or pulling it closed). MS pushed on the window and it opened approximately 4 inches. MS stated the window latch and window crank were broke and should have been replaced. MS stated the latch prevents the window from opening with a push and window crank will prevent it from being pushed open also. During a concurrent observation and interview on 1/28/22, at 4:10 PM with MS, in Resident 1's room (Room XX), Resident 1 was observed lying in bed with a sitter (direct continuous monitoring of Resident by staff member) at the foot of his bed by the entrance. The bathroom window in Resident 1's room was unlatched and MS was able to slide the window open. MS said the window should have been latched. During a concurrent observation and interview on 1/28/22, at 4:15 PM, with Resident 1's Sitter, in Resident 1's room XX, Sitter stated, she monitored the resident continuously and documented his behavior every 15 minutes in the monitoring log. Sitter stated Resident 1 used the wheelchair to go to the bathroom. Sitter stated Resident 1 walked on his own prior to the elopement. During a concurrent observation and interview on 1/28/22, at 4:30 PM, with Resident 1, in Resident 1's room XX, Resident 1 was observed resting in bed. Resident 1 had gauze (type of thin medical fabric with a loose open weave used in wound care) to the right brow area and left forehead sutures with facial bruising. Resident 1 stated he did not know what happened to him. During a concurrent interview and record review, on 1/28/22, at 4:45 PM, with Activities Director (AD), Resident 1's medical record (MR) was reviewed. AD stated resident 1 was homeless and was his own responsible party. Resident 1 eloped on 1/27/22 around 12:30 PM from Room X and he was found around 1:30 PM by staff outside the facility. AD stated she is unsure how he left the building. During a concurrent observation and interview on 1/28/22, at 5:10 PM, with Licensed Vocational Nurse (LVN) 1, in Resident's room, Resident 1 was observed to have a wander safety management bracelet on his right ankle. LVN 1 stated the wander safety management bracelet only works if the resident leaves through an outside door. LVN 1 stated Resident 1 left through the window (Room X) when he eloped on 1/28/22. During an interview on 1/28/22, at 5:30 PM, with AD, AD stated Resident 1 had eloped on 1/27/22 in the daytime, he was found and returned to the facility. AD stated they are unsure how he left the facility because he walks all around. AD stated when Resident 1 was returned to the facility, Resident 1 was moved to a room closer to the nurses' station (Room XX) and a one on one sitter was placed in his room. During a review of Resident 1's Progress Notes (PN), written by LVN 1, dated 1/8/22 at 7:47 AM, the PN indicated, on 1/8/22, Resident [1] had an attempted elopement around @ [at] 0600 [6 AM] but did not leave facility grounds. Resident had left room via window. Was found in parking lot crouched by the trash.was found bleeding on right hand. During a review of Resident 1's PN, written by LVN 3, dated 1/15/22 at 8:23 AM, the PN indicated, on 1/15/22, Resident 1 was reported missing at approximately 12 AM. The facility and grounds were searched. The police department returned Resident 1 to the facility at approximately 3:20 AM. Resident 1 did not sustain an injury. During a review of Resident 1's PN, written by Minimum Data Set Coordinator (MDSC), dated 1/27/22, at 12:30 PM, the PN indicated, on 1/27/22, Resident 1 was noted to be missing at 12:30 PM. All staff searched for Resident 1. Resident [1] was found outside of the facility premises and came safely back with staff at 1:30 PM. Wanderguard [wander safety management bracelet] was checked for functioning. q [every] 15 minute monitoring was initiated. During a review of Resident 1's PN, written by LVN 1, dated 1/28/22, at 3:13 AM, the PN indicated, on 1/28/22 at 12:45 AM, LVN 1 was notified by CNA that Resident 1 was not in his room. The facility was searched. Residents [sic] roommate stated that he saw resident [1] turn on sink [in] restroom then he left via window. @ 0100 [1 AM] 911 [emergency call] was call [sic] to report him as missing. @ 0240 [2:40 AM] 911 called back to say that he [Resident 1] was found by [Major Drive and Major Boulevard] - approximately 3-4 miles from facility]. Officer noted a head injury with some bleeding, will be sent to [hospital name]. @ [at] 0305 [3:05 AM] resident [1] arrived at hospital. During a review of Resident 1's PN IDT [Intradisciplinary Team - health care professionals who work together to development goals for Residents] Special Meeting, dated 1/28/22, at 11:02 AM, written by MDSC was reviewed. The PN IDT indicated, Resident [1] had an elopement episode on 1/28/22 at 12:45 am. Resident went through restroom's window according to his roommate [Resident 2]. Resident will be on 1:1(continuous visual observation of resident at all times) monitoring when he comes back. and will be moved to rm [Room XX]. During a concurrent observation, interview, and record review on 2/2/22, at 10:50 AM, with MDSC, Resident 1's MR was reviewed. MDSC verified Resident 1 was in Room X until after the 1/28/22 elopement. MDSC stated on 1/8/22, Resident 1 eloped out the window and was found in the facility parking lot. MDSC stated Resident 1 eloped from Room X's a window on 1/15/22 and he was found approximately 1 hour later with no injuries. MDSC stated on 1/27/22, a CNA reported to her that during her rounds, Resident 1 was unable to be found. MDSC stated the staff looked inside and outside the facility. MDSC stated Resident 1 was found outside the facility's gates. MDSC stated he had a functioning Wanderguard on and it did not alarm. MDSC stated there is a camera filming the smoking area. MDSC stated she reviewed the footage on 1/27/22 and Resident 1 was seen entering the smoking area camera but was not seen returning into the facility from the smoking area. MDSC stated there is no wander safety management bracelet alarm on the patio door as the back patio is fenced. MDSC stated there were no open gates around the facility. MDSC stated Resident 1 is strong and tall. MDSC stated Resident 1 could have used the tree stump near to climb over the fence from the patio area. MDSC stated no one saw Resident 1 leave the facility. During a concurrent interview and record review, on 2/3/22, at 1:50 PM, with LVN 2, Resident 1's MR was reviewed. LVN 2 stated on 1/27/22, she was informed by CNA 1, Resident 1 was missing from Room X. LVN 2 stated CNA 1 drove around the area and located Resident 1 at approximately 1:15 PM. LVN 2 stated he was last seen at approximately 10:30 AM. LVN 2 stated Resident 1 was on visual checks and had a wander safety management bracelet on because he has a history of elopement. LVN 2 stated on 1/28/22, Resident 1 went through the bedroom window by bed C in Room X. Resident 1 was ambulatory and was able to open a window latch and push the window open. LVN 2 stated she moved Resident 1 to Room XX when he was returned to the facility. LVN 2 stated Resident 1 told her it was dark, he could not see, he fell two times, and hit his head. During a concurrent interview and observation, on 2/3/22, at 2 PM with LVN 2, in Room X, no residents were observed. A closed window latch was observed and the window could not open. LVN 2 stated there was no screen on the window the night he (Resident 1) eloped on 1/28/22. LVN 2 stated the window opens out and was able to be pushed open. LVN 2 stated MS put a screen on the window and fixed it so it will not open now. During a concurrent interview and record review on 2/3/22 at 2:05 PM, with Director of Nursing (DON), Resident 1's Care Plan (CP), undated was reviewed. DON stated a CP addressing Resident 1's elopement risk was initiated on 1/16/22. The CP focus, The resident is an elopement risk/wanderer r/t [related to] History of attempts to leave facility unattended, impaired safety awareness. Interventions initiated 1/28/22 were 1:1 Monitoring and room change. Resident will be moved to room XX where outside the restroom window is secured and within the facility premises. DON stated the CP should have been initiated following the 1/8/22 elopement. During a concurrent interview and record review on 2/3/22 at 2:31 PM, with DON, Resident 1's medical record (MR) was reviewed. DON stated Resident 1 reportedly turned on the water to the bathroom sink and left via the window per the roommate (Resident 2). A work order was placed on 1/28/22 for MS to check the bathroom and bedroom window in Resident 1's room. DON stated there were no other window work orders prior to 1/28/22. DON stated the Resident 1's bedroom window should have been repaired so it could not be pushed opened prior to the 1/28/22 elopment. During an interview on 2/9/22, at 10:10 AM, with CNA 2, CNA 2 stated on the night Resident 1 eloped, Resident 1 was on every 15 minute monitoring. CNA 2 stated Resident 1 was in his room when she left for lunch at 11 PM and was gone when she returned at 11:30 PM. CNA 2 stated she went to Resident 1's room and the bathroom sink water was running and the door was closed. The bedside table was pulled partially in front of the bathroom door. CNA 2 stated Resident 2 told her Resident 1 had climbed out the bathroom window. CNA 2 attempted to open the bathroom window but it only opened a little bit. CNA 2 stated she did not check the bedroom window because the curtain was closed. CNA 2 stated the staff checked the facility and the police were called. During an interview on 2/9/22, at 11:27 AM, with MS, MS stated on 1/8/22, he was informed Resident 1 had eloped through the bedroom window, the screen was on the side of the window. MS stated there was no crank on the window and the bedroom window could be pushed open. During a concurrent interview and record review on 2/9/22, at 11:45 AM, with MS, the Facility Maintenance log (ML), dated 1/28/21, was reviewed. The ML indicated, on 1/28/21 the maintenance department inspected all windows in the Residents' rooms and bathrooms to ensure they were in good working order. Room X indicated a handle and lock install by MS. MS stated, the handle is the part of the crank that opens the window and the latch is a lock for the window. MS stated the crank prevents the window from being pushed open when it has been closed. MS stated, the window should have been repaired earlier. MS stated he did not have a work order to repair Resident 1's room window prior to the work order dated 1/28/22. During a review of the facility's policy and procedure (P&P) titled, Interdisciplinary Team, undated, the P&P indicated, Our facility's Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.The Interdisciplinary Team which includes, but not necessarily limited to the following personnel: a. The residents Attending physician; b. The Registered Nurse has responsibility for the resident.d. The Social Services Worker responsible for the resident; e. The Activity Director/Coordinator; f. Therapists.h. The Director of Nursing (as applicable); The Charge Nurse responsible for the resident's care; and k. Others as appropriate or necessary to meet the needs for resident. 2. The interdisciplinary team meetings will discuss resident's current condition, current plan of care, and recommended interventions to provide quality of care for resident.

Based on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach, to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status, for two of four sampled residents (Resident 3, Resident 51) when: 1. The facility failed to ensure a Registered Dietitian (RD) evaluated one of four sampled resident's (Resident 3) nutritional status, to recommend nutritional interventions, after an unplanned severe weight loss of 8.57% (percent), in which further weight loss continued to accumulate to an 11.42% severe weight loss in a three-month period, and significant unplanned weight loss of 10.79% in a six-month period. In addition, the facility failed to ensure the weight goal was established with the involvement of the resident for resident-centered care. The facility also failed to ensure the physician was notified of the unplanned severe and significant weight losses within those time frames. 2. The facility failed to ensure RD completed an annual comprehensive nutrition assessment for one of four sampled residents (Resident 51), during which time the resident had an unplanned significant weight gain. Failure to identify and address unplanned severe weight loss in the elderly (Resident 3) may be associated with an increased risk of mortality and other negative outcomes. Failure to ensure a RD completed an annual comprehensive nutrition assessment during which time Resident 51 had an unplanned severe weight gain placed the resident at risk for further impaired nutrition and health status. Findings: 1. During a review of Resident 3's Admission Record, (AR) the AR indicated, Resident 3 was an [AGE] year-old female. During a review of Resident 3's Quarterly Minimum Data Set (MDS, a resident assessment), dated 11/18/21, the MDS indicated, Resident 3 weighed 156 pounds (lbs) and had a Weight Loss of 5% or more in the last month or loss of 10% or more in the last 6 months, and was not on physician-prescribed weight-loss regimen [a program that is supervised by a medical professional that specializes primarily in weight loss for individuals that have a hard time losing weight despite their efforts]. During a concurrent observation and interview on 2/28/22, at 1:04 PM, in Resident 3's room, Resident 3 was observed to have eaten 100% of her lunch, and Resident 3 stated, The food is good. During an observation on 3/1/22, at 12:55 PM, in Resident 3's room, Resident 3 was in bed, eating her lunch independently. During a review of Resident 3's Weights and Vitals Summary, the Weights and Vitals Summary indicated, The following weights were obtained by mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility): 7/30/21 - 176 lbs 8/6/21 - 176 lbs 9/2/21 - 175 lbs 10/9/21 - 160 lbs 12/7/21 - 155 lbs 1/11/22 - 157 lbs During a review of Resident 3's Nutritional Progress Record - Quarterly (NPRQ), dated 11/18/21, the NPRQ indicated, Resident 3's Admission Weight- 172 lbs and Ideal Body Weight- 112 lbs.Supplemental Foods & Frequency -% intake/acceptance listed 'Snacks at H.S [bedtime] offered daily'.current weight 156 lbs.significant weight change at 90 and 180 days -yes.Meeting care plan goals? - No.Continue Plan of Care. completed by the Dietary Services Supervisor (DSS). There was no documentation of a referral to the RD. During a review of Resident 3's Resident Care Conference Form (RCCF), dated 11/18/21, the RCCF indicated, Nutritional Risk - low.Present Problems: Significant wt [weight] loss x 90 days 20# [lbs] x 180 days 16#, Goals: To stop the wt loss ensure adequacy nutrition, completed by the DSS. There was no documentation of a referral to the RD. There was no documented nutrition plan of care to address the documented goal for Stop the wt loss. During a review of Resident 3's Nutrition/Dietary Note (NDN), dated 11/22/21, the NDN indicated, Resident 3 included, Significant wt loss x (times) 90 days x 180 days 16# cont [continue] POC [plan of care]. completed by the DSS. There was no documentation of a referral to the RD. During a review of Resident 3's NDN, dated 2/17/22, the NDN indicated, Current wt 157#, IBW [ideal body weight] 112 [lbs], no significant changes x 180 days cont POC, completed by the DSS. There was no documentation of a referral to the RD. The Weights and Vitals Summary indicated there were significant changes in the past 180 days, as from August 2021 to February 2022, Resident 3 had lost significant weight. During a concurrent interview and record review, on 3/2/22, at 9:27 AM, with DSS, Resident 3's Initial Nutritional History/Assessment ([NAME]), dated 7/21/21, was reviewed. The [NAME] indicated, Weight (lbs) 172, UBW (lbs) - 112. DSS stated UBW means ideal body weight. DSS stated. I put 112 lbs as the ideal body weight based upon a chart I use. The DSS verified he had not discussed the documented ideal body weight with the resident, as he solely based it upon a chart. DSS provided the chart titled, Suggested Weights Ranges that listed 61 (Resident 3's height) with a SWR (suggested weight range) of 104-121 lbs. During a concurrent interview and record review, on 3/2/22, at 1:16 PM, with RD, Resident 3's RCCF, dated 7/12/21, was reviewed. The RCCF indicated, Current Weight (lbs) 172.Goal Body Weight (lbs): 112.Goals: Maintain good nutrition hydration diet. was assessed by the DSS. RD stated, I did not realize that related to the DSS documenting a goal body weight. RD verified setting a goal weight was within the scope of practice of an RD, but not a DSS. RD stated she would have expected the DSS to refer to RD after identifying a significant wt loss, and verified there was no referral to RD. RD verified the nutrition progress notes completed by the DSS contained inaccuracies when documenting 112 lbs and IBW and/or UBW and classifying the resident as low nutritional risk. RD verified UBW means a person's typical or baseline weight for most of their adulthood prior to a recent illness or fall, for example, and does not mean ideal body weight (IBW). RD verified documenting an IBW of 112 lbs was potential for miscommunication amongst IDT (interdisciplinary team- consists of other disciplines/professionals participating in the residents care with resident as the most important member. IDT assesses residents medical, functional, psychosocial, and cognitive needs and develop a single comprehensive plan of care to address the identified needs) members and may have been a factor in the lack of nutrition care and interventions to address the unplanned weight loss. RD verified significant unplanned weight loss should be avoided in geriatric nutrition standards of practice with the elderly who are limited in their ability to physically exercise, in order to preserve lean body mass. During a concurrent interview and record review, on 3/2/22, at 1:19 PM, with RD, RD stated she had not completed a nutrition assessment for Resident 3 since the [NAME], dated 7/21/21. RD reviewed the [NAME] indicated, Weight (lbs) 172, UBW (lbs) - 112. RD stated, the weight of 172 pounds was Resident 3's current weight. RD stated Resident 3's UBW was not 112 lbs and the nutrition assessment was inaccurate. The same nutrition assessment indicated RD calculated daily nutritional needs from a weight of 55 kg (121 lbs), which was 51 lbs less than Resident 3 weight. RD verified assessing daily calorie needs for 121 lbs (55 kg) had the potential to promote weight loss, and Resident 3 was not on a physician-prescribed weight-loss regimen. RD stated her goal or expectation for the resident was to maintain weight. RD verified using 55 kg was based on an adjusted body weight as determined by the RD, without the involvement of the resident's desires and goals for her own weight. During a concurrent interview and record review, on 3/2/22, at 1:56 PM, with RD, Resident 3's Weights and Vitals Summary, from 7/30/21 through 1/11/22, was reviewed. RD stated, Resident 3 had an unplanned severe weight loss, during a one-month time frame of 8.57%, (percent) from 9/21/21 at 175 lbs to 10/9/21 at 160 lbs. RD stated, Resident 3 had an unplanned severe weight loss, during a three-month time frame of 11.42%, from 9/2/21 at 175 lbs to 12/7/21 at 155 lbs. RD stated, Resident 3 had an unplanned significant weight loss during a six-month time frame of 10.79%, from 7/30/21 at 176 lbs to 1/11/22 at 157 lbs. According to the American Academy of Family Physician journal, indicated Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. (American Family Physician, February 15, 2002/Volume 65, Number 4) According to the American Academy of Family Physician journal, indicated Involuntary weight loss can lead to muscle wasting, .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician) According to the Journal of the American Dietetic Association (currently called the Academy of Nutrition and Dietetics), indicated Unintended weight loss is defined as a gradual, unplanned weight loss that may occur slowly over time or have a rapid onset. In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost. (Journal of the American Dietetic Association, October 2010/Volume 110, Number 10). During a concurrent interview and review of Resident 3's electronic health record, on 3/2/22, at 2:06 PM, with RD, RD stated she should have recalculated daily calorie, protein, and fluid needs, assessed Resident 3's nutrition intake as compared to assessed needs, and developed nutrition interventions after the initial significant unplanned weight loss. RD stated there were no nutrition assessments conducted to evaluate the significant unplanned weight loss for the one month, three month and six month time. RD stated, They were missed. RD stated the unplanned significant weight loss in the elderly could promote decline of lean body mass and be harmful, which puts the resident at increased risk for poor health outcomes. During a concurrent observation, interview and record review, on 3/2/22, at 2:56 PM, with RD, RD stated the facility's criteria was to address significant unplanned weight loss of 5% in a month, 7.5% during a three-month time frame, and 10% in a six-month time frame via a weight variance committee. RD verified there was no weight variance committee documentation located in Resident 3's clinical record. RD stated the DSS keeps a paper copy of any weight variance committee meetings conducted and/or the Minimum Data Set Coordinator (MDSC). The surveyor observed RD text the DSS, and RD stated, the DSS stated there was no record of a weight variance committee for Resident 3. RD reviewed Resident 3's clinical record and verified the only intervention the facility was providing to Resident 3 to address unplanned significant weight loss was an HS (bedtime) snack. RD stated an HS snack was not really considered an intervention because if it was a planned intervention for a specific problem, such as weight loss, it should have been physician ordered. RD stated, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RD stated the facility was not documenting consumption of non-ordered snacks so there would not be a way to evaluate the effectiveness of HS snacks, in order to compare with assessed daily nutritional needs, or to re-evaluate an alternative nutrition approach in a timely manner. During an interview on 3/2/22, at 3:09 PM, with MDSC and RD, in the presence of the Director of Nursing (DON), MDSC stated, she does not have any copies of weight variance committee for Resident 3, as the DSS keeps the copies of weight variances for any resident. MDSC verified there was no documentation of a weight variance meeting for Resident 3 in the clinical record. RD verified the only time she documented a nutrition note for Resident 3, after the initial nutrition assessment dated [DATE], was during a NDN, dated 1/26/22, the NDN indicated, Pressure ulcer [injuries to skin] resolved. Rec [recommend] d/c [discontinue] 30 ml [milliliters, a unit of measurement] Prostat [supplement to increase protein] daily, zinc (a mineral), vit [vitamin] c and MVI [multivitamin]. RD verified there was no documentation by the RD assessing, or addressing the significant unplanned weight loss, as it was missed. During an interview on 3/2/22, at 4 PM, with DON, DON verified the facility had not notified Resident 3's physician of the significant unplanned weight losses between 7/30/21 and 1/11/22. During a review of the facility's policy and procedure (P&P) titled, Weight Change Protocol, dated 2018, the P & P indicated, Early identification of a weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner.Residents who experience significant changes in weight or insidious weight loss will be assessed by the RD. The following criteria define significant or insidious weight changes: Unplanned weight loss trend that has occurred 2 times or more. This can refer to weekly or monthly weights, 3# weight loss or gain in 1 week.5# weight loss or gain in 1 month, 5.0% weight loss or gain in 1 month, 7.5% weight loss or gain in 3 months, 10% weight loss or gain in 6 months. The RD will assess, nutritionally diagnosis, suggest interventions, monitor, and evaluate the success of the interventions, ASSESSMENT; .Resident's usual weight and weight goal - based upon information from resident or decision-maker.calculate energy, protein and fluid needs using perimeters as in the initial assessment. Determine if the.intake of the resident will be sufficient to meet needs or goals.MONITORS: A Care Plan is to be developed stating the problems, the goal, and the approaches, interventions to accomplish the goal.EVALUATION: The evaluation process is done again if there is another significant weight change. During a review of the facility's policy and procedure (P&P) titled, Nutritional Screening/Assessments/Resident Care Planning, dated 2018, the P & P indicated, Policy: The resident's nutritional status and his nutritional needs will be assessed. A nutritional program specific to his needs will be planned and implemented, and then reassessed periodically for progress.Note: Regarding method of calculating adequate calorie intake: The formula chosen.consulting Dietitians is Mifflin-St.Joer. During a review of the facility's P&P titled, Weight Assessment and Intervention [Policy given by facility for their weight variance committee], revised 2008, the P&P indicated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents.The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. Analysis: Assessment information shall be analyzed by the multidisciplinary team.The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia [lack or loss of appetite for food], weight loss or increasing the risk of weight loss.Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. Individualized care plan shall address, to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment. During a review of the facility's job description for Registered Dietitian, dated, 1/1/09, the job description included, Responsible for resident nutritional assessments, follow up on Resident's nutritional needs.implements a plan of care to ensure that residents nutritional needs are being met.serves on facility committees including Weight Variance. 2. During a review of Resident 51's Weights and Vitals Summary the following weights were noted (not all inclusive): 5/5/20 - 143 lbs 8/06/20 - 146 lbs 10/12/20 - 153 lbs 11/11/20 - 160 lbs 12/10/29 - 168 lbs 1/13/21 - 173 lbs 2/05/21 - 180 lbs 3/08/21 - 187 lbs 4/06/21 - 194 lbs 6/06/21 - 204 lbs 8/05/21 - 206 lbs 9/3/21 - 212 lbs 10/09/21 - 216 lbs 12/07/21 - 208 lbs 01/11/22 - 200 lbs During a concurrent interview and record review, on 3/3/22, at 2:00 PM, with RD, Resident 51's [NAME], dated 5/6/20, was reviewed. The [NAME] indicated, Gradual weight gain towards IBW [ideal body weight] of 160 lbs desirable. RD verified the goal was to promote weight gain until Resident 51 reached 160 lbs. RD reviewed an [NAME], dated 5/12/21, the INHA indicated, Weight 194 lbs, UBW [usual body weight] 157 lbs, completed by the DSS. The second half of the same [NAME] that included fields under the headings of estimated nutritional needs, nutritional related meds (medications), nutritional related labs, comments/nutritional concerns, and recommendation/plan were left blank. RD stated she was the one responsible to complete those assessment needs and it was missed. RD verified Resident 51's increased in body weight above the planned weight goal of 160 lbs by 21.25%, and she should have completed another comprehensive nutrition assessment to re-calculate daily estimated calorie, protein and fluid needs due to unplanned significant weight gain. During a review of the facility's policy and procedure (P&P) titled, Nutritional Screening/Assessments/Resident Care Planning, dated 2018, the P & P indicated, Policy: The resident's nutritional status and his nutritional needs will be assessed.All residents will be reviewed quarterly & annually.The Consultant Dietitian [RD] should then complete.the Nutritional Assessment.

Based on observation, interview, and record review, the facility failed to protect two of 14 smoking residents (Resident 2 and Resident 4) from another resident (Resident 3) who was known to become verbally and physically aggressive when denied cigarettes. This failure resulted in a physical altercation between Resident 3 and 4 and caused fearfulness of Resident 2 towards Resident 3. These failures had the potential to cause further emotional and physical injuries to other smoking residents in the facility. Findings: During an interview with Resident 2, on 8/6/19, at 11:28 AM, Resident 2 stated one time, while she was smoking in the smoking patio, Resident 3 grabbed a cigarette right out of her mouth. Resident 2 stated Resident 3 had threatened to punch her teeth out if she would not give him a cigarette. She stated a CNA (Certified Nurse's Assistant) witnessed the event but did not stop Resident 3. Instead, CNA asked her to go back inside the facility. During a review of the clinical record for Resident 3, the Licensed Nurse Notes (LNN) dated 6/2/19, indicated Resident (Resident 3) continued to go out on the patio asking other female residents and staff for cigarettes when told no he Resident 3 would call them [***] es and became aggressive. The LNN dated 6/12/19, indicated Episodes of aggressive behavior kept asking for cigarettes when told no cigarettes he became aggressive. The LNN dated 7/5/19, indicated Resident (3) is still noted to get agitated with other residents on back patio (smoking patio) continuously asking them for a cigarette. When he is told no he yells and calls them bad names . The LNN dated 7/12/19, indicated Resident (3) was put on 1:1 monitoring yesterday 7/11/19 d/t (due to) aggressive behavior r/t (related to) increased urge to smoke. D/c'd (Discontinued) 1:1 today and changed to Q hour (every hour) because resident (3) mostly stays in the smoking patio and there is a sitter in the smoking patio who stays to watch/monitor residents. The LNN dated 7/16/19, indicated Resident (3) noted to go stand next to (a) female resident who was smoking and asked her for a cigarette. She told him no. He stood right next to her staring at her. I (the author) asked if he could go sit in his chair he said, 'No, I am just going to watch her smoke.' The LNN dated 7/28/19, indicated Resident (3) had two episodes of aggressive behavior noted this shift. One episode occurred when the AM nurse told him she did not have a lighter. Resident (3) yelled aggressively at her and punched his fist into his hand. Resident (3) had another episode of trying to take a cigarette out of the hand of a female resident. The LNN dated 8/2/19, indicated Resident (3) stays outside on the patio most of the day only came in to eat, alert and very aggressively begging for cigarettes from female residents. If female residents didn't give him a cigarette, he will grab there (sic) cigarette out of their hands female residents are very scared when they go outside to smoke. The LNN dated 8/3/19, indicated Resident (3) noted to have two episodes of aggression this shift. One on one monitor reported resident attempting to hit her. I (the writer) went to patio with another nurse and told the resident he cannot hurt staff. He stated, 'I was not trying to hit anybody.' Other residents present said 'Yes you did.' He (Resident 3) angrily punched his closed fist into his other hand and said, 'This is hitting I did not hit anyone .Resident (3) had another incident of yelling, 'F--- you' toward staff. Resident (3) also noted to follow 2 female residents to their room standing outside their door asking them for cigarettes. The LNN dated 8/4/19, indicated Resident (3) had an altercation with another Res (Resident 4) Room (number) (Resident 4's name) at the smoking area. Witnessed by staff (Staff's name) activities stated (Resident 3) approached (Resident 4) and took a cigarette away from him. (Resident 4' name) got mad pushed (Resident 3) and (Resident 3) hit Resident 4 then (Resident 4) hit (Resident 3) back. Immediately separated both Res (residents) by staffs (sic). Noted (Resident 3) right ear was bleeding. During an observation and concurrent interview with Resident 4, in the smoking patio, on 8/6/19, at 1:40 PM, it was noted Resident 4 was leaning on the rail of the gated smoking area and Resident 3 was sitting across from the gated smoking area, about 12 feet away. There were three female residents (Resident 1, Resident 2, and another Female Resident) behind Resident 4. Resident 4 described the physical altercation 8/4/19 with Resident 3: (Resident 3) grabbed a cigarette out of my hand the other day (8/4/19). He does that to everyone. That's why they (referring to the three female residents behind him) stay in here (behind him). During an interview with Registered Nurse (RN) 1, on 8/6/19, at 2:41 PM, RN 1 reviewed the clinical record for Resident 3 and stated, in the afternoon of 8/4/19, there was a smoking monitor in the smoking patio. Resident 3 went to grab a cigarette from Resident 4 and started the physical altercation. During an interview with CNA 4, on 10/14/19, at 2:43 PM, stated when she was assigned to the smoking patio, she ensured resident safety while smoking and not to get close to each other. If she noted any aggressive behaviors, she would report to the charge nurse on duty. During an interview with CNA 5, on 10/14/19, at 3:10 PM, she stated she had witnessed Resident 3 snatch a cigarette out of a lady's hand. She reported it to Resident 3's nurse. During an interview with CNA 6, on 10/14/19, at 3:15 PM, he stated when Resident 3 did not have a cigarette, he would stare at other residents who were smoking and ask for one. If he was not given a cigarette, Resident 3 would make a fist with one hand and strike his other hand forcefully expressing his anger. CNA 6 stated Resident 3 would also curse at those residents who refused to give cigarettes. CNA 6 confirmed Resident 3's behaviors were well known to the facility staff and that was the reason he did not inform his charge nurse. During an interview with Sitter 1 (staff assigned to a specific resident to provide one on one supervision), on 10/14/19, at 3:27 PM, she stated Resident 3 made verbal and physical threats to other residents. In one incident, in the smoking patio, Sitter 1 stated Resident 3 grabbed a cigarette out of her hand and threatened to hit her with his fist in air. Sitter 1 stated she reported the incident to Resident 3's nurse. During an interview with CNA 8, on 10/14/19, at 3:34 PM, she stated if Resident 3 did not get a cigarette from a resident, Resident 3 would yelled at that resident [***] you, hold up his fist, in a threatening manner. CNA 8 stated she reported to the charge nurse. During an interview with Licensed Vocational Nurse (LVN) 3, on 10/14/19, at 3:39 PM, he stated, Since he (Resident 3) doesn't have cigarettes available to him, he is not all there. The incidents were endorsed to the Nurse and the Administrator. He gets very aggressive with residents; so we moved him to a room by himself (room [ROOM NUMBER] private room and across from the nurse's station); due to his behaviors. During an interview with a LVN 2, on 10/14/19, at 2:59 PM, she stated she was made aware Resident 3 would stare at another female resident when the female resident refused to give him a cigarette. She stated Resident 3's action would cause residents to be scared or uncomfortable. LVN 2 stated she reported the event to the prior Administrator and the prior DON. She stated the LNN, dated 7/28/19, was related to Resident 3 grabbing a cigarette from a female resident. She also reported the incident to the prior Administrator and the prior DON. During an interview with Director of Nursing (DON), on 8/6/19, at 12:42 PM, she reviewed Resident 3's Smoking care plan, initiated on 6/10/19, she stated Resident 3 exhibited aggressive and impulsive behaviors towards smoking residents when he did not get cigarettes from them on his request. One of the approaches read; Observe resident for any unsafe smoking behavior/attempts to obtain smoking materials from outside source and to immediately inform facility management. The DON stated she would expect the CNAs assigned to the smoking patio to report any observed aggressive behaviors to charge nurses. During an interview with the Social Services Designee (SSD) on 10/14/19, at 3:43 PM, she stated, We all knew what was going on with (Resident 3's first name) behaviors. The SSD could not recall any reports of actual name calling or physically grabbing cigarettes out of the hands of female smokers; only nose (bleed), spitting, fighting with (Resident 4). The SSD stated, Nurses would report allegations of abuse to (the name of the prior Administrator), then he would investigate and report to me and I would handle the reporting to authorities .But I did not get any reports in regards to aggressive, grabbing, and threatening women on smoking patio. During an interview with the DON, on 10/14/19, at 3:55 PM, she stated she started the Director of Nursing responsibilities on 6/28/19. She had never received any reports of Resident 3's aggressive behavior involving female smoking residents. During an interview with the current Administrator, on 10/14/19, at 4:20 PM, he stated the prior Administrator had resigned on 8/15/19. The new Administrator did not have any knowledge of the history of the altercation between Resident 3 and 4 or female residents. During a review of the facility policy and procedure titled Abuse Prevention Policy, undated, indicated It is the policy of Valley Convalescent Hospital that each resident shall be free from any form of abuse. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents. Abuse: The willful infliction of injury .intimidation .resulting in physical harm, pain, or mental anguish .Verbal Abuse: The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families .Examples of verbal abuse include but are not limited to: threats of harm . During a review of the facility policy and procedure titled Abuse Prevention Policy, undated, indicated VI. Reporting and Response Procedure: . all health practitioners and all other employees of this facility are mandated reporters. 2. An employee who has observed or has knowledge of an incident that reasonably to bean abuse .shall report the incident to the appropriate authorities. 4. The employee who has observed or has knowledge of an incident that reasonably appears to be abuse must also report the incident immediately or as soon as possible to his/her immediate supervisor who in turn reports the incident to the Social Services Director or designee (Abuse Prevention Coordinator). The Social Services Director or designee reports the alleged incident to the Administrator and to the Director of Nursing Services. Investigation Procedure: . 5. Administrator or designee makes a reasonable attempt to reach a conclusion as to the cause of the injury and take corrective actions during the investigation to provide resident(s) with a safe environment.

Based on interview and record review, the facility failed to allow one of 4 sampled residents (Resident 3) to make choices about smoking after the resident's daughter requested the facility to take away his smoking supplies. This failure lead to Resident 3 eloping from the facility to buy cigarettes and having a physical altercation with other smoking resident, Resident 4. Findings: During a review of the clinical record for Resident 3, the Record of Admission indicated Resident 3 was admitted to the facility on [DATE]. The MDS (Minimum Data Set- an assessment tool) dated 6/12/19, indicated Resident 3's cognition was moderately impaired. He also had behavior of threatening, screaming, or cursing at others four to six days a week. The SMOKING-SAFETY SCREEN dated 6/12/19, completed by the facility, indicated Resident 3 did not have cognition loss and Safe to smoke with supervision. The physicians' order dated 6/5/19, indicated MAY SMOKE CIGARETTE WITH SUPERVISION AS SCHEDULED. The plan of care for SMOKING dated 6/10/19, indicated (Resident 3) Has aggressive behavior, and Behavior of being impulsive when he doesn't get cigarettes. During a review of the clinical record for Resident 3, the LICENSED NURSES NOTES (LNN) dated 6/11/19, at 4:50 PM, indicated Resident had an episode yesterday evening 6/10/19 where he was seen outside the facility premises per SSD (Social Services Director). Elopement assessment was done. He is at risk for elopement. MD was notified. RP (Responsible Party, Resident 3's daughter) was notified . During an interview with the DON, on 10/1/19, at 2:53 PM, the DON explained the reason of his elopement; He was looking for a store to buy cigarettes; that is the only thing that drives him. During a review of the clinical record for Resident 3, the LNN dated 6/2/19, indicated Resident (Resident 3) continued to go out on the patio asking other residents and staff for cigarettes when told no he (Resident 3) would call them [***] es and became aggressive. The LNN, dated 6/12/19, indicated Episodes of aggressive behavior kept asking for cigarettes when told no cigarettes he became aggressive . The LNN dated 7/5/19, indicated Resident (3) is still noted to get agitated with other residents on back patio (smoking patio) continuously asking them for a cigarette. When he is told no he yells and calls them bad names. The LNN dated 7/12/19, indicated Resident (3) was put on 1:1 monitoring yesterday 7/11/19 d/t (due to) aggressive behavior r/t (related to) increased urge to smoke . The LNN dated 7/16/19, indicated Resident (3) noted to go stand next to female resident who was smoking and asked her for a cigarette. She told him no. He stood right next to her staring at her. I (the author) asked if he could go sit in his chair he said, 'No, I am just going to watch her smoke.' The LNN dated 7/28/19, indicated Resident (3) had two episodes of aggressive behavior noted this shift. One episode occurred when the AM nurse told him she did not have a lighter. Resident (3) yelled aggressively at her and punched his fist into his hand. Resident (3) had another episode of trying to take a cigarette out of the hand of a female resident . The LNN dated 8/2/19, indicated Resident (3) stays outside on the patio most of the day only came in to eat, alert and very aggressively begging for cigarettes from female residents. If female residents didn't give him a cigarette, he will grab there (sic) cigarette out of their hands female residents are very scared when they go outside to smoke. The LNN dated 8/3/19, indicated Resident (3) also noted to follow 2 female residents to their room standing outside their door asking them for cigarettes . The LNN dated 8/4/19, indicated Resident (3) had an altercation with another Res (Resident 4) Room (number) (Resident 4's name) at the smoking area. Witnessed by staff (Staff's name) activities stated (Resident 3) approached (Resident 4) and took a cigarette away from him. (Resident 4' name) got mad pushed (Resident 3) and (Resident 3) hit Resident 4 then (Resident 4) hit (Resident 3) back. Immediately separated both Res (residents) by staffs (sic). Noted (Resident 3) right ear was bleeding. During an interview with the DON, on 10/1/19, at 2:53 PM, the DON reviewed the Interdisciplinary Team Review dated 7/11/19. She stated Resident 3 smoked his own cigarettes for a while after his admission to the facility. Then his daughter, who was in charge of his finance, did not want him to smoke and Resident 3 became more aggressive to other smoking residents when he could not get cigarettes from them. Resident 3's daughter instructed the facility to use nicotine patches; but his physician denied the nicotine patches. The DON stated she explained to the daughter he had rights too. The DON reviewed the clinical record for Resident 3 and was unable find documentation indicating Resident 3 was communicated to in regards to no-smoking restriction imposed by his daughter. The DON confirmed the facility did not take further actions to allow Resident 3 to exercise his preference to smoke; instead Resident 3 started to become aggressive towards other residents over cigarettes. During a review of the facility policy and procedure titled Care Plans-Comprehensive undated, indicated 3. Each resident's comprehensive care plan is designed to: . d. Reflect the resident's wishes regarding care and treatment goals; . 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (1) bed side-rail was up for mobility and safety which resulted in Resident 1 falling and sustaining a neck fracture (broken bone) contributing to Resident 1's death. Findings: The clinical record for Resident 1 was reviewed. The fall care plan for Resident 1 dated [DATE], indicated Resident 1 was at risk for falls due to incontinence (lack of bladder and/or bowel control), an amputated leg, chronic/acute condition causing resident to be unstable, dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and history of falls. The screening guide for the use of restraints (a measure that keeps someone under control or within limits) for Resident 1 dated [DATE], indicated Resident 1 had poor safety awareness and one side rail was being used for his safety. The care plan for Resident 1 titled Impaired physical functions based on ADL (activities of daily living) support needed dated [DATE], indicated one of the actions to be taken was to have one side rail up on Resident 1's bed. The ADL Care Plan, dated [DATE], indicated Resident 1 required extensive assistance with bed mobility. The Interdisciplinary Team Review for Resident 1 dated [DATE], indicated Resident 1 was alert and oriented with periods of forgetfulness with a Brief Interview for Mental Status (BIMS-a brief screening interview that aids in detecting cognitive (conscious intellectual activity as in thinking, reasoning, or remembering) impairment) of 15 out of 15 (score of ,[DATE] means cognitively intact). This review also indicated Resident 1 required supervision to total assistance with his ADLs. The Licensed Nurse Notes for Resident 1 dated [DATE], at 9 PM, indicated, I (Licensed Nurse 1- LN 1) was called to room by CNA (Certified Nursing Assistant 1) and found resident (Resident 1) on the floor. Bleeding noted above right eyebrow and below the eye. I (LN 1) asked resident (Resident 1) what happened. He (Resident 1) stated, 'I fell out of bed.' He (Resident 1) complained of head and neck pain. The Discharge Summary for Resident 1, dated [DATE], indicated, Cause of death: status [REDACTED]. Unable to swallow effectively, (Resident 1) expired (died ). During a concurrent observation of Resident 1's bed and interview with Resident 2 (Resident 1's roommate), on [DATE], at 4 PM, Resident 2 stated he saw Resident 1 roll out of bed. Resident 2 stated, I was watching TV when I heard him (Resident 1) yell, 'I'm falling, I'm falling'. All I can say is when he (Resident 1) fell , the side rails were down. I saw it clearly. Resident 2 was approximately three feet away from Resident 1's bed. Resident 1's bed was very close to the far wall by the window. Resident 1's bed had a pressure relieving air mattress (Pressure relief air mattresses help individuals prevent the formation of bedsores) and a three-quarter size side rail (a bed side rail that is approximately three quarters the length of the bed). During a review of the clinical record for Resident 2, the MDS (Minimum Data Set-Comprehensive Assessment Tool), dated [DATE], indicated under Cognitive Patterns, Resident 2 had a Brief Interview for Mental Status score of 15. During an interview with CNA 1, on [DATE], at 12:20 PM, she stated Resident 1 was positioned facing the door (his back to the window and far wall) with a pillow behind his back before the fall incident. CNA 1 stated she repositioned Resident 1 by herself and then went to the next room to answer a call light. CNA 1 stated she heard a loud falling sound and went to check Resident 1, then she stated she found Resident 1 on the floor. CNA 1 stated she was sure she put the side rail up on the side Resident 1 was facing before she left the room. CNA 1 stated, I don't know how he fell . During a concurrent interview with LN 2 and review of Resident 1's clinical record on [DATE], at 2:54 PM, LN 2 verified findings during the review of Resident 1's clinical record listed above. LN 2 stated Resident 1's side rail was for mobility and repositioning. During an interview with LN 1, on [DATE], at 2:57 PM, she stated when she came to work, Resident 1's side rail was up. LN 1 stated Resident 1 was able to help with repositioning in bed by grabbing onto the side rail. LN 1 stated Resident 1's side rails were down at the time of the fall. LN 1 stated, He (Resident 1) said he fell out of bed. During a review of the hospital record for Resident 1, the emergency room Report for Resident 1, dated [DATE], indicated a CT (computed tomography (CT) scan uses X-rays to make detailed pictures of parts of your body and the structures inside your body) of the cervical spine (neck vertebra) was performed and was read by a radiology physician as a cervical spine fracture (a broken vertebra in the neck) at the second vertebrae with a 4 millimeter separation (space) and was an unstable fracture with a high risk of nonunion (unlikely that the vertebra space will close and will heal). The facility policy and procedure titled, Fall Prevention and Reduction, undated, indicated, It is this facility's policy to prevent falls to the extent possible and within the control of the facility. If and when fall occurs, facility shall implement corrective measures to reduce incidence of fall. Plans of care shall include interventions on the following: how resident's mobility can be improved, if at all possible Alteration of resident's immediate physical environment to compliment resident's weaknesses

Based on interview, and record review, the facility staff failed to implement one to one monitoring (staff will remain with resident at all times) as directed for one of one residents (1). This failed practice resulted in Resident 1 injuring himself. Findings: During a review of the clinical record for Resident 1, the admission record, dated 5/6/10, indicated [DIAGNOSES REDACTED].) ...Resident 1's mood and behavior care plan, dated 5/6/13, indicated Resident 1 is easily angered, gets irritated easily, sudden angry outburst, verbal and physical agitation, danger to self and others, at risk of hurting self and others..., under approach, the care plan indicates staff are to keep Resident 1's environment safe and free from objects he may use to hurt himself or others. Resident 1's care plan dated 6/14/13 indicated one to one monitoring. During an interview with Certified Nursing Assistant (CNA) 1, on 6/26/13, at 8:50 AM, she stated Resident 1 told her he wanted to go to bed but he was hungry and wanted a sandwich. CNA 1 stated she asked CNA 2, who was in the hallway waiting on another resident, to come inside the building to watch Resident 1 while she went to the kitchen. CNA 1 stated when she came back from the kitchen CNA 2 was in the hallway. CNA 1 stated she went into the room to give Resident 1 his sandwich she saw blood coming from the side of his neck. During an interview with CNA 2, on 6/26/13, at 9:10 AM, she stated she never knew she was supposed to watch Resident 1. She stated she was watching a resident that was outside. During an interview with the Director of Nursing (DON), on 6/25/13, at 4:30 PM she stated Resident 1 was on one to one monitoring for his aggressive behavior toward peers. The DON stated at the time of the incident, Resident 1's care plan was not followed he was left unattended. According to the on-line American Nurses Association, "The Nursing Process" 2013 http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-Need/Thenursingprocess.html; Under the Sub-heading titled "Implementation" Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization ..." During a subsequent interview with the DON on 7/26/13, at 9:30 AM, she stated the CNA checks the resident's room daily for any objects he could use to hurt himself. On the day of the incident, the CNA did not observe anything in his room that could be used to cause injury. She added that after the incident staff were unable to locate any object in the resident's room that he could have used to cut himself. During a review of the acute care record for Resident 1, the emergency room Report dated 6/22/13, at 7:35 PM, indicated Resident 1 used small razor blade to cut himself in an attempt to end his life. The facility policy and procedure for care plans was not provided after two request. The facility policy and procedure for one on one monitoring up-dated 6/2011, indicates that once it is determined a resident requires one on one monitoring the facility will initiate the monitoring and provide the staff to monitor the resident.

Based on interview and record review, the facility failed to follow physician recommendation for one of one residents (1). This failed practice resulted in Resident 1 not receiving medication for his behaviors which caused him to injure himself. Findings: During a review of the clinical record for Resident 1, the admission record indicated [DIAGNOSES REDACTED]. order [REDACTED].) 450 mg (a unit of measure) twice a day. Resident 1's Psychiatrists (PH I) physician progress notes [REDACTED]. Resident 1's telephone order dated 3/20/13, from Resident 1's medical physician did not reflect PH I's progress notes. The order instructed staff to give 300 mg of [MEDICATION NAME] at bedtime only. It did not address resident's morning dose of the medication. Further review of the record did not show evidence staff had contacted PH I or Resident 1's medical physician for clarification of the order when it did not match the progress notes written by PH I. Resident 1 continued to receive only the bedtime dose of [MEDICATION NAME] until 6/22/13 (approximately 3 months) when the order was changed and staff were instructed to also give the morning dose of [MEDICATION NAME]. Laboratory results, dated 6/5/13 indicated resident's [MEDICATION NAME] level was not within the therapeutic range. The [MEDICATION NAME] level was 0.4 MEQ/L (milliequivalent per liter units of measure). The report indicated therapeutic range was 0.5-1.5 MEQ/L. During an interview with the Director of Nursing, on 7/15/13, at 11:45 AM, she reviewed the clinical record and was unable to find documentation that Resident 1 had received the morning dose of [MEDICATION NAME] 450 mg as indicated in the Psychiatrist Progress Notes. She was also unable to locate evidence staff had contacted physicians to obtain clarification of the medication order. During an interview with PH I on 7/3/13, at 11:20 AM, he stated Resident 1 had been started on [MEDICATION NAME] due to his behaviors and history of suicidal attempts. PH 1 stated Resident 1's behaviors had decreased and he was doing much better. PH 1 stated Resident 1 complained of side effects from the medication and on 3/20/13 he recommended that the evening dose of [MEDICATION NAME] be decreased. PH 1 was questioned by surveyor regarding the morning dose of [MEDICATION NAME], he stated Resident 1's morning [MEDICATION NAME] dose should have remained the same. PH 1 stated he would not decrease Resident 1's [MEDICATION NAME] dose that sudden because of Resident 1's behaviors and suicidal attempts. PH 1 stated the facility did not follow my recommendations and the rapid decrease in Resident 1's medication contributed to his increase in behavior and his suicide attempt. The facility policy and procedure titled "Physician Orders" undated indicated it shall be this facility's policy to provide care and services to the resident in accordance with physician orders.

Based on observation, interview, and record review, the facility failed to protect one of two sampled residents (2) from physical abuse, when staff failed to keep Resident 2, who was having aggressive behaviors, away from Resident 1, who was known to become easily agitated and physically aggressive. This failure resulted in Resident 2 being choked by Resident 1. Findings: During a concurrent observation and interview with Resident 1, on 6/11/13, at 8:45 AM, in his room. Resident 1 was lying in the bed alert, oriented, and verbally responsive. Resident 1 stated "If any one disrespects me or my mother I will kill them." Resident 1 stated he was in the dining room and Resident 2 verbally made a comment about his mother so he grabbed her shirt and pulled her backwards towards him. During a review of the clinical record for Resident 1, admission record, dated 5/6/10, indicated a [DIAGNOSES REDACTED]. wheelchair. Resident 1's Mini-Mental state examination (written assessment instrument that measures and evaluates cognitive function and mental impairments), un-dated, indicated Resident 1 was mildly cognitively impaired (a brain disorder in which thinking abilities are mildly impaired). Resident 1's mood and behavior care plan, dated 5/6/13, indicated he was easily angered, becomes easily irritated, and has sudden angry outbursts. The care plan also indicated he is verbally and physically aggressive and is a danger to self and others. He was also noted to have a history of assaulting staff and peers. Under approach, the care plan indicated staff were to keep the resident away from others upon signs and symptoms of anger or agitation. To ensure the safety of Resident 1 and other residents, staff were to visually check on Resident 1's whereabouts. Further review of the clinical record indicated Resident 1 had physical altercations with peers on 2/16/13, and on 3/3/13, Resident 1 verbally threatened to stab another resident. On 2/7/13, Resident 1 was verbally aggressive with peers, and on 3/28/13 and 4/27/13 he had a verbal and physical altercation with peers. Nurses notes, dated 6/11/13, at 5:30 PM, indicated Resident 1 was in the dining room with other residents for dinner. Resident 2 became combative and began screaming. "Words exchanged between two male client (Resident 1) got mad reach over the table held her from behind..." During a review of the clinical record for Resident 2, the admission record, dated 4/19/13, indicated Resident 2 had a [DIAGNOSES REDACTED]. Individuals with [MEDICAL CONDITION] disorder experience episodes of a frenzied mood known [MEDICAL CONDITION] with episodes of depression), and [MEDICAL CONDITION] (a mental disorder marked by severe impaired thinking, emotions, and behaviors). Resident 2's Mini-Mental state examination, indicated she was severely cognitively impaired (a deterioration or loss in intellectual capacity that places a person in jeopardy of harming him/herself or others and, therefore the person requires supervision by another person). Resident 2's Behavior Symptoms care plan, dated 5/16/13, indicated staff were to keep Resident 2 away from physically aggressive residents... Resident 2's Mood and Behavior care plan, dated 5/16/13, indicated staff were to provide a safe environment... Nurses notes, dated 6/11/13, at 6 PM, indicated Resident 2 was combative at the start of the shift. Staff redirected the resident several times but she continued to be combative and " remained out of control tried to hit anybody came close." Resident 2's behavior escalated in the dining room and Resident 2 called her a derogatory name. Resident 1 then reached over the table and held the resident from behind around her shoulder and neck." Resident 2 was taken to the Director of Nursing (DON) office where staff noted she was "feeling in shock crying... Resident 2 stated "she fears for her life in this place." Resident 2's emergency room report, dated 6/11/13, at 8:14 PM, read "female presents after being choked. Patient states she has pain all over her neck and chest that is 10 out of 10 (intense pain) Aching (persistent)... During an interview with the DON on 6/11/13, at 11:10 AM, she stated Resident 1 was in the dining room and Resident 2 made a verbal remark about Resident 1's mother. Resident 1 grabbed Resident 2 from behind pulled her down by her shoulder and placed his arm around her neck and began to choke her. During an interview with the Certified Nurse Assistant (CNA) 1, on 6/11/13, at 11:25 AM, she stated she heard yelling and screaming coming from the dining room. CNA 1 stated she ran to the dining room and Resident 1 had Resident 2 on his lap with his arms around her neck in a choke hold (involves strong choking pressure applied to the neck of another) and biting her. CNA 1 stated it took three people to separate them. CNA 1 stated Resident 2 was yelling "He's going to kill me, I can't breath". During an interview with CNA 2, on 6/11/13, at 10:25 AM, she stated Resident 1 is demanding, he hits the walls, and tries to break things. If another resident is in his way he will just push them. During an interview with Licensed Vocational Nurse (LVN) 2, on 6/11/13, at 10:41 AM, she stated Resident 1 has angry outbursts, if someone or something is blocking him he yells move and staff has to run before he throws or just pushes another resident out of his way. LVN 2 stated when Resident 1 is angry or mad he is physically and verbally abusive. Resident 1 told her (LVN 2) he is unable to control his behavior. LVN 2 stated "He's not safe here at this facility it's not safe for the other residents." The facility policy and procedure titled "Abuse Prevention Policy" undated, indicated it is the policy of the facility that each resident shall be free from any form of abuse. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents...

Based on observation, review of facility documents, and resident and staff interviews, the facility failed to ensure that it had an effective pest control program to prevent the infestation of live cockroaches throughout the facility. The saliva, droppings, and decomposing bodies of cockroaches contain proteins known to trigger allergies [REDACTED]. Cockroaches are capable of mechanically transmitting disease causing organisms such as E. coli (a type of bacteria found in the environment, foods, and intestines of people and animals). E. Coli can cause diarrhea, while others cause urinary tract infections, respiratory illness and pneumonia, and other food poisoning related illnesses. The extent of this deficient practice has affected the entire residents at the facility. The total census at the time of the recertification survey was 77. Findings: Immediate Jeopardy was declared with the presence of the Administrator on 3/26/13, at 3:47 PM. An acceptable plan of correction was provided by the Administrator on 3/26/13, at 5:15 PM. The immediate jeopardy was abated with the Administrator on 3/28/13, at 3:20 PM. During an initial tour of the facility on 3/25/13, at 11 AM, three cockroaches were observed crawling on the floor in the bathroom of resident Room 2. During the tour of the kitchen on 3/25/13, at 11:15 AM, a blue colored ice scoop holder attached to the ice machine was observed to have approximately two tablespoonful of liquid at the bottom. All the corners had a light brown colored residue. Closer observation showed a hair strand, a piece of white paper, a leg of a brownish colored insect, and a non-moving black insect. The observation was shared with the Dietary Services Supervisor (DSS). In a concurrent interview at 11:16 AM, she indicated the scoop holder was washed and sanitized daily at the end of the day. Again on 3/25/13, at 12:15 PM, two cockroaches were observed crawling on the floor next to the tray line area. The DSS's attention was called to the two roaches crawling on the kitchen floor. She stated the kitchen was scheduled to be fumigated (sprayed with chemical) on 3/28/13, three days from when the initial observations were made. At approximately 12:43 PM, seven dead roaches were observed on the floor underneath the dish machine. The DSS indicated the presence of dead roaches was a result of the spraying of the residents' room yesterday by the pest control company. The kitchen staff explained that the facility had been sprayed frequently and the kitchen at least once a month, however, the roaches migrated to the kitchen after residents' rooms were sprayed. The staff further explained they try to keep the kitchen clean. As the initial tour continued, a structural gap approximately one inch by four inches was observed on north wall of the kitchen underneath the dish machine next to the area where seven dead cockroaches were observed. The pipe from which the dish machine drained into the floor also had a gap, surrounding the pipe, where it was connected to the floor. There were other structural gaps surrounding the plumbing under the sink area in the kitchen. Above the stove, there was a visible structural gap surrounding the exhaust pipe where it entered the ceiling. These structural gaps could allow the cockroaches' entrance into the kitchen. During a group interview with eight residents on 3/26/13, at 9:15 AM, four residents stated they had observed cockroaches in the facility. During an observation on 3/26/13, at 11:15 AM, with the Maintenance Supervisor (MS) outside of the building, a window air conditioning (AC) unit was noted in the window of resident Room 14. A gap was noted between the AC unit and the filler (special tape used to fill the gap between the AC unit and window edge) measuring 12 inches in height and 1 1/4 inches in width. This structural gap was large enough to allow insects entrance into the resident's room. The MS indicated the gap needed to be repaired. During an observation of the kitchen area on 3/26/13, at 11:30 AM, at least ten or more nymph (small, not yet fully mature) cockroaches were observed crawling on a blue colored netting covering the water boiler for the dish machine. Several more roaches were noted on the steel flooring near the doorway to the nursing station. On 3/26/13, a review of the pest control logs from the pest control service Eco-Lab revealed they had identified the presence of the gaps in the kitchen dated 9/12/12, 1/24/13 and 3/25/13. The pest control logs' recommendations were to "seal the hole (or gaps) for closure and prevent entry." During an interview with the MS on 3/26/13, at 4:05 PM, he was asked about the facility's process regarding the pest control service's recommendations to seal the holes in the kitchen. The MS indicated he would look into it, but the reports were dropped off at the nursing station. According to Section 6-202.15(A) of the 2009 Food Code: "outer openings of a food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along walls, floors and ceilings." During the initial tour on 3/25/13, it was aldo observed the screen door leading to the parking lot from the kitchen had a half inch wide gap underneath it, and a one inch wide gap on the side, big enough to allow entry of crawling insects. This door was open all day throughout the survey. According to 2009 Food Code Section 6-202.15 (D(2): "if doors are open for ventilation or other purpose...the openings shall be protected against the entry of insects and rodents...properly designed and installed air curtains to control flying insects." The facility contract with the pest control company Eco-Lab was reviewed. It showed the contract was signed on 8/26/11 for the inspection of cockroaches, rats and mice once a month or more often as needed. In addition, 20 rooms will be treated per month. The facility had over fifty rooms including staff offices and storage areas. As a result of several compelling factors including the large number of live cockroaches found in the kitchen and the evidence of multi-generational (nymph and adult) presence, the activity during daylight hours (which is an indication of infestation since cockroaches are nocturnal insects), complaints by residents, failure of the facility to seal gaps identified by the pest control service for six months, it was determined the sanitary condition of the dietary services is likely to cause serious harm to the health of the entire community. On 3/26/13, the facility provided a plan of action at 5:15 PM. Details of the plan included the following: 1. Maintenance will seal the hole/gap behind the dish machine and other parts of the kitchen right away to prevent pest entry and harborage. 2. Eco-Lab was called to service and treat the kitchen tonight. 3. San Joaquin Pest Control and Orkin Pest Control were also called for consultations. 4. The kitchen will be shut down temporarily until the pest infestation is controlled. 5. The residents will be served food from outside food sources. 6. Residents' food preferences will be asked. 7. Emergency supplies, e.g. paper plates, cups, plastic utensils, will be used to serve food to the residents. 8. Kitchen staff will prepare breakfast outside of the kitchen (at the back patio). 9. Facility is in consultation with their Registered Dietician consultant with regards to the provision of food to the residents. On 3/27/13, at 8:20 AM, the kitchen was observed to have been cleaned out with only fixed equipment left. The Administrator stated the pest control agency (PC A) had returned the night before and had sprayed the kitchen. Observation of the corners and kitchen floor continued to show presence of active baby roaches crawling on the white powdery substances that had been sprayed by PC A company. Most of the holes had been sealed but there were a few areas that had not been completed. The Administrator indicated he was still awaiting the arrival of other pest control companies. On 3/26/13, at 9:20 AM, the consultant dietitian was interviewed. He stated he may have observed a roach once in the kitchen but the facility had a pest control program in place. Review of the consultant dietitian's report from March 2012 to February 2013 did not indicate recommendations on pest control. On 3/27/13, at 10:45 AM, three live roaches were found in the facility conference room and were shown to the new pest control technician who had been meeting with the Administrator to evaluate the infestation. The pest control technicians identified the type of roaches captured as "German roaches," and were "two adults and a nymph." He confirmed they were multi-generational the roaches were living and breeding onsite at the facility. According to orkin.com: The German roach may infect more homes and businesses and in greater numbers than any other species of cockroaches. The German cockroach is nocturnal, primarily infests areas close to food, moisture and warmth. The lifecycle is as little as 36 days and adults can live up to one year. The female breeds continuously and is capable of lying up to one million eggs. A typical thriving population is comprised of 75 % nymphs and 25% adults. They are common pests of kitchen and bathrooms. It is common to find them in crevices, cracks and under appliances. On 3/27/13 at 12 PM, during an observation of the tray line, more nymph cockroaches were observed on the floor three to four feet away from where food service staff were serving food. During a concurrent interview and observation with the Director of Staff Development on 3/27/13, at 4 PM, the bathrooms connecting resident Rooms 1 and 3, and 11 and 12 were noted. In the bathroom of Rooms 1 and 3, the floor board was noted to be warped and bowing for several inches. This created a structural gap in the floor, allowing a place for insects to enter the room. In the bathroom of Rooms 11 and 12, the floorboards under the sink were noted to be warped, and there were cracks and structural gaps in the floorboards by the door large enough to allow insects to enter. Upon seeing these findings, the DSD stated "Oh my." During an interview with a sampled resident (1), on 3/28/13, at 1:20 PM, he stated he had seen cockroaches on the walls of his room every night since he had been a resident in the facility. Resident 1 also stated he had previously observed cockroaches in his bed. The Immediate Jeopardy was abated on 3/28/13, at 3:20 PM after observing the facility kitchen closed and structural gaps repaired, cleaning of the kitchen, pesticide products applied throughout the facility by Orkin Pest Control, and written evidence Orkin plans to return to follow up on 4/1/13.

Based on observation, interview, and record review, the facility failed to provide pain management for two of 16 (8 and 13) sampled residents, when one resident (13) was not assessed for her pain level after complaining of arm pain for two days; when one resident (8) was not assessed for her level of pain which continued despite being given a routine dose of pain medication. 1. Resident 13 not being assessed for her arm pain had left her in pain for two days. 2. Resident 8 was not assessed for her pain severity which had limited her activities of daily living. Findings: 1. During a concurrent observation and interview with Resident 13, on 4/26/11 at 9 AM, the resident was observed lying in bed holding her left arm while it was propped on a pillow. She stated, "My left arm feels broken. It's been hurting for three days. I've been waiting for the nurse since 7 AM..." During an interview with Licensed Vocational Nurse ( LVN) 2, on 4/26/11, at 9:33 AM, she stated, "I gave her a Tylenol (pain reliever) 325 milligram (mg) at 8. I don't know if her doctor has been called, but she did tell me about her arm." When LVN 2 was asked about Resident 13's pain level she stated, "I didn't ask her pain level. I must ask it, but it didn't cross my mind to ask her pain level." During an interview with LVN 1, on 4/26/11, at 9:40 AM, she stated, "(Resident 13) told me her pain level is a ten just now. She doesn't have pain medicine, so I told the desk nurse to call her doctor." When asked what she gave the resident, she stated, "Aspirin 325 mg. It's for [MEDICAL CONDITION] (abnormal heart rhythm), but it can help with pain." During an interview with Certified Nursing Assistant (CNA) 6, at 10 AM, she stated, "I've told the nurse yesterday and today about her (Resident 13) arm. She's been hurting a lot." The clinical record for Resident 13 was reviewed on 4/26/11. The "Physician Orders" dated 3/1/11 indicated Tylenol was discontinued on 3/17/11. The "Physician Orders" dated 4/1/11 indicated the following orders: Aspirin 325 mg 1 tablet by mouth daily for [MEDICAL CONDITION] (ordered 10/14/10), Monitor pain level every shift using scale of 0-10 and offer pain medications as ordered (ordered 9/1/10), and Discharge Pt. from Hoffman (hospice, an end-of -life style of care) services due to possible extended prognosis (ordered 2/11/11). 2. During an interview with Registered Nurse (RN) 1, on 5/2/11, at 2:35 PM, she reviewed the clinical record for Resident 8. Resident 8's 4/11 "Physician orders" indicated "[MEDICATION NAME] 5/500 milligram (mg) one tablet by mouth every 8 hours routine pain (order date 5/12/10)." RN 1 stated, "She has pain." The quarterly "Pain Assessment" was reviewed and indicated no pain. RN 1 was unable to find documentation of a pain assessment in the resident's record or on the medication administration record. During an interview with LVN 3, on 5/2/11, at 2:40 PM, she stated, "Her (Resident 8) pain was a three out of 10". When asked if it was documented anywhere, LVN 3 stated, "Yes, all the time we document." LVN 3 presented the "medication administration record" and "pain assessment & intervention sheet" and there was no documentation. LVN 3 and RN 1 had no further information. The clinical record for Resident 8 was reviewed on 4/27/11. It indicated that the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's current MDS (Minimum Data Set: resident assessment tool) assessment dated [DATE], indicated Resident 8 received pain medication with great frequency, (almost constantly), and that the pain limited the resident's day-to-day activities. The intensity was described was very severe, and horrible. The Care Area Assessment (CAA) documentation notes indicated that the pain was generalized. The Medication Record (MR) indicated that Resident 8 had two types of pain medication ordered as needed. There was no order for routine pain medication. During an interview with Resident 8 on 4/28/11 at 10:15 AM, she stated she could not get up and even move in bed because she was always in pain. The resident stated, she had two types of pain medication as needed and they did not work. She stated, "I would feel better if I could have a routine pain medication round the clock." The resident stated, if the pain could be managed well with a routine medication, I could get up in my chair and attend activities." During an interview with the MDS Coordinator on 4/28/11 at 12:55 PM, she stated the resident should have a routine pain medication to manage the pain. She also acknowledged this problem was not addressed properly. She further stated, she would call the physician and discuss the need for routine pain medication.

Based on observation, interview and record review, the facility failed to accommodate the needs of one of 16 sampled residents (5) and two of six random residents (20 and 24) by not making the call system accessible. This resulted in: 1. One random resident (24) not having needs met when he was incontinent in bed and he was unable to use the call light to get help. 2. One resident (5) did not have a call light and had to depend on a roommate to call nursing staff for him. 3. One resident (20) with limited use of his hands and inability to use the call light for help, was unable to get assistance when needed. Findings: 1. During an interview on 4/28/11 at 11:10 AM with Resident 24, he indicated he was unable to use the call bell provided because he could not move his hand enough to push it. He also indicated he sometimes urinated or defecated in his bed and was unable to call for needed help, he just had to wait to be cleaned up. Resident 24 stated this made him feel "bad". 2. During a concurrent observation and interview on 2/27/11 at 4:45 PM, Resident 20 was lying in bed with the push-button call light on his bed. He indicated that because of limited use of his right hand and no use of his left hand he was unable to push the call light when he needed help. He stated, "If I need help, I can't call the nurse. If my roommate doesn't help, I just wait." He also stated, "I can't use the call light, I have tried." 3. During an observation on 4/26/11 at 10:30 AM, Resident 5 was lying in his bed on an air mattress, which was completely deflated, leaving him lying with no padding between himself and the metal frame of the bed. The call light was draped over the bedside table, with the push-button end on the side of the table farthest from resident, where the resident could not reach it to call for help. During a concurrent observation and interview with Resident 5 on 4/27/11 at 4:10 PM, he was lying in his bed, which was deflated. I asked him if that was painful and he stated, "Yes." The call light was draped over the bedside table where the resident was unable to reach it. When asked if he could call for help, he stated, "I don't have a call light. If I had one, I could use it." He demonstrated by pretending to hold a call button and push it with his thumb. He also stated, "This bed is hard," and indicated that when the air mattress was deflated it was very uncomfortable.

Based on observation, interview, and record review, the facility failed to keep one of 16 (9) sampled residents and one (17) random resident free from physical restraints not being used to treat medical symptoms when: 1. Physician orders [REDACTED]. 2. Residents were not assessed for medical symptoms justifying the use of restraints. This resulted in one of 16 sampled residents (9) and ome (17) random resident potentially being restrained for staff convenience and/or reasons other than treatment of [REDACTED]. Findings: 1. During observations in the hallway on 4/26/11 at 8:40 AM, 9:15 AM, 9:55 AM, and at 12:05 PM in Dining room [ROOM NUMBER], Resident 9 was seen in a wheelchair with a soft belt around her waist which was tied at the lower frame of the wheelchair (out of her reach), and prevented her from rising. Resident 9 was observed again in the same manner on 4/27/11 at 9:25 AM and on 4/28/11 at 11:15 AM, 12:30 PM, and 4:45 PM. The clinical record for Resident 9 was reviewed on 4/27/11. The face sheet indicated the resident's son was her responsible party, (RP). an order written [REDACTED]." There was no medical symptom (an indication or characteristic of a physical or psychological condition), listed to be treated with the soft belt. Record review on 4/27/11 failed to locate nurse assessments of the resident that described any of the medical symptoms being treated with restraints, which would have been used to make the decision to use restraints. 2. During an observation on 4/28/11 at 10:15 AM, in Activities Dining Room One, Random Resident 17 was sitting in a wheelchair with a soft belt tied around his chest and to the back of wheelchair, out of his reach. The soft belt was tightly tied in a square knot. The clinical record for Random Resident 17 was reviewed on 4/28/11. The face sheet indicated he had a RP for his care needs. The Social Services Quarterly Report dated 3/21/11 indicated the resident required total assistance in his activities of daily living. The Screening Guide for the Use of Restraints, undated, indicated "Type of Restraint: none." Under the 3/18/11 review date on the back of the form, it indicated, "No restraints," and was signed by Registered Nurse 1. During an interview with the Activity Aide, on 4/28/11 at 10:30 AM, she stated, "He always has that (soft belt restraint) on and sometimes a lap tray," (a tray that lies over the resident's lap, with the ends tucked under the arm rests of the wheelchair or fastened behind the chair). During an interview with the Director of Nursing on 4/28/11, at 10:40 AM, she was asked to look at the soft belt. She observed and made a comment on the knot being wrong and that it would be difficult to untie it in an emergency.