Every finding on record at Vernon Healthcare Center

Based on interview, and record review the facility failed to follow its Policy and Procedure (P&P) titled, Abuse Prevention and Management which indicated the Administrator or designated representative will report all allegations of abuse to the California Department of Public Health (CDPH) Licensing and Certification within two hours, for one of four sampled residents (Resident 2), when Resident 1 allegedly threw a lotion bottle at Resident 2 on 7/12/2026. This deficient practice delayed the investigation by the CDPH and placed Resident 2 at risk for further abuse and injuries. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 1 diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable worry that interferes with daily functioning), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 1's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 4/17.2026, the MDS indicated Resident 1 was usually able to understand and be understood by others. The MDS indicated Resident 1 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) from staff for upper body dressing, bed mobility, transfers and walking 10-50 feet. During a review of Resident 1's Progress Notes, dated 7/12/2026, the Progress Notes indicated Resident 1 was showing behavior of being aggressive and agitated.During a review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior) anxiety disorder and restlessness with agitation (a state of mental tension paired with physical unease or excessive, unintentional movements).During a review of Resident 2's History and Physical (H&P), dated 6/12/2026, the H&P indicated, Resident 2 had fluctuating capacity to understand and make decisions.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 required Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from staff for upper body dressing, bed mobility, transfers and walking 10-50 feet. During a telephone interview on 7/30/2026 at 4:14 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Residents 1 and 2 were previously roommates. (On 7/12/2026 she (CNA 2) heard Resident 1 and Resident 2 arguing with each other. Resident 1 threw a lotion bottle towards Resident 2 and Resident 2 sustained a cut on her face. CNA 2 stated she reported the incident to the Registered Nurse (RN) Supervisor (unspecified). During an interview on 7/31/2026 at 9:06 a.m., with RN 1, RN 1 stated on 7/12/2026, staff (unspecified) reported to him that there was an altercation between Resident 1 and Resident 2 and Resident. The altercation was considered abuse and should have been reported to the Administrator (ADM) and CDPH within two hours. RN 1 stated not reporting the altercation delayed the investigation and had the potential for further abuse and injury to the residents.During an interview on 7/31/2026 at 3:49 p.m., with the ADM, the ADM stated she did not report the altercation that occurred between Resident 1 and Resident 2 on 7/12/2026 to CDPH because she was not aware of the incident. Staff should have notified her or the Director of Nursing (DON). The ADM stated all forms of abuse should be reported (to CDPH) within two hours. Reporting abuse promptly is important to prevent future incidents and to ensure residents' safety. During a review of the facility's P&P titled, Abuse Prevention and Management, dated 6/12/2024, the P&P indicated allegations of abuse are to be reported to the Administrator or designated representative immediately. The Administrator or designated representative will send a written report to the CDPH Licensing and Certification within two hours. During a review of the facility's RN Staff Nurse Job Description undated, the Job Description indicated the RN clinical duties and responsibilities included reporting allegations of abuse per State and Federal Regulations and facility policy.

Based on observation, interview, and record review the facility failed to ensure two of four sampled residents remained separated after a resident-to-resident altercation on 7/12/2026. This failure resulted in Resident 2 entering Resident 1's room on 7/16/2026 and placed Resident 1 at risk for abuse and injuries. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 1 diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable worry that interferes with daily functioning), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 1's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 4/17/2026, the MDS indicated Resident 1 was usually able to understand and be understood by others. The MDS indicated Resident 1 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) from staff for upper body dressing, bed mobility, transfers and walking 10-50 feet. During a review of Resident 2's admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior) anxiety disorder and restlessness with agitation (a state of mental tension paired with physical unease or excessive, unintentional movements).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from staff for upper body dressing, bed mobility, transfers and walking 10-50 feet. During a review of Resident 2's History and Physical (H&P), dated 6/12/2026, the H&P indicated, Resident 2 had fluctuating capacity to understand and make decisions.During a review of Resident 3's admission Record indicated Resident was admitted to the facility on [DATE] with diagnoses including schizophrenia, anxiety, and diabetes mellitus ([DM] -a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required supervision or touching assistance from staff for upper body dressing, bed mobility and walking 10-50 feet. During an interview on 7/30/2026 at 8:45 a.m., with Resident 1's roommate, Resident 3, Resident 3 stated, (on 7/16/2026) Resident 2 came into the room (Resident 1 and 3's room). Resident 2 pulled Resident 1 off the bed and Resident 2 fell to the floor. Resident 3 stated Resident 1 and Resident 2 were fighting over a trash can and Resident 2 hit Resident 1 with the trash can.During a review of Resident 4's admission Record, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including schizophrenia, anxiety, and restlessness with agitation.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognition was able to understand and be understood by others. The MDS indicated Resident 4 required supervision or touching assistance from staff for upper body dressing, bed mobility and walking 10-50 feet. During an interview on 7/30/2026 at 11:51 a.m., with Resident 4, Resident 4 stated, (on 7/16/2026) before breakfast time, Resident 2 went into Resident 1's room and both residents (Residents 1 and 2) started to fight over the trash can and had a physical altercation with each other. During a concurrent observation of the facility's video surveillance and interview on 7/30/2026 at 3:15 p.m., with the Director of Nursing (DON), Resident 2 was observed wandering into Resident 1's room and staff escorted Resident 1 out of the room. On 7/16/2026 at 4:41 a.m., Resident 2 re-entered Resident 1's room (2nd time) and was removed from the room by the Certified Nursing Assistant (CNA) 1 at 4:51 a.m. (10 minutes later). The DON stated Resident 4 was standing near Resident 1's room and faced the direction of Resident 1's room when Resident 2 was in Resident 1's room.During a telephone interview on 7/30/2026 at 4:14 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Residents 1 and 2 were previously roommates. (On 7/12/2026 she (CNA 2) heard Resident 1 and Resident 2 arguing with each other. Resident 1 threw a lotion bottle towards Resident 2 and Resident 2 sustained a cut on her face. CNA 2 stated she reported the incident to the Registered Nurse (RN) Supervisor (unspecified) and Resident 2 was transferred to another room on 7/12/2026. CNA 2 stated after the incident, she (CNA 2) had to redirect Resident 2 because the resident (Resident 2) wanted to go to Resident 1. During an interview on 7/31/2026 at 9:06 a.m. with Registered Nurse (RN)1, RN 1 stated Resident 1 and Resident 2 were previously roommates and did not get along. On 7/12/2026, staff (unspecified) reported to him that there was an altercation between Resident 1 and Resident 2, and Resident 2 was transferred to another room. RN 1 stated staff should have kept Residents 1 and 2 separated and ensured that Resident 1 did not go into Resident 2's room on 7/16/2026 unattended because it placed Resident 1 in danger. During an interview on 7/31/2026 at 1:42 p.m., with DON, the DON stated Resident 1's and 2's rooms were near one another (despite the relocation of Resident 2 on 7/12/2026) and Resident 2 was not closely monitored for wandering. Resident 2 entered Resident 1's room (on 7/16/2026) and placed the Resident (Resident 1) at risk of physical abuse by Resident 2.During an interview on 7/31/2026 at 3:49 p.m., with Administrator (ADM), the ADM stated she was not aware of the altercation between Resident 1 and Resident on 7/12/2026. The ADM stated when Resident 2's room was changed; she was placed too close to Resident 1's room which had the potential for the residents to have another altercation with each other. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention and Management, dated 6/12/2024, the P&P indicated the facility identifies, corrects and intervenes in situations in which abuse, neglect and mistreatment is more likely to occur. The ADM, or designated representative, will provide a safe environment for the resident. If the suspected perpetrator is another resident, separate the resident so they do not interact with each other. The P&P indicated if the suspected perpetrator was another resident, separate the resident so they do not interact with each other.

Based on interview and record review, the facility failed to ensure the care plan was revised for two out of four sampled residents (Resident 1 and 2) after Residents 1 and 2 had an altercation on 7/12/2026.This deficient practice had the potential for Resident 1 and 2 to be involved in another altercation.Findingsa. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a mental health condition characterized by excessive, persistent, and uncontrollable worry that interferes with daily functioning), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 1's care plan titled, Resident had the potential to be physically and verbally aggressive, dated 4/14/2026, the care plan interventions included to analyze times of day, places, circumstances, triggers, and what de-escalated behavior and document.During a review of Resident 1's Minimum Data Sheet (MDS, a resident assessment tool), dated 4/17/2026, the MDS indicated Resident 1's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half of the effort) from staff for toileting hygiene, showering, and dressing.b. During a review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia, anxiety, and restlessness with agitation (a state of mental tension paired with physical unease or excessive, unintentional movements).During a review of Resident 2's History and Physical (H&P), dated 6/12/2026, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was severely impaired. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) from staff for toileting hygiene, showering, and dressing.During a review of Resident 2's care plan titled, Resident 2's Behavior Management manifested by aggressive behavior, dated 7/9/2026, the care plan interventions included to monitor /record behaviors such as pacing, wandering, and aggression towards staff/others.During a telephone interview on 7/31/2026 at 10:02 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 and Resident 2 had an altercation on 7/12/2026. RN 1 stated the care plan should have been revised to reflect the current issues of their behavior. RN 1 stated the revised care plan should align with the current issues the residents were demonstrating.During a concurrent interview and record review on 7/31/2026 at 1:30 p.m. with the Director of Nursing (DON), Resident 1's care plan titled, Resident had the potential to be physically and verbally aggressive, dated 4/14/2026 was reviewed. The DON stated the care plan should have been revised on 7/12/2026 due to Resident 1's aggressive behavior after Resident 1 and Resident 2 had an altercation.During a concurrent interview and record review on 7/31/2026 at 1:42 p.m., with the DON, Resident 2's care plan titled, Resident 2's Behavior Management manifested by aggressive behavior, dated 7/9/2026, was reviewed. The DON stated after the altercation, Resident 2's care plan needed to be revised to closely monitor the restlessness, touching, and wandering to prevent escalation of Resident 2's behavior.During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, dated 4/2025, the P&P indicated the facility must develop and implement a comprehensive person-centered care plan for each resident. The P&P indicated a comprehensive care plan must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment.During a review of the facility's P&P titled, RN Staff Nurse Job Description, unknown date, the P&P indicated licensed professional nurse directly under supervision of the DON that provides care and services to residents in a long-term care setting. The P&P indicated to initiate and revise care plans.

Based on interview, and record review, the facility failed to ensure an individualized care plan was developed and implemented for one of three sampled residents (Resident 2), whose discharge was delayed. This deficient practice resulted in the resident's delayed discharge and had the potential to affect the resident's psychosocial and mental well-being.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE], Resident 2's diagnoses included morbid (severe) obesity (chronic disease characterized by excessive body fat, often caused by consuming more calories than are burned through daily activity and metabolism) and muscle weakness. During a review of Resident 2's History and Physical (H&P) dated 6/16/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 6/22/2026, the MDS indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 required setup (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating. Resident 2 required supervision (Helper provides verbal cues and/or touching steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for oral hygiene, upper body dressing. Resident 2 required moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bath self, lower body dressing, putting on/taking off footwear. Resident 2 required supervision with rolling from left to right, from sitting to lying position, lying to sitting on side of the bed and set up for sitting to stand, chair/bed to chair transfer, for toilet transfer, walking 10 feet, and walking 50 feet. During a concurrent interview and record review on 8/4/2026 at 9:31 a.m., with Social Services Director (SSD), the Care Plan titled, Resident 2 wished to return to the community, dated 6/19/2026, was reviewed. The interventions included to obtain discharge order from medical doctor and evaluate Resident 2's motivation to return to the community. The SSD stated Resident 2's care plan was not individualized. The SSD stated when Resident 2's discharge was delayed due to insurance authorization, it should have been included in the care plan with interventions. During a concurrent interview and record review on 8/4/2026 at 10:00 a.m., with Director of Nursing (DON), the DON stated it was important to individualize Resident 2's discharge care plan to ensure Resident 2's specific needs were met and would have a timely and safe discharge.During a review of the facility's P&P titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated the facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to implement the Care Plan for one of three sampled residents (Resident 1) titled, [Resident 1] exhibits increased agitation, verbal aggression toward nursing staff, and refusal of prescribed medications which indicated nurses would notify the physician when Resident 1 refused prescribed medications. This deficient practice had the potential to result in delayed care and services for Resident 1, and worsening of the resident's condition and behaviors. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior), seizures (a sudden, uncontrolled jerking, blank stares, and loss of consciousness), and muscle weakness.During a review of Resident 1's Order Summary Report, the Summary Report indicated on 5/15/2026, the physician ordered to administer Risperdal (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder) oral tablet 4 MG (milligram, a metric unit of measurement, used for medication dosage and/or amount) two times a day for schizophrenia, and Aripiprazole 5 MG tablet in the evening for schizophrenia to Resident 1.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/22/2026, the MDS indicated Resident 1 had the ability to understand others and make self understood. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes the activity) for eating, oral hygiene, and upper body dressing.During a concurrent interview and record review on 7/17/2026 at 1:06 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication Administration Record (MAR) dated 7/1/2026 - 7/31/2026 was reviewed. The MAR indicated between 7/1/2026 and 7/5/2026, Resident 1 refused Risperdal on four out of ten occasions (on 7/1/2026 and 7/4/2026 at 5:00 p.m., and on 7/5/2026 at 8:00 a.m. and 5:00 p.m.) and refused Aripiprazole on two out of five occasions (on 7/1/2026 and 7/5/2026 at 6:00 p.m.) LVN 1 stated when Resident 1 refused his Resident 1 did not give a reason for refusing the medications. LVN 1 stated the Physician should have been informed of the residents' refusals in case the Physician needed to give new orders regarding the refusals. During a concurrent interview and record review on 7/17/2026 at 3:20 p.m., with the Director of Nursing (DON), Resident 1's Care Plan titled, [Resident 1] exhibits increased agitation, verbal aggression toward nursing staff, and refusal of prescribed medications dated 6/15/2026 was reviewed. The DON stated, Resident 1's Care Plan intervention indicated to notify the physician of persistent medication refusals. The physician should have been notified when Resident 1 continued to refuse his medications. During a review of the facility's Policy and Procedure (P&P) titled, Person-Centered Care Planning revised 4/24/2025, the P&P indicated the facility must develop and implement a comprehensive care plan for each resident that includes measurable objectives, and timeframes to meet a resident's medical, nursing and mental and psychosocial needs.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from physical abuse by failing to protect Resident 1 from a physically aggressive resident (Resident 2), when Resident 2 physically abused Resident 1. This deficient practice resulted in Resident 1 being physically abused by Resident 2. Resident 1 sustained right eye injury after being struck in the face, requiring emergency transfer to a General Acute Care Hospital (GACH). Resident 1 underwent emergency surgical repair (an operative procedure to treat traumatic damage to the eye and surrounding structures, preserve vision, restore the eye's anatomy and function, relieve pressure, and promote healing) of the right eye and remained hospitalized from [DATE] through 7/1/2026.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility of 5/23/2026. Resident 2's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/30/2026, the MDS indicated Resident 2's cognitive skills for daily decision making was intact (ability to think and reason). The MDS indicated Resident 2 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 2's care plan titled Physically Aggressive, initiated 5/24/2026, and revised 6/19/2026, the care plan indicated staff were to provide close visual monitoring and one-to-one (1:1) sitter supervision (an assigned staff member who always remains within arm's length or visual range of the resident). During a review of Resident 2's physician order, dated 6/19/2026, the physician order indicated 1:1 sitter for continuous visual monitoring due to assaultive (physically aggressive) behaviors. During a review of Resident 2's physician order, dated 6/22/2026, the physician order indicated Resident 2 was to remain on 1:1 supervision due to an altercation (a physical or angry confrontation) and aggressive behaviors. During a review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 6/28/2026 at 1:45 p.m., the SBAR indicated Resident 2 struck Resident 1. Resident 2's hands were assessed and noted with minor blood splatter and scratches on the right arm. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for ADLs.During a review of Resident 1's SBAR, dated 6/28/2026 at 1:38 p.m., the SBAR indicated on 6/28/2026, an unidentified Certified Nursing Assistant (CNA) observed Resident 1 lying in bed bleeding from the face and right eye. Resident 1's right eye was bulging (eyeball protrusion). Resident 1 was transferred to the general acute care hospital (GACH) for evaluation and treatment. During a review of Resident 1's GACH emergency room (ER) report, dated 6/28/2026, the report indicated Resident 1 had a right eye injury which included a prolapsed right eye (abnormal forward displacement of the eye) with diffused 360-degree hemorrhagic chemosis (severe swelling of the membrane covering the white part of the eye, with bleeding around the entire eye), shallow anterior chamber (a reduced space between the cornea the clear front surface of the eye and the iris the colored part, which indicate significant eye injury), inferior hyphema (blood collecting at the bottom of the eye), and a hard globe (an abnormal eyeball indicating significant injury). The report indicated Resident 1 required evaluation and treatment by an ophthalmologic (a medical doctor specializing in eye disease and eye injury), including erythromycin ophthalmic medication (an antibiotic eye medication used to treat or prevent infection). During a review of Resident 1's Computed Tomography scan ([CT] process of taking pictures of body parts to diagnose and treat disease or injury), dated 6/28/2026, the CT scan indicated Resident 1 had right exophthalmos (abnormal forward protrusion of the right eye), vitreous hemorrhage (bleeding inside the eye), and irregularity of the globe (abnormal shape of the eyeball) concerning for globe rupture (a break in the eyeball, representing a serious open-eye injury).During a review of Resident 1's GACH progress note, dated 6/28/2026, the progress note indicated on 6/28/2026, Resident 1 had right eye surgery which included the following procedures:a.Right globe exploration (surgical examination of the right eyeball)b.Right canthotomy (a surgical incision of the right eyeball).c.Right superior and inferior cantholysis (surgical release of the tissues of the upper and lower right eyelids).d.Right canthoplasty (surgical repair and reconstruction of the right eyelids).e.Right tarsorrhaphy (a surgical procedure in which right eye lids are temporarily or permanently joined together to partially close the eye and protect the eyeball while healing).During a review of Resident 1's GACH discharge summary, the discharge summary indicated Resident 1 was admitted to GACH on 6/28/2026 for ocular trauma (a serious injury to the right eye). Resident 1 was discharged back to the facility on 7/1/2026 (three days later). During a concurrent observation and interview on 7/8/2026 at 11:45 a.m., with Resident 1, at Resident 1's bedside, Resident 1 was observed lying in bed. Resident 1 had purplish and bluish skin discoloration surrounding the right eye. Resident 1's right eye was closed, red, and swollen with two sutures (stitches). Resident 1 stated approximately one week earlier Resident 2 entered her room and tried to kill her. Resident 1 stated Resident 2 beat her up and punched her in the face and eyes. Resident 1 stated she was scarred for life and unable to open her right eye. Resident 1 stated, I'm really worried I'm going to lose my eyeball and sight. During an observation on 7/8/2026 at 1:00 p.m., in the presence of the Director of Nursing (DON), the facility's surveillance footage, dated 6/28/2026 and timed 1:33 p.m. to 1:36 p.m., was reviewed. The surveillance footage showed the following:a. At approximately 1:33 p.m., Resident 2 walked out of his room unsupervised and entered Resident 1's room. Resident 2 remained inside Resident 1's room for approximately two minutes. b. At approximately 1:35 p.m., Resident 2 exited Resident 1's room unsupervised and returned to his room. During an interview on 7/8/2026 at 1:15 p.m., with the DON, the DON stated Resident 2 was supposed to have a 1:1 sitter for continuous monitoring due to his aggressive and assaultive behaviors. The DON stated Resident 2 should not have been unsupervised and should not have been able to leave his room and enter Resident 1's room without staff supervision. The DON stated this failure allowed Resident 2 to enter Resident 1's room and physically assault her, resulting in Resident 1 sustaining a severe right eye injury and emotional distress. The DON stated the incident could have been prevented had Resident 2's 1:1 supervision been implemented as ordered. During an interview on 7/8/2026 at 2:20 p.m., with Licensed Nurse (LVN) 1, LVN 1 stated on 6/28/2026, Resident 2 was assigned a sitter. LVN 1 at approximately 1:00 p.m., she observed Resident 2 walking alone in the hallway. LVN 1 stated when Resident 2 hit Resident 1, no staff member was present. LVN 1 stated she reviewed the 1:1 sitter assignment for 6/28/2026, which indicated Certified Nursing Assistant (CNA) 1 was the assigned sitter from 1:00 p.m. to 2:00 p.m. LVN 1 stated the incident could have been avoided if CNA 1 had implemented the 1:1 monitoring as required. LVN 1 stated failure to provide 1:1 monitoring resulted in Resident 2 being left unsupervised and able to physically assault Resident 1. LVN 1 stated Resident 1 sustained a severe right eye injury as a result of the assault. During a concurrent interview and record review on 7/8/2026 at 2:45 p.m., with the Director of Staff Development (DSD), the facility's nursing assignment and 1:1 sitter monitoring assignment dated 6/28/2026, was reviewed. The nursing assignment indicated that on 6/28/2026, hourly 1:1 sitter coverage was assigned for Resident 2. The DSD stated the nursing assignment indicated CNA 1 was assigned to provide 1:1 monitoring from 1:00 p.m., to 2:00 p.m. The DSD stated Resident 2 had 1:1 continuous monitoring due to aggressive behaviors. The DSD stated the 1:1 sitter assignment identified the specific staff member responsible for continuous monitoring during each assigned hourly period. The DSD stated the assigned 1:1 staff was expected to remain with Resident 2 and provide continuous observation. The DSD stated Resident 2 should not have been left without 1:1 supervision. The DSD stated that on 6/28/2026, during the time Resident 2 was assigned 1:1 sitter monitoring, Resident 2 was able to leave his room unsupervised. The DSD stated the facility failed to monitor Resident 2 and prevent him from entering Resident 1's room and physically attacking her. During an interview on 7/8/2026 at 3:30 p.m., with LVN 2, LVN 2 stated the incident involving Resident's 1 and 2 occurred on 6/28/2026 at approximately 1:30 p.m. LVN 2 stated an unidentified CNA asked her to assess Resident 1 because she had blood all over her face and bed sheets. LVN 2 stated she immediately entered Resident 1's room and observed Resident 1's face and hands covered in blood. Resident 1's right eyeball was coming out. LVN 2 stated at that time, Resident 1 repeatedly stated He. that man tried to kill me. LVN 2 stated Resident 1's visible injuries were severe, with extensive bleeding and significant trauma to the right eye. LVN 2 stated Resident 2 should not have been left without supervision. LVN 2 stated this resulted in Resident 1 sustaining a severe right eye injury, eyeball protrusion (sticks out), extensive bleeding, laceration (skin tear), transfer to the hospital, and surgical intervention. During an interview on 7/8/2026 at 4:30 p.m., with the Administrator (ADM), the ADM stated on 6/28/2026, Resident 2 required 1:1 supervision; however, the staff member assigned to monitor Resident 2 failed to carry out the assigned 1:1 monitoring. The ADM stated this resulted in Resident 2 being unsupervised and able to enter Resident 1's room and physically assault her causing severe injury to the resident's right eye. The ADM stated it was unfortunate that Resident 1 was physically abused by Resident 2. The ADM stated the assault caused Resident 1 serious bodily injury and adversely affected her physical and phycological well-being. The ADM stated the incident could have been prevented had the assigned 1:1 supervision been implemented. During a telephone interview on 7/8/2026 at 4:45 p.m., with CNA 1, CNA 1 stated on 6/28/2026, at the beginning of the shift, she reviewed her assignment but was not aware that she had been assigned to provide 1:1 monitoring for Resident 2 from 1:00 p.m. to 2:00 p.m. CNA 1 stated she did not implement the 1:1 monitoring which resulted in Resident 2 physically assaulting Resident 1. CNA 1 stated that if she carefully reviewed and followed her assignment, she would have remained with Resident 2, monitored his behavior, redirected him as needed, and intervened before the assault occurred. During a review of the facility's policy and procedure (P&P) titled Resident Rights, revised 1/1/2012, the P&P indicated the facility will promote and protect all residents rights, including health and safety. During a review of the facility's P&P titled Reporting Abuse, revised 1/8/2014, the P&P indicated the facility will ensure that the resident has the right to be free from physical abuse.

Based on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin for one of three sampled residents (Resident 1) when Resident 1 sustained nasal (nose) fractures (broken bone), frontal scalp hematoma (collection of blood that forms in the tissue caused by a broken blood vessel that could be due to trauma or injury) and a laceration (cut or tear in the skin) to the Resident's left eyebrow on 6/9/2026. This failure had the potential to result in unidentified abuse and neglect towards Resident 1 and could negatively affect the Resident's well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), dysphagia (difficulty in swallowing), difficulty in walking, muscle weakness, schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), and depression (a mental health condition that makes a person feel very sad, hopeless, or uninterested in things they normally enjoy). During a review of Resident 1's Minimum Data Sheet (MDS, a resident assessment tool) dated 8/27/2025, the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 was dependent on staff (Helper does all the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for activities of daily living such as bed mobility (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), lying to sitting on side of the bed (the ability to move from lying on the back to sitting on the side of the bed and with no back support), chair to bed transfers and personal hygiene. During a review of Resident 1's Change in Condition (COC) Evaluation dated 6/9/2026, the COC indicated Resident 1 was seen with large amount of blood on person, and surrounding area. Resident 1 had a laceration to the left eye area that was actively bleeding. Pressure was applied to site of injury, and the Resident was taken to the General Acute Care Hospital (GACH). During a review of Resident 1's Computed Tomography (CT) of the head and maxillofacial (face scan) dated 6/10/2026, the CT indicated Resident 1 had an acute (new) comminuted fracture (occurs when a bone shatters or breaks into three or more fragments) at the distal tip of the right and left nasal bone with soft tissue swelling, as well as a left frontal scalp hematoma with soft tissue laceration. During a review of Resident 1's GACH Reexamination/Revaluation Note dated 6/10/2026, the Note indicated Resident 1 underwent a repair of the two cm laceration of the left eyebrow and had 5 sutures (used to stitch and close wounds or lacerations) placed. During an interview on 6/22/2026 at 3:12 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated (on 6/9/2026) when he arrived for his shift at approximately 11:00 p.m., he saw Resident 1 sitting on his bed with blood on his face, bed, clothes and on the floor. LVN 2 stated he did not witness how Resident 1 sustained the injury and Resident 1 could not tell him (LVN 2) how he (Resident 1) sustained the injury. LVN 2 stated there were no staff present in Resident 1's room and Resident 1's roommates were asleep when he saw the Resident. LVN 2 stated no one at the facility had interviewed him as part of an investigation of the incident regarding Resident 1's injuries. During an interview on 6/22/2026 at 4:13 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated on 6/9/2026 at 10:30 p.m.- 11:00 p.m., she was assigned as a 1:1 (one staff delegated to supervise a single Resident) hourly sitter for Resident 1. CNA 1 stated no one at the facility had interviewed her as part of an investigation of the incident regarding Resident 1's injuries. During interviews on 6/23/2026 at 10:30 a.m. and 12:17 p.m., with the Director of Nursing (DON), The DON stated on 6/9/2026, Resident 1 was found on his bed by LVN 2, with blood on his face and the floor. Resident 1 sustained fractures of the left and right nasal bones, a left frontal scalp hematoma with soft tissue laceration to left side of face. The DON stated no one saw Resident 1 fall and Resident 1 could not verbalize the cause of the injuries. The DON stated she did not interview other Residents, including Resident 1's roommates nor staff who worked 6/9/2026 during the evening (3:00 p.m.- 11:00 p.m.) shift regarding the incident. She did not further investigate the incident because she had no reason to question whether another Resident or staff caused Resident 1's injuries. During a review of the facility's Policy and Procedure (P&P) titled, Injuries of Unknown Origin-Investigation dated 11/18/2015, the P&P indicated all unexplained injuries are promptly and thoroughly investigated by the Director of Nursing and/or other staff person appointed by the Administrator to ensure that Resident safety is not compromised and action is taken whenever possible, to avoid future occurrences. An injury of unknown source is defined as an injury that meets both of the following conditions: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury. During a record review of the facility's P&P titled, Abuse Prevention and Management dated 6/12/2024, the P&P indicated the facility commits to identifying, correcting, and intervening in situations involving abuse, neglect or injuries of unknown source. The P&P indicated the Administrator, or designated representative will initiate an investigation immediately and will provide for a safe environment for the resident. The P&P indicated the Administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation.

Based on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Abuse Prevention and Management which indicated the Administrator (ADM) or designated representative will report all injuries of unknown origin to the California Department of Public Health (CDPH) Licensing and Certification within two hours, for one of three sampled residents (Resident 1), when Resident 1 sustained nasal (nose) fractures (broken bone), frontal scalp hematoma (collection of blood that forms in the tissue caused by a broken blood vessel that could be due to trauma or injury) and a laceration (cut or tear in the skin) to the Resident's left eyebrow on 6/9/2026. This failure had the potential to delay the investigation by the CDPH and placed Resident 1 at risk for continued abuse, neglect and injuries. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), dysphagia (difficulty in swallowing), difficulty in walking, muscle weakness, schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), and depression (a mental health condition that makes a person feel very sad, hopeless, or uninterested in things they normally enjoy). During a review of Resident 1's Minimum Data Sheet (MDS, a resident assessment tool) dated 8/27/2025, the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 was dependent on staff (Helper does all the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for Activities of Daily Living such as bed mobility (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), lying to sitting on side of the bed (the ability to move from lying on the back to sitting on the side of the bed and with no back support), chair to bed transfers and personal hygiene. During a review of Resident 1's Change in Condition (COC) Evaluation dated 6/9/2026, the COC indicated Resident 1 was seen with large amount of blood on person, and surrounding area. Resident 1 had a laceration to the left eye area that was actively bleeding. Pressure was applied to site of injury, and the Resident was taken to the General Acute Care Hospital (GACH). During a review of Resident 1's Computed Tomography (CT) of the head and maxillofacial (face scan) dated 6/10/2026, the CT indicated Resident 1 had an acute (new) comminuted fracture (occurs when a bone shatters or breaks into three or more fragments) at the distal tip of the right and left nasal bone with soft tissue swelling, as well as a left frontal scalp hematoma with soft tissue laceration. During a review of Resident 1's GACH Reexamination/Revaluation Note dated 6/10/2026, the Note indicated Resident 1 underwent a repair of a two cm laceration of the left eyebrow and had 5 sutures (used to stitch and close wounds or lacerations) placed. During an interview on 6/22/2026 at 3:12 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated (on 6/9/2026) when he arrived for his shift at approximately 11:00 p.m., he saw Resident 1 sitting on his bed with blood on his face, bed, clothes and on the floor. LVN 2 stated he did not witness how Resident 1 sustained the injury and Resident 1 could not tell him (LVN 2) how he (Resident 1) sustained the injury. LVN 2 stated there were no staff present in Resident 1's room and Resident 1's roommates were asleep when he saw the Resident. During an interview on 6/22/2026 at 4:45 p.m., with Registered Nurse (RN) 2, RN 2 stated, on 6/9/2026 at approximately 11:00 p.m., LVN 2 notified her about Resident 1's injury. RN 2 stated she (RN 2) saw Resident 1 sitting on his bed, with blood on his forehead. RN 2 stated she asked Resident 1 what happened, and the Resident could not respond. During interviews on 6/23/2026 at 10:30 a.m. and 12:17 p.m., with the Director of Nursing (DON), The DON stated on 6/9/2026, LVN 2 found Resident 1 on his bed with blood on his face and the floor. Resident 1 sustained fractures of the left and right nasal bones, a left frontal scalp hematoma with soft tissue laceration to left side of face. The DON stated all injuries of unknown origin should be reported to the CDPH within 2 hours. She did not immediately notify CDPH because she assumed Resident 1's injuries were due to the Resident falling. The DON also stated no one saw Resident 1 fall, staff did not find Resident 1 on the floor, and Resident 1 could not verbalize the cause of the injuries. During an interview on 6/30/2026 with the ADM, the ADM stated she was notified of Resident 1's injuries on 6/10/2026. The incident was not reported within two hours to the CDPH because the injuries were due to a fall. The ADM stated staff did not witness Resident 1 falling. During a record review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Management, dated 6/12/2024, the P&P indicated the facility commits to identifying, correcting, and intervening in situations involving abuse, neglect or injuries of unknown source. The P&P indicated injury of unknown source is defined as an injury that meets both of the following conditions: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury, the location of the injury, or the incidents of injury over time. The P&P indicated the Administrator, or designated representative will send a written report to the CDPH Licensing and Certification within two hours.

Based on interview and record review, the facility failed to implement Resident 1's Care Plan titled, (Resident 1) was at risk for unsafe behaviors and impaired safety awareness related to schizophrenia (a mental illness that is characterized by disturbances in thought), encephalopathy (disease or damage that affects the brain), cognitive (ability to think and reason) impairment, akathisia (movement disorder) and behavioral disturbances as evidenced by agitation, restlessness, confusion, poor judgment.and ongoing need for 1:1(one to one, when one staff member is assigned to directly monitor no more than one resident. The staff shall stay within very close proximity to ensure constant supervision and immediate intervention if needed for safety reasons) monitoring for safety, which indicated the facility will maintain 1: 1 monitoring every shift to promote Resident safety and prevent unsafe behaviors. This failure resulted in Resident 1 sustaining injuries of unknown origin (an injury that was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury.) and was transferred to a General Acute Care Hospital for evaluation and treatment on 6/9/2026. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), dysphagia (difficulty in swallowing), difficulty in walking, muscle weakness, schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), and depression (a mental health condition that makes a person feel very sad, hopeless, or uninterested in things they normally enjoy). During a review of Resident 1's Minimum Data Sheet (MDS, a resident assessment tool) dated 8/27/2025, the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 was dependent on staff (Helper does all the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for activities of daily living such as bed mobility (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), lying to sitting on side of the bed (the ability to move from lying on the back to sitting on the side of the bed and with no back support), chair to bed transfers and personal hygiene. During a review of Resident 1's Change in Condition (COC) Evaluation dated 6/9/2026, the COC indicated Resident 1 was seen with large amount of blood on person, and surrounding area. Resident 1 had a laceration to the left eye area that was actively bleeding. Pressure was applied to site of injury, and the Resident was taken to the GACH. During an interview on 6/22/2026 at 3:12 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated (on 6/9/2026) when he arrived for his shift at approximately 11:00 p.m., he saw Resident 1 sitting on his bed with blood on his face, bed, clothes and on the floor. LVN 2 stated he did not witness how Resident 1 sustained the injury and Resident 1 could not tell him (LVN 2) how he (Resident 1) sustained the injury. LVN 2 stated there were no staff present in Resident 1's room and Resident 1's roommates were asleep when he saw the Resident. LVN 2 also stated Resident 1 had a 1:1 sitter on previous shifts and did not have a 1:1 sitter that evening shift (on 6/9/2026 3:00 p.m.- 11:00 p.m.). During an interview on 6/22/2026 at 4:13 p.m., with the Certified Nurse Assistant (CNA) 1, CNA 1 stated she was assigned as Resident 1's 1:1 hourly sitter on 6/9/2026 from 10:30 p.m. to 11:00 p.m. CNA 1 stated she last saw Resident 1 at 10:45 p.m. She changed Resident 1's shorts, then she left the room and did not return to Resident 1 before reporting off duty at 11:00 p.m. During concurrent interviews and record review on 6/23/2026 at 10:30 a.m. and 6/30/2026 at 10:40 a.m., with the Director of Nursing (DON), Resident 1's Care Plan titled, (Resident 1) was at risk for unsafe behaviors and impaired safety awareness related to schizophrenia, cognitive impairment, akathisia and behavioral disturbances as evidenced by agitation, restlessness, confusion, poor judgment.and ongoing need for 1:1 monitoring for safety dated 5/6/2026 was reviewed. The DON stated Resident 1's Care Plan indicated to provide 1:1 monitoring for the Resident's behaviors such as restlessness, agitation and poor judgment. The DON stated a 1:1 sitter was assigned to Resident 1 on 6/9/2026 during the 7:00 a.m.- 3:00 p.m. shift and was changed by her (the DON) to a 1:1 hourly sitter assignment to spot check the Resident as needed during the 3:00 p.m.- 11:00 p.m. shift. A 1:1 sitter assigned to the resident was expected to stay with the resident the entire shift for the safety of the resident or staff. A 1:1 hourly sitter was expected to check Resident 1 every ten to fifteen minutes and was not required to remain in Resident 1's room continuously during the shift. The DON stated Resident 1's care plan, indicated to provide ongoing one-to-one monitoring for the Resident's safety, and the facility should have continued the 1:1 sitter (not hourly) on 6/9/2026 during the 3:00 p.m. to 11:00 p.m. shift. The DON also stated there was no documentation to indicate 1:1 monitoring was provided to Resident 1. During a record review of the facility's policy and procedure (P&P) titled, Resident Safety dated 4/15/2021, the P&P indicated the facility is committed to identify circumstances that pose a risk for the safety of and wellbeing of residents. The Interdisciplinary Care Team (a group of healthcare professionals who work together to manage the Resident's care) will establish a person-centered observation or monitoring systems for the Resident to address the identified risk factors. To observe the safety and wellbeing of the Residents, a Resident check will be made at least every two hours around the clock by nursing service personnel, and the person-centered care plan may require more frequent safety checks. During a record review of the facility's P&P titled, Person-Centered Care Planning dated 5/22/2025, the P&P indicated the facility must implement a comprehensive person-centered care plan for each resident consistent with the resident rights to meet a resident's medical, nursing, and mental and psychosocial needs.

Based on interview and record review, the facility failed to notify the physician of a resident's refusal to take their scheduled medications for one of four sampled residents (Resident 2).This deficient practice had the potential for Resident 2 to decline and resulted in delayed necessary care and medical interventions due to the physician not being notified in a timely manner.Findings:During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses include bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), atrial fibrillation (irregular and often very rapid heart rhythm), and hypertension ([HTN] - high blood pressure).During a review of Resident 2's Minimum Data Set ([MDS] - a resident assessment tool), dated 5/30/2026, the MDS indicated, Resident 2's cognitive (ability to think and reason) skills for daily decision making was moderately impaired (decisions are poor, cues and supervision required). The MDS indicated, Resident 2 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene, lower body dressing, and personal hygiene.During a review of Resident 2's History and Physical (H&P), dated 5/27/2026, the H&P indicated, Resident 2 did not have the capacity to consent.During a review of Review of Resident 2's physician order, dated 5/23/2026, the physician order indicated, Resident 2 was to receive the following medications:Depakote (an anticonvulsant drug used to treat seizure disorder and other psychiatric conditions) 250 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth two times a day (9:00 a.m. and 5:00 p.m.) for seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).Eliquis (a drug that can prevent and treat blood clots) by mouth 5mg twice a day for cerebrovascular accident ([CVA] - stroke, loss of blood flow to a part of the brain) prophylaxis (prevention).Losartan Potassium (drug used to treat HTN) by mouth 25mg once a day (9:00 a.m.) for HTN.Risperdal (drug used for treatment of bipolar disorder) by mouth 1mg two times a day for bipolar disorder manifested by striking out.During a review of review of Resident 2's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), from 5/24/2026 to 5/27/2026, the MAR indicated, Resident 2 refused (coded as 2) to take Depakote, Eliquis, Losartan, and Risperdal.During a concurrent interview and record review on 6/10/2026 at 8:20 a.m., with Licensed Vocational Nurse 4 (LVN 4), Resident 2's Progress Notes, from 5/24/2026 to 5/27/2026, was reviewed. The Progress Notes did not indicate Resident 2's physician was notified of the resident's refusal of Depakote, Eliquis, Losartan, and Risperdal on 5/24/2026, 5/25/2026, 5/26/2026, and 5/27/2026. LVN 4 stated the standard of practice was to notify the physician when a resident refused medications after three consecutive episodes. LVN 4 stated when Resident 2 refused medication, the physician should be notified because it was considered as a resident's change of condition.During an interview on 6/10/2026 at 11:00 a.m., with the Director of Nursing (DON), the DON stated notifying the physician when a resident refused medication was essential for resident safety and for the physician to offer an alternative treatment plan.During a review of the facility's policy and procedure (P&P) titled, Refusal of Treatment, dated 1/1/2012, the P&P indicated, The attending physician will be notified of refusal of treatment in a time frame determined by the resident's condition and potential serious consequences of the refusal.During a review of the facility's P&P titled, Medication Administration, dated 6/26/2025, the P&P indicated, For resident refusing medication, the licensed nurse will notify the prescribing provider and document in the medical record including the reason for refusal.

Based on interview and record review, the facility failed to develop a person-centered care plan for right ear pain for one of one sampled resident (Resident 1).This deficient practice had the potential to result in a lack meeting necessary care and addressing medical needs for Resident 1.Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P), dated 2/14/2026, the H&P indicated, Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 4/10/2026, the MDS indicated, Resident 1's cognitive (ability to think and reason) skills for daily decision making was moderately impaired (decisions are poor, cues and supervision required). The MDS indicated, Resident 1 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene, upper and lower body dressing.During a review of Resident 1's Change in Condition Evaluation (an electronic assessment tool used in long-term and post-acute care to safely manage resident health changes in-house and prevent avoidable hospital transfers) dated 5/24/2026, the Change in Condition indicated on 5/24/2026, Resident 1 had right ear pain.During a concurrent interview and record review on 6/10/2026 at 8:15 a.m., with Licensed Vocational Nurse 4 (LVN 4), Resident 1's care plans, were reviewed. the care plans did not indicate a specific comprehensive care plan was developed to address Resident 1's complaint of right ear pain. LVN 4 stated care plans had a problem, goal, and interventions. LVN 4 stated the facility staff would not be able to solve Resident 1's complaint of right ear pain because there was no care plan developed and interventions implemented. LVN 4 stated care plans should be individualized and should pertain to the care of each resident. LVN 4 stated the purpose of the care plan was for continuity of care.During an interview on 6/10/2026 at 10:45 a.m., with the Director of Nursing, the DON stated a care plan was very important to address resident's areas of concern and to show facility's plan of action.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 8/24/2023, the P&P indicated, The comprehensive care plan will be reviewed and revised if there is an onset of new problems and a change of condition.

Based on interview and record review, the facility failed to monitor two of four sampled residents (Residents 1 and 3) behaviors while prescribed psychotropic medications (any drug that affects brain activities associated with mental processes and behavior).This deficient practice had the potential to result in the administration of unnecessary psychotropic medication that could cause harm to Residents 1 and 3. Findings:a. During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P), dated 2/14/2026, the H&P indicated, Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 4/10/2026, the MDS indicated, Resident 1's cognitive (ability to think and reason) skills for daily decision making was moderately impaired (decisions are poor, cues and supervision required). The MDS indicated, Resident 1 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene, upper and lower body dressing.During a review of Resident 1's physician order, dated 2/13/2026, the physician order indicated, Divalproex Sodium Delayed Release (an anticonvulsant drug used to treat seizure disorder and other psychiatric conditions) 500 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) one tablet by mouth three times a day (9:00 a.m., 1:00 p.m., and 5:00 p.m.) for schizophrenia manifested by striking out and Seroquel (psychotropic medication used for treatment of schizophrenia) 200mg one tablet by mouth two times a day (9:00 a.m., and 5:00 p.m.) for schizophrenia manifested by verbal aggression and outburst of anger.During a concurrent interview and record review on 6/10/2026 at 8:05 a.m., with Licensed Vocational Nurse 4 (LVN 4), Resident 1's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), from 2/14/2026 to 6/3/2026, was reviewed. The MAR did not indicate documented evidence of Resident 1's behavior monitoring for striking out, aggression, and angry outburst. LVN 4 stated when residents were receiving psychotropic medications, the licensed nurses should monitor for the behavior manifested by putting a hashmark and documenting the number of episodes on the MAR. LVN 4 stated behavior monitoring was important in order to keep track of the target behavior and to determine if the psychotropic medications would be decreased or increased based on the number of the frequency of the behavior.b. During a review of Resident 3's Face Sheet, the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE]. Resident 3's diagnoses included attention deficit hyperactivity disorder ([ADHD] - a neurodevelopmental difference that affects a person's ability to regulate focus, impulses, and energy levels), major depressive disorder ([MDD] - a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations).During a review of Resident 3's H&P, dated 5/30/2026, the H&P indicated, Resident 3 had fluctuating capacity to understand and make decisions.During a review of Resident 3's physician order, dated 5/29/2026, the physician order indicated Bupropion Hydrochloride Extended Release (drug used to treat MDD) one tablet by mouth two times a day (9:00 a.m. and 5:00 p.m.) for depression manifested by self-isolation.During a concurrent interview and record review on 6/10/2026 at 10:55 a.m. with the Director of Nursing (DON), Resident 3's MAR from 5/30/2026 to 6/9/2026, was reviewed. The MAR did not indicate behavior monitoring of Resident 3's self-isolation. The DON stated it was important to tally and document Resident 3's behavior in order to evaluate the continued use and dose adjustment of psychotropic medications.During a review of the facility's policy and procedure (P&P) titled, Behavior and Psychoactive Medication Management, dated 1/30/2026, the P&P indicated, Any order for psychoactive medications must include a specific behavior manifestation. The P&P did not disclose the frequency and importance of monitoring resident's behavior.

Based on observation, interview, and record review, the facility failed to protect the dignity of one of five sampled residents (Resident 5) when Resident 5 walked in the hallway wearing a diaper.This failure had the potential to result in Resident 5 feeling embarrassed.Findings:During a review of Resident 5's admission Record, dated 5/15/2026, the admission Record indicated Resident 5 diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dementia with behavioral disturbance (a progressive state of decline in mental abilities), and acute cystitis without hematuria (inflammation of the bladder typically caused by a bacterial infection).During a review of Resident 5's History and Physical (H&P), dated 3/20/2026, the H&P indicated Resident 5 had fluctuating capacity.During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 5's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 5 required setup assistance (helper sets up or cleans up, resident completes activity) from staff for toileting hygiene and substantial assistance (helper does more than half the effort) from staff for lower body dressing. The MDS indicated Resident 5 was frequently incontinent of urine. During a concurrent observation and interview on 5/14/2026 at 8:27 a.m. with Certified Nurse Assistant (CNA 1), Resident 5 was escorted by CNA 1 and walking in the hallway in a diaper, without pants. CNA 1 stated Resident 5 wanted to smoke a cigarette. CNA 1 stated Resident 5 often walked in the hallway while in a diaper. CNA1 stated walking in the hallway in a diaper could be embarrassing for Resident 5. During an interview on 5/14/2026 at 11:41 a.m. with the Director of Nursing (DON), the DON stated Resident 5's dignity was not being respected and was exposed.During a review of the facility's policy and procedure (P&P) titled, Resident Rights-Quality of Life, dated 03/2017, the P&P indicated each resident would be cared for with dignity and respect. The P&P indicated residents were encouraged and assisted to dress in their own clothes rather than in hospital gowns.

Based on observation, interview, and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Abuse- Reporting and Investigations which indicated the facility will report injuries of unknown source (bodily harm that cannot be explained) to the California Department of Public Health (CDPH) within two hours, for one of four sampled residents (Resident 1) when Resident 1 was found with a wound to her right forearm on 4/30/2026. This failure had the potential to result in a delay in the investigation by the CDPH and placed Resident 1 at risk for neglect and abuse. Findings:During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevation periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension (high blood pressure) and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 1's history and physical (H&P) dated 3/7/2026, the H&P indicated Resident 1 had cognitive (ability to think and reason) impairment.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/3/2026, the MDS indicated the resident was dependent (helper does all of the effort) for dressing, personal hygiene, showering, and transfers in and out of bed. During a review of Resident 1's Progress Note dated 4/30/2026 at 12:30 a.m., the Note indicated Resident 1 was found with an injury of unknown origin, and complained of pain level 10 out of 10 (pain scale reference: 0=no pain, 1-4=mild pain, 5-7=moderate pain, 8-9=severe pain, 10=excruciating pain). The Note indicated emergency medical services were activated, and the resident was transferred via ambulance to the General Acute Care Hospital (GACH). During a concurrent observation and interview on 5/4/2026 at 10:56 a.m., with Resident 1 in Resident 1's room, the resident was observed with gauze wrapped around her forearm. Resident 1 stated she did not know what happened to her arm and was unable to recall whether anyone had injured her arm.During a concurrent observation and interview on 5/4/2026 at 11:00 a.m., with Licensed Vocational Nurse (LVN) 2 in Resident 1's room, LVN 2 unwrapped Resident 1's right forearm gauze and observed Resident with a quarter-sized open wound that had exposed pink and red tissue. Resident 1 was also observed with another wound that had exposed reddened skin and dried blood, approximately 2 inches x 1 inch wide in size. LVN 2 stated facility staff did not know how the resident acquired the wound.During an interview on 5/4/26 at 3:39 p.m. with the Administrator (Admin), the Admin stated she did not report Resident 1's injury (of unknown source) to the CDPH because she was not made aware until this day (5/4/2026). During interviews on 5/6/2026 at 9:21 a.m. and 5/6/2026 at 3:15 p.m., with the Director of Nursing (DON), the DON stated Registered Nurse (RN) 1 notified her on 4/30/2026 that Resident 1 was sent to the GACH for a wound on her right arm. The DON stated Resident 1's wound was considered an injury of unknown origin because it was not known how the resident sustained the injury which required treatment at the GACH. The DON stated the incident should have been reported to the State Agency within two hours of the facility being made aware of it. She did not report the incident because she did not know how it occurred. The DON stated it was important to report injuries of unknown origin for residents' safety. During a phone interview on 5/6/2026 at 12:32 p.m., with RN 1, RN 1 stated (on 4/30/2026) an unidentified CNA informed him about Resident 1's injury to the right forearm. RN 1 stated Resident 1 could not state how she got the wound. RN 1 stated he reported the incident to the DON and the Physician. Resident 1 was sent to the GACH for evaluation and treatment. During a review of the facility's P&P titled, Abuse- Reporting and Investigations, dated 3/2018, the P&P indicated, the facility will report all allegations of abuse as required by law and regulations to the appropriate agencies. The facility promptly reports and thoroughly investigates allegations of abuse, mistreatment, neglect or injuries of unknown source. The P&P indicated Administrator, or designed representative will notify the CDPH by telephone and in writing within two (2) hours if initial report.

Based on observation, interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin (bodily harm that cannot be explained) for one of four sampled residents (Resident) 1, when Resident 1 was found with a wound to her right forearm on 4/30/2026.This failure had the potential to result in unidentified abuse and placed Resident 1 at risk for continued abuse and injury. Findings:During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevation periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension (high blood pressure) and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 1's history and physical (H&P) dated 3/7/2026, the H&P indicated Resident 1 had cognitive (ability to think and reason) impairment.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/3/2026, the MDS indicated the resident was dependent (helper does all of the effort) for dressing, personal hygiene, showering, and transfers in and out of bed. During a review of Resident 1's Progress Note dated 4/30/2026 at 12:30 a.m., the Note indicated Resident 1 was found with injury of unknown origin, with complaints of pain level 10 out of 10 (pain scale reference: 0=no pain, 1-4=mild pain, 5-7=moderate pain, 8-9=severe pain, 10=excruciating pain). The Note indicated emergency medical services were activated, and the resident was transferred via ambulance to the General Acute Care Hospital (GACH).During a concurrent observation and interview on 5/4/2026 at 10:56 a.m., with Resident 1 in Resident 1's room, the resident was observed with gauze wrapped around her forearm. Resident 1 stated she did not know what happened to her arm and was unable to recall whether anyone had injured her arm.During a concurrent observation and interview on 5/4/2026 at 11:00 a.m., with Licensed Vocational Nurse (LVN) 2 in Resident 1's room, LVN 2 unwrapped Resident 1's right forearm gauze and observed Resident with a quarter-sized open wound that had exposed pink and red tissue. Resident 1 was also observed with another wound that had exposed reddened skin and dried blood, approximately 2 inches x 1 inch wide in size. LVN 2 stated facility staff did not know how the resident acquired the wound.During an interview on 5/4/26 at 3:39 p.m. with the Administrator (Admin), the Admin stated she did not investigate Resident 1's injury (of unknown source) because she was not made aware until this day (5/4/2026). During interviews on 5/6/2026 at 9:21 a.m. and 5/6/2026 at 3:15 p.m., with the Director of Nursing (DON), the DON stated Registered Nurse (RN) 1 notified her on 4/30/2026 that Resident 1 was sent to the GACH for a wound on her right arm of unknown origin. The DON stated Resident 1's wound was considered an injury of unknown origin because it was not known how the resident sustained the injury which required treatment at the GACH. The DON stated she interviewed nurses and CNAs about Resident 1's arm injury, however no one knew how the resident was injured. The DON was unable to provide the names of the staff interviewed nor proof of her investigation. The DON stated she did not investigate further because she did not think another resident caused the injury. The DON stated it was important to thoroughly investigate an injury of unknown origin to keep residents safe, to determine if the incident was preventable and whether anyone should be held accountable for it. During a review of the facility's Policy and Procedure titled, Injuries of Unknown Origin-Investigation dated 11/18/2015, the P&P indicated an injury of unknown source is defined as an injury that meets both of the following conditions: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; andThe injury is suspicious because of the extent of the injury, the location of the injury or the number of injuries observed at one particular time. The P&P indicated unexplained injuries are promptly and thoroughly investigated by the DON and/or other staff person appointed by the Administrator, to ensure the resident safety is not compromised and action is taken whenever possible, to avoid future occurrences. During a review of the facility's P&P titled, Abuse Reporting and Investigations dated 3/2018, the P&P indicated the facility promptly thoroughly investigates allegations of resident abuse, mistreatment, neglect or injuries of unknown source. The P&P indicated the Administrator will provide a written report of the results of the investigation and appropriate action taken to the CDPH, within five working days of the reported allegation. During a review of the facility's P&P titled, Abuse and Neglect dated 12/22/2021, the P&P indicated, when the Administrator (or designated representative) receives a report of an incident or suspected incident of Resident abuse, neglect or injuries of an unknown source, the Administrator (or designated representative) will immediately initiate an investigation. The Administrator (or designated representative) conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime. Individuals who may have information relevant to the allegation are the resident, witnesses to the incident, other residents, roommates, family, visitors etc.

Based on interview and record review, the facility failed to ensure an altercation between two of four sample residents (Resident 3 and Resident 4) was reported to the California Department of Public Health (CDPH) when Resident 4 hit and threw coffee at Resident 3's face.This deficient practice of not reporting the altercation to the CDPH within two hours delayed the investigation and placed Resident 3 at risk for further injuries. Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3 diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a mental health condition characterized by excessive, persistent, and uncontrollable worry that interferes with daily functioning), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 3's History and Physical (H&P), dated 2/13/2026, the H&P indicated Resident 3 had the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 2/19/2026, the MDS indicated Resident 3's cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 3 required partial/moderate assistance (helper does less than half the effort for lifts or holds trunk or limbs and provides less than half the effort) by staff for toileting hygiene, showering, and dressing.During a review of Resident 3's Progress Notes, dated 4/26/2026, the Progress Notes indicated on 4/26/2026, Resident 3 reported Resident 4 had thrown a cup of coffee at her and hit her in the face. The Progress Notes indicated Resident 3 had slight redness to her chin and near her cheeks. The Progress Notes indicated Resident 3 reported pain 10 out of 10 (10 being severe pain) on a pain scale.During a review of Resident 3's Change of Condition (COC), dated 4/26/2026, the COC indicated on 4/26/2026, Resident 3 was in an altercation with Resident 4. The COC indicated Resident 3 had redness to the chin and cheek.During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 4's diagnoses included dementia (a progressive state of decline in mental abilities), anxiety (a mental health condition characterized by excessive, persistent, and uncontrollable worry that interferes with daily functioning), and metabolic encephalopathy (a brain dysfunction caused by systemic illness).During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognition was severely impaired. The MDS indicated Resident 4 required supervision (helper provides verbal cues as resident completes activity) from staff for toileting hygiene, showering, and dressing.During a telephone interview on 5/5/2026 at 2 p.m., with Registered Nurse (RN) 1, RN 1 stated she filled out an abuse reporting form and faxed it to the Ombudsman within two hours. RN 1 stated she did not get a confirmation after she faxed the form over to CDPH. RN 1 stated it had been ten days since the altercation and since CDPH did not receive notice of the incident, there was a delay for CDPH to investigate.During a concurrent interview and record review on 5/5/2026 at 3:30 p.m., with the Administrator (ADM), a letter faxed to CDPH, dated 5/4/2026 was reviewed. The letter indicated on 4/26/2026 an abuse reporting form was completed and faxed to the local Ombudsman and the local law enforcement was called. The letter indicated there was an accidental oversight during the facility's reporting process, and the abuse reporting form was not sent to CDPH. The ADM stated CDPH was not notified and should have been notified within two hours of the altercation.During a review of the facility's policy and procedure (P&P) titled, Abuse Reporting & Investigations, dated 3/2018, the P&P indicated the facility will report all allegations of abuse as required by law and regulations to the appropriate agencies. The P&P indicated the Administrator, or designed representative will notify CDPH by telephone and in writing within two hours.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 was within three to five feet ([ft.] - unit of length) for one sample resident (Resident 2) who was placed on one-to-one (1:1, close supervision) monitoring.This deficient practice of CNA 2 not standing three to five feet of Resident 2 had the potential for the resident to have another altercation.Findings:During a review of Resident 2's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 2 diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a mental health condition characterized by excessive, persistent, and uncontrollable worry that interferes with daily functioning), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 2's History and Physical (H&P), dated 3/6/2026, the H&P indicated, Resident 2 could make needs known but could not make medical decisions.During a review of Resident 2's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 3/13/2026, the MDS indicated Resident 2's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 2 had the potential for hallucinations (perceptual experiences in the absence of real external sensory stimuli). The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort for lifts or holds trunk or limbs and provides less than half the effort) by staff for toileting hygiene, showering, and dressing.During a review of Resident 2's Change of Condition (COC), dated 5/1/2026, the COC indicated on 5/1/2026, Resident 2 had become physically aggressive and had struck other residents and was placed on one-to-one supervision.During a review of Resident 2's care plan titled, Resident had Episode of Aggressive Combative Behavior towards other Residents related to Schizophrenia, dated 5/1/2026, the care plan indicated to have a one-to-one close visual monitoring.During a review of Resident 2's physician orders titled, Order Summary Report, dated 5/3/2026, the Order Summary Report indicated Resident 2 was to have a one-to-one sitter for visual monitoring related to resident-to-resident altercation for seven days.During a concurrent observation and interview on 5/4/2026 at 11:06 a.m., with Activities Assistant (AA) 1, on the outside patio, Resident 2 was observed sitting between two other residents. Resident 2 was within arm's reach of the other residents. AA 1 stated CNA 1 was too far from Resident 2 and should be no more than three to five feet away from Resident 2. AA 1 stated one to one supervision was to prevent Resident 2 from another altercation.During a concurrent observation and interview on 5/4/2026 at 11:13 a.m., with CNA 1, on the outside patio, Resident 2 was observed seated between two residents. Resident 2 was within arm's reach (the physical distance a person can extend their arm to touch or grab an object without moving their feet) of the residents. CNA 2 was sitting in a chair looking at his phone and was approximately 10 feet away from Resident 2. CNA 1 stated he was Resident 2's assigned one-to-one sitter. CNA 1 stated he was seated away from Resident 2 because he wanted to keep his distance from the cigarette smoke.During a concurrent observation and interview on 5/4/2026 at 4 p.m., with the Maintenance Supervisor, observed the Maintenance Supervisor measure the distance from chair (Resident 2) to chair (CNA 1). The distance measured 11 and 1/2 feet. The Maintenance Supervisor stated the distance was greater than five feet.During an interview on 5/5/2026 at 8:50 a.m., with the Administrator (ADM), the ADM stated CNA 1 was nearly 12 feet away from Resident 2. The ADM stated CNA 1 was too far away from Resident 2 and would not be able to stop him in time from hitting other residents that were sitting next to him.During a review of the facility's policy and procedure (P&P) titled, Resident Supervision, dated 10/2023, the P&P indicated to ensure that adequate supervision was provided to residents to prevent accidents.During a review of the facility's P&P titled, Sitters, dated 1/2024, the P&P indicated the facility will orient the sitter regarding safety practices, duties, and responsibilities of the sitter.During a review of the facility's lesson plan titled, One to One Supervision, dated 2/18/2025, the lesson plan indicated One-to-One Supervision indicated all staff have the responsibility to help prevent resident to resident altercations. The One-One Supervision indicated staff doing one-to-one duty were to maintain a safe distance of three to five feet.

Based on observation, interview, and record review the facility failed to: 1.Ensure a Change of condition ([COC] -a significant deviation from a patient baseline condition that requires immediate assessment and intervention to prevent further decline) form was initiated for Resident 3 with a skin rash (an area of irritation, inflamed, or damaged skin). 2. Provide treatment for Resident 3's skin rash. 3. Give a complete assessment report to General Acute Care Hospital ([GACH] -a hospital 24-hour medical services) regarding Resident 3's skin rash prior to admission. This deficient practice of not reporting, treating, or monitoring Resident 3's skin rash resulted in a diagnosis with scabies (highly contagious skin infestation).During a review of Resident 3's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 3's diagnoses schizophrenia (a mental illness that is characterized by disturbances in thought), cardiomegaly (enlarged heart), and chronic kidney disease (progressive, irreversible loss of renal function). During a review of Resident 3's history and physical (H&P), dated 1/11/2026, the H&P indicated Resident 3 had fluctuated capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool), dated 10/30/2025, the MDS indicated Resident 3's cognition (ability to learn, reason, remember, understand, and make decisions) was cognitively intact. The MDS indicated Resident 3 was independent (resident completes the activity by themself with no assistance from a helper) for eating, showering, and dressing. During a review of Resident 3's Progress Notes, dated 1/10/2026, the progress notes indicated resident was readmitted to the facility with generalized itchy rashes on her whole body. During a review of Resident 3's Skin Check, dated 1/10/2026, the skin check indicated Resident 3 had a rash on the abdomen, cervical region, and bilateral front and back thighs. The skin check indicated to track, and it was a new issue. During a review of Resident 3's Multidisciplinary Care Conference (IDT), dated 1/13/2026, the IDT had no indication of Resident 3's rash nor medical treatments for the itchy generalized rash. During a review of Resident 3's Skin Check, dated 1/15/2026, the skin check indicated Resident 3 had a rash on the abdomen, cervical region, and bilateral front and back thighs. The skin check indicated to track and needed to be reviewed. During a review of Resident 3's discharge summary titled, SNF/NF to Hospital Transfer Form, dated 1/15/2026, the discharge summary indicated Resident 3 had no skin issues. During a review of Resident 3's GACH records, dated 1/15/2026, the GACH records indicated Resident 3 had generalized rash on the whole body. During a review of Resident 3's GACH records, dated 1/17/2026, the GACH records indicated Resident 3 was on isolation precaution due to scabies. During a concurrent interview and record review on 1/27/2026 at 2:30 p.m., with Treatment Nurse (TN) 1, Resident 3's Progress Notes, dated 1/10/2026 was reviewed. The progress notes indicated resident was readmitted to the facility on [DATE] with generalized itchy rashes on her whole body. TN 1 stated there was no treatment initiated for the generalized rash. TN 1 stated this was a COC and the physician should have been notified so medical treatment could get started. During an interview on 1/27/2026 at 2:40 p.m., with TN 1, TN1 stated Resident 3 was not monitored for the generalized rash from 1/11/2026 to 1/15/2026. TN 1 stated the staff would not know if the rash was improving or getting worse. During an interview on 1/27/2026 at 2:45 p.m., with TN 1, TN 1 stated when Resident 3 was transferred to the hospital the licensed staff was to give a completed report which included the skin condition of the resident. TN 1 stated the hospital should know so they could properly accommodate the resident such as place her in isolation to prevent potential spread of infection. During a concurrent interview and record review on 1/28/2026 at 11:00 a.m., with Infection Preventionist (IP) Nurse, Resident 3's Progress Notes, dated 1/10/2026 was reviewed. The progress notes indicated resident was readmitted to the facility with generalized itchy rashes on her whole body. The IP Nurse stated Resident 3 should have been treated prophylactically (providing care aimed at preventing diseases, infections, or health issues before they occur or worsen) due to the generalized itchy rash. The IP Nurse stated for Resident 3 there was no COC done, she was not monitored for symptoms of the rash, and no treatment for the itching. The IP Nurse stated not following up with the symptoms could have placed the residents at risk for transmission (which a parasite spreads from an infected host to another) which could have resulted in a scabies outbreak. During a concurrent interview and record review on 1/28/2026 at 1:07 p.m., with Registered Nurse (RN) 1, Resident 3's discharge summary titled, SNF/NF to Hospital Transfer Form, dated 1/15/2026 was reviewed. The discharge summary indicated Resident 3 had no skin issues. RN 1 stated prior to transferring a resident to the hospital; we were to give a complete report. RN 1 stated this would include a detailed report of Resident 3's skin rash. RN 1 stated not notifying the hospital was poor communication on our part. RN 1 stated the poor communication had placed residents, staff, and the patients at the hospital at risk for the spread of infection. During a review of the facility's policy and procedures (P&P) titled, Prevention and Management of Scabies, dated 7/2020, the P&P indicated upon admission, residents will have skin, hair, and nail beds examined for signs and symptoms that might suggest scabies. The P&P indicated undiagnosed and untreated rash will be placed in isolation. The P&P indicated to notify the DON of any suspicious skin rash and to be treated according to the physician orders. During a review of the facility's P&P titled, Change of Conditions, dated 8/2022, the P&P indicated a licensed nurse will notify the resident physician a significant change in the resident's physical, mental, or a deterioration in health. The P&P indicated a summary of the condition change, an assessment, and SBAR. The P&P indicated a licensed nurse will communicate any changes in required interventions to the care team members involved in the resident's care. The P&P indicated a licensed nurse will document every 72 hours when there was a change in the resident's condition.

Based on observation, interview, and record review the facility failed to ensure:1. One expired large can of cherry fruit filling, in the dry storage room was disposed. 2. Four cereal bowls on the shelf in dry storage were not dated.3. The refrigerator (reach in) had containers of applesauce, juice, and jelly without use by date (the last day a manufacturer recommends consuming a product for peak quality and safety).4. The Dietary Aide (DA) 1 had touched the cleaned dishes after touching dirty dishes without removing gloves and washing her hands.These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 87 out of 93 residents who received food from the kitchen.During a concurrent observation and interview on 1/6/2026 at 8:40 a.m., with Dietary Services Supervisor (DSS), in the dry storage room, there was one large can of expired cherry fruit filling and four bowls of dry cereal without a used by date was reviewed. The DSS stated that the can of cherry fruit filling was expired should have been disposed. The DDS stated the bowls of cereal did not have a used by date. The DSS stated these items should have been thrown away so it's not used again. The DSS stated had the potential to make the residents sick.During a concurrent observation and interview on 1/6/2026 at 8:45 a.m., with the DSS, at the refrigerator (reach in), there were containers of applesauce, juice, and jelly without use by date. The DSS stated the items did not have a used by date. The DSS stated the purpose of utilizing the use by date, so the staff knows when to toss the items to prevent illnesses to residents.During a concurrent observation and interview on 1/6/2026 at 9:00 a.m., with the DSS, the Dietary Aide (DA) 1 did not remove gloves nor washed her hands after touching dirty dishes and went to touch clean dishes with the same gloves. The DSS stated one staff member is responsible for washing the dirty dishes and another dietary aide was responsible for the clean dishes. The DSS stated DA 1 was to remove her gloves and wash her hands after touching the dirty dishes. The DSS stated this would prevent cross-contamination and not spread to the residents.During a review of the facility's policy and procedures (P&P) titled, Food Storage and Handling, dated 6/2024, the P&P indicated dry storage area place opened products in storage containers that are labelled and dated. The P&P indicated canned fruit storage use within 12 months.During a review of the facility's policy and procedures (P&P) titled, Dietary Department- Infection Control, dated 6/2024, the P&P indicated proper hand washing after handling soiled equipment or utensils and immediately before engaging with clean equipment and utensils.

Based on observation, interview, and record review the facility failed to ensure one of six sampled residents (Resident 82) Certified Nursing Assistant (CNA) 1 was seated while feeding Resident 82. This deficient practice of CNA 1 not seated while feeding Resident 82 had the potential to cause him to feel uncomfortable.During a review of Resident 82's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 82's diagnoses dysphagia (difficulty swallowing), hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), and aphasia (a disorder that makes it difficult to speak).During a review of Resident 82's Minimum Data Set ([MDS] a resident assessment tool), dated 10/24/2025, the MDS indicated Resident 82's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 82 was dependent (helper does all the effort) on staff for eating, showering, and dressing.During a review of Resident 82's physician orders titled, Order Summary Report, dated 12/10/2025, the physician orders indicated Resident 82 was incapable of making healthcare decisions.During a review of Resident 82's physician orders titled, Order Summary Report, dated 12/18/2025, the physician orders indicated a controlled carbohydrate diet for Resident 82.During an observation on 1/6/2026 at 12:49 p.m., CNA 1 was feeding Resident 82 while standing. During a concurrent observation and interview on 1/6/2026 at 12:52 p.m., with CNA 1, in Resident 82's room, CNA 1 was feeding standing and leaning over Resident 82 while feeding him. CNA 1 stated the process was to sit with Resident 82 during feedings. CNA 1 stated the reason for sitting with Resident 82 was to make him feel more comfortable while he was eating.During an interview on 1/7/2026 at 3:08 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated when feeding the residents the Certified Nursing Assistants were to sit with the resident during feeding so the resident would feel dignified while eating. LVN 3 stated Resident 82 would feel more relaxed, not feel intimidated (behaviors that create fear compromises patient safety and well-being), and feel rushed to eat.During a review of facility's policy and procedures (P&P) titled, Restorative Dining Program, dated 1/2012, the P&P indicated the facility was to provide the opportunity for the residents to attain their highest level of independence in feeding. The P&P indicated feeding techniques the staff member should sit while assisting or feeding resident.During a review a facility's P&P titled, Residents Rights- Accommodation of Needs, dated 1/2012, the P&P indicated the facility's environment is designed to assist the resident and maintaining the resident's dignity and well-being

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect (failure of the facility, its employees or service providers to provide services to a resident that were necessary to avoid pain, mental anguish or emotional distress) and ensure Resident 3, who required assistance from staff with activities of daily living (ADLs - essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) received needed care and services. The facility failed to: -Provide Resident 3, who required moderate assistance (the helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) and was dependent on a helper, with transfer from chair-to-bed, per Resident 3's comprehensive assessment dated [DATE]. Resident 3 called for a Certified Nursing Assistant (CNA) to put him in bed from his wheelchair on 5/25/2025. CNA 2 told him to get out of the chair and do it himself, then left the room. -Implement the At Risk for Falls Care Plan related to gait (the way a person walks) and balance problems dated 5/23/2025, to anticipate and meet the resident's needs once Resident 3 called for assistance for transfer. -Implement the facility's policy and procedure titled, Abuse - Prevention, Screening, & Training Program, revised July 2018, regarding neglect and deprivation of goods and services by CNA 2 for Resident 3 to attain or maintain physical, mental, and psychosocial well-being and avoid physical harm, pain, mental anguish, or emotional distress. This deficient practice resulted in Resident 3 being subjected to neglect by CNA 2 while under the care of the facility. Resident 3 fell out of his wheelchair attempting on his own to return to bed. Resident 3 was angry, had pain to his face and was transferred to General Acute Care Hospital (GACH) on 5/27/2025 where he was diagnosed with generalized anxiety disorder. Findings: A review of the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis affecting left side (weakness and loss of muscle function resulting in the inability to move), and presence of a pacemaker (a small, electronic device implanted under the skin that helps regulate a person's heartbeat when it is too slow or irregular). A review of Resident 3's Minimum Data Set (MDS -a resident assessment tool), dated 3/27/2025, indicated the resident had no cognitive impairment (problems with a person's ability to think, remember, use judgement, and make decisions), had the ability to express ideas and wants, and had the ability to understand others and be understood. The MDS indicated the resident required use of a manual wheelchair and required moderate assistance from a helper for transfer to and from a bed to a wheelchair, to come to a standing position from sitting in a wheelchair, or on the side of the bed, or the ability to get in and out of a tub/shower. A review of Resident 3's Progress Notes dated 5/23/2025, indicated the resident used a manual wheelchair, required assistance to wheel the chair 50 feet or more and was dependent on a helper to transfer him from chair-to-bed. A review of Resident 3's At Risk for Falls Care Plan related to gait (the way a person walks) and balance problems dated 5/23/2025, indicated the goal was to have Resident 3 free from falls. The care plan interventions indicated to anticipate and meet the resident's needs, ensure the call light was working, within reach, and encourage the resident to use it for assistance as needed. The care plan did not indicate any interventions to provide assistance to Resident 3 during transfers. During a review of Resident 3's Fall Risk Evaluation dated 5/23/2025, the fall risk evaluation indicated Resident 3 had no falls in the past three months and was alert and oriented to person, place and time. The fall risk evaluation indicated under ambulation that Resident 3 was chairbound, required the use of assistive devices (cane, wheelchair, walker), and was not able to perform gait / balance (standing on both feet without holding on to anything). The Fall Risk Evaluation indicated Resident 3 scored a 15, as a score of 10 or higher indicated a high risk of fall. During a review of Resident 3's Change of Condition (COC) dated 5/27/2025 at 2:36 PM, the COC indicated Resident 3 reported to the Social Services Assistant (SSA) that on 5/25/2025 evening shift he was hit on the left side of his face with a call light by the CNA (CNA 2). The COC indicated Resident 3 sustained no visible facial injuries and reported discomfort rated at a 5 out of 10 (using the pain scale 0-10, 10 being the worst possible pain). The COC did not indicate CNA 2 refused to assist Resident 3 with the transfer to bed. A review of Resident 3's COC dated 5/27/2025 at 4:47 PM, indicated Resident 3 reported that he was in his room and fell to the floor from his wheelchair on 5/25/2025. Resident 3 verbalized that he was assisted by a CNA 2 back into his bed (after the fall). During a review of Resident 3's Progress Notes / Skin assessment dated [DATE], the skin assessment indicated Resident 3's left side of face was assessed to be clear and intact, no open areas noted, or abrasions noted. The skin assessment indicated Resident 3 reported pain on left side of face rated at a 5. A review of the Physician's Order dated 5/27/2025 indicated to transfer Resident 3 to the GACH for medical clearance with 7-day bed hold. A review of the GACH face sheet indicated Resident 3's chief complaint and reason for admit was an elevated troponin level (blood test indicates damage to the heart muscle, often associated with heart attack, other related conditions include heart failure and intense exercise), atrial fibrillation (heart condition where heart beats irregularly, rapidly and out of sync), and acute chest pain. A review of the GACH Physician's Order dated 5/27/2025 indicated Resident 3 was admitted to the telemetry unit (specialized area for continuous cardiac monitoring) for two nights for acute chest pain and generalized weakness. A review of Resident 3's GACH Physician Psychiatry Progress Note dated 5/30/2025 at 10:25 pm, indicated Resident 3 was anxious (a mental health condition characterized by excessive and persistent worry that is difficult to control), restless, and irritable. Resident 3 was assigned a new diagnosis of Generalized Anxiety Disorder. A review of Resident 3's GACH Physical exam dated 5/31/2025, indicated Resident 3 had difficulty ambulating due to musculoskeletal weakness. During an interview on 6/5/2025 at 10 am, Resident 3 stated he called for a CNA to put him in bed from his wheelchair. Resident 3 could not recall date or time. CNA 2 told him to get out of the chair and do it himself, then CNA 2 left the room. Resident 3 stated when he tried to get in bed, he fell. Resident 3 stated he then pressed the call light again. CNA 2 came in and snatched the call light and the cord, hit Resident 3 in the face. Resident 3 stated he felt angry and was in pain. During an interview on 6/5/2025 at 10:15 am, the Social Services Assistant (SSA) stated that on 5/27/2025 at 2:45 pm, Resident 3 came to her office and reported the incident with CNA 2. During an interview on 6/6/2025 at 1:55 pm, the Administrator (ADM) stated CNA 2 was terminated on 5/27/2025 for not satisfactorily passing his 90-day probation period. When a copy of CNA2's termination letter was requested, none was provided. A review of the Faxed Document from the facility to the Department dated 6/9/2025 indicated upon receiving a report of an allegation of abuse that occurred on 5/25/2025 during the 3 pm - 11 pm shift, the alleged perpetrator (CNA 2) was placed on administrative leave. A review on the facility's job description titled, Nursing Assistant Job Description, undated, indicated the CNA general duties and responsibilities included performing all duties as assigned and in accordance with facility's established policies and procedures, nursing care procedures and safety rules and regulations. A review of the facility P&P titled, Abuse - Prevention, Screening, & Training Program, revised July 2018, indicated the facility would prevent and did not condone any form of abuse or neglect. The P&P indicated the ADM as the abuse prevention coordinator was responsible for the coordination and implementation of the facility's abuse prevention, program policies and that the facility established a safe environment that reasonably supports residents. The P&P indicated the facility promoted an environment free from abuse, neglect, exploitation, and mistreatment of the residents. The P&P indicated, Neglect and deprivation of goods and services by staff were defined as failure to provide goods and services necessary to attain or maintain physical, mental, and psychosocial well-being and avoid physical harm, pain, mental anguish, or emotional distress. The P&P indicated the facility assured that residents were free from neglect by having the structures and processes to provide needed care and services. The P&P did not indicate any information regarding an employee 90-day probationary period. A review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised November 2018, indicated the facility would ensure that a comprehensive person-centered care plan was developed for each resident. The P&P indicated the facility would provide care that reflected best practice standards for meeting psychosocial, behavioral and safety needs of residents in order obtain or maintain the highest physical, mental, and psychosocial well-being. The care plan indicated additional changes or updates to the residents' comprehensive care plan would be made on the assessed needs of the resident. The comprehensive care plan would be periodically reviewed and revised after each MDS assessment as required.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was safely discharged to a lower level of care by failing to: 1. Follow its policy and procedure (P&P) titled, Discharge and Transfer of Residents, which indicated the facility may discharge a resident if the services provided by the facility were no longer required, when Resident 1, who required the services provided by the facility was discharged to a Board and Care facility ([B&C] a small residential home that provides lower-level of care and supervision to seniors who need assistance with daily living tasks but do not require 24-hour nursing care). 2. Ensure Resident 1 was safely discharged to B&C 1. B&C 1 was not a licensed B&C and could not provide ambulation (walking) assistance, epilepsy (recurrent seizures) management and response, or assistance with medication administration and storage. 3. Ensure Resident 1 ' s discharge planning was conducted by the Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) prior to discharging the resident to a Board and Care facility on 3/24/2025. 4. Ensure the Board and Care facility was provided with a hand-off report (a structured communication tool used to transfer patient care information from one healthcare provider to another) regarding Resident 1 ' s medical conditions to ensure the facility could meet the resident ' s needs prior to his discharge. 5. Ensure Resident 1 continued receiving prescribed medications at the B&C including Seroquel (medicine for schizophrenia [a mental illness that is characterized by disturbances in thought]), Depakote (medicine for seizures [sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), klonopin (antianxiety medicine), and Zonisamide (medicine for epilepsy). 6. Follow-up with the Board and Care to ensure Resident 1 was safe and comfortably settled, post discharge. These deficient practices resulted in Resident 1 falling at B &C 1, sustaining a laceration (a deep cut or tear) on the scalp and was admitted to a general acute care hospital (GACH 1) for evaluation and treatment from 3/30/2025 to 4/10/2025 (a total of 11 days). Resident 1 was discharged back to B&C 1 on 4/10/2025 and on 4/12/2025, Owner 1 transferred Resident 1 to B&C 2, and on 4/13/2025, Resident 1 eloped (to leave without supervision), was found confused and wandering on the street by the law enforcement (Police) and transported to GACH 2 on 4/13/2025. Resident 1 was admitted to GACH 2 from 4/14/2025 to 4/27/2025 and discharged to another facility (facility 2). These failures also had the potential to result in Resident 1 ' s exposure to worsening medical and psychiatric conditions (mental illness), adverse reaction from medication overdose, and elevated risk for serious injuries, elopement (a situation in which a resident leaves the premises or a safe area without the facility ' s knowledge and supervision), seizures and death. On 5/1/2025 at 4:15 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Director of Nursing (DON) and Administrator (Admin) due to the facility ' s failure to safely discharge Resident 1. On 5/3/2025 at 5:22 p.m., the facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After verification of IJRP implementation through observation, interview, and record review, the IJ was removed onsite on 5/3/2025 at 6:55 p.m. in the presence of the Admin and DON. The IJRP included the following immediate actions: 1). On 5/1/2025, the Social Services consultant initiated an educational in-service to licensed nurses and IDT regarding facility Discharge and Transfer policy and procedures. In-service included Surrogate Decision Maker-Informed Consent, Discharge and Transfer of Residents, Personal Representatives of Residents, Resident Rights, Treating Residents Without Decision-Making Capacity, Conducting IDT prior to discharge, and the importance of initiating discharge planning prior to discharge or transfer of a resident. In-service education is ongoing by the facility ' s Director of Nursing (DON)/Director of Staff Development (DSD)/Designee including the new processes implementation related to identified concerns to all active license nurses and IDT members. The facility has 30 licensed nurses and 24 have been provided with in-service and education. Facility does not have a licensed staff on vacation, leave nor FMLA (Family and Medical Leave Act). On 5/1/2025, the Social Services consultant worked 1:1 (one on one) with the Social Services Director (SSD). The SSD completed the Discharge Planning Review form, sections 1 (Discharge Goals/ General Information) A (Discharge Goals/ General Information) & B (Caregiver Responsibilities), 2 (Self Care Evaluation and Equipment) Q (equipment and supplies), Contacts and Sign and Date of the Discharge Summary, for training purposes. On 5/2/2025, the facility DON and Medical Records initiated an audit to residents who have been discharged to a lower level of care in the past 30 days to ensure proper discharge planning was conducted prior to discharge with resident/responsible party, an IDT meeting was conducted prior to discharge, an endorsement of the resident ' s medical history and medication reconciliation was provided to receiving facility. No similar issues were identified. Process: For those residents who lack capacity or with fluctuating capacity, the Office of Public Representative (OPR) will be contacted by the facility ' s SSD/Designee to act as an advocate in the discharge plan IDT prior to the discharge to ensure location is safe and appropriate given the residents ' conditions. If the OPR does not wish to participate, the facility IDT in conjunction with the physician will hold an IDT meeting to review and document appropriateness. Process: For those residents who lack capacity or with fluctuating capacity and have resident representatives, an IDT meeting will be held with the responsible party to review and discuss the discharge location for safety and appropriateness. 2. On 5/1/2025, the Social Services consultant initiated an educational in-service to licensed nurses and IDT regarding facility Discharge and Transfer policy and procedures. In-service included Surrogate Decision Maker-Informed Consent, Discharge and Transfer of Residents, Personal Representatives of Residents, Resident Rights, Treating Residents Without Decision-Making Capacity, Conducting IDT prior to discharge, and the importance of initiating discharge planning prior to discharge or transfer of a resident. In-service education is ongoing by the facility ' s DON/DSD/Designee including the new processes implementation related to identified concerns to all active licensed nurses and IDT members. Discharge planning will begin on the residents ' admission to the facility. The Attending Physician and the IDT will review the residents ' progress and determine a possible discharge date and document in resident ' s health record. On 5/2/2025, the facility Admin notified Resident 1 ' s attending physician, by phone of the concerns related to the resident ' s transfer to the Board and Care, the fall sustained and readmission to the hospital. On 5/2/2025, the facility Admin notified facility Medical Director by phone of the Immediate Jeopardy that was issued, deficient practice and plan to correct. On 5/3/2025, the facility Admin initiated a QAPI (Quality Assurance and Performance Improvement) regarding the Transfer and Discharge of residents. 3. Disposition of Resident ' s Drugs Upon Discharge: The facility staff will assist the physician and the resident to obtain medications after discharge from the facility. When discharged , remaining medications that have been administered to the resident while in the facility may be provided to the resident at the time of discharge if the medications were specifically ordered to be sent home with the resident. The Licensed Nurse will assure that the medication orders are reviewed with the resident and/ responsible party and explanation of all discharge medication orders occur at the time of discharge and documented on the resident ' s health record. The facility will ensure that the resident receives adequate follow-up including the ability to have a physician ' s prescription available to procure drug supply immediately after discharged from the facility and conduct a proper endorsement of resident ' s ordered medications and discharge instructions to the receiving facility and documented on the resident ' s health record. 4. On 5/2/2025, the facility ' s SSD and Admin located Resident 1. Resident 1 resided in Skilled Nursing Facility (SNF) 2 and was doing well. The facility ' s SSD/ Designee will conduct a post discharge follow up call within 72 hours to ensure that the resident has transitioned adequately to the new facility/location moving forward. 5. On 5/1/2025, the Social Services consultant initiated an educational in-service to licensed nurses and IDT regarding facility Discharge and Transfer P&P. In-service included Surrogate Decision Maker-Informed Consent, Discharge and Transfer of Residents, Personal Representatives of Residents, Resident Rights, Treating Residents Without Decision-Making Capacity, Conducting IDT prior to discharge, and the importance of initiating discharge planning prior to discharge or transfer of a resident. In-service education is ongoing by the facility ' s DON/ DSD/Designee including the new processes implementation related to identified concerns to all active licensed nurses and IDT members. Newly hired licensed nurses/IDT will be educated by the facility ' s DON/DSD on facility ' s P&P pertaining to Discharge and Transfer of residents during their orientation and as needed. 6. On 5/1/2025, the Social Services consultant initiated an educational in-service to licensed nurses and IDT regarding facility Discharge and Transfer policy and procedures. In-service included Surrogate Decision Maker-Informed Consent, Discharge and Transfer of Residents, Personal Representatives of Residents, Resident Rights, Treating Residents Without Decision-Making Capacity, Conducting IDT prior to discharge, and the importance of initiating discharge planning prior to discharge or transfer of a resident. In-service education is ongoing by the facility ' s DON/ DSD/Designee including the new processes implementation related to identified concerns to all active licensed nurses and IDT members. For those residents who lack capacity or with fluctuating capacity, the OPR will be contacted by the facility ' s SSD/Designee to act as an advocate in the discharge plan IDT prior to the discharge to ensure location is safe and appropriate given the residents ' conditions. If the OPR does not wish to participate, the facility IDT in conjunction with the physician will hold an IDT meeting to review and document appropriateness. For those residents who lack capacity or with fluctuating capacity and have resident representatives, an IDT meeting will be held with the responsible party to review and discuss the discharge location for safety and appropriateness. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE]. The Admission Record indicated Resident 1 had a history of epilepsy, encephalopathy (group of conditions that cause brain dysfunction), anxiety disorder (excessive and persistent worry, fear, and unease), and schizophrenia. During a review of Resident 1 ' s History and Physical (H&P), dated 10/3/2024, the H&P indicated Resident 1 had fluctuating capacity to make medical decisions. During a review of Resident 1 ' s Fall Risk Assessment, dated 1/9/2025, the Fall Risk Assessment indicated Resident 1 was at risk for falls due to intermittent confusion, incontinence (no control of bowel and bladder elimination), pre-disposing diseases (risk factors), use of assistive devices (mobility aids), instability while making turns, and medications. During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 1/9/2025, the MDS indicated Resident 1 was unable to express ideas and wants, and unable to understand others. The MDS indicated Resident 1 required set-up or clean-up assistance with eating and oral hygiene, required partial/ moderate assistance (helper does more than half the effort) with toileting hygiene and with shower/ bathing self. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity, throughout or intermittently) with personal hygiene. The MDS indicated Resident 1 required supervision or touching assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer and walking 50 feet with two turns. The MDS indicated Resident 1 required setup or clean-up assistance walking 10 feet and 150 feet. During a review of Resident 1 ' s physician orders, dated 3/2025, the physician orders indicated: 1. Seroquel oral tablet 200 mg (milligrams- metric unit of measurement, used for medication dosage and/or amount) by mouth at bedtime for schizophrenia m/b (manifested by) disorganized speech (talking off topic). 2. Depakote oral tablet 750 mg by mouth two times a day for seizures 3. Klonopin oral tablet 1 mg by mouth two times a day, for anxiety m/b inability to relax 4. Zonisamide 100 mg capsule, 1 capsule by mouth, one time a day for epilepsy During a review of Resident 1 ' s care plan, titled Resident wishes to move to lower level of care such as Board and Care facility, dated 3/21/2025, the care plan indicated to coordinate Resident 1 ' s discharge goals with rehabilitative therapies, follow up with resident to assure understanding of plan and make arrangements with required community resources to support independence post-discharge with home health ([HH] medical services provided in a patient's home), Registered Nurse (RN) and physical therapy (PT) services and durable medical equipment (DME - medical devices). During a review of Resident 1 ' s physician orders, dated 3/24/2025, the physician orders indicated Resident 1 may discharge to Board and Care (B&C 1) with HH services for RN/PT treatment and evaluation and a standard wheelchair on 3/24/2025. During a review of Resident 1 ' s physician report for the Residential Care Facilities for the Elderly (RCFE) Report, dated 3/24/2025, the report indicated Resident 1 was confused and disoriented at times and required medication management due to mild cognitive impairment. The report indicated Resident 1 was unable to store or administer his own medications. During a review of Resident 1 ' s Paramedic Report Sheet, dated 3/30/2025, the report sheet indicated paramedics were dispatched to B&C 1 on 3/30/2025, at 3:40 p.m., after Resident 1 fell , hit his head, and sustained a 0.5-inch (unit of measurement) laceration on the top of his head. The report sheet indicated Resident 1 was confused, slow to respond to questions, and had unequal pupils (pupils of the two eyes are not the same size). The report sheet indicated Resident 1 arrived at GACH 1 on 3/30/2025 at 4:05 p.m. During a review of Resident 1 ' s GACH 1 Emergency Department (ED) provider notes, dated 3/30/2025, the ED note indicated Resident 1 was taken into the ED by paramedics. The ED note indicated Resident 1 had a right parietal (top or side of the head) laceration with surrounding hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) and anisocoria (unequal pupil size that can indicate brain damage). The ED note indicated Resident 1 was admitted to the GACH for alteration of mental status and blunt head trauma evaluation and treatment, following a fall. During a review of Resident 1 ' s GACH 1 Discharge Planning Note, dated 4/10/2025, the discharge summary note indicated Resident 1 was discharged to B&C 1 on 4/10/2025. During a review of Resident 1 ' s GACH 1 Discharge Summary Note, dated 4/18/2025, the note indicated Resident 1 had a computerized tomography (CT- diagnostic test) scan of his head which indicated some lymphadenopathy (lymph node enlargement) and no acute (sudden onset) intracranial (within the skull) hemorrhage (excessive bleeding). The discharge summary indicated Resident 1 had a magnetic resonance imaging ([MRI] a noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body, including the organs, bones, muscles and blood vessels) scan of the brain which indicated no acute changes. The summary note indicated Resident 1 was evaluated for neurologic and malignancy (cancer-related) illnesses during his admission at GACH 1. During a review of Resident 1 ' s GACH 2 Discharge Summary, dated 4/27/2025, the Discharge Summary report indicated Resident 1 was admitted to GACH 2 from 4/14/2025 to 4/27/2025. The Discharge Summary indicated Resident 1 eloped from B&C 2 on 4/13/2025, had two Code Gold (behavioral issues, where a patient's violent or self-destructive behavior poses a threat to their own safety or the safety of others) episodes in the ED, were evaluated, and admitted to GACH 2 for observation and placement. The report indicated B&C 2 was unable to care for Resident 1 ' s high level of needs and was not an appropriate facility for Resident 1. The summary indicated Resident 1 had no capacity to make informed decisions and required long-term skilled nursing facility placement. During an interview on 4/28/2025 at 8:35 a.m., with a Social Worker from GACH 2 (SW), GACH 2 SW stated Resident 1 was discharged from the facility on 3/24/2025 and transferred to B&C 1. GACH 2 SW stated Resident 1 was admitted to GACH 1 on 3/30/2025 from B&C 1 and discharged back to B&C 1 on 4/10/2025. GACH 2 SW stated B&C 1 transferred Resident 1 to B&C 2 on 4/12/2025 because the resident ' s needs could not be met at B&C 1. GACH 2 SW stated Resident 1 eloped from B&C 2 on 4/13/2025 and was found by the Police wandering in the street. GACH 2 SW stated the Police transported Resident 1 to GACH 2 on 4/14/2025 where he was admitted and was discharged on [DATE] to another facility, where his needs could be met. GACH 2 SW stated Resident 1 was not awake or alert when he arrived at GACH 2 on 4/14/2025 and required long-term care due to his behavioral and medical needs. During an interview on 4/28/2025 at 9:21 a.m., with the owner of B&C 2 (Owner 2), Owner 2 stated Owner 1 called a Psychiatric Emergency Team (PET- a mobile team that provides mental health crisis intervention and assessment) on 4/12/2025 who referred Resident 1 to B&C 2 on 4/12/2025. Owner 2 stated within hours of arrival on 4/12/2025, Resident 1 eloped from B&C 2, walked into the street, and had a psychotic episode (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). Owner 2 stated Resident 1 required a higher level of care than a B&C could provide due to his high level of medical and psychological needs. During a concurrent interview and record review on 4/28/2025 at 12:20 p.m., with the SSD, Resident 1 ' s Discharge Planning Review Form, dated 4/24/2025 was reviewed. The SSD stated the form was initiated prior to Resident 1 ' s discharge from the facility on 3/24/2025 but was incompletely filled. The SSD stated she did not tour (go onsite) the B&C 1 or verify the B&C 1 ' s license prior to discharging Resident 1. The SSD stated she had no documentation about the services B&C 1 provided. During an interview on 4/30/2025 at 10:28 a.m., with the DON, the DON stated he was not present at Resident 1 ' s IDT meeting on 3/21/2025 and was not notified of Resident 1 ' s discharge plan or discharge. The DON stated he must be present for every IDT meeting. The DON stated he discovered that Resident 1 was discharged on [DATE], the day after Resident 1 had left the faciity on [DATE]. During an interview on 4/30/2025 at 10:35 a.m., with Owner 1, Owner 1 stated B&C 1 was not a licensed B&C and could not provide ambulation (walking) assistance, epilepsy management and response, or assistance with medication administration and storage. Owner 1 stated the staff from the facility did not inform B&C 1 of Resident 1 ' s medical diagnoses, behavior, and care needs on 3/24/2025. Owner 1 stated Resident 1 was not appropriate for B&C 1 because Resident 1 required more services than B&C 1 could provide. Owner 1 stated B&C 1 did not receive any written or verbal report about Resident 1, prior to his arrival at B&C 1 on 3/24/2025. Owner 1 stated Resident 1 exhibited continuous screaming, sexually inappropriate behavior, and agitation and could not be redirected. Owner 1 stated she observed Resident 1 on the floor, with a head injury and blood dripping from the injured site (scalp) on 3/30/2025. Owner 1 stated she called 911 and Resident 1 was transferred to GACH 1 for evaluation and treatment. Owner 1 stated Resident 1 was at GACH 1 from 3/30/25 to 4/10/2025 and was discharged back to B&C 1. Owner 1 stated Resident 1 ' s high level of needs was not appropriate for B&C 1, but GACH 1 forced her to take Resident 1 back on 4/10/2025. Owner 1 stated she called an emergency PET intervention on 4/12/2025 for Resident 1 ' s uncontrollable behaviors. Owner 1 stated she and the PET transferred Resident 1 to B&C 2, which had more services needed by Resident 1. Owner 1 stated the facility ' s staff did not call B&C 1 to follow-up on Resident 1, after the resident was discharged from the facility. During a concurrent interview and record review on 4/30/2025 at 1:00 p.m., with the facility RN 1, Resident 1 ' s RCFE report dated 3/24/2025, Progress Notes dated 3/24/2025, and Discharge Planning Review Form dated 4/24/2025, were reviewed. The facility RN 1 stated the RCFE report indicated Resident 1 required assistance in storing and administering medications. The facility RN 1 stated the Discharge Planning Review Form indicated Resident 1 ' s medication reconciliation (medication review and comparison), discharge education, and self-care evaluation were not performed and not completed. Facility RN 1 stated the SSD was responsible for completing and documenting the Discharge Planning Review Form. The facility RN 1 stated she was not informed of what B&C 1 ' s services were, did not provide hand-off report to B&C 1, and she would not have discharged Resident 1 if she knew B&C 1 was not equipped to provide the services Resident 1 required. Facility RN 1 stated Resident 1 needed medical services provided by the facility. The facility RN 1 stated Resident 1 was at risk of seizures, psychological instability, elopement, hospitalization , and death, if he did not receive the services to meet his needs. The facility RN 1 stated she was notified of Resident 1 ' s discharge plan on 3/24/2025 around 1:30 p.m. The facility RN 1 stated Resident 1 was transported to the B&C 1 on 3/24/2025 at 3:45 p.m., approximately 2 hours after the nursing department was notified. The facility RN 1 stated the Director of Marketing, and the SSD did not allow time for the nursing department to coordinate services and ensure the B&C 1 was appropriate to meet Resident 1 ' s needs. The facility RN 1 stated the SSD was responsible for coordinating Resident 1 ' s home health services. During a concurrent interview and record review on 4/30/2025 at 2:10 p.m., with the facility SSD, Resident 1 ' s progress notes dated 3/21/2025, H&P dated 10/3/2024, care plan titled Resident wishes to move to lower level of car such as Board and Care facility dated 3/21/2025, Discharge Planning Review Form dated 4/24/2025, and the facility ' s P&P titled Discharge and Transfer of Residents, dated 3/21/2025, were reviewed. The facility SSD stated the progress notes indicated Resident 1 notified her of his request for discharge on 3/21/2025. The facility SSD stated Resident 1 ' s H&P indicated Resident 1 had fluctuating capacity to make medical decisions and his capacity was not reassessed at the time of the request. The facility SSD stated the progress notes she wrote on 3/21/2025, indicating Resident 1 ' s Discharge Planning IDT, were incorrect. The facility SSD stated the notes were entered in error and no IDT was conducted for Resident 1 ' s discharge planning. The facility SSD stated the P&P indicated every resident must have an IDT to review progress and plan discharges. The facility SSD stated the P&P was not followed because an IDT meeting was not conducted to plan Resident 1 ' s discharge. The facility SSD stated IDT meetings must have representatives from nursing and activities departments present to plan safe discharges and ensure the residents get proper care after discharge. The facility SSD stated the DON, Activity Director (AD), and Director of Rehabilitation (DOR) were not notified of Resident 1 ' s discharge plans prior to the discharge. The facility SSD stated Resident 1 ' s care plan indicated therapy was supposed to coordinate discharge goals. The facility SSD stated therapy was not notified or involved in Resident 1 ' s discharge and the intervention was not performed. The facility SSD stated the Discharge Planning Review Form indicated Resident 1 initiated his discharge to a lower level of care. The facility SSD stated she was not trained or informed about her responsibility to complete the Discharge Planning Review Form, and she expected the nursing department to complete and document Medication Reconciliation, Self Care Evaluation, and Learning Needs sections. The facility SSD stated she did not follow up with the nursing department. The SSD stated she notified RN 1 (Nursing Department) about Resident 1 ' s discharge plan for 3/24/2025 at 1:30 p.m. The facility SSD stated she should have verified B&C 1 ' s license, toured the facility, or received written information about B&C 1 ' s services, but she did not. The facility SSD stated she did not follow up with B&C 1, HH, or Resident 1 after discharge. During a concurrent interview and record review on 5/1/2025 at 1:25 p.m., with the facility DOR, Resident 1 ' s Physical Therapy (PT) Discharge Summary dated 12/18/2024, Care Plan, titled Resident wishes to move to lower level of care such as Board and Care facility dated 3/21/2025, and Fall Risk Evaluation dated 1/9/2025 were reviewed. The facility DOR stated Resident 1 ' s Physical Therapy Discharge Summary indicated Resident 1 needed partial to moderate assistance for transfers and ambulation. The facility DOR stated Resident 1 required supervision during ambulation and transfer but had not been evaluated by a therapist since PT services ended on 12/2024. The facility DOR stated the care plan indicated discharge goals will be coordinated with rehabilitative therapies. The facility DOR stated rehabilitative therapy was not involved in Resident 1 ' s discharge planning and the care plan was not performed. The facility DOR stated the therapy department was not involved in Resident 1 ' s discharge planning but should have been notified to assess Resident 1 and plan services after Resident 1 ' s discharge to prevent falls. During a concurrent interview and record review on 5/1/2025 at 2:00 p.m., with the DON, Resident 1 ' s Fall Risk Evaluation dated 1/9/2025 was reviewed. The DON stated the evaluation indicated Resident 1 was at risk for falling due to wheelchair usage and instability while turning. During an interview on 5/1/2025 at 3:40 p.m., with the facility AD, the facility AD stated she was not present during Resident 1 ' s discharge planning IDT meeting on 3/21/2025. The facility AD stated she or a representative of the Activity Department must be present at all IDT meetings for resident safety. The facility AD stated she was not notified or aware of discharge planning IDT for Resident 1 prior to discharge on 3/24/2025. During a concurrent interview and record review on 5/5/2025 at 8:15 a.m., with GACH 2 SW, Resident 1 ' s GACH 2 Discharge Planning Notes dated 4/14/2025, were reviewed. GACH 2 SW stated the notes indicated, the Police found Resident 1 wandering alone in the street on 4/13/2025 and brought Resident 1 to GACH 2 and was admitted on [DATE] for altered mental status evaluation and treatment. GACH 2 SW stated Resident 1 was confused, only knew his name, and mumbled incoherent words. GACH 2 SW stated Resident 1 was transferred to a locked facility (secured) that could provide appropriate services for his needs. During an interview on 5/2/2025 at 12:40 p.m., with Home Health Registered Nurse (HH RN] home visiting nurse), the HH RN stated HH had never provided services or received a referral for Resident 1. HH RN stated she had never heard of Resident 1 and had not been in contact with the facility. During a concurrent interview and record review on 5/5/2025 at 8:50 a.m., with the facility Medical Doctor (MD), Resident 1 ' s H&P dated 10/3/2024 was reviewed. The facility MD stated Resident 1 ' s H&P indicated Resident 1 was able to make medical decisions sometimes. The facility MD stated, he and the IDT should have worked together to assess if Resident 1 could make medical decisions and plan a safe discharge. The facility MD stated he did not interview or assess Resident 1 to know if the resident had the capacity to make medical decisions when Resident 1 made the decision to discharge. The facility MD stated he trusted RN 1 and the IDT team and did not verify that the IDT team had assessed Resident 1 ' s ability to make medical decisions. The facility MD stated if there was no IDT meeting to assess Resident 1 ' s mental capacity and plan his discharge, Resident 1 ' s safety was placed at risk. The facility MD stated the facility was responsible for coordinating and ensuring safe discharge for Resident 1. During a review of the facility ' s P&P titled, Discharge and Transfer of Residents, dated 3/21/2025, the P&P indicated the facility may discharge a resident if the services provided by the facility were no longer required. The P&P indicated the attending physician, and IDT will review the resident ' s progress and determine a possible discharge date . During a review of the facility ' s P&P titled, Decision Making Capacity, dated 1/1/2012, the P&P indicated the attending physician will interview the resident and review the resident ' s medical record to determine the resident ' s capacity to consent to medical care and to provide informed consent. The P&P indicated the physician would review the resident ' s decision-making capacity and document his/her determination monthly.

Based on observation, interview and record review, the facility failed to assess residents ' pain and implement its policy and procedure (P&P) titled, Administration of Pain Medication, which indicated Licensed Nurses should administer residents ' pain medications according to the physician's order, for two of three sampled residents (Resident 1, and Resident 3). This deficient practice resulted in Residents 1 and 3 experiencing unresolved pain for extended periods. It also caused Resident 3 to have abnormal vital signs (measurements of the body's most basic functions [blood pressure, heart rate, temperature, respiratory rate, and pain level) from 7/21/2024 to 7/22/2024 which required transfer to a general acute care hospital (GACH) for evaluation and treatment. Findings: 1). During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included Stage four (4) pressure ulcer (tissue loss with visible bone, tendon, or muscle) on the sacral (tail bone) and polyneuropathy (weakness and a pins-and-needles sensation, burning pain or loss of sensation to extremities). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care screening and assessment tool) dated 6/20/2024, the MDS indicated Resident could understand and be understood by others. The MDS indicated Resident 1 was dependent and required a two or more person ' s assist with activities of daily living (ADLs) such as dressing, bathing, bed mobility, and personal hygiene. The MDS indicated Resident 1 had a Stage 4 pressure ulcer. During a review of Resident 1 ' s Order Summary Report dated 6/13/2024, the Order Summary Report indicated to assess Resident 1 for pain before treatment, during and after treatment. The Order Summary Report indicated to assess for pain every shift and chart the intensity of pain using 1-10 numeric scale (1-4 = mild pain), (5-7 = moderate pain), (8-10 = severe pain). During a review of Resident 1 ' s Order Summary Report dated 6/17/2024, the Order Summary Report indicated to administer Norco (strong pain medicine)10/325 milligrams ([mg] unit of measurement), 1 tablet by mouth every four (4) hours as needed for moderate to severe pain. The Order Summary Report indicated to hold if Resident 1 was sleepy or if respiratory rate (breaths per minute) was less than (<) 12 breaths per minute (normal respiratory rate is 12-20 breaths per minute). The Order Summary Report dated 6/17/2024 indicated to separate Xanax (anxiety medicine) from Norco administration by at least 4 hours apart. During a review of Resident 1 ' s care plan titled, Acute or chronic pain related to pressure injury (damage to skin and underlying soft tissue) to sacral wound, dated 6/25/2024, the interventions indicated to administer Norco as ordered, half hour before treatments or care. The interventions indicated to anticipate Resident 1 ' s need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions, monitor, record, and report to the nurse any signs and symptoms of nonverbal pain, the resident ' s complaints of pain or requests for pain treatment. The interventions also indicated to notify the physician if interventions were unsuccessful or if the current complaint was a significant change from the resident ' s experience of pain. During a review of Resident 1 ' s Medication Administration Record (MAR) for the month of July 2024, the MAR did not indicate Resident 1 was assessed for pain before, during and after treatment, on 7/18/2024 and 7/21/2024. During a concurrent observation and interview on 7/30/2024 at 2:36 p.m., with Resident 1 in Resident 1 ' s room, Resident 1 was observed crying as she continued stating she was unhappy, felt helpless, and frustrated because she could not do anything to get her pain relieved. Resident 1 stated on 7/29/2024 at 5:00 p.m., she (Resident 1) requested for pain medication due to a 10/10 pain on her sacral wound. Resident 1 stated Licensed Vocational Nurse (LVN 1) did not give her pain medication when she requested for it. Resident 1 stated LVN 1 told her Norco could not be given because she (Resident 1) had Robaxin (a narcotic muscle relaxant) and she (Resident 1) needed to wait until 9:00 p.m., to be medicated for pain. During an interview on 8/7/2024 at 3:39 p.m. with LVN 1, LVN 1 stated Resident 1 requested for Norco on 7/29/2024 at 5 p.m., an hour after she (Resident 1) was administered Robaxin. LVN 1 stated she told Resident 1 that she was not due for Norco till 9:00 p.m. LVN 1 stated the last time Resident 1 received Norco was on 7/29/2024, at 10:30 a.m. LVN 1 stated the Registered Nurse Supervisor (RNS) had advised her not to give Resident 1 Norco and Robaxin together because the Robaxin could cause respiratory depression (very slow or shallow breathing). LVN 1 stated RNS told her (LVN 1) to wait 4 hours (at 9 p.m.) after the Robaxin was administered, before giving Resident 1 Norco. LVN 1 stated, Resident 1 ' s doctor ' s order did not indicate to hold the Norco when Robaxin was given. LVN 1 stated she followed what the RNS instructed her to do. LVN 1 stated she should have called the Doctor to clarify if Resident 1 could be given Norco or not. LVN 1 stated not managing a resident ' s pain could result in complications like elevated blood pressure, discomfort, increased pain and could affect resident ' s quality of life. During a review of Resident 1 ' s progress notes dated 7/29/2024, the progress notes did not indicate LVN 1 addressed Resident 1 ' s complaint of 10/10 to the sacral wound on 7/29/2024 at 5 p.m. and did not indicate any pain relief interventions were provided to Resident 1. During a concurrent phone interview and record review on 8/13/2024 at 2:58 p.m., with the Director of Nursing (DON), Resident 1 ' s MAR, Change of condition (COC), and progress notes dated 7/29/2024 were reviewed. The DON stated, on 7/29/2023 at 9:01 p.m., Resident 1 had a pain level of 8/10 (site not indicated), and Norco was administered. The DON stated, per the MAR and progress notes, Resident 1 ' s pain level was not reassessed after the medication (Norco) was administered. The DON stated it was important to reassess pain after medication administration to ensure the medication was effective and to prevent worsening pain condition for the residents. 2). During a review of Resident 3 ' s Admission Record, the Admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3 ' s diagnoses included difficulty walking, fracture (broken bone) of one unspecified rib. During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 was independent with eating, and required set up for oral hygiene, shower/bathing. The MDS indicated Resident 3 required partial assistance for toileting hygiene and putting on/taking off footwear. The MDS indicated Resident 3 was incontinent (unable to control) of bowel and bladder. The MDS indicated Resident 3 had a fracture and was not on a pain medication regimen. During a review of Resident 3 ' s Order Summary Report dated 8/28/2023, the Order Summary Report indicated to assess Resident 3 for pain level every shift and chart intensity of pain using 1-10 numeric scale. During a review of Resident 3 ' s Order Summary Report dated 2/9/2024, the Order Summary Report indicated to administer hydrocodone-acetaminophen (medication to treat pain) 5/325 milligrams, 1 tablet by mouth, every 4 hours as needed for moderate pain (5- 7). During a review of Resident 3 ' s MAR for the month of July 2024, the following dates did not indicate Resident 3 was assessed for pain: 7/15/2024 evening shift (3pm-11pm) and night shift (11pm-7am). 7/16/2024 day shift (7am-3pm) and night shift. During a review of Resident 3 ' s Change of Condition (COC) dated 7/18/2024 at 6:44 a.m., the COC indicated on 7/18/2024 (time not specified), Resident 3 had declined in function (unspecified) due to generalized pain when moved. The COC did not indicate interventions were provided for Resident 3 ' s generalized pain. During a review of Resident 3 ' s COC dated 7/22/2024 at 12:53 p.m., the COC indicated on 7/22/2024 (time not specified), Resident 3 was observed lethargic (sleepy), with facial grimacing (twisting the mouth and face to convey pain, disapproval, or disgust) and yelling ouch (expressed sudden pain) his when vital signs were attempted to be taken. The COC indicated Resident 3 ' s heart rate was 127 beats per minute (normal rate is 60-100 beats per minute). The COC did not indicate any pain interventions provided to Resident 3. The COC indicated Resident 3 ' s physician was notified on 7/22/2024 at 12:00 a.m., and Resident 3 was transferred to a GACH on 7/22/2024 at 7:43 a.m. (seven hours after the physician was notified). During a review of Resident 3 ' s emergency department (ED) notes, dated 7/22/2024 at 8:16 a.m. the ED notes indicated Resident 3 had altered level of consciousness (a change in a person ' s awareness and alertness), and leukocytosis (elevated white cells in the blood occurs when body is fighting inflammation or infection) from the nursing facility. The ED notes indicated a Computerized Tomography ([CT] non-invasive medical imaging procedure that uses X-rays and computers to create detailed pictures of the inside of the body) of the chest, abdomen and pelvis result dated 7/22/2024 at 2:05 p.m. indicated a grade 2 splenic injury (a moderate injury to the spleen [organ that filters the blood to help destroy microorganisms and get rid of old or damaged red blood cells]), likely caused by adjacent (next to) left posterior (back) 10th rib comminuted fracture (broken bone that has more than two pieces). The ED notes indicated Resident 3 was admitted to trauma service on 7/22/2024 due to a splenic laceration (a medical emergency usually caused by trauma to the left side of the upper stomach or lower chest), altered mental status (lethargy), severe sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues), rapid atrial fibrillation (an irregular, rapid heart rate) and aspiration pneumonia (lung infection that develops after inhalation of food, liquid, or vomit into the lungs). The ED notes indicated Resident 3 received multiple antibiotics due to severe sepsis. During a review of Resident 3 ' s care plan titled, Acute/Chronic Pain related to Left and Right Rib Fracture, dated 8/5/2024, the interventions indicated to anticipate the resident ' s need for pain relief and respond immediately to any complaint of pain, monitor for probable cause of each pain episode and remove/ limit causes where possible, administer analgesia (pain reliever) half hour before treatments or care, as per order, evaluate effectiveness of pain interventions every shift, monitor/ record pain characteristic every shift and as needed (PRN) and monitor/ record/ report to nurses any signs and symptoms of nonverbal pain (vocalization of grunting, moaning, yelling out, silence). During an observation on 8/8/2024 at 3:42 p.m., with Certified Nurse Assistant (CNA) 8 and CNA 9, CNA 8 & CNA 9 were observed on repositioning Resident 3 while the resident was in bed. Resident 3 was observed groaning, grimacing and yelling (signs of pain). CNA 8 & CNA 9 continued to reposition Resident 3 and did not stop to assess or provide pain interventions to the resident. During a concurrent interview and record review on 8/12/2024 at 9:34 a.m., with the DON, the P&P titled Administration of Pain Medication was reviewed. The DON stated according to the P&P, the nurse should have assessed the residents ' pain location, level, and type of pain, using the pain numeric scale. The DON stated the nurse should have checked the MAR to see when the last time pain medication was given. The DON stated, if pain medication was not due, the staff should have tried other interventions. The DON stated if the medication was not effective, the staff should have contacted the doctor to obtain orders. The DON stated, if the resident needed pain management right away, licensed staff should have given the pain medication immediately. The DON stated, not providing pain medication immediately could lead to a seizure (burst of uncontrolled electrical activity in the brain that cause uncontrollable movement) and could be very uncomfortable for the resident physically and emotionally. During a concurrent phone interview and record review on 8/13/2024 at 2:58 p.m., with the DON, Resident 3 ' s MAR, COC, and progress notes dated 7/18/2024, 7/22/2024 and 7/29/2024 were reviewed. The DON stated Resident 3 ' s COC and progress notes dated 7/18/2024 did not indicate assessments were done regarding the resident ' s pain. The DON stated the progress notes did not indicate pain medications were administered on 7/18/2024 when Resident 3 complained of generalized pain and on 7/22/2024 (daytime, time not specified), when Resident 3 had a pain level of 9/10 (site not indicated). The DON stated Resident 3 should have received either acetaminophen 325 mg (pain reliever) for mild pain or Norco 5/325 mg for moderate pain. The DON stated the licensed nurse did not provide interventions for Resident 3 ' s pain. The DON stated it (unrelieved pain) may have caused emotional distress and could affect Resident 3 ' s ADLs. The DON stated the pain caused Resident 3 to be afraid to move or do anything. During a phone interview on 8/13/2024 at 3:46 p.m., with CNA 8, CNA 8 stated on 8/8/2024 at 3:42 p.m., when Resident 3 groaned, grimaced, and yelled when CNA 8 and 9 were repositioning Resident 3, Resident 3 was in severe pain. CNA 8 stated they should have stopped and notified a LVN for medication. CNA 8 stated the LVN (unidentified) had already been in Resident 3 ' s room, and CNA 8 did not think the need to notify the LVN. During a review of the facility ' s P&P titled, Change of Condition, dated 11/18/2021, the P&P indicated COCs were any sudden and marked adverse change in the resident ' s condition manifested by signs and symptoms different than usual. The COC indicated the Licensed Nurse will assess the COC and determine what interventions were appropriate. During a review of the facility ' s P&P titled Administration of Pain Medication, dated 11/2016, the P&P indicated the Licensed Nurse will administer pain medications according to the physician's order. The P&P indicated staff should assess and document the resident's intensity of pain, prior to the administering pain medication. The P&P indicated staff should reassess the intensity of the resident's pain one hour after pain medication was administered and document the resident's response to and the effectiveness of the pain medication in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for two of five sampled residents (Resident 1 and Resident 4) when: 1. Certified Nursing Assistant (CNA) 1 struck Resident 1 with latex medical gloves ([gloves] disposable medical gloves used during medical examinations and procedures) on 5/21/2024. 2. CNA 4 held Resident 4's upper extremities to restrain him while Resident 4 was in bed on 5/7/2024. These deficient practices caused Resident 4 to sustain two skin tears (a traumatic wound that is caused by direct contact between the skin and another object) to the right forearm and right wrist, with moderate pain and bleeding. These deficient practices also had the potential to result in physical and psychosocial harm to Resident 1 and 4. Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 10/25/2022. Resident 1's admitting diagnoses included paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), dementia (loss of memory, language, problem-solving and other thinking abilities), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (Intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 1's History and Physical (H&P), dated 10/25/2023, indicated Resident 1 could make her needs known, but could not make medical decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care-screening/care-planning tool), dated 5/4/2024, indicated Resident 1 had severe cognitive impairment (inability to navigate to new places, and significant difficulty completing complex tasks). The MDS indicated Resident 1 did not exhibit signs of inattention (difficulty focusing) or disorganized thinking (unclear or illogical flow of ideas). The MDS indicated Resident 1 required supervision (intermittent assistance from staff) to put on footwear. The MDS further indicated Resident 1 was otherwise independent for most activities of daily living (eating, drinking, toileting) and mobility. The MDS indicated Resident 1 used a wheelchair for mobility. A review of Resident 1's care plan, titled Resident has the tendency of being irritable and begins to yell and call staff names [racial slur] saying you don't belong here! Putting her roommate out of the room, dated 11/25/2023, indicated interventions including the staff will redirect Resident 1 in a calm manner, allow the resident time to respond, and encourage her (Resident 1) to express her feelings and needs. A review of an untitled and undated written statement of the incident by CNA 1 on 5/22/2024, indicated on 5/21/2024, CNA 1 took Resident 1 back to her room, and Resident 1 attempted to kick CNA 1. The written statement indicated Resident 1 tried to kick CNA 1 again and in the midst of the resident's kick, CNA 1 blocked the kick with her gloves striking the resident on the forearm. During an interview on 5/23/2024 at 11:25 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 5/21/2024, Resident 1 was seated in the hallway in a wheelchair. CNA 1 stated Resident 1 was saying racial slurs (an insulting remark pertaining to one's race) within a hearing distance from other residents. CNA 1 stated she pushed Resident 1's wheelchair into Resident 1's room to redirect her away from the other residents, which upset Resident 1. CNA 1 stated Resident 1 attempted to kick her. CNA 1 stated to defend herself, CNA 1 blocked Resident 1's strike with her hand, while holding a pair of latex medical gloves. CNA 1 stated the gloves struck Resident 1's forearm. During an interview on 5/23/2024 at 12:27 PM, with Registered Nurse (RN) 1, RN 1 stated on 5/21/2024 she was walking past Resident 1's room when she witnessed CNA 1 strike Resident 1's hand with a pair of latex medical gloves. RN 1 stated she approached CNA 1 to ask what happened, and CNA 1 told her Resident 1 kicked her. RN 1 stated she did not see Resident 1 kick CNA 1. RN 1 stated she observed Resident 1 talking, then observed CNA 1 strike Resident 1 with gloves she was holding in her hand. RN 1 stated it was a purposeful movement and not reflexive (produced or carried out in reaction to something). During a concurrent observation and interview, on 5/23/2024 at 2:04 PM, with Resident 1, Resident 1 stated she asked CNA 1 a question regarding her shoes. Resident 1 stated CNA 1 did not like to be asked questions. Resident 1 stated, I asked her are these my shoes?' while gesturing to the shoes she was wearing. Resident 1 stated CNA 1 did not respond to her question, then hit her with plastic gloves and told her, Go to bed. Resident 1 was observed holding an adult incontinence brief in her hand and demonstrated the way CNA 1 hit her. Resident 1 struck her own hand with the adult incontinence brief in a swatting motion (to hit something with a sharp slapping blow). Resident 1 stated she did not understand why CNA 1 hit her with the gloves. During an interview on 5/24/2024 at 2:24 PM, with the Administrator (ADM), the ADM stated there were no instances where staff should strike or hit a resident. 2. A review of Resident 4's Admission Record indicated the facility admitted Resident 4 on 5/23/2023. Resident 4's admitting diagnoses included major depressive disorder, lack of coordination, and schizoaffective disorder (a mental health disorder comprised of a combination of schizophrenia symptoms [hallucinations or delusions] and mood disorder symptoms [depression or mania (being abnormally upbeat, jumpy, or wired)]). A review of Resident 4's H&P, dated 12/15/2023, indicated Resident 4 was able to make his needs known, but was unable to make medical decisions. A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had moderate cognitive impairment. The MDS indicated Resident 4 did not exhibit any signs of inattention or disorganized thinking. The MDS further indicated Resident 4 was able to independently reposition himself in bed, and transition between lying to sitting positions. The MDS indicated Resident 4 had no impairments (decline or decrease in function) to any of his extremities. A review of Resident 4's active physician orders, dated 12/15/2023, indicated staff were required to monitor Resident 4 for outbursts of anger, and irritable or dismissive behavior. If observed, staff were required to document it in Resident 4's medical record. A review of Resident 4's Change in Condition (COC) Evaluation , dated 5/7/2024, indicated Resident 4 exhibited aggression. The report indicated Resident 4 attempted to punch and kick CNA 4. The report indicated Resident 4 had skin tears (a traumatic wound that is caused by direct contact between the skin and another object) to the right forearm and right wrist, accompanied by significant pain or bleeding . Resident 4's pain was rated a six (6) out of 10, with ten being the worst pain possible. The report did not indicate a statement was directly obtained from Resident 4 as to exactly how the forearm and wrist wounds occurred, or a statement from CNA 4. A review of Resident 4's Weekly Skin/Wound Assessment , dated 5/7/2024, indicated Resident 4 had two skin tears located on his right arm that occurred on 5/7/2024. A review of Resident 4's Medication Administration Record (MAR), dated 5/7/2024, indicated on 5/7/2024, the date of the incident between Resident 4 and CNA 4, there were no outbursts of anger, or irritable or dismissive behavior documented during any shifts. A review of CNA 4 's untitled and undated written statement of the incident, provided to the Administrator on 5/22/2024, indicated on 5/7/2024, Resident 4 attempted to kick CNA 4 and CNA 4 moved away. The document indicated Resident 4 attempted to punch CNA 4, and CNA 4 held his (Resident 4's) hands back . The document also indicated CNA 4 stepped out of the room, Resident 4 followed him, yelling, and CNA 4 hit Resident 4's hand. During an interview on 5/23/2024 at 2:20 PM, with CNA 2, CNA 2 stated she was Resident 4's CNA and was familiar with Resident 4. CNA 2 stated Resident 4 had a history of verbal and physical aggression with staff. CNA 2 stated when Resident 4 displayed these types of behaviors, she removed herself from the situation and did not attempt to restrain him. CNA 2 stated this type of intervention was usually effective. During a concurrent observation and interview, on 5/23/2024 at 2:29 PM, with Resident 4, Resident 4 was observed with two wounds to the right forearm. The wounds were uncovered, dry and pink in color. Resident 4 stated he was in bed one evening (date unknown) and wanted to turn his bedside light on, to read his book and watch television. Resident 4 stated CNA 4 approached his bedside and turned off his bedside light without permission. Resident 4 stated he told CNA 4 he wanted the light on and CNA 4 replied, No . Resident 4 stated, I told him to leave my room and he wouldn't leave . Resident 4 stated CNA 4 grabbed him and held his arms down. Resident 4 stated his arms were red where CNA 4 had grabbed him. Resident 4 further stated he was bleeding and walked to the nurse's station and told the nursing staff (names unknown) on duty what happened, stating I was bleeding and they [nursing staff] wrapped my arm . During an interview on 5/24/2024 at 9:48 AM, with Registered Nurse (RN) 1, RN 1 stated she was the supervisor on duty on 5/7/2024 (the date of the alleged abuse incident). RN 1 stated she spoke with Resident 4 immediately following the incident and Resident 4 stated CNA 4 caused the skin tears. RN 1 stated she also spoke with Resident 4's roommate (Resident 5), and Resident 5 stated Resident 4 was aggressive , and CNA 4 was trying to put [Resident 4] back in bed . RN 1 further stated if a resident attempted to hit a staff member, the staff member was supposed to call for help. RN 1 stated staff were not to physically hit, restrain or fight any resident. RN 1 stated staff were supposed to walk away. A review of Resident 5's Admission Record indicated the facility admitted Resident 5 on 1/8/2024. Resident 5's admitting diagnoses included but were not limited to: quadriplegia (inability to move all four limbs) and polyneuropathy (nerve damage). A review of Resident 5's H&P, dated 3/14/2024, indicated Resident 5 had the capacity to make his needs known, and was unable to make medical decisions. A review of Resident 5's MDS, dated [DATE], indicaed Resident 5 had severe cognitive impairment, but did not exhibit any signs of inattention or disorganized thinking. The MDS indicated Resident 5 did not exhibit any hallucinations (the perception of having seen or heard something that was not actually there) or delusions (misconceptions or beliefs that are firmly held, contrary to reality). During an interview on 5/24/2024 at 11:42 AM, with Resident 5, Resident 5 stated he overheard the incident between Resident 4 and CNA 4 but did not see anything directly because the privacy curtain between their beds was drawn. Resident 5 stated he heard CNA 4 tell Resident 4 don't ever kick me again , and then heard Resident 4 say let me go! . Resident 5 stated, The CNA must have grabbed him, stating Resident 4 began screaming bloody murder . Resident 5 then stated it sounded like CNA 4 covered Resident 4's mouth because Resident 4's voice became muffled (a dull or quiet sound produced by wrapping something). Resident 5 stated CNA 4 and Resident 4 both left the room. Resident 5 stated a nurse (name unknown) came in to talk to him (Resident 5) later in the evening on the night the incident occurred. During a concurrent interview and observation, on 5/24/2024 at 12:06 PM, at Resident 4's bedside, Resident 4 was observed in bed, with two round wounds on his right forearm. The wounds were open to air and pink in color. Resident 4 stated both of his arms were red after an incident with a staff (CNA 4) and were now back to their normal color. Resident 4 stated, See my books? I just wanted my light on so I could read. I don't know why he [CNA 4] did that, and then gestured to his arms. During a concurrent interview and record review, on 5/24/2024 at 3:05 PM, with the MDS Nurse (MDSN), Resident 4's Change in Condition Evaluation, dated 5/7/2024, was reviewed. The report indicated Resident 4 had exhibited aggression and had attempted to punch and kick CNA 4. The report did not indicate a statement was directly obtained from Resident 4 as to exactly how the forearm and wrist wounds occurred, or a statement from CNA 4. The MDSN stated the record did not match what was reported by Resident 4. The MDSN stated Resident 4 came to her office on 5/8/2024 and told her CNA 4 beat him up, was rough with him, and grabbed him on 5/7/2024. The MDSN stated she observed Resident 4's arms were dark in color and appeared to be bruised. The MDSN stated she also observed an opening in the skin of Resident 4's right arm. The MDSN stated allegations of abuse should not be taken lightly. During an interview on 5/24/2024 at 2:24 PM, with the ADM, the ADM stated staff were trained to minimize injury to themselves and residents if a resident was exhibiting physical aggression. the ADM stated staff were not supposed to attempt to restrain any resident. Multiple attempts were made to contact CNA 4 on 5/23/2024 and 5/24/2024, but CNA 4's phone number was disconnected. A review of the facility's P&P titled Abuse - Prevention, Screening, & Training Program , revised 7/2018, indicated the facility did not condone any form of resident abuse. The P&P defined abuse as the willful, deliberate infliction of injury .and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish. The P&P indicated willful meant the individual acted deliberately (not inadvertent or accidental) and not that the individual must have intended to inflict injury or harm. The P&P further defined physical abuse as, but not limited to, hitting, slapping, punching, and/or kicking , and included corporal punishment which is physical punishment used to correct and/or control behavior .

Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from fall, accident, and injury by ensuring the resident had a call light (remote that resident use to call for assistance) accessible and able to ask for assistance as needed. As a result, Resident 1 fell on [DATE] and 7/25/2023 at the facility and sustained right forearm acute (recent/new) distal radius (bone in the forearm) fracture requiring a sling (a device used to support and immobilize an injured part of the body) and a sugar-tong splint (used to stabilize injuries of the forearm and wrist by preventing forearm rotation and wrist motions) on 7/25/2023. Findings: During a review of Residents 1's Admission Record (Face Sheet), dated 4/24/2023, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 diagnoses included poly-osteoarthritis (inflammation swelling in five or more joints at the same time), scoliosis (sideways curve of the spine), generalized muscle weakness, and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). During a review of Residents 1's History and Physical (H&P), undated, the H&P indicated, Resident 1 had the capacity to make needs known but cannot make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/1/2023, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was mildly impaired, and required total assistance with activities of daily living (ADL) including bed mobility, transfers between surfaces (from bed to chair), toilet use, and personal hygiene. The MDS indicated Resident 1 was not steady, only able to stabilize with staff assistance for moving from seated to standing position and stabilize with staff assistance. The MDS indicated Resident 1 had a history of a fall prior to admission. During a review of Resident 1's document titled, Fall Risk Evaluation, dated 4/24/2023, the Fall Risk Evaluation indicated, Resident 1 had a history of one to two falls in the past three months. Resident 1 had a balance problem while standing, walking, and decreased muscular coordination. During a review of Resident 1's care plan for risk for fall, dated 4/26/2023, the care plan indicated the contributing factors included history of falls, gait/balance problems, ambulates and transfers without assistance despite encouragement not to do so, psychoactive drug (chemical substance that alters the functioning of the brain, causing changes in the way one thinks, feels and behaves) use, poly osteoarthritis, scoliosis, impaired vision, hypertensive heart disease (heart condition caused by high blood pressure). Resident 1's care plan goal was Resident 1 will be free of falls. The care plan intervention included the following: 1. Anticipate and meet the resident's needs. 2. Be sure the resident call light was within reach and encourage the resident to use it for assistance as needed. 3. Prompt response to all requests for assistance. 4. Educate the resident/family care givers about safety reminders and what to do if a fall occurs. 5. Follow facility fall protocol. 6. Hourly visual safety checks. 7. Maintain bed in lowest position. 8. Review information on past falls and attempt to determine cause of falls. Record possible root causes (reasons behind the problem). Alter and remove any potential causes if possible. Educate resident/family/caregivers/Interdisciplinary Team ([IDT] group of different disciplines working together towards a common goal of a resident). During a review of Resident 1's IDT progress note dated 4/28/2023. The IDT note indicated on 4/27/2023, Resident 1 was observed on the floor inside Resident 1's room, at the left side of the bed in kneeling position. The IDT note indicated Resident 1 stated she dropped her call light on the floor and was reaching for it, loss balance and fell . No redness, discoloration and bruise observed at the time of incident. The IDT note indicated that Resident 1 was noted to make frequent movements while in bed and gets up without assistance. The IDT note indicated in service for staff regarding frequent visual monitoring for fall was conducted and the facility interventions were effective at that time. The IDT note indicated the root cause analysis (the process of discovering the root causes of problems to identify appropriate solutions) was the fall was likely caused due to resident getting up from bed without assistance and resident was known to have frequent movement while in bed. The IDT note indicated the fall was unforeseeable as Resident 1 wanted to maintain her independence and obtain her belongings herself without assistance. During a review of Resident 1's care plan for actual fall, dated 4/28/2023, the care plan indicated Resident 1 fell on [DATE] (clarified actual fall date 4/27/2023) at the facility without injury due to poor balance and unsteady gait. The care plan indicated the goal was Resident 1 will resume usual activities without further incident of fall. The care plan interventions included to ensure call light was within reach, determine and address the causative factors of the fall. A review of Resident 1's Change in Condition ([COC] a clinical deviation from a resident's baseline) Evaluation form, dated 6/30/2023, the COC form indicated Resident 1 was observed crawling out of her room to the nurse's station cursing, resisting care, and saying things that does not add up. A review of Resident 1's COC Evaluation form, dated 7/25/2023 at 11:30 a.m., The COC evaluation form indicated Resident 1 had unwitnessed fall on 7/25/2023 at around 11:00 a.m. The COC form indicated Resident 1 informed the nurses she was going to use the restroom. The COC form indicated Resident 1 had abrasion on the right knee, swelling on the right forearm and abrasion to the right elbow. Resident 1 was encouraged to use call light to call staff for assistance. Primary clinician (physician) was notified on 7/25/2023 at 11:15 a.m., with order to transfer to General Acute Care Hospital (GACH) for further evaluation and treatment. During a review of Resident 1's IDT progress note dated 7/25/2023 at 12:15 p.m., the IDT note indicated on 7/25/2023 Resident 1 had unwitnessed fall when Resident 1 was going to the restroom. The COC indicated the fall was likely caused due to resident getting up from bed without assistance. Resident 1 was known to have poor safety awareness and overestimates her abilities. A review of Resident 1's Progress Notes (Nurses notes) dated 7/25/2023 at 9:46 p.m., the progress notes indicated Resident 1 had unwitnessed fall. Resident 1 complained of right arm pain. Resident 1 was transferred to the GACH at 4:00 p.m. on 7/25/2023. A review of Resident 1's GACH records, dated 7/25/2023, the GACH record indicated, Resident 1 stated, she was trying to get out of bed, tripped and fell before she could get to her walker. The GACH record indicated Resident 1 stated, she called out for help, but no one came for a while. The GACH record indicated Resident 1 complained of achy right wrist with pain level of six (6) out 10 (10 being the worst pain). During a review of Resident 1's GACH record, dated 7/25/2023, the GACH record indicated, Resident 1's X-ray (medical imaging that creates pictures of bones and soft tissue) of the right forearm, indicated Resident 1 had acute (recent/new) distal radius fracture. The GACH record indicated, Resident 1 had a sling and a sugar-tong splint (used to stabilize injuries of the forearm and wrist by preventing forearm rotation and wrist motions) was placed. During a concurrent observation and interview on 7/28/2023 at 10:00 a.m., with Resident 1, Resident 1's right arm was observed with cast and sling. Resident 1 stated she tried to get out of the bed on her own, because the nurses were too lazy and does not come when she calls for help. Resident 1 stated she got up went to the restroom and on the way back from the restroom she fell on [DATE]. Resident 1 does not recall the incident of falling on 4/27/2023. During a concurrent observation and interview on 8/1/2023 at 11:00 a.m., with Resident 1, inside Resident 1's room, Resident 1 stated she was not able to call for assistance when using the call light. Resident 1 stated no one comes when she pressed the call light. Resident 1 pressed the call light and there was no response from the staff. The call light was observed not completely plugged into the socket. During a concurrent observation and interview on 8/1/2023 at 11:10 a.m., inside Resident 1's room, with the Director of Staff Development (DSD), the DSD pressed the call light, and the call light did not light up outside the door. The DSD inspected the call light and stated the call light was not working because it was not completely plugged into the socket. The DSD stated, if the call light was not working, the resident will not be able to call for help and could climb out of the bed and fall. The DSD stated, Resident 1 was a high risk for fall because she had a history of falls prior to admission. The DSD stated Resident 1 fell on [DATE], 7/25/2023 and it was important to make sure Resident 1 had functional call light to prevent Resident 1 from falling again. During an interview on 8/1/2023 at 1:00 p.m., with Licensed Vocational Nurse (LVN) 1. LVN 1 stated, Resident 1 had an unsteady gait and was confused. LVN 1 stated it was important to answer call light timely and ensure Resident 1 needs were met to prevent Resident 1 from falling. During an interview on 8/1/2023 at 3:00 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated, Resident 1 fell on [DATE], was found crawling out of the bed on 6/30/2023 and fell on [DATE]. RNS 1 stated, Resident 1 was high risk for falls, and needed to be closely monitored, and supervised. RNS 1 stated, the nurses should follow the fall prevention intervention plan, ensure the call light was within reach, and stated Resident 1 should have been closely monitored and moved closer to the nursing station when Resident 1 was found crawling out of bed on 6/30/2023. During a concurrent interview and record review on 8/1/2023 at 3:30 p.m. with the Assistant Director of Nursing (ADON) 1, Resident 1's care plans were reviewed. The ADON stated the care plan indicated Resident 1 fell on [DATE] (clarified actual date of fall was 4/27/2023), crawled out of the bed on 6/30/2023, and fell on [DATE]. The ADON stated, Resident 1 fell prior to admission at another facility on 4/21/2023 and fell again on 4/27/2023 at the facility. The ADON stated, Resident 1 was a high risk for falls because of Resident 1's history of multiple falls. The ADON stated, Resident 1 should have been monitored closely since she was a high risk for falls. The ADON stated, the facility failed to follow the facility's Fall Prevention Management Program and did not have a clear intervention on how to prevent falls for Resident 1 after Resident 1 fell on [DATE]. The ADON stated, it was important to move Resident 1 closer to the nursing station to keep a closer watch on Resident 1. The ADON stated, the staff should ensure the call light was working, plugged into the socket, and within reach to prevent Resident 1 from falling. During a review of the facility's Policy and Procedure (P&P) titled, Fall Management Program, dated 3/13/2021, indicated, the facility will provide a safe environment that minimize complications associated with falls. The facility will implement a Fall Management Program that supports providing an environment free from fall hazards. The IDT and/or licensed nurse will develop a care plan according to identified risk factors and root causes. The IDT will review the circumstances surrounding the fall then summarize their conclusion on an IDT note. To prevent more falls, the IDT will review and revised the care plan as necessary. A Resident who endures more than one fall in a day, week, or month, will be considered at high risk for falls. During a review of the facility's P&P titled, Resident Safety, dated 4/15/2021, indicated, residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the resident .The IDT will establish a person-centered observation or monitoring systems for the Resident to address the identified risk factors identified .Should a safety incident occur the IDT will review contributing factors to the incident and the care plan will be modified as necessary. During a review of the facility's P&P titled Communication System, dated January 2012, the P&P indicated the facility will 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. Call cords will be placed within the resident reach. Nursing staff will answer call bells promptly, in a courteous manner. If a call bell is defective, it will be reported immediately to maintenance and replaced immediately.

Based on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse. Resident 2, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident 1 sustaining a cut on the left side of his head and right forearm. The physician ordered for Resident 1 to go to the general acute care hospital emergency department for evaluation and Resident 1 refused to go. Findings: During a review of Resident 1's admission record (Face sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's history and physical (H&P) dated 5/7/2022, the H&P indicated Resident 1 had the capacity to understand and to make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized care screening and assessment tool) dated 5/12/2022, the MDS indicated Resident 1 had moderately impaired cognitive skills (thought processes), disorganized thinking (loose thoughts, and unable to concentrate), and moderate depression. During an observation of the facility's security surveillance cameras of the smoking patio dated 6/9/2022 at 9:45 a.m., in the presence of the Assistant Administrator (Asst. Admin), Resident 1 was observed sitting by himself, when Resident 2 walked up to Resident 1 and sat down next to Resident 1. Resident 2 stood up, picked up a chair and threw it directly at Resident 1's head. Resident 1 was observed almost falling off his chair after being struck by the chair that Resident 2 threw. Resident 1 was observed holding his head and placing his head down between his legs. During a review of Resident 1's change in condition (COC) dated 6/9/2022, the COC indicated Resident 1 sustained a skin tear with bleeding on the left forearm. Resident 1's physician ordered neuro checks (a series of questions and tests to check how the brain and other body parts function) and Tylenol (pain medicine) 500 milligrams ([mg] unit of measurement) as needed for pain. The COC indicated Resident complained of pain on the left side of his head rated at 7/10 (10= severe pain). The COC indicated Resident 1 was given Tylenol (medication to treat minor aches and pain and reduce fever) 500 milligrams ([mg] unit of measurement). During a review of Resident 1's nursing progress notes (NPN) dated 6/10/2022 at 3:09 p.m., the NPN indicated Resident 1 was being monitored after a resident-to-resident altercation which resulted in a left forearm skin tear and headache. The NPN indicated Resident 1 did not have any complains of headache or pain. During a review of Resident 1's NPN dated 6/13/2022 at 11:43 p.m., the NPN indicated Resident 1 refused to be transferred to the general acute care hospital (GACH) for evaluation following the altercation with Resident 2. The NPN indicated Resident 1 stated he did not need to go the GACH. During a review of Resident 2's face sheet, the face sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's H&P dated 4/5/2022, the H&P indicated Resident 2 had the capacity to understand and to make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills were intact and was able to understand and be understood by others. The MDS also indicated Resident 2 had moderate depression. During a review of Resident 2's COC dated 6/9/2022, the COC indicated Resident 2 had a verbal and physical outburst. The COC indicated Resident 2 picked up a chair and threw it at another resident (Resident 1). During a review of Resident 2's NPN dated 6/10/2022 at 3:06 p.m., the NPN indicated Resident 2 was being monitored for verbal and physical outburst. The NPN indicated Resident 2 was slamming doors and writing on the walls and furniture. During an interview on 6/13/2022 at 10:45 a.m. with the Assistant Administrator (Asst. Admin), the Asst. Admin stated Resident 2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Asst. Admin stated Resident 2 physically abused Resident 1 by throwing the chair at his head. The Asst. Admin stated Resident 2 was supposed to be monitored at all times to prevent the abuse. The Asst. Admin stated while smoking, residents were supposed to be monitored by the activity staff to prevent altercations and ensure residents' safety. During a concurrent observation and interview on 6/13/2022 at 11:10 a.m. with Resident 1, in Resident 1's room, Resident 1 stated he was sitting by himself in the patio during a smoke break, when Resident 2 walked up, and sat on a chair next to him. Resident 1 stated Resident 2 was blurting out words and having a conversation by himself. Resident 1 stated he did not talk to Resident 2 or even look in Resident 2's direction. Resident 1 stated all he remembered was getting hit on the head by a chair. Resident 1 stated he sustained a cut on the left side of his head and on his left forearm. Resident 1's left side of the head was observed with dry blood and a dry scab (a rough protective crust that forms over a cut or wound during healing). Resident 1's forearm was observed with a dry gauze. Resident 1 stated he refused to be transferred to the GACH. During an interview on 6/13/2022 at 11:18 a.m., with Resident 3, Resident 3 stated he witnessed the incident between Resident 1 and Resident 2. Resident 3 stated, Resident 1 was sitting by himself, and did not do anything or say anything to upset Resident 2. Resident 3 stated Resident 2 picked up the chair he was sitting on and threw it directly on Resident 1's head. During an interview on 6/13/2022 at 11:45 a.m., with the Activity Director (AD) 2, AD 2 stated on 6/9/2022, he was not assigned to the smoking patio, and did not witness Resident 2 throw a chair at Resident 1. AD 2 stated AD 1 did not inform him that she would be stepping away from the smoking patio. AD 2 stated that usually, if the staff assigned to supervise residents in the patio had to step away, that assigned staff was supposed to notify another staff to take over. According to AD 2, it was important to supervise residents at all times especially in the patio to prevent altercations. During an interview on 8/3/2022 at 1:00 p.m. with the Activities Director (AD) 1, AD 1 stated on 6/9/2022, she (AD 1) was supposed to be monitoring residents in the smoking patio. AD 1 stated she did not witness the incident between Resident 1 and Resident 2 because she stepped away from the smoking patio to get cigarettes from the social services office. AD 1 stated while she was away, Resident 2 picked up a chair and threw it at Resident 1. AD 1 stated the incident could have been prevented if a staff was at the patio monitoring residents. AD 1 also stated it was important to supervise residents during smoking breaks because there could be a resident-to-resident altercation or a medical emergency. During a review of the facility's policies and procedure (P&P) titled Abuse-Prevention, Screening, and Training Program, with a revision date of July 2018, the P&P indicated the facility did not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The facility's P&P indicated the facility will develop policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The P&P indicated staff will conduct observation rounds on each shift to observe residents congregating in areas where observation was not possible and or where potential conflicts could arise. During a review of the facility's P/P titled Smoking by Residents, dated January 2017, the P/P indicated the facility would provide a safe environment for residents, staff, and visitors. Based on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse. Resident 2, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident 1 sustaining a cut on the left side of his head and right forearm. The physician ordered for Resident 1 to go to the general acute care hospital emergency department for evaluation and Resident 1 refused to go. Findings: During a review of Resident 1 ' s admission record (Face sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1 ' s history and physical (H&P) dated 5/7/2022, the H&P indicated Resident 1 had the capacity to understand and to make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized care screening and assessment tool) dated 5/12/2022, the MDS indicated Resident 1 had moderately impaired cognitive skills (thought processes), disorganized thinking (loose thoughts, and unable to concentrate), and moderate depression. During an observation of the facility ' s security surveillance cameras of the smoking patio dated 6/9/2022 at 9:45 a.m., in the presence of the Assistant Administrator (Asst. Admin), Resident 1 was observed sitting by himself, when Resident 2 walked up to Resident 1 and sat down next to Resident 1. Resident 2 stood up, picked up a chair and threw it directly at Resident 1 ' s head. Resident 1 was observed almost falling off his chair after being struck by the chair that Resident 2 threw. Resident 1 was observed holding his head and placing his head down between his legs. During a review of Resident 1 ' s change in condition (COC) dated 6/9/2022, the COC indicated Resident 1 sustained a skin tear with bleeding on the left forearm. Resident 1 ' s physician ordered neuro checks (a series of questions and tests to check how the brain and other body parts function) and Tylenol (pain medicine) 500 milligrams ([mg] unit of measurement) as needed for pain. The COC indicated Resident complained of pain on the left side of his head rated at 7/10 (10= severe pain). The COC indicated Resident 1 was given Tylenol (medication to treat minor aches and pain and reduce fever) 500 milligrams ([mg] unit of measurement). During a review of Resident 1 ' s nursing progress notes (NPN) dated 6/10/2022 at 3:09 p.m., the NPN indicated Resident 1 was being monitored after a resident-to-resident altercation which resulted in a left forearm skin tear and headache. The NPN indicated Resident 1 did not have any complains of headache or pain. During a review of Resident 1 ' s NPN dated 6/13/2022 at 11:43 p.m., the NPN indicated Resident 1 refused to be transferred to the general acute care hospital (GACH) for evaluation following the altercation with Resident 2. The NPN indicated Resident 1 stated he did not need to go the GACH. During a review of Resident 2 ' s face sheet, the face sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2 ' s H&P dated 4/5/2022, the H&P indicated Resident 2 had the capacity to understand and to make decisions. During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 ' s cognitive skills were intact and was able to understand and be understood by others. The MDS also indicated Resident 2 had moderate depression. During a review of Resident 2 ' s COC dated 6/9/2022, the COC indicated Resident 2 had a verbal and physical outburst. The COC indicated Resident 2 picked up a chair and threw it at another resident (Resident 1). During a review of Resident 2 ' s NPN dated 6/10/2022 at 3:06 p.m., the NPN indicated Resident 2 was being monitored for verbal and physical outburst. The NPN indicated Resident 2 was slamming doors and writing on the walls and furniture. During an interview on 6/13/2022 at 10:45 a.m. with the Assistant Administrator (Asst. Admin), the Asst. Admin stated Resident 2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Asst. Admin stated Resident 2 physically abused Resident 1 by throwing the chair at his head. The Asst. Admin stated Resident 2 was supposed to be monitored at all times to prevent the abuse. The Asst. Admin stated while smoking, residents were supposed to be monitored by the activity staff to prevent altercations and ensure residents' safety. During a concurrent observation and interview on 6/13/2022 at 11:10 a.m. with Resident 1, in Resident 1 ' s room, Resident 1 stated he was sitting by himself in the patio during a smoke break, when Resident 2 walked up, and sat on a chair next to him. Resident 1 stated Resident 2 was blurting out words and having a conversation by himself. Resident 1 stated he did not talk to Resident 2 or even look in Resident 2 ' s direction. Resident 1 stated all he remembered was getting hit on the head by a chair. Resident 1 stated he sustained a cut on the left side of his head and on his left forearm. Resident 1 ' s left side of the head was observed with dry blood and a dry scab (a rough protective crust that forms over a cut or wound during healing). Resident 1 ' s forearm was observed with a dry gauze. Resident 1 stated he refused to be transferred to the GACH. During an interview on 6/13/2022 at 11:18 a.m., with Resident 3, Resident 3 stated he witnessed the incident between Resident 1 and Resident 2. Resident 3 stated, Resident 1 was sitting by himself, and did not do anything or say anything to upset Resident 2. Resident 3 stated Resident 2 picked up the chair he was sitting on and threw it directly on Resident 1 ' s head. During an interview on 6/13/2022 at 11:45 a.m., with the Activity Director (AD) 2, AD 2 stated on 6/9/2022, he was not assigned to the smoking patio, and did not witness Resident 2 throw a chair at Resident 1. AD 2 stated AD 1 did not inform him that she would be stepping away from the smoking patio. AD 2 stated that usually, if the staff assigned to supervise residents in the patio had to step away, that assigned staff was supposed to notify another staff to take over. According to AD 2, it was important to supervise residents at all times especially in the patio to prevent altercations. During an interview on 8/3/2022 at 1:00 p.m. with the Activities Director (AD) 1, AD 1 stated on 6/9/2022, she (AD 1) was supposed to be monitoring residents in the smoking patio. AD 1 stated she did not witness the incident between Resident 1 and Resident 2 because she stepped away from the smoking patio to get cigarettes from the social services office. AD 1 stated while she was away, Resident 2 picked up a chair and threw it at Resident 1. AD 1 stated the incident could have been prevented if a staff was at the patio monitoring residents. AD 1 also stated it was important to supervise residents during smoking breaks because there could be a resident-to-resident altercation or a medical emergency. During a review of the facility ' s policies and procedure (P&P) titled Abuse-Prevention, Screening, and Training Program, with a revision date of July 2018, the P&P indicated the facility did not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The facility ' s P&P indicated the facility will develop policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The P&P indicated staff will conduct observation rounds on each shift to observe residents congregating in areas where observation was not possible and or where potential conflicts could arise. During a review of the facility ' s P/P titled Smoking by Residents, dated January 2017, the P/P indicated the facility would provide a safe environment for residents, staff, and visitors.

Based on interview, and record review, the facility failed to: 1. Administer 170 doses of insulin (medications used to treat high blood sugar) to 12 out of 32 sampled residents (Residents 6, 7, 8, 15, 19, 26, 27, 28, 31, 32, 34, and 37) between 6/1/22 and 6/15/22. 2. Administer 102 doses of anticonvulsants (medications used to prevent seizures [uncontrolled electrical activity in the brain]) for 18 out of 32 sampled residents (Residents 7, 10, 11, 12, 14, 16, 17, 18, 19, 21, 23, 24, 25, 29, 30, 33, 35, and 36) between 6/1/22 and 6/15/22. 3. Administer 29 doses of anticoagulants (medications used to prevent blood clots) for 7 out of 32 sampled residents (Residents 6, 9, 13, 14, 20, 22, and 37) between 6/1/22 and 6/15/22. These deficient practices of failing to administer a combined total of 301 doses of insulin, anticoagulants, or anticonvulsants had the potential to cause serious medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/17/2022 at 6:22 p.m., an Immediate Jeopardy (IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared and in the presence of the Vice President of Operations (VPO), the Assistant Administrator (AADM), Nurse Consultant 1 (NC 1) and Nurse Consultant 2 (NC 2) for the facility's failure to ensure licensed staff administered medications to Resident 6 to 37 as required by their physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility submitted an IJ Removal Plan for the correction of the IJ on 6/18/22, and on 6/18/22 at 4:37 p.m., the IJ was removed after the facility submitted an acceptable removal plan. The Department verified and confirmed on-site the implementation of the removal plan through observation, interview, and record review. The IJ situation was removed in the presence of NC 1 and the Assistant Administrator. IJ Removal Plan for the correction of the IJ, which included: a) On 6/17/22, the Registered Nurses immediately conducted an audit of all Residents' Medication Regimen as ordered by the Physician to ensure that medications are available, administered as ordered and documented on the MAR (Medication Administration Record). There were 2 other residents that were identified with medications that were not available. Licensed Nurses assessed the residents for adverse changes and the attending medical doctors (MDs) were notified. MDs ordered to continue monitoring for possible adverse outcomes from potentially missing medication doses. b) On 6/17/22, the Registered Nurses immediately conducted an audit of all Residents' Medication Regimen as ordered by the Physician to ensure that medications are available, administered as ordered and documented on the MAR (Medication Administration Record). There were 2 other residents that were identified with medications that were not available. Licensed Nurses assessed the residents for adverse changes and the attending physicians were notified. c) Medications will be given/administered as prescribed. If a medication is missed, residents will be assessed, the attending physician and responsible party will be notified, and orders will be obtained. DON will be notified of any missed medication. d) On 6/17/22, the DON/designee provided re-education to the licensed nurses on the following: Medication Administration Policy and Procedures. e) Beginning 6/23-6/24/22, the Clinical Education Specialist will provide monthly education to Licensed nurses on Medication Management. f) On 6/16/22 and 6/17/22, the Administrator, Interim DON, and DSD reviewed the Licensed Nurses Schedule for the next 2 weeks to ensure that the facility meets the staffing requirements. g) Temporary Staffing Registries will continue to be utilized as needed. The DON, DSD, IP, MDS Nurses and other Department Managers that are Licensed Nurses will be scheduled to assist with Medication Administration in the event that the facility experiences short staffing. h) At the next Quality Assurance meeting, the Administrator and Department Managers together with the Medical Director will review the action plan and compliance status related to Medication Management and Staffing. i) The DON/DSD/Designee will conduct random Med Pass Observation of at least 3 licensed nurses once a week for 4 weeks then bi-monthly for 2 months to ensure that all Medications are administered timely as ordered and documented on the MAR (Medication Administration Records). j) The DON/designee will conduct nursing rounds on different shifts and check in/call in the facility to ensure that sufficient Licensed Nurses are available to provide assessment, monitoring, and medication administration to the residents daily for the next 2 weeks. k) The DON/designee will conduct and audit of Medication Orders, Medication Availability and Medication Administration Documentation on MAR weekly for the next 4 weeks then bi-monthly for 2 months. Identified concerns will be addressed immediately and reported to the Attending Physician, Responsible Party, DON and Administrator for follow-up and resolution as warranted Findings: a. A review of Resident 6's Admission Record dated 6/17/22 indicated Resident 6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 6's Order Summary Report dated 6/17/22, indicated on 4/25/22, Resident 6's attending physician prescribed the following anticonvulsants (medications to prevent and treat seizures): 1.[MEDICATION(S)] delayed-release (DR - an oral dosage form that releases the medication slowly over a set period of time) 500 milligrams ([mg] unit of measurement) by mouth (PO) twice daily for [CONDITION(S)]. 2. [MEDICATION(S)] 500 mg PO every 12 hours for [CONDITION(S)]. A review of Resident 6's [CONDITION(S)] care plan, undated indicated staff will administer [MEDICATION(S)] DR 500 mg orally twice a day and [MEDICATION(S)] 500 mg as ordered by doctor. A review of Resident 6's Medication Administration Record (MAR) for June 2022 indicated the resident did not receive [MEDICATION(S)] to Resident 6, on the following dates and times: -6/6/22 at 9 pm -6/7/22 at 9 am and 9 pm -6/10/22 at 9 pm -6/11/22 at 9 pm A review of Resident 6's MAR for June 2022 indicated Resident 6 did not receive [MEDICATION(S)] on the following dates and times: -6/6/22 at 9 pm -6/7/22 at 9 am and 9 pm -6/10/22 at pm -6/11/22 at 9 pm A review of the facility's census, dated 6/16/22, indicated, based on room number, Resident 6 received medication from Medication Cart 1. b. A review of Resident 7's Admission Record, dated 6/17/22, indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 7's Order Summary Report, dated 6/17/22, indicated on 3/26/22, Resident 7's attending physician prescribed the following insulins: 1. Insulin [MEDICATION(S)] (a type of fast-acting insulin) to inject five units (a unit of dosage for insulin) subcutaneously (under the skin) with meals for diabetes mellitus. 2. Insulin [MEDICATION(S)] to inject per sliding scale (dose is dependent on a blood sugar reading taken immediately before) before meals and at bedtime for diabetes mellitus. 3. Insulin [MEDICATION(S)] (a type of slow-acting insulin) to inject 10 units subcutaneously in the evening for diabetes mellitus. A review of Resident 7's care plan for Diabetes Mellitus undated, indicated staff would administer Resident 7's Diabetes medications as ordered by doctor. A review of Resident 7's MAR for June 2022 indicated Resident 7 did not receive insulin [MEDICATION(S)] via sliding scale and the resident's blood sugar was not monitored on the following dates and times: -6/2/22 at 6:30 am -6/6/22 at 6:30 am and 9 pm -6/7/22 at 6:30 am, 11:30 am, 4:30 pm and 9 pm -6/8/22 at 6:30 am -6/9/22 at 6:30 am -6/10/22 at 6:30 am, 4:30 pm, and 9 pm -6/11/22 at 6:30 am and 9 pm -6/13/22 at 6:30 am A review of Resident 7's MAR for June 2022 indicated Resident 7 did not received insulin [MEDICATION(S)] on the following dates and times: -6/1/22 at 5 pm -6/7/22 at 8 am, 12 pm, and 5 pm -6/10/22 at 5 pm -6/11/22 at 5 pm A review of Resident 7's MAR for June 2022 indicated Resident 7 did not received insulin [MEDICATION(S)] on the following dates and times: -6/1/22 at 5 pm -6/7/22 at 5 pm -6/10/22 at 5 pm -6/11/22 at 5 pm A review of the facility's census, dated 6/16/22, indicated, based on room number, Resident 7 received medication from Medication Cart 1. c. A review of Resident 8's Admission Record, dated 6/17/22, indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 8's Order Summary Report, dated 6/17/22, indicated Resident 8's [MEDICATION(S)] (a type of anticoagulant medication used to prevent blood clots) 5 mg by mouth two times a day for a-fib. A review of Resident 8's undated care plan indicated Resident 8 was on anticoagulant related to a-fib. The care plan indicated the resident would receive anticoagulant medications as ordered by physician. A review of Resident 8's MAR for June 2022 indicated Resident 8 did not receive [MEDICATION(S)] on the following dates and times: -6/2/22 at 9 am -6/4/22 at 9 pm -6/6/22 at 9 pm -6/7/22 at 9 pm -6/8/22 at 9 pm -6/12/22 at 9 am and 9 pm -6/15/22 at 9 pm A review of the facility's census, dated 6/16/22, indicated, based on room number, Resident 8 received medication from Medication Cart 3. d. A review of Resident 12's Admission Record, dated 6/17/22, the Admission Record indicated Resident 12 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 12's Order Summary Report, dated 6/17/22, indicated [MEDICATION(S)] 5 mg by mouth two times a day for [CONDITION(S)] ([DVT] a blood clot that forms in the deep veins of the body) prophylaxis (actions taken to prevent disease). A review of Resident 12's care plan with an initiation date 6/13/2022, indicated Resident 12 was receiving anticoagulant for DVT prophylaxis. The care plan indicated Resident 12 was to receive [MEDICATION(S)] as ordered. A review of Resident 12's MAR for June 2022 indicated the resident did not receive [MEDICATION(S)] on the following dates and times: -6/12/22 at 5 pm -6/14/22 at 5 pm -6/16/22 at 8 am and 5pm During an interview on 6/16/2022 at 10:20 a.m. with Resident 12, Resident 12 stated she did not receive her 9 a.m. medications. Resident 12 stated she was angry and felt the nurses did not care. A review of the facility's census, dated 6/16/22, indicated, based on room number, Resident 12 received medication from Medication Cart 3. e. A review of Resident 24's Admission Record, dated 6/17/22, the Admission Record indicated Resident 24 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 24's Order Summary Report, dated 6/17/22, indicated [MEDICATION(S)] (a type of anticoagulant medication used to prevent blood clots) 5 mg by mouth two times a day for A-fib. A review of Resident 24's care plan with an initiation date of 4/11/2022, indicated Resident 24 was on anticoagulant therapy related to a-fib. The care plan indicated Resident 24 would receive the medication as ordered by the physician. A review of Resident 24's MAR for June 2022 indicated Resident 24 did not receive [MEDICATION(S)] on the following dates and times: -6/4/22 at 5 pm -6/6/22 at 8 am -6/7/22 at 8 am -6/8/22 at 5 pm -6/12/22 at 8 am and 5 pm -6/15/22 at 5 pm -6/16/22 at 8AM and 5 pm During an interview on 6/16/2022 at 10:15 a.m. with Resident 24, Resident 24 stated he had not received his 9:00 a.m. medications. Resident 24 stated he was not given scheduled medications on some days as ordered by his physician. Resident 24 stated on some days, his medications were administered very late. A review of the facility's census, dated 6/16/22, indicated, based on room number, Resident 24 received medication from Medication Cart 3. f. A review of Resident 9 to 37's clinical records indicated similar findings between 6/1/22 and 6/15/22 from Medication Carts 1, 2, and 3. A review of the facility's nursing staff assignment between 6/1/22 and 6/15/22 indicated Medication Carts 1, 2, and 3 no licensed nurses were assigned to these carts on multiple shifts, including: On 6/7/22, for Medication Cart 1 no a licensed nurse was assignment for all three (3) shifts: 7 am to 3 pm, 3 pm to 11 pm, and 11 pm to 7 am. On 6/10/22, Medication Cart 2 had no licensed nurse assigned for the 3 pm to 11 pm and 11 pm to 7 am shifts. On 6/12/22, Medication Cart 3 had no licensed nurse assigned all day for the 7 am to 3 pm, 3 pm to 11 pm, and 11 pm to 7 am shifts. During a review of the facilities census dated 6/16/2022, the census indicated there were a total of 84 residents in the facility. During a review of the facilities nursing staff assignment dated 6/16/2022, the nursing staff assignment indicated one License Vocational Nurse (LVN)1 assigned to medication cart 2 for the 7:00 a.m. to 3:00 p.m. shift. During an interview on 6/16/2022 at 9:18 a.m. with LVN 1, LVN 1 stated she was the only charge nurse, and was assigned to medication cart 2 only. LVN 1 stated, she had a total of 32 residents to administer medications to and that she was unsure of who were assigned to medications cart 1 and cart 3. LVN 1 stated she did not feel confident giving other residents their medications since she was not familiar with the residents. LVN 1 also stated that it was too much and impossible for her to administer medications to all 84 residents in the facility. During an interview on 6/17/22 at 11:32 AM with NC 1, NC 1 confirmed several residents missed multiple medications in June 2022 due to a lack of staffing and sometimes a lack of medication availability from the staff's failure to order or reorder the medication. NC 1 stated there is a major risk to residents from not receiving medication especially for anticoagulants and [CONDITION(S)] medications which could cause seizures or cause falls and injuries if not given regularly. NC 1 stated it is important moving forward that all residents receive their medications on time to prevent possible life-threatening medical complications. During an interview on 6/17/22 at 1: 55 pm with the Medical Director (MD), MD stated he was not the facility's permanent MD and was only functioning as an interim MD. The MD stated, considering the fact that residents were not medicated as ordered, he (MD) may reconsider his decision to become the facility's permanent MD. The MD stated if residents missed doses of [CONDITION(S)] medications, there was a chance these residents might experience [CONDITION(S)] activities. The MD stated it was unacceptable for residents to miss medications and missing certain medications on so many occasions could cause medical complications, some of which could be life-threatening. The MD stated the facility was short staffed and that nurses had no right to decide which residents were to be medicated or not. The MD also stated nurses must follow physicians' orders and administer medication as prescribed to prevent harm to residents. During an interview on 6/17/22 at 2:45 pm with the VPO, the VPO stated she was in charge of five facilities and was called to provide resources to any of her facilities when faced with staffing issues. The VPO stated the AADM, and other leadership staff that's no longer employed at the facility never notified her of the facility's staffing needs for prompt intervention. The VPO also stated not medicating residents as ordered could affect the quality care of these residents. A review of the facility's policy titled Medication Administration, revised 1/1/12, indicated Medication will be administered directed by a licensed nurse and upon the order of a physician or licensed practitioner. A review of the facility's policy titled Provider Pharmacy Requirements, dated 1/ 2018, indicated Regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies.

Based on observation, interview and record review, the facility failed to ensure there were Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs) to provide nursing services to 57 of 84 residents (Residents 1-57) and failed to provide LVNs and RNs to care for 3 of 3 residents (Residents 2, 4, and 5) in need of nursing care: 1. No LVNs or RNs were assigned to medication cart 1 for 29 residents and medication cart 3 for 28 residents to administer scheduled medications on June 16, 2022, on the 7 am. to 3 pm shift and the 3-11 pm shift. The residents did not receive scheduled medications. 2. No nurse was available to medicate Resident 2, who was in pain and required pain medication. 3. Resident 4 who required a breathing treatment/medication was left unmedicated because there was no LVN to administer Resident 4's treatment and medication. 4. Resident 5, who required a dressing change of the left hip, did not have a dressing change for two days because there was no treatment nurse in the facility. These deficient practices caused Resident 2 to experience unrelieved pain. It also had the potential to cause difficulty breathing to Resident 4, infected left hip to resident 5 and, the potential to place all 57 residents at risk for increase health concerns including increased health problems and death. On 6/16/2022 at 6:22 p.m., an Immediate Jeopardy (IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared and the facility's Assistant Administrator (AADM) was notified of the serious findings regarding the facility's failure to provide qualified nursing staff to provide nursing services. On 6/18/2022 at 4:37 p.m., while the surveyor was onsite, after the Plan of Action (POA) was verified and confirmed by observation, interviews, and record review, the IJ was lifted, and the AADM and Nurse Consultant (NC) were notified The facility submitted a Plan of Action (POA) for the correction of the IJ, which included: 1. On 6/16/22, the Administrator immediately contacted licensed nurses for additional support and additional licensed nurses arrived at the facility for a total of 4 registered nurses (RN) and 2 license vocational nurses (LVN) to provide additional support and assistance: a. LVN arrived at 9 pm. b. Infection Prevention (IP) Nurse LVN arrived at 9 pm. c. RN 1 Arrived at 8:30 pm. d. RN 2 arrived at 11:06 pm. e. RN 3 arrived 11:51pm. f. RN 4 arrived at 9:15 pm. 2. On 6/17/22, 6/18/22, 6/19/22, a total of 3 licensed nurses were assigned to morning and evening shift and 2 on night shift in designated zones. Should there be staff call ins- the director of nursing (DON), director of staff development (DSD), minimum date set (MDS) and Infection Prevention (IP) Nurse will act as back up and administrator and DON will attempt to contact nurses who are off and registry for replacement. 3. The facility currently has registry contracts with two registries to assist with staffing needs. In addition, on 6/16/22, the facility reached out to two other registries for additional contracts 4. On 6/17/22, additional RNs, for a total of 6 arrived at the facility to provide assistance to the facility to ensure residents pain is assessed and pain medications are administered. 5. On 6/16/22 and 6/17/22, the Vice President of Operations (VPO), AADM, DON, DSD and regional quality management consultant (RQMC) reviewed the licensed nurse staffing and assigned licensed nurses each for 3 carts for AM and PM shift for the next 2 weeks. 6. On 6/17/22, the AADM, DON, and DSD reviewed the licensed nurses and certified nurse assistant (CNA) projected schedule for the next 2 weeks to ensure that the facility meets the staffing requirements. 7. On 6/17/22, the VPO and RQMC provided education to the AADM, DSD and including nursing staff on the importance of sufficient staffing with emphasis on ensuring provision of sufficient nursing staff to meet the needs of residents. It was also emphasized to management that critical staffing should be escalated to the VPO and RQMC for guidance, support and resolution as warranted. The AADM, DSD and DON were also educated on the staffing review process. 8. The DON/designee will conduct monthly education to nursing staff on sufficient staffing for the next 3 months. 9. Daily, Mondays through Fridays, during morning stand-up meeting, the DSD will report staffing coverage for the day. Any concerns with staffing will be immediately reported to DON and administrator. Additional nursing staff will be contacted to provide support via current staffing roster and as well as through registry staffing. The DON, DSD, IP, MDS nurses and other department managers that are licensed nurses will be scheduled to assist with medication administration in the event that the facility experiences short staffing. The VPO and RQMC will be notified. 10. Daily, Monday through Friday, during stand down, DSD will report projected staffing for the succeeding day. Any concerns will be immediately resolved 11. The AADM, DSD and DON will review staffing projections and actual nursing hours per patient day (NHPPD) daily for 4 weeks, then weekly for 6 months and will report staffing concerns to the VPO and RQMC for guidance, support and resolution as warranted. 14. The Administrator and/or DON will present the results of staffing projections and actual NHPPD to the quality assurance and performance improvement (QAPI) committee for review and recommendations monthly for 3 months then quarterly thereafter until substantial compliance is achieved. The plan will be reevaluated monthly by the QA Committee and make necessary changes as warranted. Findings: 1. During a review of the facilities census dated 6/16/2022 indicated there was a total of 84 residents in the facility. During a review of the facilities nursing staffing assignment dated 6/16/2022, the nursing staffing assignment indicated one LVN (LVN1) on duty to care for 84 residents residing in the facility for the 7:00 a.m. to 3:00 p.m. shift. The staffing assignment indicated LVN 1 was assigned to medication cart 2 only. On the 3pm to 11pm shift, there was one LVN (LVN 2) scheduled for duty and there were no names on the nursing assignment. During an interview on 6/16/2022 at 9:18 a.m. with LVN 1, LVN 1 stated she was assigned to medication cart 2 only and she had a total of 32 residents to administer medications. LVN 1 stated she was unsure of who was assigned to medication cart 1 and medication cart 3. LVN 1 stated she did not feel confident giving other residents their medications since she was not familiar with them. LVN 1 stated it would be too much for her to handle medication administration to all 84 residents on her own. During an interview on 6/16/2022 at 4:30 p.m. with AADM, AADM stated he was aware that there was only one LVN on duty and he did not contact registry because he had assigned a second license nurse to work on 6/16/2022 from 7:00 a.m. to 3:00 pm., but the license nurse did not come in. When asked why he (AADM) didn't call the registry, he stated he did not contact the registry because he (AADM) had two nurses scheduled. During a review of the facilities contract with nursing registry 2 (NR 2) dated 1/5/2021 indicated the facility made a staffing agreement beginning 2/5/2021. During a telephone interview on 6/9/2022 at 2:14 p.m. with the staffing agent of nursing registry 2 (NR 2), the staffing agent stated that they had not staffed the facility with LVN's since December 2021. NR 2 stated the contract had not been terminated but was placed on hold due to non-payments. 2. During a review of Resident 2's admission record (Facesheet), the facesheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's history and physical (H&P) dated 3/1/2022, the H&P indicated Resident 2 had the capacity to understand and make decisions During a review of Resident 2's Minimum Data Set (MDS-A standardize care screening and assessment tool) dated 4/27/2022, the MDS indicated Resident 2's could understand and be understood by others. The MDS indicated Resident 2 required one person assist with activities such as dressing, bathing, bed mobility, and personal hygiene. During a review of Resident 2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/16/2022 at 9:20 a.m. with Resident 2, Resident 2 stated she had severe pain due to her [CONDITION(S)] and she had not received her medication [MEDICATION(S)] (nerve pain medication) which was due at 8:00 a.m. Resident 2 stated that the nurses are always telling her They are short staffed. 3. During a review of Resident 4's facesheet, the facesheet indicated Resident 4 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's history and physical (H&P) dated 5/28/2022, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's was able to understand and be understood by others. The MDS indicated Resident 4 required a one person assist with activities such as dressing, bathing, bed mobility, and personal hygiene. The MDS indicated Resident 4 was continent of bowel and bladder and used a wheelchair for movement. During a review of Resident 4's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/16/2022 at 10:40 a.m. with Resident 4, Resident 4 stated she had not received two breathing treatments that were due at 9:00 a.m. Resident 4 stated the nurses tell her they are busy or are short staffed. 4. During a review of Resident 5's Admission Record (facesheet), the facesheet indicated Resident 5 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 5's order summary report dated 6/17/2022, the order summary report indicated Resident 5 had orders for left hip surgical site 1 (7 staples), left hip surgical site 2 (18 staples) and left hip surgical site 3 (12 staples) be painted with [MEDICATION(S)] (a disinfectant) and covered with dry dressing every day for 21 days. During a review of Resident 5's treatment administration record (TAR) dated June 2022, the TAR indicated on 6/15/2022 and 6/16/2022 there were no license staff initials in the box to demonstrate that wound treatment had been done. During a concurrent observation and interview on 6/16/2022 at 10:45 a.m. with Resident 5, Resident 5 was observed sitting on the edge grimacing and moaning and Resident 5's wound dressing of the left hip was observed extensively saturated with yellow drainage that oozed out of the gauze and onto the bed sheets creating a large yellow stain. Resident 5's skin surrounding the wound dressing was observed with a purple and bluish discoloration and the wound dressing was observed coming off. Resident 5 stated she was in pain, and had been calling for help since 7a.m., but no one had come to help her. Resident 5 stated she had not had her dressing changed for two days and was worried her wound might get worse. During a review of the facilities policies and procedures (P&P) titled Emergency Staffing with a revision date of May 19, 2020, the P&P indicated The facility will identify and contract with staffing agencies and registries that can provide staff in a time of need. Prior to staffing shortages occurring, the facility leadership will enact extended staffing hours to 12-hour shifts.

Based on observation, interview and record review, the facility failed to provide pain management to four of four sampled residents (Residents, 2, 3, 4, and 5) as indicated in the residents' plan of care. All four residents requested pain medication, and no one was available to assess and administer medication to the residents. This deficient practice caused Residents 2, 3, 4 and 5 to be in severe pain for extended (10- 12) hours. On 6/16/2022 at 6:22 p.m., an Immediate Jeopardy (IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was declared and the facility's assistant administrator was notified of the serious findings regarding failure to medicate Residents 2, 3, 4, and 5 with pain medication. The facility submitted an IJ Removal Plan for the correction of the IJ, which included: 1. On 6/16/22, Residents 2, 3, 4, and 5 were assessed by a Licensed Vocational Nurse (LVN) for signs and symptoms of pain and were provided pain medications as ordered/indicated. On 6/16/22, additional licensed nurses arrived at the facility for a total of 4 RNs and 2 LVNs to provide additional support and assistance a. LVN 2 arrived at 9pm b. Infection Preventionist (IP Nurse) LVN arrived at 9pm c. Registered Nurse (RN)1 arrived at 8:30 pm d. RN 2 arrived at 11:06 pm e. RN 3 arrived 11:51pm f. RN 4 arrived at 9:15pm g. On 6/16/22, the Director of Nursing (DON) and Regional Quality Management Consultant (RQMC) conducted immediate medication administration observation to the licensed nurses present during 3-11 shift in all zones. 2. On 6/16/22 and 6/17/22, the Director of Nursing (DON)/designees/Licensed Nurses conducted pain interviews of current residents to ensure that pain is assessed, and pain medication is administered as ordered. No other residents were identified other than the above sample residents who complained of pain and did not receive pain medication. 3. On 6/16/22 at 10:50 p.m. the DON/designee provided re-education to the licensed nurses on the following: a. Pain Management b. Medication Administration c. On 6/17/22, the RN Consultant provided education for the Licensed Nurses on Medication Administration, Pain Management and Sufficient Staffing. d. Beginning 6/23-6/24/22, the Clinical Education Specialist will provide monthly education to Licensed nurses on Medication Management, Pain Management and Sufficient Staffing. e. On 6/16/22 and 6/17/22, the Administrator, Interim DON, and the Director of Staff Development (DSD) reviewed the Licensed Nurses and Certified Nursing Assistant (CNA) Projected Schedule for the next 2 weeks to ensure that the facility meets the staffing requirements. f. Temporary Staffing Registries will continue to be utilized as needed. The DON, DSD, the Infection Prevention Nurse (IP), the Minimum Data Set Nurse (MDS Nurses) and other Department Managers that are Licensed Nurses will be scheduled to assist with Medication Administration in the event that the facility experiences short staffing. g. At the next Quality Assurance meeting, the Administrator and Department Managers together with the Medical Director will review the action plan and compliance status related to Medication Management and Staffing 4. The DON/DSD/Designee will conduct random Med Pass Observation of at least 3 licensed nurses once a week for 4 weeks then bi-monthly for 2 months to ensure that all Medications are administered timely as ordered including pain medications 5. The DON/designee will conduct nursing rounds on different shifts and check in/call in the facility to ensure that sufficient Licensed Nurses are available to provide assessment, monitoring, and medication administration to the residents daily for the next 2 weeks. 6. The DON will present the results of the Medication Pass Observation and Pain Management Audit to the Quality Assurance (QA) and Performance Improvement Committee for review and recommendations monthly for 3 months then quarterly thereafter. The plan will be reevaluated monthly by the QA Committee and make necessary changes as warranted. On 6/18/2022 at 4:37 p.m., while the surveyor was onsite, after the Plan of Action (POA) was verified and confirmed by observation, interviews, and record review, the IJ was lifted, and the Assistant Administrator and Nurse Consultant were notified. Findings: 1. During a review of Resident 2's admission record (Facesheet), the facesheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's history and physical (H&P) dated 3/1/2022, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS] a standardize care screening and assessment tool) dated 4/27/2022, the MDS indicated Resident could understand and be understood by others. The MDS indicated Resident 2 required a one person's assist with activities of daily living (ADLs) such as dressing, bathing, bed mobility, and personal hygiene. During a review of Resident 2's Order Summary Report dated 5/10/21, the Order Summary Report indicated monitor pain level every shift rating scale 1-4 (mild pain), 5-7 (moderate pain), 8-9 (severe pain) and 10 (very severe pain). During a review of Resident 2's order summary dated 6/9/2022, the order summary indicated, [MEDICATION(S)] (medication to treat moderate pain)100 milligrams ([mg] unit of measurement), give 1 capsule by mouth every 8 hours for moderate pain. The order summary indicated [MEDICATION(S)]-Acetaminophen (pain medication used to treat severe pain)10-325 mg every six (6) hours for severe pain, and [MEDICATION(S)]-Acetaminophen 10-325 mg every four (4) hours as needed for pain. During a review of Resident 2's undated care plan for chronic pain, the care plan's interventions indicated staff will anticipate and respond immediately to the resident's complaints of pain. During a review of Resident 2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident 2 on 6/16/2022 at 9:20 a.m., Resident 2 stated her face and head hurt and she felt burning and tingling throughout her body. Resident 2 stated she was in a lot of pain rated at 9 out of 10. 2. During a review of Resident 3's facesheet, the facesheet indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's H&P dated 6/4/2022, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required a one person's assist with activities of daily living including dressing, bathing, bed mobility, and personal hygiene. The MDS also indicated Resident 3 was incontinent (unable to control) of bowel and bladder. During a review of Resident 3's Order Summary Report dated 6/3/2022, the Order Summary Report indicated monitor pain levels every shift, and [MEDICATION(S)]-APAP (pain medication used to treat severe pain) 7.5-325 mg every eight (8) hours for chronic pain. During a review of Resident 3's undated care plan for chronic pain, the care plan indicated [MEDICATION(S)] (medication to treat pain) and [MEDICATION(S)] (medication to treat nerve pain) would be administered per physician orders. The care plan indicated to anticipate Resident 3's pain and medicate immediately to any complaints of pain. During a review of Resident 3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -6/1/22at 2pm -6/2/22 at 6am -6//22 at 6am -6/4/22 at 8pm -6/5/22 at 11pm -6/6/22 at 2pm -6/7/22 at 6am, and 2pm -6/12/22 at 6am, 2pm and 11pm The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident 3 on 6/16/2022 at 10:15 a.m., Resident 3 stated she (Resident 3) had back pain at a level of 9 out of 10. Resident 3 stated she had [MEDICATION(S)] scheduled the morning of 6/16/2022. Resident 3 stated she had not been assessed for pain in more than 5 days and had not been medicated for pain. Resident 3 stated she was frustrated with the license nurses for not giving her pain medicine as ordered. Resident 3 stated she had called the nurses, but nurses never came. Resident 3 added that she gave up calling. 3. During a review of Resident 4's facesheet, the facesheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's H&P dated 5/28/2022, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 could understand and be understood by others. The MDS indicated Resident 4 required a one person's assist with ADLs including dressing, bathing, bed mobility, and personal hygiene. The MDS indicated Resident 2 was continent of bowel and bladder and used a wheelchair for movement. During a review of Resident 4's Order Summary Report dated 6/17/2022, the Order Summary Report indicated [MEDICATION(S)] (strong medication to treat pain) 5-325 mg every six (6) hours as needed for pain. During a review of Resident 4's undated care plan for pain the care plan indicated Resident 4's pain would be alleviated by pain medication and the resident will receive [MEDICATION(S)] as needed, and per physicians' orders. During a review of Resident 4's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident 4 on 6/16/2022 at 10:25 a.m., Resident 4 stated she had pain on her right knee with a pain level of 9 out of 10. Resident 4 stated she had been asking for pain medication since 7a.m., on 6/16/2022 and had not been given any pain medicine. Resident 4 stated nurses do not give her pain medication on time. 4. During a review of Resident 5's facesheet, the facesheet indicated Resident 5 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 5's Order Summary Report dated 6/16/2022 indicated pain assessment every shift. The Order Summary Report indicated [MEDICATION(S)] every four (4) hours as needed for severe pain. During a review of Resident 5's undated care plan for pain, the care plan indicated staff will anticipate and respond to Resident 5's pain immediately. During a review of Resident 5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview on 6/16/2022 at 10:40 a.m., Resident 5 was observed sitting at the edge of the bed, moaning and grimacing. Resident 5 stated both of her knees were hurting and she was in severe pain rated at 9 out of 10. Resident 5 stated she was trying to lay back down in her bed but was unable to do so due to pain. Resident 5 stated she had been calling for help to get pain medication, but no staff helped her. During a review of the facilities policies and procedures (P&P) titled Pain Management with a revision date of November 2016, the P&P indicated the license nurse will administer pain medications as ordered and document medication administration in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy also indicates the licensed nurse will assess the resident for pain and document results on the MAR, each shift, using the 0-10 pain scale (pain scales use numbers from 0 to 10. A score of 0 means no pain, and 10 means the worst pain you have ever felt). During a review of the facilities P&P titled Administration of Pain medication with a revision date of November 2016, the P&P indicated Residents who received PRN (as needed) medication routinely will be reassessed for around the clock pain medication to ensure the highest level of comfort. During a review of the facilities undated LVN job description, the LVN job description indicated LVNs will administer professional services and provide care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being. The job description indicated LVNs will provide clinical data and observation to contribute to the nursing plan of care and prepare/administer medications as ordered by the physician and within the legal scope of practice.

Based on interview and record review, the facility failed to provide pain management to one of three sampled residents (Resident 1) as indicated in the resident's plan of care. Resident 1 asked a Licensed Vocational Nurse (LVN 2) for pain medication and the LVN did not assess the resident's pain or provide pain medication to Resident 1. This deficient practice caused Resident 1 to be in severe pain on 5/4/2022, for twelve (12) hours, and on 5/5/2022 for nine (9) hours. It also had the potential to cause pain and suffering for other residents in the facility. Findings: During a review of Resident 1's Admission record (facesheet), the facesheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set ([MDS] a standardized care screening and assessment tool) dated 4/25/2022 indicated Resident 1's was able to understand and be understood by others. The MDS indicated Resident 1 required a one person's assist with activities including bed mobility, transfer (moving between surfaces to and from bed, chair, wheelchair), dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 required physical help in bathing. The MDS indicated Resident 1 had an unsteady gait when moving from a seating to a standing position, moving on and off the toilet and that the resident used a wheelchair for movement. During a review of Resident 1's order summary report dated 5/2/2022, the summary report indicated Ibuprofen (used to treat mild to moderate pain) 800 milligrams ([mg] unit of measurement) every eight (8) hours as needed for moderate pain, and [MEDICATION(S)]-Acetaminophen (medication used to treat severe pain) 10-325 milligrams every six (6) hours as needed for severe pain (7-10). During a review of Resident 1's care plan for pain management dated 10/9/2021 the care plan's interventions indicated administer pain medication as ordered, assess pain management and treatments for effectiveness. The interventions indicated evaluate need to provide pain medication prior to treatment or therapy, evaluate need for routine pain medication rather than PRN (as needed), monitor for vocal complaints and assess level of pain using a pain rating scale. The interventions also indicated the use of non-pharmacological interventions including repositioning, calming environment, relaxation techniques and providing reassurance. During a review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. On 5/4/2022 at 11:46 a.m., for a pian level of 8/10 2. On 5/5/2022 at 12:40 p.m. and 6:40 p.m., for a pian level of 7/10 3. On 5/6/2022 at 8:34 a.m., for a pian level of 8/10 During an interview with Resident 1 on 5/5/2022 at 2:55 p.m., Resident 1 stated on 5/4/2022 at 5:45 p.m., she (the resident) asked a Licensed Vocational Nurse (LVN 2) for [MEDICATION(S)], and LVN 2 replied In a minute. Resident 1 then asked LVN 2 if she was her nurse, and LVN 2 responded I am just doing you a favor, because I do not need to give you your medications. I'm only in charge of my residents. Resident 1 stated when she told LVN 2 that LVN 2 was in charge of all residents, LVN 2 stated you are being hostile, and I am not giving you your pain medication. You will have to wait for the Director of Nursing. Resident 1 stated her joints were hurting and a pain was at 9/10, they are making me suffer and no one at the facility is doing anything about it. During a telephone interview with Resident 1 on 5/6/2022 at 9:30 a.m., with Resident 1, the resident stated the only nurse that worked on 5/5/2022 from 11pm- 7am, was LVN 2 and LVN 2 refused to administer her [MEDICATION(S)] again. Resident 1 stated her pain was at 8/10 and the last time she received [MEDICATION(S)] was on 5/5/2022 at 6:40 p.m. Resident 1 stated she did not get her [MEDICATION(S)] again until 5/6/2022 at 8:34 a.m. Resident 1 stated the staff made her suffer on purpose, she was unable to eat her breakfast because she was in too much pain, and she had been lying in bed icing her ankle. Resident 1 also stated that when there was a time lapse with her pain medication, it triggered a throbbing headache. During a telephone interview on 5/6/2022 at 1p.m., with LVN 2, LVN 2 stated that she was in the middle of medication administration when Resident 1 approached her asking for pain medication. LVN 2 stated she explained to Resident 1 that after medication administration, she would give the resident's pain medication. According to LVN 2, Resident 1 became angry and shouted, you just don't want to give me my pain medication. LVN 2 stated she did not refuse to give Resident 1's pain medication and was not going to stop in the middle of administering medications to other residents just to medicate Resident 1 for pain. LVN 2 stated after she was done with medication administration, she noticed Resident 1's bedroom door was closed, and she did not follow up with the resident to assess her pain and administer pain medication. LVN 2 stated it was important for the residents to received pain medication to relieve their discomfort. During an interview on 5/5/2022 at 3p.m. with the Assistant Administrator (AADM) and Director of Nursing (DON), the AADM stated almost all LVNs felt unsafe working with Resident 1 because the was demanding when she asked for pain medication. AADM stated LVNs felt harassed by Resident 1. The DON stated if there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated staff cannot leave a resident in pain because it could aggravate the health of that resident. During a review of the facilities policies and procedures (P&P) titled Pain Management with a revision date of November 2016, the P&P indicated the license nurse will administer pain medications as ordered and document medication administration in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the facilities P&P titled Administration of Pain medication with a revision date of November 2016, the P&P indicated Residents who received PRN (as needed) medication routinely will be reassessed for around the clock pain medication to ensure the highest level of comfort. During a review of the facilities undated LVN job description, the LVN job description indicated LVNs will administer professional services and provide care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental and emotional well-being. The job description indicated LVNs will provide clinical data and observation to contribute to the nursing plan of care and prepare/administer medications as ordered by the physician and within the legal scope of practice.

Based on observation, interview, and record review, the facility failed to ensure certified nurse assistant (CNA 1) did not hit and physically attack one of three sampled residents (Resident 1) and threaten and intimidate one of three sampled residents (Resident 2), who witnessed the abuse. Resident 2 asked CNA1 What was going on? CNA1 told Resident 2 If you do not keep quiet, I will F-k you up and hit you the same way. As a result, Resident 1 sustained abrasions to his right eyebrow and a black eye. Resident 1 also began to experience feelings of depression, was psychologically disturbed and voiced that he felt stressed while living in the facility and Resident 2 was threatened. Additionally, facility staff failed to report the altercation to the facility's supervisor for investigation. Findings: During a review of Resident 1's admission record (Face sheet) indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's History and Physical dated 5/25/21, indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/17/21, indicated the resident had mild cognitive (ability to make decisions, understand, learn) impairment, with daily decision making. The MDS assessment further indicated the resident required extensive assistance with activities of daily living (ADL's) such as bed mobility, transfers, locomotion on and off the unit, dressing, toilet, and personal hygiene. During a review of Resident 1's Care Plan dated 8/25/21 indicated Resident 1, required assistance with activities of daily living (ADL) in bed mobility, walking, locomotion, dressing, transfers, eating, toilet use, personal hygiene, and bathing. The listed care plan intervention indicated facility staff are to help with ADL care as needed, allow sufficient time for ADL, and to turn and reposition as ordered. During a review of Resident 1's Care Plan titled Allegation of Abuse dated 8/25/21, indicated Resident 1 made allegations of being physically abused by staff. The listed interventions noted the following: 1. Conduct a body and pain assessment. 2. Suspend the staff right away. 3. Perform treatment as ordered and apply triple antibiotic ointment for seven days. During a review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Obtain x-rays of Resident 1's skull (head). 2. Perform neuro checks (assesses motor and sensory skills, hearing and speech, vision, coordination, and balance) per facility protocols. 3. Conduct visual checks every 30 minutes for 72 hours. 4. Monitor Resident 1's right eye abrasion. During a concurrent observation and interview on 8/26/21 at 12:45 p.m., with Resident 1, in Resident 1's bedroom, Resident 1 was observed lying in bed and had an abrasion injury on the right side of his upper right eyebrow. Resident 1 stated he had a pain level of seven on a scale of one to 10, (10 on the pain scale represents the most severe or worst pain ever experienced). Resident 1 stated CNA1 hit him on the face. He had a bowel movement and asked CNA1 to change his gown and give him (Resident 1) a new pair of pants and a shirt. When CNA1 held the bed controller to raise the bed Resident 1 snatched the bed controller from CNA1. Then they (Resident 1 and CNA1) began to argue and CNA1 took the bed controller back from Resident 1 and threw it at the resident's face. Resident 1 stated the nurses are aware that Resident 1 fears heights and will scream out each time the nurses change him and raise the bed. During a further interview, Resident 1 stated he yelled and screamed for help during the attack during the early morning of the 11-7a.m shift, but nobody came. Resident 1 further stated each time he pushed the call light button, all the nurses who provide care for him threatened if he keeps pushing the call light the nurses would raise his bed, because Resident 1 fears the bed being raised. The nurses threaten to raise the bed so that he would stop pushing the call light when he needed help. Resident 1 further stated I feel depressed and unsafe in the facility, I have not felt this way before since my stay in the facility. I want to leave the facility. During an interview on 8/26/21 at 1 p.m., with Licensed vocational Nurse (LVN 1), LVN1 stated I was not in the facility when the incident happened, when I came in the morning, I went into Resident 1's room and noticed the resident had a black eye. I asked the resident what happened, and he stated CNA 1 hit him during care and caused him to have a black eye (right eye) and an abrasion over his right eyebrow. When LVN1 asked the charge nurse about the night of the incident, she stated she did not know about the incident because CNA1 did not report the incident to her charge nurse. During an interview on 8/26/21 at 1:51 p.m., with CNA1, CNA1 stated she did not report the incident to the night shift charge nurse because there was no bleeding on the resident's face at the time of the incident. CNA1 stated Resident 1's face had a little knot and a little bleeding, and the skin was red and torn at the time of the incident. It did not look normal, but she did not report it to the charge nurse, because it was not big. CNA1 further stated that she had received in-service training for abuse prevention and reporting. During an interview on 8/26/21 at 1:25 p.m., with Resident 2, Resident 2 stated the incident happened early in the morning on 8/25/21, around 3 A.M. He had gotten up to use the bathroom and heard a loud noise between CNA1 and Resident 1. CNA 1 was using force and was aggressive towards Resident 1. When Resident 2 asked what was going on, CNA1 stated if she hears from him (Resident 2) she would F .ck him up the same way. Resident 2 then stopped and continued with his morning prayer. During an interview on 8/26/21, at 2:37 p.m., with CNA2, CNA2 stated he has worked in the facility since March 2021 on the day shift (7-3P.M shift). When he walked into the resident's room, CNA2 saw a fresh straight scratch on Resident 1's face. Resident 1 complained his eye was hurting, because the assigned night shift CNA1 hit him during care. CNA2 reported the incident to the charge nurse on duty. During an interview on 8/26/21 at 3 p.m., during an interview Registered Nurse (RN1), RN1 stated he was the RN supervisor who was on duty during the 11-7 A.M shift on 8/24/21, which ended 8/25/21 at 7a.m. RN 1 did rounds at the beginning of the shift and the resident was sleeping at the time. Around 4A.M., in the morning, RN 1 did rounds again and saw a scratch on the resident's face. When RN 1 asked the resident, what happened and how did he get a scratch on the face, Resident 1 stated the nurse struck him on the face while changing him during care. RN 1 further stated he did not realize the incident happened on her shift and that was why he did not follow up immediately. RN1 further stated during the change of shift huddle at 7 a. m., the incoming CNA 3 reported to him and the 7 a.m., charge nurse that Resident 1 had redness and abrasions on his face. It was then that he realized the incident happened during his shift and the alleged CNA did not notify him about the incident. When he asked the alleged CNA, she stated it was not important because the resident was not bleeding too much. RN1 stated Resident 1's roommate witnessed the incident and asked CNA1 to stop, but she told the roommate if you do not keep quiet, I will hit you the same way. RN 1 further stated that based on his interview and observation, he concluded that CNA1 did hit Resident 1, and this was why CNA1 did not report the incident to him. CNA1 wanted to work out the case because she wanted to complete a double shift but was sent home after the incident was discovered. During an interview on 8/26/21 at 3:54 p.m., with the administrator (ADM), ADM stated she interviewed the resident's roommate and the roommate stated he heard a commotion going on and asked what was going on. CNA1 told him to be quiet. If not, she would also hit him the same way. The incident was substantiated and CNA1 was terminated and will not be allowed to return to work in the facility. She further stated after the investigation, she will report CNA1 to the appropriate authorities. A review of the Facility's Policy and Procedure titled Abuse- Prevention, Screening, & Training Program dated 7/2018 defined abuse as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, physical or chemical restraint not required to treat symptoms and/or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish. Physical abuse ' is defined as, but not limited to, hitting, slapping, punching, and kicking. It also includes corporal punishment which is physical punishment used to correct or control behavior.

Based on interview and record review, the facility failed to ensure one of three (3) sampled resident (Resident 1) received medication as prescribed by the physician and with adequate monitoring of medication side effects, assessment, and proper disposal of medication as per the facility's policy and procedures (P/P) titled, Controlled Medication Disposal, dated 2/23/15 (Cross referenced to F580). Resident 1 had an order for [REDACTED].) for chronic pain. The licensed nurses fail to document the application and removal date and time after 72 hrs. prior to the placement of the next patch on 2/1/2020, 2/4/2020, 2/13/2020, 2/19/2020. There was also no documented site of the [MEDICATION NAME] placement on 2/22/2020 and 2/25/2020 as per the facility's policy and procedure. These deficient practices resulted in Resident 1 requiring an emergency transfer to the general acute care hospital (GACH) for respiratory distress with a decreased rate of 10 breaths per minute ((bpm) normal Reference Range (NRR) 16-20 bpm) and low oxygen levels (NRR 94-100 percent (%) on room air). Resident 1 was found to have four (4) intact [MEDICATION NAME]es on various parts of his body and one last dated 11/2019 upon initial admission to the GACH's Emergency Department (ED). On 3/12/2020 at 3:12 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's inability to provide the necessary care and services to monitor and assess a resident use of a narcotic. The facility's ADM and DON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 3/15/2020 at 1:11 p.m., the ADM submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. On 2/27/2020 an audit was conducted to identify other residents receiving [MEDICATION NAME]. No other residents were identified with an opioid (narcotic) patch. An investigation initiated on 3/2/2020 of the licensed nurses that administered the patch. Two licensed nurses were suspended on 3/2/2020 due to improper documentation and assessment of the [MEDICATION NAME] placement. 2. Developed a process for opioid patches disposal on 3/2/2020. The process included confirmation/documentation of opioid patch placement every shift and removal by two licensed nurses to be completed and sign. The patch will be folded in half (adhesive side to adhesive side), placed in the foil wrapper and return to the box. Upon utilizing of the five (5) patches in the box, the licensed nurse will be responsible for returning the box with the five used patches to the DON with the controlled substance log to be properly disposed together with the pharmacist. 3. Licensed Nurses were educated on the facility's policy for [MEDICATION NAME]es ([MEDICATION NAME] is a medicated adhesive patch that is placed on the skin to deliver a specific dose of medication through the skin and into the bloodstream) and the updated process by the Director of Staff Development (DSD) on 3/5/2020 through 3/12/2020. Nurses scheduled for upcoming shifts will be in-serviced prior to the start of their shift. 4. Licensed Nurses were in-serviced on 3/12/2020 regarding F757 Drug Regimen Free from Unnecessary Drugs. The remaining nurses will be in-serviced prior to their next scheduled shift. 5. The Pharmacist Consultant in-serviced all licensed nurses on 3/14/2020 regarding [MEDICATION NAME] Drug Delivery System (patch) application and medication handling. 6. Residents with [MEDICATION NAME]es will be checked daily for 14 days, then three times a week for 90 days by the DON or designee to ensure only one patch is intact and the removal of the patch is properly documented by two nurses. Any negative findings will be reported directly to the Administrator. 7. All the Medication Administration Records (MAR) will include black box warning as part of the order for the [MEDICATION NAME]es. 8. The Director of Medical Records (DMR) will audit the resident's MARs with [MEDICATION NAME]es weekly for 90 days to ensure the Mar includes checking for patch placement every shift. On 3/15/2020 at 1:11 p.m., while onsite the surveyor verified and confirmed the POA was implemented through observation, interviews and record reviews including in-services provided to the licensed nurses by the pharmacist consultant and the pharmacist regarding the appropriate use and disposal of [MEDICATION NAME]es, in-service by the DSD and DON regarding care planning and documentation of medication administration. The IJ was removed and the ADM and DON were notified. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. The face sheet did not indicate Resident 1 had a [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 1/3/2020 indicated Resident 1 was usually able to make himself understood and understand others. The MDS indicated Resident 1 was totally dependent of a one-person physical assist for bed mobility, eating and personal hygiene. A review of Resident 1's care plan titled, Black Box Warning, dated 12/14/19 indicated Resident 1 was at risk for side effects from medications. The goal was for Resident 1 to have minimal side effects from the medication. The staffs' approach included to have the medications reviewed upon admission by the pharmacist, monitor the resident for any side effects, vital signs, abnormalities and report to the physician. The care plan did not indicate what medications were on the list for Black Box Warning. A review of the physician's orders [REDACTED]. A review of Resident 1's physician's telephone order, dated 1/28/2020 and timed at 5:10 p.m., indicated to apply a [MEDICATION NAME] 12 mcg/hour, every 72 hours, for chronic pain. A review of Resident 1's document titled, Topical Patches Sheet indicated to immediately witness and sign by two licensed nurses when a patch was removed and disposed. The Sheet indicated on 2/1/2020, 2/4/2020, 2/13/2020, and 2/19/2020 there was no second signature by a licensed nurse to witness the removal and disposal of Resident 1's [MEDICATION NAME]. A Review of Resident 1's MAR for the month of 2/2020 indicated Resident 1 received nine (9) [MEDICATION NAME]es. The MAR sheet did not indicate the location the patch was placed or removed on Resident 1 on 2/22/2020 and 2/25/2020. A review of Resident 1's Change of Condition ((COC) sudden, clinical deviation from a resident's baseline) form, dated 2/27/2020 and timed at 12:05 a.m. indicated on 2/26/2020 at 11:03 p.m., Resident 1 respiration rate 10 bpm and the staff was unable to read oxygen saturation (amount of oxygen in the blood). The COC indicated Resident 1 was noted lethargic (sluggish) placed in an upright position and administered two (2) Liters pe minute (L/m) of oxygen via nasal cannula (lightweight tube place on the nose to deliver oxygen). The COC indicated at 12:15 p.m., on 2/27/2020, Resident 1 was found not responding, pale and lethargic. Orders received from Resident 1's physician to transfer to the GACH via 911 (emergency services). A review of Resident 1's physician telephone order, dated 2/27/2020 indicated to transfer Resident 1 to the GACH via 911 for decrease respiration rate, oxygen desaturation (low oxygen) an altered level of consciousness ((ALOC) abnormal measurement of a resident's awakening and responsiveness to stimuli). A review of Resident 1's Prehospital Care Report Summary, dated 2/27/2020 indicated paramedics were dispatched at 1:14 a.m. on 2/27/2020 for decrease in oxygenation. The report indicated the facility's staff contacted 911 for Resident 1's oxygen levels at room air being below 90%. The report indicated Resident 1 was transferred to the GACH for further evaluation of respiratory distress and ALOC. A review of Resident 1's GACH History and Physical (H/P), dated 2/27/2020 and timed at 9:13 a.m., indicated Resident 1 was admitted to the GACH for worsening of an altered mental status and low oxygenation. The H/P indicated upon arrival, Resident 1 was found to have four [MEDICATION NAME]es on various areas of his body (with no exact location) and were promptly removed. A review of Resident 1's GACH Order Consults, dated 2/28/2020 and timed at 10:54 a.m. indicated Resident 1 was found with four old [MEDICATION NAME]es upon admission to the GACH on 2/27/2020. On 3/10/2020 at 4 p.m., during a telephone interview, Resident 1's Responsible Party (RP) stated not being informed by the facility's staff of the resident's first COC on 2/26/2020. The RP stated she was notified on 2/27/2020 at 6 a.m., of Resident 1's transferred to the GACH. The RP stated she notified the facility's ADM and DON on 2/27/2020 of the neglect Resident 1 suffered when the facility's licensed nurses left four (4) [MEDICATION NAME]es on various parts of the resident's body. On 3/11/2020 at 10:12 p.m., during a telephone interview, the GACH Social Services Worker (SW) stated Resident 1 was admitted to the GACH on 2/27/2020 for respiratory distress. The SW stated Resident 1 appeared malnourish, dirty, unkept, and had four [MEDICATION NAME]es found on him one of them dating back to 11/2019. On 3/12/2020 at 9:13 a.m., during an interview, the DON stated she was made aware of the [MEDICATION NAME]es found on Resident 1 by the GACH. The DON stated an investigation was conducted by her and the DON after verifying the information it was found that Licensed Vocational Nurse 1 and 2 (LVN 1 and 2) did not document several dates on 2/2020 of Resident 1's [MEDICATION NAME]es when they removed and were placed. The DON stated LVN 3 was suspended because she failed to assess Resident 1's COC and identify the four patches on various parts of Resident 1's body and transfer him to the GACH immediately after receiving the physician order [REDACTED]. On 3/12/2020 at 10:22 a.m., during an interview and review of the facility's policy and procedures Specific Medication Administration Procedures ([MEDICATION NAME] application), with the ADM and the DON, the ADM stated the policy and procedures did not indicate proper disposal of the [MEDICATION NAME] upon removal. The ADM stated LVNs 1 and 2 were suspended upon identification and verification of the medication error by not signing the [MEDICATION NAME] disposal day on the MAR and narcotic sheet. A review of LVNs 1 and 2 Notice to Employee as to Change in Relationship, dated 3/6/2020 indicated LVNs 1 and 2 were discharge from the facility effective 3/6/2020 for failure to follow facility's and pharmacy policy and procedures for medication error. On 3/15/2020 at 11 a.m., during an interview, the ADM stated the facility did not have the second part of the [MEDICATION NAME] Patch policy which included how to dispose of the [MEDICATION NAME] upon removal off the resident. The ADM stated the second part of the policy was obtained on 3/12/2020 from the pharmacy. On 3/18/2020 at 11:02 a.m., during a telephone interview, LVN 1 stated not remembering who co-signed the [MEDICATION NAME] sheet the days she (LVN 1) removed them. LVN 1 stated she disposed the patches in the trash upon removing them from Resident 1. LVN 1 stated she did not receive an in-service on the administration and disposal of [MEDICATION NAME]es. LVN 1 stated, she did not know why there was no signature of the second nurse upon the removal of the patches on the dates she administered medication. LVN 1 stated not remembering the dates she administered the [MEDICATION NAME] Patches to Resident 1. On 3/18/2020 at 12:50 p.m., during a telephone interview, LVN 2 stated she disposed Resident 1's patches by flushing them in the toilet. LVN 2 stated she was aware the proper way to dispose of the [MEDICATION NAME] upon removal was to have a witness cosign the disposal. LVN 2 stated not having a second witness when disposing of the patches. LVN 2 stated she had not been in-serviced on the disposal of [MEDICATION NAME] but was aware because it was common sense to have a second person sign the disposal. A review of the facility's policy and procedures titled, Specific Medication Administration Procedures ([MEDICATION NAME] application), dated 2/23/15 indicated the facility staff would place the patch after identifying the location of the body to be placed and document on the MAR the site it was placed. A review of the facility's policy and procedures titled, Controlled Medication Disposal, dated 2/23/15 indicated the DON and the pharmacist consultant were responsible for the facility's compliance in handling of controlled medications. The policy indicated when a dose of controlled medication was removed from the container for administration and was refused or removed, it was destroyed in the presence of two licensed nurses and flushed in the toilet.

Based on interview and record review, the facility failed to notify a physician when one of three sample residents (Resident 1), Resident 1 had a change of condition ((COC) sudden, clinical deviation from a resident's baseline) on 2/26/2020 at 11:03 p.m. when Resident 1 first experienced lethargy (sluggish), decrease respiratory rate of 10 breaths per minute ((bpm) Normal Reference Range (NRR) 16-20 bpm) and an unreadable oxygen saturation (measure of how much oxygen the blood is carrying (NRR 94-100 percent (%) in room air)); follow physician's orders [REDACTED]. These deficient practices resulted in a delay of provision of care and a transfer to the GACH on 2/27/2020 at 1:47 a.m. (2 hours and 45 minutes after initial COC) for shortness of breath (SOB) and altered mental Status (AMS). Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 1/3/2020 indicated Resident 1 was usually able to make himself understood and understand others. The MDS indicated Resident 1 was totally dependent on a one-person physical assist for bed mobility, eating and personal hygiene. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's COC form, dated 2/27/2020 and timed at 12:05 a.m. indicated on 2/26/2020 at 11:03 p.m. Resident 1's respiration rate was 10 bpm and had an unreadable oxygen saturation (amount of oxygen in the blood) level. The COC indicated Resident 1 was noted lethargic, placed in an upright position and two (2) liters of oxygen was administered via nasal canula (lightweight tube place on the nose to deliver oxygen). At 12:15 a.m. on 2/27/2020, Resident 1 was found unresponsive, pale and lethargic, physician was notified, and orders received to transfer Resident to the GACH via 911. A review of Resident 1's physician telephone order, dated 2/27/2020 and timed at 12:15 a.m. indicated to transfer indicated to transfer Resident 1 to a GACH via 911 for decrease respiration rate, desaturation (low oxygen) and altered level of consciousness ((ALOC) abnormal measurement of a resident's awakening and responsiveness to stimuli). A review of Resident 1's Prehospital Care Report Summary, dated 2/27/2020 indicated the paramedics were dispatched at 1:14 a.m. on 2/27/2020 for Resident 1's decreased oxygenation. The report indicated Licensed Vocational Nurse 3 (LVN 3) contacted 911 at 1:14 a.m. for Resident 1's decreased oxygen levels of 90% on room air and Resident 1 was transferred to the GACH for further evaluation. A review of Resident 1's GACH history and physical (H/P), dated 2/27/2020 and timed at 9:13 a.m., indicated Resident 1 was admitted to the GACH for worsening AMS and low oxygenation. The H/P indicated upon arrival Resident 1 was found to have four [MEDICATION NAME]es on various parts of his body that were promptly removed. The H/P indicated Resident 1 had acute [MEDICAL CONDITION] (brain disease, damage, or malfunction) and dehydration (excessive loss of body water). A review of the revised 10/15/19 DailyMed report, indicated serious, life-threatening, or fatal respiratory depression occurs with the use of opioids (narcotics), even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the resident's status. The report indicated Life-threatening respiratory depression is more likely to occur in elderly, cachectic (marked weight loss and muscle loss), or debilitated patients because they may have altered pharmacokinetics (branch of pharmacology concerned with the movement of drugs within the body) compared to younger, healthier residents. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4c3a6171-19e4-40c2-83f3-fb54d4736e4b#S5.4 On 3/10/2020 at 4 p.m., during a telephone interview, Resident 1's Responsible Party (RP) stated not being informed by the facility's staff of the first COC on 2/26/2020. The RP stated she was notified on 2/27/2020 at 6 a.m., of Resident 1's transferred to the GACH. The RP stated she notified the facility's ADM and DON on 2/27/2020 of the neglect Resident 1 suffered when the facility's licensed nurses left four (4) [MEDICATION NAME]es on various parts of the resident's body. On 3/11/2020 at 10:12 p.m., during a telephone interview, the GACH's Social Services Worker (GSW) stated Resident 1 was admitted to the GACH on 2/27/2020 for respiratory distress. The GSW stated Resident 1 appeared malnourish, dirty, unkept, and with four [MEDICATION NAME]es found on his body. On 3/12/2020 at 9:13 a.m., during an interview, the DON stated she was made aware of the [MEDICATION NAME]es found on Resident 1 by the GACH. The DON stated an investigation was conducted and Licensed Vocational Nurse 1 and 2 (LVN 1 and 2) did not document several dates Resident 1's [MEDICATION NAME]es removed. The DON stated LVN 3 was suspended because she failed to assess Resident 1 prior to being transferred to the GACH and to identify the patches. On 3/12/2020 at 3:10 p.m., during an interview with the DON and ADM, the ADM stated LVN 3 was suspended and later terminated for failing to follow the physician's orders [REDACTED]. A review of LVN 3's Notice to Employee as to Change in Relationship, dated 3/6/2020 indicated LVN 3 was terminated for not following the facility's policy and procedures to assess Resident 1 prior to the hospital transfer. On 3/19/2020 at 4:17 p.m., during a telephone interview, LVN 3 stated on 2/26/2020 at 11 p.m. during rounds, Resident 1 was noted restless, had difficulty breathing and chest pain. LVN 3 stated she administered 2 liters of oxygen via nasal canula to Resident 1 but stated she was not able to read Resident 1's oxygen saturation level. LVN 3 stated she checked on Resident 1 an hour later (12:05 am on 2/27/2020) and Resident 1 was lethargic and short of breath (SOB). LVN 3 stated she called Resident 1's physician and received an order to transfer the resident via 911. LVN 3 stated she waited an hour and then call 911 at 1:14 a.m., on 2/27/2020 because she was getting Resident 1's paperwork ready prior to the paramedics arrival so that the paramedics would not complain. Paramedics complained when the resident's paperwork was not ready, as they did every time they came in. When ask, LVN 3 stated an order for [REDACTED]. On 3/27/2020 at 1:17 p.m., during an interview, CNA 1 stated Resident 1 had a Foley catheter since his admission on 12/2019. CNA 1 sated she notify the treatment nurse of Resident 1's catheter tubing did not appear it was placed right because the opening of Resident 1's pee hole, was becoming bigger with white pus on it and as if it was cutting open the penis. CNA 1 stated she mention it on different occasions to the treatment nurse and 3/2020 being the last time they removed it because it appeared swollen, cutting open the tip of the penis and greenish from the tubbing. CNA 1 stated the treatment nurse stated to keep Resident 1 with no catheter so allow time to heal. CNA 1 stated Resident 1 did not had injuries to his penis when he was readmitted on ,[DATE]. A review of the facility's policy and procedures titled, Change of Condition Notification, revised on 4/1/15, indicated that the facility will promptly inform the resident's Attending Physician and notify the legal representative of a significant change in resident's physical, mental or psychosocial status. The policy indicated the licensed nurse would assess the resident and notify the physician immediately of an emergency such as unexpected shortness of breath or intense pain. The policy indicated the staff would document findings each shift for 72 hours.

Based on interview and record review, the facility's nursing staff failed to follow physician orders [REDACTED]., trauma and injury for one of three sampled residents (Resident 1). Resident 1 had an indwelling urinary catheter for wound maintenance and there was no documented evidence the nursing staff were changing the catheter tube. This deficient practice of not assessing and changing the catheter as prescribed by the physician resulted in Resident 1 sustaining a urethral (duct by which urine is conveyed out of the body from the bladder) trauma (physical injury) from the urinary catheter. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 1/3/2020 indicated Resident 1 was usually able to make himself understood and understand others. The MDS indicated Resident 1 was totally dependent on a one-person physical assist for bed mobility, eating and personal hygiene. The MDS indicated Resident 1 had an indwelling urinary catheter in place. A review of Resident 1's physician's orders [REDACTED]. A second physician order [REDACTED]. A review of Resident 1's readmission assessment dated [DATE] indicated Resident 1 was readmitted with a Foley catheter. A review of Resident 1's care plans did not indicate a care plan for Resident 1's indwelling urinary catheter was created. A review of Resident 1's initial admission assessment dated [DATE] indicated no lacerations to Resident 1's penis was assessed or documented. A review of Resident 1's physician telephone order, dated 2/27/2020 indicated to transfer Resident 1 to the general acute care hospital (GACH) via 911 (emergency service number) for decrease respiration rate, desaturation (low oxygen) and altered level of consciousness ((ALOC) abnormal measurement of a resident's awakening and responsiveness to stimuli). A review of Resident 1's GACH Skin Integrity Record, dated 2/27/2020 indicated there was a penis urethra wound present on admission. The photos taken by the GACH's staff, dated 2/27/2020 noted Resident 1's catheter with spots of blood on the tubing and with redness on the urethral during the admission assessment. A review of another photo taken upon admission to the GACH on 2/27/2020 indicated Resident 1's urinary catheter was coated with a slimy dark grayish substance towards the tip of the catheter upon removal. On 3/10/2020 at 4 p.m., during a telephone interview, Resident 1's Responsible Party (RP) stated not being informed by the facility's staff of the first Change of Condition ((COC) sudden, clinical deviation from a resident's baseline) form on 2/26/2020. The RP stated she was notified on 2/27/2020 at 6 a.m., of Resident 1's transfer to the GACH. The RP stated she notified the facility's Administrator (ADM) and Director of Nursing (DON) on 2/27/2020 of the neglect Resident 1 suffered when the facility's licensed nurses left four (4) [MEDICATION NAME]es on the resident. The RP stated Resident 1 was admitted with no injuries to his penis and Certified Nurse Assistant 1 (CNA 1) had mention to the staff of Resident 1's penis splitting in half. On 3/12/2020 at 10 a.m., during an interview and review of Resident 1's Treatment Assessment Record (TAR), Licensed Vocational Nurse 4 (LVN 4) stated Resident 1 had a urinary catheter that she last assessed on 2/24/2020 and she stated Resident 1 had a laceration to his penial area upon admission on 12/14/19 (sic). LVN 4 stated there was no care plans for Resident 1's urinary catheter care found or nursing progress notes regarding any care she or other staff provided to the resident's penial area. A review of Resident 1's 2/2020 TAR indicated LVN 4's initials for urinary catheter treatment and assessment on 2/26/2020 through 2/29/2020. LVN 4 stated Resident 1 was transferred to the GACH on 2/26/2020 and she (LVN 4) documented four (4) days mistakenly because she was in a hurry. LVN 4 stated and confirmed there was no assessment or nurses notes upon admission on 4/26/19 regarding Resident 1 being admitted with a laceration to his penis. LVN 4 stated she had no documentation of Resident 1's wound treatments to Resident 1's penial area or the date she (LVN 4) changed Resident 1's catheter tubing. On 3/27/2020 at 1:17 p.m., during an interview, CNA 1 stated Resident 1 had a Foley catheter since his admission on 12/2019. CNA 1 sated she notify the treatment nurse of Resident 1's catheter tubbing did not appear it was placed right because the opening of Resident 1's pee hole, was becoming bigger with white puss on it and as if it was cutting open the penis. CNA 1 stated she mention it on different occasions to the treatment nurse and 3/2020 being the last time they removed it because it appeared swollen, cutting open the tip of the penis and greenish drainage from the tubing. CNA 1 stated the treatment nurse stated to keep Resident 1 without a catheter to allow time to heal. CNA 1 stated Resident 1 did not had injuries to his penis when he was readmitted in 12/2019. A review of the facility's policy and procedure titled, Comprehensive Person-Center Care Planning, dated 11/2017 indicated it was the facility's responsibility to provide person-center care that reflects best practice standards for meeting health, safety, and environmental needs for the residents. The policy indicated a case line care plan should reflect the resident's stated goals and objectives, and include interventions that addressed his/her concerns.

Based on interview and record review, the facility failed to ensure that the attending physician conducted a medical evaluation for three of three sampled residents (Residents 1, 2 and 3). Resident 1, who was diabetic (having diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of sugars resulting in elevated sugar in the blood and urine)) and had unstable blood sugar levels, was not seen by the primary physician (Physician 1) since admission on [DATE]. Resident 2, who was also diabetic was readmitted back to the facility on [DATE], and had not seen Physician 1 since readmission. Resident 3 was readmitted to the facility on [DATE] and was not seen by Physician 1 since readmission. These deficient practices of residents not being evaluated by Physician 1 resulted Residents 1, 2, and 3 medical care not being supervised by a physician and the potential for harm to Resident 1. Resident 1 was transferred twice to a general acute care hospital (GACH) for immediate interventions related to unstable blood sugar levels, and once when the paramedics came and provided care for Resident 1's low blood sugars. Findings: a. A review of Resident 1's Admission Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE] with a recent admission on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Transfer Form, dated [DATE], indicated Resident 1 was transferred to a GACH on [DATE] (21 days after admission), for [MEDICAL CONDITION] (high blood sugar). The transfer form indicated Resident 1's symptoms of [MEDICAL CONDITION] and altered mental status were first noticed on [DATE] at 5 p.m. A review of Resident 1's Nurses' Note, dated [DATE] and timed at 3:30 p.m., indicated that Resident 1 was monitored after an episode of [DIAGNOSES REDACTED] (low blood sugar). A Nurse's Note, dated [DATE] and timed at 6:19 p.m., indicated Resident 1 was transferred via ambulance to a GACH due to [MEDICAL CONDITION]. A review of Resident 1's Minimum Data Set ((MDS), a standardized care screening and assessment tool), dated [DATE], indicated the resident was severely impaired in cognitive (thought process) skills. The MDS indicated Resident 1 required a one-person physical assist with bed mobility, transferring from one surface to another, eating, toilet use and personal hygiene. Resident 1 was receiving insulin (hormone used to lower elevated blood sugar) seven (7) days a week. A review of Resident 1's physician orders, dated [DATE], indicated the resident should receive Trazadone (used to treat depression) 150 milligrams (unit of measurement) by mouth at bed time for depression, [MEDICATION NAME] (hormone medication used to rapidly increase blood sugar levels) 1 (one) milligrams (mg) intramuscularly ((IM) an injection into the muscle) as needed if blood sugar levels were below 60 mg/dl, Basaglar insulin (medicine used to lower blood sugar levels) 10 (ten) units subcutaneously ((SQ) injected under the skin) at bed time. Resident 1 was to have finger stick (act of puncturing the tip of the finger to obtain a small sample of blood) for blood sugar monitoring before meals and at bed time. A review of Resident 1's physician's telephone orders, signed by the licensed nurse and not Physician 1, dated [DATE], indicated Resident 1 was to receive 20 units of Basaglar SQ at bedtime for DM. A review of Resident 1's Discharge Summary and Post Discharge Plan of Care, dated [DATE], indicated Resident 1 was developmentally delayed (a delay in gaining skills expected by a certain age) and had a laboratory blood sugar level of 409 milligrams per deciliter ((mg/dl) normal reference range (NRR) is ,[DATE] mg/dl). A review of Resident 1's care plan, dated [DATE], indicated Resident 1 had a potential for injury, related to [DIAGNOSES REDACTED] (low blood sugar) due to insulin use and knowledge deficit. The staff's interventions indicated to administer medications as ordered, observe the resident for signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] (such as weakness, excessive thirst, excessive sweating, or confusion), obtain laboratory tests as ordered and report the results to the physician. A review of Resident 1's Change of Condition (C[NAME]) form, dated [DATE] and timed at 8:20 p.m., indicated on [DATE] at 8 a.m., Resident 1 had an altered mental status ((AMS) a changed level of awareness or mental state that falls short of unconsciousness) and was hard to arouse. Resident 1's blood sugar was low at 38 mg/dl and one milligram of [MEDICATION NAME] was administered intramuscularly and paramedics were called and came and started an intravenous ((IV) into the veins) line and administered IV fluids to Resident 1. Resident 1's blood sugar increased to 309 mg/dl after Resident 1 was given the [MEDICATION NAME]. According to the C[NAME] report, Resident 1 was alert and responsive and the physician was called. Physician 1 ordered Resident 1's insulin to be deceased to 10 units at bedtime instead of the previous order of 20 units. A review of Resident 1's Interdisciplinary Team ((IDT) a group of medical specialist that coordinate, collaborate, and plan the delivery of care for residents), dated [DATE] indicated that Resident 1 was compliant with care, but had unstable blood sugar levels. The note indicated Resident 1 would be discharged when his diabetes was control and the resident no longer required insulin. According to the IDT note, Resident 1 had no history and physical (H/P) and physician's progress notes completed by Physician 1, as this was verified by the Director of Nurses (DON). On [DATE], at 3:25 p.m., during a telephone interview, a Regional Center (nonprofit private corporation that contract with the Department of Developmental Services to provide or coordinate services/support for individuals with developmental disabilities) Staff (RCS) follows/oversees Resident 1's care, who attended Resident 1's IDT meeting on [DATE], stated Resident 1 was admitted to the facility on [DATE] with uncontrolled blood sugar levels and the physician did not see the resident for over a month after admission to the facility. The RCS stated the physician was only giving telephone orders without seeing Resident 1. According to the RCS, the physician (Physician 1) ordered laboratory work on [DATE] such as; an Hemoglobin A1c ((HgA1c) a common blood test used to diagnose diabetes and to monitor how well the blood sugar levels are being managed), [MEDICAL CONDITION] stimulating hormone ((TSH) a blood test that measures this hormone that regulate the way the body uses energy) complete blood count ((CBC) a test that evaluates the cells that circulate in blood in the body), and a basic metabolic panel ((BMP) a blood test that provides information about the body's fluid balance) for Resident 1 and the facility's staff did not ensure the laboratory work was done for four days and the physician did not request for the results. On [DATE] at 9:05 a.m., during a concurrent interview and a review of Resident 1's progress notes documented by the licensed nurses, the facility's Director of Nursing (DON) stated that Resident 1 had episodes of [MEDICAL CONDITION] and [DIAGNOSES REDACTED] levels in the facility. The DON stated that in (MONTH) 2019, Resident 1 had an episode of [MEDICAL CONDITION] and the physician gave orders to change the insulin dosage, but she (DON) stated she insisted for the physician to give orders for Resident 1 to be transferred to a GACH for further evaluation. The DON stated Physician 1 had not visited Resident 1 since admission and that Physician 1 was supposed to see Resident 1, 2, and 3 72 hours after admission for an initial assessment. The DON stated Resident 1 had no H/P and physician's progress notes completed by Physician 1 verifying that Physician 1 did not do an evaluation. According to the DON, Physician 1's failure to see residents in a timely manner were discussed in the (MONTH) 2019's Quality Assurance ((QA) a function concerned with confirming how and that quality requirements will be met) meeting with the facility's Medical Director. On [DATE] at 10 a.m., during a concurrent interview and a review of the facility's laboratory requisition book, a Licensed Vocational Nurse (LVN 1) stated that there were no laboratory results and no indication that Resident 1's laboratory orders, dated [DATE], were done as ordered. LVN 1 stated the absence of laboratory results indicated the laboratory tests were not done and that it could be the reason Resident 1's blood sugar remained uncontrolled. According to LVN 1, not drawing Resident 1's laboratory tests could lead to the death of Resident 1 if the blood sugar remained uncontrolled. On [DATE] at 10:12 a.m., during a concurrent interview and a review of Resident 1's clinical record, the MDS Nurse stated that during an IDT meeting conducted on [DATE], concerns were discussed that Resident 1's physician had not seen the resident since admission; wrote physician's progress notes or conducted the H/P and that lab orders (HgbA1C, TSH, CBC, and BMP) were not being done. On [DATE] at 10:44 a.m., during a concurrent interview and review of Resident 1's H/P and physician's progress notes, the DMR stated Physician 1 had 12 residents assigned under his care, but had not seen Residents 1 and 2 since they were admitted to the facility and that the Administrator was aware. The DMR stated that the medical records staff job entailed calling the physicians and reminding them to update the residents' medical records. The DMR stated that he had never seen or talked with Physician 1, because Physician 1 would never answer the calls and/or the telephone messages. According to the DMR, the H/Ps and physician progress notes [REDACTED]. On [DATE] at 11:01 a.m., during an interview, the Administrator stated that it was important for Physician 1 to see residents within 72 hours of admission to assess the residents and provide the staff with directions on how to care for the residents. According to the ADM, Physician 1 was difficult at times and would promise to come see the residents assigned to him, but would not come in a timely manner. The ADM stated that the inability of the physician to assess Resident 1 upon admission in the facility was concerning because the resident's blood sugar levels were up and down. According to the ADM, on [DATE], there was a meeting regarding Physician 1's inability to see Resident 1 for over a month since the resident's initial admission. The ADM stated that the facility had planned on limiting the number of residents assigned to Physician 1 as a resolution. On [DATE], at 1:52 p.m., during an interview, the facility's Medical Director (a physician who heads the smooth running of the facility and fills in when other physicians are unable to see their residents) stated that during the facility's meeting in (MONTH) 2019, it was brought to his attention that Physician 1 was not seeing his residents in the facility 72 hours after admission, but he did not go see Resident 1. The Medical Director stated that if the staff were unable to reach Physician 1, he as the facility's Medical Director should have been called and notified. The Medical Director stated that Physician 1 was supposed to see his residents 72 hours after admission or five (5) days after admission, if the physician was following the resident's care while in a GACH, prior to the admission in the facility. The Medical Director stated that Physician 1 had to perform a face-to-face assessment on the residents, especially Resident 1, whose blood sugar levels were unstable. b. A review of Resident 2's Admission Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a most recent readmission on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's physician orders, unsigned by Physician 1, dated [DATE] did not indicate Resident 2 was to have blood sugar checks and/or receive diabetes medications. A review of Resident 2's MDS, dated [DATE], indicated the resident was able to understand and be understood by others and cognition (thought process) was intact. The MDS indicated Resident 2 required a one-person physical assist with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. Resident 2 was receiving an anti-psychotic medication (used to treat mental diseases) and an anti-anxiety medication (used to treat anxiety). A review of Resident 2's care plan, dated [DATE] indicated Resident 2 had periods of confusion and disorientation related to poor judgement and [MEDICAL CONDITION]. The staff's interventions included to assess the resident for contributing factors, such as medications and/or [DIAGNOSES REDACTED]. On [DATE] at 10:44 a.m., during a concurrent interview and a review of the facility's list of residents not seen by Physician 1 from (MONTH) 2019 through (MONTH) 2019, the DMR stated Resident 2 had no H/P and/or physician progress notes [REDACTED]. The DMR stated Physician 1 was unreachable and he had notified the ADM to contact Physician 1. On [DATE] at 12:52 p.m., during an interview, Resident 2 was unable to state if she had been seen by a physician. c. A review a Resident 3' Admission Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a most recent readmission on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of a Resident 3's care plan, dated [DATE] indicated Resident 3 was at risk for weight loss due to depression. The staff's interventions included to allow sufficient time for the resident to chew and swallow, obtain lab tests as ordered and monitor for signs and symptoms of dehydration (excessive loss of body water) and notify the physician as indicated. A review of Resident 3's physician orders, unsigned by Physician 1, dated [DATE] indicated the resident was receiving [MEDICATION NAME] (antipsychotic medication) 200 mg by mouth at bed time for [MEDICAL CONDITION] and Singular (used to treat symptoms of year-round ([MEDICATION NAME]) allergies [REDACTED]. A review of Resident 3's H/P, dated [DATE] indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 was able to understand and be understood by others. Resident 3's cognition and memory were intact. The MDS indicated Resident 3 required a one-person physical assist with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. According to the MDS, Resident 3 was receiving antipsychotic and antidepressant medications. On [DATE] at 10:44 a.m., during a concurrent interview and a review of a list of residents not seen by Physician 1 from (MONTH) 2019 through (MONTH) 2019, the DMR stated Resident 3 had no physician progress notes [REDACTED]. The DMR stated the ADM was made aware that Physician 1 had not seen Resident 3. The DMR stated that the nurse practitioner ((NP) an advanced practice registered nurse; trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose illness and disease, prescribe medication and formulate treatment plans) falsified Physician 1's signature on Resident 3's H/P and progress notes. On [DATE] at 12:50 p.m., during an interview, Resident 3 stated that he was admitted to the facility in (MONTH) 2019 and believed that he was seen by Physician 1 in (MONTH) 2019 for the first time. A review of the facility's policy, with a revised date of [DATE] and titled, Physician Services and Visits, indicated the purpose of the policy was to ensure the facility provided residents with care under an attending physician. This policy indicated the resident's attending physician would participate in assessing, planning care, monitoring changes in residents' medical status and providing consultation and/or treatment when called by the facility. It also indicated the physician would provide an evaluation including a written report of a physical examination within five days prior to admission or within 72 hours following admission. According to this policy, the attending physician must evaluate residents as needed and at least every 30 days and document visits in residents' health records. A review of the facility's policy, with a revised date of [DATE] and titled, Role of Medical Director, Attending Physician, indicated the purpose of the policy was to ensure the requisite level of quality and provision of medical services were provided by the facility. This policy indicated the medical director would note and review any trends or outstanding problems of the nursing staff in general, review acceptable standards of medical practice to care of specific problems in the facility and review physicians' role in admissions, discharges, transfers and continued stays. According to this policy, the Medical Director and attending Physicians will perform quality of care functions by periodically distributing individual quality assessment and assurance reports to individual physicians and reviewing facility's practices to ensure compliance with acceptable standards.

Based on observation, interview, and record review, the facility failed to ensure that the environment was as free of accidents for five of 35 residents, family members and visitors who visited the facility's patio daily (Residents 1, 2, 3, 5, and 6). The facility's communal patio area had been recently identified in 5/2019 as a hazard after a resident had fallen and the facility provided a plan of correction that stipulated it would be repaired, but it was not. For Resident 2, who was wheelchair bound, the resident had a fall with no injury on the patio on 5/14/19, after the wheelchair wheels got stuck to the left of the patio uneven pavement and the resident fell out of the wheelchair to the ground, the facility's administrator stated and included in his plan of correction that it would be repaired immediately the uneven concrete to prevent further falls, but did not. For Resident 1, who was wheelchair bound, the resident had an unwitnessed fall and fell out of the wheelchair after the wheelchair's wheels got stuck on an uneven concrete on the right side of the patio causing the resident to fall and sustain a fracture (broken bone) of the right fifth finger (pinky) and a broken front tooth. For Resident 5, who was ambulatory, the resident tripped on an uneven concrete area to the right of the patio. For Residents 3 and 6, both stated they have fallen in the past due to the uneven patio concrete on the left patio area. Theses deficient practices resulted in Residents 1, 2, 3 and 6 having unwitnessed falls with Resident 1's fall resulting in a fracture and a broken tooth. It also had a potential to result in falls and fractures to other residents. A pattern of the facility's system failure to ensure that the environment remained accident-hazard free, which included providing the necessary supervision in the patio and each resident being free from accidents due to environment not being maintained in good condition was identified. The facility's outside patio, where the residents socialize and smoked unsupervised, had uneven concrete areas, which resulted in a resident previously falling (5/2019), sustaining injuries, and the facility providing a plan of correction (P[NAME]) that included that they would repair the uneven concrete areas, and they did not. Five residents had falls (Residents 1, 2, 3, 5, and 6) due to the uneven broken patio concrete. The system failed as result of the facility's failure to provide adequate supervision and maintain an accident free environment which resulted in an immediate threat to the health and safety of 35 residents, family and visitors who frequent the patio area daily. On 6/13/19 at 1:30 p.m., an Immediate Jeopardy ((IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared for the facility's lack of supervision and non-compliance of their previous plan of correction provision of a hazard free environment. The administrator (ADM) and the Director of Nursing (DON) were notified of the serious noncompliance that threatened the residents' health and safety resulting in multiple falls with one of the falls resulting in injuries and a deformed finger. The facility submitted a Plan of Action (POA) on 6/13/19 for the correction of the IJ that included: 1. On 6/13/19, the facility will hire 24-hour supervision to supervise the residents while in the outside patio area until the concrete pavement had been repaired. 2. The facility contacted a maintenance consultant to repair the uneven patio concrete pavement by Monday 6/17/19. 3. The facility would assess and provide enough supervision for the residents to go out to the patio area prior to the completion of the uneven concrete pavement. On 6/14/19 at 1:47 p.m., after the team verified that the POA was implemented, both the DON and the ADM were notified, the IJ was lifted. Findings: a. A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set ((MDS), a resident assessment and care-screening tool), dated 1/17/19 indicated the resident's Brief Interview for Mental Status (BIMS) score was 15 (12-15 means cognition (thought process) intact) for daily decision-making and had no memory problems. The MDS indicated Resident 1 required one-person physical assist with bed mobility, transferring and locomotion off the unit. According to the MDS, Resident 1 used a walker and/or wheelchair for mobility. The MDS indicated Resident 1 had two or more falls with no injury and was receiving an antidepressant (medications to treat depression). A review of Resident 1's care plan, dated 3/6/19 indicated Resident 1 required assistance with walking, movement and transferring due to weakness and poor motivation. The staff's interventions included to monitor the resident for changes in self-performance of activities of daily living (ADLs), and provide assistance with ADLs as needed. A review of Resident 1's care plan, dated 3/6/19 indicated Resident 1 was at risk for falls due to limited mobility, poor balance, vision and cognitive deficit. The staff's interventions included to provide an environment that minimized hazards over which the facility had control, provide education to the resident, responsible party and the staff regarding special care needs and provide Resident 1 with activities that would enhance mobility. A review of a Resident 1's History and Physical (H/P), dated 3/8/19, indicated Resident 1 had the capacity to understand and make decisions. A review of an Interdisciplinary Team ((IDT) coordinated group of experts from several different fields who work together toward a common goal for the resident) dated 5/31/19 indicated Resident 1 fell outside on the patio and jammed his pinky (small) finger. The IDT note indicated Resident 1 helped himself up from the ground and did not tell anyone he had fallen. According to the IDT note, Resident 1's right small pinky finger was swollen (enlarged/distended) and the x-ray result indicated Resident 1 had a fracture to the right pinky (last finger) finger. A review of Nurses' Notes, dated 5/31/19-6/1/19, indicated Resident 1 was monitored for an alleged fall incident. A review of an Incident and Accident Report Form, dated 5/30/19 and timed at 9 a.m., indicated Resident 1 fell weeks prior because of the uneven concrete on the patio and the unlocked wheelchair resulting in his pinky finger being jammed. A review of a Post-Fall Huddle Form, dated 5/30/19 indicated Resident 1 stated he had fallen two weeks prior from the wheelchair and that he did not tell anyone because he felt embarrassed. It also indicated the resident stated that he was unable to bend his finger. The Interview Record, dated 5/30/19 indicated Resident 1 stated that there were no witnesses in the patio when he fell and that he could no longer bend his finger, as the result of the fall. A review of a Post-Fall Assessment, dated 5/30/19, indicated Resident 1 had pain to the right pinky finger and was unable to bend it. A review of Resident 1's physician's orders [REDACTED]. A review of a Radiology Report, dated 5/30/19 indicated Resident 1 had a small [MEDICAL CONDITION] on the middle aspect of the right fifth finger. On 6/13/19, at 7:30 a.m., during an observation and interview, Resident 1 was lying in bed with the right pinky finger bent and almost touching the palm of the right hand. A small black discoloration was noted on the knuckle of the right small finger. The right pinky finger did not have any dressing, brace or splint and one of his front teeth was observed to be shorter than the rest of his teeth. Resident 1 stated that a week ago he was in the patio area ridding a wheelchair when the wheel of the chair bumped on an uneven area and tipped over, causing him to fall face forward. Resident 1 stated, I fell very hard on the ground and [NAME]ed up my finger. Resident 1 also stated that he broke his pinky finger and a tooth. Resident 1 stated that if ridding slowly, one could get over the bump on the patio area without tipping and falling over. According to Resident 1 he pushed himself from the knees unto the wheelchair after the fall because there was no one in the patio at the time, to pick him up. Resident 1 also stated that his lip and right small finger were bleeding and that he broke a tooth from the fall. Resident 1 added that the fall happened before 8 a.m., when he went out to smoke alone and even if he yelled, no staff could have heard him because the patio door was closed. Resident 1 stated residents fell on the patio area all the time. Resident 1 did not know the names of those who fell but stated that he observed a male and female fall. At 8:11 a.m., on 6/13/19, during a concurrent observation of the patio area and an interview, the Administrator stated that several brick areas in the patio had sunk in while the concrete area was half an inch or higher than the bricks and they were aware of that it needed to be repaired and it was not. The ADM stated that the plan was to [NAME] hammer (break up) the bricks and put concrete so that those areas could be leveled and even. The ADM stated that several areas in the patio were uneven and that was a potential for wheelchairs to get stuck causing wheelchair bound residents to fall out of wheelchairs and be injured. According to the ADM, ambulatory residents could also fall and have injuries if they stepped on the uneven surfaces. The ADM stated he will contact the corporate management for replacing. On 6/13/19 at 9:12 a.m., during a concurrent observation and interview of the patio, the facility's Maintenance Supervisor (MS) stated that there were several uneven and broken concrete brick ribbons. There were five (5) areas with broken concrete and brick ribbons measuring approximately a quarter of an inch (1/4) to one and a quarter inch (1 ¼), that were potential fall hazards. The MS stated that he had been in the facility for four years and the patio area had uneven and broken concrete areas during that time. On 6/13/19 at 1:57 p.m., during an interview, Registered Nurse 1 (RN 1) stated that on 5/30/19, Resident 1 asked for treatment to his right small (pinky/last finger) finger and stated that he had fallen from his wheelchair in the patio area weeks prior. RN 1 stated that the finger looked deformed, but the resident's pain level was 3 out of 10 (9-10= severe pain). On 6/14/19 at 11:27 a.m., during an interview, Resident 1 stated that his right pinky finger would never be straight again, and it hurt badly sometimes. Resident 1 also stated that he was embarrassed of the staff that he fell but did not think it was a big deal because other residents fell on the patio area all the time. On 6/21/19, at 12:46 p.m., during an interview, the Director of Rehab (DOR) stated that Resident 1's pinky finger brace was to help in healing the fracture, as well as to remind the resident to be careful when grasping things to prevent making the fracture worse. b. A review of Resident 2's Admission Face Sheet indicated Resident 2 was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's Fall Risk Assessment, dated 3/2019, indicated Resident 2 was not at risk for falls. A review of Resident 2's H/P, dated 4/19/19 indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE] indicated Resident 2 had a BIMS score of 15 (cognition (thought process) intact). The MDS indicated Resident 2 required a one-person physical assist with bed mobility, transferring and locomotion off the unit. According to the MDS, Resident 2 used a wheelchair for mobility and Resident 2 smoked tobacco. A review of another MDS, dated [DATE], indicated Resident 2 had a fall with no injury. A review of Resident 2's care plan, dated 5/13/19 indicated Resident 2 had a fall outside on the patio when her wheelchair missed the cement pavement. The staff's interventions included to provide Resident 2 with safety education. A review of an IDT record, dated 5/13/19, indicated Resident 2 fell in the patio when her wheelchair missed the concrete pavement and tipped over. It also indicated Resident 2 was educated not to wheel her wheelchair on the uneven surface of the patio area. On 6/13/18 at 9:32 a.m., during an interview, Resident 2 stated that a month prior her wheelchair hit an uneven bumpy area in the patio, tipped over causing her to fall to the ground, but sustained no injuries. Resident 2 stated that there were usually no staff members in the patio when the residents would fall, but the staff would show up after falls have occurred. Resident 2 stated that the patio area was a hazard, because it had uneven areas that had been there for over three years, since her admission. c. A review of Resident 3's Admission Face Sheet indicated Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's H/P, dated 5/13/19 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 3's undated Fall Risk Assessment indicated Resident 3 had a score of 15 indicating Resident 3 had a high fall risk. A review of Resident 3's care plan, dated 5/10/19, indicated Resident 3 was at risk for falls due to limited mobility, decreased endurance and cognitive deficit. The staff's interventions included to provide the resident with an environment that supported and minimized hazards over which the facility had control, orient the resident to environment each time changes were made and to provide Resident 3 with activities that promoted mobility, if not in conflict with the resident's medical condition. A review of Resident 3's MDS, dated [DATE] indicated the resident had a BIMS score of 6 (0-6 =cognitively impaired). The MDS indicated Resident 3 required a one-person physical assist with bed mobility, transferring and locomotion off the unit. The MDS indicated Resident 3 used a walker/wheelchair for mobility and was receiving antipsychotic (medications to treat mental disorders). On 6/13/17, at 7:50 a.m., during an interview, Resident 8, who was alert and oriented stated that Resident 3 tripped on an uneven concrete to the right of the patio and fell . Resident 8 stated that there was no staff in the patio when the fall occurred. Resident 8 also stated that he thought Resident 3 required more assistance than the facility could offer. Resident 8 stated the staff did not watch the residents in the patio most of the time. On 6/13/19 at 9:20 a.m., during an interview, Resident 5, who was alert and oriented stated he had witnessed an elderly, slow walking woman (Resident 3), fall two (2) times on the patio. Resident 5 stated during both the resident's falls there were no staff members present. At 9:32 a.m., on 6/13/18, during an interview, Resident 2, who was alert and oriented stated when Resident 3 fell in the patio a week prior, there was no staff member present. Resident 2 stated that a month prior her wheelchair hit an uneven bumpy area in the patio, tipped over causing her to fall to the ground, but sustained no injuries. Resident 2 stated that there were usually no staff members in the patio when the residents would fall, but the staff would show up after falls have occurred. Resident 2 stated that the patio area was a hazard, because it had uneven areas that had been there for over three years, since her admission. Resident 2 stated that she witnessed Resident 3 fall but did not know about Resident 1's fall. d. A review of Resident 6's Admission Face Sheet indicated Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 6's H/P, dated 4/26/19, indicated the resident had the capacity to understand and make decisions. A review of an undated Fall Risk Assessment indicated Resident 6 had a fall risk score of 2 meaning the resident was not at risk for falls. A review of Resident 6's care plan, dated 4/25/19, indicated Resident 6 was at risk for falls due to limited mobility, poor balance, lack of awareness and unsteady gait. The staff's interventions included to provide an environment that supported and minimized hazards over which the facility had control and provide education to the resident, family and staff about special care needs for Resident 6. A review of Resident 6's MDS, dated [DATE] indicated Resident 6 had a BIMS score of 15. The MDS indicated Resident 6 required a one-person physical assist with bed mobility, transferring and locomotion off the unit. The MDS indicated Resident 6 did not use a walker or wheelchair for mobility. According to the MDS, Resident 6 was receiving antipsychotic (used to treat symptoms of [MEDICAL CONDITION] such as delusions (hearing voices, hallucinations, paranoia, or confused thoughts)) and antidepressant (help relieve the symptoms of depression, such as low mood, anxiety, and worthlessness) medications. On 6/13/19 at 8:40 a.m., during an interview, the AD stated that residents were to be supervised at all times while in the patio to prevent falls, resident to resident altercations and injuries from cigarette burns. On 6/13/19 at 9:20 a.m., during an interview, Resident 5, who was alert and oriented, stated that Resident 6 tripped on a broken concrete to the right of the patio area and fell weeks ago. Resident 5 stated that residents were unsupervised in the patio area and that there were no staff in the patio when Resident 6 fell . Resident 5 stated that the facility had to put warning signs at the uneven patio areas indicating walk slowly, do not run here to prevent residents from falling in the uneven patio surface. According to Resident 5, Resident 6's fall resulted from the uneven patio surface. On 6/14/19 at 11:43 a.m., during an interview, Resident 6 stated that a couple of residents had fallen from their wheelchairs in the patio. Resident 6 stated that due to the uneven surface, the residents' wheelchairs would get stuck and tip over. Resident 6 stated that there was no staff, especially at night time, to supervise the residents smoking in the patio. Resident 6 stated that the residents would help to pick each other up from the ground after a fall because the staff was usually not there when the fall occurred. According to Resident 6, he stumbled on a broken brick at the uneven concrete area and fell on e time. e. A review of Resident 5's Admission Face Sheet indicated Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 5's MDS, dated [DATE] indicated Resident 5 had a BIMS score of 15 (cognition intact). The MDS indicated Resident 5 required limited assistance of one-person physical assist with bed mobility, transfers and locomotion off unit. The MDS also indicated Resident 5 did not use a walker or a wheelchair for mobility. According to the MDS, Resident 5 used tobacco and was receiving antipsychotic medications. A review of Resident 5's undated Fall Management Evaluation indicated the resident was at risk for falls. Resident 5 had a fall risk score of 10 (high risk for falls). A review of Resident 5's care plan, dated 4/25/19 indicated Resident 5 was at risk for falls due to limited mobility, unsteady gait and poor balance. The staff's interventions included to provide the resident with an environment that supported and minimized hazards over which the facility had control and provide the resident with activities that promoted mobility if not in conflict with the resident's medical condition. A review of Resident 5's H/P, dated 4/26/19 indicated the resident had a fluctuating capacity to understand and make decisions. On 6/13/19 at 9:20 a.m., during a concurrent observation and interview, Resident 5 was observed smoking in the patio area smoking. Resident 5 stated she staggered one time while smoking and almost fell in the patio because those broken concretes are dangerous for someone walking under your feet. Resident 5 pointed at a broken brick area stating she stumped her feet on the area and almost fell to the ground and there were no staff in the patio at the time. Resident 5 stated that it was more difficult for residents who used wheelchairs because the wheels would get stuck on the broken concrete uneven patio surfaces. Resident 5 stated that the uneven patio areas were dangerous for residents who walked unsteadily. On 6/13/19 at 11:36 a.m. during an interview, a Licensed Vocational Nurse (LVN1) stated that Resident 4's wheelchair got into a ditch in the patio area and the resident's fall was prevented by MA 1. On 6/13/19 at 4:16 p.m., during a concurrent review of the facility's video recording camera, and in the presence of the ADM and Administrator in Training (AIT), Residents 6, 7, 8, and five other residents were observed in the patio area on 6/13/19 between the hours of 6 a.m-7:53 a.m., unsupervised. Some of these residents were smoking and others were not. The AIT stated that, there was no staff in the patio. According to the AIT the staff were supposed to monitor residents at all times while in the patio to prevent falls, altercations and cigarette burns. A review of the facility's policy, with a revised date of 11/7/16 and titled, Fall Management Program indicated the facility would implement a fall management program by providing an environment free from hazards.

Based on interview and record review, the facility failed to follow its policy to ensure that one of the three sampled Residents (Resident 1) who was admitted to the facility with a Foley catheter (flexible tube inserted into the bladder to drain urine) did not develop a Urinary tract Infection ([MEDICAL CONDITION] bladder infection). This deficient practice resulted in Resident 1 being transferred to the general acute care hospital (GACH) and was treated for [REDACTED]. Resident 1 required intubation (process of inserting a tube through the mouth and then into the airway for ventilation to assist with breathing), intravenous ((IV) through the vein) antibiotics (medications used to treat infections), and remained hospitalized for [REDACTED]. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Physician and Telephone Order, dated 8/9/18 and timed at 11 a.m., indicated an order for [REDACTED]. A review of Resident 1's Interdisciplinary Team ((IDT) group of disciplines working together towards a common goal for a resident) Baseline Care Plan and Summary, dated 8/9/18, indicated that staff's bowel and bladder goals were to minimize Resident 1's urinary tract infection ([MEDICAL CONDITION] bladder infection) episodes, provide good peri (washing of the genitals and anal area) care every (q) shift, incontinence (inability to control bowel and bladder function) care, (Foley) catheter care, and a hydration program. A review of Resident 1's licensed nurse Weekly Summary, dated 8/16/18, indicated the resident was incontinent and had a Foley catheter. Under the sections, Indication for Foley and On B&B (bowel and bladder) Training the boxes were left blank. A review of Resident 1's medical record, on 8/28/18 at 3:10 p.m., indicated there was no documentation indicating that an attempt was made to perform bladder training on Resident 1 for possible discontinuation of the Foley catheter. The medical record indicated there was no documentation Resident 1 was re-assessed by the physician for the need of the Foley catheter as indicated in the facility's policy. A review of Resident 1's medical record indicated on 8/20/18, Resident 1 was transferred to a general acute care hospital (GACH) via 911 (emergency transport) due to respiratory distress. A review of Resident 1's GACH emergency room (ER) MD Documentation, dated 8/21/2018, indicated that Resident 1 presented with an indwelling Foley catheter with purulent (containing or consisting of pus (a thick, opaque, usually yellowish-white, fluid matter that is formed as part of an [MEDICAL CONDITION] response typically associated with an infection)) urine. A review of the GACH's Discharge Summary, dated 8/29/2018, indicated that Resident 1 was treated for [REDACTED]. The GACH note indicated Resident 1 was intubated and treated intravenously ((IV) through the vein) with [MEDICATION NAME] and Amoxicyllin (antibiotics used to treat an infection). On 8/28/18 at 3:30 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1), who was also the treatment nurse, stated that it is her responsibility to perform catheter care to all the residents with Foley catheters. LVN 1 stated she was unable to care for Resident 1 on 8/19/18, because she went home early. A review of the facility's policy and procedure titled, Catheter- Care of, dated (MONTH) 1, 2012, indicated residents with a Foley catheter will be cared for utilizing the most current Center for Disease Control and Prevention (CDC) Guidelines to prevent urinary tract infections. The policy indicated the attending physician will conduct a comprehensive assessment that addresses the need for an indwelling urinary catheter. The policy indicated licensed nurses must periodically reassess the resident's need for continued catheter use and/or any complications associated with catheter use. According to the policy, nursing staff will assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and amount of urine.

Based on observation, interview, and record review, the facility failed to follow its policy for a resident with high risk for falls and implement a plan of care for the need of a safety/fall prevention device for one of three sampled residents (Residents 1). Resident 1, who was assessed as a high risk for falls, had seven documented falls . This deficient practice resulted in Resident 1 falling on the floor, while sitting up in his wheelchair and without a safety precaution device. Resident 1 sustained a three centimeter (cm) hematoma (a collection of blood on the brain due to injury or trauma) and a left [MEDICAL CONDITION] (skin cut). Resident 1 was transferred to the general acute care hospital (GACH) diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Record indicated the resident was originally admitted to the facility on [DATE], and last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H/P), dated 8/28/18, indicated Resident 1 did not have the capacity to understand or make decisions. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/8/17, indicated the resident's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 1 required extensive assistance with one person physical assist during transfers. According to the MDS, Resident 1's balance was not steady and the resident was only able to stabilize his balance with assistance, and used a wheelchair for mobility. A review of Resident 1's recapitulated (summary) physician's orders [REDACTED]. A review of a Care Plan titled, Fall Risk and Management, updated on 12/8/17, indicated the staff's interventions included to provide Resident 1 with an environment that supports minimized hazards over which the facility has control, bed in a low position, encourage the use of an assistive device (wheelchair), and falling star (program initiated to identify residents at risk for falls) prevention program. A review of a Care Plan titled, At Risk for Falls/Injuries related to Cognitive Skills, updated on 12/8/17, and re-introduced on 2/18/18, indicated the staff's interventions included to monitor Resident 1, anticipate and intervene for factors causing the prior falls, monitor the resident's environment for wet spots or items below visual field, and use of appropriate device as ordered. A review of Resident 1's titled, Falling Star Program, updated on 12/8/17, and re-introduced on 2/3/18, indicated the resident was a high risk for falls due to multiple falls. The staff's interventions included to provide frequent safety checks, bed in the lowest/functional position, and identified high fall risk with STAR on the resident's door. A review of the Interdisciplinary Team ((IDT) a group of disciplines working together towards a common goal for the resident) Conference Record, dated 1/15/18, indicated on 1/12/18, at approximately 9:30 a.m., Resident 1 was found lying on the floor after falling asleep and falling onto the floor from his wheelchair. A review of Resident 1's Fall Assessment, dated 1/21/18 and 2/3/18, indicated the resident had a high risk for falls with a score of 13 and 17. According to the fall risk assessment, a score of 10 or more represents a high risk for falls. A review of the Situation, Background, Assessment and Response ((SBAR) a communication tool used by the nursing staff) record, dated 2/3/18, and timed at 10 a.m., indicated Resident 1 was leaning forward towards the ground from his wheelchair and fell on to his side. The SBAR further indicated Resident 1 did not sustain any injuries. A review of Resident 1's transfer record, dated 2/14/18, and timed at 11:30 a.m., indicated Resident 1 was transferred to the GACH due to left- sided forehead swelling and laceration after sustaining a fall in the facility. A review of the GACH's History and Physical (H/P), dated 2/17/18, indicated Resident 1 was brought to the emergency department by the paramedics after a fall from the bed onto the floor. The H/P indicated Resident 1 sustained a three centimeter (cm) abrasion (a scraped spot or area where a part of the skin is rubbed off) and a hematoma to the left forehead. The H/P further indicated Resident 1 was admitted for further evaluation. A review of Resident 1's clinical record, on 3/8/18, indicated the resident had seven episodes of falls in the facility on the following dates: 1. On 9/18/17, Resident 1 had a fall from the bed, sustaining a one-inch left eye laceration. 2. On 10/2/17, Resident 1 had a fall from the bed, without injury. 3. On 10/30/17, Resident 1 had a fall from the bed, sustaining a [MEDICAL CONDITION] requiring a transfer to the GACH. 4. On 11/29/17, Resident 1 had a fall from the bed, sustaining a skin tear to the left knee. 5. On 1/12/18, Resident 1 had a fall from the wheelchair, without injury. 6. On 2/3/18, Resident 1 had a fall from the wheelchair, without injury. 7. On 2/14/18, there was no documented indication on the resident's fall, in which the resident sustained [REDACTED]. During an observation, on 3/8/18 at 7:30 a.m., Resident 1 was lying in a low bed with bilateral (both sides) floor mats without any indication of a falling star identifier over the resident's head of bed or on the name plate upon entrance of Resident 1's room. During an interview, on 3/8/18 at 1:40 p.m., Restorative Nurse Assistant 1 (RNA 1) stated Resident 1 could not ambulate (ability to walk). RNA 1 stated she provided range of motion exercises to Resident 1. During an interview, on 3/8/18 at 1:42 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on 2/14/18, during morning care, Certified Nursing Assistant 1 (CNA 1) turned Resident 1 onto his side and the resident fell on to the floor. LVN 1 stated Resident 1 had previously fallen out of his wheelchair and onto the floor. LVN 1 further indicated Resident 1 did not have a bed alarm, however had bilateral floor mats which indicated Resident 1 was part of the falling star program. During an interview, on 3/8/18 at 2 p.m., LVNs 1 and 2 stated when residents were assessed as a high risk for falls, the licensed staff would obtain an order from the resident's physician for a low bed and bilateral floor mats. LVNs 1 and 2 stated when a resident experienced multiple falls, that resident would be placed on the falling star program which included a fall risk wrist band and a blue star beside the name plate outside the resident's door. LVN 2 further stated Resident 1 did not have a fall risk arm/wrist band nor a blue star beside his name plate. During an interview, on 3/8/18 at 2:50 p.m., the Director of Nursing (DON) stated a lap buddy (physical restraint that is near or on the body which restricts movement) should have been ordered to prevent Resident 1 from falling forward from his wheelchair. The DON stated Resident 1 would be placed on the falling star program and currently, Resident 1 did not have an order for [REDACTED].>During a telephone interview, on 5/8/18 at 3:06 p.m., LVN 1 stated that she failed to document Resident 1's fall on 2/14/18. A review of the facility's policy titled, Fall Management Program, dated 11/7/16, indicated residents with recurrent falls may be identified by a special logo or designation to alert the staff to their high risk activity, may require more frequent observation of activities and whereabouts, may require a structured environment or routine and may require special equipment to promote independence such a merry walker (walker/chair combination used to help residents move independently and maintain stability), walker, grab bars, trapeze (triangular shaped metal bar above a bed, used to help the resident move and support weight during transfer or position change), commode chair, raised toilet seat, etc. A review of the facility's policy titled, Falling Star Program, dated 3/8/18, indicated residents identified in the Falling Star Program would have a minimum of two identifiers: a falling star sticker posted by the patients name outside the room, and a blue wrist band identifier. If a fall incident had occurred, the IDT would meet to review and perform the root cause analysis and would follow the Fall Prevention and Management policy and procedure.

Based on interview and record review, the facility failed to follow its policy and residents' plan of care to ensure one of 10 sampled residents (Resident 35) was free from physical abuse and neglect. The facility failed to provide a Spanish speaking staff, as stipulated in the resident's plan of care during the resident's care, as a result Resident 35 became resistive/combative due to the language barrier. Certified Nursing Assistant 2 (CNA 2) grabbed Resident 35 by the jaw and hit him with the call light on the left hand. These deficient practices resulted in Resident 35 sustaining a skin tear measuring two (2) centimeters (cm) by 2 cm to the forearm and had the potential to affect other residents in the facility. Findings: A review of the Resident 35's Face Sheet (Admission Record) indicated the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 35's [DIAGNOSES REDACTED]. A review of Resident 35's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 3/27/17, indicated the resident was moderately impaired in cognitively skills, totally dependent (full staff performance every time during entire 7-day period) for bed mobility, transferring, locomotion, dressing, eating, toilet use, and personal hygiene from a two-person assist physical assist. A review of Resident 35's care plan titled, Activities of Daily Living, dated 3/30/16, identified the resident of requiring assistance with personal hygiene, bathing, and dressing due to [MEDICAL CONDITION] and dementia. The staff's approaches included to explain the procedures to the resident that needed to be done to gain cooperation, approach the resident calmly, and provide a Spanish speaking care giver. (please see interview with CNA 2) A review of Resident 35's Nurses Note, dated 4/26/17, and timed at 10 p.m., indicated at 11:45 a.m., that day, CAN 2 reported that the resident was combative during care, swinging at CNA 2 and hitting the call light against the headboard and struck his arm against the headboard. The note indicated Resident 35 had skin tears with minimal amount of bleeding and skin discoloration. The physician was called and ordered to cleanse the skin tears with [MEDICATION NAME] solution, pat dry, apply triple antibiotic ointment and cover with a dry dressing for 14 days. According to the note, Resident 35's family member (FM) was notified. On 5/5/17 at 10:55 a.m., during an interview, Resident 35 stated CNA 2 grabbed him by the jaw and hit him with the call light cord on the left hand. Resident 35 stated the incident happened during care and he was unaware why CNA 2 hit him. On 5/5/17 at 11:12 a.m., during the telephone interview, Resident 35's FM stated the resident reported to him that CNA 2 pressed his jaw and he was unable to eat for several days, and hit Resident 35 with the call light. FM stated that Resident 35 was not able to remember if it happened while the CNA 2 was trying to change or clean him. A review of Resident 35's Assessment Note, dated 4/26/17 indicated Resident 35 had a skin tear on the left posterior (back aspect) forearm measuring 2 cm by 2 cm with skin discoloration. According to the note, Resident 35 had no complaints of pain to the left forearm. The nurses note did not indicate there was no pain assessment done regarding the resident's jaw based on Resident 35's allegation of been grabbed by the jaw. (based on resident 35's interview) On 5/10/17 at 12:33 p.m., during a telephone interview, Administrator (ADM) stated that CNA 2 was suspended because she was still under her 90 day hiring probation. ADM stated that the facility has to make sure that residents are safe and free from abuse although she was not sure if the alleged allegations did occur. During a telephone interview on 5/11/17 at 9:43 a.m., CNA 2 stated that on 4/26/17, she went into Resident 35's room to provide care, Resident 35 became agitated when CNA 2 attempted to remove residents' gown. CNA 2 stated that she made three (3) attempts to remove resident 35's gown before going to break, but she was not successful due to resident's agitation and language barrier. CNA 2 stated that she did not speak Spanish nor understood what Resident 35 was saying. CNA 2 stated that on 4/25/17, another staff assist her during the provision of Resident 35's care by holding the resident's hands due to his aggressive behaviors. During the concurrent interview, CNA clarified that she did not speak or understood Spanish and that Resident 35's FM had mention to the facility that Resident 35 needed a staff that spoke Spanish. During a telephone interview on 5/24/17 at 9:42 a.m., Licensed Vocational Nurse 4 (LVN 4) stated that a jaw assessment was not performed initially because she was not aware that Resident 35 had been held by CNA 2 by the jaw. LVN 4 stated that during her interview with Resident 35, she required a translator due to not been able to understand the residents primary language. On 5/10/17 at 1:38 p.m., during a telephone interview, CNA 3 stated that on 4/26/17 he was called into Resident 35's room to translate for CNA 2 because she did not speak Spanish. CNA 3 stated that she was not able to speak to Resident 35 because he was agitated. During a telephone interview on 5/24/17 at 9:54 a.m., the Social Services Director (SSD) stated that during her interview conducted on 4/27/17, Resident 35 reported that CNA 2 grabbed him by the jaw after he had mention to her that he was experiencing pain on his testicles (are oval-shaped organs that sit in a sac that hangs behind the penis) and then swung the call light at Resident 35 causing the laceration to the left forearm. The SSD stated there were no reports made to her of Resident 35 being aggressive towards staff and that Resident 35 was Spanish speaker. A review of the facility's final investigation dated 5/1/17 indicated that the alleged abuse was reported to the Local law enforcement and the Ombudsman. The report indicated that CNA 2 was suspended as soon the allegation was made on 4/26/17. A review of the facility's policy and procedure on Abuse Prevention, Reporting, and Investigations with a revised date of 11/2016, indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment. Physical abuse is defined as hitting, slapping, pinching and/or kicking. According to the policy, neglect was defined as a failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotion distress.

Based on observation, interview, and record review, the facility staff failed to thoroughly investigate and report all allegations of physical and verbal abuse; mistreatment, neglect, or abuse including injuries of unknown origin. The facility failed to report immediately to the administrator of the facility and to the Department (Licensing and Certification Program) immediately (as soon as possible but not to exceed 24 hours after discovery of the incident) or within 24 hours of the observation, knowledge, or suspicion of the allegations of abuse and injuries of unknown source. The facility failed to complete thorough investigations and report the findings of all investigations to the Department in accordance with the facility's policy and procedures for eight residents out of 11 sampled residents (1, 2, 4, 6, 7, 8, 9, 10). In addition, the facility failed to ensure it screens all nurse aide employees against the State Nurse Aide register to ensure the facility does not employ staff who had a finding of abuse or neglect entered against them into the State Nurse Aide Register. Resident 1 alleged being called a derogatory name by a certified nursing assistant (CNA 1). Residents 1 and 2 were allegedly rough handled by CNA 1. Resident 4 alleged LVN 1 of treating him like a child and not an adult and talked down to him when the resident asked for his [MEDICAL CONDITION] medication. Resident 4 was not given his [MEDICAL CONDITION] medication by LVN 1 who told the resident Leave me alone when I say it's not here, it's not here . I have other patients. The allegation was reported by Resident 4 to LVN 5 but did not report to the Administrator. Resident 6 was not given his ointment pain medication by LVN 1. During an interview, LVN 7 stated Resident 6 told her about not receiving his pain medication but LVN 7 did not report the allegation to the Administrator. Resident 7 had allegations of not receiving the appropriate pain medication from the facility, verbal abuse from LVN 1, including financial abuse allegation. This documentation was found in the grievance log and the social services director (SSD 1) conducted the initial investigation. The Administrator was made aware after seven days and did not conduct a thorough investigation and report the allegations to the Department and other Law Enforcement Agencies. Resident 8 had bruises of unknown source to the left arm and upper chest as reported by the resident's family to LVN 3 on [DATE]. LVN 3 did not report the injury of unknown source to the Administrator. Resident 9's SBAR (Situation, Background, Appearance, Review and notify) Communication Form dated [DATE] indicated redness of unknown source to the right side of the face. During an interview, LVN 3 and RN 2 stated the DON was made aware but the incident was not thoroughly investigated and reported to the Department. Resident 10, who was 355 pounds (lbs) had an unexpected death when facility staff found resident in bed lying on her stomach. Resident 10's position in bed when she was found unresponsive was not reported to the attending physician and the Administrator. These deficient practices resulted in Immediate Jeopardy which affected all residents of the facility. The Administrator was notified that Immediate Jeopardy had been identified at 5:14 p.m., on [DATE]. The Immediate Jeopardy was not abated prior to exit from the facility on [DATE], at 3:30 p.m. AS of [DATE], the Immediate Jeopardy has not been abated. Findings: 1. On [DATE] at 2:58 p.m., Resident 1 was awake lying in bed with the head of the bed (HOB) elevated. Resident 1 stated CNA 1 called him a derogatory name. Resident 1 also stated that CNA 1 roughed handled him while providing care and hit Resident 1's head against the side rail. A review of Resident 1's clinical record indicated Resident 1 was Re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated [DATE], indicated Resident 1 was severely impaired in cognitive skills for daily decision making and was total dependent on staff to provide personal hygiene and required two people assist for bed mobility. 2. On [DATE] at 2:55 p.m., Resident 2 was sitting awake on a wheelchair (w/c) outside in the patio area. Resident 2 stated that CNA 1 roughed handled him like a football during transfers from w/c to bed. Resident 2 stated he witnessed CNA 1 calling a derogatory name to Resident 1 and that CNA 1 roughed handled Resident 1. Resident 2 stated that DSD was notified of the allegations on [DATE]. On [DATE] at 3:23 p.m., the director of staff development (DSD) stated that Resident 2 informed him on [DATE] that Resident 2 did not want CNA 1 to be assigned to Residents 1 and 2. DSD stated that Resident 1 requested a female CNA. DSD stated he did not investigate the reason as to why Residents 1 and 2 did not want CNA 1 to be assigned to them. DSD stated he only re-assigned CNA to a different assignment. DSD stated he did not report CNA 1 to the administrator and to the director of nurses (DON). On [DATE] at 3:50 p.m., DON stated that she was not aware of Residents1 and 2's allegations regarding CNA 1. A review of Resident 2's clinical record indicated Resident 2 was admitted to the facility on [DATE], and was re admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's history and physical dated [DATE], indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE], indicated Resident 2 was cognitively intact and required one person staff assist for transfers. 3. During a group meeting on [DATE] at 2:28 p.m., Resident 4 stated that licensed vocational nurse (LVN 1) did not give him a sleeping pill on the night of [DATE]. Resident 4 stated that LVN 1 treated him like a child and not like an adult by ignoring his request to obtain a sleeping pill, and made him irritated and upset. Resident 4 stated LVN 1 denied medications to him and other residents. Resident 4 stated he witnessed LVN 1 treating other residents in a disrespectful manner and by using harsh language such as Shut the hell up, when other residents requested medications. Resident 4 stated he notified LVN 5 and that LVN 5 gave the [MEDICAL CONDITION] medication. A review of Resident 4's clinical record indicated Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 4's history and physical dated [DATE], indicated Resident 4 had the capacity to understand and make decisions. A review of the Resident 4's MDS dated [DATE], indicated Resident 4 was cognitively intact and required extensive assistance for transfers with one person physical assist. A review of Resident 4's physician's orders [REDACTED]. A review of Resident 4's care plan titled [MEDICAL CONDITION], dated [DATE] indicated Resident 4 had history of [MEDICAL CONDITION], and the nurses' interventions were to administer medications as needed (PRN). A review of Resident 4's Medication Administration Record [REDACTED]. On [DATE] at 6:21 p.m., the director of nurses (DON) stated that she was not notified by LVN 1 and LVN 5 regarding Resident 4 not receiving the [MEDICAL CONDITION] medication when Resident 4 requested it to LVN 1. DON stated that LVN 5 did not notify her regarding Resident 4's allegations of LVN 1 treating Resident 4 like a child and denying him the [MEDICAL CONDITION] medication. On [DATE] at 6:05 p.m., LVN 6 stated she was assigned to Resident 4 on [DATE]. LVN 6 stated she remembered giving him the [MEDICATION NAME] medication for [MEDICAL CONDITION] on [DATE]. LVN 6 stated that the MAR indicated [REDACTED]. On [DATE] at 6:40 p.m., the director of staff development (DSD), stated that LVN 1 was assigned to Resident 4 on [DATE]. 4. On [DATE] at 3:28 p.m., Resident 6 was sitting in a w/c awake. Resident 6 stated that LVN 3 did not give him a pain relief ointment medication for knee pain when he requested it during the third and fourth week of January. Resident 6 stated he complained of ,[DATE] using a pain scale (0 no pain, ,[DATE] mild pain, ,[DATE] moderate pain, and ,[DATE] severe pain, and 10 the worst pain possible pain).Resident 6 stated LVN 3 and other nurses ignored him when he requested the pain relief ointment medication for knee pain. On [DATE] at 3:36 p.m., LVN 7 stated that Resident 6 complained about not receiving his pain medications. LVN 7 stated that MAR indicated [REDACTED]. LVN 7 stated that the ointment pain medication was ordered for Resident 6 to receive it three times a day PRN for joint pain. On [DATE] at 8:15 a.m., physical therapist (PT) stated that Resident 6 received physical therapy exercises. PT stated that it was important for Resident 6 to receive pain relief medications to avoid discomfort and assist with mobility. A review of Resident 6's clinical record indicated Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 6's undated history and physical, indicated Resident 6 had the capacity to understand and made decisions. A review of Resident 6's MDS dated [DATE], indicated Resident 6 was able to verbalize needs and had clear comprehension of verbal content and was cognitively intact for daily decision making. Resident 6's MDS also indicated Resident 6 needed extensive assistance for transfers and required a one staff physical assist. A review of Resident 6's physicians orders dated [DATE], indicated for Resident 6 to receive [MEDICATION NAME] sodium 1% gel ,[DATE] grams to both knees three times a day. A review of Resident 6's care plan titled Pain, and dated [DATE], indicated Resident 6 had history of bilateral knee, leg and arm pain, and the nurses interventions were to provide medications as ordered. 6. On [DATE] at 12:56 p.m., family member 1 (FAM 1), stated during a telephone interview that Resident 8 had several unknown bruises to his left upper arm on [DATE] or [DATE]. FAM 1 stated she and FAM 2 informed LVN 3. FAM 1 stated no investigation was done. FAM 1 also stated that CNA 2 yelled loudly and said derogatory words at Resident 8 on [DATE] and FAM 1 and FAM 2 reported this allegation on [DATE] to social services. A review of Resident 8's clinical record indicated Resident 8 was first admitted to the facility on [DATE] and was re admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 6's history and physical dated [DATE], indicated Resident 8 did not have the capacity to understand and make decisions. A review of Resident 6's MDS dated [DATE], indicated Resident 8 was severely impaired in cognitively skills and required extensive assistance from staff for activity of daily living (ADLs). A review of Resident 6's interdisciplinary team (IDT) conference record dated [DATE], indicated Resident 8 was found with skin discoloration reported by the family on [DATE] at 7p.m. The IDT notes further indicate that the DON was going to investigate what occurred. A review of Resident 8's grievance complaint form dated [DATE], indicated Resident 8's FAM 1 reported CNA 2 of verbal misconduct to social services. On [DATE] at 5:42 p.m., social services (SS), stated that FAM 1 and 2's complaints regarding verbal misconduct from CNA 2 to Resident 8 were not reported to the department and were not investigated. SS stated that she concluded that verbal misconduct from CNA 2 to Resident 8 did not need to be investigated because she believed it was not abuse. On[DATE] at 6:24 p.m., the administrator (ADM), stated that he was the abuse coordinator. ADM stated he reviewed Resident 8's grievance record, and determined that FAM 1 and FAM 2's complaint regarding verbal misconduct was not considered abuse. ADM stated he did not Report FAM 1 and FAM 2's complaint about CNA 2 towards Resident 8. On [DATE] at 4:06 p.m., registered nurse (RN 1) stated that Resident 8's medical record indicated that Resident 8 had a skin discoloration and bruising on [DATE]. RN 1 stated that Resident 8's bruising was considered an injury of unknown cause and that an investigation should have been conducted. On [DATE] at 4:33 p.m., LVN 3 stated that FAM 1 and FAM 2 reported Resident 8's bruises found on [DATE] to her. LVN 3 stated she reported the bruises to the DON via text message and LVN 3 stated she did not do a proper skin body assessment. On [DATE] at 4:39 p.m., DON stated that Resident had a large bruise to his left arm. DON stated she believed Aspirin caused Resident 8's left arm to bruise or that perhaps Resident 8 put his left arm around the side rail. DON stated she did not conduct a proper investigation. DON stated that the IDT notes indicated that an investigation was supposed to be conducted but it was never done. DON stated there was no care plan or any documentation in placed regarding Resident 8 putting his left arm around the side rail. DON stated she did not report the bruises. DON stated she did not report Resident 8's bruises to the administrator. 8. A review of Resident 10's closed record, indicated Resident 10 was first admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. A further review of Resident 10's closed record indicated Resident 10 expired in the facility on [DATE]. A review of Resident 10's history and physical dated [DATE], indicated Resident 10 had fluctuating capacity to understand and make decisions. A review of Resident 10's MDS dated [DATE], indicated Resident 10 was cognitively intact for decision making and was total dependent on staff with bed mobility (how resident moved to and from lying position, turned side to side, and positioned body while in bed) requiring one person physical assist and was also total dependent on staff for transfers requiring two or more people to assist. A review of Resident 10's monthly record of vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and weights dated with the month October indicated Resident 10 weighed 355 pounds (a unit of weight (Lbs.)). A review of Resident 10's care plan titled Activities of Daily Living, dated [DATE], indicated that Resident 10 was dependent on staff for bed mobility and that nursing interventions were to handle Resident 10 gently and observe joint limitations. A review of Resident 10's care plan titled Bowel and bladder function, dated [DATE], indicated Resident 10 was incontinent (having no or insufficient voluntary control over urination or defecation of bowel and bladder), and the nursing interventions were to do perineal (the washing of the genital and rectal areas of the body) care as needed. A review of Resident10's care plan titled [MEDICAL CONDITION] Medication, dated [DATE], indicated Resident 10 had history of [MEDICAL CONDITION] and that nursing interventions were to listen to any Resident 10's concerns and to speak to Resident 10 in a calmly voice. A review of Resident 10's nurses notes dated [DATE] and timed at 8:36 a.m., indicated that it was reported at 4:16 a.m., that Resident 10 was found not breathing and had no pulse, and that cardiopulmonary resuscitation ((CPR) a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered [MEDICAL CONDITION]) was initiated. The nurses notes indicated that Resident 10 was pronounced dead at 4:24 a.m., by the fire department and that medical doctor (MD 1) was notified. On [DATE] at 10:09a.m., CNA 4 stated Resident 10 was incontinent and needed 2 people assist while moving her in bed. CNA 4 stated that Resident 10 liked to be facing up while in bed never in her stomach. CNA 4 stated staff needed to use a lifter (machine to assist with transfers) to transfer Resident 10 from bed to w/c and from w/c to bed. On [DATE] at 7:19 a.m., CNA 5 stated she found Resident 10 lying on her stomach and was unresponsive on [DATE] around 4:15 a.m. CNA 5 stated she called for help. On [DATE] at 7:40 a.m., CNA 3 stated that Resident 10 needed 2 or more people to assist her in bed mobility. CNA 3 stated Resident 10 was not able to change positions by herself in bed. On [DATE] at 7:59 a.m., during a telephone interview, LVN 5 stated that she was assigned to Resident 10 on [DATE] during the night shift. LVN 5 stated that she called 911 and notified the MD1 that fire department pronounced Resident 10 deceased . On [DATE] at 8:35 a.m., during a telephone interview, LVN 4 stated that she found Resident 10 was found lying flat on her stomach and was unresponsive and did not feel Resident 10's pulse. LVN 4 stated that she and other staff members turned Resident 10 to her back and began chest compressions. LVN 4 stated that LVN 5 was aware on how Resident 10's position was found and stated she assumed that LVN 5 notified MD 1 regarding Resident 10's laying on a prone position (a body position in which one lies flat with the chest down and back up). On [DATE] at 10:42 a.m., DON stated that Resident 10's record did not indicate Resident 10 had any change of condition prior to Resident 10's death. DON stated that LVN 5 notified her regarding Resident 10's death but LVN 5 did not mention that Resident 10 was found lying on her stomach and unresponsive. DON stated there was no investigation done. During the concurrent interview, DON stated that she was not expecting the license nurses to do an incident report for Resident 10's death. DON stated she did not communicate with MD 1. DON stated that Resident 10's death was not considered a coroner's (an official who investigates violent, sudden, or suspicious deaths) case. On [DATE] at 1:32 p.m., Resident 11 stated that Resident 10 was screaming for nurses to help her on [DATE] before 11p.m., and that nurses did not respond. Resident 11 stated that around 11pm a male staff nurse later identified as RN 1 came in the room with four other staff members and were holding Resident 10 against her bed. Resident 11 stated Resident 10 was agitated and was screaming requesting to see a doctor. Resident 11 stated that staff should have listened when she was calling for help. On [DATE] at 1:50 p.m., RN 1 stated that he responded to Resident 10's calling for help. RN 1 stated that he did not assess Resident 10's condition and did not check vital signs. RN 1 stated that Resident 10 was agitated and that RN 1 and other staff held her down in bed between 11:15 p.m. to 11:30 p.m., to prevent Resident 10 from falling. RN 1 stated that there was no documentation regarding Resident 10's agitation and that he did not inform the doctor. RN 1 stated that he could not recall Resident 10's position. On [DATE] at 3:14 p.m., CNA 6 stated that he assisted RN 1 on [DATE] to repositioned Resident 10 back to bed. CNA 6 stated that Resident 10 was agitated and was screaming. CNA 6 stated that they repositioned her in bed and he could not remember what position was used for Resident 10. On [DATE] at 12:55 p.m., RN 2 stated that Resident 10's medical record did not indicate that Resident 10 was screaming for help on [DATE] around 11 p.m. RN 2 stated that if any resident had any episodes of screaming or called for help, the nurses are supposed to assess and document any change of condition and needed to notify the doctor. RN 2 stated that there was no nursing assessment done for Resident 10. On [DATE] at 10:23 a.m., ADM stated that Resident 10's death was not investigated and was not reported to the department. ADM stated he did not communicate with MD 1. ADM stated there was no documentation regarding Resident 10's death. ADM stated that it depended on MD 1 if he wanted to investigate Resident 10's death and that MD 1 did not communicate with him. ADM stated he assumed that he did not have to report or to investigate Resident 10's death. On [DATE] at 12:01 p.m., MD 1 stated that he was not notified by LVN 4 or by LVN 5 that Resident 10 was found lying prone unresponsive. MD 1 stated he did not interview LVN 4 or LVN 5 as to what position Resident 10 was found. MD1 stated that in his professional opinion as a medical doctor, if LVN 4 and LVN 5 told him that Resident 10 was found prone and unresponsive with no pulse, he would have called the police and started an investigation. MD 1 stated he would called Resident 10's prone position very suspicious and would have ordered an autopsy (a postmortem examination to discover the cause of death or the extent of disease). A review of the facility's policy titled Unusual Occurrence Reporting, with a revision date of [DATE], indicated that unusual occurrences such as death of a resident, needed to be reported to the appropriate agency within 24 hours. 5. A review of Resident 7's clinical record indicated the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a standardized assessment and care planning tool) dated [DATE] indicated Resident 7 was able to verbalize needs and had clear comprehension of verbal content. However, the MDS indicated Resident 7 was moderately impaired (decisions poor; cues/supervision required) in cognitive skills for daily decision making and was totally depended to staff in bed mobility, transfers, locomotion and was unable to walk. The MDS indicated Resident 7 had occasional pain that was rated at an 8 on a zero to ten scale (with zero being no pain and ten as the worst pain). A review of the Resident Grievance/Complaint Investigation Report, dated [DATE] indicated Resident 7 alleged not receiving medications and the charge nurse of the facility spoke to resident inappropriately. A documented statement was attached from the Appeals and Grievance Department of Resident 7's Health Plan dated [DATE] notifying the facility that Resident 7 was alleging the facility of being given another medication and not receiving medication for her pain, being given a medication to murder her, and that on [DATE], a licensed nurse (LVN 2) told her that You are going to take what I give you or nothing at all. Resident 7 also alleged the facility of taking her money. Further review of the Resident Grievance/Complaint Investigation Report indicated the Administrator became aware of the incident on [DATE], seven days after the complaint/grievance was received. A review of the facility document titled Employee Interview; Operational Manual- Abuse and Neglect, dated [DATE], indicated LVN 2 was interviewed about an allegation claimed by Resident 7 to take her medications she gives her or nothing at all. The Employee Interview indicated LVN 2 stated that Resident 7 did not complain about her or requested a different charge nurse to take care of her and only takes pain medications as needed and refuses routine medications. There was no documented evidence that a thorough investigation was completed for Resident 7's allegations of verbal abuse, financial abuse, and not receiving the appropriate pain medication for her pain. There was no documented evidence that Resident 7 or any other possible witnesses was interviewed aside from LVN 2. On [DATE], at 5:42 p.m., during an interview, social services director (SSD 1) stated she screened and decided if grievances/complaints were abuse or not. SSD 1 stated she conducted the investigation and informed the director of nurses and the administrator afterwards. SSD 1 stated Resident 7 had periods of hallucinations and history of refusing her medications. On [DATE], at 6:24 p.m., during an interview, the Administrator who was the abuse coordinator stated he is the only one who screens abuse allegations, and that every abuse allegations should be reported to the department and other law enforcement agencies. The Administrator stated that he reviewed the complaint/grievance of Resident 7 but did not do further investigation or report it to the Department because the SSD 1 already conducted an investigation and concluded it was not abuse because the resident had history of refusing medications. 7. A review of Resident 9's clinical record indicated the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a standardized assessment and care planning tool) dated [DATE] indicated Resident 9 was usually able to verbalize needs when prompted or given time, responds adequately to simple, direct communication and was moderately impaired (decisions poor; cues/supervision required) in cognitive skills for daily decision making and required extensive assistance to staff in bed mobility, transfers, dressing, and personal hygiene. A review of an SBAR Communication Form dated [DATE] timed at 8 a.m., indicated Resident 9 had a palm-sized reddened area to the right side of the face that was warm to touch but no signs and symptoms of pain. On [DATE], at 4:30 p.m., during an interview, the licensed vocational nurse (LVN 3) stated that the reason why Resident 9's redness to the face needed to be reported to the DON and administrator because it was a mark on the face and could be a sign of abuse. On [DATE], at 4:55 p.m., during an interview, the director of nurses (DON) stated she was aware of the redness noted to Resident 9's face on [DATE] but was informed that it was [MEDICAL CONDITION] and thought the resident received antibiotics for it. During a concurrent interview, and in the presence of the DON, LVN 3 stated that the DON was informed through a text message or called about Resident 9's redness to the face. On [DATE], at 2 p.m., during an interview, the registered nurse (RN 2) who spoke to Resident 9's attending physician after she assessed the redness to the resident's face, she assumed it was [MEDICAL CONDITION] given the resident's history and informed the attending physician that it might be [MEDICAL CONDITION]. RN 2 stated the attending physician did not order anything but to monitor and call back if condition gets worst. RN 2 stated she was not sure of the source of the redness to the resident's face and the redness disappeared approximately within 3 days. There was no documented evidence that Resident 9 was treated or diagnosed by attending physician for [MEDICAL CONDITION] to the face upon reviewing the clinical records from dates [DATE] to [DATE]. The DON could not provide documented evidence that a thorough investigation was completed for Resident 9's injury of unknown source and reported to the Department within 24 hours upon discovery. 9. On [DATE], at 5 p.m., during a concurrent record review of CNA 1's personnel files and interview, the facility's Director of Staff Development (DSD) stated he was responsible for obtaining certificates, licenses, and background checks prior to employing certified nurse assistants (CNA). The DSD stated that background checks consisted of criminal record checks and an OIG (Office of the Inspector General) exclusion list. The DSD stated he was not aware of the State Nurse Aide Registry. During the review of CNA 1's personnel files there was no documented evidence that the DSD verified CNA 1's status against the State Nurse Aide Registry and the Licensing and Certification Verification (L&C) website of the Department. The DSD stated he does not print out the page of the L & C Verification Detail Page at the CDPH (California Department of Public Health) website after he verified if the certificate of a CNA is active or not because it was a waste of paper. A review of the facility's policy and procedure titled Abuse- Reporting and Investigations, revised dated ,[DATE], indicated the facility will report all allegations of abuse a required by law and regulations and promptly and thoroughly investigate reports of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property or injuries of unknown source. The policy and procedure indicated that if the allegations of abuse is allegedly caused by a resident, who had been diagnosed with [REDACTED]. In addition, a written report will be made to the local Ombudsman or law enforcement agency and the California Department of Public Health (Licensing and Certification) within 24 hours. The facility's policy and procedure also indicated that the individual who was conducting the investigation will consult daily with the Administrator concerning progress/findings of the investigation.

Based on interview and record review, the facility failed to implement its policy and procedure to protect residents from abuse, mistreatment, neglect, and thoroughly investigate all allegations of abuse, mistreatment, and neglect, including injuries of unknown origin in accordance with the facility's policy and procedure for 8 of 11 sampled residents (1, 2, 4, 6, 7, 8, 9, 10). The failure to have an effective program to assure residents were free from abuse, mistreatment, and neglect, presented an Immediate Jeopardy to all residents of the facility. The Administrator was notified that Immediate Jeopardy had been identified at 5:14 p.m., on [DATE]. The Immediate Jeopardy was not abated prior to exit from the facility on [DATE], at 3:30 p.m. Findings: 1. A review of Resident 10's closed record indicated Resident 10 expired in the facility on [DATE]. A review of Resident 10's nurses notes dated [DATE] and timed at 8:36 a.m., indicated that it was reported at 4:16 a.m., that Resident 10 was found not breathing and had no pulse, and that cardiopulmonary resuscitation ((CPR) a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered [MEDICAL CONDITION]) was initiated. The nurses notes indicated that Resident 10 was pronounced dead at 4:24 a.m., by the fire department and that medical doctor (MD 1) was notified. On [DATE] at 7:19 a.m., CNA 5 stated she found Resident 10 lying on her stomach and was unresponsive on [DATE] around 4:15 a.m. CNA 5 stated she called for help. On [DATE] at 8:35 a.m., during a telephone interview, LVN 4 stated that she found Resident 10 was found lying flat on her stomach and was unresponsive and did not feel Resident 10's pulse. LVN 4 stated that she and other staff members turned Resident 10 to her back and began chest compressions. LVN 4 stated that LVN 5 was aware on how Resident 10's position was found and stated she assumed that LVN 5 notified MD 1 regarding Resident 10's laying on a prone position (a body position in which one lies flat with the chest down and back up). On [DATE] at 10:42 a.m., DON stated that she was not expecting the license nurses to do an incident report for Resident 10's death. DON stated that Resident 10's death was not considered a coroner's (an official who investigates violent, sudden, or suspicious deaths) case. DON did not investigate and stated that Resident 10's death was considered an unusual occurrence but did not have any documented evidence. On [DATE] at 10:23 a.m., ADM stated that Resident 10's death was not investigated and was not reported to the Department. ADM stated there was no documentation regarding Resident 10's death. On [DATE] at 12:01 p.m., MD 1 stated that he was not notified by LVN 4 or by LVN 5 that Resident 10 was found lying prone unresponsive. MD 1 stated he did not interview LVN 4 or LVN 5 as to what position Resident 10 was found. MD1 stated that in his professional opinion as a medical doctor, if LVN 4 and LVN 5 told him that Resident 10 was found prone and unresponsive with no pulse, he would have called the police and started an investigation. MD 1 stated he would called Resident 10's prone position very suspicious and would have ordered an autopsy (a postmortem examination to discover the cause of death or the extent of disease). 2. On [DATE] at 2:58 p.m., Resident 1 stated CNA 1 called him a derogatory name. Resident 1 also stated that CNA 1 roughed handled him while providing care and hit Resident 1's head against the side rail. 3. Resident 2 stated that CNA 1 roughed handled him like a football during transfers from w/c to bed. Resident 2 stated he witnessed CNA 1 calling a derogatory name to Resident 1 and that CNA 1 roughed handled Resident 1. Resident 2 stated that DSD was notified of the allegations on [DATE]. On [DATE] at 3:23 p.m., the director of staff development (DSD) stated that Resident 2 notified him regarding CNA 1 but did not conduct an investigation. DSD stated he did not report it to the Department or to the ADM. On [DATE] at 3:50 p.m., DON stated that she was not aware of Residents1 and 2's allegations regarding CNA 1. DON stated that DSD should have told here about the allegations. 4. During a group meeting on [DATE] at 2:28 p.m., Resident 4 stated that licensed vocational nurse (LVN 1) did not give him a sleeping pill on the night of [DATE]. Resident 4 stated that LVN 1 treated him like a child and not like an adult by ignoring his request to obtain a sleeping pill, and made him irritated and upset. Resident 4 stated LVN 1 denied medications to him and other residents. Resident 4 stated he witnessed LVN 1 treating other residents in a disrespectful manner and by using harsh language such as Shut the hell up, when other residents requested medications. Resident 4 stated he notified LVN 5 and that LVN 5 gave the [MEDICAL CONDITION] medication. A review of Resident 4's physician's orders [REDACTED]. A review of Resident 4's care plan titled [MEDICAL CONDITION], dated [DATE] indicated Resident 4 had history of [MEDICAL CONDITION], and the nurses' interventions were to administer medications as needed (PRN). A review of Resident 4's Medication Administration Record [REDACTED]. On [DATE] at 6:21 p.m., the director of nurses (DON) stated that she was not notified by LVN 1 and LVN 5 regarding Resident 4 not receiving the [MEDICAL CONDITION] medication when Resident 4 requested it to LVN 1. DON stated that LVN 5 did not notify her regarding Resident 4's allegations of LVN 1 treating Resident 4 like a child and denying him the [MEDICAL CONDITION] medication. DON stated there was no investigation done. 5. On [DATE] at 3:28 p.m., Resident 6 stated that LVN 3 did not give him a pain relief ointment medication for knee pain when he requested it during the third and fourth week of January. Resident 6 stated he complained of ,[DATE] using a pain scale (0 no pain, ,[DATE] mild pain, ,[DATE] moderate pain, and ,[DATE] severe pain, and 10 the worst pain possible pain).Resident 6 stated LVN 3 and other nurses ignored him when he requested the pain relief ointment medication for knee pain. On [DATE] at 3:36 p.m., LVN 7 stated that Resident 6 complained about not receiving his pain medications. LVN 7 stated that MAR indicated [REDACTED]. LVN 7 stated that the ointment pain medication was ordered for Resident 6 to receive it three times a day PRN for joint pain. LVN 7 stated she did not report Resident 6's allegations. On [DATE] at 8:15 a.m., physical therapist (PT) stated that Resident 6 received physical therapy exercises. PT stated that it was important for Resident 6 to receive pain relief medications to avoid discomfort and assist with mobility. A review of Resident 6's physicians orders dated [DATE], indicated for Resident 6 to receive [MEDICATION NAME] sodium 1% gel ,[DATE] grams to both knees three times a day. A review of Resident 6's care plan titled Pain, and dated [DATE], indicated Resident 6 had history of bilateral knee, leg and arm pain, and the nurses interventions were to provide medications as ordered. 6. A review of Resident 6's interdisciplinary team (IDT) conference record dated [DATE], indicated Resident 8 was found with skin discoloration reported by the family on [DATE] at 7p.m. The IDT notes further indicate that the DON was going to investigate what occurred. A review of Resident 8's grievance complaint form dated [DATE], indicated Resident 8's FAM 1 reported CNA 2 of verbal misconduct to social services. On [DATE] at 5:42 p.m., social services (SS), stated that FAM 1 and 2's complaints regarding verbal misconduct from CNA 2 to Resident 8 were not reported to the Department and were not investigated. SS stated that she concluded that verbal misconduct from CNA 2 to Resident 8 did not need to be investigated because she believed it was not abuse. On [DATE] at 6:24 p.m., the administrator (ADM), stated that he was the abuse coordinator. ADM stated he reviewed Resident 8's grievance record, and determined that FAM 1 and FAM 2's complaint regarding verbal misconduct was not considered abuse. ADM stated he did not Report FAM 1 and FAM 2's complaint about CNA 2 towards Resident 8. On [DATE] at 4:39 p.m., DON stated that Resident had a large bruise to his left arm. DON stated she believed Aspirin caused Resident 8's left arm to bruise or that perhaps Resident 8 put his left arm around the side rail. DON stated she did not conduct a proper investigation. DON stated that the IDT notes indicated that an investigation was supposed to be conducted but it was never done. DON stated there was no care plan or any documentation in placed regarding Resident 8 putting his left arm around the side rail. DON stated she did not report the bruises. DON stated she did not report Resident 8's bruises to the administrator. 7.a A review of an SBAR Communication Form dated [DATE] timed at 8 a.m., indicated Resident 9 had a palm-sized reddened area to the right side of the face that was warm to touch but no signs and symptoms of pain. On [DATE], at 4:55 p.m., during an interview, the director of nurses (DON) stated she was aware of the redness noted to Resident 9's face on [DATE] but was informed that it was [MEDICAL CONDITION] and thought the resident received antibiotics for it. During a concurrent interview, and in the presence of the DON, LVN 3 stated that the DON was informed through a text message or called about Resident 9's redness to the face. There was no documented evidence that Resident 9 was treated or diagnosed by attending physician for [MEDICAL CONDITION] to the face upon reviewing the clinical records from dates [DATE] to [DATE]. The DON could not provide documented evidence that a thorough investigation was completed for Resident 9's injury of unknown source and reported to the Department within 24 hours upon discovery. A review of Resident 9's SBAR Communication Form dated [DATE] indicated the Bioethics IDT (Interdisciplinary Team) signed the facility document dated [DATE] indicating the facility's IDT was notified of the incident. However, the facility's IDT responsible for reviewing this resident's incident had not identified that the redness to the resident's right side of the face was a possible indicator of abuse and had not assured that an investigation was promptly initiated, with steps taken to protect the resident from possible further abuse or neglect. 7.b A review of an SBAR (Situation, Background, Appearance, Review and notify) Communication Form dated [DATE], indicated Resident 9 had an amber colored urine (darker than yellow). The SBAR Form indicated that the attending physician was notified and ordered a urinalysis with culture and sensitivity to rule out infection (laboratory test to analyze the urine for infection and other diseases). On [DATE], at 9:30 a.m., the licensed vocational nurse (LVN 8) stated he attempted to collect the urine of Resident 9 on [DATE] by asking the resident to urinate in the specimen cup, however Resident 9 refused several times. The physician was not notified. On [DATE], at 3 p.m., during an interview, the registered nurse (RN 2) informed the surveyor that Resident 9's urine specimen collected on [DATE] via straight catheterization (placing a urinary catheter tube in the body to drain and collect urine from the bladder) had not been sent out to the facility's laboratory. There was no evidence that Resident 9 was closely monitored and assured that neglect will not reoccur when the facility staff missed sending the Resident 9's urine specimen to the laboratory for analysis as ordered by the physician from [DATE] and up to the day the survey team exited the facility on [DATE]. 8. A review of the Resident Grievance/Complaint Investigation Report, dated [DATE] indicated Resident 7 filed a complaint/grievance through her Health Plan notifying the facility that Resident 7 was alleging the facility of being given another medication and not receiving medication for her pain, being given a medication to murder her, and that on [DATE], a licensed nurse (LVN 2) told her that You are going to take what I give you or nothing at all. Resident 7 also alleged the facility of taking her money. Further review of the Resident Grievance/Complaint Investigation Report indicated the Administrator became aware of the incident on [DATE], seven days after the complaint/grievance was received. A review of the facility document titled Employee Interview; Operational Manual- Abuse and Neglect, dated [DATE], indicated LVN 2 was interviewed about an allegation claimed by Resident 7 to take her medications she gives her or nothing at all. The Employee Interview indicated LVN 2 stated that Resident 7 did not complain about her or requested a different charge nurse to take care of her and only takes pain medications as needed and refuses routine medications. There was no documented evidence that a thorough investigation was completed for Resident 7's allegations of verbal abuse, financial abuse, and not receiving the appropriate pain medication for her pain. There was no documented evidence that Resident 7 or any other possible witnesses was interviewed aside from LVN 2. Review of facility records indicated that Resident 7 or other possible witnesses aside from LVN 2 were not interviewed by the Administrator or his representative regarding the resident's allegations. On [DATE], at 6 p.m., during an interview, when the administrator was asked why Resident 7's grievance/complaint was not investigated thoroughly and reported to the Department by the Abuse Coordinator, he stated he knew that it was not abuse just by knowing the resident. 9. A review of the facility's policy and procedure on Abuse Prevention, Reporting, and Investigations revised dated ,[DATE] indicated the facility's failure to implement its own policies and procedures: 9a. Facility conducts mandatory facility staff training on dementia management such as responding to aggressive behavior. During an interview with RN 1, on [DATE] at 1:50 p.m., he did not recall having been trained how to manage obese residents with aggressive behavior. 9b. Facility notification of outside agencies of allegations of abuse with no serious bodily injury caused by a resident with dementia diagnosed by a physician. The Administrator interview dated [DATE], at 6 p.m., stated he knew not to report and investigated allegations made by a resident with mental illness just by knowing the resident. 9c. The policy did not stipulate the method as to how the facility will investigate all allegations of abuse, mistreatment, and neglect thoroughly to cover all aspects of the incident and determine a root cause analysis of the allegations. 9d. The policy did not stipulate who and how facility staff can report to the Department or other law enforcement agencies all allegations of abuse when the abuse coordinator or designated representative were not in the facility especially on weekends.

Based on observation, interview, and record review, the facility failed to protect and prevent mental abuse and neglect for eight of 11 sampled residents(Residents 2,3,4,5,6,7,9,10),as follows: Resident 10, who weighed 355 pounds, had episodes of agitated behavior, screaming for help and requesting to see a doctor on [DATE] at approximately 11 p.m The facility staff failed to identify why the resident was screaming and requesting to see a doctor and failed to call the doctor. Resident 10 was found unresponsive lying on her stomach and pronounced dead at 4:24 a.m. Resident 4, was treated like a child and ignored when he requested his sleeping pill. This resulted in Resident 4 feeling irritated, upset and unable to sleep. Resident 6, who complained of ,[DATE] (severe pain) was not given his pain relief ointment medication when requested that caused the resident to experience unnecessary knee pain. Resident 7, who requested Tylenol with [MEDICATION NAME] (control pain medication) instead of her current pain medication [MEDICATION NAME] was talked to in a derogatory manner by the licensed vocational nurse (LVN 2) and her request for other type of pain medication was ignored. Resident 9, who had hematuria (blood in urine),did not have her urine specimen collected as ordered by the physician on [DATE]. On [DATE], the physician made another order for urinalysis and to collect the specimen by an in and out straight catheter. This specimen was not sent to the laboratory for analysis and another order was received ,[DATE] /17 (eight days after the initial order). This deficient practice resulted in Resident 9's neglect, which led to discomfort, delay in diagnosing the cause of hematuria and delayed intervention that had the potential to jeopardize the resident's health. Residents 2, 3, 4 and 5 verbalized experiencing insult and sarcasm (the use of words that mean the opposite of what one really want to say in order to insult someone) from certified nursing assistant (CNA 1). The administrator was notified that Immediate Jeopardy had been identified at 5:14 p.m., on [DATE]. The Immediate Jeopardy was not abated prior to exit from the facility on [DATE], at 3:30 p.m. As of [DATE], the immediate jeopardy has not been abated. Findings: 1. A closed record review of Resident 10's Admission Record (Face Sheet), indicated that Resident 10 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. The closed record indicated that Resident 10 expired in the facility on [DATE]. A review of Resident 10's history and physical dated [DATE], indicated Resident 10 had fluctuating capacity to understand and make decisions. A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], indicated Resident 10's cognitive skills for daily decision-making were intact. The MDS indicated the resident was totally dependent on staff with one person physical assist with bed mobility (how resident moved to and from lying position, turned side to side, and positioned body while in bed), and two or more staff assist for transfers. A review of Resident 10's Monthly Record of Vital Signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and Weights for the month of October indicated Resident 10 weighed 355 pounds (a unit of weight (Lbs.)). A review of Resident 10's care plan titled Activities of Daily Living, dated [DATE], indicated that Resident 10 was dependent on staff for bed mobility and that nursing interventions were to handle Resident 10 gently and observe joint limitations. A review of Resident 10's care plan titled Bowel and bladder function, dated [DATE], indicated Resident 10 was incontinent (having no or insufficient voluntary control over urination or defecation of bowel and bladder). The nursing interventions included to do perineal (the washing of the genital and rectal areas of the body) care as needed. A review of Resident10's care plan titled [MEDICAL CONDITION] Medication, dated [DATE], indicated Resident 10 had history of [MEDICAL CONDITION]. The nursing interventions included to listen to any Resident 10's concerns and to speak to Resident 10 in a calm voice. A review of Resident 10's Nurses Notes dated [DATE] at 8:36 a.m., indicated at 4:16 a.m., Resident 10 was found not breathing and had no pulse. The documentation indicated that a cardiopulmonary resuscitation (CPR, a medical procedure involving repeated compression of a resident's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered [MEDICAL CONDITION]) was initiated. The nurses notes indicated that Resident 10 was pronounced dead at 4:24 a.m., by the fire department and the medical doctor (MD 1) was notified. On [DATE] at 10:09 a.m., CNA 4 stated that Resident 10 was incontinent and needed two person assist to move her in bed. CNA 4 stated that Resident 10 liked to lie on her back while in bed but never on her stomach. CNA 4 stated staff needed to use a lifter (machine to assist with transfers) to transfer Resident 10 from bed to wheelchair and from wheelchair to bed. On [DATE] at 7:19 a.m., CNA 5 stated on [DATE] around 4:15 a.m., she found Resident 10 lying on her stomach and was unresponsive. CNA 5 stated that she called for help. On [DATE] at 7:40 a.m., CNA 3 stated that Resident 10 needed two or more people to assist her in bed mobility. CNA 3 stated Resident 10 was not able to change position by herself in bed. On [DATE] at 7:59 a.m., during a telephone interview, LVN 5 stated that she was assigned to Resident 10 on [DATE] during the night shift. LVN 5 stated that she called 911 (emergency phone number) and notified e MD 1 that the fire department pronounced Resident 10 deceased . On [DATE] at 8:35 a.m., during a telephone interview, LVN 4 stated that she found Resident 10 lying flat on her stomach unresponsive and did not have a pulse. LVN 4 stated that she and other staff members turned Resident 10 on her back and began chest compressions. LVN 4 stated that she notified LVN 5 on how Resident 10's position was found and stated she assumed that LVN 5 notified MD 1 regarding Resident 10's lying in a prone position (a body position in which one lies flat with the chest down and back up). On [DATE] at 10:42 a.m., during an interview, the DON stated that Resident 10's record did not indicate that Resident 10 had a change of condition prior to Resident 10's death. The DON stated that LVN 5 notified her regarding Resident 10's death but LVN 5 did not mention that Resident 10 was found lying on her stomach and unresponsive. DON stated that there was no investigation done, and she was not expecting the licensed nurses to do an incident report for Resident 10's death. DON stated that she did not communicate with Resident 10's MD 1 how Resident 10 was found on [DATE]. DON stated that Resident 10's death was not considered a coroner's (an official who investigates violent, sudden, or suspicious deaths) case. On [DATE] at 1:32 p.m., during an interview Resident 11 (roommate of Resident 10) stated that on [DATE] before 11p.m., Resident 10 was screaming for nurses to help her. Resident 11 stated that nurses ignored and did not respond to Resident 10. Resident 11 stated that around 11p.m., a male staff nurse, later identified as RN 1 came in their room with four other staff members and were holding Resident 10 against her bed. Resident 11 stated Resident 10 was agitated and was screaming, requesting to see a doctor. Resident 11 stated that staff should have listened when she was calling for help. On [DATE] at 1:50 p.m., during an interview, RN 1 stated that he responded when Resident 10 was calling for help. RN 1 stated that he did not assess Resident 10's condition and did not check her vital signs. RN 1 stated that on [DATE] Resident 10 was agitated. RN 1 stated that he and the other staff held Resident 10 down in bed between 11:15 p.m. to 11:30 p.m., to prevent Resident 10 from falling. RN 1 stated that he did not document that Resident 10 was agitated that night, and he did not notify the doctor. RN 1 stated that he could not recall Resident 10's position. On [DATE] at 3:14 p.m., during an interview, CNA 4 stated that he assisted RN 1 on [DATE] to reposition Resident 10 back to bed. CNA 4 stated that Resident 10 was agitated and was screaming. CNA 4 stated that they (staff) repositioned Resident 10 in bed, but could not remember which position Resident 10 was placed. On [DATE] at 12:55 p.m., during an interview and review of Resident 10's medical record, RN 2 stated that there was no documentation that Resident 10 was screaming for help on [DATE] around 11 p.m. RN 2 stated that if any resident had any episodes of screaming or calling for help, the nurses are supposed to assess and document the change of condition and the doctor needed to be notified. RN 2 stated that there was no nursing assessment done for Resident 10. On [DATE] at 10:23 a.m., during an interview, the administrator (ADM) stated that Resident 10's death was not investigated and was not reported to the department. ADM stated that he did not communicate with MD 1, how Resident 10 was found on [DATE]. ADM stated there was no documentation regarding Resident 10's death. ADM stated that it depends on MD 1 if he wanted to investigate Resident 10's death. ADM stated he assumed that he did not have to report or to investigate Resident 10's death. On [DATE] at 12:01 p.m., MD 1 stated that he was not notified by LVN 4 or by LVN 5 that Resident 10 was found lying prone unresponsive. MD 1 stated he did not interview LVN 4 or LVN 5 as to what position Resident 10 was found. MD 1 stated that in his professional opinion as a medical doctor, if LVN 4 and LVN 5 told him that Resident 10 was found prone and unresponsive with no pulse, he would have called the police and started an investigation. MD 1 stated he would called Resident 10's prone position very suspicious and would have ordered an autopsy (a postmortem examination to discover the cause of death or the extent of disease). A review of the facility's [DATE], revised policy and procedure titled Unusual Occurrence Reporting, indicated that unusual occurrences such as death of a resident, needed to be reported to the appropriate agency within 24 hours. A review of the facility's [DATE], revised policy and procedure titled Change of Condition Notification, indicated that facility required licensed nurses to assess the change of condition of residents and determine what nursing interventions were appropriate and to consult with attending physician if there were any changes in resident's physical, mental or psychosocial status. 2. During residents group meeting on [DATE] at 2:28 p.m., Resident 4 stated that licensed vocational nurse (LVN 1) did not give him a sleeping pill on the night of [DATE]. Resident 4 stated that LVN 1 treated him like a child and not like an adult by ignoring his request to obtain a sleeping pill. Resident 4 stated that LVN 1 action made him irritated and upset. Resident 4 stated that LVN 1 denied medications to him and other residents. Resident 4 stated he witnessed LVN 1 treating other residents in a disrespectful manner and by using harsh language such as Shut the hell up, when other residents requested medications. Resident 4 stated that he notified LVN 5 and LVN 5 gave him his sleeping pill. A review of Resident 4's Admission Record indicated the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of Resident 4's history and physical dated [DATE], indicated Resident 4 had the capacity to understand and make decisions. A review of the Resident 4's MDS dated [DATE], indicated Resident 4 was cognitively intact and required extensive assistance for transfers with one person physical assist. A review of Resident 4's physician's orders [REDACTED]. A review of Resident 4's care plan titled [MEDICAL CONDITION], dated [DATE] indicated Resident 4 had history of [MEDICAL CONDITION]. The interventions included to administer medications as needed (PRN). On [DATE] at 6:21 p.m., the director of nurses (DON) stated that she was not notified by LVN 1 and LVN 5 regarding Resident 4 not receiving the [MEDICAL CONDITION] medication when Resident 4 requested it. DON stated that LVN 5 did not notify her regarding Resident 4's allegations that LVN 1 was treating Resident 4 like a child and denying him the [MEDICAL CONDITION] medication. On [DATE] at 6:40 p.m., the director of staff development (DSD), confirmed that LVN 1 was assigned to Resident 4 on [DATE]. 3. On [DATE] at 3:28 p.m., Resident 6 was observed sitting in a wheelchair, Resident 6 stated that LVN 3 did not apply his pain relief ointment medication. Resident 6 stated he requested the ointment the third and fourth week of January for his knee pain. Resident 6 stated he complained of ,[DATE] using a pain scale (0 no pain, ,[DATE] mild pain, ,[DATE] moderate pain, and ,[DATE] severe pain, and 10 the worst possible pain). Resident 6 stated LVN 3 and the other nurses ignored him when he requested the pain relief ointment medication for his knee pain. On [DATE] at 3:36 p.m., LVN 7 stated that Resident 6 complained about not receiving his pain medications. LVN 7 stated that MAR indicated [REDACTED]. LVN 7 stated that the ointment pain medication was ordered for Resident 6 to receive three times a day as needed (PRN) for joint pain. On [DATE] at 8:15 a.m., physical therapist (PT) stated that Resident 6 received physical therapy exercises. PT stated that it was important for Resident 6 to receive pain relief medications to avoid discomfort and assist with mobility. A review of Resident 6's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 6's undated history and physical, indicated Resident 6 had the capacity to understand and made decisions. A review of Resident 6's MDS dated [DATE], indicated Resident 6 was able to verbalize needs and had clear comprehension of verbal content and was cognitively intact for daily decision-making. The MDS indicated the resident required extensive assistance for transfers with one staff physical assist. A review of Resident 6's physician's orders [REDACTED]. A review of Resident 6's care plan titled Pain, dated [DATE], indicated Resident 6 had a history of [REDACTED]. 4. A review of Resident 7's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE] indicated Resident 7 was able to verbalize needs and had clear comprehension of verbal content. The MDS indicated Resident 7 was moderately impaired (decisions poor; cues/supervision required) in cognitive skills for daily decision-making and was totally dependent on staff in bed mobility, transfers, locomotion and was unable to walk. The MDS indicated Resident 7 had occasional pain that was rated at an 8 on a zero to ten scale (with zero being no pain and ten as the worst pain). A review of the Resident Grievance/Complaint Investigation Report, dated [DATE] indicated that Resident 7 alleged not receiving medications. A documented statement was attached from the Appeals and Grievance Department of Resident 7's Health Plan dated [DATE] notifying the facility of several allegations of Resident 7. The note indicated that one of the complaint allegations was being given another medication and not receiving any medication for her pain and the licensed vocational nurse (LVN 2) telling her that You are going to take what I give you or nothing at all. Further review of the Resident Grievance/Complaint Investigation Report indicated the administrator became aware of the incident on [DATE], seven days after the complaint/grievance was received. The Employee Interview dated [DATE] indicated that LVN 2 stated that Resident 7 did not complain about her or requested a different charge nurse to take care of her and only takes pain medications as needed and refuses routine medications. The interview nor the grievance report investigation did not indicate questioning LVN 2 if she asked Resident 7 the reason why she did not want her current pain medication. On [DATE], at 5:42 p.m., during an interview, social service director (SSD 1) stated she conducted the initial investigation of Resident 7's allegation of not receiving her pain medications by reviewing the resident's Medication Administration Record [REDACTED]. SSD 1 stated she could not substantiate Resident 7's allegations upon review of the resident's clinical record because the resident had periods of hallucinations and history of refusing medications. On [DATE], at 6 p.m., during an interview, Resident 7 stated she keep on telling the facility and LVN 2 that her current pain medication ([MEDICATION NAME]) was not working and that she wanted Tylenol with [MEDICATION NAME] because it was the pain medication that worked for her in the past. Resident 7 stated I am a diabetic, I have arthritis in my fingers, hands, all over my body, and I have pain every day. Resident 7 stated she was taking the [MEDICATION NAME] because she did not have a choice. Resident 7 further stated that she told LVN 2 about her concerns with her pain medication but LVN 2 ignored her concerns and stated I'm not giving you nothing, you won't get nothing at all. Resident 7 stated the attitude of the nurses in the facility was very poor, tends to ignore residents, and possesses bad manners. Resident 7 stated referring to the conversation with LVN 2, It was not the right way to talk to a person. On [DATE], at 3:30 p.m., during an interview, LVN 2 stated she was aware of Resident 7's concerns with her pain medication and request to receive Tylenol with [MEDICATION NAME]. LVN 2 stated she had told Resident 7 that she only had [MEDICATION NAME] ordered for her pain medication and did not receive Tylenol with [MEDICATION NAME] in the past since the resident was admitted to the facility. LVN 2 stated that she did ask Resident 7 why she was requesting Tylenol with [MEDICATION NAME]. A review of the facility's ,[DATE], revised policy and procedure titled Pain Management, indicated the licensed nurse will notify the attending physician if a resident's pain has not been relieved with current pain medication. 5. A review of Resident 9's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE] indicated Resident 9 was usually able to verbalize needs when prompted or given time, responds adequately to simple direct communication and was moderately impaired (decisions poor; cues/supervision required) in cognitive skills for daily decision making. The MDS indicated the resident required extensive assistance from the staff in bed mobility, and personal hygiene and was frequently incontinent (having no or insufficient voluntary control over urination) of urine. A review of an SBAR (Situation, Background, Appearance, Review and notify) Communication Form dated [DATE], indicated Resident 9 had an amber colored urine (darker than yellow). The SBAR Form indicated that the attending physician was notified and ordered a urinalysis with culture and sensitivity to rule out infection (laboratory test to analyze the urine for infection and other diseases). Further review of Resident 9's clinical record indicated that on [DATE] Resident 9 had a previous incident of hematuria (blood in the urine) and received oral antibiotics after the urinalysis result came out positive for infection. On [DATE], at approximately 9 a.m., during a concurrent review of Resident 9's clinical record with the medical records director (MRD), there was no documented evidence that the physician order [REDACTED]. On [DATE], at 9:30 a.m., the licensed vocational nurse (LVN 8) stated he attempted to collect the urine of Resident 9 on [DATE] by asking the resident to urinate in the specimen cup, however Resident 9 refused several times. LVN 8 stated he did not notify the attending physician that the urine was not collected because he assumed that the charge nurse or the nurse supervisor will notify the physician. LVN 8 stated he did not attempt to get an order from the physician to collect Resident 9's urine via an in and out straight catheterization (placing a urinary catheter tube in the body to drain and collect urine from the bladder) knowing Resident 9 was incontinent and was unable to urinate independently. On [DATE], at 2 p.m., during an interview, the registered nurse (RN 2) stated they notified the attending physician on [DATE] (five days after the initial physician order [REDACTED]. RN 2 stated that the physician ordered to collect the resident's urine specimen via in and out straight catheterization on [DATE]. However, RN 2 was unable to find the urinalysis result collected on [DATE] in the resident's clinical record. At 3 p.m., RN 2 stated she found out that Resident 9's urine specimen was not sent out to the laboratory for analysis. RN 2 stated she found Resident 9's urine specimen dated [DATE] collected via straight catheterization still stored in the facility's specimen refrigerator. RN 2 stated she instructed LVN 9 to collect another urine specimen that day ([DATE]) via straight catheterization because the urine specimen was already old. 6. On [DATE], at 2:25 p.m., during a group interview with four alert and oriented residents (Residents 2, 3, 4, and 5), Residents 4 stated he had heard a licensed nurse say to other residents Shut the hell up, ignored residents who calls for help at night, and did not like how other facility staff (licensed nurses and certified nursing assistants) treated him like a child and not an adult. Resident 4 also stated he did not want to say names of the licensed staffs but would like the nurses to have better manners. During the course of the group interview, Residents 2, 3, 4 and 5 was asked how CNA 1's (who had recent allegations of verbal and physical abuse from other residents) attitude towards them. Residents 2, 3, 4 and 5 stated CNA 1 was sarcastic (the use of words that mean the opposite of what one really want to say in order to insult someone) when he talks to them. Residents 3, 4, and 5 stated CNA 1 and other licensed and unlicensed nursing staff talks down to them and had a jerky attitude (someone who treats other people badly).

Based on interview and record review, the facility failed to ensure a resident, who was identified to be high risk for fall, had established fall care plan with interventions addressing the resident's risk factors to prevent a fall according to the facility's policy and procedure for one of one sampled resident (Resident 1). The height of Resident 1's bed was not placed in a low position; there was no floor mattress (a landing pad) beside his bed, and no alarm in the bed. This failed practice resulted in Resident 1's fall sustaining a brain hematoma (a localized swelling filled with blood) with altered level of consciousness and grand mal seizure (a loss of consciousness and violent muscle contractions), and was transferred to the hospital. Findings: A review of Resident 1's clinical record indicated he was readmitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment and care screening tool), dated 5/20/13, indicated Resident 1 had long-term and short-term memory problems, required extensive assistance (staff provided weight bearing support and at times required full staff performance) to total assistance for bed mobility, transfer, ambulation, dressing, and personal hygiene and was incontinent (had no control) of bowel and bladder. A review of the "Fall Risk Assessment Form," dated 1/21/13, and 4/21/13, indicated Resident 1 was high risk for falls. A review of Resident 1's fall care plan, dated 11/15/12, indicated risk factors that included limited mobility, poor balance, decreased mental ability, decreased ability to communicate, unsteady when walking, and lack of awareness. The fall care plan's goal included Resident 1 would minimize his risk for fall through interventions. There was no documented evidence of interventions or measures to address Resident 1's risk factors to prevent a fall. A review of the physician's orders [REDACTED]. The fall care plan was not updated to reflect Resident 1's behavior of getting out of bed unassisted (additional risk factor). A review of the Nurses' Progress Notes, dated 5/19/13, at 10:45 p.m., indicated a certified nursing assistant (CNA) heard a noise from Resident 1's room and found Resident 1 sitting on the floor next to his bed. Resident 1 had his back leaning against the bed and was facing the wall. Resident 1 was assessed by a licensed nurse and was indicated no injury was found. Resident 1 was assisted back to bed by two CNAs. The Nurses Notes, dated 5/20/13, at 4 a.m., indicated Resident 1 had a change of condition. Resident 1 was observed to be shaking and his vital signs consisted of blood pressure ((BP) the pressure exerted by the circulating volume of blood on the walls of the arteries) was measured at 150/112 millimeter mercury (mmHg, normal reference range is less than 120/80 mmHg ), heart rate was 160 beats per minute (normal reference range from 60 to 100 beats per minute), respirations were 22 breaths per minute (normal reference range for an adult person at rest range from 12 to 16 breaths per minute), and temperature was 101 degrees Fahrenheit (normal reference range from 97.8 degrees F to 99 degrees F). The physician was notified at 4:02 a.m. and Resident 1 was transferred at 4:08 a.m. to the hospital via paramedics. A review of the hospital's "Emergency Department (ED) Medical Chart," dated 5/20/13, indicated Resident 1 arrived in the ED on 5/20/13, due to altered level of consciousness, grand mal seizure, and hypotension (abnormal low blood pressure). Resident 1 was placed on Trendelenburg position (head lower than feet) due to BP of 64/46 mmHg, Dilantin 1 gram (an antiseizure medication) was given intravenously (IV, directly into a vein), and bolus (a dose) of 500 cubic centimeter (cc) 0.9 percent (%) normal saline (salt solution) was given via IV, then was transferred to the intensive care unit (ICU). A review of Resident 1's MRI (magnetic resonance imaging, a test that uses magnetic and radio waves to take detailed pictures of organs and other structures inside the body) of the brain, dated 5/21/13, indicated Resident 1 had bleeding in his brain and had several hematomas: left front brain, subdural (on the surface) both sides, and deep in his brain. On 2/11/14, at 1:45 p.m., during an interview, the licensed vocational nurse (LVN 1) stated Resident 1 was not provided with floor mattress and alarm in the bed prior to his fall on 5/19/13. On 2/11/14, at 2 p.m., during an interview, the MDS coordinator stated she did not see any floor mattress beside Resident 1's bed and no alarm in the bed prior to Resident 1's fall on 5/19/13. On 2/11/14, at 2:30 p.m., during an interview and record review, the director of nursing (DON) stated there should have been interventions or measures established in the fall care plan for Resident 1 prior to his fall on 5/19/13. The DON stated that at the time of the fall, the height of Resident 1's bed was not in the low position, there was no floor mattress beside his bed and there was no alarm in the bed. The DON stated there were no fall precautions for Resident 1. On 2/11/14, at 3 p.m., during an interview, LVN 2 stated she did not see any floor mattress beside Resident 1's bed and there was no alarm in his bed on 5/19/13. On 2/11/14 at 3:15 p.m., during an interview, CNA 1 stated on the night of 5/19/13, she heard a loud noise, went to Resident 1's room, and found Resident 1 facing the wall while sitting on the floor. She stated there was no alarm on Resident 1's bed and she could not remember seeing any floor mattress beside his bed. On 2/11/14 at 4 p.m., during an interview, CNA 2 stated when he saw Resident 1 on the floor on 5/19/13, he did not see any alarm on Resident 1's bed and he could not remember seeing any floor mattress beside his bed. A review of the facility's policy and procedure titled, "Fall prevention and Management Program," revised 12/1/12, indicated to provide a safe environment that minimizes complications associated with falls. The licensed nurse and/or interdisciplinary team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) will develop a plan of care according to the identified risk factors and root cause.

Based on observation, interview, and record review, the facility failed to implement the one-to-one (1:1) supervision (an assigned staff supervises and closely watches/monitors a resident at all times) according to the plan of care that was developed to manage the wandering behavior for one of 24 sampled residents (1). Resident 1, who had dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior), was able to wander into the rooms of female residents, Resident 4, 5, 6, and 16, at various times between 4/25/14 and 9/20/14, and was able to enter the room of a male resident with dementia, Resident 3, and hit him on the left eye area of his face two weeks prior to 9/20/14 (exact date undetermined). The facility did not conduct a comprehensive assessment on Resident 1 to identify his wandering behavior since his admission to the facility. The facility placed Resident 1 on 1:1 supervision on 9/12/14 to prevent him from hurting other residents and wandering into other residents' rooms. However, on 9/18/14, Resident 1 was able to enter inside the room of Resident 5 and 6 by himself. On 9/20/14. Resident 1 was able to enter inside the room of Resident 4 by himself. These female residents, Resident 4, 5, and 6, felt threatened that Resident 1 might hit them. Resident 4 was scared that Resident 1 might do something inappropriate to her. This failure resulted in psychological harm to the female residents who felt trhreatend by Resident 1's behavior and had the potential to result in physical harm to Resident 1 himself and to other residents. On 9/20/14 at 4:25 p.m., the survey team declared an Immediate Jeopardy (IJ) and the facility's administrator and director of nursing were immediately notified of the serious findings. The facility submitted a plan of correction (POC) on 9/21/14, for the IJ removal. The administrator and director of nurses were again notified after the survey team confirmed the facility's plan of correction was implemented. The IJ was subsequently lifted on 9/21/14 at 3:45 p.m. Findings: 1. A review of Resident 1's clinical record indicated the resident was admitted to the facility on [DATE], transferred to the hospital on [DATE], and was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly review assessment Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/30/14, Resident 1 was able to make his needs known and able to understand others usually. He was moderately impaired (decisions poor; cues/supervision required) in cognitive skills for daily decision making and required limited assistance (resident highly involved in the activity; staff provide guided maneuvering) in walking and during locomotion (how the resident moves between locations). A review of the clinical record indicated Resident 1 was transferred to the hospital on [DATE] due to generalized weakness and anemia (the blood lacks healthy red blood cells). Resident 1's history and physical from the hospital, dated 8/20/14, indicated that at the time of the hospital admission, Resident 1 was noted to be severely confused, wandering off out of his room in the hallway with unsteady gait. Another hospital record of Resident 1 for date of consultation 8/21/14 indicated Resident 1 appeared to wander the hallways without any direction. A progress note dated 8/22/14, indicated Resident 1 had been wandering the hallways aimlessly. Resident 1 was discharged back to the facility on [DATE]. A review of the Resident 1's re-admission assessment, dated 8/24/14 at 12:55 p.m., indicated that Resident 1 was confused and had poor safety judgment. According to the Elopement Risk Assessment, dated 8/24/14, Resident 1 was at risk for potential elopement from the facility. The assessment form indicated the resident was ambulatory with or without a device. There was no risk assessment conducted to identify the resident's risk for wandering inside the facility or inside other residents' rooms. A review of the facility's undated interview record indicated that Resident 4, an alert female resident, stated Resident 1 wandered most of the evening. Resident 5, another alert female resident, stated Resident 1 had wandered inside her room at 3 a.m. in the morning and sat at the foot of bed. Resident 5 stated Resident 1 came in her room, sat on her bed and fell asleep. Resident 5 stated she had seen Resident 1 put up his fist at the staff when the staff tried to re-direct him and she had also seen Resident 1 strike a staff on two (2) different occasions. A review of the psychiatrist progress notes, dated 9/10/14, indicated Resident 1 was confused and disorganized, and wandered into other residents' rooms. A review of the facility's letter to the Department, dated 9/12/14, indicated it was brought to the administrator's attention on 9/11/14 that Resident 3 had discoloration on his left eye area and the source of the injury was unknown. On 9/20/14 at 1 p.m., during an interview with Resident 13, the roommate of Resident 3 (a cognitively impaired male resident), he stated that during the evening shift at 7 p.m., while he was lying in bed, he saw Resident 1 wandering at the hallway and entering their room. Resident 1 sat on Resident 3's bed while he (Resident 3) was sleeping. Resident 3 woke up and tried to move his leg to get Resident 1 out of his bed. Resident 13 stated Resident 1 got mad and punched Resident 3 on his left eye which resulted in the discoloration on the left eye area. Resident 13 stated a female CNA came inside their room and took Resident 1 out of the room. A review of the plan of care, dated 9/12/14, indicated Resident 1 had dementia, had no capacity of making decisions, wanders, confused, resist care, disrobes, and had a history of [REDACTED]. One of the interventions was placing the resident on "one on one episode" or 1:1 supervision/monitoring. Prior to 9/12/14, there was no individualized plan of care developed to address and manage the resident's behavior of wandering inside other residents' rooms. A review of the facility's policy and procedure titled "Wandering & Elopement," dated 1/1/12, indicated that it was the policy of the facility to identify resident at risk for elopement and minimize any possible injury as a result of the elopement. The facility policy and procedure did not address the procedures to identify and manage residents at risk for wandering inside the facility or inside other residents' rooms. On 9/18/14 at 9:15 a.m., during a concurrent interview with Resident 5 and 6, alert female residents who shared the same room, they stated Resident 1 had entered their room several times and had also entered other residents' rooms. Resident 5 and 6 stated Resident 1 became combative by hitting staff when the staff tried to get him out of another resident's room. On 9/20/14 at 10:05 a.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated since Resident 1 was admitted to the facility on [DATE], she had heard reports that Resident 1 wandered in other residents' rooms. On 9/18/14 at 9:20 a.m., during an interview, Resident 5 stated there was one incident when Resident 1 climbed on her bed at 3 a.m., sat at the foot of her bed with his legs spread open and facing her, and she had to call staff to get Resident 1 out of her room. During a concurrent interview, Resident 6 stated Resident 1 had entered her room and ate her food on her bedside table. Resident 6 stated she just allowed Resident 1 to eat her food because she would not fight him. Resident 6 stated she would just ask staff to buy her food because she would not fight Resident 1. On 9/18/14 at 11:30 a.m., during an interview, the administrator stated Resident 1 was one of the two (2) wanderers in the facility. The other wanderer was Resident 2. The administrator stated Resident 1 had wandered in the room of Resident 2 and punched Resident 2 in the stomach. The administrator stated she had no knowledge Resident 1 was wandering inside female residents' rooms. On 9/18/14 at 2:25 p.m., the clinical record of Resident 1 was reviewed with Registered Nurse (RN) 1. RN 1 stated, during a concurrent interview, that Resident 1 was placed on 1:1 supervision and this was a nursing intervention from the plan of care dated 9/12/14. RN 1 stated Resident 1 wandered in the facility but she was not aware he was wandering inside female residents' rooms. On 9/18/14 at 2:40 p.m., during an interview, CNA 3 stated Resident 1 wanders into female residents' rooms and everyone knew he is a wanderer and that he wanders into female rooms. CNA 3 stated Resident 1 wandered during the day and night. On 9/20/14 at 10:05 a.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated since Resident 1 was admitted to the facility, she heard reports that Resident 1 wandered in other residents' rooms. On 9/20/14 at 11 a.m., during an interview, Resident 4, an alert female resident, stated Resident 1 had entered her room more than four (4) times in the past and it happened during the day and night. Resident 4 stated there were times that she had to use the call light for the staff to get Resident 1 out of her room and there were times staff followed Resident 1 inside her room to get him out of her room. Resident 4 stated Resident 1 had attempted to climb on her bed a couple of times and she had to use the call light for staff to get him out of her room. Resident 4 also stated her roommate, Resident 16, had said before "Get off my bed" to Resident 1 when he tried to climb on Resident 16's bed. During the course of the interview, Resident 4 stated Resident 1 was by himself inside her room "last night," estimating the time it happened as past midnight of 9/20/14 and she used the call light so staff would go inside her room and get Resident 1 out of her room. Resident 4 stated a female staff entered her room to get Resident 1 out of her room after she pushed her call light. Resident 4 stated Resident 1 walked all the way inside her room without staff beside him. Resident 4 stated she felt scared by the presence of Resident 1 inside her room because she did not know what he (Resident 1) would do next and she had seen Resident 1 hit staff who tried to get him out of the room. Resident 4 stated she felt threatened that Resident 1 might hit her or do something inappropriate to her. Resident 4 stated she had a broken back, she could not lift her right arm, and she could not do anything to defend herself. On 9/20/14 at 11:25 a.m., during an interview, CNA 4 stated she was the assigned sitter (1:1 monitor) for Resident 1. CNA 4 stated she did not receive any report from the outgoing shift that Resident 1 had wandered inside a female resident's room. CNA 4 stated that if there was anything unusual that occurred during the previous shift, she would get a report from the outgoing sitter. An attempt to interview Resident 1 was conducted after the interview with CNA 4, but Resident 1 did not answer the questions. ON 9/20/14 at 2 p.m., during an interview, Resident 5 and 6 stated Resident 1 entered their room by himself last Thursday, 9/18/14, at 8 p.m. and he just stood in front of their closets. Resident 5 and 6 stated they had to call a staff member who was passing by at the hallway to get Resident 1 out of their room. Resident 5 and 6 stated they felt threatened by the presence of Resident 1 inside their room because he might hit them. The clinical record of Resident 1 was reviewed with the director of nursing (DON) on 9/20/14 at 1:15 p.m. According to the DON, she did not see any documentation that Resident 1 had wandered specifically inside another resident's room. The DON stated that at a minimum, she expected the staff to communicate when a resident wandered inside another resident's room. The DON stated that conducting an assessment and developing a care plan should be ongoing and could be done anytime. The DON stated the facility did not have a form to use as a tool for assessing and identifying residents at risk for wandering inside other residents' rooms and the Elopement Risk Assessment was the only form/tool the facility had. The DON also stated Resident 1 did not have a plan of care developed to address his wandering behavior inside another resident's room until 9/12/14. On 9/20/14 at 4:20 p.m., the administrator and the DON were informed that the facility's policy and procedure titled "Wandering & Elopement," dated 1/1/12, only addressed residents at risk for elopement. The administrator and DON could not provide any other policy and procedure that addressed residents at risk for wandering inside the facility, specifically inside other residents' rooms. On 9/20/14 at 4:25 p.m., the survey team declared an Immediate Jeopardy (IJ) and the facility's administrator and director of nursing were immediately notified of the serious findings. The facility submitted a plan of correction (POC) on 9/21/14, for the IJ removal. The administrator and director of nurses were again notified after the survey team confirmed the facility's plan of correction was implemented. The IJ was subsequently lifted on 9/21/14 at 3:45 p.m. The facility's plan of correction was implemented by reinforcing the 1:1 supervision at all times for Resident 1 until he was transferred out of the facility to a higher level of care; developing an assessment form to identify residents at risk for wandering inside the facility and in other residents' rooms; assessing all residents for risk for wandering; developing a policy and procedure to manage residents at risk for wandering; developing a policy and procedure for the one-to-one monitoring program; and revising the nursing assignment to indicate the assigned staff to relieve the staff engaged in 1:1 monitoring of Resident 1 when the staff take breaks from the monitoring/supervision assignments. A review of the physician's orders [REDACTED]. According to the nursing notes, dated 9/20/14, the resident left the facility and was transported to the hospital at 7:15 p.m. A review of Resident 2's clinical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's admission assessment MDS, dated [DATE] indicated Resident 2 was moderately impaired in cognitive skills for daily decision-making, needed extensive assistance (resident involved in activity, staff provide weight bearing support) when walking, and required limited assistance (resident involved in activity, staff provide guided maneuvering) in locomotion (how the resident moves between locations). A review of Resident 3's clinical record indicated the resident was re-admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. A review of Resident 4's clinical record indicated the resident was admitted to the facility on [DATE] and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The admission assessment MDS, dated [DATE], indicated was alert and able to make her needs known, unable to walk, needed extensive assistance in bed mobility, dressing, and toilet use, and she was totally dependent on staff for transfers. A review of Resident 5's clinical record indicated the resident was admitted to the facility on [DATE] and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly review assessment MDS, dated [DATE], the resident was alert and able to make her needs known, and needed supervision in performing activities of daily living. A review of Resident 6's clinical record indicated the resident was admitted to the facility on [DATE] and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The admission assessment MDS, dated [DATE], indicated the resident was alert and able to make her needs known, needed limited assistance in walking, and required extensive assistance in bed mobility and transfers. A review of Resident 13's clinical record indicated the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated the resident was alert and able to make his needs known. A review of Resident 16's clinical record indicated the resident was admitted to the facility on [DATE] and was re-admitted on [DATE] with [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures to protect residents from abuse and neglect. The facility failed to assure policies included specific information necessary to assure compliance with regulatory requirements in the areas of reporting and screening. In addition, the facility failed to implement abuse policies relevant to the seven required components (screening, training, prevention, identification, investigation, protection, and reporting). The failure to have an effective program to assure residents were free from abuse and neglect presented Immediate Jeopardy to all residents of the facility. The Administrator was notified on 9/11/14 at approximately 2:10 pm. Immediate Jeopardy was not abated prior to exit from the abbreviated survey on 9/11/14 at 7:30 pm. Findings include: IDENTIFICATION: 1. Review of the facility policy titled "Abuse-Prevention Program" dated 1/1/12 revealed "The facility utilizes preventative audits to identify occurrences and patterns of potential mistreatment/abuse". Interview with the Administrator on 9/11/14 at 10:40 am revealed the preventative audits in the policy were known as "Angel Rounds" and explained that all department heads were assigned a group of residents. The department head was then required to observe the resident's condition, and interview the residents to see if there were any concerns, including possible abuse or neglect. The Administrator stated the rounds were to be completed daily and any findings were to be reviewed in the daily stand up meeting. Review of the form to be used in conducting "Angel Rounds" revealed the front of the form contained 27 categories to be documented as either "met" or "not met". The categories included such items as resident appearance, positioning, oral hygiene, nail care, body odor, access to water, availability of call lights, use of privacy curtains, specialized care needs such as tube feedings/splint use, and the facility environment. The back of the form contained a "Resident Satisfaction Survey". Questions on this survey included possible indicators of abuse ("Do you feel safe in the facility") and neglect ("Staff response to call light timely?"). Review of this system revealed it had not been effective in identifying possible abuse/neglect. For example, review of the 9/3 - 9/30/14 "Angel Rounds" schedule provided by the Administrator revealed that Resident 23's name was listed. However, the department head responsible for reviewing this resident had not identified that the bruising around Resident 23's eye, which had been visible since at least 9/4/14, was a possible indicator of abuse; and had not assured that an investigation was promptly initiated, with steps taken to protect the resident from possible further abuse or neglect. (Refer to F 225.) Although the Administrator had stated that all department heads were to complete daily rounds, review of the book provided by the Administrator revealed it contained no documented evidence any department heads, other than the facility receptionist, had completed "Angel Rounds" in August or September, 2014. Review of the "Angel Rounds" forms completed by the receptionist revealed that none of the rounds documented answers to the "Satisfaction Survey" on the reverse side of the form. Review on 9/11/14 of the only "Angel Rounds" form documented on by the receptionist in September (9/3/14) revealed none of the 27 possible categories listed had been documented as either "met" or "not met". There was no evidence any of the care areas listed had been evaluated. The form failed to document any pertinent observations of the three residents in room [ROOM NUMBER], simply noting "all up". For the three residents in room [ROOM NUMBER], the receptionist documented that at 9:00 am the residents were "waiting for care" and "will check back later". For the two residents in room [ROOM NUMBER], the receptionist also documented the need to "check back later". Review of the form revealed no evidence to indicate staff ever checked back on the residents to see if or when they received the care they required. Review of the seven "Angel Rounds" the receptionist completed in August, 2014 revealed the same pattern, with no documentation to indicate any of the 27 categories had been reviewed to determine if they were or were not met. On three of the seven audits, the receptionist again had noted residents were awaiting care as of 9:00 am or later; however, there was no follow-up to determine if the care was ever provided or the residents failed to receive the services they needed. Interview with E 18 on 9/11/14 at 11:30 am revealed he was a department head and served as the Housekeeping Supervisor. E 18 related that "Angel Rounds" were to be done daily. However, interview with E 18 revealed it "has been awhile" since his rounds were last completed. Review of notes made by E 18 revealed "Angel Rounds" had not been completed eight of 11 days in September, 2014. Further interview with E 18 revealed he did not use the facility "Angel Rounds" forms and he provided a check sheet he used for the three rounds he had completed in September (9/2/14, 9/3/14, and 9/5/14). Review of the sheet used by E 18 revealed it was a housekeeping/physical plant log. Interview with E 18 revealed, "I check for safety hazards and housekeeping issues. I do it from a cleanliness/safety standard". E 18 revealed he was not looking at the clinical concerns listed on the "Angel Rounds" form, and was not conducting/documenting resident interviews regarding care. On 9/11/14 at 11:35 am, E 17 identified herself as one of the facility's co-social services staff and stated she served as a department head for completing "Angel Rounds". E 17 also stated she was not using the facility's "Angel Rounds" form but, "I just write down notes on note paper if something needs fixing". Review of E 17's notes revealed no documented evidence any rounds had been completed after 9/5/14. When questioned, E 17 stated "I just haven't gotten to it". Review of the notes of the visits which E 17 did make revealed no documented evidence each of the areas listed on the "Angel Rounds" form to be assessed had been reviewed for the residents she was assigned. Interview on 9/11/14 at 11:50 am revealed E 44 identified herself as a department head, stating she was the Activities Supervisor. E 44 stated, "Yes, I do 'Angel Rounds'. Any I do would be in the book". The "Angel Rounds" book was reviewed with E 44, who confirmed there was no documentation that she had completed any of these audits in September, 2014. SCREENING: 2. A policy titled "Abuse - Prevention Program" dated 1/1/12 was provided by the Administrator as the current policy used by the facility. Under "Hiring Protocols" the policy revealed "The facility does not knowingly employ anyone who has been convicted of abusing, neglecting, or mistreating other people". However, it did not reflect the additional requirement specified in F 225 that the facility did not employ anyone who had a finding entered into the state nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. Review of the policy also revealed "The facility conducts background checks on all applicants". Review of the policy revealed it did not specify what the background checks consisted of, or indicate the need to screen staff against the state nurse aide registry for findings of abuse, neglect, mistreatment, and misappropriation. PREVENTION 3. A policy titled "Abuse - Prevention Program" dated 1/1/12 was provided by the Administrator as the current policy used by the facility. Review of this policy revealed "The Facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met". However, observation during the abbreviated survey revealed staff was not deployed in a manner to meet resident needs. Observation on 9/10/14 revealed one nurse passing medications which were outside of the allowed time frame to multiple residents. Residents did not receive their medications and care (such as blood glucose monitoring) as ordered. Although other nurses, including the Director of Nursing (DON) were present in the building, the facility failed to intervene and provide sufficient qualified staff to assure residents received their medications and care as ordered until surveyor intervention. (Refer to F 224, F 309, and F 332.) 4. Review of the "Abuse-Prevention Program" policy also revealed "Resident Assessments and Care Planning are performed to monitor resident needs and address behaviors that may lead to conflict". However, findings during the abbreviated survey revealed identified resident needs were not care planned. Residents were at risk for wandering, elopement, aggressive behaviors, and suicidal ideation; individualized care plans were not developed in response to these problems. (Refer to F 279.) INVESTIGATION: 5. A policy titled "Abuse - Prevention Program" dated 1/1/12 was provided by the Administrator as the current policy used by the facility. Review of this policy revealed "The Facility has protocols for investigations of resident abuse, theft/misappropriation of resident property, resident-to-resident abuse and resident-to-staff abuse". However, review of resident records, the facility's grievance log, and the facility's investigation files revealed that protocols were not followed. Staff failed to report alleged abuse. Also, investigations were not immediately initiated when residents were alleged to have been abused, or when injuries of unknown origin (such as bruising around an eye) which were suspicious for abuse were identified. Investigations were not thorough and conclusions were not determined. (Refer to F 225.) Interview with the Administrator on 9/11/14 at 10:00 am revealed, "Staff are not giving me the allegations in time". She added staff "are not reporting to me because they think the allegation is not true". She noted that although the facility provided mandatory abuse training, "We're not emphasizing on the reporting of all allegations" even if staff do not find them credible. She stated that although staff had to watch a video about the subject, "We're not enforcing that they must" report all allegations or suspicions of abuse, and neglect. 6. Review of the facility "Violence Between Residents" policy dated 1/1/12 revealed it also was not followed. The policy stated that "Any occurrence of such behaviors are promptly reported to the Charge Nurse, the Director of Nursing (DON) Services and the Administrator". However, review of facility records revealed that the Charge Nurse, the DON, and Administrator were not notified, and no investigation was begun (until surveyor intervention) after staff documented that Resident 8 hit another resident in the stomach. (Refer to F 225.) REPORTING: 7. A policy titled "Abuse - Prevention Program" dated 1/1/12 was provided by the Administrator as the current policy used by the facility. Review of this policy revealed "The facility will report incidents of abuse promptly to appropriate agencies". Review of this policy revealed it did not define the agencies, including the State Survey Agency (SSA), to which reports were required. The policy also failed to define the term "promptly" or include the requirement that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property were to be reported immediately. The policy also failed to include the requirement for the facility to report the results of all investigations to the SSA (and other agencies as required) within five working days of the incident. Review of this policy revealed that although it referenced two forms, it did not cross-reference to any other policies for more specific information. Review of facility investigations revealed that multiple allegations of abuse were not immediately reported to the SSA. The results of all investigations were not reported to the SSA within 5 working days of the incident. (Refer to F 225.) Interview with the Administrator on 9/11/14 at 9:55 am revealed "I wasn't aware" of the requirement to report the results of all investigations to the SSA within five working days of the incident. 8. Review of the facility "Violence Between Residents" policy dated 1/1/12 revealed it also was not followed. The policy stated that "Any occurrence of such behaviors are promptly reported to the Charge Nurse, the Director of Nursing Services and the Administrator". The policy also noted the facility must "Report incidents, findings, and corrective measures to appropriate agencies as outlined in Policy Nos. AP - 12 - Unusual Occurrences, AP - 13 - Adverse Events and AN-04 Elder Justice Act". However, review of facility records revealed that the Charge Nurse, the DON and Administrator were not notified, even though staff documented that Resident 8 hit another resident in the stomach. No investigation of this resident-to-resident abuse was initiated or reported to required agencies until surveyor intervention during the abbreviated survey. (Refer to F 225.) Review of policy AP-12 dated 8/1/12, which was referenced in the "Violence Between Residents" policy, stated "Unusual occurrences (which included allegations of abuse or neglect) are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing". Interview with the Administrator on 9/11/14 at 10:00 am revealed she was unaware she had not met the 24 hour time frame (described in AP-12) for all allegations of abuse she reported. Further interview with the Administrator on 9/11/14 at 10:40 am revealed that although she had found a copy of AP-13 (referenced in the "Violence Between Residents" policy) it was about the "False Claims Act" and it did not correlate to reporting suspected abuse/neglect of residents to appropriate agencies. PROTECTION: 9. Review of the facility policy titled "Entrance to and Exit from the Facility" dated 1/1/12 revealed "Residents who wish to leave the facility for reasons other than medical treatment must obtain a pass. Residents requesting a pass to leave the facility even with the presence of a physician order will be screened by the Director of Social Services prior to obtaining a pass". The policy also provided the evaluation and documentation the Director of Social Services must complete before a pass could be given. However, interview with Social Services staff revealed this was not being completed for multiple residents who left the facility for reasons other than therapy on a daily basis. (Refer to F 224.) 10. Observation and interviews revealed the facility did not protect residents from the fear of retaliation when they expressed concerns about abuse and neglect in the facility. For example, a confidential interview with a resident on 9/9/14 at 8:40 am revealed that after talking to the survey team about care concerns the previous day, the DON asked the resident what he/she had told the survey team and instructed the resident, "Next time you talk to me first". In response to these concerns, the Administrator was notified on 9/9/14 at 9:18 am that residents had expressed concerns about retaliation, due to information they shared with the survey team and observations made as part of the abbreviated survey. The Administrator was informed that residents had the right to report concerns about care needs not being met, and she stated that she would reiterate this to all staff. Although no resident names were mentioned to the Administrator, at 9:25 am on 9/9/14, the Director of Nursing (DON) approached the survey team and confirmed she had questioned a resident about what had been told to the survey team. Another confidential interview on 9/9/14 at 4:20 pm revealed ongoing fear of retaliation. Interview with this cognitively intact resident revealed that earlier that afternoon, the DON had come into the resident's room and woken the resident from their nap. The resident stated the DON "asked what we talked about". The resident related the DON then stated "It's not your business" to discuss care concerns. Interview with the resident confirmed this incident occurred at a time of day after the Administrator had initially been informed of concerns regarding retaliation and interference with residents voicing concerns about care. On 9/10/14 at 9:00 am, this resident again expressed concerns and repeated that they had been napping the previous afternoon, when the DON entered the room, woke the resident up, and asked what the resident had told the survey team about care in the facility. During the confidential interview, the resident stated the DON said, "Didn't I tell you?" to not talk to the survey team.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, were reported immediately to the administrator of the facility and to the State Survey and Certification Agency (SSA.) Allegations of abuse and injuries of unknown origin were not immediately reported and investigated. The facility failed to complete thorough investigations. Results of all investigations were not reported to required officials, including the SSA, within five working days of the incident. The failure to thoroughly investigate and/or report allegations of abuse as required included four (Residents 1, 2, 7, and 8) of 12 sampled residents and 13 (Residents 14, 15, 16, 17, 18, 19, 20, 21, 23, 25, 26, 76, and 77) supplemental residents. In addition, the facility failed to ensure it did not employ staff who had a finding of abuse or neglect entered against them into the State Nurse Aide registry prior to employment. The facility's failure to: 1. Immediately report all allegations of abuse and/or neglect to the Administrator, and required agencies including the SSA, 2. Investigate allegations of abuse and/or neglect, 3. Report all findings within 5 days to the SSA, and 4. Screen all nurse aide employees against the State Nurse Aide register; resulted in Immediate Jeopardy which affected all residents of the facility. The Administrator was notified that Immediate Jeopardy had been identified at approximately 2:10 pm on 9/11/14. The Immediate Jeopardy was not abated prior to exit from the facility on 9/11/14 at 7:30 pm. Findings include: REPORTING/INVESTIGATIONS 1. The clinical record revealed Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurses' notes revealed on 8/16/14 Resident 8 hit another resident in the stomach. Interview on 9/9/14 at 10:30 am with Social Services Designee (SSD) 3 revealed that she completed abuse investigations. The SSD related that if she received an allegation, she reported it to the Administrator and began an investigation. Further interview with SSD 3 revealed "I am not aware" of an allegation that Resident 8 hit another resident. SSD 3 stated the allegation of abuse "was never reported to me" and had never been investigated. SSD 3 concluded the allegation should have been immediately reported and investigated, with steps taken to prevent further abuse of residents. Interview with the Administrator on 9/9/14 at 11:35 am revealed she was also unaware Resident 8 hit another resident. She confirmed no investigation was completed regarding the alleged abuse, and the allegation had not been reported to the State Survey Agency (SSA) or other required agencies. The Administrator related that although direct care staff was aware of the abuse, (as evidenced by their charting of the incident) "It appears nothing was done in response". 2. Observation on 9/11/14 at 8:45 am revealed a note book at the back nurses' station, that contained information about various residents in the facility and the need to monitor their condition. Review of the book revealed documentation that on 9/4/14, Resident 23's left eye was "discolored". Observation on 9/11/14 at 8:50 am revealed Resident 23 lying in bed. The resident still had bruising visible around the top, side, and bottom of the left eye. An interview was attempted with the resident; however, his responses to questions could not be understood. Review of the clinical record revealed no evidence of how the resident had sustained bruising to the eye. Interview on 9/11/14 at 8:55 am with Licensed Vocational Nurse (LVN) 55 revealed she was the charge nurse for the day. She stated the notebook which had documented the bruising to Resident 23's eye on 9/4/14 was her record for what needed to be monitored during a shift. Further interview with LVN 55 revealed that when bruising was first noted, staff should have started a "change in condition" form for the resident. LVN 55 reviewed the clinical record and confirmed that no change in condition form had been initiated for Resident 23. Interview on 9/11/14 at 9:00 am with the Staff Development Coordinator (SDC) revealed an injury of unknown origin such as bruising around an eye should have been reported and investigated as possible abuse. Additional interview on 9/11/14 at 9:05 am with LVN 55 revealed, "No, I did not report it (bruising around the eye) as suspected abuse". LVN 55 stated that, "I think I asked him what happened since I marked it down in my book, but I don't remember what he said". Upon her review of the clinical record, LVN 55 stated there was no documentation regarding an interview of the resident, and acknowledged there were no nurses' notes regarding the resident's condition since 9/1/14. At 9:10 am, LVN 55 confirmed, "No, I did not report bruising as abuse. It had already been found when I came on shift - I was just monitoring". LVN 55 concluded by stating that the nurse who first saw the bruising around the resident's eye should have immediately reported the injury of unknown origin as suspected abuse. Interview with the Administrator on 9/10/14 at 3:00 pm revealed that she was the Abuse Coordinator for the facility. At that time, the Administrator provided facility records of all investigations of alleged abuse, neglect, or injuries of unknown origin which had been completed since she became Administrator in March, 2014. Review of these records revealed no investigations involving Resident 23. An additional interview with the Administrator on 9/11/14 at 9:55 am revealed that if staff saw that a resident had a bruise, it should be assessed, as bruising (based on its location) was "suspicious" and a possible indicator of abuse. The Administrator related that the nurse who first found an injury of unknown origin was supposed to complete an incident report, inform the floor supervisor, who would then notify the Director of Nursing (DON) "who would report it to me". However, further interview with the Administrator on 9/11/14 at 10:00 am revealed, "I had not been told of bruising" around Resident 23's eye. She confirmed that bruising in this area could be indicative of abuse (from being hit) and "it should have been investigated". However, she continued, since she was unaware of the injury of unknown origin, it had not been investigated or reported to the SSA and other agencies as required. 3. Review of the clinical record revealed Resident 1 was a [AGE] year old male with [DIAGNOSES REDACTED]. Resident 1 was assisted by a motorized wheelchair for mobility. Review of the nurse's note dated 1/15/14 at 3:00 pm revealed Resident 1 was found in the parking lot next to the facility on the ground. When facility staff asked the resident what happened, he responded, "Someone tipped me out of my w/c (wheelchair) because I owed him $2.00". The charge nurse asked the resident if he knew who it was and he stated "Yes, but I'm not tell (sic) you guys. I've already told the police and fire department I don't need their assistance". The charge nurse assisted Resident 1 back inside the facility. The charge nurse noticed a Band-Aid over the resident's eye and asked what happened and he stated, "The fire department put it there because I hit my head when I hit the ground". The charge nurse removed the Band-Aid and noted a half inch laceration to the right eyebrow as a result of the assault. Review of the facility report of the incident indicated that the facility addressed the incident as an accident and not a case of assault. The interventions implemented were relative to accident/fall safety which included; Informing the physician, x-ray of the head, rehabilitation screen, continued treatment to the resident's eyebrow laceration, a pharmacy medication review, and a post fall assessment. There was no indication that the facility reported this assault to the SSA as required by the regulation nor did the facility initiate interventions to protect Resident 1 from further abuse. During an interview on 9/8/14 at 5:30 pm the Administrator confirmed the facility did not immediately report or complete a five day follow up per the regulation. The Administrator confirmed the incident should have been reported and the interventions that were put into place after Resident 1 was assaulted were all fall/accident related and not aimed at protecting the resident from further abuse. 4. Review of a resident grievance/complaint investigation report dated 8/5/14 revealed while in the hallway in her wheelchair, Resident 7 became entangled with Resident 77's wheelchair and Resident 77 "poked" at Resident 7. Resident 7 told him not to touch her and he attempted to strike her. Resident 7 had to block the blow with her right arm. Resident 77 then made a second attempt to strike Resident 7 and made contact with her right arm. Certified Nursing Assistant (CNA) 177 was identified as a witness to the incident. The investigation report stated that all witnesses were to give written statements; however, no witness statements were obtained by the facility. Further review of the report stated that the response would be to redirect Resident 77 away from Resident 7. The facility took no action to protect other residents from Resident 77. During an interview on 9/10/14 at 12:05 pm, the Administrator, who was also the abuse coordinator, stated that she was never made aware of the Resident 7/Resident 77 abuse altercation that occurred on 8/5/14 and so it was not reported. During an interview on 9/10/14 at 9:45 am, the Social Services Designee (SSD) 3 confirmed that the facility had no written witness statements regarding the Resident 7/Resident 77 incident that occurred on 8/5/14. SSD 3 confirmed that the facility did not interview other residents or staff in the facility that may have witnessed the altercation. She confirmed that their only intervention for this incident was to redirect Resident 77 away from Resident 7. 5. Review of the facility grievance/complaint form revealed that on 7/20/14, Resident 2 made an allegation of abuse. Resident 2 was trying to pass by Resident 76 who was blocking the hallway. Resident 2 stated she was struck in the back with a cup of water that Resident 76 had thrown at her. According to the report, Resident 2 further stated that Resident 76 was cursing at her and threatened to knock her into "the middle of next week". The complaint was filed on 7/20/14; however, an investigation was not initiated until 7/22/14. Review of the facility records revealed that the allegation of abuse was not reported to the appropriate agencies. During an interview on 9/10/14 at 12:05 pm, the Administrator confirmed that the 7/20/14 abuse allegation by Resident 2 was never reported because she believed "it never happened". Further review of the facility grievance/complaint form related to Resident 2's allegation of abuse on 7/20/14 revealed that while Social Services staff did interview the LVN and charge nurse that they thought were the two witnesses to the incident (names were unknown in the report), once they stated that they were not aware of any incident, they failed to interview other staff and residents on the unit who might have witnessed the incident, as the incident took place in the hallway. 6. Review of facility investigations revealed that on 8/27/14, SSD 3 reported an allegation of physical abuse (listed as assault/battery) to the SSA. Review of the report revealed that on 8/26/14, a resident-to-resident altercation occurred when Resident 15 allegedly threw water on Resident 2 and hit her with a plastic pail. Staff then observed Resident 2 hitting Resident 15 with her cane. Review of the clinical record revealed Resident 2 indicated that Resident 15, who was in the room next to her, was in the shared bathroom and when Resident 2 asked her to stop touching her stuff that was in the bathroom, Resident 15 threw a bucket of water and a trashcan at her hitting her with both. During an interview on 9/9/14 at 8:15 am, Resident 2 stated that the facility had a lot of people with "mental problems" and she had already been attacked several times and did not feel safe in the facility. She stated a lot of the residents that seemed to rotate in and out of the facility were younger and could really hurt the older, more frail, residents. Review of the "Resident Abuse Investigation Report Form" revealed that the "Summary of investigator's findings" section of the form was blank. No summary of the findings was documented in the report. The portion of the form which asked, "Did the findings indicate that abuse occurred" was also blank, and no conclusion to the investigation was documented. The only "corrective action" listed on the form was that "Both residents were sent to the hospital". No other corrective actions were listed on the Investigative Report form to prevent additional instances of abuse. Further review of the Abuse Investigation Report Form revealed that the portion which asked "Did the resident and/or the representative participate in determining the corrective action that was taken" was also blank. Although the form noted that, "If no, please explain why they did not participate" review of the space for this question revealed it was blank and no information was provided. Review of the Abuse Investigation Report form revealed that the space for the signature and date of both the Investigating Representative and Administrator was also blank. Further review of the complete investigation file revealed that although a report of the initial allegation was made to the SSA within 24 hours of the alleged abuse, there was no evidence that the results of the investigation were reported to the SSA within five working days. 7. Review of facility investigations revealed on 8/29/14, an allegation of physical abuse of Resident 14 was reported to the SSA. According to the initial report sent to the SSA, a male certified nursing assistant (CNA), whose name was provided, "Ruffed" (sic) up" Resident 14. Review of the initial report revealed that the Administrator documented, "We do not currently have a CNA by that name on any shift nor have we had an employee by that name in the last 90 days". Review of facility records revealed that the Administrator's statement was not accurate. Review of personnel records on 9/11/14 revealed the facility did have a female CNA with the name that Resident 14 had provided. Further review of the investigation file revealed no documented evidence that an "Abuse Investigation Report Form" was completed in response to this allegation of physical abuse. There was also no documented evidence a thorough investigation was completed even though, per an Interdisciplinary Team (IDT) Conference Record dated 8/29/14, Resident 14 provided a physical description of the person who "grabbed" his wrist and put an elbow to his jaw while applying his body weight. Further review of the complete investigation record revealed that although a report of the initial allegation was made to the SSA within 24 hours of the alleged abuse, there was no documented evidence that the results of the investigation were reported to the State Survey Agency (SSA) within five working days. Interview with the Administrator on 9/11/14 at 10:00 am stated that she was in error when she reported to the SSA that the facility had no employees by the name that Resident 14 alleged was rough with him. She confirmed that the facility did have a female employee by this name; however, she had not considered that this employee could possibly be the staff Resident 14 (whose [DIAGNOSES REDACTED]. Although the resident had given a description of the alleged perpetrator, she acknowledged there was no attempt to see if Resident 14 could identify anyone, stating the resident's allegation, "didn't sound credible to me". 8. Review of facility investigations revealed an allegation of physical and verbal abuse of Resident 16. According to the initial report forwarded to the SSA on 5/23/14, Resident 16 reported to the Ombudsman (date not listed) that another resident "stated he would beat him" and "hit him on the arm". Review of the initial report revealed the Ombudsman and Administrator tried to interview the resident; however, he refused to speak with him at that time. The Administrator "assured the Ombudsman that I will try again to interview (Resident 16) on the following day". Further review of the initial report revealed that on 5/22/14, the Administrator again unsuccessfully attempted to interview the resident. Also on 5/22/14, staff who worked with the resident over the previous 48 hours was interviewed. Although the facility was aware of the allegation that the resident had been hit and begun an investigation, review of facility records revealed the abuse allegation was not immediately reported to the SSA. The initial report to the SSA was not made until 5/23/14, when the victim named another resident (Resident 17) as the alleged perpetrator. Interview with the Administrator on 9/11/14 at 10:00 am revealed that she was not aware the abuse allegation had not been immediately reported, stating, "I thought I was in the 24 hour window". 9. Review of facility investigations revealed an allegation that Resident 18 was physically abused by another resident, Resident 19. According to the "Report of Suspected Dependent Adult/Elder Abuse" form, the physical abuse which was marked as "assault/battery" resulted in the need for "minor medical care". Although the "Report of Suspected Dependent Adult/Elder Abuse" documented this incident as occurring on 4/20/14 at approximately 10:00 am, review of facility records revealed that the initial notification of alleged abuse was not reported to the SSA until 1:15 pm on 4/21/14, over 24 hours later. Further review of the investigation file revealed no documented evidence that an "Abuse Investigation Report Form" was completed in response to this allegation of physical abuse. There was also no documented evidence a thorough investigation was completed even though, according to the initial report forwarded to the SSA on 4/21/14, the police were notified and Resident 19 was taken into custody after she "became upset throwing two caution signs and then later attempted to throw a chair" at Resident 18. Further review of the investigation file revealed no evidence that the results of the investigation were reported to the SSA within five working days. Interview with the Administrator on 9/11/14 at 10:00 am revealed that she was not aware that this allegation had not been reported immediately to the SSA. She stated it occurred on a Sunday, and she began the investigation and reported the allegation to the SSA on Monday, 4/21/14, when she returned to work. Further interview with the Administrator revealed that staff working on the weekend "could have called" to report the allegation, as any staff with knowledge was a mandatory reporter. However, she continued, staff were waiting for her to do it and noted, "We need to add weekend reporting" to the facility's abuse education efforts. 10. Review of a "Report of Suspected Dependent Adult/Elder Abuse" form revealed an allegation of physical abuse, identified as "assault/battery". According to this report, on 7/16/14, a resident "witnessed (Resident 20) choke (Resident 21)". Although the "Report of Suspected Dependent Abuse/Elder Abuse" form documented this occurred on 7/16/14, further review of the facility investigation file revealed an unsigned note dated 7/15/14. This documentation revealed that Resident 2 reported witnessing the resident "put his hands around her throat and started choking" Resident 21, who was "historical (sic), gasping for air and crying". Further review of the investigative file revealed an investigation had begun by 7/16/14, as there was a witness statement dated that day. Although the "Report of Suspected Dependent Adult/Elder Abuse" documented this incident as occurring on 7/16/14, review of facility records revealed that the initial notification of alleged abuse was not reported to the SSA until two days later at 5:08 pm on 7/18/14. Further review of the 7/18/14 notification to the SSA revealed the Administrator wrote, "We will continue our investigation and forward finding to you". However, review of the complete investigation record revealed no evidence that further information or findings were ever reported to the SSA. Interview with the Administrator on 9/11/14 at 9:55 am revealed that prior to surveyor intervention on 9/10/14, "I wasn't aware" of the requirement to report the results of all investigations to the SSA within five working days of the incident. 11. For Resident 25 and 26, the facility failed to provide documented evidence that a resident-to-resident altercation on 9/12/13 was thoroughly investigated and a five day summary of the investigation was completed and corrected actions were implemented. This failure subjected residents and staff to the continued inappropriate behaviors of Residents 25 and 26, which had the potential to negatively affect the health and safety of the residents and staff in the facility. 12. Interview with the Administrator on 9/11/14 at 9:55 am revealed the nurse who first found an injury of unknown origin or received an allegation of abuse or neglect was supposed to complete an incident report, inform the floor supervisor, who would then notify the DON, "who would report it to me". Further interview with the Administrator on 9/11/14 at 10:00 am revealed that staff had received training on reporting abuse, but, "I see that staff is not getting to me in a timely manner". She continued that abuse allegations were not being reported as required and stated, "I can't investigate if I'm not told". The Administrator reiterated "Staff are not giving me the allegations in time," adding, "Everybody dropped the ball". Further interview with the Administrator on 9/11/14 at 10:00 am revealed staff, "are not reporting to me because they think the allegation is not true". She noted that although the facility provided mandatory abuse training, "We're not emphasizing on the reporting of all allegations" even if staff do not find them credible. She stated that staff had to watch a video about the subject, but "We're not enforcing that they must" report all allegations or suspicions of abuse and neglect. SCREENING - STATE NURSE AIDE REGISTER: 13. Interview with the Staff Development Coordinator (SDC) on 9/11/14 at 12:30 pm revealed that she was the staff responsible for obtaining certificates, licenses, and background checks when new employees were hired. She related that the background checks consisted of criminal record checks and an OIG (Office of Inspector General) exclusion list. However, interview with the SDC continued, "I'm not familiar with an abuse register". The SDC stated she had not requested nurse aide abuse registry checks on any employee since she started in March 2014. Further interview confirmed she was not aware that all nurse aide staff must have verification to ensure that no findings of abuse or neglect had been entered against them on the state nurse aide register prior to their employment. 14. In response to the observations during medication pass on 9/10/14 (Refer to F 224, F 309), the facility was asked to provide the personnel record of LVN 118. On 9/11/14 at 4:00pm an interview was conducted with the SDC. During this interview, the SDC related she was unable to locate a personnel file for LVN 118, who was hired on 6/17/14. At that time, the SDC was unable to provide evidence of required screening, including a criminal record check or verification of licensure status as a Licensed Vocational Nurse.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure each resident attained their highest practicable well-being. The facility: failed to ensure residents received the care they needed to avoid harm; failed to ensure facility staff followed physician orders; failed to ensure residents received essential medications including, but not limited to, insulin and anti-[MEDICAL CONDITION] medication; failed to ensure staff did not falsify the administration of insulin and monitoring (blood sugar readings); failed to ensure pain management was provided when needed; failed to ensure residents were not subjected to pain and suffering and failed to ensure monitoring for clinical condition was completed. The failure to provide the necessary care and services to meet each resident's individual needs affected seven (Residents 2, 3, 5, 6, 8, 9, and 10) of 12 sampled residents as well as supplemental residents (Residents 13, 16, 23, 24, 27, 28, 31, 32, 34, 35, 37, 38, 40, 41, 42, 43, 44, 45, 46, 47, 48, 50, 52, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, and 75.) The Administrator was notified on 9/11/14 at approximately 2:10 pm that Immediate Jeopardy, with the likelihood of death or serious physical or psychosocial harm, was identified. The Immediate Jeopardy was not abated prior to exit from the facility on 9/11/14 at 7:30 pm. Findings include: 1. Review of the clinical record revealed Resident 10 was admitted to the facility on [DATE] for physical and occupational therapy after a hip replacement. The facility face sheet indicated the resident was her own responsible party. Review of the "Admission Assessment" completed on 8/27/14 revealed the resident was alert, oriented and had no cognitive impairment. admission orders [REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident 10 frequently had pain, which she rated as an "8" on a scale of 1-10, where "10" was "the worst pain you can imagine". The MDS noted that due to pain the resident had limited her day-to-day activities and pain had made it hard for her to sleep. a. Review of the "Pain Assessment Flow Sheet" revealed that on 9/9/14 at 9:00 pm and 9/10/14 at 6:00 am, staff documented the resident received [MEDICATION NAME] 10 mg/325 mg ([MEDICATION NAME]/[MEDICATION NAME] equivalent) for pain. However, review of the Medication Administration Record (MAR) revealed that neither of these doses of medication were documented as being given. b. Observation on 9/10/14 at 9:00 am revealed Resident 10 lying on the bed in her room. The resident was rubbing her knee, holding her leg. She stated she was in extreme pain, relating, "I'm horrible". Further interview revealed that she had to stop physical therapy that morning due to her pain. She stated she had asked for pain medication at the nursing station approximately 5 minutes earlier. However, an unknown staff "...told me, no, I couldn't ask at the desk. They told me I had to go to my room, and then they'd get to me". Further interview with the resident revealed her pain was at a level of "10" on a scale of 1-10. Observation revealed that as of 9:15 am, no staff had come to assess pain or provide pain management/relief for Resident 10. The resident remained on her bed, stating that she was waiting in her room as staff had told her to. Observation revealed staff failed to assess Resident 10 or provide any pain relief (either medication or non pharmacological) until 10:12 am, when the resident left her room and found a nurse passing medications. At this time, Licensed Vocational Nurse (LVN) 58 asked Resident 10 her pain level and the resident responded that it was still "10", noting that "I had to leave therapy it was hurting so bad - it made me cry". Although R 10 informed LVN 58 that her pain level was a "10", review of the documentation completed by the nurse revealed that when she administered the PRN pain medication, she documented the resident's pain at a lower level ("8"). Interview with LVN 58 on 9/10/14 at 10:10 am confirmed that she had not immediately responded to Resident 10's complaint of severe pain. She stated to Resident 10, "I was on the phone, I didn't hear you" ask for pain medication. LVN 58 further noted that no staff had "told me you needed a pill". Interview with LVN 58 at 10:20 am confirmed "Yes, she asked for pain meds. It was my fault that I didn't attend to her when she was in pain". Interview on 9/10/14 at 10:20 am with the physical therapist (PT) confirmed Resident 10 had not been able to complete her therapy that morning, due to pain. The PT stated, "I took her to the nurse, she told her she was in pain and the nurse said she would go to her room". c. During observation on 9/10/14 at 10:12 am, Resident 10 also asked LVN 58 if the physician had called about changing her pain medication. The resident, who stated she was a former health care professional, related that on the previous day, she had talked to the nurse about having the physician change her routine pain medication schedule from every eight hours to every six hours because, "Eight hours is too long" and she was having breakthrough pain. Review of the clinical record for Resident 10 revealed on 9/8/14 the physician ordered a pain management consult. Nurses' notes on 9/8/14 noted the pain management consult "order noted and carried out". However, review of the clinical record revealed no documented evidence that the pain management consult had been scheduled. Interview on 9/10/14 at 10:45 am with LVN 28 revealed "We have a pain management doctor we send residents out to. When we get an order, we call and get an appointment" which usually takes "a couple of days". Interview on 9/10/14 at 11:35 am with LVN 55 revealed nursing staff were responsible for making the appointment with the pain management physician. She stated that since the physician's order was noted by staff at night on 9/8/14, the nurse on the day shift for 9/9/14 should have made the appointment when the physician's office opened; however, it "apparently" had not been scheduled. Interview on 9/10/14 at 11:20 am with the facility's two Social Service designees revealed it was "very concerning" that a pain management appointment had not been made for a resident whose pain was significant enough to result in tears and cessation of therapy. d. Review of the Pain Care Area Assessment (CAA), completed on 9/3/14, revealed the need to "Make sure that the pain will be managed accordingly. Provide non-pharmacological interventions such as relaxation and repositioning, and monitor effectiveness of pain meds and non-pharmacological interventions". However, review of the clinical record revealed the need for non-pharmacological interventions which was identified on the Pain CAA was not included on the pain care plan for Resident 10. Further review of the pain care plan for Resident 10, initiated 8/27/14, revealed staff was to monitor pain every day. Review of the clinical record revealed no documented evidence of daily pain monitoring. Interview with LVN 58 on 9/10/14 at 10:20 am revealed if a resident was supposed to be on daily monitoring for pain, there should be a "pain monitor" form on the MAR. She noted that pain monitor sheets were supposed to be completed for every resident on every shift. LVN 58 confirmed there was no pain monitor assessment sheet on the MAR for Resident 10 and stated, "It appears it was not done". Review of the "Pain Management" policy dated 1/1/12, revealed "The Licensed Nurse will develop a care plan for pain management including non-pharmacological interventions". The policy also noted that "The Licensed Nurse will administer pain medication as ordered ....Nursing Staff will implement timely interventions to reduce the increase in severity of pain". The policy related that "The Licensed Nurse will assess the resident for pain and document results on the MAR each shift using the 1-10 pain scale". 2. On 9/10/14 the following observations of Resident 24 were made: a. 4:05 pm, Resident 24 was screaming in her room. The Assistant Director of Nursing (ADON) entered the room and was heard telling the resident she would send her nurse. The ADON came out of the room and told Licensed Vocational Nurse Staff (LVN) 58 that Resident 24 needed pain medication. b. 4:06 pm, the surveyor entered the room after the ADON left the room and asked the resident why she was screaming. Resident 24 stated she requested pain medication at 3:25 pm, and was told she had to wait until 4:00 pm. She stated that her routine pain medication that was administered every six hours was not [MEDICATION NAME] for six hours. When asked her pain level on a scale of 0-10, Resident 24 responded "25-100". She stated the pain was in her joints and the change in administration time for her pain medication was still not working. She further stated that the nurses and doctors had been working for a month to refer her to a pain specialist. c. 4:15 pm, LVN 58 entered the room and asked the resident about her pain. Resident 24 screamed "If one more person asks about my pain, I want pain medication or something". LVN 58 told the resident she would administer her pain medication. On 9/10/14 at 4:17 pm an interview was conducted with LVN 58. When asked about Resident 24's pain medication, LVN 58 stated the resident was on routine pain medication, [MEDICATION NAME] (narcotic) 30 milligrams (mg) every 6 hours. When asked about what non-pharmaceutical interventions were implemented for the resident, LVN 58 stated she had not worked with the resident and was not familiar with her pain management. On 9/11/14, the following observations were made: 9:30 am, Resident 24 was screaming in her room. A certified nursing assistant (CNA) entered the room and closed the door. The screaming stopped. 2:50 pm, Resident 24 was screaming in her room for a female nurse. The ADON entered the room and told the resident she would send in her nurse. 2:52 pm, LVN 98 entered the room and told the resident she would get her CNA and left the room. 2:53 pm, Resident still screaming. The surveyor entered the room and the resident stated she needed help to reposition her legs which were stuck in the mattress and were hurting. When asked why she did not pull her call light, she stated that it was caught under the side rail. The surveyor untangled the call light cord and pulled the call light. 2:54 pm, a male CNA entered the room; Resident 24 screamed that she wanted a female CNA. 2:54 pm, a female CNA entered the room and stated that she would take care of the resident. An interview was conducted on 9/11/14 at 3:20 pm with LVN 98. When asked if she had assessed Resident 24 for pain when she was in the room she stated "No, the resident asked for a CNA". LVN 98 stated she really did not know the resident or what they were doing for her pain. She stated that when she went into the room, the resident requested her CNA and she did not ask the resident what she wanted; she went to locate the CNA assigned to care for the resident. LVN 98 stated she did not assess the resident needs when the resident was screaming. A review of the clinical record revealed Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS- a comprehensive assessment of the resident) completed on 7/1/14, noted a Brief Interview for Mental Status (BIMS) score of 13. A score of 13 to 15 stipulated that the resident was cognitively intact. The resident required extensive assist of one staff for turning and positioning in bed and extensive assistance of two staff for transfer in and out of bed. A review of 9/14 physician orders for Resident 24 revealed: a. 5/23/14, [MEDICATION NAME] 20 milligrams (mg) three times daily for muscle spasm. b. 5/23/14, [MEDICATION NAME] 50 mg at bedtime for [MEDICAL CONDITION] pain. c. 8/26/14, [MEDICATION NAME] (narcotic) 30 mg at 4:00 am, 10:00 am, 4:00 pm, 10:00 pm, per patient request, pain management (The time was changed from 8/21/14). A review of the quarterly pain assessment for Resident 24 completed on 7/8/14 revealed a score of 12. It stipulated that a score above 10, the resident was high risk for pain. A review of the MAR from 7/1/14 through 9/11/14, noted the resident's constant complaints of pain between 8/10 and 10/10 (0 = no pain and 10 = worst, horrible pain). A review of the pain re-assessment completed on 8/21/14 noted five days with pain scores of 10/10 (very severe, horrible). It also noted the pain was affecting the resident's sleep and limiting her day activities. A review of the pain re-assessment completed on 9/10/14 noted the resident complained of pain 9/10 and 10/10 almost constantly. Resident 24 was on medication for pain management and the non-pharmacological intervention was for staff to reposition the resident. A review of the "Nurses' Weekly Progress Notes" completed on 9/1/14 noted no complaints of pain (0/10). This contradicted the MAR which noted pain levels of 9/10 and 10/10. A review of the care plan titled "Pain" related to joint pain, muscle spasms, initiated on 4/2/14, revised on 4/8/14 and again on 5/23/14, noted the following interventions: a. Monitor pain daily using scale b. Assist during transfers and positioning c. Medications as ordered d. Inform MD PRN if ineffective Added on 4/8/14: [MEDICATION NAME] (narcotic medication to treat severe pain) as ordered Occupational Therapy as ordered On 4/23/14, the following interventions were added to the care plan: [MEDICATION NAME] (anti-spasm medication) as ordered [MEDICATION NAME] (narcotic to treat moderate to severe pain) as ordered [MEDICATION NAME] (medication to treat muscle/nerve pain) as ordered On 8/21/14, [MEDICATION NAME] (narcotic to treat severe pain) 30 mg every 6 hours was added. A review of the nurses' notes from 8/4/14 to 9/11/14 noted the following: a. 8/4/14, received consult from pain specialist, no new orders. b. 8/21/14, the physician was notified of the resident request for routine [MEDICATION NAME] instead of the as needed order. The physician gave orders for [MEDICATION NAME] 30 mg every 6 hours. c. 8/26/14, Resident requested time change for the [MEDICATION NAME] and the physician agreed. There was no documentation of the resident's pain level or interventions implemented in the nurses' notes. d. 9/10/14, "Resident verbalized c/o (complaints) [MEDICATION NAME] 30 mg po (by mouth) Q (every) 6 h (hours) not effective with her pain; MD (physician) made aware with new orders to follow up and schedule appointment with pain physician. Appointment scheduled for 9/17/14, at 9:45 am. On 9/11/14, at 4:45 pm, an interview and concurrent review of the clinical record for Resident 24 was conducted with the ADON. She was informed of observations made on 9/10/14 and 9/11/14 of staff responses when the resident was screaming in her room. When asked who was responsible for assessing the effectiveness of pain medication, the ADON stated that it was the responsibility of the charge nurses administering the pain medications to assess the effectiveness of the pain medications, and report to the physicians if the pain medications were not effective. When asked about Resident 24's current pain level of 8/10 to 10/10, she stated the resident had an appointment on 9/17/14 with the pain specialist. When asked what new interventions were implemented, since there was no change in medications and the appointment with the pain specialist was seven days out, the ADON did not respond. A review of the facility policy and procedure titled "Pain Management", revised 1/1/12, included the following: "11. Pain Management: A. The Licensed Nurse will administer pain medication as ordered and document all medication administered on the Medication Administration Record (MAR). C. The Licensed Nurse will assess the resident for pain and document results on the MAR each shift using the 1-10 scale. i. The shift pain score will indicate the highest pain level that occurred on that shift. E. Nursing Staff will implement timely interventions to reduce the increase in severity of pain. I. Nursing Staff will also utilize non-pharmacological interventions by adjusting the resident's environment to reduce pain ..." "111. Documentation: A. Pain Assessments will be maintained in the resident's medical record. i. Document the explanation to the resident/responsible party how the pain scale works. B. The Licensed Nurse will update the Care Plan for pain management with any change in treatment/or medication." 3. During the initial tour of the facility accompanied by LVN 94 on 9/8/14 at 10:27 am, the call light in Resident 27's room was on. Upon entering the room, Resident 27 was observed lying in bed and complained of right leg pain. LVN 94 asked the resident if she could reposition and elevate her right leg and what her pain score was. Resident 27 stated that the pain to her right leg was a 10/10 (severe, horrible pain) and was verified with LVN 94 who notified the medication nurse of the resident complaint of pain. On 9/8/14, at 12:30 pm, Resident 27 was in bed with her lunch tray. Resident 27 stated she was not hungry. When asked about her pain, she stated the pain medication she was administered earlier did not relieve the right leg pain. On 9/9/14 at 8:10 am, Resident 27 was asked about her pain. She stated she did not sleep well last night because of pain to her right leg. She further stated that the nurse was communicating with her physician on pain management. On 9/10/14 at 8:40 am, Resident 27 stated that her pain was relieved and she slept well last night. On 9/11/14 at 2:30 pm, when asked about the pain, Resident 27 stated that it was 6/10. When asked if she had requested pain medication she stated "no". When asked why, she stated that she did not want the medication because it made her constipated (difficult to pass stool). She stated, "It was awful". She further stated that she felt the constipation was worse than the pain. When asked if she had discussed laxative management with the medication nurse, she stated "no". A review of the clinical record revealed Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS completed on 7/28/14 noted a BIMS score of 15. A score of 13 to 15 stipulated that the resident was cognitively intact. Resident 27 complained of occasional pain of 6/10 (0= no pain and 10 = worst pain). A review of the MAR noted on 9/8/14 at 11:00 am, Resident 27 had a pain score of 5/10. [MEDICATION NAME] (a narcotic for moderate to severe pain) 5 mg/300 mg was effective and the pain scale went to 0/10. A side effect of narcotics includes constipation. This documentation contradicted the resident complaint of 10/10 pain level observed at around 10:27 am and no pain relief at 12:30 pm. A review of the 9/14 MAR noted Resident 27 was administered [MEDICATION NAME] (medication to treat constipation) 30 cubic centimeter (cc) on 9/9/14, but no results were documented. A review of the physician recapitulated orders for 9/14 included the following: a. 7/3/14, Monitor pain Q shift using pain scale: 0 = no pain 1-3 = mild pain 4-6 = moderate pain 7-10 = severe pain b. [MEDICATION NAME] (narcotic use to treat moderate to severe pain) 5 mg/300 mg I tab PO Q 8 hours moderate pain (4-6) c. [MEDICATION NAME] 30 cc PO QD PRN constipation. d. 8/31/14, There was no medication ordered to treat pain level 7/10 - 10/10. The [MEDICATION NAME] 5 mg/300 mg tabs PO Q 8 hours for severe pain (7-10) was discontinued on 8/ 31/14. 9/10/14, a venous Doppler (diagnostic testing for clots/blockage in the veins, limiting blood flow) to right leg, for swelling and rule out [MEDICAL CONDITION] (clot formation in the veins) was ordered. There was no documentation in the nurses' notes related to the severe pain to the resident's right leg or swelling on 9/8, 9/9 or 9/10/14. On 9/11/14 at 4:35 pm, an interview was conducted and the clinical record for Resident 27 was reviewed with the ADON. When asked about the resident's pain, she stated the resident had pain medication as needed. She further stated she was not aware the resident did not want to take pain medications because of constipation. RN 89 verified the result from the [MEDICATION NAME] administered on 9/9/14 was not documented on the MAR. Also, the ADON was informed that on 9/8/14 at 10:27 am, Resident 27 complained of pain at a level of 10/10 to the right leg that was verified by LVN 94 during the tour; however, the pain was documented as generalized pain of 5/10 on the MAR. Additionally, there was no assessment of the right leg pain and swelling that required an order for [REDACTED]. The ADON stated the licensed nurses administering the medications were responsible for assessing residents and accurately documenting interventions and effectiveness of medications. 4. Interview on 9/8/14 at 12:30 pm with Resident 6 revealed he had refused to go to an appointment that morning (9/8/14) because his "physician made decisions without his permission or knowledge" with a "bad pain doctor". He also said that he "doesn't get enough" Klonopin to help manage his pain and the facility "won't get an increase". He also said he had requested that the facility obtain the brand name blood thinning medicine ([MEDICATION NAME]) versus the generic brand ([MEDICATION NAME] sodium) that was supplied by the facility's pharmacy. He said, "I don't feel good (in his legs) because I'm not getting the clotting medicine" that worked best for him. He said he had conversations with the Assistant Director of Nursing (ADON) about these concerns, but that they remained unresolved. Review of the "Pain Assessment" for 8 /15/14, the date Resident 6 was admitted , revealed the resident "denies pain upon admission". A "Pain Re-Assessment" dated 8/6/14 revealed Resident 6 had "generalized pain" rated on the pain scale as "5-8 - Severe" with a rating of 10/10 being the Worst Pain Intensity in the last 5 days. Review of a "Resident Care Plan" dated 8/5/14 revealed a concern for "Pain related to: muscle spasms, severe [MEDICAL CONDITION] (tissue swelling), [MEDICAL CONDITIONS], DM((diabetes mellitus),[MEDICAL CONDITION](hypertension), Afib ([MEDICAL CONDITION]-abnormal heart rhythm) and [MEDICAL CONDITION], Resident stated that he has pain d/t (due to) brain damage". The "Approach Plan" column had not been updated to reflect the reclassification for the use of Klonopin for anxiety related to pain. Review of the MDS assessment with an Assessment Reference Date (ARD) of 8/17/14 revealed Resident 6 had a score of 15 from the BIMS, which indicated his cognitive patterns were intact. The MDS indicated he had no "Mood" or "Behavior" symptoms, but he had rejected care 1 - 3 of the 7 day window before and including the ARD. The "Pain Assessment Interview" revealed he had pain "almost constantly" that "made it hard for (him) to sleep at night" and "limited (his) day-to-day activities". Resident 6 rated the pain intensity on the MDS as 8 out of 10. Interview on 9/9/14 at 8:30 am with Resident 6 revealed he was waiting for his pain medication and he "wants the pain meds (medications) with food". He said he "usually takes until 10:00 am with breakfast". He also said the "doctor came last night " and it was "the first time I've seen him here". He said the doctor "apologized for the miscommunication on his appointment" yesterday morning on 9/8/14. Interview on 9/9/14 at 11:00 am, the ADON confirmed Resident 6 refused to go to the pain specialist appointment yesterday. Review of the nurses' notes during the interview revealed on 8/19/14, Resident 6 had requested referral to a pain specialist. A note dated 8/28/14 revealed the resident had "constant verbalization of pain; constant changing of pain routine times". The physician was made aware and gave "orders for referral to pain mgt (management) MD (medical doctor)". The appointment was made, "Social Service made aware for transportation," and the resident was "made aware". The ADON didn't explain why there was a delay between 8/19/14 and 8/28/14 before the appointment had been scheduled, nor did she indicate whether the resident was aware of which pain specialist he would be going to. The ADON stated that there was currently "no plan for next steps" related to seeing a pain specialist. Also, during the interview on 9/9/14 at 11:00 am, the ADON confirmed the psychiatrist did not want to increase the Klonopin, but the reason for the use of that medication had been "reclassified". Review of the "Anti-Anxiety Medication Administration Record" revealed an order dated 8/5/14 for "Klonopin 1 mg" every four hours as needed for "verbalization of feeling of nervousness". The frequency was changed on 8/17/14 to every six hours, and then on 8/19/14 it was changed back to every four hours "NTE (not to exceed) 4 mg/24 hrs (4 milligrams every 24 hours) for anxiety M/B (manifested by) verbalization of pain". Review of an "Interdisciplinary Team Conference" dated 8/18/14 and a nurse's note on 8/19/14 revealed the change in the Klonopin order was the result of the resident's request. The note also indicated, "Resident refuse to take his medications on time, verbalize I will take it later, but nursing staff staff (sic) encourage him to take it on time it was presented, or will come back later when he is ready. But resident want the medication to be left on the bed side, but nursing staff explain to him that is not proper to leave medication on the bed side of a resident". Review of a "Resident Care Plan" dated 8/19/14 revealed "Alteration in behavior as manifested by:" with a handwritten note of "Not compliant with meds (medications) and nursing care". The "Approach Plan" included to "Not argue with resident" and "Withdraw calmly if met with resistance when giving meds/care, and try again in 10-15 mins (minutes)". There was no indication in the nurses' notes or on the "Resident Care Plan" that consideration was given to accommodating the resident's desire to self-administer his own medication when he was ready. Review of the "Anxiolytic [MEDICAL CONDITION] Intervention" forms between 8/6/14 and 9/8/14 revealed Klonopin had been administered five times on 8/6/14 and four times on 8/10/14 but out of the remaining 32 days it had been administered only twice on 9 days, only once on 11 days, and not at all on 12 days. Review of the MAR dated August 2014 revealed administration on 8/28/14 of "[MEDICATION NAME] 2 mg tab (tablet) PO (by mouth) STAT (immediately)" was refused by the resident. He also refused his routine "[MEDICATION NAME]" dose the remaining days in August. The September 2014 MAR noted that Resident 6 had refused the medication for all of September 1 - 9. Interview on 9/9/14 at 3:20 pm revealed Resident 6 repeated his concerns with unresolved pain and having to wait for his pain medication. Interview on 9/10/14 at 8:30 am with the Social Services Designee (SSD) 3 revealed she had talked with Resident 6 about the pain specialist, but "he refused to go to the doctor's appointment". She said his "private insurance doesn't cover a different doctor, but he didn't believe me". She said nursing had documented that. Interview on 9/10/14 at 10:00 am with Resident 6 revealed he was waiting for his pain medication and the ADON told him "she would give it at 10:00 am". CNA 9 responded to his call light twice during the interview and said to Resident 6 that the nurse was "getting other residents' meds, she will be here soon". One additional time, CNA 9 turned off his light from behind the privacy curtain on the roommate's side without acknowledging Resident 6. The Licensed Vocational Nurse (LVN) 58 did not arrive to the room until 10:25 am to administer the pain medication to Resident 6. Interview on 9/10/14 at 10:40 am with LVN 58 revealed she had completed the medication pass for all of her assigned residents before returning to Resident 6's room to administer his pain medication. She said she "did not give him the medication at the time he requested due to timing". She provided no further clarification as to what she meant by timing. Review of the MAR dated "September 2014" revealed an order for [REDACTED].= (equal to) 120 mg PO (by mouth) Q 8 HRS (every 8 hours)" for pain management and "[MEDICATION NAME] IR (immediate release) 15mg 1 tab (tablet) PO QID (four times a day) PRN (as needed)" for "Break through pain". Review of the MAR dated "SEPT '14" (September 2014) revealed the routine doses [MEDICATION NAME] were given as ordered at 5:00 am, 1:00 pm and 9:00pm on 9/8/14, 9/9/14, and the morning dose at 5:00 am. Review of the "Pain Assessment Flow Sheet" and the "Controlled Medications Count Sheet" revealed doses of [MEDICATION NAME] IR were administered six times on 9/8/14 at 12:00 am, 4:00 am, 8:00 am, 2:30 pm, 6:45pm and 11:30 pm. Further review of the medication records revealed the [MEDICATION NAME] IR had already been administered four times during the morning hours of 9/10/14 at 1:30am, 6:00am, 8:20 am, and 10:28am. Review of nurses' notes dated 9/10/14 at 9:45 am revealed the "Resident verbalized c/o need to receive Klonopin 1 mg more than 4 times a day ordered by the MD (medical doctor)". The doctor was "made aware" and the doctor responded, "Do not change the frequency of Klonopin; will discuss with resident other medication options when I visit next wk (week)". Interview on 9/10/14 at 11:00 am with the ADON revealed she had a conversation with Resident 6 about [MEDICATION NAME] when the physician ordered a change in dosage based on lab (laboratory) results. She referred to a nurse's note dated 8/24/14 that revealed the resident was made aware of the physician's new order for a 2 mg dosage of [MEDICATION NAME] "now". Interview with the ADON at that time revealed the resident "wanted to know what pharmacy" the facility used to obtain the medications. She told him the pharmacy, "then directed the nurse to get a pill from the E-kit (emergency supply of medication)". After he refused to take the pill from the E-kit, she said she had contacted the facility pharmacy and "learned that there is not a difference in the types". She said that was the only conversation she had with him about the [MEDICATION NAME]. When asked if she was aware that Resident 6 was refusing to take the medication when administered, she said she wasn't and that the "nurses should have reported the refusals to the doctor". 5. A group interview was conducted on 9/9/14 at 1:30 pm with eight residents, whom the facility had identified as alert, oriented, and reliable historians. Interview revealed three of them (Residents 42, 44 and 74) reported they went to the nurses when they needed pain medication. Resident 42 indicated the need to ask the nurse for their medication because they "are impatient" while Resident 44 noted the need to ask staff for pain medication because they "get tired of waiting". 6. Interview with Resident 10 on 9/9/14 at 8:40 am revealed her roommate, Resident 9, had experienced three [MEDICAL CONDITION] in the last four days. Resident 10, who described herself as a former health care professional, stated that during one [MEDICAL CONDITION], "foam was running out of her mouth," and "staff didn't know what to do". Review of the clinical record revealed Resident 9 was admitted to the facility on [DATE]. Although [MEDICAL CONDITION] disorder was not listed on Resident 9's admission orders [REDACTED]. In addition, the MAR documented the Resident 9 was to receive [MEDICATION NAME] (anti-epileptic) 250 mg/5 ml (milliliters) QID (four times per day) "for [MEDICAL CONDITION]". Further review of the clinical record revealed no documented evidence the physician-ordered monitoring for [MEDICAL CONDITION] was initiated prior to the resident being transferred to the hospital on [DATE] for a [MEDICAL CONDITION]. Review of nurses' notes on 9/6/14 at 5:05 am revealed that "while rendering care, (resident name) starting having a [MEDICAL CONDITION] ...after fifth minute (resident name) was still seizing". At 5:10 am the physician was notifi

Based on observation, interview, and record review, the facility failed to assure that each resident was free from mistreatment and neglect. The facility failed to ensure residents received the care they needed to avoid harm; failed to ensure residents were provided supervision when they left the facility and to ensure actions were taken to monitor their safety when their whereabouts were unknown for days; failed to ensure residents received essential medications including, but not limited to, insulin, anti-[MEDICAL CONDITION] medication and pain medication as ordered; failed to ensure physician orders [REDACTED]. The failure to provide the services each resident needed affected eight (Residents 1, 2, 3, 5, 6, 8, 9, and 10) of 12 sampled residents and 41 supplemental residents (Residents 16, 22, 23, 24, 27, 28, 31, 32, 34, 35, 37, 38, 40, 41, 42, 43, 44, 45, 46, 47, 48, 50, 52, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 70, 71, 72, and 75) presented a risk of death or serious harm. The Administrator was notified that Immediate Jeopardy was identified at approximately 2:10 pm on 9/11/14 and was not abated prior to exit from the facility on 9/11/14 at 7:30 pm. Findings include: 1. Review of the clinical record revealed Resident 1 was a [AGE] year old male with [DIAGNOSES REDACTED]. His mobility was assisted by a motorized wheelchair. Review of the nurses' notes dated 12/21/12 revealed a bystander came into the facility and stated "Your patient was hit by car". The resident was across the street on the ground, lying on his back, with his wheelchair tipped over. The resident was transferred to the hospital via emergency services. Review of the nurses' notes dated 1/15/14 at 3:00 pm revealed Resident 1 was found in the parking lot next to the facility, on the ground. When facility staff asked the resident what happened he responded, "Someone tipped me out of my w/c (wheelchair) because I owed him $2.00". The charge nurse asked the resident if he knew who it was and he stated "Yes but I'm not tell (sic) you guys, I've already told the police and fire department I don't need their assistance". The charge nurse assisted Resident 1 back inside the facility. The charge nurse noticed a band-aid over the resident's eye and asked what happened and he stated, "The fire department put it there because I hit my head when I hit the ground". The charge nurse removed the band-aid and noted a half inch laceration to the right eyebrow as a result of the assault. Review of the Resident Pass Log revealed Resident 1 continued going out on pass unsupervised on a regular basis, multiple times on many days, signing himself out. On 9/8/14, Resident 1 signed himself out at 11:35 am and returned at 3:45 pm; on 9/8 at 3:50 pm and returned at 4:15 pm and on 9/8/14 at 5:25 pm and returned at 5:30 pm. There was no documented evidence of destination or expected duration for any of these departures from the facility in any log or the resident's chart. The Resident Pass Log further revealed many of the facility residents signed themselves in and out of the facility on a regular basis. The Resident Pass Log had entries for date, resident name, time in, and time out. Although the log also had a place for documentation of who the resident was accompanied by when they went on "leave", observation revealed residents were routinely unaccompanied and not provided supervision when they left the facility. During an interview with the Administrator on 9/8/14 at 5:30 pm the surveyor asked what the facility had put into place after the two incidents to ensure the safety for Resident 1 while he was out of the facility and the administrator responded "Nothing". Review of the care plan revealed no interventions for ensuring safety for Resident 1 while out of the facility on pass. Review of facility policy RR-17 "Obtaining a Pass Out of the Facility" dated 1/1/12 revealed nursing staff were to assess the resident prior to leaving on pass to ensure the resident's condition had not changed since the attending physician issued the pass and were to re-assess the resident's status when they returned. As part of the re-assessment the nurse was to review the resident's skin and document any changes, bruises, skin tears, or similar. Review of facility policy AP-16 "Entrance to and Exit from the Facility" dated 1/1/12 revealed "requests to leave the facility must be communicated to the Director of Nursing and to the Director of Social Services ... The Director of Nursing or his/her designee will verify that the resident's physician has provided an order approving leave from the facility...If the resident is leaving the facility for a reason other than to receive medical treatment, the Director of Social Services will evaluate and document the following before giving the resident the pass; the reason for leaving, the residents decision making capacity, destination, duration, responsible party accompanying the resident, if necessary". During an interview on 9/8/14 at 3:45 pm Resident 1 revealed the resident signs himself out of the facility and goes around town in his motorized wheelchair. He stated he had just come back from visiting his dad and that he just signs in and out of the facility with security and that he can come and go from the facility as he wishes. The nurses do not evaluate him when he leaves or returns. 2. During an interview 9/10/14 at 12:05 pm, the Administrator stated the facility has residents who leave on pass all the time and just never return to the facility. The surveyor asked how the facility knew the residents who did not return to the facility while out on pass were all right, and that something had not happened to them, or they needed assistance. She stated the facility did not know but "figured they had just gone back to the streets as that is where a lot of the residents come from". The administrator gave Resident 22 as an example of a resident who went out on pass and never returned. She stated the resident's failure to return from a pass was never reported to anyone outside of their company, and was not investigated to ensure the resident's safety. Review of the clinical record revealed Resident 22 was a [AGE] year old male with [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE] from a hospital where he was taken after being placed on a 5150 hold (involuntary psychiatric hold) for being a danger to himself. He stated he wanted to harm himself and overdose. Review of the care plan for Resident 22 revealed no documented evidence of an intervention to assess or address safety concerns related to the recent suicidal thoughts. Review of a nurse's note dated 7/17/14 at 6:30 pm revealed the resident went out on pass. Review of a nurse's note dated 7/18/14 at 7m stated the resident was still out on pass, the physician was made aware, and discharged the resident against medical advice (AMA). The note further stated the resident's belongings were kept in the Social Services office and the medications were stored in the medication room. Review of the physician discharge summary revealed the physician discharged Resident 22 AMA. Further review of the clinical record for Resident 22 revealed no one had heard from the resident since he left the facility. There was no documented evidence of an investigation to ensure the resident's safety was initiated when he failed to return to the facility and no agency was notified of the resident never returning to the facility. 3. A group interview was conducted on 9/9/14 at 1:30 pm with eight residents the facility had identified as alert, oriented, and reliable historians. Interviews with the group confirmed residents routinely left the facility unsupervised. Residents stated if they were going to a medical appointment staff would accompany them but otherwise, the facility provided no supervision when they left by foot, or used public transit to go shopping, attend appointments, and participate in personal activities. During an interview on 9/10/14 at 9:45 am, the Social Services Designee (SSD) 3 stated she had no documentation to show every resident was assessed every time they went out on pass. SSD 3 confirmed many of their residents go in and out of the facility multiple times a day and noted that if she followed the policy, she would be doing the assessments all day. 4. An observation on 9/10/14 at 5:00 pm revealed Licensed Vocational Nurse (LVN) 118 failed to perform a Finger Stick Blood Sugar (FSBS) test (measuring blood sugar levels) for Resident 2. LVN 118 also failed to administer routine insulin as ordered on [DATE] at 5:00 pm. Insulin per sliding scale (scale indicating additional needed dose) was also ordered for 5:00 pm but as the FSBS was not performed this medication was not administered. These failures had the potential to result in [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (elevated blood sugar) which could be life-threatening. A review of the clinical record noted Resident 2 was admitted to the facility on [DATE] and was readmitted on [DATE]. The [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a comprehensive assessment of the resident) completed on 8/12/14 noted the Brief Interview for Mental Status (BIMS, determines mental capacity) was 14. A score of 13 to 15 stipulated Resident 2 was cognitively intact. A review of the September 2014 recapitulated (summarized) physician orders [REDACTED]. a. 8/27/14, Finger Stick Blood Sugar (FSBS) every meal and at bedtime: 7:00 am, 11:30 am, 5:00 pm, 9:00 pm with Humalog (brand name) Insulin (a hormone that regulates the metabolism of food) sliding scale coverage. b. 8/27/14, Humalog Insulin 9 units subcutaneous (SQ) every day at 5:00 pm with meals. The following observations were made on 9/10/14 between 4:35 pm and 8:04 pm, accompanying LVN 118 during the 5:00 pm medication pass: a. At 5:22 pm, Resident 2 was not in her room when LVN 118 went to perform the resident's 5:00 pm FSBS. b. At 5:59 pm while LVN 118 was still passing 5:00 pm medications, Resident 2 went by the medication cart in the hallway. LVN 118 asked Resident 2 if she had eaten her dinner because she needed to perform a FSBS and administer insulin with her meal. Resident 2 stated she had already eaten her dinner and told LVN 118 she could perform the FSBS at 9:00 pm. In addition, Resident 2 was not administered her routine 5:00 pm insulin as ordered. Although observation revealed LVN 118 did not administer the 5:00 pm dose of insulin to Resident 2, review of the 9/14 FSBS log revealed that on 9/10/14, LVN 118 documented she administered the Humalog 9 units SQ in the right arm at 5:00 pm with meal. LVN 118 also documented on "9/10/14, 4:30 pm, FSBS was not obtained. Res (resident) has already eaten dinner when offered". Further review of the FSBS log revealed staff had documented refusal of routine insulin on 9/2/14, 9/3/14, and 9/9/14. However, an interview with Resident 2 on 9/11/14 at 9:53 am revealed this was not true. When asked about refusing her medications, Resident 2 stated, "I do not refuse, they are just late passing the medications". When asked if it was on a particular shift when the medications were administered late, Resident 2 stated, "It depends on the nurses. Some of the nurses are new and do not know how to pass medications on time". Further interview with Resident 2 on 9/11/14 at 9:53 am confirmed the nurse had not administered the 5:00 pm insulin the previous day. When asked if she received insulin on 9/10/14 at 5:00 pm Resident 2 stated, "No, you was with the nurse yesterday, did you see her give me any insulin? They take too long to pass medications and I want to eat my food when it's hot. My expectation is that the nurse passing the medications will pass the medications on time and know what medications they are giving you and when they should pass it". She further stated, "I am a brittle diabetic (extreme swings in blood sugar levels resulting in [DIAGNOSES REDACTED] or [MEDICAL CONDITION]) and my sugars ran from 35 (milligrams/deciliter (mg/dl) to 567 (mg/dl). I have experienced diabetic coma in the past". The following facility policies and procedures were reviewed: 1. " Reporting Abuse" undated, noted under abuse definitions: "XVII. A. Neglect includes but not limited to: ii. Failure to provide medical care for physical and mental health needs ..." 5. A review of the clinical record noted Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of September 2014 physician orders [REDACTED]. Call the physician for Accucheck less than 60 and greater than 400". On 9/10/14, during medication pass between 4:35 pm and 8:04 pm, while accompanying LVN 118, the following observations were made: a. 5:20 pm, LVN 118 went to Resident 9's room to perform the 4:30 pm FSBS. Resident 9 was not in the room. b. 5:22 pm, a Certified Nursing Assistant (CNA) pushed Resident 9 in her wheel chair to her room and assisted the resident into bed. The CNA arranged the food on the dinner tray within the resident's reach. c. 6:30 pm, Resident 9 ate 100% of meal served. d. 8:04 pm, LVN 118 administered [MEDICATION NAME] [MEDICATION]) 500 milligrams (mg), 10 milliliters (ml) to Resident 9 who was sitting in her wheel chair by her bed. (This medication was ordered for 5:00 pm - Refer to Example #7.) During this observation, LVN 118 did not complete a FSBS. Review of the Medication Administration Record [REDACTED]. An interview was conducted on 9/10/14 at 8:06 pm with LVN 118. When questioned about the FSBS results, LVN 118 initially stated she performed the FSBS on 9/10/14 before 4:00 pm. LVN 118 was reminded that on 9/10/14 at 5:20 pm she went to Resident 9's room to perform the FSBS but the resident was not in her room. LVN 118 then stated she performed the FSBS after 3:00 pm. Interview was conducted on 9/10/14 at 8:14 pm with the Director of Nursing (DON). The DON was informed that LVN 118 was not observed performing a FSBS for Resident 9 on 9/10/14 between 4:35 pm and 8:04 pm. On 9/11/14 a review of FSBS results on the three glucometers (machines used to measure blood sugar) was conducted with the Director of Nursing. Review of the glucometer used by LVN 118 revealed no FSBS results of 136 (mg/dl) on 9/10/14. 6. Interview on 9/10/14 at 4:35 pm with Licensed Vocational Nurse (LVN) 118 prior to the start of the medication pass revealed she was a "float nurse" and was not familiar with new residents. LVN 118 stated she did not have a list of residents requiring FSBS before dinner. During the medication pass observation from 4:35 pm to 8:04 pm, LVN 118 was observed flipping through the MAR indicated [REDACTED]. In response to the observation of services not being provided and falsification of the insulin administration and FSBS log, the facility was asked to provide a list of all diabetic residents/residents who required FSBS. A review of the list provided by the facility revealed 35 residents (Residents 2, 3, 8, 16, 27, 28, 37, 38, 40, 41, 42, 45, 46, 48, 50, 52, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, and 75). However, the list could not be verified as an accurate, comprehensive list as it did not include Resident 9, the resident whose FSBS was falsified on 9/10/14. 7. In addition to not providing Resident 9 with monitoring of her diabetic condition, on 9/10/14 staff also failed to administer anti-[MEDICAL CONDITION] medication as ordered. The failure to administer the anti-[MEDICAL CONDITION] medication on-time had the potential to subject Resident 9 to [MEDICAL CONDITION] (uncontrolled body tremors) activity which could result in medical complications [REDACTED]. Review of the clinical record revealed Resident 9 had previously been transferred to the hospital on [DATE] for a [MEDICAL CONDITION]. Review of the hospital emergency department record revealed the resident had been transferred there "for [MEDICAL CONDITION] approximately 18" minutes. Review of laboratory results obtained at the hospital revealed Resident 9's [MEDICATION NAME] acid level (blood drug level) was less than 12.5, with a reference range of 50-100. Review of hospital discharge instructions revealed "[MEDICATION NAME] level was below detection and not therapeutic". The discharge instruction revealed the resident needed to "Take all medications as prescribed, especially your [MEDICATION NAME] for [MEDICAL CONDITION] disorder". (Refer to F 309.) As of 9/10/14, physician orders [REDACTED]. On 9/10/14 during medication pass between 4:35 pm and 8:04 pm, accompanying LVN 118, the following observations were made: a. 5:20 pm, LVN 118 went to Resident 9's room; however, the resident was not in the room. b. 5:22 pm, a Certified Nursing Assistant (CNA) pushed Resident 9 in her wheel chair to her room and assisted the resident into bed. c. 6:30 pm, Resident 9 was still in her room. d. 8:04 pm, LVN 118 administered the 5:00 pm dose of [MEDICATION NAME] to Resident 9 who was sitting in her wheel chair by her bed. A review of the MAR for Resident 9 and an interview was conducted on 9/10/14 at 8:06 pm with LVN 118. At that time, LVN 118 acknowledged she administered the [MEDICATION NAME] on 9/10/14 at 8:04 pm instead of 5:00 pm as ordered. On 9/11/14, the DON was notified that although LVN 118 documented Resident 9 had received the anti-[MEDICAL CONDITION] medication as ordered at 5:00 pm, observation revealed the nurse did not administer it until 8:04 pm. Interview with the DON at that time revealed there were additional nurses in the facility that could have been called upon to ensure medications were given as ordered. The DON acknowledged that, if the survey team had not observed the medication pass, facility staff would have been unaware LVN 118 falsely documented that Resident 9 received [MEDICATION NAME] at 5:00 pm, instead of over 3 hours later. 8. Observation revealed an additional 13 of 25 residents did not receive service or medications ordered for 5:00 pm on 9/10/14 as of 8:06 pm. This failure had the potential to negatively affect the health and well being of the residents resulting in serious medical complications. (Refer to F 309.) a. A review of the 9/14 physician orders [REDACTED]. 9/2/14, [MEDICATION NAME] (used to reduce levels of phosphorus in people with kidney disease who are on [MEDICAL TREATMENT]) 888 mg two tablets three times daily with meals for [MEDICAL CONDITION]. On 9/10/14, between 4:35 pm and 8:06 pm, observation revealed staff failed to administer [MEDICATION NAME] with dinner to Resident 8. b. A review of the 9/14 physician orders [REDACTED]. 1. 6/13/14, [MEDICATION NAME] (stool softener) 100 mg bid (twice daily, 9:00 am and 5:00 pm) for bowel management. 2. 6/21/14, [MEDICATION NAME] (ulcer medication) 1 gram before meals and bedtime (6:30 am, 11:30 am, 4:30 pm and 9:00 pm) for stomach ulcer. On 9/10/14, as of 8:06 PM, Resident 23 was not administered the [MEDICATION NAME] or the [MEDICATION NAME] ordered before dinner. c. A review of the 9/14 physician orders [REDACTED]. 5/7/14, [MEDICATION NAME]-[MEDICATION NAME] (combination medication to treat [MEDICAL CONDITION] disease - a progressive nervous system disorder that affects movement) 10/100 milligrams (mg) 1 tablet PO (by mouth) tid (three times daily). On 9/10/14, between 4:35 pm and 8:06 pm, Resident 31 was not administered the [MEDICATION NAME]-[MEDICATION NAME] as ordered for 5:00 pm. d. A review of the 9/14 physician orders [REDACTED]. 3/29/14, [MEDICATION NAME] (medication to treat elevated blood pressure) 25 mg PO two times daily, 9:00 am and 5:00 pm. Hold for S (systolic the upper reading) BP (blood pressure) lower than 110 (mm of mercury (mm Hg)). On 9/10/14, as of 8:06 pm, the BP was not checked nor was the 5:00 pm [MEDICATION NAME] administered for Resident 32. e. A review of the 9/14 physician orders [REDACTED]. 1. [MEDICATION NAME] (brand name of medication to treat [MEDICAL CONDITION]) eye drops place one drop to both eyes two times daily. 2. [MEDICATION NAME] (brand name of medication to treat [MEDICAL CONDITION]) eye drops 1 drop to left eye two times daily (9:00 am and 5:00 pm). On 9/10/14, as of 8:06 pm, Resident 34's eye drops had not been administered as ordered. f. A review of the 9/14 physician orders [REDACTED]. 5/30/14, [MEDICATION NAME] (brand name of medication to treat mood disorder) 250 mg two times daily (9:00 am and 5:00 pm) for mood stabilizer. On 9/10/14, as of 8:06 pm, 5:00 pm [MEDICATION NAME] was not administered to Resident 35. g. A review of Resident 40's 9/14 physician orders [REDACTED]. 1. ProStat (protein supplement) 30 ml via G (gastrostomy)-tube (feeding tube inserted through the abdomen into the stomach) two times daily at 6:00 am and 6:00 pm. 2. [MEDICATION NAME] (lowers B/P) 0.1 mg two times daily at 6:00 am and 6:00 pm. Hold for SBP less than 110 (mm Hg). 3. [MEDICATION NAME] (lowers B/P) 6.25 mg 1 bid at 6:00 am and 6:00 pm. Hold for SBP less than 110 (mm Hg). On 9/10/14, as of 8:06 pm, Resident 40's 5:00 pm Prostat, [MEDICATION NAME] and [MEDICATION NAME] were not administered or B/P performed. h. A review of Resident 41's 9/14 physician orders [REDACTED]. 1. [MEDICATION NAME] (medication to lower blood sugar) 100 mg at 5:00 pm with dinner. 2. [MEDICATION NAME] (medication to lower B/P) 25 mg bid at 9:00 am and 5:00 pm. Hold if SPB less than 110 (mm Hg). On 9/10/ 14, as of 8:06 pm, the B/P was not checked for Resident 41, nor was the [MEDICATION NAME] and [MEDICATION NAME] administered as ordered for 5:00 pm. i. A review of Resident 43's 9/14 physician orders [REDACTED]. 1. [MEDICATION NAME] (lowers B/P) 50 mg bid for hypertension. Hold if SBP less than 110 (mm Hg) or heart rate less than 60 (beats per minute (bpm)). 2. [MEDICATION NAME] eye drops (treats [MEDICAL CONDITION]) one drop to both eyes bid for [MEDICAL CONDITION]. On 9/10/14, as of 8:06 pm, the B/P and heart rate were not checked for Resident 43, nor was the [MEDICATION NAME] or [MEDICATION NAME] administered at 5:00 pm as ordered. j. A review of Resident 44's 9/14 physician orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME] propionate 250 mcg (micrograms)/salmeterol 50 mcg) (used to treat asthma and other chronic respiratory diseases) discus 1 puff bid (9:00 am and 5:00 pm) for [MEDICAL CONDITIONS] (group of lung diseases that block airflow and make breathing difficult). Rinse mouth after each use. On 9/10/14, as of 8:06 pm, Resident 44 was not administered the [MEDICATION NAME] ordered for 5:00 pm. k. A review of Resident 47's 9/14 physician orders [REDACTED]. 1. [MEDICATION NAME] (reduces [MEDICAL CONDITION] activity) 150 mg bid (9:00 am and 5:00 pm) for [MEDICAL CONDITION] activity. 2. [MEDICATION NAME] (reduces [MEDICAL CONDITION] activity) 200 mg bid (9:00 am and 5:00 pm) for [MEDICAL CONDITION] activity. On 9/10/14, as of 8:06 pm, Resident 47 was not administered the 5:00 pm doses of [MEDICATION NAME] or [MEDICATION NAME]. l. A review of Resident 48's 9/14 physician orders [REDACTED]. 1. [MEDICATION NAME] HFA (medication to assist in breathing) 110 mcg inhaler 2 puffs bid (9:00 am and 5:00 pm) for [MEDICAL CONDITION]. 2. Glimerpiride (help lower blood sugar) 2 mg bid with meals (9:00 am and 5:00 pm). 3. Atrovent (assist with breathing) inhaler 17 mcg 2 puffs 4 times daily (9:00 am, 1:00 pm, 5:00 pm, 9:00 pm) for [MEDICAL CONDITION]. 4. Sodium Chloride (salt supplement) 1 gram three times daily (9:00 am, 1:00 pm and 5:00 pm) for [MEDICAL CONDITION] (low salt in blood). 5. [MEDICATION NAME] (lowers blood sugar) 1,000 mg tablet two times daily with meals (breakfast and dinner). On 9/10/14, as of 8:06 pm, Resident 48 was not administered any of the above medications as ordered for 5:00 pm. m. A review of Resident 52's 9/14 physician orders [REDACTED]. 1. [MEDICATION NAME] (lowers B/P) 75 mg three times daily at 2:00 pm, 6:00 pm and 10:00 pm for hypertension (elevated B/P). 2. Phoslo (control phosphorus blood levels) 667 mg, 3 gelcap three times daily with meals at 7:00 am, 10:00 pm and 5:00 pm for [MEDICAL CONDITION]. On 9/10/14, as of 8:06 pm, Resident 52 was not administered Phoslo gelcaps with dinner or the [MEDICATION NAME] at 5:00 pm as ordered. An interview was conducted on 9/10/14 at 4:35 PM with LVN 118, prior to the start of the medication pass. LVN 118 stated it usually took her three hours to administer the 5:00 PM medications. She further stated she was a "float nurse" and was not familiar with the new residents. 9. Review of the clinical record revealed Resident 10 was admitted to the facility on [DATE] for physical and occupational therapy after a hip replacement. Review of the "Admission Assessment" completed on 8/27/14 revealed the resident was alert and oriented and had no cognitive impairment. admission orders [REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident 10 frequently had pain, which she rated as an "8" on a scale of 1-10, where "10" was "the worst pain you can imagine". The MDS noted that due to pain, the resident had limited her day-to-day activities and pain had made it hard for her to sleep. Observation on 9/10/14 at 9:00 am revealed Resident 10 lying on the bed in her room. The resident was rubbing her knee, holding her leg. She stated she was in extreme pain, relating, "I'm horrible". Further interview revealed she had to stop physical therapy that morning due to her pain. She stated she had asked for pain medication at the nursing station approximately 5 minutes earlier. However, an unknown staff, "...told me, no, I couldn't ask at the desk. They told me I had to go to my room, and then they'd get to me". Further interview with the resident revealed her pain was at a level of "10" on a scale of 1-10. Observation revealed that as of 9:15 am, no staff had come to assess the pain or provide pain management/relief for Resident 10. The resident remained on her bed, stating she was waiting in her room as staff had told her to. Observation revealed staff failed to assess Resident 10 or provide any pain relief (either medication or non-pharmacological) until 10:12 am, when the resident left her room and found a nurse passing medications. At this time, LVN 58 asked Resident 10 her pain level and the resident responded that it was still "10", noting that "I had to leave therapy it was hurting so bad - it made me cry". Interview with LVN 58 on 9/10/14 at 10:10 confirmed she had not immediately responded to Resident 10's complaint of severe pain. She stated to Resident 10, "I was on the phone, I didn't hear you" ask for pain medication. LVN 58 further noted that no staff had, "told me you needed a pill". At 10:20 am, LVN 58 acknowledged, "Yes, she asked for pain meds. It was my fault that I didn't attend to her when she was in pain". Interview on 9/10/14 at 10:20 am with the physical therapist confirmed nursing staff had been aware of Resident 10's complaint of pain and request for medication. She stated when the resident had not been able to complete her therapy that morning due to pain, "I took her to the nurse, she told her she was in pain and the nurse said she would go to her room". Record review also revealed staff failed to monitor the resident's pain level on a daily basis as ordered. A pain management consult ordered by the physician was not scheduled until surveyor intervention. (Refer to F 309.) 10. On 9/10/14, the following observations of Resident 24 were made: a. 4:05 pm, Resident 24 was screaming in her room. The Assistant Director of Nursing (ADON) entered the room and was heard telling the resident she would send her nurse. The ADON came out of the room and told LVN 58 Resident 24 needed pain medication. b. 4:06pm, the surveyor entered the room after the ADON left the room and asked the resident why she was screaming. Resident 24 stated she requested pain medication at 3:25 pm, and was told she had to wait until 4:00 pm. She stated her routine pain medication administered every six hours was not [MEDICATION NAME] for six hours. When asked her pain level on a scale of 0-10, Resident 24 responded "25-100". She stated the pain was in her joints and the change in administration time for her pain medication was still not working. She further stated the nurses and doctors had been working for a month to refer her to a pain specialist. c. 4:15 pm, LVN 58 entered the room and asked the resident about her pain. Resident 24 screamed, "If one more person asks about my pain, I want pain medication or something". LVN 58 told the resident she would administer her pain medication. On 9/10/14 at 4:17 pm an interview was conducted with LVN 58. When asked about Resident 24's pain medication, LVN 58 stated the resident was on routine pain medication, [MEDICATION NAME] 30 milligrams (mg) every 6 hours, at 4:00 pm. When asked about what non-pharmaceutical interventions were implemented for the resident, LVN 58 stated she had not worked with the resident and was not familiar with her pain management. On 9/11/14, the following observations were made: 9:30 am, Resident 24 was screaming in her room. A CNA entered the room and closed the door. The screaming stopped. 2:50 pm, Resident 24 was screaming in her room for a female nurse. The ADON entered the room and told the resident she would send in her nurse. 2:52 pm, LVN 98 entered room and told the resident she would get her Certified Nursing Assistant and left the room. 2:53 pm, The resident was still screaming and when the surveyor entered the room, the resident stated she needed help to reposition her legs which were stuck in the mattress and were hurting. When asked why she did not pull her call light, she stated it was caught under the side rail. An interview was conducted on 9/11/14 at 3:20 pm with LVN 98. When asked if she had assessed Resident 24 for pain when she was in the room she stated "No, the resident asked for a CNA". LVN 98 stated she really did not know the resident or what they were doing for her pain. She stated when she went into the room, the resident requested her CNA and she did not ask the resident what she wanted; she went to locate the CNA assigned to care for the resident. LVN 98 stated she did not assess the resident's needs when the resident was screaming. A review of the clinical record revealed Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS completed on 7/1/14 revealed the resident was cognitively intact, required extensive assist of one staff for turning and positioning in bed and extensive assistance of two staff for transfer in and out of bed. A review of the 9/14 physician orders [REDACTED]. 8/26/14, [MEDICATION NAME] (narcotic medication to treat severe pain) 30 mg at 4:00 am, 10:00 am, 4:00 pm, 10:00 pm, per patient request, pain management. (The time was changed from 8/21/2014). A review of the MAR from 7/1/14 through 9/11/14 noted the resident's constant complaints of pain between 8/10 and 10/10 (0 = no pain and 10 = worst, horrible pain). A review of the pain re-assessment completed on 8/21/14 noted five days with pain scores of 10/10. It also noted the pain was affecting the resident's sleep and limiting her day activities. A review of the pain re-assessment for Resident 24 completed on 9/10/14 noted the resident complained of pain at a level of 9/10 and 10/10 almost constantly. The resident was on medication for pain management and the non-pharmacological intervention was for staff to reposition the resident. (Refer to F 309.) 11. Interview on 9/8/14 at 12:30 pm revealed Resident 6 had refused to go to an appointment that morning (9/8/14) because his "physician made decisions without his permission or knowledge" with a "bad pain doctor". He also said he "doesn't get enough" Klonopin to help manage his pain and the facility "won't get an increase". H

Based on observation, interview, and record review, the facility failed to ensure significant medications errors (ones which cause the resident discomfort or jeopardizes his or her health and safety) were not committed for two residents (Residents 2 and 9) receiving medications from Cart 3 on the evening of 9/10/14 during the 5:00 pm medication pass. Findings include: The following observations were made on 9/10/14 between 4:35 pm and 8:04 pm, with Licensed Vocational Nurse (LVN) 118 during the 5:00 pm medication pass: 1a. At 5:22pm, Resident 2 was not in her room when LVN 118 went to perform the resident's 5:00 pm Finger Stick Blood Sugar (FSBS) check. b. At 5:59 pm while LVN 118 was still passing medications, Resident 2 went by the medication cart in her wheel chair. LVN 118 asked Resident 2 if she had eaten her dinner and Resident 2 stated she had eaten her dinner. LVN 118 stated she had not performed her FSBS before dinner. Resident 2 told LVN 118 she could perform the FSBS at 9:00 pm. Resident 2 was not administered her routine 5:00 pm insulin. A review of the clinical record noted Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. The [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a comprehensive assessment of the resident) completed on 8/12/14, noted the Brief Interview for Mental Status (BIMS, determines ones mental capacity) was 14. A score of 13 to 15 stipulated the resident was cognitively intact. A review of the 9/14 physician orders [REDACTED]. a. "8/27/14, Finger Stick Blood Sugar (FSBS) before every meal and at bedtime: 7:00 am, 11:30 am, 5:00 pm, 9:00 pm with Humalog (brand name of medication) Insulin (a hormone that regulates the metabolism of food) sliding scale coverage (determines additional doses) for the following blood glucose results (measured in milligrams/deciliter (mg/dl)): < 60 (blood glucose) = call MD (medical doctor) 60 - 149 = 0 units of insulin 150 - 200 = 2 units 201 - 250 = 4 units 251 - 300 = 6 units 301 - 350 = 8 units 351 - 400 = 10 units > 400 = call MD b. 8/27/14, Humalog Insulin 9 units subcutaneous (SQ) daily at 5:00 pm with meals". Although observation revealed Resident 2 did not receive the 5:00 pm dose of insulin, review of the 9/14 finger stick blood sugar (FSBS) log revealed LVN 118 documented: a. "9/10/14 4:30 pm, FSBS was not obtained. Res (resident) has already eaten dinner when offered". b. Humalog 9 units SQ Q (every) 5:00 pm with meals was initialed and documented, stipulating the insulin was administered in the resident's arm on 9/10/14 at 5:00 pm with meals. On 9/11/14 at 9:53 am an interview was conducted with Resident 2. When asked if she received insulin on 9/10/14 at 5:00 pm Resident 2 stated, "No, you was with the nurse yesterday, did you see her give me any insulin? They take too long to pass medications and I want to eat my food when it's hot. My expectation is that the nurse passing the medications will pass the medications on time and know what medications they are giving you and when they should pass it". She further stated, "I am a brittle diabetic and my sugars ran from 35 (mg/dl) to 567 (mg/dl). I have experienced diabetic coma in the past". When asked about refusing her medications, Resident 2 stated, "I do not refuse, they are just late passing the medications". When asked if the medications were administered late on a particular shift, Resident 2 stated, "It depends on the nurses. Some of the nurses are new and do not know how to pass medications on time". The following facility policies and procedures were reviewed: 1. "Medication - Administration", revised 1/1/12, noted: "1. A. ii Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines; "B. i. Medications may be administered one hour before or after the scheduled medication administration time". 2. "Diabetic Care", revised 1/1/2012, noted, "1. A Licensed Nurse will monitor the resident's blood glucose per the Attending physician's orders [REDACTED]. 2. A review of the clinical record noted Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medication included [MEDICATION NAME] (name-brand anti-[MEDICAL CONDITION] medication). Further review of the record revealed Resident 9 was transferred to the hospital on [DATE] for prolonged [MEDICAL CONDITION] activity. Review of hospital records revealed on 9/6/14 the resident's [MEDICATION NAME] acid [MEDICATION]) level (drug blood level) was less than 12.5 (micrograms/milliliter(mcg/ml)), with a reference range of 50-100 (mcg/ml). Review of hospital discharge instructions revealed the resident's "[MEDICATION NAME] level was below detection and not therapeutic". Current physician orders [REDACTED]. a. "Finger Stick Blood Sugars (FSBS) before meals at 6:30 am and 4:30 pm. Call the physician for FSBS less than 60 (mg/dl) and greater than 400 (mg/dl); b. [MEDICATION NAME] [MEDICATION]) 500 milligrams/10 milliliters two times daily (9:00 am, 5:00 pm)". Observation during medication pass on 9/10/14 between 4:35 pm and 8:04 pm with LVN 118 revealed Resident 9 did not receive the 5:00 pm dose of [MEDICATION NAME] until 8:04 pm. In addition, observation revealed the FSBS was not performed as ordered. (Refer to F 224, F 309, F 332.) The failure to administer [MEDICATION NAME] as ordered was considered a significant error as this medication needed to be administered accurately and timely to maintain a constant blood level to reduce the reoccurrences of [MEDICAL CONDITION].