Every finding on record at Villa del Sol Post Acute

Based on observation, interview, and record review, the facility failed to ensure the room temperature of two of twelve sampled residents (Resident 3 and Resident 13) was within normal range (71-81 Fahrenheit [a temperature scale used to measure freezing and boiling degrees under standard atmospheric pressure]). The thermostat of Resident 3 and Resident 13's room was 85 degrees Fahrenheit. This failure resulted in Resident 3 and Resident 13 feeling uncomfortable and frustrated and had the potential to negatively affect their quality of life.Findings: A. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis including hypertension (HTN-high blood pressure) cerebral infarction (a disruption of blood flow into the brain) with left hemiplegia (paralysis that affects one side of the body), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and obesity (a disease of having too much fat). During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool) dated 7/3/2026, the MDS indicated Resident 3 was able make decisions that were reasonable and consistent and required one to two person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing, toileting, repositioning in bed and transferring from chair to bed and vice-versa to a person performs daily). The MDS indicated Resident 3 was frequently incontinent (loss of control) with bowel and bladder functions. During a review of Resident 3's untitled care plan revised 7/30/2021, the care plan indicated Resident 3 had a psychosocial well-being problem related to cerebrovascular disease (stroke- a condition that interfere with blood flow to the brain), depression (a mood disorder that causes persistent feelings of sadness and loss of interest) and obesity. The care plan indicated goals including for Resident 3 to be free from problems of psychosocial well-being with interventions including communication between Resident 3, her family members and caregivers about care and living environment. B. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including vertigo (a feeling that one or its environment him, is moving or spinning), hypertension, obesity and chronic pain (pain that lasts longer than three months in one or more parts of the body).During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13 was able make decisions that were reasonable and consistent and required one to two person assist to complete her ADLs such as bathing, dressing, toileting, bed mobility such as rolling left and right, sitting to lying position and vice versa and standing from sitting position in bed. The MDS indicated Resident 13 was frequently incontinent with bowel and bladder functions. During a review of Resident 13's untitled care plan revised 11/5/2025, the care plan indicated Resident 13 has acute and chronic pain. The care plan indicated a goal for Resident 3 to have satisfactory pain control with interventions including monitoring for factors that precipitate (cause to happen suddenly) and aggravate (to make worse or more severe) pain and to utilize non-medication interventions for pain relief. During an observation and interview on 7/24/2026 at 4:10 p.m., Resident 3 was in a sitting position in her bed with a frown on her face and she (Resident 3) stated it was her birthday that day, but her room was warm and she was displeased instead of being happy. Resident 3 stated even though the facility provided her a fan, she was still uncomfortable. During an observation and interview on 7/24/2026 at 4:40 p.m., Resident 13 was in a sitting position in her bed with a look of discomfort on her face and she (Resident 13) stated her room has been warm today and her pain was getting worse. Resident 13 stated the facility provided her a fan, but it was not helping.During an interview on 7/24/2026 at 5:04 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 3 and Resident 13 have verbalized to her during rounds that it was warmer that day and Resident 3 and Resident 13 were frustrated. CNA1 stated she informed all the licensed nurses about it. CNA1 stated the temperature in the resident care areas should always be comfortable for the residents to feel happy. During an observation on 7/24/2026 at 5:05 p.m., Licensed Vocational Nurse (LVN)1 confirmed the thermostat in the room of Resident 3 indicated a temperature of 85 degrees Fahrenheit. During a subsequent interview, LVN 1 stated the care areas of Resident 3 and Resident 13 felt warmer that day and Resident 3 and Resident 13 have complained about the warmth of their room at 3p.m. to 11 p.m. shift. LVN1 stated the room temperature of the resident care areas should have been within normal range (71 to 81 degrees Fahrenheit) to ensure their comfort and quality of life. During an interview on 7/24/2026 at 5:08 p.m., Maintenance Director (MTD) stated he was not informed by the nursing staff that Resident 3 and Resident 13 were uncomfortable in their rooms. MTD stated he had performed spot checks on the residents' room temperatures that day, but Resident 3 and Resident 13 rooms were not scheduled to be checked. MTD stated since it was summer and the weather tend to get hot; he and all of the facility staff should have checked all of the resident care areas daily to identify any resident's room that needs attention. During an interview on 7/25/2026 at 12:45 p.m., the Administrator (ADM) stated it was the responsibility of all facility staff to work together to ensure the residents are comfortable in their care areas during extreme weather conditions for a safe and comfortable environment. During a review of the facility's Policy and Procedure (P/p) titled Safe and Homelike Environment revised 12/19/2022, the P/p indicated the facility shall provide a safe, clean, comfortable and homelike environment by, but not limited to, ensuring the ambient temperatures in the facility and the resident care areas must be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hyperthermia and is comfortable for the residents. During a review of the facility's Policy and Procedure (P/p) titled Resident Rights revised 12/19/2022, the P/p indicated the residents has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interview and record review the facility failed to ensure one of three residents' (Resident 1) prescription (physician ordered) medications were acquired and administered in a timely manner.The failure resulted in a disruption of Resident 1's treatment plan and had the potential to delay recovery and put Resident 1's health at risk.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes (chronic condition where the body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels) with foot ulcer (open sore), end stage renal disease (ESRD -irreversible kidney failure), atherosclerosis of coronary artery bypass graft (the development or progression of fatty plaque within the surgically implanted vessels), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), stricture of artery (restricted blood flow), nonrheumatic aortic valve stenosis (narrowing of the heart's aortic valve that restricts blood flow from the left ventricle to the aorta), gastroesophageal reflux disease (GERD - chronic digestive condition where stomach acid and contents repeatedly flow back up into the esophagus), and anxiety disorder (persistent, excessive worry or fear that is disproportionate to everyday situations and interferes with daily activities).During a review of Resident 1's Progress Notes titled Nursing advanced Clinical Admission, 6/6/2026 at 1 a.m., the notes indicated Resident 1 was alert and oriented with some confusion. The notes indicated resident 1 was able to move all extremities. During a review of Resident 1's Order Summary Report, the orders indicated the following medications, 6/5/2026: 1. Aspirin 81 milligrams Oral Tablet (medication to prevent cerebrovascular accident (loss of blood flow to a part of the brain) one tablet by mouth one time a day.2. Alprazolam Oral Tablet (medication for anxiety) 0.25 milligrams, one tablet by mouth every 8 hours as needed.3. Carvedilol Oral Tablet (medication for high blood pressure)3.125 milligrams, one tablet by mouth two times a day.4. Clonazepam Tablet 0.5 milligrams (medication for anxiety) one tablet by mouth at bedtime.5. Fentanyl Patch (pain medication) 72 Hour 25 microgram per hour, one patch trans dermally (on the skin) every 72 hours.6. Midodrine Oral Tablet 5 milligrams, one tablet by mouth every morning and at bedtime for (low blood pressure).7. Sucroferric Oxyhydroxide Oral Tablet Chewable 500 milligrams (medication for GERD) one tablet by mouth in the morning.8. Xphozah Oral Tablet 30 milligrams (medication for chronic kidney disease) one tablet by mouth in the morning.9. Lactulose Solution (medication to help with bowel movement) 20 grams by mouth every morning and at bedtime.10. Farxiga Oral Tablet 5 milligrams (medication for diabetes) one tablet by mouth one time a day. 11. Megestrol Acetate Suspension (medication to help increase appetite) 400 milligrams by mouth one time a day 12. Metoprolol (medication for high blood pressure) 25 milligrams one tablet by mouth one time a day. 13. Sodium Zirconium Cyclosilicate Oral Packet 5 grams (medication for chronic kidney disease) 1 packet by mouth in the morning.14. Terazosin HCl Oral Capsule 1 MG (medication for high blood pressure) one capsule by mouth in the morning.During a concurrent interview and record review on 6/29/2026 at 12:17 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Medication Administration Record, (MAR), 6/2026, was reviewed. The ADON stated Resident 1 missed one dose of Aspirin, Clonazepam, Farxiga, Megestrol, metoprolol, Sodium Zirconium Cyclosilicate Oral Packet, Sucroferric Oxyhydroxide Oral Tablet Chewable, lactulose, and the fentanyl Patch. The ADON stated Resident 1 missed two doses of Tenapanor HCl and Midodrine. The ADON stated Resident 1 missed 3 doses of Carvedilol Oral Tablet. The ADON stated the physician was not notified of the missed doses.During a concurrent interview and record review on 6/29/2026 at 12:17 p.m., with the (ADON), Resident 1's Pharmacy Manifest and Consolidated Delivery Sheets, 6/6/2026, were reviewed. The ADON stated the Xanax, Fentanyl Patch, and Clonazepam were not delivered.During an interview with the Director of Nursing (DON) on 6/29/2026 at 1:12 p.m. the DON stated that medications ordered need to be acquired and administered as physician ordered to help their medical condition. During a review of the facility's Policy and Procedure (P/P) titled, Medication Administration, revised 12/19/2022, the P/P indicated medication will be administered as ordered by the physician in accordance with professional standards in a timely manner.During a review of the facility's P/P titled, Medication Reordering, revised 12/19/2022, the P/P indicated acquisition of medication should be completed in a ensure medications are administered in a timely manner to meet the resident's needs.

Based on interview and record review the facility failed to ensure one of one resident's (Resident 1) blood glucose (simple sugar - the body's primary source of energy) level was checked prior to insulin (hormone that removes excess sugar from the blood can be produced by the body or given artificially via medication) administration.The failure had the potential to result in hypoglycemia (low blood glucose). Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes (chronic condition where the body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels) with foot ulcer (open sore).During a review of Resident 1's Progress Notes titled Nursing advanced Clinical Admission, 6/6/2026 at 1 a.m., the notes indicated Resident 1 was alert and oriented with some confusion. The notes indicated Resident 1 and was able to move all extremities. During a review of Resident 1's Order Summary Report, 6/5/2026, the orders indicated 6/5/2026, Insulin Glargine (medication for diabetes), Inject 10 units subcutaneously (under the skin) at bedtime. During a concurrent interview and record review on 6/29/2026 at 12:17 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Medication Administration Record, (MAR), 6/2026, and medical records was reviewed. The ADON stated Resident 1 received the insulin dose on 6/6/2026 at 9 pm but there was no blood glucose level documented. The ADON stated the blood glucose level should have been checked prior to insulin administration.During an interview with the Director of Nursing (DON) on 6/29/2026 at 1:12 p.m., the DON stated that the blood glucose level needs to be checked prior to insulin administration. During a review of the facility's Policy and Procedure (P/P) titled, Nursing Care of the Resident with Diabetes Mellitus, revised 12/19/2022, the P/P indicated medication will be administered as ordered by the physician in accordance with professional standards in a timely manner.During a review of the facility's P/P titled, Medication Reordering, revised 12/19/2022, the P/P indicated the purpose of the policy was to prevent hypoglycemia and hyperglycemia (high blood glucose). The P/P indicated documentation should reflect carefully assessed diabetic resident including blood sugar results.

Based on interview and record review the facility failed to ensure one of one resident's (Resident 1) medical records were accurate.This failure resulted in an inaccurate depiction of resident status.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes (chronic condition where the body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels) with foot ulcer (open sore), end stage renal disease (ESRD -irreversible kidney failure), atherosclerosis of coronary artery bypass graft (the development or progression of fatty plaque within the surgically implanted vessels), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), stricture of artery (restricted blood flow), nonrheumatic aortic valve stenosis (narrowing of the heart's aortic valve that restricts blood flow from the left ventricle to the aorta), gastroesophageal reflux disease (GERD - chronic digestive condition where stomach acid and contents repeatedly flow back up into the esophagus), and anxiety disorder (persistent, excessive worry or fear that is disproportionate to everyday situations and interferes with daily activities).During a review of Resident 1's Progress Notes titled Nursing advanced Clinical Admission, 6/6/2026 at 1 a.m., the notes indicated Resident 1 was alert and oriented with some confusion. The notes indicated Resident 1 was able to move all extremities. During a review of Resident 1's Order Summary Report, the orders indicated the, Oxycodone HCl Tablet (pain medication) 15 milligrams one tablet by mouth every 4 hours as needed dated 6/5/2026 During a concurrent interview and record review on 6/29/2026 at 12:17 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Medication Administration Record, (MAR), 6/2026, was reviewed. The ADON stated Resident 1 received three doses of Oxycodone, on 6/6/2026 at 1:52 p.m. 6/7/2026 at 4:29 p.m., and 6/7/2026 at 11:24 p.m. During a concurrent interview and record review on 6/29/2026 at 12:17 p.m., with the ADON, the facility's Emergency Kit log was reviewed and the log indicated Resident 1 received Percocet on 6/6/2026 at 1:52 p.m. 6/7/2026 at 4:15 a.m., and on 6/7/2026 at 4:22 p.m. The ADON stated Resident 1's MAR documentation was incorrect because the resident passed away on 6/7/2026 at approximately 5:19 p.m.During an interview with the Director of Nursing (DON) on 6/29/2026 at 1:12 p.m. the DON stated that medical records need to be accurate to reflect the residents' actual condition. During a review of the facility's Policy and Procedure (P/P) titled, Documentation in Medical Record, revised 12/19/2022, the P/P indicated documentation needs to be accurate and factual.

Based on interview and record review, the facility failed to ensure Certified Nurse Assistant (CNA) 1 did not allow a resident (Resident 1) who was assessed as a fall risk, had a history of a fall, and required substantial/maximum assistance (helper does more than half of the effort) from staff for transfers and mobility, ambulate to the bathroom alone, and without assistance for one of three sampled residents (Resident 1). This failure resulted in Resident 1 falling from the bed on 11/8/2025 and had the potential for Resident 1 to sustain more serious injuries such as brain injury, fractures (a partial or complete break in the bone), and death. Resident 1 was transferred to a General Acute Hospital (GACH) for further evaluation. 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]. Resident 1 had diagnoses including cerebral infarction (a type of stroke caused by a blockage or blood flow to part of the brain), difficulty walking and muscle weakness.During a review of Resident 1's History and Physical (H&P), dated 10/28/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/30/2025, the MDS indicated Resident 1's cognition (ability to register and recall information) intact was able to understand and be understood by others. The MDS indicated Resident 1 required substantial/maximum assistance from staff for rolling left to right (ability to roll from lying on back to left and right side, and return to lying on back on the bed), sit to lying (ability to move from sitting on side of the bed to lying flat on the bed), lying to sitting on the side of the bed (ability to move from lying on the back to sitting on the side of the bed with no back support), and sit to stand (ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed). The MDS indicated Resident 1 was frequently incontinent (involuntary voiding of urine and stool) in both his bowel and bladder functions. The MDS indicated Resident 1 had impairment on side of his body affecting both his upper and lower extremities. During a review of Resident 1's Fall Risk Evaluation, dated 10/25/2025, the Fall Risk Evaluation indicated Resident 1 was at risk for falls.During a review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents), dated 10/25/2025, the SBAR indicated Resident 1 had an unwitnessed fall and was reported to have rolled out of bed on 10/25/2026 at approximately 3:38 a.m.During a review of Resident 1's SBAR, dated 11/8/2025, the SBAR indicated Resident 1 had witnessed fall on 11/8/2025 at approximately 5:20 p.m. The SBAR indicated CNA 1 asked Resident 1 if Resident 1 needed help, Resident 1 stated he wanted to go the restroom, but he did not need any help walking and going to the bathroom. The SBAR indicated Resident 1 stood up, took a few steps before losing strength in his left leg falling on his left side onto the floor and rolling onto his back. During a review of Resident 1's Order Summary Report (Physician's Orders), dated 11/8/2025, the Physician's Orders indicated an order was written to transfer Resident 1 to a GACH for further evaluation to determine whether he sustained injuries resulting from the fall. During a review of Resident 1's Transfer Form, dated 11/8/2025, the Transfer Form indicated Resident 1 was transferred to a GACH on 11/8/2025 at 8:47 p.m.During a review of Resident 1's GACH Discharge Documents, dated 11/8/2025, the Discharge Documents indicated Resident 1 underwent laboratory tests, Computed Tomography ([CT] an imaging test that uses multiple X ray [an imaging test that uses a small amount of radiation to create pictures of structures inside the body, such as bones and organs] pictures and a computer to create detailed images of the inside of the body) scan of the head, Electrocardiogram ([EKG] a test that records the electrical activity of the heart), and X-ray during the emergency department evaluation. No serious findings were identified and Resident 1 returned to the facility on [DATE].During a telephone interview on 6/23/2026 at 3 p.m., CNA 1 stated that on 11/8/2025 she entered Resident 1's room and asked if he needed assistance. Resident 1 said he needed to use the restroom. CNA 1 stated she did not know Resident 1's level of functioning and asked if he needed help ambulating. Resident 1 told her he could go alone. CNA 1 stated she watched Resident 1 stand up from the bed and take a few steps before he fell to the floor. She stated she could not prevent the fall because she was unable to stop or catch him. CNA 1 also stated she did not know Resident 1 required maximum assistance to stand and ambulate and acknowledged she should have provided the appropriate level of assistance when he said he wanted to go to the restroom.During an interview on 6/23/2026 at 3:55 p.m., the Physical Therapist (PT) stated that based on his review of Resident 1's Physical Therapy evaluation dated 10/25/2025, Resident 1 required substantial to maximum assistance (resident performs 25 percent or less of the physical effort required to complete a task, such as standing, transferring, or walking. Staff provide most or all physical support, which may include lifting, stabilizing, guiding movement, or supporting the resident's weight to ensure safety during the activity) for transfers, including moving from sitting to standing. The PT stated Resident 1 could ambulate 10 feet only with substantial or maximum assistance and to maintain Resident 1's safety, bedside staff must be present to provide this level of assistance whenever Resident 1 attempts to get out of bed to use the restroom.During an interview on 6/23/2026 at 4:30 p.m., the Director of Nursing (DON) stated the nursing staff should have provided the appropriate level of assistance to Resident 1 when he stated he wanted to ambulate to the restroom. The DON noted that at the beginning of the shift, the staff discusses residents 'needs and their plan of care during huddles. The DON stated verbal communication can be inconsistent and stated the facility would benefit from an alternative method to support staff awareness of residents' required assistance levels. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living, (ADLs), revised 12/19/2022, the P&P indicated the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable, care and services may consist of the following activities of daily activities such as bathing, dressing, grooming, and oral care, transfer and ambulation, toileting.During a review of the facility's P&P titled, Fall Prevention Program, revised 4/2026, the P&P indicated each resident will be assessed for fall risk and will receive care and services in accordance with their individual level of risk to minimize the likelihood of falls.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person centered care plan for two of ten sampled residents (Resident 19 and Resident 23) by failing to:A. Ensure a comprehensive care plan was initiated for Resident 19 addressing hearing needs and physical therapy ([PT], a rehabilitation profession that restores, maintains, and promotes optimal physical function) services.B. Develop, and implement a comprehensive, person centered care plan addressing Resident 23's toenail fungal infection as recommended by the podiatrist.These failures had the potential to result in unmet needs for Residents 19 and 23, negatively affecting their well being and contributing to poor resident outcomes.Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including fracture of surgical neck of right humerus (a type fracture [broken bone] of the upper arm), diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 19's history and physical (H&P), dated [DATE], the H&P indicated Resident 19 had the capacity to understand and make decisions. During a review of Resident 19's Minimum Data Set ([MDS], a resident assessment tool) dated [DATE], the MDS indicated Resident 19 was severely impaired in cognitive (thought process) functioning and required substantial support. The MDS indicated Resident 19 required supervision (helper provides verbal cues as resident completes activity) with eating but was dependent (helper does all the effort) with hygiene, bathing and dressing. The MDS indicated Resident 19 was dependent with mobility such as rolling, sitting and transfers. During a review of Resident 19's Order Summary Report, the Order Summary Report indicated that resident may have ear, nose and throat consultation as needed. The Order Summary Report indicated PT and or occupational therapy ([OT], a healthcare profession that helps people of all ages regain or improve the skills needed for daily living and working) evaluation and treatment. During a review of Resident 19's hearing consult note dated [DATE], the hearing consult notes indicated Resident 19 had moderately severe hearing loss to both left ear and right ear. The hearing consult note indicated the resident had hearing loss significant enough to qualify for hearing aids (a small, electronic, battery-operated medical device worn in or behind the ear that amplifies sound) and was eligible for them. The hearing consult note indicated Resident 19 had a greater hearing loss at higher frequencies (measure the number of sound wave vibrations per second) in the left ear, meaning the resident had greater difficulty discriminating between different sounds during conversations and hearing higher-pitched voices and sounds. During a review of Resident 19's physical therapy (PT) notes dated [DATE], the physical therapy notes indicated Resident 19 currently presented with generalized weakness and impaired bilateral (both) ankle range of motion ([ROM], full movement potential of a joint) resulting in increased immobility which limits Resident 19's independence with functional mobility (ability to move around to do activities of daily living). Resident 19 will benefit with PT services at this time to address these impairments with therapeutic exercises (planned performance of physical movements, postures, or activities designed to prevent impairments, restore physical function, reduce pain, and improve overall health and fitness) and activities (a structured physical activity prescribed to restore or maintain strength, flexibility, balance, and endurance), neuromuscular re-education (a PT/OT technique designed to retrain the nervous system to communicate properly with your muscles), wheelchair training to improve resident's muscle strength and endurance and improve her skills with functional activities (the physical and cognitive tasks performed in daily life, such as walking, eating, dressing, or working) to promote her return to prior level of function. During a review of Resident 19's occupational therapy (OT, rehabilitative profession that provides services to increase and/maintain a person's capability to participate in everyday life activities) notes dated [DATE], the occupational therapy notes indicated that Resident 19 presented with impairments in strength, gross motor coordination (involves using the large muscles in the arms, and legs to do movements like walking, running, and jumping), fine motor coordination (the ability to use small muscles in the hands, fingers, and wrists to perform small, and accurate movements), functional activity tolerance (a person's capacity to perform daily tasks like bathing, walking, or working without experiencing physical and/or emotional tiredness), active (engaging in action, producing motion) range of motion on right shoulder and postural stability (the ability to maintain the body's center of gravity within its base of support, allowing a person to stay upright) and balance resulting in limitations and/or restrictions in the areas of self-care and mobility which requires skilled OT services to increase independence with activities of daily living ([ADLs], basic, everyday self-care tasks required to manage one's health and maintain physical independence), maximize independence with ADLs, increase functional activity tolerance, strengthening, facilitate being able to sit, increase safety awareness and maximize rehabilitation (the process of helping individuals restore, maintain, or improve the physical, mental, or cognitive abilities they need for daily living) potential in order to live in environment with least amount of supervision. During a review of Resident 19's comprehensive care plan, undated, the comprehensive care plan did not indicate a focus or problem statement identifying the resident's hearing deficit or need for hearing aids, nor goals and interventions to ensure the resident could hear adequately and maintain functional hearing ability. The comprehensive care plan did not include focus or problem statement identifying that Resident 19 was receiving PT and OT services, nor goals and interventions to prevent decline in mobility or range of motion. During a concurrent interview and record review on [DATE] at 2:08 p.m., with the Social Services Director (SSD), Resident 19's undated comprehensive care plan was reviewed. The SSD stated there was no care plan implemented for Resident 19's hearing loss, and/or need for hearing aids. The SSD stated a care plan was a plan of care for residents with interventions and goals for addressing the specific needs of the residents. The SSD stated there should have been a care plan implemented for hearing loss with revisions as needed to make sure the goals and interventions are aligned with the resident's needs. During an interview on [DATE] at 4:25 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated there should be a care plan for residents receiving PT and/or OT services. RNS 1 stated there should be a care plan for residents receiving therapy, so the goals and interventions aligned with the resident's treatments. During a concurrent interview and record review on [DATE] at 4:32 p.m., with the Director of Rehabilitation (DOR), the physical therapy notes and occupational therapy notes dated [DATE] and comprehensive care plan, undated were reviewed. The DOR stated Resident 19 was receiving PT and OT services and started doing therapy with standing and splint placement. The DOR stated care plan for PT and OT should have been implemented for Resident 19 and that it was something the nursing staff should have started when Resident 19 was started on therapy services. The DOR stated a care plan was a plan of care for residents and how to care for the residents in the facility based on the services they receive. During an interview on [DATE] at 3:15 p.m. with the Director of Nursing (DON), the DON stated a care plan was important because it guides the facility staff for the care being provided to the residents. care plan should be implemented for each resident based on the care needed. The DON stated the care plan for hearing aid, HOH, and hearing loss should have been implemented because Resident 19 was hard of hearing, had a hearing test done that required hearing aids. The DON stated the care plan should be implemented to make sure the goals and interventions apply to the residents and if the interventions need to be revised, it can be revised as needed. The DON stated the care plan for PT/OT services should have been implemented. The DON stated a care plan for therapy was to see if the resident was getting better with the therapy services provided. The DON stated the care plan should have been implemented to follow the care of the resident receiving therapy services. During a review of the facility's policy and procedures (P&P) titled Comprehensive Care Plans, revised on [DATE], indicated, it is the policy to develop and implement a comprehensive person-centered care plan for each resident, consistent with 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 resident's comprehensive assessment. the comprehensive care plan will describe the following such as the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and any services that would otherwise be furnished.the comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress and alternative interventions will be documented, as needed. B. During a review of Resident 23's admission Record, the admission record indicated Resident 23 was initially admitted to the facility on [DATE] and was last readmitted on [DATE] with diagnoses including End Stage Renal Disease (ESRD – irreversible kidney failure), anemia (a condition in which the body does not have enough healthy red blood cells), heart failure (a condition in which the heart has difficulty pumping enough blood to meet the body's needs), and DM. During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23's cognition was moderately impaired. The MDS indicated Resident 23 required maximal assistance (helper performs more than half of the effort) from one staff member for toilet hygiene and showering, moderate assistance (helper performs less than half of the effort) from one staff member for bed mobility, transfers, and dressing, and supervision or touching assistance (helper provides verbal cues and/or touching, steadying, or contact guard assistance while the resident completes the activity) from one staff member for oral hygiene and eating. During a concurrent observation and interview on [DATE], at 9:40 a.m., with Resident 23 in her room, Resident 23 was observed lying in bed watching television and asked to have her socks removed so her toenails could be observed. Resident 23's toenails were brittle, thick, long, and blackish yellow in color. Resident 23's feet appeared dry, and skin flakes were noted falling off when the socks were removed. Resident 23 stated she had been seen by the podiatrist few months ago but had not received any treatment for the fungal infection on her toenails. Resident 23 stated her toenails were long and painful when she stood up or when they were touched. Resident 23 stated the appearance of her infected toenails caused her embarrassment. Resident 23 stated if the facility podiatrist could not treat her toenails, she wanted to be seen by an outside specialist. During a review of Resident 23's Order Summary Report (OSR), dated [DATE], the OSR indicated an order for may see podiatrist was ordered on [DATE]. The OSR indicated an order dated [DATE] to apply A&D ointment (ointment that helps protect and heal skin) to the left and right foot and leave open to air for 60 days. The OSR also indicated that hydrocortisone 1% external cream (a medication used to treat itchiness and inflammation) was ordered on [DATE] to be applied topically to the affected area every six hours as needed for itchiness. The OSR indicated there was no order for clotrimazole (a medicated ointment to treat fungal infection) 1 percent (%) cream. The OSR indicated there were no orders to place a foot pillow or to avoid Resident 23 being barefoot during transportation as recommended. During a concurrent interview and record review on [DATE], at 11:38 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 23's Convalescent Podiatry Care Evaluation & Treatment, note dated [DATE], was reviewed. The Convalescent Podiatry Care Evaluation & Treatment note indicated Resident 23's toenails were thickened, discolored, brittle, and painful upon palpation (assessing a body with touch) . The Convalescent Podiatry Care Evaluation & Treatment note indicated Resident 23 had requested topical (applied to the skin) medication. The Convalescent Podiatry Care Evaluation & Treatment note indicated, the podiatrist recommended applying clotrimazole (a medicated ointment to treat fungal infection) 1 percent (%) cream daily, elevating the lower extremities with a foot pillow, applying lotion per facility protocol (A&D ointment or ammonium lactate 12%), providing footwear with a wide toe box, flexible upper, good arch support, and cushioned insoles, and avoiding going barefoot during transportation. RNS 1 stated that all recommendations should have been carried out as ordered and care -planned. RNS 1 stated she was unaware of the current condition of Resident 23's toenails. RNS 1 stated facility staff should have followed through with the podiatrist's recommendations to prevent further deformity (the state of being misshapen, distorted, or malformed) and pain in Resident 23's toenails. During a concurrent interview and record review on [DATE], at 4:07 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 23's Care Plan Report (CPR) titled Resident 23 has impairment to skin integrity related to fungal infection of bilateral toenails, revised [DATE], was reviewed. The CPR Goal indicated that the resident's condition would resolve without complication by the next review date of [DATE]. The CPR Interventions included monitoring for adverse effects of clotrimazole use, providing treatment as ordered, keeping the skin and toenails clean and dry, and obtaining a podiatry consultation as ordered. The MDSC stated that the podiatrist's recommended interventions should have been reflected in the care plan and implemented to prevent worsening of the infection and to appropriately treat the current condition. The MDSC stated the order for a foot pillow under the both feet was not implemented. The MDSC stated that the intervention treatment as ordered was not specific and should have listed the recommended treatments. During an interview on [DATE], at 11:28 a.m., with the DON, the DON stated that the resident's care plan is the resident's specific plan of care and should be implemented as written. The DON stated that care plan interventions should be implemented and routinely reevaluated. The DON further stated that care plan interventions should reflect the recommendations from specialists and should be implemented to prevent recurrent events or complications. During a review of the facility's P&P titled Comprehensive Care Plan, revised [DATE], the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with 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 resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment . 7. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options.

Based on interview and record review, the facility failed to ensure two out of four sampled residents (Resident 13 and 89) received Restorative Nursing Assistance services ([RNA] services focused on helping residents regain or maintain physical mobility) as indicated in the care plan. These failures had the potential to result in physical decline.Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident13 was admitted to the facility on [DATE] with diagnoses including fracture (broken bone) of lower end of left femur (thigh bone), subsequent encounter for closed fracture (bone breaks but the skin remains intact) with routine healing, general weakness, lack of coordination, abnormal posture, and derangement of meniscus (damage in the knee) due to old tear, unspecified knee.During a review of Resident 13's Minimum Data Set ([MDS] a resident assessment tool), dated 3/20/2026, the MDS indicated Resident 13's cognition was intact. The MDS indicated Resident 13 needed set-up assistance with oral hygiene and partial assistance (helper does less than half the effort to complete the task) with toileting hygiene, showering, and dressing. During a review of Resident 13's undated Care Plan titled, Restorative Nursing Program the intervention indicated, starting 4/9/2026, Active Range of Motion ([AROM] movement of a joint produced entirely by the resident's own voluntary muscle contractions, without any outside assistance) both upper extremities (arms), three times a week as tolerated.During a review of Resident 13's undated Care Plan titled, Potential for decline in range of motion (the measurement of the distance and direction a specific joint can move), bed mobility skills, self-feeding skills related to fracture indicated the intervention, starting 4/9/2026, AROM right lower extremities, gentle Active Assist of Range of Motion ([AAROM] a physical therapy and rehabilitation technique where the resident uses their own muscle power to move a joint, while an external force-such as a therapist assists with the movement) left lower extremity, or may use bilateral lower extremity (BLE) omni cycle (motorized equipment used for rehabilitation) for 15 minutes three times a week, as tolerated.During a review of Resident 13's Documentation Survey Report v2, 4/2026 and 5/2026, the report indicated the facility staff did not administer RNA services three times a week during the weeks of 4/19/2026, 4/26/2026, and 5/3/2026. During a concurrent interview and record review on 5/19/2026 at 3:06 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 13's RNA services provided from 4/2024 to 5/2026 were reviewed. RNS 1 stated Resident 13 did not receive RNA services from 4/2024 to 5/2026 three times a week as care planned. During a review of Resident 89's admission Record, the admission Record indicated Resident 89 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis (muscle break down), contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) in multiple sites, and reduced mobility. During a review of Resident 89's MDS, dated [DATE], the MDS indicated Resident 89's cognition was moderately impaired. The MDS indicated Resident 89 needed supervision when eating, partial assistance with oral hygiene, toileting hygiene, maximal assistance (helper does more than half the effort to complete the task) with personal hygiene, and showering. During a review of Resident 89's undated care plan titled, Restorative Nursing Program indicated the following interventions, starting 6/26/2025:1. AAROM both upper extremities, five times a week.2. Apply knee splints (medical device used to immobilize, protect, and support an injured body part) to left and right knees, to be worn by the resident for up to 3 hours five times a week, as tolerated.3. Passive Range of Motion ([PROM] movement applied to a joint entirely by an external force-such as a caregiver) both lower extremities five times a week as tolerated.During a review of Resident 89's Documentation Survey Report v2, 11/2025, 12/2025, and 1/2026, the reports indicated RNA services were not administered five times a week: on the weeks of 11/9/2025, 11/23/2025, 11/30/2025, 12/21/2025, and 1/4/2026. During a concurrent interview and record review on 5/21/2026 at 10:33 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 89's RNA services provided from 11/2025 to 1/2026 were reviewed and RNS 1 stated Resident 89 did not receive RNA services from 11/2025 to 1/2026 five times a week as care planned. During an interview on 5/21/2026 at 12:24 p.m. with the Director of Nursing (DON), the DON stated RNA services were important to maintain and improve the residents' range of motion. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Programs, revised 4/20/2026, the P&P indicated it was the policy of the facility to provide maintenance and restorative services to maintain or improve resident's abilities to the highest practicable level.

Based on interview and record review, the facility failed to ensure bowel and bladder frequency was documented according to facility documentation practices for one of one sample resident (Resident 14).This failure had the potential to result in delay of diagnosis and treatment of bowel or bladder issues.Findings:During a concurrent interview and record review on 5/20/26 at 10:27 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 14's B&B- Bowel elimination documentation and medication administration record (MAR) dated 5/4/2026 through 5/10/2026 were reviewed. LVN 3 stated the documentation indicated Resident 14 did not have a bowel movement from 5/4/2026 through 5/10/2026. LVN 3 stated if a resident has no bowel movement in three days that facility will implement interventions and give administer stool softeners indicated.During an interview on 5/20/2026 at 10:27 a.m. with LVN 4, LVN 4 stated she remembered Resident 14 having a bowel movement within the timeframe of 5/4/2026 through 5/10/2026 because she translates for the CNAs to communicate to with residents. During an interview on 5/20/2026 at 10:48 a.m. with Resident 14 and LVN 4, LVN 4 translated and inquired whether the resident had experienced any difficulties with bowel movements and the frequency of his restroom use. Resident 14 stated that he had no issues and reported having a bowel movement every day or every two days.During an interview on 5/21/2026 at 4:08 p.m., with Director of Staff Development (DSD) 2, DSD 2 stated correct documentation was important in providing a clear indicator of the resident's daily status, functional abilities, overall health for the day, and any change in condition. DSD 2 stated CNAs failing to chart accurately could lead to safety issues. The DSD 2 stated that errors in CNA documentation could be problematic, as charge nurses depend on this information to provide hands on care to residents.During a review of the facility's policy and procedure (P&P) titled Documentation in Medical Record, dated 12/19/2022 indicated documentation shall be accurate, relevant and complete, containing sufficient details about the resident's care and/or response to care.

Based on observation, interview, and record review, the facility failed to assess, and address the resident's preferences by making reasonable efforts to accommodate her needs, and document regarding a preferred seating location in the activity room for one of two sampled residents (Resident 43):These failures have the potential to cause emotional distress, decreased satisfaction with care, and a diminished quality of life.Findings:During a review of Resident 43's admission Record, the admission Record indicated the facility admitted Resident 43 on 8/5/2009 and readmitted on [DATE] with diagnoses including hemiplegia (weakness to one side of the body), hemiparesis (inability to move one side of the body) following cerebral infraction (stroke-blockage of the flow of blood brain, causing or resulting in brain tissue death), contracture (loss of motion of a joint) of left ankle and left elbow.During a review of Resident 43's History and Physical (H&P), dated 8/11/2025, the H&P indicated Resident 43 had the ability to understand and make decisions.During a review of Resident 43's Minimum Data Set (MDS- a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 43 was cognitively (functions your brain uses to think, pay attention, process information, and remember things) intact. The MDS indicated Resident 43 required set up assistance with eating, supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) with oral hygiene, moderate assistance (helper does less than half the effort to complete the task) with personal hygiene, was dependent(helper does all of the effort) with toileting hygiene, showering. The MDS also indicated Resident 43 used a manual wheelchair for mobility.During a review of Resident 34's admission Record, the admission record indicated the facility admitted Resident 34 on 10/5/2024 with diagnoses including hemiplegia, hemiparesis affecting right dominant side.During a review of Resident 34's H&P, dated 3/25/2026, the H&P indicated, Resident 58 had ability to make health care decisions.During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34 was cognitively intact. The MDS indicated Resident 34 required supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) with eating, moderate assistance (helper does less than half the effort to complete the task) with oral hygiene, maximal assistance (helper does more than half the effort to complete task) with toileting hygiene, showering, and personal hygiene.During a concurrent observation and interview on 5/18/2026 at 10:23 a.m., in Resident 43's room, Resident 43 was observed in seated in an oversized wheelchair and wearing pressure relieving ankle foot orthosis (PRAFO, plastic boot-shaped brace to support your foot and ankle in the right position) on the left leg, doing crossword puzzles. Resident 43 stated there was limited appropriate seating available to meet her needs in the activity room. Resident 43 stated there was only one table in the activity room, which was wider, better suited to her size, and did not interfere with her wheelchair footrests. Resident 43 stated she was not always able to secure the preferred seat due to her condition and scheduled treatments in the morning.During an interview on 5/20/2026 at 2:17 p.m., with Resident 43, Resident 43 stated, on the previous Friday (5/15/2026), Resident 34 was seated at the table she (Resident 43) could comfortably sit at. Resident 43 stated when she brought this to the Activity Directors (AD)'s attention, the AD did not address her concern or attempt to accommodate her seating preference, and informed her, in front of the rest of the residents in the activity room, that seating was first come first served. Resident 43 stated she felt embarrassed and uncomfortable.During an interview on 5/20/2026 at 2:55 p.m., with the AD, the AD stated, on the previous Friday, Resident 34 was already sitting at Resident 43's preferred seat when Resident 43 arrived and expressed her preference regarding the seat in the activity room. The AD stated she asked Resident 43 to sit at a different table. The AD did not assess Resident 43's seating needs, explore alternatives, options or document regarding Resident 43's preferences.During an interview on 5/21/2026 at 10:12 a.m. with Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility 1, RNA 1 stated there was one out of six tables in the activity room where Resident 43 appeared comfortable, that table near the door was lower and wider, did not interfere with Resident 43's wheelchair leg rests, and allowed Resident 43 to comfortably rest her arms during activities. RNA 1 stated Resident 43 could not comfortably sit at the other tables. RNA 1 stated facility staff should have assessed and discussed Resident 43's seating preference and explored possible alternatives, to ensure Resident 43 could comfortably participate in activities.During an interview on 5/21/2026 at 3:24 p.m., with the Director of Nursing (DON), the DON stated Activity Staff should assess residents' needs when residents express their preferences to ensure their rights are respected and try to provide alternatives or communication to find a way to meet their needs.During a review of the facility's policy and procedure (P&P) titled, Promoting/ Maintaining Resident Dignity, dated 12/19/2022, the P&P indicated during interactions with residents, staff must report, document and act upon information regarding resident preferences.During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, dated 12/19/2022, the P&P indicated the facility staff shall make efforts to reasonably accommodate the needs and preferences of the resident as they make use of their physical environment.During a review of the facility's policy and procedure (P&P) titled, Activities, dated 12/19/2023, the P&P indicated the facility will consider accommodations in schedules, supplies and timing to optimize a resident's ability to participate in an activity of choice. The P&P also indicated the facility will provide one or more rooms designated for resident dining and activities. These rooms will be adequately furnished.

Based on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS], a resident assessment tool) for one of five sampled residents (Resident 19) who had aggressive physical (any intentional action that causes or is intended to cause bodily harm, pain, or injury to another person, or oneself) and verbal behavior (communication intended to harm, control, or intimidate another person) symptoms receiving medication.This deficient practice had the potential to result in inaccurate assessments and services for the resident due to inaccurate MDS assessment and care screening.Findings:During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive state of decline in mental abilities). During a review of Resident 19's history and physical (H&P), dated 1/9/2026, the H&P indicated Resident 19 had the capacity to understand and make decisions.During a review of Resident 19's MDS dated [DATE], the MDS indicated Resident 19 was severely impaired in cognitive (thought process) functioning. The MDS indicated Resident 19 required supervision (helper provides verbal cues as resident completes activity) with eating but was dependent (helper does all the effort) with hygiene, bathing and dressing. The MDS indicated Resident 19 was dependent with mobility such as rolling, sitting and transfers. The MDS indicated Resident 19 did not have physical behavioral symptoms (hitting, kicking, pushing others), verbal behavioral symptoms (screaming or cursing at others), or other behavioral symptoms (hitting or scratching self, or throwing items). During a review of Resident 19's Order Summary Report, the Order Summary Report indicated monitoring episodes of ((a mental condition where a person has trouble telling what is real from what is not) manifested by physical aggression as evidence by grabbing, scratching towards others and recording the number of times the behavior was observed every shift. The Order Summary Report indicated to monitor episodes of psychosis manifested by verbal aggression as evidence by screaming and cursing at others and recording the number of times the behavior was observed every shift.During a review of Resident 19's Monitoring Record (the systematic process of observing, defining, and logging specific actions over time) dated March 2026, indicated, Resident 19 had 16 days of physical aggression as evidence by grabbing, scratching towards others was observed, and had 18 days of verbal aggression as evidence by screaming, and cursing at others was observed. During a review of Resident 19's Monitor Record, dated April 2026, indicated, Resident 19 had 19 days of physical aggression as evidence by grabbing, scratching towards others was observed, and had 20 days of verbal aggression as evidence by screaming, and cursing at others was observed.During a review of Resident 19's Monitor Record, dated May 2026, indicated, Resident 19 had 15 days of physical aggression as evidence by grabbing, scratching towards others was observed so far, and had 15 days of verbal aggression as evidence by screaming, and cursing at others was observed so far.During a concurrent interview and record review on 5/21/2026 at 10:20 a.m., with the Social Service Assistant (SSA), the MDS dated [DATE] and the Monitor Record for March, April and May 2026 were reviewed. The SSA stated the Monitor Record indicated Resident 19 had episodes of physical aggression and verbal aggression for the month of March, April, and May 2026 and the MDS assessment indicated Resident 19 had no behaviors, but should have indicated 4 to 6 days per week. The SSA stated when she was doing the MDS assessment, she went based off what she observed from the resident but that it was not accurate as the SSA only saw Resident 19 for short periods at a time and not every second of the day. The SSA stated she should have double checked with other facility staff such as the nursing staff who observe and care for this resident all day every day. The SSA stated Resident 19 did have a care plan for physical and verbal aggression and that should have been an indicator Resident 19 had some behavioral symptoms. During a concurrent interview and record review on 5/21/2026 at 10:42 a.m. with MDS Nurse (MDSN), the MDS dated [DATE] and Monitor Record for March, April and May 2026 were reviewed. MDSN stated that the role of the MDSN was to ensure the accuracy of the MDS assessment before submission to the Centers for Medicare & Medicaid Services ([CMS, a federal agency within the U.S. Department of Health and Human Services responsible for operating and administering the federal Medicare program, as well as partnering with state governments to run Medicaid). The MDSN stated that she was expected to communicate with other facility staff who contribute to the MDS assessment to confirm its accuracy. The MDSN stated Resident 19 did have behavioral symptoms according to the Monitor Record and the MDS assessment should have indicated so. During an interview on 5/21/2026 at 3:25 p.m., with the Director of Nursing (DON), the DON stated that the MDS assessment must provide an accurate evaluation of all residents in the facility. The DON stated that the comprehensive MDS assessment outlines resident care needs including behaviors, psychosocial status, dietary needs, and more that get submitted to CMS. The DON stated that the assessment reflects the care and treatment provided to the residents and therefore must be accurate.During a review of the facility's policy and procedure (P&P) titled MDS 3.0 Completion, revised 12/19/2022, indicated, residents are assessed, using a comprehensive assessment process, to identify care needs. the responsibility of all sections of the MDS will be clearly assigned. People completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections. The R.N. Coordinator signs, dates, and attests to timely completion of the MDS, once all other disciplines have completed their sections.During a review of the facility's P&P titled MDS Coordinator (Nurse), dated 2024, indicated the MDS Coordinator does the coordination of the facility's Resident Assessment Instrument (RAI) process in accordance with state and federal regulations and ensure accurate completion of all MDS assessments and any supporting assessments or clinical documentation.

Based on interview and record review, the facility failed to ensure a comprehensive, person centered care plan was revised and updated after an unwitnessed second fall on 3/17/2026 that resulted in a cut to the left temple (the area on either side of the head behind the eyes) for one of five sampled residents (Resident 7). This failure had the potential to result in repeated falls and injuries for Resident 7. During a review of Resident 7's admission Record, the admission record indicated that Resident 7 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses included Parkinson's disease (a progressive disorder of the nervous system characterized by tremors, muscle rigidity, and slow, imprecise movements), dementia (a progressive decline in cognitive functioning), syncope (a temporary loss of consciousness), and a history of falls.During a review of Resident 7's History and Physical (H&P), dated 1/29/2026, the H&P indicated that Resident 7 did not have the capacity (ability) to understand information and make decisions.During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 5/5/2026, the MDS indicated that Resident 7 required maximal assistance (helper performs more than half of the effort) from one staff member for transfers, showering, toileting hygiene, and lower body dressing. The resident required moderate assistance (helper performs less than half of the effort) from one staff member for oral hygiene, upper body dressing, personal hygiene, and bed mobility. The resident required supervision or touching assistance (helper provides verbal cues and/or touching, steadying, or contact guard assistance while the resident completes the activity) from one staff member for eating.During a review of Resident 7's Nursing Progress Note, dated 3/17/2026, the Nursing Progress Note indicated that Resident 7 was found sitting on the floor mat facing the cabinet, with a skin cut noted on the left temple. The Nursing Progress Note further indicated that Resident 7 was transferred to a General Acute Care Hospital (GACH) via 911, as directed by the primary care physician. The Nursing Progress Note indicated, upon return from GACH, Resident 7 was noted to have Steri-Strips (thin, sterile, adhesive skin closures used to secure small cuts, lacerations, and surgical incisions) applied to the left eyebrow, near the left templeDuring a phone interview on 5/18/2026, at 12:26 p.m., with Resident 7's Family Member (FM) 1, FM 1 stated that Resident 7 had two fall incidents on 1/20/2026 and 3/17/2026. FM 1 stated that both falls were unwitnessed, and Resident 7 was found on the floor. FM 1 stated that Resident 7 sustained a fracture (broken bone) during the first fall incident and suffered a deep cut above the eyebrow during the second fall incident. FM 1 stated she was not notified of Resident 7's falls right away and was very concerned about Resident 7's safety.During a concurrent interview and record review on 5/20/2026, at 11:58 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 7's Situation, Background, Assessment, Recommendation (SBAR; a technique that can be used to facilitate prompt and appropriate communication between healthcare staff) Summary for Providers, dated 3/17/2026, was reviewed. The SBAR Summary for Providers indicated Resident 7 was found sitting on the floor mat near the foot of the bed, facing the bedside nightstand drawer, with a skin cut noted on the left temple area and slight bleeding. RNS 1 stated that Resident 7 had a first fall incident on 1/20/2026 which resulted in an acute mildly displaced right femoral neck fracture (a type of hip fracture occurring just below the ball and socket joint), and the 3/17/2026 incident was the second fall. RNS 1 stated that both fall incidents represented a change in condition, and Resident 7's care plan should have been updated and revised to reflect both incidents and update, change or improve interventions to prevent falls.During a concurrent interview and record review on 5/20/2026, at 4:17 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 7's Care Plan (CP) titled Resident 7 is at risk for repeat falls/injury. readmitted on [DATE] after right hip total arthroplasty (surgical reconstruction or replacement of a joint), revised 4/17/2026, was reviewed. The CP Goal indicated that Resident 7 would not sustain a major injury from a fall through the review date of 5/2/2026. The CP Interventions indicated, instructing 1:1 staff to stay with the resident at all times and placing the call light within reach. The CP did not include any documentation regarding the second unwitnessed fall that occurred on 3/17/2026, which resulted in a deep cut to the left temple area. The MDSC stated that staff should have updated and revised the care plan whenever there was a change in condition, and that the second unwitnessed fall on 3/17/2026 was considered a change in condition. The MDSC stated that the care plan should have been updated to reflect the second fall and should have included interventions specific to this incident, as different causes of unwitnessed falls may require different interventions. The MDSC stated that the purpose of care planning is to prevent repeated incidents and injuries.During an interview on 5/21/2026, at 3: 26 p.m., with the Director of Nursing (DON), the DON stated, stated that residents' care plans are required to be updated and revised whenever there is a change in condition and at least quarterly to ensure they reflect the residents' current health status. The DON further stated that the Resident 7's second fall incident constituted a change in condition, and the care plan should have been updated and revised to address the fall, implement additional interventions, and prevent further injuries or repeated falls. The DON stated, she acknowledged that this revision did not occur.During a review of the facility's Policy and Procedure (P&P) titled, Care Plan Revisions Upon Status Change, revised 12/19/2022, the P&P indicated, Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident conditions and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the residents will report resident responses to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff members will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.

Based on observation, interview, and record review the facility failed to provide nail care to one of four sampled residents (Resident 89).This failure resulted in Resident 89 having long, unclean fingernails and had the potential to result in infections.Findings:During a review of Resident 89's admission Record, the admission Record indicated Resident 89 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis (rare muscle injury where your muscles break down), contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) in multiple sites, and reduced mobility.During a review of Resident 89's Minimum Data Set ([MDS] a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 89's cognition was moderately impaired. The MDS indicated Resident 89 needed maximal assistance (helper does more than half the effort to complete the task) with personal hygiene.During a review of Resident 89's Care Plan initiated 8/21/2023, the care plan focus indicated, Resident 89 had Self-Care Deficit require assistance with most activities of daily living ([ADL] activities such as bathing, dressing and toileting a person performs daily). The care plan indicated to provide Resident 89 assistance with ADLs as needed.During a concurrent observation and interview on 5/18/2026 at 11:27 a.m., in Resident 89 room with Resident 89, Resident 89 had long dirty fingernails and Resident 89 stated she preferred to have clean fingernails.During a concurrent observation and interview on 5/18/2026 at 11:30 a.m., in Resident 89 room with Certified Nurse Assistant (CNA) 2, CNA 2 observed Resident 89's long dirty fingernails and stated the nails looked dirty and needed to be cleaned or trimmed.During an interview on 5/21/2026 at 12:24 p.m. with the Director of Nursing (DON), the DON stated Resident 89's nails should be kept clean and trimmed for a dignified experience and for hygienic reasons.During a review of the facility's policy and procedure (P&P) titled, Nail Care revised 12/19/2022, the P&P indicated routine cleaning, inspection, and trimming of nails will be provided as the need arises.

Based on observations, interviews, and record review, the facility failed to implement the podiatrist (a medical specialist dedicated to the prevention, diagnosis, and treatment of disorders of the foot, ankle, and lower leg) recommended treatment for a toenail fungal infection for one of three sampled residents (Resident 23).This failure resulted in a delay in necessary foot care services and had the potential to negatively affect Resident 23's physical health and psychosocial well being.Findings:During a review of Resident 23's admission Record, the admission record indicated Resident 23 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident 23's documented diagnoses included End Stage Renal Disease (ESRD - irreversible kidney failure), anemia (a condition in which the body does not have enough healthy red blood cells), heart failure (a condition in which the heart has difficulty pumping enough blood to meet the body's needs), and Diabetes Mellitus (DM - a disorder characterized by impaired blood sugar control and poor wound healing).During a review of Resident 23's Minimum Data Set (MDS - resident assessment tool), dated 5/5/2026, the MDS indicated Resident 23's cognition was moderately impaired (a decline in mental functioning-memory, language, or reasoning). The MDS indicated that Resident 23 required maximal assistance (helper performs more than half of the effort) from one staff member for toilet hygiene and showering, moderate assistance (helper performs less than half of the effort) from one staff member for bed mobility, transfers, and dressing, and supervision or touching assistance (helper provides verbal cues and/or touching, steadying, or contact guard assistance while the resident completes the activity) from one staff member for oral hygiene and eating.During a review of Resident 23's Order Summary Report (OSR), dated 5/19/2026, the OSR indicated that an order for may see podiatrist was ordered on 2/6/2026. The OSR indicated an order dated 3/25/2026 to apply A&D ointment to the left and right feet and leave open to air for 60 days. The OSR also indicated that hydrocortisone 1% external cream (a medication used to treat itchiness and inflammation) was ordered on 2/6/2026 to be applied topically to the affected area every six hours as needed for itchiness. The OSR indicated there was no order for clotrimazole. The OSR indicated there were no orders to place a foot pillow or to avoid Resident 23 being barefoot during transportation as recommended. During a concurrent observation and interview on 5/18/2026, at 9:40 a.m., with Resident 23 in her room, Resident 23 was observed lying in bed watching television and asked to have her socks removed so her toenails could be observed. Resident 23's toenails were brittle, thick, long, and blackish yellow in color. Resident 23's feet appeared dry, and skin flakes were noted falling off when the socks were removed. Resident 23 stated she had been seen by the podiatrist few months ago but had not received any treatment for the fungal infection on her toenails. Resident 23 stated her toenails were long and painful when she stood up or when they were touched. Resident 23 stated the appearance of her infected toenails caused her embarrassment. Resident 23 stated if the facility podiatrist could not treat her toenails, she wanted to be seen by an outside specialist.During a concurrent interview and record review on 5/20/2026, at 11:38 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 23's Convalescent Podiatry Care Evaluation & Treatment, dated 3/25/2026, was reviewed. The Convalescent Podiatry Care Evaluation & Treatment indicated that Resident 23's toenails were thickened, discolored, brittle, and painful upon palpation. The Convalescent Podiatry Care Evaluation & Treatment indicated that Resident 23 had requested topical medication. The Convalescent Podiatry Care Evaluation & Treatment indicated, the podiatrist recommended applying clotrimazole (an medicated ointment to treat fungal infection) 1 percent (%) cream daily, elevating the lower extremities with a foot pillow, applying lotion per facility protocol (A&D ointment or ammonium lactate 12%), providing footwear with a wide toe box, flexible upper, good arch support, and cushioned insoles, and avoiding going barefoot during transportation. RNS 1 stated that all recommendations should have been carried out as ordered and care -planned. RNS 1 stated she was unaware of the current condition of Resident 23's toenails. RNS 1 stated the staff should have followed through with the podiatrist's recommendations to prevent further deformity (the state of being misshapen, distorted, or malformed) and pain in Resident 23's toenails.During an interview on 5/20/2026, at 1:55 p.m., with the Social Service Director (SSD), the SSD stated she was not aware of Resident 23's current condition of her toenails. The SSD stated she should have contacted the podiatrist's office to schedule visits more frequently. The SSD stated the podiatrist visits were routinely scheduled every 60 days when there were no significant concerns; however, based on Resident 23's current condition, she might have needed more frequent visits. The SSD stated that Resident 23 was diagnosed with Diabetes Mellitus (DM) and emphasized that foot care is critical in preventing complications such as diabetic foot ulcers (open sores or wounds on the foot commonly associated with diabetes due to poor circulation and nerve damage). The SSD stated that she would have referred Resident 23 to an outside specialist if she had known Resident 23 was dissatisfied with her current treatment.During an interview on 5/21/2026, at 11:28 a.m., with the Director of Nursing (DON), the DON stated that staff should have followed through with the podiatrist's recommendations and implemented them. The DON stated that staff should have placed a pillow under the resident's legs and feet to prevent pressure injury (localized, pressure related damage to the skin and/or underlying tissue, usually over a bony prominence), applied clotrimazole to treat the fungal infection, applied lotion to restore moisture, and ensured the resident had well fitted shoes to prevent diabetic ulcers and deformities. The DON stated that the fungal toenail infection was a serious concern for individuals with diabetes because the nails can become thick and brittle, creating pressure points inside shoes that may lead to skin tears, ulcers, and severe secondary bacterial infections that are difficult to heal due to poor circulation. The DON further stated that the condition could also affect Resident 23's psychosocial well being and contribute to social isolation.During a review of the facility's Policy and Procedure(P&P) titled, Skin Integrity- Foot Care, revised 9/12/2023, the P&P indicated, Policy: It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. This policy pertains to maintaining the skin integrity of the foot. Policy Explanation and Compliance Guidelines: 1. The facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from the residents' medical conditions. a. The facility will utilize a systematic approach for the prevention and management of foot ulcers, including efforts to identify risk; stabilize, reduce, or remove underlying risk factors; monitor the impact of the interventions; and modify the interventions as appropriate . 2. Assessment of Risk. b. The comprehensive assessment process will be utilized for identifying additional risk factors or conditions that increase risk for impaired skin integrity of the foot. Examples include, but are not limited to: diabetes, peripheral vascular disease, peripheral arterial disease, venous insufficiency, peripheral neuropathy, and lack of sensation in feet. 3. Interventions for Prevention and to Promote Healing . ii. Appropriate offloading or orthopedic devices, diabetic shoes, or pressure-relieving. Iii. Referrals to podiatrists, vascular or orthopedic surgeons, or wound care physicians will be made when appropriate.During a review of the facility's Policy and Procedure(P&P) titled, Podiatry Services, revised 12/2/2024, the P&P indicated, Policy Explanation and Compliance Guidelines: 2.Foot disorders which may require treatment include, but are not limited to: corns, neuromas, calluses, hallux valgus (bunions), digiti flexus (hammertoe), heel spurs, and nail disorders.3.Employees should refer any identified need for foot care to the social

Based on interview and record review, the facility failed to ensure a performance review for one of two Certified Nurse Assistants (CNA 9) was completed at least once every 12 months.This failure had the potential to result in poor resident health outcomes.Findings:During a concurrent interview and record review on 5/20/2026, at 2:19 p.m., with the Director of Staff Development (DSD), CNA 9's Employee File, dated from 8/2022 to 5/2026 was reviewed. The Employee File indicated, no performance evaluation was completed or documented for the year 2025, nor was an annual evaluation completed as required. The DSD stated, the employee performance evaluations are required to be completed and documented upon hire, 90 days after hire, and annually thereafter. The DSD stated, CNA 9's performance evaluation had not been conducted or documented.During an interview on 5/21/2026, at 11:48 a.m., with the Director of Nursing (DON), the DON stated that employee performance evaluations should be conducted at least annually to identify strengths and weaknesses in an employee's skills. The DON stated, annual performance evaluations are essential to reinforce strengths and address weaknesses to ensure staff are competent to provide appropriate care to residents.During a review of the facility's Policy and Procedure (P&P) titled, Evaluation Process, revised 12/19/2022, the P&P indicated, Policy: It is the policy of our facility to review the work performance of employees with a formal written evaluation annually. Policy Explanation and Compliance Guidelines: c. The manager/Supervisor is to complete the Employee Evaluation Form .f. Once the evaluation review is complete, the employee and manager should sign the evaluation form. g. Original evaluation tools are to be forwarded to the Human resources within the facility to be processed and placed in the appropriate personnel file.

Based on observation, interview and record review the facility failed to:a. Ensure one of five residents (Resident 91) received ondansetron (medication to treat nausea and vomiting) in a timely manner. As a result, Resident 91was not treated for nausea and vomiting for seventeen hours, which had the potential to cause discomfort. b. Maintain accurate documentation of hydrocodone acetaminophen (a controlled medication [medications with a high potential for abuse] used to manage moderate to severe acute and chronic pain) tablet on the controlled drug record ([CDR], a document indicating the inventory and administration of controlled substances) sheet, affecting one resident (Resident 5) in one of two inspected medication carts (Station 2 Medication Cart).This deficient practice of failure to maintain accurate documentation of controlled medications poses a significant risk for misuse, drug diversion, and inaccurate medication count. Findings: a.During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was admitted to the facility on [DATE] with diagnoses including fracture (broken bone) of neck, and protein-calorie malnutrition (nutritional deficiency that occurs when the body lacks both adequate calories and protein). During a review of Resident 91's Minimum Data Set ([MDS] a resident assessment tool), dated 4/6/2026, the MDS indicated Resident 91's cognition (thought process)was intact. The MDS indicated Resident 91 required partial assistance (helper does less than half the effort) with eating, oral hygiene, was dependent (helper does all the effort to complete the task) with toileting hygiene, and showering. During a review of Resident 91's Nurses Progress Notes, 4/12/2026 at 9:26 a.m., the note indicated the resident was nauseated and does not have the medication. During a review of Resident 91's Change in Condition Evaluation – V 5.1 C, 4/12/2026 at 9:27 a.m., the form indicated Resident 91 complained of nausea and had vomited in the trash can. During a review of Resident 91's order, dated 4/12/2026 9:39 a.m., the order indicated Ondansetron tablet 4 milligrams, give one tablet by mouth every 6 hours as needed for nausea and vomiting. During a review of Resident 91's Nurses Progress Notes 4/12/2026 5:13 p.m. Resident 91 reported vomiting and having abdominal discomfort. During a review of Resident 91's Medication administration Record (MAR), 4/2026, the MAR indicated Resident 91 did not receive Ondansetron on 4/12/2026 at 9:39 a.m. and at 5:12 p.m. Resident 91 received Ondansetron on 4/13/2026 at 1:55 a. and it was effective. During a concurrent interview and record review on 5/19/2026 at 2:06 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 91's medical records were reviewed. RN1 stated on 4/12/2026 at approximately 9:30 a.m., Resident 91 had nausea and vomiting and the medication the physician ordered was unavailable. RNS 1 stated on 4/12/2026 at 5:13 p.m., Resident 91 complained of nausea and vomiting and did not receive the Ondansetron. RNS 1 stated Resident 91 received his medication the next day on 4/13/2026 at approximately 1:55 a.m., 16 hours after it was ordered. RN 1 stated Resident 19 should have received his medication right away. During an interview with the Director of Nursing (DON) on 5/21/2026 at 12:24 p.m. the DON stated if a resident complained of nausea and was vomiting the ordered medication should be administered as soon as possible. During a review of the facility's Policy and Procedure (P/P) titled, Medication Administration, revised 12/19/2022, the P/P indicated medication will be administered as ordered by the physician in accordance with professional standards in a timely manner. During a review of the facility's P/P titled, Medication Reordering, revised 12/19/2022, the P/P indicated acquisition of medication should be completed in a ensure medications are administered in a timely manner to meet the residents needs. b. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to facility on 11/10/2023 and readmitted on [DATE]. Resident 5's diagnoses included End Stage Renal Disease ([ESRD], irreversible kidney failure), diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and congestive heart failure ([CHF], a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 5's History and Physical (H&P), dated 3/13/2026, the H&P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set ([MDS], a resident assessment tool), dated 5/12/2026, the MDS indicated Resident 5 had intact cognitive (thought process) function. The MDS indicated Resident 5 required supervision (helper provides verbal cues and/or touch assistance) to moderate assistance (helper does less than half the effort) with self-care abilities such as eating, hygiene, bathing and dressing. The MDS indicated Resident 5 required supervision with mobility such as rolling, sitting, standing and transfers. During a review of Resident 5's Order Summary Report, dated 5/18/2026, the Order Summary Report indicated hydrocodone-acetaminophen tablet 7.5-325 milligram ([mg], a unit of measurement for medication) give one tablet by mouth every four hours as needed for severe pain seven to ten out of ten pain (pain scale rating pain from 0 no pain to 10 excruciating pain) During a review of Resident 5's Medication Administration Record (MAR) for May 2026, the MAR indicated on 5/21/2026, hydrocodone-acetaminophen tablet 7.5-325 mg medication was last given at 2:17 a.m. During a concurrent observation, interview and record review on 5/21/2026 at 2:20 p.m., with Licensed Vocational Nurse (LVN) 4 at the Station 2 Medication Cart, Resident 5's hydrocodone-acetaminophen medication bubble pack, and the facility's CDR sheet for hydrocodone-acetaminophen tablet were reviewed. Resident 5's hydrocodone-acetaminophen medication bubble packs had 32 tablets. The facility's CDR sheet indicated a quantity of 33 tablets remaining with the last dose administered on 5/20/2026 at 8:04 p.m. LVN 4 opened up the MAR on the computer on the Station 2 Medication Cart for Resident 5 and the MAR indicated Resident 5 received the hydrocodone-acetaminophen tablet 7.5-325 mg pain medication around 2:00 a.m. LVN 4 stated the licensed nurse that administered the medication at that time forgot to write on the CDR sheet that the pain medication was given so that was why there was a discrepancy with the medication count on the CDR sheet. LVN 4 stated the importance of making sure the CDR sheet count matches the number of tablets in the bubble pack because the medication was a narcotic medication and both the CDR sheet and the bubble pack had to match to ensure there was no diversion. LVN 4 stated the CDR was a legal document and facility staff had to make sure the medication was given to the correct resident and that no error was made. During an interview on 5/28/2026 at 3:35 p.m. with the Director of Nursing (DON), the DON stated the CDR sheet needed to be accurate. The DON stated if it was not accurate, there could be possible diversion, so the facility staff must make sure the medication was given to the correct resident. The DON stated the MAR, CDR sheet and bubble pack should all match to make sure medication was given to the correct resident, not to the wrong resident or even facility staff. The DON stated there should be no discrepancy as this medication was a narcotic (a potent, medically defined class of psychoactive drugs that dull the senses, relieve moderate to severe pain, and often induce stupor or sleep) medication. During the facility's policy and procedure (P&P) titled Medication Administration, revised 12/19/2022, indicated, medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.sign MAR after administered.if medication is a controlled substance, sign narcotic book.correct any discrepancies and report to nurse manager.

Based on observation, interview, and record review, the facility failed to provide the fruit cup and health shake (nutrient dense beverage) as indicated on one of five residents breakfast menu (Resident 12).This failure had the potential to result in loss of appetite and cause unplanned weight loss.Findings:During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 12's Minimum Data Set ([MDS] a resident assessment tool), dated 4/16/2026, the MDS indicated Resident 12 had severely impaired cognition. The MDS indicated Resident 12 was dependent (helper does all the effort to complete the task) on staff with activities of daily living (activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 12's Order Summary report, dated 5/19/2026, the orders indicated Regular Diet, with minced and moist texture (features finely mashed or ground foods that are soft, cohesive, and easy to swallow), fortified (adding nutrient dense to meal) and a health shake 4 ounces with meals.During a concurrent observation and interview on 5/19/2026 at 7:48 a.m., in Resident 12's room, with Certified Nurse Assistant (CNA) 1, there was no fruit cup and health shake on Resident 12's tray and bedside table. CNA 1 stated there was no fruit cup or health shake on Resident 12's tray for breakfast while CNA 1 was helping Resident 12 to eat.During a concurrent interview and record review on 5/19/2026 at 8:05 a.m. with the Dietary Supervisor (DS), the facility's Diet Spreadsheet: Menu Copy for Spring 2026 was reviewed. The DS confirmed and stated for breakfast today a minced and moist fruit cup or apple sauce should have been included in Resident 12's breakfast.During a concurrent interview and record review on 5/19/2026 at 8:10 a.m., with CNA 1, Resident 12's diet ticket (paper indicating what the resident diet should have in their meal) was reviewed and the ticket indicated food items that included a fruit cup and health shake. CNA 1 stated for breakfast this morning, Resident 12 did not consume a fruit cup or health shake because the items were missing.During an interview on 5/21/2026 at 12:24 p.m. with the Director of Nursing (DON), the DON stated the diet ticket and menu should be followed for nutrition and health reasons.During a review of the facility's policy titled, Menus and Adequate Nutrition, revised 12/19/2022, the policy indicated residents will be offered that meet their choices and needs. The policy indicated menus will be posted and followed.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control practices for three of 30 sampled residents (Resident 8, 32 and 37) when:a. The facility failed to ensure padded side rails that were wrapped with porous foams were disinfected properly for two of six sampled residents (Resident 8 and 37).b. The facility failed to ensure the laundry hamper for Resident 32 was free from bowel residue. These failures had the potential to increase the risk of cross-contamination (the transfer of bacteria, viruses, microorganisms or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and spread infection among the residents, staff and visitors. Findings: During an observation on 5/18/2026 at 10:22 a.m. in Resident 8's room, the resident's upper side rails were observed padded with black foam. a. During a review of Resident 8's admission Record, the admission Record indicated the facility admitted the resident on 6/24/2019 and readmitted on [DATE] with diagnoses including Dysphagia (difficulty swallowing), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) and atherosclerotic heart disease (buildup of plaque in the coronary arteries). During a review of Resident 8's Minimum Data Set (MDS-a resident assessment tool), dated 3/26/2026, the MDS stated the resident's cognitive skills for daily decision making were severely impaired. The MDS stated Resident 8 was dependent (helper does all the effort) for oral hygiene, toileting hygiene, showering, and personal hygiene. During a review of Resident 8's Order Summary Report, dated 5/19/2026, the Order Summary Report indicated starting 3/17/2026, Resident 8 may have padded bilateral 1/2 side rails as seizure precaution. During an observation on 5/18/2026 at 10:01 a.m. in Resident 37's room, the resident's upper side rails were observed padded with black foam. During a review of Resident 37's admission Record, the admission Record indicated the facility admitted Resident 8 on 2/16/2024 with diagnoses including multiple sites contracture (loss of motion of a joint) of muscle, multiple sclerosis (a disease in which the immune system attacks the protective covering of the nerves causing nerve damage) and seizures (abnormal electrical activity in the brain). During a review of Resident 37's MDS dated [DATE], the MDS indicated Resident 8's cognition (functions your brain uses to think, pay attention, process information, and remember things) was moderately impaired. The MDS indicated Resident 8 was dependent (helper does all effort) on eating, oral hygiene, toileting hygiene, showering and personal hygiene. During a review of Resident 37's Order Summary Report, dated 5/19/2026, the Order Summary Report indicated starting 3/17/2026, Resident 37 may have padded bilateral 1/2 side rails as seizure precaution. During an interview on 5/19/2026 at 2:13 p.m. with housekeeper (HK) 1, HK 1 stated she performed deep cleaning in residents' rooms including the side rails wrapped with porous foams using disinfectants identified as Sani-Klean weekly. HK 1 stated she cleaned all equipment, including the foam-wrapped side rails, using a disinfectant. During a concurrent interview and record review on 5/19/2026 at 3:04 p.m. with the Infection Preventionist (IP), manufacturer's guidelines for Sani-Klean, undated, was reviewed. The IP stated the porous foams on Resident 8 and 37's side rails were used for seizure precautions. The IP stated the product was designed for nonporous surfaces. The IP stated using the disinfectants on the porous foam was not appropriate because they were porous and could cause the surface not to be cleaned properly and break down the foam. The IP stated, this practice would place vulnerable residents including Resident 8 and 37 at risk for infection. During an interview on 5/21/2026 at 3:24 p.m. with the Director of Nursing (DON), the DON stated the facility should disinfect padded side rails that were wrapped with porous foam properly for the residents to prevent the spread of infection. During a review of the faculty 's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Equipment, dated 12/19/2022, the P&P indicated, staff should verify the disinfectant is compatible with the equipment and follow manufacturer recommendations for cleaning equipment. During a review of the manufacturer's guideline titled, Sani-Klean, undated, the guideline indicated the disinfectant is designed for hard and non-porous surfaces. b. During a concurrent observation and interview on 5/19/2026 at 4:01 p.m., in Resident 32's room, Resident 32's personal laundry hamper was located in the corner of the room with a sign posted on the lid of the hamper indicating if clothes have poop on them, please place them separately in a plastic bag and put them in the facility laundry, thank you. The handle of the hamper was noted to have a thin layer of a brown-colored, caked-on substance. Certified Nurse Assistant (CNA) 7 stated the brown substance on the hamper handle was feces. During a concurrent interview and record review on 5/21/2026 at 10:09 a.m. with Housekeeping Supervisor (HS), a photograph was shown to the HS. The HS stated that the photograph of the hamper handle showed visible feces was Resident 32's personal hamper. HS stated it was important for a resident's room to be clean and free from feces on objects to prevent passing disease to other residents, prevent contamination, and keep residents clean. During a concurrent interview and record review on 5/21/2026 at 3:45 p.m. with the Director of Nursing (DON), the DON stated the presence of feces on objects in a resident's room was unsanitary and poses an infection control risk. The DON stated that maintaining cleanliness helps ensure a homelike environment, prevents unsanitary conditions, and supports infection control practices. During a review of the facility's policy and procedure (P&P) titled Routine Cleaning and Disinfection dated 12/29/2022, indicated it is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.

Based on interview and record review, the facility failed to report an allegation of physical abuse for one of two sampled residents (Resident 2), when Resident 2 reported to facility staff that she (Resident 2) was handled roughly by two hospital staff at a General Acute Care Hospital (GACH 1) prior to her admission to the facility (4/9/2026). And, they failed to report an injury of unknown origin when an Xray (a procedure that takes pictures of the inside of the body to diagnose broken bones and other injuries) taken on 4/24/2026 confirmed Resident 2 had a displaced fracture (when a broken bone snaps into two or more pieces and moves, causing the ends to become misaligned) of the proximal (closer to the point of attachment) shaft of the right femur (largest bone extending from the hip to the knee [hip fracture]). These deficient practices resulted in the CDPH not being aware of Resident 2's allegation of abuse and her injury of unknown origin causing a delay the CDPH's investigation and the potential for pertinent information to be lost and/or forgotten. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with the diagnosis of osteogenesis imperfecta (a rare genetic disorder characterized by extremely fragile bones that break easily, often with little or no trauma). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 4/13/2026, the MDS indicated Resident 2's cognition was intact and Resident 2 was dependent (helper does all of the effort) on facility staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers dated 4/23/2026 and timed at 3:22 p.m., the SBAR Summary for Providers indicated Resident 2's right hip had a prominent protrusion (something that sticks out or bulges out from a surface or its surroundings), redness and warmth. The SBAR Summary for Providers indicated the physician ordered an Xray of Resident 2's right hip. During a review of Resident 2's Nurses Progress Notes dated 4/23/2026 and timed at 4:07 p.m., the Nurses Progress Notes indicated Resident 2's Family Member (FM) reported that Resident 2 was not handled properly at GACH 1 where she was previously admitted . The FM stated Resident 2's hip was not like that (with a protrusion, red and warm) before getting admitted to GACH 1. During a review of Resident 2's Physician's Order dated 4/23/2026, the Physician's Order indicated to obtain a right hip Xray due to prominent protrusion, redness, and warmth. During a review of Resident 2's SBAR Summary for Providers dated 4/24/2026, the SBAR Summary for Providers indicated Resident 2's Xray results indicated an acute displaced right hip fracture. Resident 2 was transferred to GACH 2 for further evaluation and treatment. During a review of Resident 2's Radiology Results Report dated 4/23/2026, the Radiology Results Report indicated Resident 2 had an acute displaced fracture of the proximal shaft of the right femur. During an interview on 4/29/2026 at 3:28 p.m., Physical Therapist (PT) stated when he completed Resident 2's PT Evaluation (4/10/2026), Resident 2 reported to she had pain to her right hip and when she was at GACH 1 she was handled roughly by the nurses. PT 1 stated he did not report what Resident 2 told him because he thought her complaint of pain was related her diagnosis of osteogenesis imperfecta. PT 1 stated he should have reported it to the supervisory staff at the facility. During an interview on 4/30/2026 at 12:14 p.m., Registered Nurse (RN 1) stated on 4/23/2026 when she assessed Resident 2 her right hip was protruding more than it had been on admission [DATE]). There was more redness in the inner thigh, and it was a little warm to touch. RN 1 stated Resident 2 reported to her she was rough handled by nurses at GACH 1 and that was what caused her injury. RN 1 stated Resident 2 reported she had not fallen and there was no other explanation of what might have caused her injury. During an interview on 4/29/2026 at 1:01 p.m., the Director of Nursing (DON) stated the CDPH was not notified of Resident 2's hip fracture because Resident 2 was able to explain that she did not fall or have any incident that would cause the fracture and their Consultant told them Resident 2's fracture did not need to be reported. The DON stated Resident 2's allegation of being rough handled by nurses at GACH 1 should have been reported but she (DON) was concerned with Resident 2's fracture and missed reporting it Resident 2's allegation. During a review of the facility's Policy and Procedure (P/P) titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation dated 12/19/2022, the P/P indicated it is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property immediately to the Administrator of the facility to other appropriate agencies in accordance with current state and federal regulations with prescribed timeframes.

Based on observation, interview, and record review, the facility failed to ensure a resident (Resident 1), who had a history of falls and was assessed as a high fall risk, room door remained open for visibility for one of five sampled residents (Resident 1). This failure had the potential to prevent nursing staff from observing Resident 1 and identifying her care and safety needs in a timely manner. Findings:During a review of Resident 1's admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including dementia (a progressive state of decline in mental abilities), polyneuropathies (a type of nerve disorder that affects multiple nerves outside the brain and spinal cord), muscle weakness, and difficulty walking.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/27/2026, the MDS indicated Resident 1 was not able to make decisions that were reasonable and consistent and required one person assistance from staff to complete her activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). The MDS indicated Resident 1 was incontinent (involuntary voiding) of bowel (urine) and bladder (stool). During a review of Resident 1's Fall Risk assessment dated [DATE], and timed at 4:36 p.m., the Fall Risk Assessment indicated Resident 1 had a score of 16 (high fall risk). The Fall Risk Assessment indicated Resident 1 was a risk for fall because of her history of falls, intermittent (on and off) confusion, poor balance while standing, and was taking three or more medications with three or more predisposing (influencing) diseases.During a review of Resident 1's untitled Care Plan dated 1/26/2026, the Care Plan indicated Resident 1 was at risk for falls and injury with goals including Resident 1 will be free from falls and/or minor injury and will not sustain a serious injury. The Care Plan's interventions included anticipating and meeting Resident 1's needs, providing Resident 1 with appropriate footwear when ambulating, and providing a safe environment.During a review of Resident 1's Change in Condition Evaluation (COC) dated 1/31/2026 and timed at 2:30 p.m., the COC indicated Resident 1 informed a licensed nurse that she (Resident 1) fell early in the morning and sustained a left elbow skin tear.During a review of Resident 1's Interdisciplinary Care Conference ([IDT] a group of professionals from different fields that collaborate on shared patient goals) Notes dated 2/2/2026, the IDT Notes indicated a care conference was implemented after Resident 1 had a fall. The IDT Notes indicated Resident 1 was assessed to be impulsive with a balance deficit and she (Resident 1) tried to ambulate beyond her capabilities and without assistance. The IDT Notes indicated recommendations including providing Resident 1 with frequent visual checks, timely assistance as needed and reminding the nurses for Resident 1's safety precautions and plan of care.During an interview on 4/9/2026 at 4:25 p.m., Responsible Party (RP) 1 stated she has observed on multiple occasions when she visited the facility, Resident 1's door was always closed. RP 1 stated Resident 1 had fallen in the past and she was worried that the facility staff will not be able to monitor Resident 1. RP 1 stated Resident 1 was unsafe because she was inaccessible to the nursing staff. During an observation on 4/13/2026 at 9:25 a.m., in the facility hallway, Resident 1's room door was observed closed. During a concurrent observation and interview on 4/13/2026 at 9:26 a.m., in Resident 1's room, Resident 1 was observed standing barefoot by the foot part of her bed. Resident 1 stated she just came out of the bathroom and does not know why her room door was closed.During an interview on 4/13/2026 at 9:30 a.m., Licensed Vocational Nurse (LVN) 1 stated and confirmed Resident 1's door was closed and the nursing staff should have kept Resident 1's door open because Resident 1 was a fall risk. LVN 1 stated Resident 1 should be visible at all times to ensure safety. During an interview on 4/13/2026 at 10:07 a.m., Certified Nursing Assistant (CNA) 1 stated he was informed during the nursing huddle (a brief ten to fifteen minute stand-up meeting held at the start of the shift or workday to align the team, discuss patient safety and proactively address potential issues) that Resident 1 was a fall risk, but he was not aware of how often he needed to check on Resident 1. CNA 1 stated Resident 1 wanted her door closed and he did not inform the licensed nurses about it. CNA 1 stated he should have communicated this occurrence to the licensed nurse because Resident 1 was confused and can fall. During an interview on 4/13/2026 at 1:10 p.m., Registered Nurse Supervisor (RNS) 1 stated Resident 1 was a fall risk since admission at the facility. RNS 1 confirmed Resident 1 had an unwitnessed fall on 1/31/2026, sustained a left elbow skin tear and the IDT recommended providing Resident 1 with frequent visual checks, timely assistance as needed and reminding the nurses for Resident 1's safety precautions and plan of care. RNS 1 stated she have observed Resident 1 was closing the door of her care area multiple times since last week (did not specify the date) but she was unable to call RP1, inform the attending physician and formulate a plan of care to address this safety concern. RNS 1 stated the nursing staff will not be able to monitor Resident 1 and attend to her care and safety needs in a timely manner if her door remains closed.During an interview on 4/13/2026 at 2:45 p.m., the Director of Nursing Services (DON), the DON stated CNA 1 should have informed LVN1 of Resident 1's door being closed to ensure Resident 1's safety and well-being. The DON stated the nursing staff of the facility should work together to ensure the residents' care areas are accessible to provide the residents' care needs in a timely manner and to prevent a fall and/or injury. During a review of the facility's policy and procedure (P&P) titled, Accidents and Supervision, revised 12/19/2022, the P&P indicated the residents' environment shall be free of accident hazards and the residents shall receive adequate supervision to mitigate risk and/or prevent accidents by:a. identifying hazards and risksb. evaluating and analyzing hazards and risksc. implementing interventions to reduce hazards and risks, andd. monitor for effectiveness and modifying interventions when necessary.During a review of the facility's P&P titled, Fall Prevention Program, revised 12/28/2023, the P&P indicated the facility shall provide each resident care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The P&P indicated the facility shall provide each resident with universal environmental interventions that decrease the risk of resident falling, including, but not limited to:a. a clear pathway to the bathroom and bedroom doorsb. shoes, slippers and/or socks with non-slip soles when ambulating, andc. increased frequency of rounds.

Based on interview and record review, the facility failed to ensure a resident (Resident 1), who had a history of falls and was assessed as a high fall risk, care plan interventions were revised after Resident 1 had an unwitnessed fall on 1/31/2026. This deficient practice had the potential for the nursing staff to be unaware of Resident 1's current fall risk precautions and interventions that could delay and/or affect delivery of her care.Findings:During a review of Resident 1's admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including dementia (a progressive state of decline in mental abilities), polyneuropathies (a type of nerve disorder that affects multiple nerves outside the brain and spinal cord), muscle weakness, and difficulty walking.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/27/2026, the MDS indicated Resident 1 was not able to make decisions that were reasonable and consistent and required one person assistance from staff to complete her activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). The MDS indicated Resident 1 was incontinent (involuntary voiding) of bowel (urine) and bladder (stool).During a review of Resident 1's Fall Risk assessment dated [DATE], and timed at 4:36 p.m., the Fall Risk Assessment indicated Resident 1 had a score of 16 (high fall risk). The Fall Risk Assessment indicated Resident 1 was a risk for fall because of her history of falls, intermittent (on and off) confusion, poor balance while standing, and was taking three or more medications with three or more predisposing (influencing) diseases.During a review of Resident 1's untitled Care Plan dated 1/26/2026, the Care Plan indicated Resident 1 was at risk for falls and injury with goals including Resident 1 will be free from falls and/or minor injury and will not sustain a serious injury. The Care Plan's interventions included anticipating and meeting Resident 1's needs, providing Resident 1 with appropriate footwear when ambulating, and providing a safe environment.During a review of Resident 1's Change in Condition Evaluation (COC) dated 1/31/2026 and timed at 2:30 p.m., the COC indicated Resident 1 informed a licensed nurse that she (Resident 1) fell early in the morning and sustained a left elbow skin tear.During a review of Resident 1's Interdisciplinary Care Conference ([IDT] a group of professionals from different fields that collaborate on shared patient goals) Notes dated 2/2/2026, the IDT Notes indicated a care conference was implemented after Resident 1 had a fall. The IDT Notes indicated Resident 1 was assessed to be impulsive with a balance deficit and she (Resident 1) tried to ambulate beyond her capabilities and without assistance. The IDT Notes indicated recommendations including providing Resident 1 with frequent visual checks, timely assistance as needed and reminding the nurses for Resident 1's safety precautions and plan of care.During a continued review of Resident 1's untitled Care Plan dated 1/26/2026, the Care Plan indicated Resident 1 was at risk for falls and injury. There was no documentation indicating revisions and/or updates of Resident 1's fall risk interventions after Resident 1 fell on 1/31/2026.During an interview on 4/13/2026 at 10:07 a.m., Certified Nursing Assistant (CNA) 1 stated he was informed during the nursing huddle (a brief ten to fifteen minute stand-up meeting held at the start of the shift or workday to align the team, discuss patient safety and proactively address potential issues) that Resident 1 was a fall risk, but he was not aware of how often he needed to check on Resident 1. During an interview on 4/13/2026 at 1:10 p.m., Registered Nurse Supervisor (RNS) 1 stated Resident 1 was a fall risk since admission at the facility. RNS 1 confirmed Resident 1 had an unwitnessed fall on 1/31/2026, sustained a left elbow skin tear and the IDT recommended providing Resident 1 with frequent visual checks, timely assistance as needed and reminding the nurses for Resident 1's safety precautions and plan of care. RNS 1 stated Resident 1's fall risk interventions should have been revised and updated after Resident 1's fall incident to ensure timely monitoring and provision of her care needs.During an interview on 4/13/2026 at 2:45 p.m., the Director of Nursing Services (DON) stated Resident 1's interventions for fall risk precautions should have been revised and/or updated by the licensed nurses as soon as the IDT has identified Resident 1's safety needs. The DON stated it was important for Resident 1's plan of care to be updated so the nursing staff can implement the current fall risk precautions and interventions to prevent another fall and/or injury.During a review of the facility's Policy and Procedure (P/P) titled, Comprehensive Care Plans revised 12/19/2022, the P&P indicated the facility shall develop, implement and revise a comprehensive person- centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet the residents' medical, nursing, mental and psychosocial needs based in the resident's comprehensive assessment. The residents' comprehensive care plan will be prepared by the facility's interdisciplinary team. During a review of the facility's P&P titled, Fall Prevention Program, revised 12/28/2023, the P&P indicated the facility shall review the residents' care plan and update as indicated.

Based on interview and record review, the facility failed to ensure the resident, who had lower extremities paralysis (inability to move the legs and lower body, typically caused by spinal injury or disease), a right leg below the knee amputation [(BKA) surgical removal of leg below the knee), and was unable to stand without support, was free from falls and injuries during transfer with a mechanical lift (a device designed to help caregivers move a person from a sitting to standing position and from one place to another) for one of three sampled residents (Resident1). The facility failed to: 1. Ensure a certified nursing assistant (CNA 1) used a full body mechanical lift during Resident 1 ' s passive transfer (resident does not participate in the transfer) instead of a Sit-to-Stand lift (a device designed to assist patients who have some mobility but need help to rise from a sitting position and be able to apply pressure with legs). 2. Ensure CNA 1 used a second person, who was a trained CNA on residents ' transfers, to assist her (CNA 1) to transfer Resident 1 from a shower chair to bed as indicated in Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool) assessment. 3. Ensure CNA 1, who was a registry staff (personnel provided by a placement service on a temporary or on a day-to-day basis, in a facility) was trained on the use of appropriate mechanical lift for a safe Resident 1s ' transfers, based on the resident assessment and needs. 4. Ensure staff followed the facility ' s policy and procedure (P/P) titled Safe Resident Handling/ Transfers dated 9/2/2022, in performing mechanical lifts/ transfers according to the manufacturer ' s instructions for use of the device and utilized two persons physical assistance when transferring residents with a mechanical lift. 5. Ensured the Director of Staff Development (DSD) followed the facility P/P titled Safe Resident Handling/ Transfers dated 9/2/2022, to educated staff from registry on a safe use of mechanical lift devices with staff demonstration of competency in the use of mechanical lifts prior its use to transfer facility ' s residents. These failures resulted in Resident 1 falling from a mechanical lift during transfer by only one person, CNA 1, from a shower chair to bed and sustaining a left femur (thigh bone) fracture (broken bone) with swelling, decreased mobility, and requiring a transfer to a general acute care hospital (GACH) for evaluation. Findings: During a review of Resident 1 ' s Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including complete paraplegia (unable to move the legs or lower body) and BKA. During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated Resident 1 had the ability to be understood and to understand others. The MDS indicated, Resident 1 needed a two or more persons extensive (resident involved in activity, staff provide weight-bearing support) physical assistance for bed mobility and toilet use. The MDS indicated Resident 1 was totally dependent on staff for bathing. The MDS indicated Resident 1 had bilateral lower leg impairment that interfered with daily functions or placed the resident at risk of injury. During a review of Resident 1 ' s Physical Therapy (PT) PT Recertification, Progress Report & Updated Therapy plan (PTPR) dated 11/17/2023 (date of service), the PTPR indicated Resident 1 was wheelchair bound and non-ambulatory (not walking). The PTPR indicated Resident 1 was totally dependent on staff for transfers and a mechanical lift (type of device utilized for passive transfers) must be utilized to transfer Resident 1 between surfaces. The PTPR indicated Resident 1 had balance deficits and was a fall risk. During a review of Resident 1 ' s Care Plan (CP) dated 10/24/2022, the CP indicated Resident 1 was at risk for falls related to paraplegia with the goal for Resident 1 to remain free of falls. The CP Interventions included anticipating and meeting Resident 1 ' s needs and to have PT evaluation and treatment. During a Review of Resident 1 ' s CP dated 1/5/2023, the CP indicated Resident 1 had an actual fall related to loss of balance during transfer with staff utilizing a mechanical lift. The CP goal for Resident 1 was to have no further falls with interventions including identify contributing factors to the fall, intervene appropriately, and to assess the appropriate transfer lift to use after the accident. During a review of Resident 1 ' s Situation Background Assessment and Recommendation [(SBAR) a written communication tool health care providers use to share essential, relevant information during crucial situations] communication forms dated 12/30/2022 and 1/1/2023, the SBAR indicated that on 12/30/2022 a swelling of Resident 1 ' s left femur was noted and an x-ray (a medical test that provides images of the structures inside the body) was ordered. The SBAR indicated on 1/1/2023 a new or worsening edema (swelling) related to trauma (physical injury) due to fall was noted on Resident 1 ' s left femur. The Resident 1 ' s SBAR indicated the left femur site was swollen and hot to touch, and the resident denied pain. The SBAR indicated the recommendation was to transfer Resident 1 to GACH on 1/1/2023 (3 days after the fall incident). During a review of Resident 1 ' s Order Summary Report ' s (OSR) dated 1/2023, the OSR indicated a STAT (immediate) x-ray of the resident ' s left femur due to possible fracture was ordered on 12/30/2022. The OSR indicated an order was placed on 1/1/2023 for transfer to GACH 1 for fracture of left proximal (situated nearer to the point of attachment) femoral (related to femur or the thigh) diaphysis (central part of long bone). During a review of Resident 1 ' s left femur X-ray results (XRR) dated 1/1/2023, the XRR indicated Resident 1 had an acute (recent onset) spiral (when a bone is broken with a twisting motion) fracture of the proximal femoral diaphysis, with approximately three (3.0) centimeter [(cm) a unit of measurement of length] medial displacement (abnormal position of the distal [situated away from the center of the body or from the point of attachment] fracture fragment in relation to the proximal bone) and rotation of the distal fracture moiety (each of two parts into which a thing is or can be divided). During a review of Resident 1 ' s facility ' s Transfer Form [(SHTF)- a written tool used to summarize vital information regarding a resident before transfer to another facility), dated 1/1/2023, the SHTF indicated Resident 1 was transferred to GACH 1 on 1/1/2023 at 2:30 p.m., for evaluation of the left femur fracture. During a record review of Resident 1 ' s History and Physical (H&P) report from GACH 1, dated 1/2/2023, the H&P indicated while Resident 1 was being transferred, Resident 1 ' s caregiver unfortunately manipulated the resident ' s leg, and this resulted in a loud crack. The H&P indicated Resident 1 had swelling of the thigh and an x-ray showed an acute fracture. During a review of the facility ' s investigative report dated 1/1/2023, Resident 1 ' s documented interview indicated, a nurse was transferring Resident 1 from the shower chair to the bed using the standing machine (mechanical lift) and he (Resident 1) began to feel dizzy and hot. Resident 1 ' s documented statement indicated he felt himself going down slowly and the next thing he knew, his left leg was folding against the bottom of the standing machine. Resident 1 indicated the nurse transferred him back in bed by herself, following the incident. During a review of Resident 1 ' s, H&P from the facility dated 1/5/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions and Resident 1 had a left femoral fracture with reduced mobility. During a review of Resident 1 ' s Occupational Therapy [(OT) - therapy provided to improve independence with skills of everyday life) Recertification, Progress Report & Updated Therapy Plan (OTPR) dated 1/5/2023, the OTRP indicated Resident 1 was transferred from the facility to GACH 1 due to a fracture of the left femur, no surgery was recommended, and the resident was transferred back to the facility from GACH 1 once he was stabilized. The OTPR indicated Resident 1 presented with a decline in independence in activities of daily living [(ADLs, activities related to personal care)] during this session due to decreased muscle strength, impaired muscle endurance, decreased functional activity tolerance, and impaired sitting balance. The OTPR indicated Resident 1 had poor sitting balance during ADLs. During a review of Resident 1 ' s MDS, dated [DATE] (after the accident), the MDS indicated Resident 1 required two or more-persons physical assistance for bed mobility and transfer between surfaces. The MDS indicated Resident 1 was not steady with surface-to-surface transfers including transfer between the bed and chair or wheelchair and moving on and off the toilet. The MDS indicated Resident 1 was only able to stabilize during transfer with staff assistance. During an interview on 5/11/2023 at 10:21 a.m., Resident 1 stated three days prior to New Year ' s (12/29/2022) CNA 1 insisted on transferring him from the shower chair to the bed using a mechanical lift for safety, but it was unsafe because he ended up falling while using the lift. Resident 1 stated he told CNA 1 he did not want to use that lift, but CNA 1 made him use the mechanical lift anyway. Resident 1 stated CNA1 was helping him by herself and wrapped him up like a cocoon in the sling with his arms crossed against his chest and his legs dangling down out of the sling. Resident 1 stated the sling was pressing against his lungs when the lift began moving and he started to feel dizzy, next thing he knew the lift started going down and his leg bent under him on the footrest, and he heard a loud popping sound. Resident 1 stated, CNA1 put him back in bed by herself and kept apologizing to him before she left the room. Resident 1 stated no staff came in for the rest of the day to evaluate his leg or ask him what happened. Resident 1 stated when CNA 6 came in the next day on 12/30/2022 to help him she noticed the swelling and informed the charge nurse so then they performed an x-ray, and he was sent out to the hospital for a left leg fracture. Resident 1 stated he did not initially have pain but once the swelling started happening, he felt pain 20 out of 10 on a pain scale rating (a system to assess the level of a person ' s pain from 0 to10. A score of 0 meaning no pain and 10 being the worst pain possible). During subsequent interviews on 5/11/2023 at 11:05 a.m. and 12:07 p.m., CNA 2 stated the facility had two different types of lifts for transfers, the mechanical transfer lift which was for totally dependent residents with a full body sling (supports the upper body and lower body), and the sit-to-stand lift for residents that only required limited assistance. CNA 2 stated it was the facility ' s policy to utilize two staff physical assistance to transfer resident by utilizing either type of lifts. CNA2 stated a few months ago, management provided an in-service (staff education) and informed the staff that a registry staff had inappropriately used the sit-to-stand lift machine to transfer Resident 1, and the resident had sustained a left leg fracture. During an interview on 5/11/2023 at 12:39 p.m., the licensed vocational nurse (LVN1) stated she was assigned to Resident 1 the day after the fall. LVN1 stated the CNA 6 assigned to Resident 1 during 7a.m. to 3 p.m. shift on 12/30/2022 informed her (LVN 1) that Resident 1 had a swelling of his left leg. LVN 1 stated she went to assess Resident 1 and the resident had his left upper thigh swollen immensely that she was sure the incident did not occur during her (LVN 1) shift (due to the amount of swelling). LVN 1 stated she was unsure how Resident 1 was hurt but Resident 1 was not complaining of any pain during her shift. During an interview on 5/11/2023 at 12:53 p.m., with the Physical Therapy Assistant (PTA 1), the PTA 1 stated if a resident was assessed as a two-persons physical assistant, two people needed to complete the transfer. PTA 1 stated a mechanical transfer lift with a full body sling was more suitable than the sit-to-stand lift for a totally dependent resident. During an interview on 5/12/2023 at 9:18 a.m. and subsequent interview at 11:23 a.m., CNA 3 stated the resident needed to be able to stand and put a pressure on their legs for at least a few minutes when the sit-to-stand lift is being utilized. CNA 3 stated Resident 1 was a two-persons assistance and staff when used a lift to transfer Resident 1 needed to use two persons for safety. CNA 3 stated she helped to orient the registry staff, when they came to the facility, where to find supply but did not demonstrate to them how to use the lifts unless they asked. During an interview on 5/12/2023 at 11:45 a.m., the DSD stated when registry staff worked at the facility, the facility CNAs gave them a tour and informed the registry staff to ask for help if needed. The DSD stated it was facility ' s policy to utilize a two-persons team for all lifts. The DSD stated they had not given orientation to the registry staff on the types of lifts utilized in the facility unless they had questions. The DSD stated her staff was aware that the sit-to-stand lift could only be used for residents who could put pressure on their legs. During an interview on 5/12/2023 at 12:47 p.m., with Resident 1 ' s Physician (MD 1), MD 1 stated Resident 1 was not able to feel pain the same as you or I due to his spinal cord injury/paraplegia. MD 1 stated that by coincidence he was in the facility on 12/30/2022 (the day after Resident 1 was injured) when he became aware of the resident ' s left leg swelling and ordered an x-ray. MD 1 stated Resident 1 was seen by an orthopedic surgeon at GACH 1 and the surgeon did not recommend surgery due to the risks of surgery outweighing the benefits and Resident 1 was already non-ambulatory due to paralysis. MD 1 stated there was a possibility that Resident 1 could have had a complication due to the fracture, called compartment-syndrome (serious condition that involves increased pressure in a muscle compartment that can lead to muscle and nerve damage and problems with blood flow) that could occur due to the swelling caused by the fracture. During an interview on 5/12/2023 at 1:09 p.m., the DON stated when staff not using the proper mechanical lift or not utilizing two-persons assistants was endangering Resident 1 ' s safety. The DON stated Resident 1 was assessed to have a two-persons assistance, therefore two staff should had been assisting Resident 1 during any transfer. During an interview on 5/17/2023 at 2:50 p.m., CNA 1 stated she was the registry nurse assigned to Resident 1 on 12/29/2022 and remembered the incident that happened with Resident 1 while she was using the mechanical lift to transfer the resident. CNA 1 stated she had just finished showering Resident 1 and needed to transfer him from the shower chair back to bed. CNA 1 stated she placed Resident 1 in the lift and then he (Resident 1) started to go down, his leg just bent against the bottom of the lift. CNA 1 stated she placed Resident 1 back in bed and he was not complaining of any pain. CNA 1 stated she never received training or orientation from the facility on the use of lifts and no one from the facility asked her if she knew how to use the lift prior to her using it. During a review of the sit-to-stand lift manufacturers instruction guide dated 4/2012, the instruction guide indicated personnel using the lift needed to be trained on the correct operation and use of the lift. The instruction guide indicated as caregivers, they needed to assure the patient was not at risk for falling forward or to any side during lifting. During a review of the facility ' s P/P titled Safe Resident Handling/ Transfers dated 9/2/2022, the P/P indicated it was the facility ' s policy to ensure residents were handled and transferred safely to prevent or minimize risks for injury, provided and promoted a safe, secure, and comfortable experience for the resident. The P/P indicated mechanical lifts included equipment such as full body lifts and sit-to-stand lifts and staff was to perform mechanical lifts/ transfers according to the manufacturer ' s instructions for use of the device. The P/P indicated staff was to ensure the sling designed for the lift was utilized with that specific lift. The P/P indicated two staff members must be utilized when transferring residents with a mechanical lift. The P/P indicated staff was to be educated on the use of safe handling/ transfer practices to include use of mechanical lift devices and staff was to demonstrate competency in the use of mechanical lifts prior to use. During a review of the facility ' s P/P titled Fall Prevention Program, dated 9/2/2022, the P/P indicated a fall was an event in which an individual unintentionally comes to rest on the ground, floor, or other level. The P/P indicated a near miss (when a resident would have fallen if someone else had not caught the resident from doing so) was also considered a fall.

Based on interview and record review, the facility failed to follow its policy and procedure on abuse to ensure one of five sampled residents (Resident 1) was free from sexual abuse for Resident 1 was sexually abused by Resident 2, who had a history of [REDACTED]. Resident 2 inappropriately touched Resident 1's breast without Resident 1's consent in the presence of another resident (Resident 3) crossed referenced to (F689). This deficient practice resulted in Resident 1's rights to be free from abuse violated by Resident 2 sexually abusing Resident 1. It also had the potential for other residents to be sexual abuse by Resident 2. A review of CNA 1's written Declaration, dated 3/10/2020, CNA 1 indicated on 3/2/2020 she notified the DON of the allegation made by Resident 3 of Resident 2 rubbing on Resident 1's breast and the DON stated Resident 3 should not make up stories. CNA 1 indicated the DSD was notified, who subsequently notified the ADM and SSD immediately. CNA 1 documented on 3/3/2020 at 2 p.m., in a meeting with the ADM, SSD, DON and DSD, after stating what Resident 3 had alleged about Resident 2's sexual behavior on 3/2/2020, the ADM stated, It was just a misunderstanding. CNA 1 indicated she felt nothing was being done regarding the abuse incident by the ADM, so she (CNA 1) stated she reported the alleged incident to the Ombudsman (patient advocate). A review of the DSD's written declaration, dated 3/10/2020 indicated on 3/2/2020 CNA 1 reported Resident 3 alleged Resident 2 touched Resident 1 on the breast. The DSD reported to the ADM after the DON told CNA 1 Resident 3 should stop making up stories. The DSD indicated staff were in-serviced on abuse immediately. The DSD also indicated the ADM stated she would get to the bottom of the allegation. The DSD indicated on 3/9/2020 he was asked by the ADM and someone from the corporate office to in-service the staff on sexual abuse regarding another resident (Resident 4) instead of Resident 2, who Resident 3 had alleged to have been the abuser. The DSD stated he was upset, disgusted, confused, and could not believe the facility was covering the truth by replacing Resident 2 with another resident (Resident 4). The DSD stated a similar incident happened before where staff made numerous complaints about another resident, who abused residents, but the DON and ADM did nothing about it. On 3/11/2020 at 7:06 p.m., during an interview and record review with the Administrator (ADM) and the Director of Nursing (DON), 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 ensure residents were protected from being sexually abused by a resident with wandering and inappropriate sexual behaviors. The facility's ADM and DON, were notified of Resident 2's inappropriately touching Resident 1's breast without Resident 1's consent. The DON and ADM were previously notified by CNA 1, but they did not investigate the incident. On 3/12/2020 at 5:17 p.m., the Interim ADM and Acting DON submitted a Plan of Action (POA) for the correction of the IJ which included: 1. A body check was performed on Resident 1 on 3/12/2020 and the physician, responsible party and ombudsman were notified of the incident. 2. Resident 2 was placed on 1:1 monitoring on 3/11/2020. A psychiatric evaluation would be obtained. Resident 2's physician, family and ombudsman were notified on 3/12/2020. 3. Resident 3 was interviewed and offered 1:1 monitoring to provide assurance of feeling safe and secure. 4. The care plan for Resident 1 was updated to reflect appropriately interventions and measurable goals for the alleged abuse victim. 5. The care plans for Residents 2 and 4 (facility's selected alleged abuser) resident were updated to reflect appropriate interventions and measurable goals to protect other residents from abuse. 6. The DON was suspended on 3/12/2020, pending an investigation. 7. The facility was investigating the alleged abuse incident. The IJ was lifted on 3/13/2020 at 8:49 p.m., after the team verified and confirmed, while onsite, the POA was implemented through observation, interview and record review. Findings: a. A review of Resident 1's Admission Face sheet indicated Resident 1 was admitted to the facility on [DATE], with a most recent admission on 2/1/2012. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's history and physical (H/P) report, dated 8/28/2019 indicated Resident 1 was wheelchair bound, was able to express simple needs but required assistance with all activities of daily livings (ADLs). A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 12/15/19 indicated Resident 1 usually was able to understand and be understood and was only able to recall after cueing. The MDS indicated Resident 1 required a two-person physical assist with bed mobility, transferring to and from the bed, chair, wheelchair and standing position and with personal hygiene. The MDS indicated Resident 1 required a one- person assist moving from one location of the facility to another, dressing, eating and toilet use. The MDS indicated Resident 1 used a wheelchair for mobility. A review of Resident 1's care plan, created after the sexual abuse incident, dated 3/2/2020 indicated Resident 1 was at risk for emotional distress related to the sexual assault by another resident (Resident 2). The staff's interventions included to assess for possible signs of distress such as crying and withdrawal and report promptly, listen to the resident's feelings and concern, refocus behavior to something positive and take the resident away from the triggering event. On 3/10/2020 at 11:31 a.m., during an interview, the social service designee (SSD) stated she interviewed Resident 1 and the resident could not remember anything regarding the sexual abuse incident. The SSD stated Resident 1 was monosyllabic (a person who uses short, abrupt words in conversation) and could not tell what happened. The DDS also stated that on 3/2/2020, the Director of Staff Development (DSD) had informed the SSD that Resident 2 allegedly touched Resident 1's breast. The SSD stated that she notified the DON and did not follow up to ensure Resident 1 was safe. On 3/10/2020 at 3:34 p.m., during a concurrent interview and review of in-service training's, the Director of Staff Development (DSD) stated on 3/2/2020 to 3/4/2020, an abuse in-service training was provided because on 3/2/2020, CNA 1 notified the DSD about Resident 2 inappropriately touching Resident 1. The DSD stated CNA 1 stated the DON was dismissive (not interested) about Resident 1's abuse incident. The DSD stated he asked CNA 1 to write a statement and it was sent to the ADM, who stated she would talk to the DON. The DSD stated on 3/2/2020, the Social Services Director (SSD) was also made aware of Resident 2's inappropriate sexual behavior towards Resident 1. b. A review of Resident 2's Admission Face sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's H/ P report, dated 2/6/2020 indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2's care plans indicated there was no care plan to address the resident's sexual inappropriate behavior, although the facility's staff identified Resident 2's behavior on 2/25/2020. A review of Resident 2's MDS, dated [DATE] indicated Resident 2 usually had the ability to understand and be understood by others. The MDS indicated Resident 2 required a one-person physical assist with bed mobility, transferring to, from, and in the bed, chair, wheelchair and standing position, moving from one location of the facility to another, dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 2 used a wheelchair for mobility. A review of Resident 2's Nurse's Progress Note dated 2/15/2020 and timed at 3:25 p.m., indicated Resident 2 wheeled himself throughout the facility and was observed attempting to enter female residents' rooms. A review of Resident 2's nurse's progress note, dated 2/15/2020 and timed at 9:45 p.m., indicated Resident 2, who was ambulatory (but used a wheelchair for mobility) was transferred to a room near the nurse's station for visual monitoring. A review of Resident 2's nurse's progress note, dated 2/15/2020 and timed at 10:35 p.m., indicated Resident 2, who was verbally responsive but confused, was transferred to Station 2. A review of Resident 2's Nurse's progress note, dated 2/25/2020 at an unknown time indicated Resident 2 was observed by a LVN 2 standing in front of a female resident's room (Resident 5) looking at her. The note indicated Resident 2 was moved to another room. On 3/10/2020 at 12:02 p.m., during a telephone interview, Certified Nursing Assistant 1 (CNA 1) stated on 3/2/2020 Resident 3 reported witnessing Resident 2 touching Resident 1 on the breast. CNA 1 stated the DON was notified and stated Resident 3 should stop making up stories. On 3/10/2020 at 3:34 p.m., during a concurrent interview and review of in-service trainings, the Director of Staff Development (DSD) stated on 3/2/2020 to 3/4/2020, an abuse in-service training was provided because on 3/2/2020, CNA 1 notified the DSD about Resident 2 inappropriately touching Resident 1. The DSD stated CNA 1 stated the DON was dismissive (not interested) about Resident 1's abuse incident. The DSD stated he asked CNA 1 to write a statement and it was sent to the ADM, who stated she would talk to the DON. The DSD stated the Social Services Director (SSD) was also made aware of Resident 2's inappropriate sexual behavior. On 3/10/2020 at 4:01 p.m., during a concurrent interview and review of Resident 2's nurse's progress notes, monitoring log and care plan, the DON stated there was no care plan to address Resident 2's sexual inappropriate behavior, no monitoring log and no progress notes indicating Resident 2 was being monitored after the abuse incident on 3/2/2020. The DON stated on 3/2/2020, CNA 1 notified her of Resident 3's allegation of witnessing Resident 2 rubbing on Resident 1's breast. The DON stated when an alleged abuse incident was reported, the facility's policy was to place the abused and abuser on monitoring for safety. The DON stated Resident 2 was not monitored because they did not investigate Resident 2's alleged abuse incident. On 3/12/2020 at 12:47 p.m., during a telephone interview, LVN 2 stated Resident 2 was ambulatory and used a wheelchair and would often attempt to enter a female resident's room. LVN 2 stated the DON asked Resident 2 to be moved to another station with less female residents. LVN 2 stated Resident 5 had complained that Resident 1 attempted to enter her room. LVN 2 stated there was no monitoring log for Resident 2 to monitor his whereabouts. On 3/13/2020 at 8:10 p.m., during an interview, Resident 2 stated he touched Resident 1's breast but did not mean to disrespect Resident 1. Resident 2 stated he stopped after Resident 1 made a bad face. c. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on [DATE] with a most recent admission on 5/18/10. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's H/P, dated 7/12/19 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. On 3/10/2020 at 2:47 p.m. during an interview, Resident 3 stated on 3/1/2020 at approximately 10 a.m., Resident 2 was observed in the dining room touching Resident 1 on the breast. Resident 3 stated Resident 2 had a tendency of trying to touch women and went around the facility looking for rooms with women. A review of the facility's policy and procedure dated 4/15/19 and titled, Protection of Resident: Reducing the Threat of Abuse and Neglect indicated residents had the right to be free from abuse and neglect and that the facility would prevent and prohibit all types of abuse and neglect. This policy also indicated the facility would identify, correct and intervene in abuse situations. A review of the facility's undated policy and procedure titled, Event Management & Emergency Procedures, indicated the resident must not be subject to abuse by anyone and had the right to live at ease in a safe environment without the fear of retaliation. The policy indicated all associates were mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative. The policy indicated the person suspecting the resident abuse will immediately report to their supervisors. The policy indicated caution must be taken when handling evidence that can be use in a criminal investigation.

Based on observation, interview, and record review, the facility failed to monitor, supervise and create a plan of care for a resident who required supervision for sexual inappropriate behavior for one of five sampled residents (Resident 2). Resident 2, who had behaviors of wandering the facility looking at female residents and going into the female residents' rooms, while making the female residents feel uncomfortable with sexual inappropriate behavior toward female residents was not supervised by the facility's staff. Resident 2, while unsupervised, went into the dining room and touched Resident 1's breast without her consent (crossed referenced to F600). This deficient practice resulted in Resident 1's rights being violated after Resident 2 was allowed to continue to wander the facility unsupervised, after the facility's staff had identified Resident 2's sexual inappropriate behavior on 2/15/2020. This noncompliance resulted in Resident 1 being sexually abused and had the potential for other residents to be sexual abused by Resident 2 due to the facility's lack of supervision. On 3/11/2020 at 7:06 p.m., a system failure was identified regarding the facility's lack of supervision resulting in abuse and 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 ensure residents were protected from sexual abuse by an unsupervised resident with wandering and inappropriate sexual behaviors. The Director of Nurses (DON) was notified by Certified Nursing Assistant 1(CNA 1) and the DON did not investigate the incident or take any action. The facility's Administrator (ADM) and DON were notified of Resident 2 violating Resident 1's rights by inappropriately touching Resident 1's breast without Resident 1's consent. On 3/12/2020 at 5:17 p.m., the Interim ADM and Acting DON submitted a Plan of Action (POA) for the correction of the IJ which included: 1. A body check was performed on Resident 1 on 3/12/2020 and the physician, responsible party and ombudsman were notified of the incident on 3/12/2020. 2. Resident 2 was placed on 1:1 monitoring on 3/11/2020. A psychiatric evaluation would be obtained. 3. Resident 3 was interviewed and offered 1:1 monitoring to provide assurance of feeling safe and secure. 4. The care plan for Resident 1 was updated to reflect appropriately interventions and measurable goals for the alleged abuse victim. 5. The care plans for Residents 2 and 4 (facility selected alleged abuser) resident were updated to reflect appropriate interventions and measurable goals to protect other residents from abuse. 6. The DON was suspended on 3/12/2020, pending investigation. 7. The facility was investigating the alleged abuse incident. The IJ was lifted on 3/13/2020 at 8:49 p.m., after the team verified and confirmed, while onsite, the POA was implemented through observation, interview and record review. Findings: a. A review of Resident 2's Admission Face sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's history and physical (H/ P) report, dated 2/6/2020 indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2's care plans indicated there was no care plan to address the resident's sexual inappropriate behavior, although the facility's staff identified Resident 2's behavior of trying to enter female residents' room on 2/25/2020. A review of Resident 2's Minimum Data Set (MDS), dated [DATE] indicated Resident 2 usually had the ability to understand and be understood by others. The MDS indicated Resident 2 required a one-person physical assist with bed mobility, transferring to, from, and in the bed, chair, wheelchair and standing position, moving from one location of the facility to another, dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 2 used a wheelchair for mobility. A review of Resident 2's nurse's progress note, dated 2/15/2020 and timed at 9:45 p.m., indicated Resident 2, who was ambulatory (but used a wheelchair for mobility) was transferred to a room near the nurse's station for visual monitoring. A review of Resident 2's nurse's progress note, dated 2/15/2020 and timed at 10:35 p.m., indicated Resident 2, who was verbally responsive but confused, was transferred to Station 2. A review of Resident 2's Nurse's Progress Note dated 2/15/2020 and timed at 3:25 p.m., indicated Resident 2 wheeled himself throughout the facility and was observed attempting to enter female residents' rooms. A review of Resident 2's Nurse's progress note, dated 2/25/2020 at an unknown time indicated Resident 2 was observed by a Licensed Vocational Nurse (LVN 2) standing in front of a female resident's room (Resident 5) looking at her. The note indicated Resident 2 was moved to another room. On 3/10/2020 at 12:02 p.m., during a telephone interview, Certified Nursing Assistant 1 (CNA 1) stated on 3/2/2020 Resident 3 reported witnessing Resident 2 touching Resident 1 on the breast. CNA 1 stated the DON was notified and the DON stated Resident 3 should stop making up stories. On 3/10/2020 at 3:34 p.m., during a concurrent interview and review of in-service training's, the Director of Staff Development (DSD) stated on 3/2/2020 to 3/4/2020, an abuse in-service training was provided. The DSD stated CNA 1 notified her about Resident 2 inappropriately touching Resident 1. The DSD stated CNA 1 informed the DON but the DON was dismissive (not interested) about Resident 1's abuse incident. The DSD stated he asked CNA 1 to write a statement and it was sent to the ADM, who stated she would talk to the DON. The DSD stated the Social Services Director (SSD) was also made aware of Resident 2's inappropriate sexual behavior. On 3/10/2020 at 4:01 p.m., during a concurrent interview and review of Resident 2's nurse's progress notes, monitoring log and care plan, the DON stated there was no care plan to address Resident 2's sexual inappropriate behavior, no monitoring log and no progress notes indicating Resident 2 was being monitored after the abuse incident on 3/2/2020. The DON stated on 3/2/2020, CNA 1 notified her of Resident 3's allegation of witnessing Resident 2 rubbing on Resident 1's breast. The DON stated when an alleged abuse incident was reported, the facility's protocol was to place the abused and abuser on monitoring for safety. The DON stated Resident 2 was not monitored because they did not investigate Resident 2's alleged abuse incident. On 3/12/2020 at 12:47 p.m., during a telephone interview, LVN 2 stated Resident 2 was ambulatory and used a wheelchair and he would often attempt to enter a female resident's room. LVN 2 stated the DON asked Resident 2 to be moved to another station with less female residents. LVN 2 stated Resident 5 had complained that Resident 1 attempted to enter her room. LVN 2 stated there was no monitoring log for Resident 2 to monitor his whereabouts. On 3/13/2020 at 8:10 p.m., during an interview, Resident 2 stated he did touch Resident 1's breast but did not mean to disrespect Resident 1. Resident 2 stated he stopped after Resident 1 made a bad face. b. A review of Resident 1's Admission Face sheet indicated Resident 1 was admitted to the facility on [DATE], with a most recent admission on 2/1/2012. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's history and physical (H/P) report, dated 8/28/19 indicated Resident 1 was wheelchair bound, was able to express simple needs but required assistance with all activities of daily livings (ADLs). A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 12/15/19, indicated Resident 1 usually was able to understand and be understood by others and was only able to recall after cueing. The MDS indicated Resident 1 required a two-person physical assist with bed mobility, transferring to and from the bed, chair, wheelchair and standing position and with personal hygiene. The MDS indicated Resident 1 required a one- person assist moving from one location of the facility to another, dressing, eating and toilet use. The MDS indicated Resident 1 used a wheelchair for mobility. A review of Resident 1's care plan, created after the sexual abuse incident, dated 3/2/2020 indicated Resident 1 was at risk for emotional distress related to the sexual assault by another resident (Resident 2). The staff's interventions included to assess for possible signs of distress such as crying and withdrawal and report promptly, listen to the resident's feelings and concern, refocus behavior to something positive and take the resident away from the triggering event. On 3/10/2020 at 11:31 a.m., during an interview, the social service designee (SSD) stated she interviewed Resident 1 and the resident could not remember anything regarding the sexual abuse incident. The SSD stated Resident 1 was monosyllabic (a person who uses short, abrupt words in conversation) and could not tell what happened. c. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on [DATE] with a most recent admission on 5/18/10. A review of Resident 3's H/P, dated 7/12/19 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. On 3/10/2020 at 2:47 p.m. during an interview, Resident 3 stated on 3/1/2020 at approximately 10 a.m., Resident 2 was observed in the dining room touching Resident 1 on the breast. Resident 3 stated Resident 2 had a tendency of trying to touch women and went around the facility looking for rooms with women. A review of CNA 1's written Declaration, dated 3/10/2020, CNA 1 indicated on 3/2/2020 she notified the DON of the allegation made by Resident 3 of Resident 2 rubbing on Resident 1's breast and the DON stated Resident 3 should not make up stories. CNA 1 indicated the DSD was notified, who subsequently notified the ADM and SSD immediately. CNA 1 documented on 3/3/2020 at 2 p.m., in a meeting with the ADM, SSD, DON and DSD, after stating what Resident 3 had alleged about Resident 2's sexual behavior on 3/2/2020, the ADM stated, It was just a misunderstanding. CNA 1 indicated she felt nothing was being done regarding the abuse incident by the ADM, so she (CNA 1) stated she reported the alleged incident to the Ombudsman (patient advocate). A review of the DSD's written declaration, dated 3/10/2020 indicated on 3/2/2020 CNA 1 reported that Resident 3 alleged Resident 2 touched Resident 1 on the breast. The DSD reported to the ADM after the DON told CNA 1 Resident 3 should stop making up stories. The DSD indicated staff were in-serviced on abuse immediately. The DSD also indicated the ADM stated she would get to the bottom of the allegation. The DSD indicated on 3/9/2020 he was asked by the ADM and someone from the corporate office to in-service the staff on sexual abuse regarding another resident (Resident 4) instead of Resident 2, whom Resident 3 had alleged to have been the abuser of Resident 1. The DSD stated he was upset, disgusted, confused, and could not believe the facility was covering the truth by replacing Resident 2 with another resident (Resident 4). The DSD stated a similar incident happened before where staff made numerous complaints about another resident, who had abused residents, but the DON and ADM did nothing about it. A review of the facility's policy and procedure, dated 4/15/19 and titled, Protection of Resident: Reducing the Threat of Abuse and Neglect indicated residents had the right to be free from abuse and neglect and that the facility would prevent and prohibit all types of abuse and neglect. This policy also indicated the facility would identify, correct and intervene in abuse situations. A review of the facility's policy and procedure (P/P), dated 12/13/18 and last reviewed on 4/15/19 and titled, Unsafe Wandering and Elopement, indicated the purpose of the policy was to promote residents' safety and reduce unsafe wandering. The P/P indicated under Avoidable the staff would implement interventions, including adequate supervision, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the resident's risk.

Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Residents 2, 3, 4, and 5) were not sexually, physically, verbally, and emotionally abused by Resident 1 (Cross referenced to F656 and F[AGE]6). On [DATE] at 4:20 p.m., Resident 1 performed a nonconsensual (not agreed to) oral sex (sexual activity in which the genitals of one person are stimulated by the mouth of another) to Resident 2. On [DATE] with an unknown time, Resident 1 touched Resident 3's breast without consent and attempted to kiss her. Resident 4 feared that Resident 1 would do something to her after Resident 1 walked into her room twice (dates unknown). On 11/4/19 (time unknown), Resident 5 requested a room change after the resident became fearful of Resident 1's sexual comments, aggressive actions, and verbal threat. These deficient practices resulted in Resident 1 sexually assaulting Resident 2 and 3; and Resident 4 and 5 feeling fearful of Resident 1's sexual behaviors. Resident 1 violated the rights of Resident 2, 3, 4, and 5 to live in an environment free from abuse and fear. Resident 2 would cry when approached by a family member and had to be reassured that she is safe prior to approaching her. Resident 2 was immediately discharged (unplanned discharge) home per family's request. Resident 3 felt scared for her life that Resident 1 would return to her room after being sexually assaulted. Resident 3 was transferred to another room near the nursing station for close monitoring. Resident 5 requested a room transfer due to he felt unsafe around Resident 1 because of Resident 1's aggressive actions towards him and verbal threat to kill him. On [DATE] at 5:18 p.m., during an interview and record review, with the Administrator (ADM) and the Director of Nursing (DON), the Department called an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for the facility's noncompliance to ensure all residents were free from abuse. The Department notified the facility's ADM and DON of the immediacy and seriousness of the residents' health and safety being threatened and jeopardized (a situation in which there is danger of harm). On 12/22/19 at 12:30 p.m., the ADM and DON submitted an acceptable Plan of Action (POA) for the correction of the IJ which included as follows: 1. Resident 1 was arrested and taken into police custody on [DATE]. 2. Resident 2 was discharged home and was no longer resident at facility. 3. Resident 3 was seen by a psychiatrist (a physician who specialize in the treatment of [REDACTED]. 4. The psychiatrist (a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of [REDACTED]. 5. In-service to all staff regarding sexual abuse reporting and preserving the environment and evidence (of the abuse or crime), while ensuring resident's (Resident 2's) safety. 6. Assess residents with wandering behaviors and placed on a one-on-one (1:1, on staff supervises or monitors one resident at all times) until the Interdisciplinary Team ((IDT) group of healthcare providers from different fields who work together for the best care or best outcome for residents) an appropriate care plan. 7. An outside provider will provide in-services to all staff regarding abuse management. On 12/22/19 at 12:30 p.m., during a concurrent observation, interview and record review, the Department notified the ADM and DON the IJ was lifted after the team verified on-site the POA was followed and implemented. Findings: A review of the facility's final investigation related to Resident 1 abusing Residents 2 and 3, dated [DATE], indicated a sexual assault occurred. The report indicated Resident 1 performed oral sex on Resident 2 and touched Resident 3's breast. A review of the Sheriffs' Supplemental Report Special Victims, dated [DATE], indicated Resident 1 made a licking like motion with his tongue and began to laugh when approached by the officer (the Sheriff). The report indicated Resident 1 stated, I licked her vagina (a female's genitalia/private part), she told me to do it. I was talking to her and she pushed my head down towards her woman parts and I licked her. She told me to go inside of her, but I didn't want to. The Sheriff's report indicated Resident 2 was unable to consent to sexual activity and Resident 3 was able to identify Resident 1 as the abuser. The report indicated Resident 3 stated Resident 1 touched her breast and left the room (the room shared by Resident 2 and 3) when Resident 3 screamed and then returned after spending 10 minutes with Resident 2 to touch Resident 2. The report indicated Certified Nurse Assistant 1 (CNA 1) heard Resident 3 screaming, Get out of here you abuser, and CNA 1 observed Resident 2's adult disposable brief opened and the resident's vagina exposed. 1. A review of Resident 1's Face Sheet (Admission Record) indicated the facility admitted the resident on 10/18/18 and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's care plan titled, Inappropriate Behavior of Exposing Self in Public/Sexual Behavior in Public Areas, initiated on 10/5/19, indicated the resident would not have episodes of exposing self in any place and will have a psych (psychiatric) evaluation to monitor medications and behavior. The staffs' interventions included to have two nurses with the resident during care, to monitor the resident's whereabouts, to provide the resident with a 1:1 sitter, and to discontinue the 1:1 sitter once the resident's behaviors had improved. A review Resident 1's physician progress notes [REDACTED]. A review of Resident 1's Behavior Management Team note, dated 10/25/19, indicated the resident remained to have [MEDICAL CONDITION] events, was attacking women, and had an increase in agitation. The note indicated to continue monitoring Resident 1's behaviors. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 10/26/19, indicated the resident's cognition (ability to acquire knowledge and understanding) was moderately impaired with poor decision-making and he required limited assist (staff provide guided-maneuvering of limbs or other non-weight bearing assistance) with one-person physical assist for locomotion (how resident moves between locations) on and off the unit. A review of Resident 1's IDT Psychological Note, dated 10/29/19 and timed at 2:11 p.m. indicated the resident continued to experience [MEDICAL CONDITION] with agitation. A review of Resident 1's History and Physical (H/P), dated [DATE], indicated the facility admitted the resident with increased behaviors of paranoia (delusions of persecution, unwarranted jealousy). The H/P indicated Resident 1 had the capacity to understand and make decisions but had an increased paranoia. The H/P indicated a plan to monitor Resident 1's behavior, to provide the resident a 1:1 sitter. A review of an unsigned and untimed physician's telephone order for Resident 1, dated 11/12/19, indicated to discontinue the order for 1:1 sitter. A review of Resident 1's physician progress notes [REDACTED]. A review of Resident 1's Care Plan Conference Record, dated 11/26/19, indicated the DON noted Resident 1's sexual behaviors escalating (increasing). The record indicated Resident 1's mental behavior had worsened since 8/2019 and the psychiatrist had attempted to adjust the medications unsuccessfully. A review of Resident 1's Nurse's Progress note, dated 11/26/19 and timed at 12:42 p.m., indicated Resident 1 was continuously touching himself throughout the day in the presence of the staff. The progress note indicated Resident 1 was instructed to go into his room where he could have privacy. A review of Resident 1's Nurse's Progress note, dated [DATE] and timed at 4:10 p.m., indicated Resident 1 was in Residents 2 and 3's (shared) room and Resident 1 touched Resident 3's breast. The progress note indicated CNA 1 took care of Resident 2 after noticing the blanket covering Resident 2 shifted and the resident's adult disposable brief opened. The progress note indicated CNA 1 notified the Director of Staff Development (DSD). The progress note indicated Resident 1 admitted to sexually assaulting Resident 2. 2. A review of Resident 2's Admission Record indicated the facility admitted the resident on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's H/P, dated [DATE], indicated the resident was non-verbal and did not have the capacity to make decisions. A review of Resident 2's MDS, dated [DATE], indicated the resident's cognition was severely impaired for daily decision-making. The MDS indicated Resident 2 required extensive assist (staff provide weight bearing support) of two or more staff assist for bed mobility. A review of Resident 2's physician telephone order, dated [DATE] and timed at 10:30 p.m., which was made after the sexual abuse incident of Resident 2, indicated to discharge Resident 2 home per family request. A review of the Notice of Transfer/Discharge, dated [DATE] and timed at 10:30 p.m., indicated the reason for the discharge was the safety of Resident 2 in the facility was endangered by being there. On [DATE] at 9:30 a.m., during a telephone interview, Responsible Party 1 ((RP1) family member of Resident 2) stated on [DATE] (time not mentioned), she received a call from the facility indicating Resident 2 would be sent to the general acute care hospital (GACH) for further evaluation due to an assault. RP 1 stated she was notified by the facility staff (RP 1 did not identify the staff) that a staff (CNA 1) found Resident 2 in her room with her adult disposable brief taken off. RP 1 stated upon her arrival to the facility, she was greeted by two police officers who informed her Resident 1 admitted to sexually assaulting Resident 2. RP 1 stated Resident 2 was dressed and placed in the dining room after the resident was found with her disposable brief taken off. RP 1 was heard crying stating Resident 2 was not the same, when a family member approached her (Resident 2) the resident would shrug her shoulders, pull her face away, and cry. RP 1 stated Resident 2 had to be reassured she was safe before being approach. RP 1 stated Resident 2 would not smile and could not be approached without her being afraid. 3. A review of Resident 3's Admission Record indicated the facility admitted the resident on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated the resident was able to make decisions and she had no memory problems for daily decision-making. The MDS indicated Resident 3 required extensive assist with two or more staff physical assist for bed mobility. A review of the Room Change Notification, dated 12/5/19, indicated the facility transferred Resident 3 to another room in front of the facility's nurse station to be closely monitored. On 12/5/19 at 1:15 p.m., during an interview, Resident 3 stated Resident 1 kept going into her room, trying to kiss her, and would place his hand down her blouse and touch her breast (on [DATE]). Resident 3 stated she told Resident 1 to stop and pushed him away. Resident 3 stated Resident 1 then went to Resident 2's bed and she (Resident 3) did not see what happened due to Resident 2's privacy curtain being closed. On [DATE] at 3 p.m., during a follow-up interview and observation in the resident's room, Resident 3's eyes were watery while stating after Resident 1 sexually attacked her (on [DATE]), he then went to Resident 2's bed, he closed the curtain (used to provide privacy to Resident 2), and he was there (in Resident 2's bed area) for a long time. Resident 3 stated she started yelling for Resident 1 to get out and leave Resident 2 alone. Resident 3 stated her heart was beating fast due to not knowing what Resident 1 was doing to Resident 2. Resident 3 stated after Resident 1 left the room, she was scared for her life that Resident 1 would come back. 4. A review of Resident 4's Admission Record indicated the facility admitted the resident on [DATE] and last readmitted on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's MDS, dated [DATE], indicated the resident was able to make decisions and had no memory problems for daily decision-making. The MDS indicated Resident 4 required extensive assist with two or more staff physical assist for bed mobility. On [DATE] at 3:38 p.m., during an interview, Resident 4 stated Resident 1 attempted to enter her room on two separate occasions (did not remember the dates) and the staffs were aware (resident did not remember the staff). Resident 4 stated feeling afraid that Resident 1 could do something to her. 5. A review of Resident 5's Admission Record indicated the facility admitted the resident on [DATE] and last readmitted on [DATE]. Resident 5's [DIAGNOSES REDACTED]. A review of Resident 5's MDS, dated [DATE], indicated the resident was able to make decisions and had no memory problems for daily decision-making. A review of Resident 5's Room Change Notification, dated 11/4/19, indicated the resident requested a room change (due to Resident 5 felt scared and unsafe around Resident 1 per Resident 5's interview on [DATE] at 8:05 p.m.). Resident 1 and 5 shared a room prior to the request for room transfer. On 12/5/19 at 1:35 p.m., during an interview, the DON stated Resident 1 admitted to sexually assaulting Residents 2 and 3. The DON stated she was aware of Resident 1's sexual behaviors of masturbating (stimulate one's own genitals for sexual pleasure) in public and increase in aggression. On 12/5/19 at 3:40 p.m., during an interview, CNA 1 stated on [DATE], Resident 3 notified her (after Resident 1 left Resident 3's room) that Resident 1 touched Resident 3's breast; Resident 1 left Resident 3's room after Resident 3 pushed him away; and that Resident 1 went to Resident 2's bedside. On [DATE] at 4 p.m., during a subsequent interview, CNA 1 stated on [DATE], while making rounds at 4 p.m., Resident 3 informed her that Resident 1 came into her room and touched her and then went to Resident 2's bed. CNA 1 stated upon entering the room (the shared room of Residents 2 and 3) to check on Resident 2, Resident 2's pillow was on the floor, Resident 2's disposable brief and blanket were off the bed, Resident 2's vaginal area was exposed, and Resident 2 was crying. CNA 1 stated she asked CNA 2 for help and CNA 2 told her to clean and change Resident 2 and place the resident in the dining room. CNA 1 stated she cleaned and changed Resident 2's clothing; she took the resident to the dining room and returned to Resident 2's and 3's shared room to check on Resident 3. CNA 1 stated while she was cleaning Resident 2's bed, Resident 1 returned to Resident 2's bed area, opened the privacy curtain, and was surprised to see the staff (CNA 1) and not Resident 2 in the bed area. CNA 1 stated she notified the DSD. CNA 1 stated that she should not have change the resident and waited for the supervisor to assess the resident to safe the evidence for the police. On [DATE] at 5:10 p.m., during a subsequent interview in the presence of the ADM, the DON stated she was aware of Resident 1's [MEDICAL CONDITION]. The DON stated the nurse practitioner ((NP) mid-level practitioner trained to assess, order and interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe treatment plans) evaluated Resident 1 after his behaviors increased. The DON stated the staff did not think Resident 1's [MEDICAL CONDITION] were a big deal to worry about it. On [DATE] at 7 p.m., during an interview, the DSD stated that both CNA 1 and 2 should had left Resident 2 in bed and call the supervisor so that any evidence could be preserve for evidence. On [DATE] at 7:06 p.m., during a telephone interview in the presence of the DSD, CNA 2 stated on [DATE] she was called into Residents 2's and 3's shared room to check on Resident 2. CNA 2 stated upon entering Resident 2's room, she noticed the blankets were off the resident and the resident's adult brief opened. CNA 2 stated she told CNA 1 to change Resident 2 and take her to the dining room. CNA 2 stated Resident 1 would always touch himself and the nurses and would make inappropriate sexual comments towards the nurses. On [DATE] at 8:05 p.m., during an interview, Resident 5 stated he requested a room change because Resident 1 would act aggressively towards him and would tell him he would kill him if he was having sex with Resident 1's girlfriend. Resident 5 stated he felt scared and unsafe due to Resident 1 touching himself and making inappropriate comments. On 12/21/19 at 11:45 a.m., during a concurrent interview and review of Resident 1's care plans, the DON stated a care plan for monitoring Resident 1's whereabouts was initiated on [DATE], and a second care plan with an intervention for a 1:1 monitoring was initiated on [DATE] and discontinued on 11/12/19. The DON stated Resident 1 received sexual education regarding inappropriate touching, but the person who provided the education failed to document the education provided. The DON stated the staff was monitoring Resident 1 every half hour during the month of 11/2019. A review of the facility's undated policy titled, Event Management & Emergency Procedures, indicated the resident must not be subjected to abuse by anyone and had the right to live at ease in a safe environment without the fear of retaliation. The policy indicated caution must be taken when handling evidence that can be use in a criminal investigation.

Based on observation, interview, and record review, the facility failed to implement a resident's plan of care, which included visual checks and a functioning bed alarm, for one of three sampled residents (Resident 1). Resident 1, who was assessed as a high risk for falls and had a history of [REDACTED]. These deficient practices resulted in Resident 1 falling from the bed and sustaining a 1.05 centimeter (cm) [MEDICAL CONDITION] (a deep cut or tear in skin), which required a transfer to the general acute care hospital (GACH) for head trauma and laceration repair. Findings: A review of Resident 1's Admission Records indicated the resident was initially 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 assessment and care-screening tool, dated 5/21/18, indicated Resident 1 was severely impaired in decision-making regarding tasks of daily life, and required an extensive one-person physical assist for dressing, personal hygiene, toilet use, and transfers between surfaces. The MDS indicated Resident 1 was occasionally incontinent (the ability to control the excretion) of bladder, and used a walker and wheelchair for mobility. The MDS indicated Resident 1 had two falls since admission to the facility, one with no injury and one with injury. The MDS further indicated Resident 1 was receiving antipsychotic (group of drugs that are used to treat serious mental health conditions such as [MEDICAL CONDITION] as well as other emotional and mental conditions) medications. A review of Resident 1's care plan titled Falls, initiated on 11/28/15, and revised on 7/5/17, indicated certified nursing assistants (CNAs) were to provide adaptive devices and observe Resident 1. The care plan indicated that all staff were to apply the resident's bed alarm while the resident was in bed and in the wheel chair, and place the commode (portable chair with a hole in the seat and a pot underneath that is used as a toilet) by the bedside. The care plan indicated Resident 1 verbalized having a fall on 7/5/17. The care plan did not indicate a set time, frequency, and duration of when the nursing staff were to perform monitoring of Resident 1. A review of Resident 1's Fall Risk Assessment, dated 2/24/18, indicated Resident 1 had a score of 17 (a score of 10 or higher indicates a resident is at risk) on the fall risk evaluation sheet. A review of Resident 1's Progress Note, dated 5/17/18, and timed at 2:03 p.m., indicated Licensed Vocational Nurse 2 (LVN 2) called Resident 1's physician and received an order for [REDACTED]. A review of Resident 1's Nursing Progress Note, dated 5/17/18, and timed at 3:16 p.m., indicated Resident 1's family member was observed running down the hallway yelling for help due to Resident 1 falling to the floor. The note indicated Resident 1 was found on her back, next to a commode and had a 1.05 centimeter (cm) [MEDICAL CONDITION]. A review of Resident 1's Nursing Progress Note, dated 5/17/18, and timed at 3:48 p.m., indicated the resident was found on the floor beside a commode at (12:40 p.m.), on her back with a 1.05 cm to the back of the head bleeding. The progress note indicated there was an order to transfer Resident 1 to a general acute care hospital (GACH) per family's request for the laceration of the head. The progress note indicated compression was applied to the laceration to prevent bleeding. A review of Resident 1's GACH Emergency/Urgent Care records, dated 5/17/18 and timed at 9:31 p.m., indicated the resident had an unwitnessed fall from a commode with a scalp laceration requiring three sutures (a medical device used to hold body tissues together after an injury or surgery). A review of a Progress Note, dated 5/17/18 and timed at 11:20 p.m., indicated Resident 1 returned back to the facility from the GACH. The resident had a one-inch laceration with three staples (used in surgery in place of sutures to close skin wounds) skin discoloration on the left lateral knee, redness on the back of the base of the neck, and left lateral back. On 8/21/18 at 11 a.m., during an observation, Resident 1 was observed in bed was in low position, with no floor mats on either side of the bed, and no visible bed alarms. Resident 1's family members were observed gathered around the resident crying in tears. Resident 1 was non-responsive to verbal commands and directives from family members. Resident 1's room was observed to be located right across from the nursing station. On 8/21/18 at 11:05 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had fall preventive measures, such as a bed alarm to sound off whenever Resident 1 would try to get up from the bed. LVN 1 stated she did not hear any alarms going off at the time of Resident 1's fall on 5/17/18. LVN 1 stated she did not perform checks for the functionality of Resident 1's bed alarm at the beginning of her shift and she was not at the nurse's station at the time of the fall incident. On 8/21/18 at 11:07 a.m., during an interview, Resident 1's family member (FM 1) stated on 5/17/18, she found Resident 1 on the floor and immediately tried to get help. FM 1 stated at the time of the fall, there were no nurses at the nurse's station. FM 1 stated that the bed alarm did not activate during the time of Resident 1's fall. FM 1 stated when FM 1 approached LVN 1 for assistance, LVN 1 responded unkindly and refused to help FM 1 after the fall to assess the resident's injuries. On 8/21/18 at 11:10 a.m., during an interview, the Administrator stated the reason that Resident 1 does not have a bed alarm currently was because the resident was no longer actively trying to get out of bed as before. The Administrator stated Resident 1 was now under hospice care (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life). On 8/21/18 at 12 p.m., during an interview, LVN 2 stated the use of bed alarms, wheelchair alarms, beds in low position with floor mats, and visual monitoring were used as a means to prevent residents from falling. LVN 2 stated that the reason Resident 1 was moved closer to the nursing station was to be monitored by staff in preventing Resident 1 from falling. On 8/21/18 at 12:17 p.m., during an interview, LVN 3 stated resident fall precautions included having a room located near the nursing station, performing frequent rounds, and the use of bed and wheelchair alarms. LVN 3 stated Resident 1 had a history of [REDACTED]. LVN 3 stated she did not hear the bed alarm go off during the time of Resident 1's fall on 5/17/18. On 8/21/18 at 12:25 p.m., during an interview, CNA 1 stated Resident 1 had a bed alarm and CNAs, as well as the licensed staff, were to check the alarms at the beginning of the shift. On 8/21/18 at 12:30 p.m., during an interview, the Social Services Director (SSD) stated FM 1 came to her and complained about LVN 1. The SSD stated FM 1 indicated LVN 1 was not helping assess and evaluate Resident 1's fall injuries. On 8/21/18 at 12:45 p.m., during an interview, LVN 4 stated that Resident 1 was on fall precautions at the time of the fall incident on 5/17/18. LVN 4 stated she was Resident 1's nurse on the day of the fall. LVN 4 stated Resident 1 had a bed alarm, but she did not check if the bed alarm was working at the beginning of her shift. LVN 4 stated she was supposed to check the bed alarm to help prevent Resident 1 from falling. LVN 4 stated she was not at the nurse's station at the time of Resident 1's fall and was unaware who was providing visual monitoring for Resident 1. On 8/21/18 at 1:30 p.m., during a telephone interview, CNA 2, who was Resident 1's primary caregiver on the day of the fall, stated she did not check Resident 1's bed alarm to see if it was working, but should have, as well as the licensed staff. CNA 2 stated she did not hear any alarms go off at the time of Resident 1's fall on 5/17/18. On 8/21/18 at 2 p.m., during an interview, the Director of Nurses (DON) stated that Resident 1 was assessed as a high risk for falls during a fall assessment evaluation, dated 2/24/18, and required close monitoring and supervision from nursing staff. The DON stated that Resident 1 had a bed alarm and nursing staff were to check the alarms prior to the beginning of their shift. The DON added there were no logs or flow charts to document the operational status of the bed alarms, but the licensed nurses were to include the bed alarm checks as part of the narrative in the progress notes. The DON verified there was no progress note for 5/17/18, prior to Resident 1's fall to indicate that the bed alarm was checked for functionality. A review of the facility's undated policy and procedure titled, Falls Management, indicated an interdisciplinary plan of care will be developed, implemented, reviewed and updates as necessary to reflect each resident's current safety needs and fall reduction interventions. The policy indicated each resident will be assessed throughout the course of treatment for [REDACTED].