Every finding on record at West Hollywood Healthcare & Wellness Centre, LP

Based on observation and interview, the facility failed to ensure kitchen staff labeled all foods stored in the kitchen refrigerator and dry storage with the correct food name, date of food delivery, date the food container was opened, and best by date and stored in the correct temperature according to the facility's policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Food Storage and Handling with a revision date of 2/29/2024 evidenced by: One bag of fruit look like grapes was stored in reach-in refrigerator (RR - an upright, commercial cooling unit with front doors that lets workers grab food and drinks quickly without walking inside) 3 without the date the bag was opened. One unlabeled plastic bag containing 36 cucumber like vegetables was stored in RR 3.One open box of pure honey stored in the manufacturer's original box found in the dry storage section of the kitchen had an expiration date of 7/06/2025, did not indicate date received or the date first opened. One large, plastic container containing 15 zucchinis like vegetables with an expiration date of 8/21/2026, was observed next to the 1-compartment sink labeled vegetable sink. However, the large, plastic container did not indicate the date received or the date first opened. These deficient practices had the potential for any and all facility residents who consume food from the kitchen to suffer from foodborne illnesses (refer to illnesses such as nausea, vomiting, and diarrhea, caused by the ingestion of contaminated food or beverages) and food to contamination (the introduction of pathogens or infectious material into or on normally clean or sterile objects, spaces, or surface) resulting in hospitalization. Findings: During the initial kitchen tour observation and concurrent interview on 8/24/2026 at 8:06 AM with the facility's Dietary Service Supervisor (DSS - manages daily food service operations, ensuring safe, nutritious, and appealing meals while supervising staff, controlling budgets, and upholding health regulations), the following were observed:One bag of fruits that looked like grapes was stored in RR 3 without the date the bag was opened. DSS stated the date when the bag of grapes is first opened is important because it will, tell us when the grapes will expire and that to serve the food with unknown expiration date may cause residents to get sick. One unlabeled plastic bag containing 36 cucumber like vegetables was stored in RR 3. DSS stated should have the food should be labelled with the specific item to tell us (kitchen staff) when the cucumbers will expire and when the bag as opened. The DSS stated, without any food label, we cannot know if it's okay to serve the food to the residents and with unknown expiration date, the cucumber may cause residents to get sick. One open box of pure honey stored in the manufacturer's original box found in the dry storage section of the kitchen had an expiration date of 7/06/2025, did not indicate date received or the date first opened. DSS stated that the honey, should have been discarded a long time ago. This is because the box did not have a food label that would tell anyone when the box of pure honey was received, and when the box was first opened. One large, plastic container containing 15 zucchinis like vegetables with an expiration date of 8/21/2026, was observed next to the 1-compartment sink labeled vegetable sink. However, the large, plastic container did not indicate the date received or the date first opened. DSS stated and confirmed that the zucchinis were placed next to the vegetable sink to prepare for slicing and eventually served to the residents for the day's (8/24/2026) lunch. DSS stated, I didn't look at the expiration date, I don't know why, I usually do. The DSS discarded the 15 zucchinis into the trash bin. A review of the facility's kitchen in-service education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) dated 4/13/2026, indicated dietary staff were educated on Food Labeling.Labeling Use by Date class with an objective of properly labeling, dating, storing and rotating foods. The class course content indicated that the foods must be labeled and dated as required. The teaching method used for this class were verbal instruction, review of the facility's P&P titled Food Storage and Handling and to review labeling, dating, and stock rotation. The class evaluation consisted of the staff demonstration of proper labeling, dating, and rotation, which products need labeling, how to label products, and which items need dating which includes date items were received, used by date, and date all items when opened. A review of the facility's P&P titled Food Storage and Handling with a revision date of 2/29/2024 indicated, All fresh fruits storage should be labeled and dated. The P&P also indicated that all dry food storage products should be labeled and dated.

Based on observation, interviews and record review, the facility failed to ensure staff protected the rights to privacy and confidentiality of medical records for two of the eight residents (Resident 75 and Resident 76). This deficient practice resulted in violating the residents' rights to privacy and confidentiality of records had the potential to cause psychological and financial harm to Residents 75 and 76.Findings: 1.During a review of Resident 75's admission record (face sheet) indicated Resident 75 was admitted to the facility on [DATE] with the following diagnoses: dysphagia following cerebral infarction (difficulty swallowing); aphasia following cerebral infarction (a language disorder that occurs when a stroke damages brain areas responsible for language processing); slurred speech; muscle weakness, generalized (lack of physical or muscle strength); cognitive communication deficit (trouble participating in conversations); Alzheimer's disease (a common type of dementia that affects memory, thinking and behavior); essential primary hypertension (HTN- high blood pressure without a single identifiable cause); and depression (a common but serious mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 75's Minimum Data Set (MDS - a resident assessment tool) dated 6/22/2026, indicated, Resident 75 had moderately impaired cognition (to make poor decisions, cues and supervisions required). The MDS also indicated, Resident 75 used a wheelchair to get around the facility. During a facility tour on 8/24/2026 at 1:08 PM, a computer with the screen open on the Nurses' Station 1 desk was observed displaying Resident 75's medical information which included Resident 75's name, medical record number, the effective date when Resident 75 returned to the facility, and unfinished nursing notes written by RN Supervisor (RNS) 1. During a concurrent interview and record review on 8/24/2026 at 1:20 PM with RNS 1, Resident 75's medical record on the the computer on Nurses' Station 1 desk was reviewed. RNS 1 confirmed and stated that RNS 1 name was on the bottom of the nursing notes page for Resident 75. RNS 1 stated that Health Insurance Portability and Accountability Act (HIPAA - privacy rule which establishes national standards to protect individuals' medical records and other individually identifiable health information) is, privacy of patient's medical and personal information.we need to make sure we keep it (patient's medical and personal information) private and safe all the time. RNS 1 further stated that when Resident 75's medical information are left unattended, someone may take the information and use it for identity theft or financial gain. RNS 1 stated that by leaving Resident 75's medical information on a computer screen unattended, Resident 75 may feel upset, that Resident 75's right to privacy and confidentiality was violated. RNS 1 also stated, before leaving the computer, I will make sure I close or log out of everything. 2. During a review of Resident 76's admission record, the record indicated Resident 76 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus (T2DM - a disorder characterized by difficulty in blood sugar control and poor wound healing); asthma (a chronic lung disease that causes your airways to swell, narrow, and fill with mucus, leading to difficulty breathing, wheezing, coughing, and chest tightness); spinal stenosis (narrowing of open spaces within the spine, which can put pressure on the spinal cord and the nerves that travel through it); encephalopathy (brain dysfunction that can appear as confusion, memory loss, personality changes and/or coma in the most severe form); and schizophrenia (a serious mental illness that is characterized by disturbances in thought). During a review of Resident 76's H&P dated 8/20/2026, the H&P indicated, Resident 76 has the capacity but currently does not seem to be able to make complex medical decisions. During a review of Resident 76's MDS dated [DATE], indicated, Resident 76 had moderately impaired cognition (make poor decisions, cues and supervisions required). MDS also indicated, Resident 75 used a wheelchair to get around the facility. During a facility tour on 8/24/2026 at 11:08 AM, surveyor observed a computer sitting in an alcove (a small, recessed section of a room) across from Nurses' Station 1 with the computer screen opened and left unattended by Certified Nurse Assistant (CNA) 2. The opened computer screen displayed Resident 76's medical and personal information: resident's name, medical record number, date of birth , physician, location (room number), code status (level of medical interventions a person wishes to have started if their heart or breathing stops), allergies, vital signs which included temperature, pulse (heart rate), weight, pain level, oxygen status, respiratory status and blood pressure reading. During a concurrent interview and record review with CNA 2, CNA 2 stated Resident 76's medical and personal information was left displayed on the computer screen unattended because CNA 2 had to answer/attend to a call light from another resident and forgot to log out first from the computer. CNA 2 confirmed and stated that CNA 2's name was on the top right corner of the open computer screen displaying Resident 76's medical and personal information. CNA 2 stated the federal law, HIPAA is about privacy of information regarding the patient and that only for the staff assigned to care for the resident can access the resident's information. CNA 2 stated when patient medical and personal information were not kept private, Resident 76 is not gonna be happy. I can't think of anything else. CNA 2 further stated should have logged out of the computer as soon as I get up to go to somewhere else. During a concurrent interview and record view on 8/26/2026 at 2:11 PM with the Director of Nursing (DON), the DON stated that the HIPAA federal law refers to ensuring that all resident medical and personal information must be secured, kept private and confidential at all times. A review of the facility's in-service education (education) document dated of 6/11/2026, indicated that nursing staff were provided education on a course titled Resident Rights with the following objective: verbalize understanding of Resident Rights under state and federal laws. The course content indicated that the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) was also discussed. A review of the facility's P&P titled Education Requirements-medical Records Manual-HIPAA with a review date of 1/26/2026 indicated: Purpose: To ensure the security and integrity of medical records at the facility. Policy: Resident medical records will be maintained in the computerized system in a manner that protects the Electronic Protected Health Information (ePHI) from unauthorized use, access, modification, or destruction. Procedure: 1. Technical Safeguards B.ensure that after a certain period of inactivity, the user will be logged off of the electronic record keeping system.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two of two sampled residents (Residents 5 and 52) reviewed for accidents by failing to ensure: 1. Nursing staff accurately completed the quarterly fall assessment per the facility's policy and procedures (P&P) titled, Fall Management, for Resident 5.2. Nursing staff did not identify, evaluate, and implement accident risks and hazard interventions in order to provide a safe environment for Resident 52. These deficient practices had the potential to result in injuries to Resident 5 and Resident 52. Findings: a. A review of Resident 5's admission record indicated the facility re-admitted the resident, on 6/3/2026 with diagnoses that included muscle weakness, benign tumor of the cranial nerves and lumbar radiculopathy (pinched or irritated nerve in the lower back that causes pain, tingling, or numbness to travel down the leg). A review of the Quarterly Minimum Data Set (MDS- a resident assessment tool), dated 7/4/2026, indicated Resident 5's cognition was severely impaired (never/rarely made decisions). The MDS also indicated Resident 5 used a wheelchair as a mobility device and that the resident was totally dependent upon staff for all Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily). A review of Resident 5's At risk for Falls and Injury (Fractures) care plan, initiated 4/2/2026, indicated the resident was at risk for falls and injury due to impaired physical mobility, muscle weakness and impaired gait balance. The care plan interventions indicated the resident needs a safe environment with even floors free spills and/ or clutter, adequate, glare free lighting, a working and reachable call light, low bed, floor mats, personal items within reach. The care plan interventions also included for staff to follow the facility's fall protocol. During an interview on 8/26/2026 at 11:03 AM, Certified Nurse Assistant (CNA) 2 stated Resident 5 was at risk for falls. CNA 1 stated Resident 5 usually has a fall mat by the bed, however the laundry staff was currently cleaning the fall mat. During a concurrent interview and record review with Registered Nurse Supervisor (RN) 1 on 8/26/2026 at 1:16 PM, Resident 5's Fall Risk Evaluations were reviewed. RN 1 stated Resident 5's gait/balance section of the fall risk assessment was not completed. RN 1 stated that not completing this section lead to Resident 5's fall risk assessment being inaccurate. RN 1 further stated an inaccurate fall risk assessment possibly can lead to the resident's fall risk to go undetected and the correct interventions to prevent the resident from falling not to be initiated. During an interview on 8/27/2026 at 4:41 PM, the Director of Nursing (DON) stated the fall risk assessment identifies residents at risk for falls. The DON also stated based on the fall risk assessment, the staff base the care plan interventions based on the resident's fall risk assessment. The DON further stated that accurate resident assessment can lead to the correct interventions being implemented to prevent the resident from falling. A review of the facility's policy and procedures (P&P) titled, Fall Management Program, reviewed 1/26/2026, indicated, It's purpose was to provide residents a safe environment that minimizes complications associated with falls. The P&P also indicated under the section Fall Risk Evaluation A. As part of the admission Assessment, the licensed nurse will complete a fall risk evaluation. If a fall risk factor Is identified, document interventions on the Resident's care plan. Document interventions for every Resident regardless of fall risk evaluation score B. A licensed nurse will conduct a new fall risk evaluation quarterly, annually, upon Identification of a significant change of condition, post fall and as needed C. The Interdisciplinary Team (IDT) and/or the licensed nurse will develop a care plan according to the Identified risk factors and root cause(s} per Care Area Assessment (CAA). b. A review of Resident 52's admission record indicated Resident 52 was originally admitted to the facility on [DATE], with diagnoses that included compression fracture (a bone break of the spine due to pressure, particularly from a fall or impact accident) of T9-T10 (the 9th, and 10th, bone down the middle section of the human spine), Generalized Muscle Weakness (a lack of physical strength felt all over the body making routine movement difficult), History of Falling (a documented medical history of falling in the past). A review of the History and Physical report completed on 7/10/2026 at 12:29, indicated Resident 52 does have the capacity to understand and make decisions. A review of Resident 51's MDS dated [DATE], indicated Resident 52's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) is intact. The MDS indicated Resident 52 does require minimal assistance for toileting hygiene, shower bathing and personal hygiene, and used a walker (a device with four legs used to assist residents with walking) for mobility. During concurrent observation interview on 8/24/2026 at 9:31 AM Resident 52 attempted to sit on her bed for an interview with this writer when the bed moved away from under Resident 52 before she could sit on the bed. Resident 52 was able to use her walker to stabilize herself and stand to prevent Resident 52 from falling. Upon further observation, Resident 52's bed brakes were not locked to steady the bed and to prevent the bed from moving. Resident 52 stated that the staff usually move the bed to the side to allow the staff to move the resident's roommate in and out of the room. Resident 52 stated that the staff usually come back and reposition her bed and lock the wheels in place before she gets out of bed. Resident 52 stated she did not know that the bed was not locked in place before she attempted to get on the bed. During an interview on 08/24/2026 at 9:36 AM CNA 1 stated that Resident 52's bed was not locked, should be locked, and will lock it now. CNA 1 stated beds should remain locked to prevent residents from falling and for residents safety. CNA 1 stated that staff use a Hoyer lift (a mechanical lifting device that is used to move residents that cannot walk) to move/transfer Resident 52's roommate and that Resident 52's bed needs to be moved to the side to allow Resident 52's roommate to be moved/transferred. CNA 1 stated that Resident 52's bed is returned in place and locked once the roommate has been moved/transferred. CNA 1 stated he does not check the beds to make sure they are locked during his morning rounds. During an interview on 08/26/2026 at 2:25 PM, both Director of Staff Development (DSD) and the Infection Preventionist (IP) Nurse stated that the CNAs must check for potential safety hazards which includes, room clutter on floors, call lights within easy reach, bed in lowest position, and locked beds for safety. During an interview on 08/27/2026 at 4:44 PM, Director of Nursing (DON) stated that all staff should be aware to check for safety hazards such as; wet floors, tripping hazards for ambulatory residents, call light within easy reach of all residents, ensure the bed is locked and in lowest possible position to help prevent accidents. A review of facility policy and procedures titled Safety of Residents dated 1/11/2012 indicated Purpose To Provide a safe environment for residents and Facility Staff.

Based on interview and record review, the facility failed to submit Payroll Based Journal (PBJ - is a mandatory electronic reporting system used by long-term care facilities to submit daily, auditable direct-care staffing hours to the) direct care staffing information to Center for Medicare and Medicaid Services (CMS - is the federal agency that provides health coverage to more than 160 million through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace) within the Federal Fiscal Quarter/Year: Quarter 1 2026 (October 1 - December 31). This deficient practice triggered that the facility no Registered Nurse (RN) coverage for at least 8 consecutive hours a day, four or more days a week with the potential for the facility to not manage and oversee nursing services provided to all residents including resident assessments, consulting with physicians, and administering intravenous fluids or medications.Findings: During a review of the CMS PBJ Staffing Data Report (a report stating the number of staff members and hours worked providing care for residents), run date 08/20/2026, indicated, that on 1st fiscal quarter, the facility did not have RN hours coverage for four or More Days within Federal Fiscal Quarter 1 2026 (October 1 - December 31). During an interview with Director of Staff Development (DSD) on 8/27/2026 at 10:45 AM DSD stated that there was a technical problem at the facility's headquarters that caused a delay in submitting the PBJ Staffing Data Report for the 1st quarter of the fiscal year (October 1 - December 31) and that the facility did not submit its PBJ Staffing Data Report until February 2026. During an interview with Director of Nursing (DON) on 8/27/2026 at 4:24 PM, DON stated, It is important to follow the guidelines and timeframes to submit staffing documentation to ensure that there is adequate staffing coverage to care for residents residing in the facility. During a review of the facility's policy and procedures (P&P) titled, Nursing Department - Staffing, Scheduling & Postings, reviewed on 1/26/2026, the P&P indicated, PurposeTo ensure than adequate number of nursing personnel are available to meet resident needs.PolicyThe Facility will employ Nursing Staff that will be on duty in at least the number and with the qualifications required to provide the necessary nursing services for residents admitted for care.In staffing an adequate number of nursing service personnel, scheduling will be done as needed to meet resident needs, and such information will be posted as required. Procedure I. Nurse StaffingE. Each Facility will employ sufficient nursing staff to provide a minimum daily average of 3.5 nursing hours per patient day.

Based on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 1) was permitted to remain in the facility pending the results of an appeal of a discharge. Resident 1 submitted an appeal for the discharge on [DATE]; however, the facility discharged Resident 1 on the same day, prior to receiving the appeal decision. On 5/23/26, Resident 1's appeal to remain in the facility was approved, but Resident 1 had already been transferred from the facility.This deficient practice resulted in Resident 1 being discharged without due process, which could negatively impact Resident 1's continuity of care and treatment.During a review of Resident 1's Face Sheet (FS) dated 6/2/2026, the FS indicated Resident 1 originally admitted on [DATE] and re-admitted on [DATE], with the diagnoses that included but not limit to: paraplegia (a condition a person cannot move or feel their legs because of an injury or damage to the lower part of the spinal cord), muscle weakness, depressive disorder (a condition where a person feels very sad, empty, or hopeless for a long time.), and urinary tract infection (an infection when germs, usually bacteria, get into the urinary system and cause irritation or discomfort).During a review of Resident 1's Minimum Date Set (MDS, a resident assessment tool) dated 4/23/2026, the MDS indicated Resident 1 is cognitive intact (a person's thinking and understanding are normal).During a review of Resident 1's Discharge summary dated [DATE], the Discharge Summary indicated Resident 1 was discharged on 5/21/2026.During a review of Resident 1's Census List dated 6/2/2026, the Census List indicated Resident discharged on 5/21/2026 at 11:05 am.During an interview on 6/2/2026 at 11:53 am with Resident 1, Resident 1 stated he filed an appeal on 5/21/2026, but he was discharged the same day.During a concurrent interview and record review on 6/2/2026 at 1:45 pm with admission Coordinator (ADC), Resident 1's Immediate Notification Medicare Beneficiary Appeal Request (INMBAP, a request for facility to respond with supporting medical record regarding with resident's appeal) dated 5/21/2026 and Resident 1's Beneficiary and Family Centered Care - Quality Improvement Organization Determination letter (BFCC-QIO DL, a letter that tells a nursing home resident the result of their appeal after they disagree with being discharged .) dated 5/23/2026 were reviewed. The INMBAP indicated on 5/21/2026 at 9:56 am, facility received Resident 1's appeal request of facility decision of terminate service. ADC stated she was not aware of this appeal. The BFCC-QIO DL indicated Resident 1 won the appeal and facility was notified on 5/23/2026 at 8:09 am. ADC stated no follow up was done because resident was already discharged .During an interview on 6/2/2026 at 1:45 pm with Social Service Director (SSD), SSD stated they were unaware Resident 1 had filed an appeal on the day of discharge, however, the time of appeal was submitted at 9:56 am, and Resident left the facility at 11:05 am, Resident 1 had an on-going appeal before his discharge and he was discharged .During an interview on 6/2/2026 at 2:07 pm with the Director of Nursing (DON), DON stated Resident 1 should not have been discharged on 5/21/2026. Any resident has an active appeal, the facility must hold the discharge and keep the resident until the appeal decision is received; failing to do so, resulting in Resident 1 being improperly discharged and negatively affected his care and treatment.During a review of the facility's policy and procedures (P&P) titled, Transfer and Discharge dated 1/26/2026, the P&P indicated facility follows Centers for Medicare & Medicaid Services (CMS, the government group that sets the rules for hospitals, nursing homes, and other healthcare places to make sure patients are treated safely and correctly) regulations for discharge and appeal.

Based on interview and record review, the facility failed for one of three sampled residents (Resident 1) to:1. Develop a policy and procedure for acceptance of gifts, money, or items of value from residents by facility staff.2. Implement its' policy titled Resident Funds by failing to ensure staff (Medical Records Director) did not handle resident's money/check.3. Establish clear expectations, staff guidance, requirements of financial transactions, and reporting requirements related to resident gifts to staff to ensure protection of resident funds in accordance with resident rights and abuse prevention requirements.These deficient practices had the potential to place residents at risk for financial exploitation and abuse. Findings: During a review of Resident 1's admission Records, the Records indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses including parkinsonism (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic kidney disease (CKD-kidneys are damaged and cannot filter blood as well as they should), major depressive disorder (characterized by a persistent feeling of sadness or a lack of interest in outside stimuli), muscle weakness (a lack of strength in the muscles), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). During a review of Resident 1's History and Physical (H&P) dated 11/18/2025, the HP indicated, Resident 1 had a history of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic kidney disease (CKD-kidneys are damaged and cannot filter blood as well as they should), and has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 2/14/2026, the MDS indicated Resident 1 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) to make decisions on selfcare activities. The MDS indicated Resident 1 was dependent on staff with substantial/maximal assistance on staff for lower body dressing, shower/bath, partial/moderate assistance for upper body dressing, personal hygiene, and toileting hygiene. During an interview on 5/19/2026 at 10:24 AM with Resident 1, Resident 1 was observed sitting in a wheelchair in the facility's activity room. Resident 1 acknowledged writing a check for monthly share of cost (SOC- the monthly amount a Medicaid (or state equivalent like Medi-Cal) recipient must pay toward their nursing home care from their own income before the state program covers the rest miscellaneous personal expenses. Resident denied writing a check for the specific amount the complaint allegations indicated for $3271. Resident 1 does not remember writing a check for $3271. Resident 1 acknowledged recently writing checks for tax preparer, SOC and transportation services. Resident 1 acknowledged giving $40 cash to one of the staff members within the last month. During an interview on 5/19/2026 at 12:55 PM with medical records director (MR), the MR stated, Resident 1 had asked me to cash a check for him at the end of April 2026. MR went to the bank to cash Resident 1's check for $3271, the bank staff couldn't verify ownership of the check is and could not speak to Resident 1, as a result declined to cash the check. MR advised Resident 1 the check can be cashed through mobile/online banking. MR deposited Resident 1's check through mobile banking to MR's personal account. MR stated, it is not a practice in a bigger picture to deposit residents' checks to personal account. MR acknowledged receiving training and in-service on abuse prevention and reporting, mishandling residents' personal funds is one form of abuse. During an interview on 5/19/2026 at 1:39 PM with the facility business office manager (BOM), the BOM stated it is not a practice for facility staff to go with a resident or by themselves to cash a check on residents' behalf. The best route for residents to access cash is through business office and social services. During an interview on 5/19/2026 at 2:05 PM with the director of nursing (DON), the DON stated staff assigned to escort residents to run errands, are not allowed to deal with resident finance, are not allowed to cash a check for any reason, and nursing staff do not deal with finance. The DON stated cash, funds, and finance transactions are managed always by business office or social services. The DON stated, there is no policy for gifts. During an interview on 5/19/2026 at 2:23 PM with the facility administrator (ADM), the ADM stated, Resident 1 pays monthly SOC with checks. The ADM stated there is no limit if a resident wants to give money to anyone. I don't believe the residents are allowed to give gifts. ADM does not believe the facility has a policy for gifts. During a review of the facility's policy and procedures (P&P) titled Abuse Prevention and Management revised 1/26/2026, the P&P indicated The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The Facility develops policies, procedures, training programs, and screening and prevention systems.During a review of the facility's P&P titled Resident Funds-General. reviewed on 1/26/26, the P&P, indicated, No licensee, owner, Administrator, Facility Staff member, or their immediate relative or representatives may act as an authorized representative of resident funds, unless the resident is a relative within the second degree of relation. In the event there is not a representative for the resident and the resident is not capable, facility will follow the Surrogate Decision making policy which can include the facility becoming rep payee in order to protect the residents' access to their funds.

Based on observation, interview, and record review, the facility failed to ensure resident funds were safeguarded from misappropriation (unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of personal funds when facility staff deposited a resident's personal check into the staff member's personal account for of three sample residents, Resident 1. This deficient practice had the potential for financial exploitation, loss of resident funds, and psychosocial harm to Resident 1. Findings: During a review of Resident 1's admission Records, the Records indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses including parkinsonism (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic kidney disease (CKD-kidneys are damaged and cannot filter blood as well as they should), major depressive disorder (characterized by a persistent feeling of sadness or a lack of interest in outside stimuli), muscle weakness (a lack of strength in the muscles), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). During a review of Resident 1's History and Physical (H&P) dated 11/18/2025, the HP indicated, Resident 1 had a history of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic kidney disease (CKD-kidneys are damaged and cannot filter blood as well as they should), and has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment tool), dated 2/14/2026, the MDS indicated Resident 1 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) to make decisions on selfcare activities. The MDS indicated Resident 1 was dependent on staff with substantial/maximal assistance on staff for lower body dressing, shower/bath, partial/moderate assistance for upper body dressing, personal hygiene, and toileting hygiene. During a review of Resident 1's Care Plan (CP- a document outlining a detailed approach customized to an individual resident need and care), titled [Resident 1] noted with increased anxiety, which is now affecting overall functioning and requiring increased assistance with ADLs (activity of daily living) dated 5/1/26 indicated goals for Resident 1 were the resident would demonstrate reduced anxiety and improved cooperation with care. The CP interventions indicated Provide calm, reassuring approach and allow extra time during care to reduce anxiety. Coordinate with psychological services per resident preference and monitor response. During concurrent observation and interview on 5/19/2026 at 10:24 AM with Resident 1, Resident 1 was observed sitting in a wheelchair in the facility's activity room. Resident 1 stated, self manages personal funds and finances. Resident 1 acknowledged writing a check for monthly share of cost (SOC- the monthly amount a Medicaid (or state equivalent like Medi-Cal) recipient must pay toward their nursing home care from their own income before the state program covers the rest miscellaneous personal expenses. Resident 1 denied writing a check for the specific amount the complaint allegations indicated for $3271. Resident 1 does not remember writing a check for $3271. During a concurrent interview and record review on 5/19/2026 at 11:54 with the business office manager (BOM), Resident 1's invoices and SOC were reviewed. The BOM stated, Resident 1 recently wrote out a check for SOC, tax preparation, and transportations. The BOM is unaware Resident 1 wrote a check for $3271. BOM stated, Resident 1 informed BOM that the bank called and notified Resident 1, someone from outside the facility is scamming Resident 1. BOM stated, only business office and social services department to some extent manages residents finance, no other staff has access and is not allowed to access residents' funds. During an interview on 5/19/2026 at 12:55 PM with medical records director (MR), the MR stated, Resident 1 had asked me to cash a check for him at the end of April 2026. MR went to the bank to cash Resident 1's check for $3271. The bank staff couldn't verify ownership of the check and could not speak to Resident 1 during a phone call made while MR was at the bank, as a result the bank declined to cash the check. MR advised Resident 1 the check can be cashed through mobile/online banking. MR deposited Resident 1's check to MR personal account through mobile banking. MR stated, it is not a practice in a bigger picture to deposit residents' checks to personal account. MR acknowledged receiving training and in-service on abuse prevention and reporting. MR stated, mishandling residents' personal funds is one form of abuse. During a second interview on 5/19/2026 at 1:39 PM with BOM, the BOM stated it is not a practice for facility staff to go with a resident or by themselves to cash a check on residents' behalf. The best route for residents to access cash is through business office and social services. During an interview on 5/19/2026 at 2:05 PM with the director of nursing (DON), the DON stated staff assigned to escort residents to run errands are not allowed to deal with resident finance, are not allowed to cash a check for any reason, and nursing staff do not deal with finance. The DON stated cash, funds, and finance transactions are done always by business office or social services. The DON further stated, unaware of Resident 1 giving cash or check to any staff at the facility, it is not appropriate for any staff to cash a check, staff was supposed to decline and direct Resident 1 to the appropriate department to handle the check. During an interview on 5/19/2026 at 2:23 PM with the facility administrator (ADM), the ADM stated, Resident 1 pays monthly SOC with checks. The ADM stated it is not allowed for any staff to cash a check into their own account. It looks funny, it could be suspicious.During a follow-up interview on 5/26/2026 at 4:41 PM with the ADM, the ADM stated, MR does not have any role and access in resident finances. ADM stated, MR had cashed three separate checks for Resident one to a total of over six thousand dollars which was found by ADM in Resident 1's possession after abuse allegations were investigated. During an investigation interview on 5/19/2026 at 12:55 PM, MR denied cashing checks except for one attempt for $3271 for Resident 1.During a review of the facility's policy and procedures (P&P) titled Resident Funds-General revised on 1/26/2026, the P&P indicated No licensee, owner, Administrator, Facility Staff member, or their immediate relative or representatives may act as an authorized representative of resident funds, unless the resident is a relative within the second degree of relation. In the event there is not a representative for the resident and the resident is not capable, facility will follow the Surrogate Decision making policy which can include the facility becoming rep payee in order to protect the resident's access to their funds. During a review of the facility's P&P titled Abuse Prevention and Management revised 1/26/2026, the P&P indicated The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The Facility develops policies, procedures, training programs, and screening and prevention systems.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to ensure: 1. Food is labelled with expiration date 2. Discard expired foods 3. Food refrigerator(s) and freezers were clean. 4. Implement food cooling down method according to the facility policy and procedures titled Hazardous Foods Cooling Monitor dated 1/27/2025. 5. The Ice machine and the water fountain are not dirty These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) medically compromised residents who received food from the kitchen. Findings: During the initial tour of the kitchen on 6/10/2025 at 8 AM, with the Dietary Supervisor (DS), the kitchen refrigerator the following were noted. -Expired pudding dated 6/10/2025 -A container of strawberries with used by date of 6/9/2025. -A container of cooked fish sticks -3 containers of cream soup, cooked meatloaf. -The ice machine tray noted to be dirty, water machine tray noted to be dusty and dirty. -The residents outside food storage refrigerator freezer temperature was less than (<) 4 degrees, the freezer and refrigerator were dirty with old and dried food, The refrigerator temperature was greater than (>) 40 degrees. Two open bottles of yogurt were not labelled with expiration date. A clear container without no name, room number, of expiration date on the container. 3 boxes of sausages in the refrigerator with a use within 2 days or use by date of 7/2/2025 and must be frozen. During an interview on 6/10/2025 at 8:36 AM, DS stated the residents can get sick if they consume foods that have expired. DS stated the dietary cooks are supposed to follow the cooling down method of any cooked foods stored in the refrigerator. DS stated the license nurses are responsible to receive residents' food from the outside and are also responsible to label and date the residents' food. DS stated it is the responsibility of the Maintenance Supervisor (MS) to discard expired foods from the resident's refrigerator and to clean the outside food storage refrigerator. DS stated the MS is responsible to clean the resident's refrigerator. ice machine, and water machine. During an interview on 6/10/2025 at 8:56 AM, with Dietary [NAME] (DC) stated she cooked the meatloaf two days ago and did not follow the cool down method prior to storing the leftovers in the refrigerator. DC stated she prepared the tuna 3 days ago and did not follow the cool down method. DC stated she has attended in-services and is aware on how to properly follow the cool down method. DC stated she do not know why she did not follow the cool down method prior to storing the meatloaf, soup and the tuna. DC stated if she does not follow the cool down method prior to storing left over foods in the refrigerator the residents can get very sick. During a concurrent record review on 6/10/2025 at 9:22 AM, of the cool down method record with the DS, there was no record of the cooked leftover meat load, 3 containers of soups, or the 17 cooked fish sticks. During an observation and interview on 6/10/2025 at 10:03 AM, with the Maitenance Supervisor (MS) of the ice machine, water dispenser, and residents outside food storage refrigerator was dirty. During an interview MS stated he clean the ice machine, water dispenser daily, and he clean the residents outside food storage refrigerator every three days so that he can remove all the old foods. MS stated it is the nurse's responsibility to make sure the residents food brought in from the outside is labeled and stored properly. MS stated if the ice machine, water dispenser, or the resident's refrigerator is not cleaned, and the residents consume expired foods that are bought in from the outside, the residents can get very sick. MS stated he do not have a monthly log for cleaning the ice machine and there was no log for cleaning the water dispenser. MS stated there is no manual for cleaning the water dispenser, and that the facility does not have a policy for cleaning the water dispenser. During an interview on 6/13/2025 at 9:17 AM, with the Registered Dietician (RD), RD stated the dietary cooks are supposed to follow the cooling down method whenever cooking and storing left over foods in the refrigerator. RD stated the dietary cooks are supposed to follow the cool down method when preparing tuna because they are supposed to check the temperature prior to storing the tuna in the refrigerator. RD stated if the dietary cooks are not following the cool down method the residents can get sick. RD stated if the residents consume expired foods, they can get really sick. RD stated she completes in-service for the cool down method quarterly and as needed for the dietary staff. RD stated that the MS is responsible for discarding expired foods in the residents refrigerator. During a record review, the facility policy and procedures (P&P) titled Policy and Procedure Implementation Form dated 5/22/2025, indicated: Policy and procedure Revision: 4. When refrigerated, it will be labeled, dated, and discarded after 48 hours if not consumed 5. Unopened/sealed foods must be discarded by the manufacture's printed best buy or used by date. During a record review, the facility P&P titled Hazardous Foods Cooling Monitor with a reviewed date of 1/27/2025, indicated: Purpose: To provide the dietary department with guidelines for service, storage and reheating of hazardous foods. Procedure: ll. Label and date the containers. lll. Place the container in the refrigerator or freezer for cooling. A. Leave the container uncovered of loosely covered during the cooling process. lV. Hot food should be cooled from 140 degrees to 70 degrees within two hours and cooled from 70 degrees to 41 degrees or lower in an additional four hours. V. Cool food prepared from ambient temperature (such as tuna salad) must be cooled to 41 degrees or lower within fours. Vl. Record food every hour. During a record review, the facility P&P titled Ice Machine-Operation and Cleaning with a reviewed date of 1/27/2025, indicated Policy: The dietary staff will operate the ice machine according to the manufactures guidelines. The ice machine will be cleaned routinely. Procedure: 11. F. On no less than monthly basis, remove the ice to wash the inside of the machine. During a record review, the facility Instruction Manual for Ice Dispenser Models DB-130H and DB-200H indicated: B. Cleaning and Sanitizing Instructions: The ice dispenser must be cleaned and sanitized at least once a year. More frequent cleaning and sanitizing may be required in some water conditions. For icemaker cleaning and sanitizing instructions, see the icemaker instruction manual.

Based on observation, interview, and record review, the facility failed to implement and maintain infection control measures by failing to ensure the end of a gastric tube (GT- is a tube inserted through the abdomen into the stomach for nutrition, hydration, and medication) that is connected to a resident was secured, capped, and was not on the floor for one of two sampled residents (Resident 4). This deficient practices had the potential to result in infection and hospitalization for Resident 4. Findings: During a record review, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnoses including urinary tract infection (an infection in your urinary system, which includes your bladder, urethra, and kidneys, gastrostomy (a surgical procedure where a doctor makes an opening in the stomach, usually to access its interior). During a record review, the Skilled Nursing Facility Follow-up Visit dated 6/3/2025, indicated, Resident 4 has GT. During a record review, the Order Summary Report for Resident 4 dated 6/12/2025, indicated Enteral Feed (a method of providing nutrition directly into the gastrointestinal (GI) tract through a tube) every evening and night shift Jevity (a brand name for a medical product that provides nutritional support for people who are unable to eat or have difficulty eating) 1.5 at 40 milliliters (ml-unit of measurement) per (/hr) via pump x 10 hour=400 ml/24 hour 600 calories/24 hours via G-tube for dysphagia. The Order summary Report indicated Jevity to be turned on 8 pm, off at 6 am, or until dose is reached. During a record review, the Minimum Data Set (MDS - resident assessment tool) dated 5/15/2025, indicated Resident 4's cognitive (mental process of acquiring knowledge and understanding through thought, and understanding) skills for daily decision making were intact. It further indicated Resident 4 needed substantial/maximal assistance with putting on her shoes, upper and lower body dressing, and toileting hygiene. During a record review of Resident 4's care plan titled Enteral Feeding initiated on 8/9/2024 and revised on 4/15/2025, indicated Resident 4 is on feeding tube. During an observation on 6/11/2025 at 11:28 AM, Resident 4 noted to be clean, well groomed, and dressed appropriately for the weather, hair noted to be well groomed. The GT feeding machine was turned off and disconnected from Resident 4. The GT bottle (Jevity) was connected to the feeding tube pump and was lying on floor uncapped (not covered) and a moderate amount of the Jevity was leaking on the floor. During an Interview with Licensed Vocational Nurse (LVN) 1 stated when disconnecting the GT from the resident, the tip of the was supposed to place a cap to cover the gastric tubbing to prevent it from getting contaminated and it is a infection control issue. LVN 1 stated if a nurse uses a contaminated feeding tubing that was on the floor uncovered and reconnect the tubing back to the resident, the resident can get very sick and inquire an infection. During an interview on 6/13/2025 at 9:55 AM, with LVN 2 stated if a cap is not placed on the GT once disconnected from the residents the resident can get an infection and become septic (a serious condition in which the body responds improperly to an infection). During an interview on 6/13/2025 at 1:16 PM, with the Director of Nursing (DON), stated the licenses nurses are always supposed to cap the G-tube tubbing whenever they disconnect it from the resident to prevent infection control. The DON stated if the GT falls on the floor and the nurse reconnects it back to the resident the resident, the resident could inquire a bad infection and get very sick. During a record review, the facility policy and procedures titled Infection Control-Policy and Procedure with a reviewed date of 1/27/25, indicated, Purpose: To provide infection control policies and procedures required for a safe and sanitary environment. Policy: The facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment. Procedure: ll. Objectives: A. Prevent, detect, investigate, and control infections in the facility. B. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. lV. Staff are trained on the infection control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. Based on interview and record review, the facility failed to implement and/or maintain infection control measures for when: 1. the facility failed remove intravenous catheter (IV -a thin, flexible tube inserted into the vein to deliver fluids, medications, or other treatments directly into the blood stream) when IV therapy was completed for one of one sampled resident (Resident 6). 2. Prevent g-tube feeding tube from falling on the floor. 3. Place a cap on g-tube feeding tube when not in use. These deficient practices had the potential to result in infection and possible hospitalization for Resident 4 and Resident 6. Findings: A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 6/16/2020 and readmitted Resident 6 on 5/6/2025 with diagnoses including hypertension (elevated blood pressure), chronic kidney disease (when kidneys, that filter waste from the blood become damaged and don't work as well as they should), and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing. A review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/13/2025, indicated Resident 6 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 required substantial/maximal staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 6's physician orders dated 6/7/2025 with an end date of 6/8/2025, indicated sodium chloride solution (Salt water) 0.9 percent (% -unit of measure as a part of one hundred), use 1 liter (unit of measure for fluids) intravenously one time a day for hydration until 6/8/2025 0:00 A.M., at 75 cubic centimeters per hour (cc/h -unit of volume in liquid). During an observation on 6/10/2025, at 9:12 A.M., in Resident 6's room, a peripheral iv line gauge 24 was observed on Resident 6's left forearm dated 6/8/2025. During an interview on 6/11/2025, at 9:04 A.M., with Licensed vocational Nurse (LVN 1), LNV 1 stated, Resident 6 had an IV access for hydration that was discontinued yesterday (6/10/2025). During an interview, on 6/13/2025, at 12:55 P.M., with the Registered Nurse Supervisor (RNS 1), RNS 1 stated, Resident IV access are discontinued as soon as the hydration is done to prevent infection. During an interview, on 6/13/2025, at 12:55 P.M., with the Director of Nursing (DON), the DON stated, IV access are kept in place only if there is an order from the physician to maintain it in place, other wise the IV access is discontinued to prevent infection and possible skin breakdown. DON stated there was no documented evidence that the physician ordered for then IV access to remain in place otherwise, the IV needs to be discontinued after the hydration is complete. A review of the facility's Policy and Procedure (P&P), titled, Removal of a Peripheral (Over the needle, peripheral short) Catheter revised 1/27/2025, indicated, Peripheral IV catheters will be removed safely and aseptically by a nurse with demonstrated competency in this procedure . when therapy is completed .

Based on observation, interview, and record review the facility failed to maintain one of two laundry service rooms (laundry room [ROOM NUMBER]) in good repair. By failing to ensure the floors were free of cracks, buckets holding chemicals were free of cracks and holes, the ceiling was clean, and the door leading to the trash area was intact. These deficient practices had the potential to result in an infestation of rodents, and or pests such as ants and roaches due to holes and substantial cracks found in the floor, and open pipes, including a broken door leading to the trash area of the laundry room. Findings: During observation of the laundry service area on 6/10/2025 at 11:03 AM the second room used for laundry services; had multiple areas in disrepair. In the second laundry services room that housed the washers, behind the washers the floor and wall were extremely dirty with cracks and one open pipe, under laundry chemical buckets the wooden platform that held the buckets of chemicals had holes and cracks in the base of the platform that stood about three inches off the floor. The floor area under the platform that supported the laundry chemicals was cracked and had a hole in the floor about 10 to 12 inches long. The ceiling had dark spots that looked to be a substance of unknown origin other than dirt, the ceiling in various places had peeling paint coming of in flakes. The door that led to the trash area was broken at the bottom area and the floor was several different colors. During concurrent observation of laundry room [ROOM NUMBER] and interview on 6/10/2025 at 11:12 AM Maintenance Supervisor (MS) stated that he was the acting supervisor for laundry services as well as the supervisor for maintenance of the building. During observation of the laundry room [ROOM NUMBER], it was noted that the wooden platform that supported the chemicals used to wash the linen and resident clothes was rotted or has suffered water damage. The floors behind the washing machine were cracked, with small holes, including one large hole about 10 to 12 inches in length. The wall just behind the washing machine had an open pipe. The door inside the laundry room leading to the trash area was broken at the bottom. In addition, the ceiling had a black discoloration in the corner and the ceiling paint was peeling and cracked. MS stated that he would have to perform some repairs and get estimates for other repairs and stated the repairs needed to be completed immediately. During concurrent observation and interview on 6/10/2025 at 11:25 AM the Administrator (ADM) stated the floor in laundry room [ROOM NUMBER] had to be repaired and it would be done as soon as an estimate was presented by the maintenance supervisor. The ADM stated the door in laundry room [ROOM NUMBER] would be repaired or replaced, and the ceiling appeared to have dirt, and it would be cleaned. The ADM stated all the other repairs such as paint removal and cleaning the ceiling could be done by the maintenance supervisor immediately. During a record review, the facility's Policy and Procedures (P&P) titled Maintenance Service dated revised 1/27/2025, indicated Policy: The Maintenance Department maintains all areas of the building, grounds, and equipment Procedure 1. The Maintenance Department is responsible for maintain the building, grounds, and equipment in a safe and operable manner at all times. 2. Functions of the Maintenance Department may include, but are not limited to: A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; B. Maintaining the building in good repair and free from hazards;

Based on observation, interview, and record review, the facility failed to ensure that 13 out of 34 rooms (room [ROOM NUMBER], 4, 8, 9, 11, 14, 15, 16, 17, 18, 20, 22, and 33) met the 80 square feet (sq. ft.) per resident This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for 39 Residents. Findings: The room waiver request and Client Accommodation analysis indicated the following rooms contained three residents and: RM# RM. Size (sq.ft) SQ.FT/Resident 3 209 69.7 4 209 69.7 8 220 73.3 9 220 73.3 11 220 73.3 14 220 73.3 15 220 73.3 16 216.66 72.2 17 209 69.7 18 209 69.7 20 209 69.7 22 209 69.7 33 220 73.3 The minimum requirement for a three bedroom should be at least 240 sq. ft. During general observations from 6/10/2025 to 6/13/2025, both residents and staff had enough space to move about freely inside the rooms. The nursing staff had adequate space to safely provide care to the residents with the side tables, dressers, and resident care equipment in rooms. During an interview on 6/13/2025 at 8:34 AM, Restorative Nurse Aide 1 (RNA 1) stated rooms 17, 18, 20 and 22 provided adequate space to provide care for the residents. During a record review, the facility policy and procedures, Resident Rooms and Environment, dated 1/27/2025, indicated, It was the facility policy to provide residents with a safe, clean, comfortable and home like environment. The staff facility staff will provide residents with their pleasant environment and person-centered care that emphasizes the residents comfort, independence, and personal needs and preferences.

Based on observation, interview, and record review the facility failed to ensure closet doors were functional in nine of nine resident rooms (Rooms 17, 18, 20, 21, 22, 23, 24, 25, and 26). This failures had the potential to cause harm to the residents. Findings: During an interview on 6/12/2025 at 11:30 AM, Family Member (FM) 1 stated Resident 32's space in his room is too small. Stated the closet door is broken. Stated she reported to one of the head nurses, but she cannot remember her name. FM 1 stated she followed up with the head nurse and she stated that she reported the broken closet door to the MS and as of today the closet door remains broken. During an observation and concurrent interview on 6/13/2025 at 11:54 AM, with the Maintenance Supervisor (MS), the closet doors were not attached at the bottom in resident rooms 17, 18, 20, 21, 22, 23, 24, 25, and 26. The closet doors were noted to swing open from the bottom. The MS stated the nurses unhook the closet sliding doors at the bottom so that they can store the resident's wheelchairs in the closet because there is not enough space in the resident's rooms to store the wheelchairs. During a concurrent record review on 6/13/2025 at 12:16 PM, with the MS, the facility request for repair log wa reviewed. The repair request log indicated that there was no logged in request for the repair of the closet doors for rooms 17, 18, 20, 21, 22, 23, 24, 25, and 26. During an interview on 6/13/2025 at 2:06 PM, Director of Nursing (DON) stated that the nurses are not supposed to be unhooking the resident's closet doors at the bottom to store the resident's wheelchairs. DON stated residents can get injured if the resident closets are being unhooked at the bottom and is swinging open at the bottom. During an interview and concurrent record review on 6/13//2025 at 3:16 PM, Medical Records Designee stated the document titled Director of Environment Services is the job description for the Maintenance Supervisor. During a record review, the facility policy and procedures titled Director of Environmental Services indicated, Principle Responsibilities: Technical: Ensure a safe, comfortable, sanitary environment for residents, staff and visitors in accordance with Federal, State, and Corporate requirements.

Based on interview and record review, for one of one sampled resident (Resident 6), the facility failed to notify a physician of an abnormal potassium level (electrolyte in the body that regulates heart muscle contractions and maintaining proper electrical signals within the heart) level of 5.6 (milliquivalent per liter (mEq/L - unit of measurement. Reference range 3.5 to 5.1 mEq/L) on 6/6/2025 at 11:26 P.M. Resident 6's physician was not notified of the abnormal potassium level until 6/7/2025, at 5:50 P.M. This deficient practice had the potential to result in Resident 6 suffering palpitations (a noticeably rapid, strong, or irregular heartbeat due to agitation, exertion, or illness), chest pain, hypertension (elevated blood pressure) and a heart attack ( myocardial infarction (MI), occurs when blood flow to the heart muscle is suddenly blocked, depriving it of oxygen), which could result in death. Findings: During a record review, Resident 6's admission Record indicated the facility admitted Resident 6 on 6/16/2020 and readmitted Resident 6 on 5/6/2025 with diagnoses including hypertension, chronic kidney disease (when kidneys, that filter waste from the blood become damaged and don't work as well as they should), and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing. During a record review, Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 5/13/2025, indicated Resident 6 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 required substantial/maximal staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review, Resident 6's laboratory results collected on 6/6/2025 at, 4:32 A.M., and resulted on 6/6/2025, at 11:26 PM., indicated Resident 6's blood Potassium was 5.6 mEq/L and flagged as high. During a record review, Resident 6's change of condition (COC -a noticeable and significant shift in someone's health or circumstance), dated 6/7/2025, at 5:50 P.M., indicated hyperkalemia (abnormally high level of potassium in the blood). During a concurrent interview and record review, on 6/13/2025, at 11:28 AM, with the Registered Nurse Supervisor (RNS) 2, Resident 6's laboratory (lab) results collected on 6/6/2025 at, 4:32 A.M., and resulted on 6/6/2025, at 11:26 P.M., were reviewed. RNS 2 stated Resident 6's laboratory results were abnormal, including a potassium level of 5.6 mEq/L). RNS 2 stated laboratory results needed to be reported to the physician or nurse practitioner (NP - a licensed, advanced practice registered nurse [APRN] who has completed graduate-level education and advanced clinical training) as soon as the facility receives the laboratory results. RNS 2 stated that Resident 6's physician was not notified of Resident 6's abnormal potassium level of 5.6 mEq/L until 6/7/2025, at 5:50 P.M. RNS 2 stated, Resident 6's lab results of potassium level of 5.6 mEq/L could have affected the resident's heart and that Resident 6 needed to receive medication promptly to lower the potassium level as a level that high could lead to a heart attack. During an interview, on 6/13/2025, at 12:55 PM, with the Director of Nursing (DON), the DON stated, abnormal lab results must be reported to the physician or NP as soon as the facility recieves the abnormal results. The DON stated hyperkalemia could lead to Resident 6 having palpitations, chest pain, hypertension and a heart attack. During a record review, the facility Policy and Procedures (P&P), titled, Laboratory Services revised 1/27/2025, indicated, The licensed nurse promptly notifies the attending physician of the laboratory test findings and reports the results according to the following guidelines: II. Results abnormal -Telephone/page attending physician and fax to attending physician with date and time noted on the results.

Based on observation, interview, and record review, the facility failed to: 1. Follow the doctors orders by covering sacral wound for Resident 32. 2. Ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident's goals for care and professional standards of practice that will meet each resident's need by puttying a dressing on the resident's sacral pressure (refers to the pressure exerted on the sacrum [the bony area at the base of the spine) due to prolonged sitting or lying down]) injury. These failures had the potential to cause further injury and infection to the Resident 32's sacral pressure injury. Findings: During a record review, Resident 32's admission Record indicated Resident 32 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnoses including sepsis (a dangerous and potentially life-threatening condition where the body's response to an infection goes into overdrive), pressure ulcer of the sacral region, stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle. It is the most severe type of pressure ulcer also known as a bedsore). During a record review, the Minimum Data Set (MDS-resident assessment tool) dated 5/22/2025, indicated Resident 32's cognitive (mental process of acquiring knowledge and understanding through thought, and understanding) skills for daily decision making were intact. It further indicated Resident 32 needed substantial/maximal assistance with putting on her shoes, upper and lower body dressing, showering, toileting, and personal hygiene. During a record review, a document titled Skilled Nursing Facility Follow-up Visit for Resident 32 dated 6/2/2025, indicated, Assessment/plan indicated Resident 32 has osteomyelitis of the sacrum and coccyx, stage 4 sacrococcyx pressure ulcer, status post (s/p-after) skin graft to sacrococcyx pressure ulcer on 4/13/2025. During a record review, a document titled Order Summary Report for Resident 32 dated 6/11/2025, indicated Resident 32 had an order for Silvadene External Cream 1% (is a prescription-only topical medication for treating and preventing severe burn wounds). Apply to sacralcoccyx topically everyday shift every 3 days for pressure injury, cleanse with NS (normal saline), pat dry, apply Silvadene and Santyl ointment (a medication used to remove damaged or burned skin, aiding in wound care and the growth of healthy skin), apply foam dressing (wound care material used to create and maintain a moist wound environment, particularly in wounds with moderate to heavy drainage). During a record review, care plan for Resident 32 initiated on 8/16/2024 and revised on11/16/2024 indicated Resident 32 has a coccyx (is the small bone located at the very bottom of the spine) pressure injury. Update: Site reclassified as sacrum. The care plan goal included, Will have no s/s (signs and symptoms) of infection. The care plan target date is 8/15/2025 During a record review, the Treatment Administration Record for Ressdent 32 dated from 6/1/2025 to 6/30/2025, indicated cleanse with NS (normal saline), pat dry, apply Santyl ointment, apply foam dressing every day shift. During a wound care observation of Resident 32's sacralcoccyx and right foot wound care with Treatment Nurse (TN) 1 and TN 2 on 6/12/2025 at 9:19 AM, Resident 32's sacral pressure injury did not have a dressing in place. Resident 32 tolerated wound care well. Resident 32 did not complain of pain during wound care. During a concurrent interview with TN 1, TN 1 stated there should always a dressing on the sacral wound to prevent infection and interference of wound healing. TN 1 stated if the sacral wound dressing comes off or get soiled, the charge Nurse or the Registered Nurse (RN) Supervisor is supposed to replace the dressing. During an interview on 6/12/2025 at 10:26 AM, Certified Nursing Assistant (CNA) 2 stated Resident 32 did not have a dressing to the sacral wound during Activities of Daily Living (ADL) care in the morning and reported to TN 2 that Resident 32 did not a dressing to the sacral wound. CNA 2 stated she do not remove the resident's dressings from pressure injury sites because it is not in her job description. During an interview on 6/12/2025 at 2:16 PM, the Director of Nursing (DON) stated Resident 32 should always have a dressing to his sacral pressure injury. DON stated she has instructed all the CNA's to never remove a dressing from any of the resident's pressure injuries. DON stated if a resident's pressure injury is not covered with a dressing the resident could get an infection, and the pressure injury could get worse. During a record review, the facility policy and procedures (P&P) titled Skin and Wound Management, with a reviewed date of 1/27/2025, indicated: Purpose: To maintain and /or improve resident's tissue tolerance in order to prevent injury and/or infection, skin breakdown, the potential for skin breakdown, and the risk for the development of pressure ulcers and/or other skin conditions. During a record review, the facility document titled Treatment Nurse Job Description, indicated: Position Description: Under the direction and supervision of the Director of Nursing Services, the Treatment Nurse is responsible for all the treatments that are prescribed by the attending physician for all residents in the facility.

Based on interview and record review, the facility failed to provide intravenous catheter (IV -a thin, flexible tube inserted into the vein to deliver fluids, medications, or other treatments directly into the blood stream) treatment in accordance with professional standards for one of one sampled resident (Resident 6) by failing to remove Resident 6's IV catheter on 6/8/2025 when ordered IV hydration was completed. This deficient practice had the potential to result in infection and possible hospitalization for Resident 6. Findings: During a record review, Resident 6's admission Record indicated the facility admitted Resident 6 on 6/16/2020 and readmitted Resident 6 on 5/6/2025 with diagnoses including hypertension (elevated blood pressure), chronic kidney disease (when kidneys, that filter waste from the blood become damaged and don't work as well as they should), and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing. During a record review, Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 5/13/2025, indicated Resident 6 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 6 required substantial/maximal staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review, Resident 6's physician orders dated 6/7/2025 with an end date of 6/8/2025, indicated sodium chloride solution (Salt water) 0.9 percent (% -unit of measure as a part of one hundred), use 1 liter (unit of measure for fluids) intravenously one time a day for hydration until 6/8/2025 0:00 A.M.(midnight), at 75 cubic centimeters per hour (cc/h -unit of volume in liquid). During an observation on 6/10/2025, at 9:12 A.M., in Resident 6's room, a peripheral IV line was observed on Resident 6's left forearm dated 6/8/2025. During an interview on 6/11/2025, at 9:04 A.M., with Licensed vocational Nurse (LVN) 1), LVN 1 stated, Resident 6 had an IV access for hydration that was discontinued the day prior (6/10/2025). During an interview, on 6/13/2025, at 12:55 P.M., with the Registered Nurse Supervisor (RNS) 1, RNS 1 stated resident IV access are discontinued as soon as the hydration is done to prevent infection. During an interview, on 6/13/2025, at 12:55 P.M., with the Director of Nursing (DON), the DON stated, IV access was only kept in place if there was an order from the physician to maintain the IV access in place, other wise the IV access was to be discontinued to prevent infection and possible skin breakdown. The DON stated there was no documented evidence that the physician ordered Resident 6's IV remain in place. The DON stated the IV should have been discontinued after the hydration was complete. During a record review, the facility Policy and Procedures (P&P), titled, Removal of a Peripheral (Over the needle, peripheral short) Catheter revised 1/27/2025, indicated, Peripheral IV catheters will be removed safely and aseptically by a nurse with demonstrated competency in this procedure . when therapy is completed .

Based on observations, interviews, and record reviews, the facility failed to provide necessary respiratory care services for one of one sampled resident (Resident 19), by failing to: 1. Ensure Resident 19's oxygen tubing was changed weekly in accordance with the facility's policy and procedures (P&P) titled Oxygen Therapy revised 1/27/2025. 2. Ensure a physician's order for oxygen was complete and accurate in accordance with the facility's P&P titled Physician Orders revised 1/27/2025. This deficient practice had the potential to result in infection, medication error and possibly hospitalization for Resident 19. Findings: During a record review, Resident 19's admission Record indicated the facility admitted Resident 19 on 11/27/2018 and readmitted Resident 19 on 12/2/2024 with diagnoses including congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Acute respiratory failure with hypoxia (when the lungs are having a hard time getting enough oxygen into the blood and body), and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review, Resident 19's Minimum Data Set (MDS - a resident assessment tool) dated 3/26/2025, indicated Resident 19 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 19 required partial/moderate staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review of the physician's order dated 4/14/2025, the physician's orders indicated Oxygen at 2 liter per minute (l/min) (Liters-unit of measure for liquids) via nasal cannula (a thin, flexible tube that has two prongs that fit into the nostril used to give extra oxygen for people who need it) to keep saturation acute respiratory failure. During a concurrent observation in Resident 19's room and interview on 6/10/2025, at 11:58 AM, with the Licensed Vocational Nurse (LVN 1), Resident 19 was observed with oxygen nasal cannula on, the cannula had a label on it dated 6/2/2025. LVN 1 stated nasal cannula tubing was required to be changed weekly, and that the date on Resident 19's nasal cannula tubing was 6/2/2025. LVN 1 stated the nasal cannula tubing should have been changed for infection control and to make sure that the tubing was nice and clean. LVN 1 stated not changing the nasal cannula tubing could lead to infection. During a concurrent interview and record review on 6/13/2025 at 12:39 PM, with the Registered Nurse Supervisor (RNS 1), Resident 19's oxygen physician order was reviewed. RNS 1 stated that the oxygen order did not specify if the order was as needed or routine. RNS 1 stated Resident 19's oxygen order did not have parameters (specific, measurable instructions or guidelines that ensure medications are given safely and effectively.) and the order was incomplete. RNS 1 stated the incomplete order could compromise the resident's respiratory condition and if too much oxygen was given it could be a potential medication error. During a concurrent interview and record review on 6/13/2025, at 1:14 PM, with the Director of Nursing (DON), Resident 19's oxygen physician order was reviewed. The DON stated that physicians order was incomplete. The DON stated Resident 19 had an order for oxygen, however, the oxygen order had no parameters so that the facility staff could know when the oxygen could be stopped or when Resident 19 required supplemental oxygen. The DON stated oxygen was considered a medication and an incomplete order of the oxygen could lead to a possible medication error. The DON stated that oxygen tubing needed to be changed every seven days to prevent infection. During a record review, the facility P&P, titled, Oxygen Therapy revised 1/27/2025, indicated, Purpose: To ensure the safe storage and administration of oxygen in the facility . Oxygen is administered under safe and sanitary conditions to meet resident needs. Licensed Nursing staff will administer oxygen as prescribed . II. Oxygen -storage, maintenance, and handling C. Oxygen tubing, mask, and cannula will be changed no more than every seven (7) days and as needed. The supplies will be dated each time they are changed. During a record review, the facility P&P, titled, Oxygen Therapy revised 1/27/2025, indicated, Physician Orders revised 1/27/2025, indicated, .Orders will include a clear and complete description to provide clarity on the physician's plan of care.

Based on record review and interview the facility failed to ensure one of three sampled residents (Resident 59) who required dialysis (a medical treatment that cleans the blood when the kidneys are unable to do so) received services consistent with professional standards. By failing to assess the resident's current vital signs (body temperature, blood pressure, pulse [heart rate], and breathing rate to help assess the general physical health of a person) prior to transporting the resident to the dialysis center. This deficient practice had the potential for Resident 59 to experience adverse complications that would not be identified by facility staff in a timely manner. Findings: During a record review, Resident 59's admission record indicated the facility admitted the resident on 2/3/2025 and readmitted the resident on 5//52025 with diagnoses including but not limited to ESRD (End Stage Renal Disease-irreversible kidney failure), dependence on renal dialysis and kidney transplant failure. During a record review, Resident 59's Minimum Data Stet (MDS - a resident assessment tool) dated 5/12/2025, indicated the resident's cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions) moderately impaired. The MDS indicated Resident 59 required substantial assistance from facility staff to set up assistance with all activities of daily living. The MDs indicated Resident 59 was receiving dialysis treatment. During a record review, Resident 59's dialysis care plan, initiated 2/4/2025, indicated the resident required hemodialysis (HD) due to ESRD and a history of kidney transplant rejection. A review of the care plan indicated the goal was for the resident to have immediate intervention should any sign or symptom of complications from dialysis occurred. The interventions included to monitor vital signs as ordered and to notify the physician of significant abnormalities, monitor/document/report signs of bleeding, hemorrhage, bacteremia and septic shock and to monitor/document/report as needed new/worsening peripheral edema. During a record review, Resident 59's physician orders, dated 5/5/2025 indicated the resident was to receive dialysis treatment at an outside dialysis clinic on Tuesdays, Thursday and Saturday at 3:45 PM. The physician order indicated Resident 59's pick up time was 3:20 PM. During a record review, Resident 59's Pre-Dialysis Evaluation forms indicated that: - On 5/27/2025, the resident's pre- dialysis vital signs were blood pressure 130/72, respirations 18, pulse 79 and temperature 97.8. The Pre-Dialysis Evaluation form also indicated these vital signs were taken at 7:12 AM on 5/27/2025. The Pre-Dialysis Evaluation Form indicated Resident 59 left the facility and was transported to the dialysis center at 3:30 PM. - On 6/5/2025 -the resident's pre- dialysis vital signs were blood pressure 134/72, pulse 76, resp 18 and temp 97.2 at 9:42 am. The form further indicated Resident 59 left the facility at 3:30 PM. During an interview on 6/10/2025 at 8:30 AM, Resident 59 confirmed having been receiving dialysis treatments for the past 25 years. During an interview on 6/12/2025 at 11:14 AM, Licensed Vocational Nurse (LVN) 2 stated Resident 59's dialysis schedule was Tuesday, Thursday, Saturday and the resident usually leaves for dialysis at around 3:30 or 4 PM. During a concurrent interview and record review on 6/13/2025 at 8:36 AM, Resident 59's dialysis communication forms were reviewed with Registered Nurse Supervisor 1 (RNS 1). RNS 1 stated on 6/5/2025 and 5/27/2025, the charge nurse took Resident 59's vitals more than 4 hours prior to the resident leaving for dialysis. RNS 1 stated nursing staff were to take the resident's vital signs within 2 hours of leaving for the dialysis center. RNS 1 stated vitals were taken prior to leaving for dialysis in order to know the resident's status and prevent an adverse outcome. During an interview on 6/13/2025 at 10:34 AM, the Director of Nursing (DON) stated staff were to assess the resident's appropriateness to leave for dialysis. The DON stated part of assessing the resident prior to leaving the facility was taking the resident's vital signs. The DON stated based on the resident vital signs, the resident might not be appropriate to go for dialysis and the resident's physician would have to be contacted and/or the resident might need to go to a general acute care hospital (GACH). During a record review, the facility's Long Term Care Facility Outpatient Dialsys Services Care Coordination Agreement, dated 10/13/2023, under the section Transportation indicated, the Long Term Care Facility shall be responsible for ensuring that residents are (I ) medically stable to undergo such transportation, to medically suitable to receive treatment at the hospital facility and three timely transport to and from dialysis facility. During a record review, the facility policy and procedures titled, Dialysis Care, dated 1/29/2024, indicated under the section Communication and Collaboration, nursing staff will communicate the following information in writing to the dialysis staff: a. The resident's current vital signs b. Weight; and c. Any changes of conditions specific to the resident with each treatment.

Based on interview and record review, the facility failed to ensure residents were informed, offered or followed up regarding Advance Directive (ACHD - written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) in a timely manner for four of 18 sampled residents (Residents 48, 43, 3, and 58). This deficient practice had the potential to cause conflict with resident's wishes regarding health care. Findings: 1. A review of Resident 43's Admission Record indicated Resident 43 was admitted to the facility on [DATE] with diagnosis including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), and paroxysmal atrial fibrillation (afib- a sudden irregular and very rapid heart rhythm that and can lead to blood clots in the heart). A review of Resident 43's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 5/6/2024, indicated Resident 43's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were mildly impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). The same MDS indicated, Resident 43 Advance Directive was not completed. A review of Resident 43's Advance Directive form assessment during admission, dated 5/2/2024, indicated that Resident 43 chose the option that she (Resident 43) has executed an ACHD. A review of Resident 43's Baseline Care Plan, dated 5/1/2024 indicated, Social Services documentation with what was provided to Resident 43 was blank. A review of Resident 43's Progress Notes as of 5/26/2024, there were no notes by the Social Services Department regarding obtaining a copy of Resident 43's Advance Directive. During a concurrent interview and record review with Social Services Director (SSD) on 5/26/2024 at 5:23 p.m., SSD stated, residents were inquired if they have an ACHD and/or if they would like to execute an ACHD upon admission by the Admission Coordinator (AC). SSD reviewed Resident 43's electronic record with surveyor and stated, according to ACHD assessment form upon admission indicated Resident 43 have an ACHD but there was no copy of Resident 43's ACHD. SSD stated, if a resident has executed an ACHD, SSD is to follow-up with a copy, and it should be filed. SSD stated, she did not follow-up with Resident 43's regarding her actual ACHD. SSD further stated, she did not document that she followed-up with Resident 43's actual ACHD. SSD stated, ACHD is important so that they know what resident's wishes are when they are no longer able to make decision. 2. A review of Resident 3's Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, Parkinson's disease (a disorder in the brain that affects movement, often including tremors), dysphagia (difficulty swallowing food or liquid), and Alzheimer's disease (a progressing brain disorder that destroys memory and other important mental function). A review of Resident 3's MDS dated [DATE], indicated Resident 3's cognitive skills for daily decision-making were moderately impaired and required total dependence from staff for ADLs-eating, toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to lying. The same MDS also indicated, Resident 3's Advance Directive was not completed. A review of Resident 3's Advance Directive form assessment during admission, dated 5/26/2023, indicated that Resident 3/family representative chose the option that she (Resident 3) has executed an ACHD. A review of Resident 3's Baseline Care Plan, dated 5/17/2023 indicated, SSD documented that, ancillaries offered and provided as needed. A review of Resident 3's Progress Notes as of 5/26/2024, there was no notes by the Social Services Department regarding obtaining a copy of Resident 3's Advance Directive and what are the ancillaries that SSD offered and provided. During a concurrent interview and record review with SSD on 5/26/2024 at 5:25 p.m., SSD stated, residents were inquired if they have an ACHD and/or if they would like to execute an ACHD upon admission by the AC. SSD reviewed Resident 3's electronic record with surveyor and stated, according to ACHD assessment form upon admission indicated Resident 3 have an ACHD but there was no copy of Resident 43's ACHD. SSD stated, if a resident has executed an ACHD, SSD is to follow-up with a copy, and it should be filed. SSD stated, she did not follow-up with Resident 43's regarding her actual ACHD. SSD further stated, she did not document that she followed-up with Resident 43's actual ACHD. SSD stated, ACHD is important so that they know what resident's wishes are when they are no longer able to make decision. 3. A review of Resident 48's Admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and pneumonia (lung infection that inflames air sacs with fluid or pus). A review of Resident 48's MDS dated [DATE], indicated Resident 48's cognitive skills for daily decision-making were moderately impaired and required maximal to total dependence ADLs-eating, toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and rolling left to right. The same MDS also indicated, Resident 48 does not have Advance Directive. A review of Resident 48's Advance Directive form assessment during admission, dated 4/9/2024, indicated that Resident 48 chose the option that she (Resident 48) will bring in a copy of the Advance Directive for the medical record. A review of Resident 48's Baseline Care Plan, dated 4/29/2024 indicated, SSD documented that, discharge planning was discussed, home health services and psychosocial wellbeing and support. There were no notes indicating about AHCD. A review of Resident 48's Progress Notes as of 5/26/2024, there was no notes by the Social Services Department regarding obtaining a copy of Resident 3's Advance Directive. During a concurrent interview and record review with SSD on 5/26/2024 at 5:28 p.m., SSD stated, residents were inquired if they have an ACHD and/or if they would like to execute an ACHD upon admission by the AC. SSD reviewed Resident 48's electronic record with surveyor and stated, according to ACHD assessment form upon admission indicated Resident 48 have an ACHD and resident's representative will bring a copy for their record but there was no copy of Resident 48's ACHD. SSD stated, if a resident has executed an ACHD, SSD is to follow-up with a copy, and it should be filed. SSD stated, she did not follow-up with Resident 43's regarding her actual ACHD. SSD further stated, she did not document that she followed-up with Resident 43's actual ACHD. SSD stated, ACHD is important so that they know what resident's wishes are when they are no longer able to make decision. 4. A review of Resident 58's Admission Record indicated resident was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy, hypertension (HTN - elevated blood pressure), history of falling and muscle weakness. A review of Resident 58's MDS dated [DATE], indicated Resident 58's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). The same MDS also indicated, Resident 48's Advance Directive was not completed. A review of Resident 58's Advance Directive form assessment during admission, dated 4/17/2024, indicated that Resident 58 chose the option that she (Resident 48) was interested in executing an Advance Directive (refer to Social Services). A review of Resident 58's Baseline Care Plan, dated 4/29/2024 indicated, SSD documented that, discharge planning was discussed, home health services, ancillaries offered and psychosocial wellbeing support. There were no notes indicating about a referral for AHCD. A review of Resident 58's Progress Notes as of 5/26/2024, there was no notes by the Social Services Department regarding following up with Resident 58's request to execute an Advance Directive and what are the ancillaries that were offered. During a concurrent interview and record review with SSD on 5/26/2024 at 5:31 p.m., SSD stated, residents were inquired if they have an ACHD and/or if they would like to execute an ACHD upon admission by the AC. SSD reviewed Resident 58's electronic record with surveyor and stated, according to ACHD assessment form upon admission, it indicated Resident 58 was interested in executing an ACHD. Resident 58's had a power of attorney (POA) financial on file, dated 4/26/2024 which indicated, that this form is not valid for healthcare decisions. SSD stated, if a resident requested to execute an ACHD, SSD is to follow-up with a referral. SSD further stated, she did not document that she followed-up with Resident 58's request. SSD stated, ACHD is important so that they know what resident's wishes are when they are no longer able to make decision. During an interview with Director of Nursing (DON) on 5/27/2024 at 2:58 p.m., DON stated, the POA for on file for Resident 58 was for financial decisions and it was not valid for health care decisions. During a follow-up interview with SSD and AC on 5/26/2024 at 8:07 p.m., AC stated, residents are inquired about ACHD upon admission, and they document it, but surveyor does not have access to their documentation in the electronic charting. AC stated, if resident would like to execute an ACHD and/or they have executed an ACHD, they must follow-up with residents. AC stated, they don't document for any follow-up and/or education that was provided with residents. SSD stated and agreed with stating, they don't need to document any follow-up and education that was provided to residents. SSD stated, all they need to do is document it during admission process. A review of the facility's policy and procedures (P&P) titled, Advance Directive, reviewed on 1/29/2024, the P&P indicated, the facility will respect a resident's advance directive and will comply with the resident's wishes expressed in an advance directive. Upon admission, the Admission Staff or designee will obtain a copy of a resident's advance directive. A copy of the resident's advance directive will be included in the resident's medical record. If a resident does not have an Advance Directive, the facility will provide the resident and/or resident's next of kin with information about advance directives upon request . During the Social Services Assessment process, the Director of Social Services or designee will also ask the resident whether he or she has a written advance directive.

Based on interview and record review, the facility failed to notify the physician when the resident continued to refuse to take her medications for one of two sampled residents (Resident 58). This deficient practice had the potential to result in delayed provision of necessary care, treatment and services. Cross Reference F656 Findings: A review of Resident 58's Admission Record indicated resident was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), hypertension (HTN - elevated blood pressure), history of falling and muscle weakness. A review of Resident 58's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 4/21/2024, indicated Resident 58's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). During an interview with Resident 58 on 5/25/2024 at 11:28 a.m., Resident 58 stated, she has multiple of vitamins and medications that nurses bring in every morning, but she does not like taking them. Resident 58 stated, she likes to take the medications with food or after eating so she would ask the nurses to put it on an empty bottle of medication. Resident 58 stated, nurses does not inform her of what the risks of not taking the medications. During a review of Resident 58's Medication Administration Record (MAR) for the month of May 2024, the MAR indicated the following: i. amlodipine (can treat high blood pressure and chest pain) oral tablet 5 milligram (mg - unit of measurement) - give 1 tablet by mouth one time a day for HTN. ii. arginaid oral packet (nutritional supplements) - give 1 packet by mouth one time a day for wound healing. iii. atorvastatin calcium (medication use to lower cholesterol and triglycerides [fats] levels) oral tablet 20 mg - give 1 tablet by mouth in the evening. iv. docusate sodium (prevents and treats occasional constipation) oral tablet 100 mg - give 1 tablet by mouth one time a day for bowel management. v. Enoxaparin sodium (used to prevent deep venous thrombosis, [a condition in which harmful blood clots] form in the blood vessels of the legs) injection prefilled syringe 40mg/0.4 millimeter (ml) - inject 40 mg subcutaneously (SQ - the injection is given in the fatty tissue, just under the skin) one time a day for blood clots. vi. Multivitamins-minerals oral tablet - give 1 tablet by mouth one time a day. vii. Zinc sulfate (supplemental for growth and for the development and health of body tissues) capsule 200 mg - give 1 capsule by mouth one time a day. viii. Pro-stat (indicated for increased protein needs) oral liquid - give 30 ml by mouth two times a day. ix. Vitamin C (used for growth and repair of tissues in parts of body) oral tablet 500 mg - give 1 tablet by mouth two times a day. Resident 58's MAR indicated, there were multiple consecutive days of refusals documented for the medications listed above. A review of Resident 58's Progress Notes as of 5/27/2024, indicated, there was no documentation that physician was notified, and if any education was provided to Resident 58 upon refusals of medications. During an interview with Director of Nursing (DON) on 5/27/2024 at 11:34 a.m., DON stated, physician should be notified for refusals of medications, it should be documented the reason of refusals and if any educations was provided to residents. A review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, reviewed on 1/29/2024, the P&P indicated, that medication refusal must be reported to the prescriber after (XX) number of doses are refused and there must be a documentation of prescriber notification of such. A review of the facility's P&P titled, Refusal of Treatment, reviewed on 1/29/2024, the P&P indicated that the Attending Physician will be notified of refusal of treatment in a time frame determined by the resident's condition and potential serious consequences of the refusal.

Based on observation, interview, and record review, the facility failed to ensure nine out of nine sampled residents (Residents 48, 43, 50, 178, 44, 40, 36, 277, 278 and 227) were free from physical restraint by failing to: 1. Obtain a physician's order and informed consent from residents/responsible party for the use of bilateral bed side rails according to facility's policy and procedures (P & P) titled, Bed Rails, for Residents 50, 178, 44, 40, 36, 277, and 278 2. Obtain a physician's order for the use of bilateral bed siderails for Resident 48. 3. Obtain a physician's order and informed consent from residents/responsible party for the use of the bilateral bed side rails and bed side rails assessment were accurate for Resident 43. These deficient practices had the potential to result in entrapment, injury, and residents not being treated with respect and dignity with the use of restraints. Cross Reference F656 Findings: 1a. A review of Resident 43's Admission Record indicated Resident 43 was admitted to the facility on [DATE] with diagnosis including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), and paroxysmal atrial fibrillation (afib- a sudden irregular and very rapid heart rhythm that and can lead to blood clots in the heart). A review of Resident 43's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 5/6/2024, indicated Resident 43's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were mildly impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). A review of Resident 43's physician order summary report (POSR), as of 5/27/2024, POSR indicated no orders for side rails. A review of Resident 43's informed consent as of 5/27/2024 indicated, there was no informed consent signed from resident/responsible party for the use of bilateral bed siderails. A review of Resident 43's Bed Rail Assessment, dated 4/29/2024 indicated, side rails/assist bar are not indicated at this time. A review of Resident 43's Care Plan (CP) as of 5/27/2024 indicated, there was no CP developed for the use of bilateral bed siderails. During a concurrent observation and interview with Resident 43 on 5/25/2024 at 12:00 p.m., Resident 43 was observed with a bilateral upper bed siderails up. Resident 43 stated, she is unable to get up on her own and needs assistance with getting out of bed and walking. Resident 43 was observed unable to move the bilateral bed siderails down on her own. During a concurrent observation of Resident 43 and interview with Director of Nursing (DON), on 5/26/2024 at 7:25 p.m., DON stated and confirmed, Resident 43 is on bilateral bed side rails. During a follow-up interview with DON, on 5/26/2024 at 11:50 a.m., DON stated, the use of bilateral bed siderails does not need a physician's order and no informed consent needed as they were not utilizing it for restraints. When asked regarding Resident 43's bed rails assessment which indicated, side rails/assist bar are not indicated at this time, DON was unable to answer. When asked if Resident 43 is able to move the siderails on her own, DON stated, no. 1b. A review of Resident 48's Admission Record indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and pneumonia (lung infection that inflames air sacs with fluid or pus). A review of Resident 48's MDS dated [DATE], indicated Resident 48's cognitive skills for daily decision-making were moderately impaired and required maximal to total dependence from staff for activities of daily livings (ADLs-eating, toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and rolling left to right). A review of Resident 48's POSR, as of 5/27/2024, POSR indicated no orders for side rails. A review of Resident 48's care plan (CP), indicated Resident 48 was at risk for fall related to gait/balance problems initiated on 4/29/2024. The CP indicated an intervention that facility will provide siderails for turning and repositioning. During a concurrent observation and interview with Resident 48 on 5/26/2024 at 11:16 a.m., Resident 48 was observed with a bilateral bed siderail up. Resident 48 stated, she is unable to get up on her own and unable to move herself up from bed to sitting position. Resident 48 was observed unable to move the bilateral bed side rails down on her own. During a concurrent observation of Resident 48 and interview with DON, on 5/26/2024 at 7:27 p.m., DON stated and confirmed, Resident 48 is on bilateral bed side rails and bed siderails does not need a physician's order because it is a nursing scope of practice. During a follow-up interview with DON on 5/27/2024 at 11:53 a.m., DON stated, the use of bilateral bed siderails does not need a physician's order and no informed consent needed as they were not utilizing it for restraints. When asked if Resident 48 is able to move the bed siderails on her own, DON stated, no. 1c. A review of Resident 50's Admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including surgical aftercare following surgery on the skin, congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle) and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) A review of Resident 50's MDS dated [DATE], indicated Resident 50's cognitive skills for daily decision-making were mildly impaired and required total dependence from staff for ADLs- toileting hygiene, shower/bathing self, lower body dressing, repositioning from sit to lying and lying to sitting on side of bed. A review of Resident 50's POSR, as of 5/27/2024, POSR indicated no orders for side rails. A review of Resident 50's informed consent as of 5/27/2024 indicated, there was no informed consent signed from resident/responsible party for the use of bilateral bed siderails. A review of Resident 50's CP, indicated Resident 50 was at risk for fall related to gait/balance problems initiated on 4/26/2024. The CP indicated an intervention that facility will provide siderails for turning and repositioning. During a concurrent observation and interview with Resident 50 on 5/26/2024 at 9:25 a.m., Resident 50 stated, he is unable to get up on his own and needs assistance to get up from bed to wheelchair. Resident 50 was asked if he's able to put his bed siderails down on his own and Resident 50 stated, he cannot. During a concurrent observation of Resident 50 and interview with DON on 5/26/2024 at 7:30 p.m., DON stated and confirmed, Resident 50 is on bilateral bed side rails for mobility and bed siderails does not need a physician's order because it is a nursing scope of practice. During a follow-up interview with DON on 5/27/2024 at 11:53 a.m., DON stated, the use of bilateral bed siderails does not need a physician's order and no informed consent needed as they were not utilizing it for restraints. When asked if Resident 50 is able to move the bed siderails on her own, DON stated, no. A review of the facility's P&P titled, Bed Rails, reviewed on 1/29/2024, the P&P indicated that facility will attempt alternatives prior to the installation of bed rails, prior to installation, assess the resident's risk of entrapment with bed rails. Review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation. The same P&P also indicated that, a bed rails is an assistive device and must be used in accordance with the following regulations: a. Only permissible if they are used to treat a Resident's medical symptoms b. Are classified as a physical restraint when bed rails are used to limit a Resident's freedom of movement (i.e., prevent the Resident from leaving the bed) c. The length of the bed rail (quarter, half, full, etc.) does not determine if the bed rail is a restraint or an enabler d. Bed rails cannot be used for staff convenience or as discipline, such as prevention of falls when less restrictive methods have not been attempted or ruled out e. A detailed order by a healthcare provider (e.g., a physician, nurse practitioner) is required before any restraints can be utilized. A review of the facility's P&P titled, Informed Consent, reviewed on 1/29/2024, the P&P indicated that Informed consent is required for any medical intervention that is not emergency care or routine nursing care; When informed consent is required, the physician who orders or performs the intervention is required to obtain informed consent. 43261 1d. A review of Resident 44's Admission Record indicated Resident 44 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including injury of head, dementia (loss of cognitive functioning-thinking, remembering, and reasoning), generalized weakness, history of falling and epilepsy (a disorder in which a nerve cell activity in the brain is disturbed causing seizure [a sudden, uncontrolled electrical disturbance in the brain]). A review of Resident 44's MDS dated [DATE], indicated Resident 44's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was moderately impaired and requiring maximal assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). A review of Resident 44's physician order summary report (POSR), as of 5/27/2024, POSR indicated no orders for side rails. A review of Resident 44's care plan, indicated Resident 44 was at risk for fall related to gait/balance and history of falls, reviewed on 3/15/2024. Care plan also indicated interventions that facility will provide siderails for turning and repositioning. During an observation on 5/26/2024 at 10:02 a.m., Resident 44 was observed in bed with padded bilateral upper side rails up. During an interview with the LVN 3 on 5/27/2024 at 11:50 a.m., LVN 3 stated that Resident 44 needed to have padded bilateral upper side rails up when in bed for safety. LVN 3 stated that since according to the care plan that bilateral upper side rails up are supposed to be for turning and repositioning, side rails should only be used when Resident 44 was being turned and repositioned. LVN 3 also stated that she was unsure if side rails as enabler needs to have a physician order. During an interview with the DON, on 5/27/2024 at 5:23 p.m., DON stated not needing a physician order for having bilateral upper side rails up for turning and repositioning. DON also stated that as long as there was a care plan in the intervention indicating that a resident needs a side rail for turning and repositioning, resident should be okay to have the side rails up at all times when in bed. 1e. A review of Resident 178's Admission Record indicated Resident 178 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), end stage renal failure (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), hemodialysis (HD-filtering the blood of a person whose kidneys are not working normally) dependence and generalized muscle weakness. A review of Resident 178's MDS, dated [DATE], indicated Resident 178's cognitive skills for daily decision-making was moderately impaired and requiring maximal assistance from staff for ADLs. MDS also indicated Resident 178 was on hemodialysis since admission. A review of Resident 178's POSR, as of 5/27/2024, POSR indicated no orders for side rails. A review of Resident 178's care plan, indicated Resident 178 has an ADL self-care performance deficit, reviewed on 5/6/2024. Care plan also indicated interventions that facility will provide siderails for repositioning. During an observation on 5/25/2024 at 11:23 a.m., Resident 178 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 10:02 a.m., Resident 178 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 4:20 p.m., Resident 178 was observed in bed with bilateral upper side rails up. During an interview with the LVN 3 on 5/27/2024 at 11:41 a.m., LVN 3 stated being unsure if Resident 178 needed to have bilateral upper side rails up when in bed. LVN 3 stated that since according to the care plan that bilateral upper side rails up are supposed to be used for turning and repositioning, side rails should only be used when Resident 178 was being turned and repositioned. LVN 3 also stated that she was unsure if side rails as enabler needs to have a physician order. During an interview with the DON, on 5/27/2024 at 5:23 p.m., DON stated not needing a physician order for having bilateral upper side rails up for turning and repositioning. DON also stated that as long as there was a care plan in the intervention indicating that a resident needs a side rail for turning and repositioning, resident should be okay to have the side rails up at all times when in bed. A review of facility's P&P, titled, Restraints, reviewed on 1/29/2024, P&P indicated that facility will honor resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. P&P also indicated that restraints require a physician orders. 44252 1g. A review of Resident 36's Admission Record, dated 5/28/2024, indicated Resident 36 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including DM, major depressive disorder (depressed mood or loss of interest in activities, causing significant impairment in daily life), abnormal posture, and generalize muscle weakness. A review of Resident 36's MDS, dated [DATE], indicated Resident 36's had moderate cognitive impairment, and required substantial/maximal assistance from staff for toileting, bathing, dressing, personal hygiene and bed mobility. A review of Resident 36's POSR, as of 5/28/2024, POSR indicated no orders or consent for side rails. During an observation on 5/25/2024 at 12:48 p.m., Resident 36 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 9:48 a.m., Resident 36 was observed in bed with bilateral upper side rails up. During an observation on 5/27/2024 at 11:01 a.m., Resident 36 was observed in bed with bilateral upper side rails up. 1h. A review of Resident 40's Admission Record, dated 5/28/2024, indicated Resident 40 was originally admitted to the facility on [DATE], with diagnoses including, depressive disorder (depressed mood or loss of interest in activities, causing significant impairment in daily life), heart failure (a medical condition where the heart muscle doesn't pump blood as well as it should), hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath). A review of Resident 40's MDS, dated [DATE], indicated Resident 40's had mild cognitive impairment, and required moderate to maximal assistance from staff for toileting, bathing, dressing, personal hygiene, and bed mobility. A review of Resident 40's POSR, as of 5/28/2024, POSR indicated no orders or consent for side rails. During an observation on 5/25/2024 at 12:56 p.m., Resident 40 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 9:49 a.m., Resident 40 was observed in bed with bilateral upper side rails up. During an observation on 5/27/2024 at 3:00 p.m., Resident 40 was observed in bed with bilateral upper side rails up. 1i. A review of Resident 277's Admission Record indicated Resident 277 was originally admitted to the facility on [DATE], with diagnoses including hypertensive (high blood pressure) heart disease with heart failure (disease when heart doesn't pump enough blood for your body's needs), muscle weakness, difficulty walking and anemia (not enough oxygen carrying red blood cells in the blood). A review of Resident 277's MDS, dated [DATE], indicated Resident 277 had mild cognitive impairment and required supervision or touching assistance from staff for eating, oral hygiene, and upper body dressing, and moderate and maximum assistance from staff for toileting, bathing, lower body dressing and personal hygiene. A review of Resident 277's POSR, as of 5/28/2024, POSR indicated no orders or consent for side rails. During an observation on 5/25/2024 at 11:06 a.m., Resident 277 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 10:00 a.m., Resident 277 was observed in bed with bilateral upper side rails up. During an observation on 5/27/2024 at 11:05 a.m., Resident 277 was observed in bed with bilateral upper side rails up. 1j. A review of Resident 278's Admission Record indicated Resident 278 was originally admitted to the facility on [DATE], with diagnoses including diabetes mellitus, muscle weakness, discitis (inflammation of the intervertebral [area between bones of the spine] disc space) lumbar (lower back) region, and malignant neoplasm (cancerous tumor) of the breast. A review of Resident 278's MDS, dated [DATE], indicated Resident 278 had moderate cognitive impairment and required supervision or touching assistance from staff for toileting, bathing, dressing and personal hygiene. A review of Resident 278's POSR, as of 5/28/2024, POSR indicated no orders or consent for side rails. During an observation on 5/25/2024 at 5:28 p.m., Resident 278 was observed in bed with bilateral upper side rails up. During an observation on 5/26/2024 at 9:42 a.m., Resident 278 was observed in bed with bilateral upper side rails up. During an observation on 5/27/2024 at 11:05 a.m., Resident 278 was observed in bed with bilateral upper side rails up.

(Rev. 173, Issued: [DATE], Effective: [DATE], Implementation: [DATE]) §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) maintained parameters of acceptable nutrition and hydration and had adequate food and fluid intake. The facility failed to: -Provide Resident 1 with a speech therapist (a medical practitioner who can determine the presence and severity of person's difficulty in swallowing) evaluation, per the care plan and physician's order. -Accurately monitor and assess Resident 1's intake and output of at least 50% each meal, per the care plan. - Notify the physician that Resident 1 was refusing food and frequently consumed less than 50% of meals. -Reassess and change care plan interventions for Resident 1 to address the resident's weight loss. -Conduct an interdisciplinary team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) conference or weight variance committee to manage Resident 1's weight loss, per facility policy. As a result, Resident 1 had significant weight loss of 11.89 pounds (lbs), (9.45%), in one month ([DATE]), 16.8 lbs, (13.46%) in two months ([DATE]), and on [DATE] at 1:21 AM, Resident 1 was transferred to a general acute care hospital (GACH) emergency room (ER) due to [CONDITION(S)] (increased heart rate) and expired the same day at 1:57 AM at the GACH. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the [AGE] year-old male resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician's Order dated [DATE], indicated Resident 1 was to receive a controlled carbohydrate (CCHO - a diet consisting of the same amount of carbohydrates every day) mechanical soft diet (a texture-modified diet that restricts foods that are difficult to chew or swallow). A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's weight log indicated that his weight was 124.8 lbs on [DATE], and 117 lbs on [DATE] (a 7.8 lb, [6.25%] weight loss in one week). A review of Resident 1's initial Minimum Data Set (MDS, a comprehensive assessment and care-planning tool) dated [DATE], indicated Resident 1 never / rarely made decisions, had little interest or pleasure in doing things, felt down, depressed or hopeless and had trouble sleeping two to six days of the week. The MDS indicated Resident 1 required total care, was dependent on staff for toileting and personal hygiene and required extensive assistance with one-person physical assist for eating. A review of the February 2021 certified nursing assistant (CNA) activities of daily living (ADL) flowsheet indicated that in the first two weeks of admission, from [DATE] to [DATE], Resident 1 ate 0 to 50 percent at twelve out of 15 breakfasts. The flowsheet indicated that on [DATE] thru [DATE], Resident 1 ate 60 to 80 percent of his breakfast. Resident 1 ate zero to 50 % of 12 out of 15 lunches. Resident 1 ate ninety percent on [DATE] and [DATE], he ate 70 percent on [DATE]. The flow sheets indicated Resident 1 ate 0 to 50 percent of all meals served for dinners. A review of Resident 1's Physician's Order Summary Report, dated [DATE], indicated Resident 1 should be evaluated by a speech therapist (ST), should be consult by a registered dietician (RD), encourage hydration and nutrition. A review of the resident's clinical record had no documented evidence indicated Resident 1 received a speech therapy evaluation or fluid was encouraged. A review of Resident 1's another Physician's Orders dated [DATE], indicated to change the resident's diet to a fortified (extra nutrients added) mechanical soft diet and to give eight ounces (oz) high protein nutrition (HPN) three times daily with meals. A review of the Situation- Background - Assessment and Response (SBAR) change in condition form dated, [DATE], indicated Resident 1 refused breakfast and lunch for three days, starting on [DATE]. A review of Resident 1's Care Plan developed on [DATE] for risk of weight loss, indicated Resident 1 had a body weight twenty percent or more under ideal weight. The interventions included help as necessary, maintain intake and output log as indicated, offer fluids frequently, provide education to resident, responsible party and staff regarding special care needs and refer to a speech therapist consult as needed. There was no evidence the care plan was revised or updated. A review of Resident 1's nurses' progress notes [DATE] through [DATE]. indicated Resident 1 was monitored for poor appetite. However, a review of the resident's clinical record did not have documented evidence indicated the resident had been monitored for poor oral intake, poor appetite, or for weight loss. A review of Resident 1's situation-Background- Assessment- Recommendation (SBAR) change of condition form dated [DATE], indicated Resident 1 ate 30% of breakfast, and 40% of lunch indicating poor intake. A review of Resident 1's weight log dated [DATE], indicated the resident weight was 113 lbs. This represented an 11.8 lb, (9.45%) weight loss in one month. Resident 1 continued to lose weight. Two weeks later, on [DATE], Resident 1's weight was 110.5 lbs. Another two weeks later, on [DATE], his weight was 109 lbs. The last weight recorded on [DATE] was 108 lbs, a 16.8 lb, (13.46%) weight loss in two months. A review of the facility policy and procedure titled, Meals - Serving between Meal Nourishment, revised [DATE], indicated the percentage of nourishment consumed was recorded in the resident's medical record and to update the resident's care plan as necessary. A review of the Physician's Orders indicated Resident 1 was prescribed D5% -0.45% NACL IV (a solution containing dextrose and sodium chloride in water intended for intravenous administration) solution one liter for hydration on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE] (seven days). A review of Resident 1's Interdisciplinary Team (IDT) conference notes dated on [DATE], [DATE] and [DATE], indicated the IDT met to evaluate Resident 1's pressure injury on his tail bone region. The IDT conference summary notes also indicated the resident had poor oral intake. However, the notes did not indicate that the resident had a weight loss or provide interventions to correct the resident's weight loss. A review of Resident 1's Physician's Order, dated [DATE], indicated the resident was to receive protein shake and water every hour. A review of the Physician's Orders indicated Resident 1 was prescribed D5% -0.45% NACL IV solution one liter for hydration on ,d+[DATE], ,d+[DATE] and [DATE] (three additional days). A review of the nursing progress notes, dated [DATE] at 1:21 AM indicated Resident 1 was transferred to a general acute care hospital (GACH) emergency room (ER) due to [CONDITION(S)] (increased heart rate) of 150 beats per minute, shortness of breath, with Oxygen saturation of 69% on room air (normal 90%), respiratory rate of elevated at 29 breaths per minute (normal ,d+[DATE]). A review of Resident 1's clinical records indicated SBARs dated [DATE] and [DATE], indicated change in condition forms for Resident 1's poor oral intake. However, the was no documented evidence for a significant weight loss. A review of Resident 1's Certificate of Death indicated Resident 1 expired on [DATE] at 1:57 AM at the GACH. The causes of his death were respiratory failure, [CONDITION(S)] and Alzheimer's dementia. During an interview with Licensed Vocational Nurse (LVN) 1 on [DATE] at 11:40 AM, LVN 1 stated that a resident's weight was monitored, and the certified nursing assistants (CNAs) document the resident's intake of food and nourishment on ADL flowsheet. Nourishment included snacks, health shakes and protein shakes. LVN 1 stated if a resident's intake went down to 50%, this was an alert that the facility staff must do something. LVN 1 stated, If a resident refused meals three times, we do a change of condition and we get the registered dietician (RD) and the physician involved. LVN 1 also stated, I don't know the facility protocol but when the resident loses three to five lbs, I become concerned. LVN 1 stated that weight loss in a resident can lead to electrolyte (minerals in your blood and other body fluids that affect how your body functions in many ways) imbalances that can affect his cardiac system. If a resident loses a significant amount of weight, it was important to know the resident's intake, so that we can figure out interventions to reverse the weight loss. During an interview with registered nurse (RN) 1 on [DATE] at 1:08 PM, RN 1 stated upon admission, the resident was weighed weekly for four weeks. If the resident loses weight, we extend the weekly weights or change the frequency to every other day. RN 1 stated it was important to monitor the resident's weight to ensure the nutrients provided to heal and maintain muscle. When a resident loses weight, we first notify the doctor or nurse practitioner (NP) and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated, We monitor the resident's intake of food and their output in the activities of daily living log. If a resident continues to lose weight, the Interdisciplinary Team (IDT) will meet in conjunction with the family to form a plan to stop the resident's weight loss. RN 1 further stated that nursing implements a care plan. We have to revise the care plan and make another intervention in a week if they continue to lose weight. During an interview and record review with LVN 2 on [DATE] at 11:40 AM, Resident 1's medical record was reviewed. LVN 2 stated Resident 1 was having steady weight loss and the weight loss from ,d+[DATE] to [DATE] was 7.8 lbs and that was a very large weight loss that should have been reported to the doctor on [DATE]. LVN 2 stated there was no documentation of the doctor being informed. Each time Resident 1 had a significant weight change the doctor should have been alerted. LVN 2 further stated that Resident 1 had a pressure ulcer, and his weight loss could affect its' healing and in general it could affect the president's ability to thrive. LVN 2 stated Resident 1's weight loss should have been care planned, reviewed and updated, when his weight continued to drop. When the resident continued to lose weight, We should have kept trying different interventions. After reviewing the weight loss care plan, developed on [DATE], LVN 2 stated that if there was a review date it would be listed. LVN 2 stated that she was unsure if the facility did calorie counts. After reviewing the RD note [DATE], LVN 2 stated that the RD recommended multivitamin (MVI) with minerals and to add the two calorie (cal) HN (a calorie and protein dense nutrition drink that may be given to assist a resident with weight gain). LVN 2 stated that the weight variance committee should have become involved in this case. During an interview and concurrent record review on [DATE] at 2:10 PM, with the Director of Nursing (DON), Resident 1's medical record was reviewed. After review of Resident 1's weight log, the DON stated that Resident 1's weight was 124.8 lbs on [DATE] and 117 lbs on [DATE], this was close to an 8 lb weight loss and there should be nursing progress notes regarding the weight loss. After review of the nursing progress notes, the DON stated that there was no documentation regarding Resident 1's weight loss. The DON stated, I cannot find any IDTs for the weekly weights and could not find any weight variance notes. The DON stated the IDT conference was important because you need the input from all the disciplines on the team.When the DON was asked about Resident 1 receiving the physician ordered ST evaluation, she stated it could not be found and that she could not recall if an ST evaluation was done. When asked about documentation indicating the CNA fed Resident 1, the DON stated, There was no order, we would just write it on the assignment sheet. The DON stated that there was one SBAR for refusing meals and when asked about Resident 1's care plan dated [DATE] for weight loss stated, I can't tell if the care plan was revised, and the care plan should have been revised if the resident continued to lose weight. The DON further stated it was important to update the care plan interventions to ensure the care plan was effective. While reviewing the policy and procedure, regarding nourishment percentage documentation, and asked should the CNA have documented the percentage of nourishment ingested, the DON stated, I am not sure. It would be important to know exactly how much the resident is taking in and not just generalities. When asked about the documentation Resident 1 was offered protein shake and water every hour per the [DATE] physician order the DON was unable to answer. During a phone interview with registered dietician (RD) 1, on [DATE] at 11:05 AM, RD 1 stated a significant weight change was defined as a change in weight of five pounds or more than 5 percent in a month, or if there was a two percent change in a week. RD 1 stated, If a significant weight change happened, there will be a weight variance and the DON, supervisor, social services and others will discuss the weight change, and I will make recommendations. All residents with significant weight change will get four weeks of weekly weights as part of the interventions. RD 1 stated Resident 1 weighed 124. 8 then decreased weight to 117 lbs. classified as a significant weight change as it was more than two percent in one week. It was important to find the root cause of any weight change. RD 1 stated, The weight variance committee should be analyzing the interventions taking place because the resident could continue to experience weight loss and we don't want the resident to get weaker. When RD 1 was asked about being aware of any interventions applied for Resident 1's weight loss, the RD stated, I don't remember. When asked how the RD would know how many calories the resident was taking, the RD stated, The CNA reports the percentage of each meal and based on that we know how many calories the resident was taking in. The facility had to make certain that the CNAs were documenting each meal and that will help me make better recommendations. During an interview with Resident 1's family member (FM) 1 on [DATE] at 1:08 PM, FM 1 stated the facility did nothing to address the resident's weight loss, He was being neglected at the facility and not fed. FM 1 stated I visited in the evening, sometimes Resident 1's food tray would have a protein drink, sometimes it would not. The facility did not mention to me about him refusing to eat or having a CNA feed him. FM 1 stated, When I was there, the CNA would drop his evening meal and leave. I would make sure he had the Ensure, he would drink it all and sometimes more than one can if he was hungry. His roommate would tell me that he needed to be fed. FM 1 stated the plan for Resident 1 was to get wound care at the facility and then to return home that no medical personnel told her that he was nearing the end of his life. FM 1 further stated the facility did not call when Resident 1 was transferred to the hospital. FM 1 stated, He was skeletal when he died . I am angry. I am just angry. A review of the facility policy and procedure titled, Nutritional Status Evaluation Committee, revised [DATE], indicated that its purpose is to ensure the physical well-being of residents through the management of weight variance. It further indicated the resident's weight will be monitored for variance and the Nutritional Status Evaluation Committee will intervene when appropriate. It also stated prior to each meeting the Director of Nursing Services or designee will compile a list of residents who are at risk for weight changes. Residents with 2% weight change in one week, 5% and/or 5 lb weight change in one month, or 7.5% weight change in 3 months may be included on the list for discussion. Residents on the list will be reviewed monthly until their weight has stabilized. Objectives of the nutritional status evaluation committee includes but is not limited to identifying medical or pharmacological conditions, which may be affecting weight changes. evaluating changes in diet, identifying residents with signs of dysphagia (chewing or swallowing problems) for proper intervention and diet modification. and identify behaviors in the feeding environment that may be contributing to weight loss. A review of the facility policy and procedure titled, Food and Fluid Percentage Documentation, revised [DATE], indicated the CNA will record the percentage of all food and fluid intake in the Resident's ADL flowsheet after each meal. The documentation of nourishment percentages between meals consumed by the resident will be recorded in the resident's ADL flowsheet by the CNA. A review of the facility policy and procedure titled, Evaluation of Weight & Nutritional Status, revised [DATE], indicated any resident weight that varies from previous reporting period by 5% in 30 days, 7.5 % in 90 days, 10% in 180 days, will be evaluated by the IDT - Nutrition & Weight Variance Committee to determine the cause of weight loss and the intervention(s) required. Once weight loss as described above was identified, the IDT - Nutrition and Weight Variance Committee will identify and implement appropriate interventions; update and revise the Care Plan, as appropriate; notify the attending physician; and notify the registered dietician. It further indicated when there was a weight variance of five pounds in one month, the weight loss will be evaluated by the IDT - Nutrition & Weight Variance Committee to determine the cause of and respond as appropriate.

Based on interview and record review, the facility failed to identify and ensure one of two sampled residents (Resident 3), who was at risk for cardiac (heart) distress related [CONDITION(S)] (damaged kidneys cannot filter blood as needed causes risks of high blood pressure and heart disease) received care and services in accordance with professional standards of practice and had an initial care plan with interventions to address Resident 3's heart condition by failing to: 1. Implement Resident 3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Recognize and assess Resident 3's change of condition related to the resident's hypertension (high blood pressure, a common condition when the force of blood against the artery wall is too high) when the resident's blood pressure was elevated at ,d+[DATE] millimeters of mercury (mm/hg, a unit of pressure) on [DATE]. 3. Develop and implement Resident 3's care plan for at risk for cardiac distress related to [CONDITION(S)], and to notify the physician when the resident had abnormal blood pressure or low heart rate. 4. Obtain Resident 3's vital signs at the beginning of the night shift on [DATE] when the resident had change in condition, per facility policy. As a result, on [DATE] at 4:45 AM, Resident 3 was found unresponsive, not breathing, and Cardiopulmonary Resuscitation (CPR) was initiated. Resident 3 was pronounced deceased by the paramedics at 5:07 AM on [DATE]. Findings: A review of the Admission Record indicated Resident 3 was an [AGE] year-old female, admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS - a comprehensive assessment and care planning tool), dated [DATE], indicated Resident 3 was severely impaired with cognitive skills for daily decision-making (unable to make decisions) and active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident 3 was expected to be returned to the community. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a review of Resident 3's medical record there was no care plan for any heart condition, hypertension or blood pressure medications. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . At 5:30 PM the blood pressure was ,d+[DATE], medication administered. A review of Resident 3's medical record indicated there was no documentation that the physician was notified of the elevated blood pressure. The medical record indicated there was no documentation on [DATE] indicating a set of vital signs was attempted at the start of the shift at 11 PM or through the night to 4:45 AM for Resident 3. A review of Resident 3's progress notes dated [DATE] at 8:22 AM, indicated at 11 PM on [DATE], Resident 3 was sleeping on her back, no distress, no sign of any discomfort. At 2:30 AM, on [DATE], the progress note indicated Resident 3 was in bed and observed with movement. At 4:45 AM the progress note indicated Resident 3 was unresponsive and not breathing, CPR was initiated, and code blue was called. The progress note indicated the paramedics arrived and assisted but was unable to resuscitate Resident 3 and the resident was pronounced deceased by the paramedics at 5:07 AM on [DATE]. A review of the Certificate of Death dated [DATE] indicated Resident 3's immediate cause of death was [CONDITION(S)] and coronary artery disease. During a telephone interview on [DATE] at 10 AM, the Director of Nurses (DON) stated she could not find any notes indicating the physician was ever notified of Resident 3's changes in blood pressure on ,d+[DATE] and [DATE]. The DON stated the nurses must notify the physician when the residents have a change in condition. The DON further stated the nurses needed to notify the physician when Resident 3's blood pressure was ,d+[DATE] on [DATE], when Resident 3 refused her medication and not given, and when the blood pressure was elevated on [DATE]. During a telephone interview with Licensed Vocational Nurse 1 (LVN 1) on [DATE] at 9 AM, LVN 1 stated she did not administer the resident's blood pressure medication on [DATE] because the reading was low (,d+[DATE]). LVN 1 stated she did not notify the physician because she was new and did not know she had to notify the physician. LVN 1 stated she did not document in the nurse's progress notes the change or elevation in residents' blood pressure (,d+[DATE]) on [DATE] nor did she notify the physician. During a telephone interview on [DATE] at 3:30 PM with Licensed Vocational Nurse 2 (LVN 2), when asked what did the X indicate on the MAR, LVN 2 stated Resident 3 refused to have her blood pressure taken on [DATE] at 5:30 PM and she documented the X. LVN 2 stated she called the physician to notify the resident was refusing her medications, but she failed to document in the nurse's progress notes or change in condition form. On [DATE] at 11 AM, during a telephone interview, Licensed Vocational Nurse 3 (LVN 3) stated she was assigned to work with Resident 3 on [DATE] during the 11 PM to 7 AM shift. LVN 3 stated she was not aware Resident 3's blood pressure was elevated or that a set of vitals was not taken at the beginning of her shift, [DATE]. On [DATE] at 11 AM, during a telephone interview, the DON stated there should have been a set of vital signs taken during the night shift of [DATE] for Resident 3. The DON stated, the blood pressure and heart rate needed to be monitored because Resident 3 had an elevated blood pressure in the morning. A change of condition should have been initiated. The physician needed to be notified and Resident 3's blood pressure needed to be monitored to assess Resident 3's condition. During a telephone interview with the Physician on [DATE] at 3:30 PM, the Physician stated he did not recall being notified about Resident 3's change in blood pressure being low at ,d+[DATE]. The Physician stated had he been notified; he would have ordered for the nurse to recheck the blood pressure and if it remained low he would have ordered to transfer the resident to the General Acute Care Hospital (GACH). The Physician stated had he been notified about the high blood pressure at ,d+[DATE], he would have ordered to recheck the blood pressure and if it remained high, then he would need to adjust the medication. During an interview on [DATE] at 9:30 AM, the DON stated she could not locate Resident 3's care plan for blood pressure medications and Resident 3 needed to have one in place in order to provide the necessary interventions such as calling the physician when there was a drop in blood pressure or an elevated blood pressure. During an interview on [DATE] at 12 PM, the DON stated the facility failed to notify the physician and legal representative when Resident 3's blood pressure dropped on [DATE] to ,d+[DATE] and failed to notify them when the blood pressure increased on [DATE] to ,d+[DATE]. A review of the facility's policy and procedure titled, Change of Condition Notification, revised [DATE] indicated the facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition such as a significant change in the resident's physical, mental or psychosocial status. The policy indicated notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification was required. A licensed Nurse will document the following: Date, time, and pertinent detail of the incident and the subsequent assessment in the Nursing notes, the time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether order was received. A review of the facility's policy and procedure titled, Obtaining Vital Signs, revised on [DATE] indicated vital signs are clinical measurements that indicate the state of a resident's basic body functions. Vital signs will be taken with the following frequency but not limited to as ordered by the physician, when there is a change in the resident's condition, and every shift for 72 hours after an incident or unusual occurrence. A review of facility's policy and procedure titled, Comprehensive Person-Centered Care Planning, revised [DATE], indicated the facility will provide person centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs or residents in order to obtain or maintain the highest physical, and psychosocial well-being. The baseline care plan summary will be developed and implemented, using the necessary combination of problem specific are plans, within 48 hours of the resident's admission. It will include, at minimum, the following information necessary on each care plan to properly care for the resident, initial goals based on the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 2), who was placed in the same room with Resident 1, was not subjected to physical abuse inflicted by Resident 1. The facility failed to: -Evaluate Resident 2's safety when it was decided to place him in the same room upon re-admission and after Resident 1 became protective of his room preventing entry of staff which resulted in moving out Resident 3 from Resident 1's room. -Provide Resident 1, who had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Affected individuals may have grandiose delusions [strong beliefs of things that are untrue], associated with protecting themselves from the perceived plot) and was not receiving medication to control his behavior, with a psychiatrist (medical practitioner specializing in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -Monitor Resident 1 for mood and behavior symptoms that posed a threat to self and others. -Implement its policy on abuse to ensure Resident 2 was free from physical abuse. As a result, on 7/5/2021 at 12:55 a.m., while Resident 2 was asleep in bed, Resident 1 hit him with a table on the face and arms. Resident 2 required emergency transfer to general acute care hospital 1 (GACH 1), where he was diagnosed with broken facial bones, broken teeth, left facial hematoma (collection of blood), swelling and laceration (deep cut or tear in the skin) to the left side of the face. Resident 2 stated fell ing traumatized, frightened at night, and having difficulty to sleep. Findings: A review of Resident 2's Admission Record (Face Sheet) indicated the facility readmitted the resident, a [AGE] year-old male on 6/29/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 was placed in Resident 1's room (which was a different room from Resident 2's previous stay). A review of Resident 2's Admission Nursing Notes, dated 6/29/2021, indicated the resident was alert and oriented to person, place, and time; and required extensive assistance with activities of daily living (ADLs such as walking, dressing, locomotion, and personal hygiene). A review of Resident 2's SBAR (Situation, Background, Assessment, Recommendation - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident), dated 7/5/2021, indicated Resident 2 was assaulted by his roommate (Resident 1) at 12:55 a.m. Resident 1 hit Resident 2 on the face, head, and arms. Resident 2 had a cut on the left side of the nose measuring 3.5 cm with blood noted flowing out of the cut and had discoloration to both arms. Resident 2 was removed from the room and placed near Nurses' Station 1. Paramedics were called and took Resident 2 to GACH 1. A review of Resident 2's After Visit Summary from GACH 1, dated 7/5/2021, indicated Resident 2 had computerized tomography scans (CT scans - a series of X-ray images taken by computers to create more detailed images of bones, blood vessels, and tissues inside the body) of his head. The CT scans indicated Resident 2 had broken facial bones, broken teeth, left facial hematoma, swelling to the left side of the face, and a laceration to the left side of the face. Resident 2 was discharged back to the facility with antibiotic and follow up visit in one week with an otorhinolaryngology specialist (doctor who specializes in in care of the ears, nose, and throat). According to a review of Resident 2's Progress Notes dated 7/5/2021 at 4:48 p.m., Resident 2 returned to the facility at 12 p.m., from GACH 1, in fair condition with two stitches on the right upper lip and right nares, and a swollen upper palate and lip. A review of Resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Admission Record (Face Sheet) indicated the facility originally admitted the resident, a [AGE] year-old male, on 6/24/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 did not have a family member or other responsible party, or emergency contact listed in the face sheet. A review of Resident 1's admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician did not order [CONDITION(S)] medications. A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a review of Resident 1's Psychosocial Care Plan developed on 6/28/2021, for the resident's misdirected anger and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included psychiatric consult; assessing for negative emotions, anger, anxiety, and depression; providing emotional support; encouraging expression of feelings; and providing education to the resident and staff about special care needs. A review of Resident 1's SBAR form, dated 6/29/2021 (four days after admission), indicated Resident 1 had a change in behavior in which he denied staff entrance to his room, where he resided with Resident 3. A review of Resident 1's Social Services Progress Note, dated 6/29/2021, indicated Social Services Director 1 (SSD 1) tried to interview Resident 1 and get inside Resident 1's room, but the resident placed something to block the door. SSD 1 explained to Resident 1 he wanted to interview him, and he could not block the door for his safety, but Resident 1 started to get agitated and stated, I will call the police, I don't want to talk to you. A review of Resident 1's MDS, dated [DATE], indicated Resident 1 had moderately impaired cognition, was experiencing symptoms of depression such as feeling down, depressed or hopeless, and had little interest or pleasure in doing things nearly every day. Resident 1 did not hallucinate (sensory experiences that appear real but are created by the person's mind), did not manifest physical, verbal, or other behavior symptoms directed towards others, was not receiving antipsychotic medications (used to control behavioral symptoms), and was not on antidepressant medications (used to reduce symptoms of depression). Resident 1 required limited to extensive assistance with ADLs. A review of Resident 1's Care Conference notes, dated 7/1/2021, indicated an Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) meeting was held with Resident 1 to discuss respecting his new roommate and facility rules. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .). According to a review of Resident 1's SBAR, dated 7/5/2021, Resident 1 assaulted his roommate (Resident 2) using a table at 12:55 a.m. Resident 2 was in bed. When asked the reason for hitting the roommate, Resident 1 stated, It's self-defense, he stole my credit card. Resident 2 had a bleeding cut on the left side of the nose measuring 3.5 centimeters (cm) in length and skin discoloration to both arms. Resident 2 was asked what happened and stated, I don't know, I was just sleeping when he hit me. The paramedics and police were called. A review of Resident 1's Progress Notes dated 7/5/2021 at 3:49 a.m., indicated the police took Resident 1 in his wheelchair and he was refusing to go with the officers. On 7/15/2021 at 6:30 a.m., during an observation and concurrent interview, Resident 2 had bruises on the left eye, left arm, left hand, missing teeth, and a laceration to his lip and left nose. Resident 2 stated, It happened (on 7/5/2021) after midnight. He (Resident 1) came to my side, took the table, and threw it. I woke to the blow on my face. I was disoriented and the table broke. Nine of my teeth broke, my nose was detached from my face. Nurses heard the noise and came to my room and rescued me. I was profusely bleeding. There was no reason to attack me, I never had an argument with him. Resident 2 further stated, Sometimes I can't sleep at night, because I'm traumatized, I get scared especially at night. During an interview on 7/15/2021 at 6:20 a.m., Registered Nurse Supervisor (RN 1) stated the incident happened on 7/5/2021 at 12:55 a.m. The Charge Nurse heard something and went to see what it was. The Charge Nurse found Resident 1 holding a piece of wood from a bedside table. Both RN 1 and the Charge Nurse saw Resident 2 with blood all over his face and moved Resident 2 out of the room. The Charge Nurse called the paramedics and the police. The paramedics took Resident 2 to GACH 1. The police left with Resident 1 at 4:30 a.m. and Resident 1 did not return to the facility. On 7/15/2021 at 7:50 a.m., during an interview, Director of Nursing 1 (DON 1) stated on 6/29/2021, Resident 3 touched Resident 1's wheelchair which made him upset so Resident 1 tried to block the door to their room with his wheelchair. On 8/17/2021 at 10 a.m., during an interview, Licensed Vocational Nurse (LVN 2) stated he was the Charge Nurse on the night of the incident (7/5/2021) between Residents 1 and 2. LVN 2 stated, that around 12:45 a.m. he heard three loud sounds. He ran to where the sound came from and saw Resident 1 in the room holding the top of a bedside table and Resident 2 was in bed with blood all over his face. Resident 1 stated, Why did you take my credit card. LVN 2 told Resident 1 to stay where he was and got Resident 2 out of the room and called 911. The police took Resident 1. During an interview on 8/17/2021 at 4:29 p.m., Resident 2's attending physician (MD 1) stated the psychiatrist evaluation and consult were part of the routine orders and the nurses can use them in case a resident needs it. MD 1 stated Resident 1 would have benefited from a psychiatric evaluation and treatment. On 8/18/2021 at 10:15 a.m., during an interview, Resident 3's family member (FM 1) stated he remembered Resident 1 being Resident 3's previous roommate and Resident 3 was moved to another room because Resident 1 was aggressive and was yelling. FM 1 stated one day Resident 1 blocked with a wheelchair the door to prevent people from entering the room. Resident 1 started yelling, You're harassing me, I'm going to call the police, when he barely opened the door and moved the wheelchair to the side. FM 1 stated FM 2 went to visit Resident 3 the next day and Resident 1 did the same thing. Resident 1 screamed he was being harassed and threatened that his personal property or belongings could not be touched. On 8/19/2021 at 11:19 a.m., during an interview with SSD 2 and concurrent review of Resident 1's social services documentation, SSD 2 stated that for all admitted residents social services staff performed an initial screening/assessment which included psychosocial evaluation, mood, and behavioral symptoms. The initial social service assessment helped to evaluate if the resident needed psych evaluation. SSD 2 was unable to find Resident 1's initial social service assessment and confirmed the social service psychosocial evaluation was not done. During an interview with DON 2 on 8/19/2021 at 11:30 a.m., and a concurrent review of Resident 1's IDT meetings, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON 2 acknowledged Resident 1 did not receive psychiatric evaluation and treatment as ordered and as needed due to his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/20/2021 at 2:27 PM, during and interview and concurrent review of Resident 2 admitted to the facility, DON 1 stated Resident 2 was readmitted to the facility on [DATE] into Resident 1's room because he was past the number of days for a bed hold (a reservation that allows a resident to stay in, or return to, a care facility) and could not return to his previous room. A review of the facility's policy and procedures on Resident-to-Resident Altercations, revised 11/1/2015, indicated the facility acts promptly and conscientiously to prevent and address altercations between residents. Facility staff observes residents for aggressive or inappropriate behavior toward other residents, family members, visitors, or facility staff. Any occurrences of such behavior are promptly reported to the Charge Nurse, the Director of Nursing Services, and the Administrator. Response to an altercation: Separate the residents, and institute measures to calm the situation. Determine what happened, including what might have led to aggressive conduct on the part of one or more of the residents involved in the altercation. Notify each resident's representative and Attending Physician of the incident. Review the events with the Charge Nurse and Director of Nursing Services, including interventions staff can take to prevent additional incidents. Consult with the Attending Physician to identify treatable conditions such as [CONDITION(S)] that may have caused to contributed to the problem. Make necessary changes in the Care Plan for any or all of the involved residents as necessary. Document interventions and their effectiveness in the resident's medical record. Consult with psychiatric or psychological services as needed for assistance in assessing the resident, identifying causes, and developing a Care Plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Team. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident. A review of the facility's policy and procedures on Interdisciplinary (IDT) Skilled Review, revised 9/5/2017, indicated upon admission, an Admission Skill Meeting form will be initiated. Within 72 hours, the IDT will gather information from the resident, responsible party, or significant other regarding expectations, discharge plans, and goals, etc. The resident's admission baseline status or usual performance will be obtained and documented on AP-23-Form B as based on assessment which includes observation, data collection, etc. A review of the facility's policy and procedures on Social Service Assessment, revised 12/1/2013, indicated the Director of Social Services or designee will complete a Social Service Assessment for new and readmitted residents with seven (7) days of admission. The Social Services Assessment will address the resident's physical and psychosocial needs that should be considered in developing the resident's plan of care. A review of the facility's policy and procedures on Comprehensive Person-Centered Care Planning, revised 11/2018, indicated the facility was to provide person-centered, comprehensive, and interdisciplinary care that reflect best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents to obtain or maintain the highest physical, mental, and psychosocial well-being. A baseline care plan will be initiated upon admission by the admitting nurse using the necessary combination of problem specific care plans to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Affected individuals may have grandiose delusions [strong beliefs of things that are untrue], associated with protecting themselves from the perceived plot) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), was provided with the necessary behavioral health care as indicated in the plan of care. The facility failed to: -Provide Resident 1 with a psychiatrist (medical practitioner specializing in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -Monitor Resident 1 for mood and behavior symptoms that posed a threat to self and others. -Provide Resident 1 with emotional support as indicated in the resident's care plan, -Discuss with the attending physician and the psychiatrist the lack of [CONDITION(S)] medications (any drug capable of affecting the mind, emotions, and behavior) to treat the resident's mental illnesses and behavioral manifestations. -Evaluate Resident 2's safety when it was decided to place him in the same room upon re-admission and after Resident 1 became protective of his room preventing entry of staff which resulted in moving out Resident 3 from Resident 1's room. -Ensure Social Services Director (SSD) or designee completed a psychosocial evaluation for Resident 1 within seven days from admission as per facility's policy. -Ensure the interdisciplinary team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) met within 72 hours from Resident 1's admission to evaluate his care needs as per facility's policy. As a result, on 7/5/2021 at 12:55 a.m., Resident 1 hit with a table Resident 2's face and arms, while Resident 2 was in bed. Resident 2 required emergency transfer to general acute care hospital 1 (GACH 1), where he was diagnosed with broken facial bones, broken teeth, left facial hematoma (collection of blood), swelling and laceration (deep cut or tear in the skin) to the left side of the face. Resident 2 stated fell ing traumatized, frightened at night, and having difficulty to sleep. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility originally admitted the resident, a [AGE] year-old male, on 6/24/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 did not have a family member or other responsible party, or emergency contact listed in the face sheet. A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Psychosocial Care Plan developed on 6/28/2021, for the resident's misdirected anger and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included psychiatric consult; assessing for negative emotions, anger, anxiety, and depression; providing emotional support; encouraging expression of feelings; and providing education to the resident and staff about special care needs. According to a review of Resident 1's SBAR form (Situation, Background, Assessment, Recommendation - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident), dated 6/29/2021 (four days after admission), Resident 1 had a change in behavior in which he denied staff entrance to his room, where he resided with Resident 3. A review of Resident 1's Social Services Progress Note, dated 6/29/2021, indicated SSD 1 tried to interview Resident 1 and get inside Resident 1's room, but the resident placed something to block the door. SSD 1 explained to Resident 1 he wanted to interview him, and that he could not block the door for his safety, but Resident 1 started to get agitated and stated, I will call the police, I don't want to talk to you. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 7/1/2021, indicated Resident 1 had moderately impaired cognition, was experiencing symptoms of depression such as feeling down, depressed or hopeless, and had little interest or pleasure in doing things nearly every day. Resident 1 did not hallucinate (sensory experiences that appear real but are created by the person's mind), did not manifest physical, verbal, or other behavior symptoms directed towards others, was not receiving antipsychotic medications (used to control behavioral symptoms), and was not on antidepressant medications (used to reduce symptoms of depression). Resident 1 required limited to extensive assistance with activities of daily living (ADLs, such as walking, dressing, locomotion, and personal hygiene). A review of the facility's Census Report dated 7/1/2021 indicated Resident 2, was readmitted on [DATE] and placed in Resident 1's room (which was a different room from Resident 2's previous stay). Resident 3 had been moved to another room. A review of Resident 1's Care Conference notes, dated 7/1/2021, indicated an Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) meeting was held with Resident 1 to discuss respecting his new roommate and facility rules. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .). According to a review of Resident 1's SBAR dated 7/5/2021, Resident 1 assaulted his roommate (Resident 2) using a table at 12:55 a.m. Resident 2 was in bed. When asked the reason for hitting the roommate, Resident 1 stated, It's self-defense, he stole my credit card. Resident 2 had a bleeding cut on the left side of the nose measuring 3.5 centimeters (cm) in length and skin discoloration to both arms. Resident 2 was asked what happened and stated, I don't know, I was just sleeping when he hit me. The paramedics and police were called. A review of Resident 1's Progress Notes dated 7/5/2021 at 3:49 a.m., indicated the police took Resident 1 in his wheelchair and he was refusing to go with the officers. A review of Resident 2's Admission Record indicated the facility admitted the resident, a [AGE] year-old male on 6/29/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's Admission Nursing Notes, dated 6/29/2021, indicated the resident was alert and oriented to person, place, and time; and required extensive assistance with activities of daily living (ADLs such as walking, dressing, locomotion, and personal hygiene). A review of Resident 2's SBAR dated 7/5/2021, indicated Resident 2 was assaulted by his roommate (Resident 1) at 12:55 a.m. Resident 1 hit Resident 2 on the face, head, and arms. Resident 2 had a cut on the left side of the nose measuring 3.5 cm with blood noted flowing out of the cut and had discoloration to both arms. Resident 2 was removed from the room and placed near Nurses' Station 1. Paramedics were called and took Resident 2 to GACH 1. According to a review of Resident 2's After Visit Summary from GACH 1, dated 7/5/2021, Resident 2 had computerized tomography scans (CT scans - a series of X-ray images taken by computers to create more detailed images of bones, blood vessels, and tissues inside the body) of his head. The CT scans indicated Resident 2 had broken facial bones, broken teeth, left facial hematoma, swelling to the left side of the face, and a laceration to the left side of the face. Resident 2 was discharged back to the facility with antibiotic and follow up visit in one week with an otorhinolaryngology specialist (doctor who specializes in in care of the ears, nose, and throat). A review of Resident 2's Progress Notes dated 7/5/2021 at 4:48 p.m., indicated Resident 2 returned to the facility at 12 p.m., from GACH 1, in fair condition with two stitches on the right upper lip and right nares, and a swollen upper palate and lip. A review of Resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/15/2021 at 6:20 a.m., during an interview, Registered Nurse Supervisor (RN 1) stated the incident happened on 7/5/2021 at 12:55 a.m. The Charge Nurse heard something and went to see what it was. The Charge Nurse found Resident 1 holding a piece of wood from a bedside table. Both RN 1 and the Charge Nurse saw Resident 2 with blood all over his face and moved Resident 2 out of the room. The Charge Nurse called the paramedics and the police. Paramedics took Resident 2 to GACH 1. The police left with Resident 1 at 4:30 a.m. and Resident 1 did not return to the facility. On 7/15/2021 at 6:30 a.m., during an observation and concurrent interview, Resident 2 had bruises on the left eye, left arm, left hand, missing teeth, and a laceration to his lip and left nose. Resident 2 stated, It happened (on 7/5/2021) after midnight. He (Resident 1) came to my side, took the table, and threw it. I woke to the blow on my face. I was disoriented and the table broke. Nine of my teeth broke, my nose was detached from my face. Nurses heard the noise and came to my room and rescued me. I was profusely bleeding. There was no reason to attack me, I never had an argument with him. Resident 2 further stated, Sometimes I can't sleep at night, because I'm traumatized, I get scared especially at night. During an interview on 7/15/2021 at 7:50 a.m., Director of Nursing 1 (DON 1) stated on 6/29/2021, Resident 3 touched Resident 1's wheelchair which made him upset so Resident 1 tried to block the door to their room with his wheelchair. On 8/17/2021 at 10 a.m., during an interview, Licensed Vocational Nurse (LVN 2) stated he was the Charge Nurse on the night of the incident (7/5/2021) between Residents 1 and 2. LVN 2 stated, that around 12:45 a.m. he heard three loud sounds. He ran to where the sound came from and saw Resident 1 in the room holding the top of a bedside table and Resident 2 was in bed with blood all over his face. Resident 1 stated, Why did you take my credit card. LVN 2 told Resident 1 to stay where he was and got Resident 2 out of the room and called 911. The police took Resident 1. On 8/17/2021 at 4:29 p.m., during an interview, Resident 2's attending physician (MD 1) stated psychiatrist evaluation and consult were part of the routine orders and the nurses can use them in case a resident needs it. MD 1 stated Resident 1 would have benefited from a psychiatric evaluation and treatment. On 8/18/2021 at 10:15 a.m., during an interview, Resident 3's family member (FM 1) stated he remembered Resident 1 being Resident 3's previous roommate and Resident 3 was moved to another room because Resident 1 was aggressive and was yelling. FM 1 stated one day Resident 1 blocked with a wheelchair the door to prevent people from entering the room. Resident 1 started yelling, You're harassing me, I'm going to call the police, when he barely opened the door and moved the wheelchair to the side. FM 1 stated FM 2 went to visit Resident 3 the next day and Resident 1 did the same thing. Resident 1 screamed he was being harassed and threatened that his personal property or belongings could not be touched. During an interview with SSD 2 on 8/19/2021 at 11:19 a.m., and concurrent review of Resident 1's social services documentation, SSD 2 stated that for all admitted residents social services staff performed an initial screening/assessment which included psychosocial evaluation, mood, and behavioral symptoms. The initial social service assessment helped to evaluate if the resident needed psych evaluation. SSD 2 was unable to find Resident 1's initial social service assessment and confirmed the social service psychosocial evaluation was not done. On 8/19/2021 at 11:30 a.m., during an interview with DON 2 and a concurrent review of Resident 1's IDT meetings, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON 2 acknowledged Resident 1 did not receive psychiatric evaluation and treatment as ordered and as needed due to his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/20/2021 at 2:27 p.m., during and interview and concurrent review of Resident 2's admitted to the facility, DON 1 stated Resident 2 was readmitted to the facility on [DATE] into Resident 1's room because he was past the seven-day bed hold (Medical pays the facility for holding the bed to allow a resident to return to the same bed occupied before a temporary hospitalization ). A review of the facility's policy and procedures on Interdisciplinary (IDT) Skilled Review, revised 9/5/2017, indicated upon admission, an Admission Skill Meeting form will be initiated. Within 72 hours, the IDT will gather information from the resident, responsible party, or significant other regarding expectations, discharge plans, and goals, etc. The resident's admission baseline status or usual performance will be obtained and documented on AP-23-Form B as based on assessment which includes observation, data collection, etc. A review of the facility's policy and procedures on Social Service Assessment, revised 12/1/2013, indicated the Director of Social Services or designee will complete a Social Service Assessment for new and readmitted residents with seven (7) days of admission. The Social Services Assessment will address the resident's physical and psychosocial needs that should be considered in developing the resident's plan of care. A review of the facility's policy and procedures on Comprehensive Person-Centered Care Planning, revised 11/2018, indicated the facility was to provide person-centered, comprehensive, and interdisciplinary care that reflect best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents to obtain or maintain the highest physical, mental, and psychosocial well-being. A baseline care plan will be initiated upon admission by the admitting nurse using the necessary combination of problem specific care plans to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission.

Based on interview and record review, the facility failed to identify and evaluate accident risks and provide a safe environment to prevent accidents and injuries for one of two sampled residents (Resident 1). For Resident 1, who was diagnosed with dementia (a chronic disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes and impaired reasoning) and assessed as high fall risk, the facility failed to develop an initial care plan with adequate interventions to address Resident 1's risk for fall and failed to monitor the resident every shift for 72 hours, per the care plan interventions. These deficient practices resulted in Resident 1 screaming for help after she suffered a fall on 2/13/2021 at 11:30 p.m. Resident 1 was transferred to the General Acute Care Hospital (GACH) 1 where she was diagnosed with a commuted right radial fracture (broken wrist bone into more than two pieces). Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] disorder (mental disorder characterized by abnormal thought processes and unstable mood), anxiety, dementia, and depression. A review of the Fall Risk assessment dated [DATE], indicated Resident 1 had a total score of 65 and was a high fall risk. The assessment did not indicate what score represented a low or moderate fall risk, as the ranges were not included. The fall risk assessment indicated Resident 1 had a secondary diagnosis, which was not documented, that Resident 1 used an ambulatory aid (crutches, cane or walker), gait was impaired, and the resident forgets limitations. The fall risk assessment indicated to implement fall prevention interventions. The Fall Risk Assessment did not include the medications administered to Resident 1, such as the antipsychotic or the antidepressant which would change Resident 1's fall risk total score. A review of the Care Plan for fall, dated 11/14/2020, indicated Resident 1 had limitations in functional mobility needing assistance from staff, memory problems, and complex medical diagnoses. The care plan goal indicated the risk for fall will be minimized for 90 days and the interventions included to monitor for side effects of medication (the care plan did not indicate which medication). The interventions also indicated to remind resident to use the call light and to report side effects to the physician. A review of the Minimum Data Set (MDS, standardized care and screening tool) dated 11/20/2020 indicated Resident 1 was totally dependent with one person assist for transfer and toilet use. The MDS indicated Resident 1 was not steady while moving from seated to standing position or while walking. A review of the Physician's Order Summary Report for 2/2021, indicated Resident 1 received [MEDICATION(S)] ([MEDICATION(S)], antidepressant medication) 25 milligram (mg.), one tablet by mouth at bedtime, for depression. Resident 1 also received [MEDICATION(S)] ([MEDICATION(S)], antipsychotic medication) 25 mg, one tablet by mouth at bedtime, for [CONDITION(S)] disorder. A review of the psychiatrist's Patient Visit Information Notes, dated 2/9/2021, indicated Resident 1 reported feeling very anxious, not sleeping at night and very restless in bed. Resident 1 complained of feeling sad about recent physical health decline. The Notes indicated the [MEDICATION(S)] was increased from 25 mg to 50 mg orally daily. The Notes also indicated to give [MEDICATION(S)] 25 mg in the morning and 50 mg at night orally as mood stabilizer for [CONDITION(S)] disorder (a person's mood changes from a depressed feeling to a high manic feeling or vice versa). A review of the Care Plan dated 2/10/2021 indicated Resident 1's [MEDICATION(S)] and [MEDICATION(S)] had a dosage increase. The care plan goal indicated Resident 1 will have no complications and will minimize risk for further decline in condition. The care plan interventions included to assess Resident 1 for pain every shift, monitor vital signs every shift for 72 hours, notify the physician and family representative of changes as appropriate. According to a review of the Nurse's Drug Guide, 2017, the side effects for [MEDICATION(S)] included dizziness, [CONDITION(S)] (low blood pressure), somnolence (sleepiness), and a sudden change in heart rate and blood pressure when rising too quickly from a sitting or lying position. A review of the Nurse's Drug Guide 2017 indicated the side effects of [MEDICATION(S)] included dizziness, somnolence, [CONDITION(S)] (low blood pressure). A review of Resident 1's Care Plan for lorazepam ([MEDICATION(S)]- antianxiety medication), dated 2/12/2021, indicated Resident 1 had a new order for [MEDICATION(S)] one mg, one tablet as needed for 14 days by mouth at bedtime for anxiety. The Care Plan goal indicated Resident 1 will have no complications and will minimize risk for further decline. The care plan interventions included to monitor for pain every shift, to monitor vital signs for 72 hours, observe Resident 1 every shift for 72 hours. A review of the Nurse's Drug Guide, 2017 indicated [MEDICATION(S)]'s most common side effects included drowsiness, sedation and weakness, dizziness, and unsteadiness. A review of the Medication Administration Record (MAR) dated February 2021, indicated Resident 1 was given [MEDICATION(S)] 25 mg. one tablet at 9 a.m. and 50 mg one tablet at 9 p.m., on 2/10/21, 2/11/21, 2/12/21 and 2/13/21. Resident 1 was also administered [MEDICATION(S)] 50m from 2/10 - 2/13/21 every morning. A review of the MAR indicated Resident 1 was administered [MEDICATION(S)] one mg., as needed for anxiety on 2/12/21. A review of the Progress Notes, dated 2/13/2021 at 9:57 p.m., indicated Resident 1 was noted with drowsiness, and sleeping more than usual. The Progress Notes indicated Resident 1's psychiatrist was notified and awaiting return call. A review of the Progress Notes dated 2/14/2021 at 2:18 a.m., indicated on 2/13/2021 at 11:30 p.m., Resident 1 was observed to be asleep. At 11:40 p.m., Resident 1 was overheard screaming for help and was found on the floor, prone position with legs bent and right arm positioned in her back. The Progress Note indicated Resident 1 stated she was in a hurry to get up to go to the bathroom. Resident 1 stated she lost her balance and fell . Resident 1 complained of pain on the right wrist with pain rated at a score of eight out of 10 (using a scale of zero to 10, zero indicated no pain and 10 indicated the worst possible pain). Resident 1's primary physician was notified and gave an order to transfer Resident 1 to the general acute care hospital emergency (GACH 1 ER) by regular ambulance. A review of the GACH 1 ER Report, dated 2/14/2021, indicated Resident 1's right upper extremity with deformity and swelling to distal forearm with tenderness to right elbow, forearm, wrist and hand. The X-ray report indicated Resident 1 sustained comminuted (bone was broken into more than two pieces), impacted distal right radial fracture (break in the bone that occurs near the wrist) with intra articular extension of the right arm (fracture of the wrist joint). Closed reduction (set a broken bone without surgery) was performed and a splint (a medical device that heals the fractured bones by keeping the broken ends together and in alignment) was applied. During an interview on 3/2/2021 at 9:50 a.m., Resident 1 stated she had a fall and broke her arm. Resident 1 stated she was right-handed, unable to use her right arm, and that she suffered occasional pain. During a telephone interview and concurrent record review, on 3/31/2021 at 2:20 pm, Resident 1's Progress Notes were reviewed. Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's vital signs were not obtained on 2/10, 2/11, or 2/12/2021 during the night shift and the vital signs were not obtained on 2/13/21 during the morning and afternoon shift. LVN 1 stated the vital signs should be done for 72 hours, per Resident 1's Care Plan. During a telephone interview on 4/2/2021 at 4:14 p.m., the facility Pharmacist stated the most common side effects of [MEDICATION(S)] and [MEDICATION(S)] were dizziness and [CONDITION(S)]. The Pharmacist stated taking Resident 1's vital signs would help determine the side effects of the medications. During a telephone interview on 4/5/2021 at 2:26 p.m., the interim DON stated there was no monitoring for the side effects of the [MEDICATION(S)], such as drowsiness and change in cognition. On 4/7/2021 at 7:37 a.m., during a telephone interview, the interim director of nursing (DON) stated the vital signs should be taken because the [MEDICATION(S)], [MEDICATION(S)], and the [MEDICATION(S)] can change cognition (mental action of acquiring understanding), cause dizziness, low blood pressure, and can lower the heart rate. During an interview on 4/16/2021 at 1:30 p.m., Resident 1's Care Plan for fall, dated 11/14/2020 was reviewed with the director of staff development (DSD). The Care Plan indicated Resident 1 was at risk for fall related to limitation in functional mobility needing assistance from staff, advancing age. The DSD stated Resident 1's use of [CONDITION(S)] medications should be included as one of the risk factors for fall. During a telephone interview, on 4/ 1, at 2:40 p.m., the DSD stated she did not see the correlation or the importance of having the intervention to monitor Resident1's pain every shift, for the [MEDICATION(S)], [MEDICATION(S)] or the [MEDICATION(S)] care plan. A review of the facility's policy titled, Fall Management Program, revised 8/21/2020, indicated the purpose was to provide residents a safe environment that minimizes complications associated with falls. The facility will implement a fall program that supports providing an environment free from fall hazards. The policy did not indicate Fall Prevention Interventions, as mentioned in the Fall Risk Assessment. A review of the facility policy titled, Behavior/Psychoactive Drug Management, revised 11/2018 indicated it was the policy of the facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standard of care, that reflects and provide a therapeutic environment that supports residents to obtain or maintain the highest physical, mental and psychosocial well-being. The policy indicated the resident should be observed for side effects and adverse consequences that would include: 1. General/anticholinergic (drugs used to treat a variety of medical conditions that affect the contraction and relaxation of muscles): constipation, blurred vision, dry mouth, [CONDITION(S)], sedation, 2. Cardiovascular side effects (relating to the heart) including orthostatic [CONDITION(S)] (when a blood pressure suddenly drops when standing up or sitting down), arrhythmia (heart beats with an irregular or abnormal rhythm) A review of the facility policy titled, Comprehensive Person-Centered Care Planning, revised 11/2018, indicated the facility would provide a person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial well-being. The policy indicated the baseline care plan must include the minimum healthcare information necessary to properly care for each resident specific health and safety concerns to prevent decline or injury and would identify needs for supervision, behavioral interventions and assistance with activities of daily living as necessary. All goals and objectives, interventions from current baseline care plan will be included in the resident's comprehensive care plan. A review of the facility's policy titled, Obtaining Vital Signs, revised 8/22/2019 indicated the purpose was to take clinical measurements that indicate the state of a resident's basic body functions. Vital [NAME] are take as appropriate (including temperature, blood pressure, pulse and respiration rate). Vital signs will be taken when there was a change in the resident's condition and every shift for 72 hours after an incident.

Based on observation, interview, and record review, the facility failed to ensure two of nine sampled residents (Residents 1 and 5) was provided with adequate supervision and the facility remain free of accident hazards by checking the food temperature including hot tea as indicated in the facility's policy. Resident 1, who had poor safety awareness was found on 3/15/18 at 11 p.m., at the back of the facility, alley. Resident 1 had unwitnessed fall, down six flight of stairs resulted to a closed head injury (a type of [MEDICAL CONDITION]), multiple skin tears to the left upper extremity and was diagnosed with [REDACTED]. Resident 5 was served hot tea without ensuring it was not at scalding temperature. As a result, on 4/18/16, Resident 5 sustained a 2.5 centimeters (cm) by 1.5 cm second-degree burn (blister) on the chest. Findings: On 4/18/17, at 12:10 p.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care. A review of the admission record indicated Resident 1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Care Plan for fall risk dated 1/21/16 due to resident poor safety awareness and weakness. The interventions included assist Resident 1 with transfers and mobility and keep the resident in frequent monitored areas. A review of Resident 1's Minimum Data Set (MDS- an assessment and care planning tool) dated 3/7/16, indicated the resident had unclear speech, had difficulty with communication, required extensive assistance with one-person physical with dressing, eating, personal hygiene, locomotion, and transfers (moves between bed, chair, standing position). Resident 1 required a wheelchair as mobility device. According to the Change of Condition assessment, dated 3/15/16, timed at 11 p.m., indicated Resident 1 was found on the floor after falling down six steps from the wheelchair, outside, at the back of the facility. Resident 1 sustained multiple skin tears and had a bump on the left side of the head with skin tear. Resident 1 was complaining of pain, guarding his right arm and grimacing and yelling with any attempt to move his right arm. The documentation indicated Resident 1 became drowsy, less active, and unresponsive and was sent to General Acute Care Hospital 1 (GACH 1). A review of GACH 1 Emergency Treatment Record, dated 3/16/16, indicated Resident 1, a [AGE] year-old male after falling down five steps, had a closed head injury (a type of [MEDICAL CONDITION]) and multiple skin tears to the left upper extremity. Resident 1 was diagnosed with [REDACTED]. Resident 1 was transferred back to the facility on [DATE]. On 4/18/18, at 12:30 p.m. during observation of the location where Resident 1 was found on the floor after falling with his wheelchair six flight of stairs, the stairs was at the back of the facility that goes to an alley. On 4/18/18, at 3:25 p.m., during an interview, the Administrator stated there was no investigation as of why Resident 1 was outside the facility on that area (facility alley) without supervision on 3/15/18 at 11 p.m. A review of the facility's policy titled, Fall Management Program, revised 11/7/16, indicated after a fall, the interdisciplinary team (IDT) will initiate an investigation and will summarize conclusions and the care plan will be revised in an effort to prevent further falls. b. A review of Resident 5's admission record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated Resident 5 was able to communicate, had no memory problem, required supervision from staff with eating, and extensive assistance with dressing and toilet use. A review of the Situation Background Assessment Results (SBAR) / Change of Condition (C[NAME]) assessment dated [DATE] indicated Resident 5 was in the dining area for activities and received hot tea. Resident 5 took a sip of tea and spit scalding tea onto her chest causing a burn, measured 2.5 centimeters (cm) by 1.5 cm that became a blister (second-degree burn). A review of the physician's orders [REDACTED]. A review of the 4/2016 treatment record indicated Resident 5 received [MEDICATION NAME] cream treatment daily for 10 days until the blister resolved. During an interview with the Activities Director (AD), on 6/28/18, at 12:50 p.m., the AD stated the kitchen brings coffee and hot water for tea, to be served to residents while in the morning activities. The AD stated she observes the steam to determine the temperature of the liquids before serving coffee / tea to a resident. During an interview with the Administrator, on 6/29/18 at 2:21 p.m. he stated He did not remember Resident 5 sustaining a burn to the chest area. He also stated there was no investigation done regarding the incident. The facility policy Food Temperatures, date revised (MONTH) 1, 2014, indicated that foods prepared and served in the facility would be served at proper temperatures to ensure food safety. To measure food temperature, it is recommended to use a thermometer with a practical range of 0 degree Fahrenheit to 220 degree Fahrenheit. Coffee preferable temperature range 160-175 degree Fahrenheit. If temperatures do not meet applicable serving temperatures, reheat the product or chill the product to the proper temperature.

Based on interview and record review, the facility failed to ensure respiratory care needs were provided for one of nine sampled residents (Resident 8), including: 1. Failure to ensure Resident 8 receive consistent used of the [MEDICAL CONDITION] machine (a non-invasive machines for therapy for people with sleep apnea (a disorder in which breathing stops and starts repeatedly during sleep), [MEDICAL CONDITION] treatments are designed to keep the airway from collapsing and allow users to breathe easily and regularly during sleep) as ordered by the physician. 2. Failure to assessed and identify Resident 8 change of condition on [DATE], at 11 p.m. as manifested by low oxygen saturation (measures the percentage of oxygen in the bloodstream) level of 88 percent (%) (Normal range 95 - 100), restlessness and confusion and notify the medical doctor. 3. Failure to follow physician order [REDACTED]. As a result, on [DATE] at 4:24 a.m., Resident 8 was found on the floor, faced down and unresponsive. Cardiopulmonary Resuscitation (CPR - a medical technique for reviving someone whose heart has stopped beating by pressing on their chest and breathing into their mouth) was initiated and paramedics were called. The paramedics arrived and pronounced Resident 8 dead at 4:49 a.m. Resident 8's Death Certificate indicated resident cause of death acute [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). Findings: A review of Resident 8's Admission Record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 8's Minimum Data Set (MDS - standardized assessment and care-planning tool), dated [DATE], indicated the resident had clear speech, had the ability to express ideas and wants, was able to understand others, required extensive assistance from staff with transfer from bed to chair, dressing, and personal hygiene. A review of the physician's orders [REDACTED]. On the same date, another order for [MEDICAL CONDITION] as needed with settings of FIO2 40%, ,[DATE]. A review of Resident 8 physician's orders [REDACTED].) to keep saturation (measures the percentage of oxygen in the bloodstream) above 93 percent, monitor and record oxygen saturation every shift. According to Resident 8's Clinical Nursing Notes, dated [DATE], at 10:20 p.m., [DATE] at 11:07 p.m., and [DATE] at 10:14 p.m., Resident 8 was receiving oxygen at two liters per minute (L/min) via nasal cannula with head of bed elevated. There was no documentation of used of the [MEDICAL CONDITION] machine. On [DATE] at 3:10 p.m., a review of Resident 8's clinical record was conducted with the Medical Records Director (MRD). The MRD was unable to find the ,[DATE] Treatment Administration Record to determine if Resident 8 received the [MEDICAL CONDITION] as ordered. A review of the ,[DATE] Treatment Administration Record indicated Resident 8 was applied the [MEDICAL CONDITION] machine on ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. A review of Resident 8's Nursing Notes dated [DATE], timed at 2:41 a.m. indicated Resident 8 had episodes of confusion with oxygen at 2 L/min via nasal cannula. There was no documentation addressing the [MEDICAL CONDITION] machine use. The note added Resident 8 wanted the police to come to the facility to check the oxygen (confusion). According to Resident 8's Nursing Notes dated [DATE], at 11 p.m., Resident 8 had an oxygen saturation of 88% (normal range 95 - 100). Resident 8 was sitting at the edge of the bed with no oxygen in place. The licensed nurse put oxygen and repositioned Resident 8. A review of nursing note entries indicated Resident 8 was again sitting up and removing his oxygen nasal cannula (restless), and the nurse was redirecting Resident 8 to lay down. There was no documented evidence the resident's oxygen saturation level was re-check. A review of Resident 8's Nursing Notes dated [DATE], timed at 4:24 a.m., indicated Resident 8 was found on the floor, faced down and unresponsive. Cardiopulmonary Resuscitation was initiated and paramedics were called. The paramedics arrived and pronounced Resident 8 dead at 4:49 a.m. A review of Resident 8's Nursing Notes, from [DATE] through [DATE], indicated, Resident 8's attending physician was not notified regarding Resident 8's increasing restlessness, agitation, and confusion. A review of Resident 8's Death Certificate indicated Resident 8 died on [DATE] at 4:49 a.m. from acute [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). During an interview with the current Administrator, on [DATE], at 12:40 p.m., he stated staff were looking for Resident 8's clinical record and found some parts of the record (computer documentation); however, they were unable to locate the Treatment Administration Record for ,[DATE]. The facility policy titled, Oxygen Therapy, revised (MONTH) (YEAR), indicated oxygen was administered under safe and sanitary conditions to meet resident needs. Licensed nursing staff would administer oxygen as prescribed. Staff would be provided in-service on appropriate administration and safe handling of oxygen equipment and supplies on hire and annually.

Based on observation, interview, and record review, the facility failed to implement their abuse policy and procedure, thoroughly investigate and protect residents from abuse for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1's feelings being hurt and caused him to become angry. Findings: A review of the Admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a comprehensive assessment tool and care-screening tool) dated 4/16/17 indicated Resident 1 had moderate cognitive impairment (a decline in decision making abilities) and required extensive assistance with personal hygiene and toilet use. During an interview on 5/9/17 at 2:20 p.m., Resident 1 stated on 4/4/17 at 9:30 p.m., when Certified Nurse Assistant (CNA 1) removed his wet gown and diaper, CNA 1 threw the wet diaper and a clean gown in his face. Resident 1 stated he felt really hurt and waited until he saw the administrator to report the incident. During an interview on 5/9/17 at 3:15 p.m., CNA 1 stated on 5/5/17, the administrator contacted her by phone about an abuse allegation regarding Resident 1 that occurred on May 4, 2017. CNA 1 stated on 5/4/17 around 9:30 p.m., upon entering Resident 1's room, she saw a wet diaper on the floor, picked up the diaper and placed the diaper in the dirty hamper. CNA 1 denied throwing a diaper in the resident's face. CNA 1 further stated that she was not assigned to Resident 1 on 5/8/17 and 5/9/17 because the Administrator had made changes on the CNA assignment. During an interview on 5/9/17 at 3:20 p.m., the Director of Staff Development (DSD) stated for any form of abuse allegation, the perpetrator is suspended immediately from work pending investigations. The DSD further stated CNA 1 never had any disciplinary write ups, was well liked by the residents who would always request for CNA 1 to care for them. During a concurrent interview and record review on 5/9/17 at 3:40 p.m., the administrator stated on 5/5/17 between 11:30 a.m., and 12:00 p.m., Resident 1 approached him and the Director of Nursing (DON) and stated CNA 1 threw a wet diaper in his face. The Administrator further stated CNA 1 was not suspended after the abuse allegation due to the CNA's minimal wages, he thought it was not right to suspend CNA 1 and this would have resulted in a staffing shortage. During a telephone interview on 5/10/17 at 3:30 p.m., the Administrator stated only four residents had been interviewed and no staff members were interviewed following the abuse allegation and there were no complaints from other residents regarding CNA 1. The Administrator did not provide an explanation of why he had not interviewed any other CNAs regarding the allegation of abuse. A review of the facility's policy titled Abuse Reporting and Investigation dated 11/2016 indicated the facility promptly investigates reports of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property, or injuries of unknown source when appropriate. The policy further indicated if the suspected perpetrator is an employee, to remove the employee immediately from care of the resident(s) and immediately suspend the employee pending the outcome of the investigation. During a review of CNA's employee record the Background Screening Report dated 9/30/15, indicated on 1/02/08, CNA 1 had a misdemeanor charge for disturbing the peace, fighting, loud noise, or offensive words in public.

Based on observation, interview and record review, the facility failed to ensure Resident A, who was assessed as requiring staff supervision for safety while smoking, was supervised while she was smoking on the patio, as indicated in her care plan. Resident A, who was not supervised while smoking a cigarette on the patio, dropped her cigarette lighter, and when she reached to get it, she fell from her wheelchair and sustained an abrasion (scraped area of skin) over her left eyebrow, with swelling. Findings: The Department received an entity reported incident (ERI CA 665) on July 20, 2012, regarding a resident falling out of her wheelchair while smoking. On August 14, 2012, at 7:45 a.m., an unannounced visit was conducted to investigate the resident's fall incident. Resident A was observed lying in bed with a green-tinted discoloration (appeared to be old bruising) to the left side of her face and next to her eye. During an interview with the resident, she stated when she was smoking on the patio (almost one month ago), she dropped her cigarette lighter, and when she attempted to pick it up, she slipped and fell . The clinical record for Resident A was reviewed on August 9, 2012. The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment and care screening tool, dated July 11, 2012, indicated the resident was moderately impaired in her cognitive skills for daily decision-making and had no behavioral problems. She required extensive assistance with two-persons physical assist with transfers (between surfaces including to or from bed, wheelchair, and a standing position). The MDS indicated the resident was not steady, only able to stabilize with staff assistance when moving from a seated position to a standing position. She required limited assistance with one person physical assist for eating (includes handling of utensils), and required extensive assistance with one person physical assist for personal hygiene (including combing hair, brushing teeth, applying makeup, and washing/drying the face and hands). The plan of care initiated June 30, 2012, indicated the resident required supervision/assistance with smoking due to being a risk for falls and/or poor safety awareness. Interventions included staff were "to provide smoking materials and supervision during smoking hours." A review of the undated Resident Smoking Assessment, indicated the resident needed to be supervised while smoking. The assessment indicated that smoking materials were to be secured at the nurses station, and safety measures required were for the resident to wear a smoking apron for safety, due to physical weakness/paralysis. A review of the Change of Condition assessment dated [DATE] at 9:20 p.m., indicated the resident was found on her left side lying next to her wheelchair outside of her room on the patio. The resident sustained [REDACTED]. An ice pack was applied to the left eyebrow to stop the bleeding and the physician was notified of the incident. There was no picture taken of the resident after the incident to show the extent of her injuries. A review of the facility's incident investigation dated July 18, 2012, indicated on July 18, 2012 at 9:18 p.m., Resident A stated she dropped her lighter and she leaned over to pick it up when she lost her balance and fell . The investigation indicated at 9:25 p.m., the licensed nurse assessed Resident A, noted blood to her left eye with swelling, that she almost was unable to open her eye. The physician was notified. When the paramedics arrived the resident refused to be transferred to the general acute care hospital (GACH). During an interview with Certified Nurse Assistance (CNA) 1 on August 9, 2012, at 3:10 p.m., he said he wheeled Resident A to the patio on July 18, 2012, at approximately 9:15 p.m. so she could smoke. CNA 1 left the resident sitting in her wheelchair alone on the patio. CNA 1 returned to the resident's room to remove the soiled linen from the room. He heard the resident calling out for help from the patio, and when he returned to the patio, he found the resident on the ground. CNA 1 stated he should not left the resident alone unsupervised on the patio while she was smoking. The facility policy and procedure titled "Smoking" dated August 12, 2008, indicated if a resident requires assistance and or monitoring for smoking safety, residents are not allowed to smoke unaccompanied.