Pacific Villa, Inc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff competency in cardiopulmonary resuscitation (CPR- emergency lifesaving procedure that is performed when someone's stopped breathing or heartbeat has stopped) for one of three reviewed staff members (CNA 2). The facility failed to:1.Ensure CNA 2 demonstrates the knowledge and skills necessary to perform CPR by obtaining Basic Life Support (BLS-verifies training in essential, life-saving techniques for healthcare professionals and first responders focusing on CPR ) certification that includes an online training and in-person skills demonstrations.The failure to ensure CNA 2 completed the required hands on CPR skills competency had the potential to result in CNA 2 performing CPR ineffectively during life threatening emergencies (dangerous or serious that it could kill or pose a very high risk of death if not handled or treated immediately) in the facility.Findings:During a concurrent interview and record review on [DATE] at 10:13 a.m. with the Director of Staff Development (DSD), CNA 2's Basic Life Support (BLS (BLS- trains participants to promptly recognize several life-threatening emergencies, give high-quality CPR, deliver appropriate breaths and provide early use of an automated defibrillator [AED used to treat sudden cardiac arrest by delivering a controlled electrical shock to restore a normal heart rhythm]) certificate and the facility's policy titled Cardiopulmonary Resuscitation were reviewed. The DSD stated CNA 2 completed an online-only BLS course, and she acknowledged that she had accepted the certificate at that time. The DSD stated the facility's policy requires CPR training to include hands on competency for BLS, and because CNA 2 did not complete an in person skills demonstration, she would not be competent to perform CPR during an emergency.During an interview on [DATE] at 2:08 p.m., with the Director of Nursing (DON), the DON stated CNAs obtaining BLS certification through online only courses could negatively impact resident care, as staff would be unable to perform proper CPR safely or respond appropriately during emergencies.During a review of facility's policy and procedure (P&P) titled, CPR, undated, the P&P indicated Facility's staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. The P&P indicated CPR certification which includes an online knowledge component still requires in-person skills demonstrations to obtain certification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Activity Assistant accurately documented on Activity Attendance Record provided for one of five sampled residents (Residents 63) in 2/12/2026,2/13/2026,2/14/2026 and 2/2/24/2026.This deficient practice had the potential for confusion in the care and services provided to Resident 63 and placed the resident at risk of not receiving appropriate care due to inaccurate and incomplete medical information.Findings:During review of Resident 63's admission Records, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), major depression ( mood disorder that causes a persistent feeling of sadness and loss of interest) and muscle weakness (loss of muscle strength).During a review of Resident 63's Minimum Data Set (MDS- resident assessment tool) dated 02/22/2026, the MDS indicated Resident 63's cognitive (ability to think, understand, learn, and remember) skills for daily decisions making was moderately impaired. The MDS indicated Resident 63 required setup or clean up assistance (helper set up or clean up; resident completes activity) from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a concurrent interview and record review on 02/26/2026 at 7:55 a.m. with the Activity Assistant (AA), Resident 63's Activity Attendance record was reviewed. The AA stated she did not know why the dates 2/12, 2/13, 2/14, and 02/24/2026 were not signed in the activity records. AA stated other activity staff sometimes assist with activities, and staff may have failed to sign the records. The AA stated she believed the activities were completed for Resident 63 on those dates. The AA stated if an activity was not recorded or documented, then it was considered not done. The AA stated failing to document accurately and timely prevent staff from knowing what activities were provided and when they were completed for Resident 63.During an interview on 02/27/2026 at 1:20 p.m. with the Director of Nursing (DON), the DON stated any activities completed for each resident must be documented to reflect that they were provided. The DON stated that all staff should know and understand the importance of documenting what was done, as documentation demonstrates the service was provided.During a review of the facility's policy and procedures (P&P) titled, Documentation, undated the P&P indicated Facility to maintain accurate, complete, and reliable documentation as part of the residents' medical records and designated service log. Staff are responsible for documenting service they personally provide in a clear, objective, and timely manner. The entry is completed and signed by the individual who provided the service.

Based on observation, interview and record review, the facility failed to observe infection control measures for 82 of 82 sampled residents. The facility failed to:1.Implement and document regular monitoring of water temperature for their water management plan ( a written safety plan that identifies, monitors, and controls water systems to prevent the growth of legionella bacteria[bacteria commonly found In water that can cause a severe type of pneumonia known as Legionnaires disease {[serious lung infection caused by legionella bacteria that grow in warm water}] ) designed to minimize growth and transmission of Legionella in the facility water systems.This failure had the potential of not detecting deviations in water temperature that can create conditions conducive to Legionella growth leading to an outbreak (occurs when two or more people get sick with Legionnaire's disease [serious lung infection caused by legionella bacteria that grow in warm water] from the same contaminated water source).2.Ensure dirty linens were placed in a plastic bag and plastic bags were closed securely before placing them in an open laundry bin intended for soiled linen outside the facility.This failure had the potential to cause cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) leading to spread of infection among the residents and staff. Findings:1.During an interview on 2/26/2026 at 11:28 a.m. with the Maintenance Supervisor (MS), the MS stated the facility checked the water temperature daily for Legionella in the resident's room, laundry and kitchen and documented in a log. MS stated the water temperature should be at 110 degrees Fahrenheit ( F- unit of measurement) to 115 degrees F. MS stated Assistant Maintenance had the binder for the water temperature log.During an interview on 2/26/2026 at 12:11 p.m. with the Assistant Maintence (AM), the AM stated he misplaced the binder for the water temperature and he did not have it. AM stated he took the temperature of the water in the morning but unable to remember where he placed the binder. AM stated he checked the temperature of the water in the laundry and kitchen. AM stated 72 F was the temperature that was safe for the residents to use and the facility prevents the growth of Legionella in the water by monitoring and documenting the temperatures of the water. AM unable to answer what temperatures of the water should he alert the Administrator (ADM) and Infection Preventionist Nurse (IPN).During a concurrent interview and record review on 2/26/2026 at 12:29 p.m. with the IPN, the facility's policy and procedure (P&P) titled, Legionella Surveillance, revised 2022 was reviewed. The P&P indicated Legionella grows best in water temperatures of 77 degrees F to 108 degrees F. IPN stated not monitoring and documenting the temperature of the water can put all residents at risk for legionnaires disease (serious lung infection caused by legionella bacteria) because the facility will not know if the water was contaminated with Legionella.During an interview on 2/26/2026 at 3:56 p.m. with the ADM, the ADM stated he oversees the Maintenance Department and was part of a team that reviews the policy for Water Management Plan. ADM stated the AM left the binder at home and temperatures were not being checked consistently. ADM stated not monitoring the water temperature can put the residents at risk for Legionella outbreak (occurs when two or more people get sick with Legionnaire's disease from the same contaminated water source).During a review of facility's P&P titled, Legionella Surveillance, revised 2022, the P&P indicated primary strategies for prevention and control of Legionella infection included temperature controls. The P&P indicated cold water shall be stored and distributed below 68 F, hot water should be stored above 140 F and circulated at a minimum return temperature of 124 F.During a review of facility's P&P titled, Water Management Program, revised 2022, the P&P indicated water temperature logs are used for risk assessment by the water management team to identify where legionella and other waterborne pathogens can grow and spread in the facility's water systems.2.During a concurrent observation and interview on 2/26/2026 at 8:15 a.m. with the Housekeeping Supervisor, observed an uncovered large blue bin for dirty linens were located outside the facility. HS stated the facility outsource laundry services for their dirty linens. Observed dirty linens not placed in a plastic bag and mixed with other plastic bags filled with dirty laundry. Observed open plastic bags filled with dirty linens in the uncovered large blue bin. HS stated all dirty linens were placed in a plastic bag and securely closed before putting them in the blue bin. HS stated certified nursing assistants (CNAs) sort the dirty laundry and should place them in a closed plastic bag to prevent spread of infection.During a concurrent observation and interview on 2/26/2026 at 9:34 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 brought the rolling hampers outside the facility and tied the plastic bags filled with dirty linens before placing them in the uncovered blue bin. CNA 1 stated he closed the plastic bag securely to ensure no dirty linens will fall out of the plastic bag causing cross contamination and spread of infection in the facility.During an interview on 2/26/2026 at 11:08 a.m. with the IPN, the IPN stated dirty linens should be placed in a bag and should be closed securely before placing them in the uncovered laundry bin outside facility to ensure prevention of cross contamination and spread of infection. IPN stated leaving the dirty linens not in the plastic bags or plastic bags not securely closed can attract insects or bugs and can cause spread of infection.During a review of facility's P&P titled, Handling Soiled Linen, undated, the P&P indicated The facility will handle, process and transport linen in a safe and sanitary manner to prevent spread of infection. The P&P indicated soiled linen should be placed in a linen bag or designated lined receptacle and the bag should be closed securely and placed in the soiled utility room.

Based on observation interview and record review the facility failed to ensure food items kept in the refrigerator and freezer were labeled and dated.These failures had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) for all residents residing in the facility.Findings:During a concurrent observation and interview on 2/24/2026 at 8:50 a.m. in the kitchen with the Assistant Dietary Manager (ADM), the walk on freezer was observed with a bag of frozen tamales, a bag of frozen carrots, frozen turkey, frozen chicken and a frozen roast beef were scattered throughout the walk-in freezer out of the boxes unlabeled and undated. The ADM stated the tamales, carrots, turkey, chicken and roast beef should be labeled and dated. During an interview on 2/27/2026 at 12:42 p.m. with the ADM, the ADM stated the food in the walk-in freezer should be inside the correct box with an open date. The ADM stated the food needed to be labeled and dated so the facility will know what the product is and if it's expired. The ADM stated if there was an old food product it is important to know the date it was opened so the residents would not get sick from Salmonella (a common bacteria that causes food poisoning) or Escherichia coli (E. coli- bacteria spread by eating undercooked ground beef, contaminated produce or unpasteurized dairy). The ADM stated labeling and dating the food helps to prevent residents from getting sick, especially residents that are in a high-risk environment for foodborne illneses. During an interview on 2/27/2026 at 12:55 p.m. with the Dietary Supervisor (DS) the DS stated when the kitchen received food products, the kitchen staff need to label the food product and write the date it was received. The DS stated the dietary staff needed to know how long the food has been in the freezer because expired food could cause food borne illness. During a review of the facility's policy and procedure (P&P), titled Food Receiving and Storage, undated, the P&P indicated All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 12) attempted a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue psychotropic [acting on the mind] medication three months after starting on the psychotropic medication) for Resident 12.This failure resulted in Resident 12 receiving Remeron (an antidepressant) 0.5 milligrams ([mg] unit of measurement) for depression and Risperdal (an antipsychotic medication used to treat schizophrenia) 0.5 mg for schizoaffective disorder without a documented gradual dose reduction. Findings:During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was originally admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), major depressive disorder (serious mental health condition characterized by persistent sadness and loss of interest), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During an interview on 2/27/2026 at 1:25 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 12 had an order for Remeron 0.5 mg for depression and Risperdal 0.5 for schizoaffective disorder. RNS 1 stated there was no documentation that a GDR was done. RNS 1 stated the GDR is to ensure Resident 12 received the right amount of medication. RNS 1 stated that the GDR is important to monitor and decrease the dosage of the medication.During an interview on 2/27/2026 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the GDR is done to reduce the administration of unnecessary medications that have side effects like sleepiness which could have an effect on the residents' Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of the facility's Policy and procedure (P&P), titled Tapering Medications and Gradual Drug Dose Reduction, undated, the P&P indicated, Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement its abuse policy and procedure for one of 20 sampled residents (Resident 9). The facility failed to:1. Follow facility's policy and procedure (P&P) titled, Abuse, Neglect, and Injury Reporting Policy, undated, which indicated injuries of unknown origin will be promptly evaluated and reported in accordance with federal and California regulations.This failure had the potential to result in undetected abuse and compromised resident safety, affecting Resident 9 and other residents in the facility.Findings:During a concurrent observation on 2/24/2026 at 10:14 a.m. with Resident 9, Resident 9's right arm was on a sling (a supportive device typically a strap or cloth used to immobilize, support, and protect an injured arm, shoulder or wrist).During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 9 diagnoses included autistic disorder ( a condition related to brain development ), unspecified dislocation of right shoulder joint ( ball-shaped top of the upper arm bone has popped out of its socket, causing severe pain, swelling, and inability to move), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (persistent, excessive fear or worry that interferes with life).During a review of Resident 9's Change in Condition (COC-a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 1/6/2026 timed at 12:02 p.m., the COC indicated Resident 9 was complaining of pain to right shoulder due to dislocation ( a joint injury where bones are forced out of their normal positions). The COC indicated Resident 9's physician ordered to transfer Resident 9 to GACH to manage the right shoulder dislocation.During a review of Resident 9's general acute care hospital (GACH) 1 Hospital Records titled, General History of Present Illness (HPI-detailed and chronological description of the development pf the patient's present illness) dated 1/6/2026 at 5:15 p.m., the HPI indicated Resident 9 came to the emergency room for right shoulder pain from Skilled Nursing Facility (SNF). The HPI indicated Resident 9 was assaulted in another GACH.During a review of Resident 9's GACH 1 Medical Records titled, X-ray of Right Shoulder, dated 1/6/2026 timed at 6:50 p.m., the x-ray of the right shoulder indicated there is no fracture (broken bone) or dislocation and mild soft tissue swelling (a slight temporary buildup of fluid in the tissue causing puffiness) was present.During a review of Resident 9's Care Plan titled, The Resident has Alteration in comfort related to Dislocation of Right Shoulder Joint, initiated on 1/14/2026 and revised on 1/15/2026, the Care Plan indicated to monitor pain every shift, administer pain medicine and Resident 9 will wear sling for his right shoulder as ordered.During a review of Resident 9's Rehabilitation Screening ( a quick initial checkup if a person needs specialized therapy to improve their daily functioning such as mobility) dated 1/15/2026, the Rehabilitation Screening indicated no Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) or Physical Therapy ( healthcare service that helps a resident move better and restores physical function after an injury, surgery or disease) was warranted. The Rehabilitation Screening indicated Resident 9 had a non-weight bearing ( no weight, contact or pressure is applied on the affected area) to right upper arm with soft sling.During a review of Resident 9's History and Physical (H&P) dated 1/16/2026, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS- resident assessment tool) dated 1/25/2026, the MDS indicated Resident 9 had an intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 9 required supervision or touching assistance (helper provides verbal cues and contact guard assistance as the resident completes an activity) with transfer to and from a bed to chair, toilet transfer, oral hygiene, toileting hygiene and dressing.During a review of Resident 9's Radiology Report of right shoulder x-ray dated 2/23/2026, the right shoulder x-ray report indicated greater tuberosity (large lateral bony prominence on the upper arm bone ) minimally comminuted fracture (bone broken into 3 or 4 pieces) and acute appearing humeral head fracture (a new, sudden break in the long bone of the upper arm usually caused by a fall, accident or direct blows).During a review of Resident 9's COC Evaluation dated 2/23/2026, the COC indicated Resident 9 had a humeral fracture (broken bone in the upper arm, between the shoulder and elbow) and would be transferred to GACH 2 for orthopedic evaluation (a comprehensive assessment by a specialist to find the cause of pain or limited movement).During a review of Resident 9's Care Plan titled, The resident had a humeral head fracture, initiated 2/24/2026, the Care Plan interventions included orthopedic evaluation and administration of anti-inflammatory (medicine that decrease swelling and pain) pain medications.During an interview on 2/26/2026 at 1:52 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 9 was transferred to a GACH on 1/6/2026 because Resident 9 was not compliant with the use of a sling. RNS 1 stated she became aware on 2/23/2026 that Resident 9 had sustained a humeral fracture. She stated she did not know how the fracture occurred, and the injury was not investigated to rule out abuse or neglect. RNS 1 stated Resident 9's right humerus fracture should have been investigated and reported to the California Department of Public Health immediately per facility's policy and procedure titled Abuse, Neglect, and Injury Reporting Policy.During an interview on 2/27/2026 at 1:08 p.m., RNS 1 stated Resident 9 was admitted to the facility on [DATE] for a right shoulder dislocation and was transferred to a GACH on 1/6/2026. RNS 1 stated the right shoulder X ray taken on 1/6/2026 showed no fracture or dislocation, with only mild tissue swelling noted. RNS 1 stated a subsequent X ray obtained on 2/23/2026 revealed a fracture of the right humerus, and she did not know how the resident developed the injury. RNS 1 stated the facility should have initiated an investigation on 2/23/2026 when the fracture was discovered, as the cause of the injury was unknown. She stated the facility sent Resident 9 to GACH on 2/23/2026 for evaluation, and the resident returned early in the morning of 2/24/2026. RNS 1 stated the facility needed to determine what occurred, how it occurred, and why the fracture developed, and that an investigation should have been started immediately to rule out abuse or neglect. RNS 1 stated she did not know why an investigation was not initiated. RNS 1 stated the fracture should have been reported to the California Department of Public Health (CDPH) immediately because it met the definition of an injury of unknown origin under the facility's policy and required investigation to determine whether abuse occurred. RNS 1 stated she did not know what happened between 1/6/2026 and 2/23/2026 that could have resulted in the fracture. RNS 1 stated she informed the Director of Nursing (DON) of the fracture on 2/23/2026 but did not discuss initiating an investigation or reporting the incident to CDPH. She stated the facility should have investigated the injury to ensure Resident 9's safety, protect other residents, and prevent potential abuse.During an interviews on 2/26/2026 at 4:26 p.m. and on 2/27/2026 at 1:08 p.m., with the DON and a record review of the facility's policy titled Abuse, Neglect, and Injury Reporting Policy (undated), the Director of Nursing (DON) stated Resident 9 was admitted to the facility on [DATE] with a dislocated right shoulder and was wearing a sling. The DON stated she did not know how Resident 9 developed a right humeral fracture on 2/23/2026. The DON stated she neither reported the incident to the California Department of Public Health (CDPH) nor initiated an investigation to rule out abuse. The DON stated she had been sidetracked and that it was her mistake, explaining it did not occur to her that the fracture was an injury of unknown origin. The DON stated she did not notify the Administrator when Resident 9 was found to have a right humeral fracture on 2/23/2026. She stated the Administrator was aware of the prior shoulder dislocation but not of the newly identified humeral fracture on 2/23/2026. The DON stated the right humeral fracture should have been reported to CDPH immediately so that the incident could be investigated to rule out abuse or neglect.During a review of facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, undated, the P&P indicated to take appropriate actions when abuse, or neglect is suspected. The P&P indicated the facility will consider factors indicating possible abuse, neglect and exploitations of residents the following possible indicators such as physical injury of a resident from unknown source.During a review of facility's P&P titled, Abuse, Neglect, and Injury Reporting Policy, undated, the P&P indicated injuries of unknown origin will be promptly evaluated and reported in accordance with federal and California regulations. The P&P indicated an injury of unknown origin is considered when the injury was not observed by staff, injury is inconsistent with the resident's clinical condition, or there is insufficient information to determine the cause after assessment.Cross reference F609 and F610

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to report an injury of unknown origin (the cause of injury was not observed by any person or could not be explained by the resident) to the California Department of Public Health (CDPH) for one of 20 sampled residents (Resident 9) when Resident 9 sustained a right humeral fracture (a break in the upper arm bone between the shoulder and elbow, typically associated with falls or direct impact) on 2/23/2026.This failure had the potential to delay an investigation to determine whether abuse or neglect contributed to Resident 9's injury.Findings:During an observation on 2/24/2026 at 10:14 a.m. with Resident 9's right arm was on a sling (a supportive device typically a strap or cloth used to immobilize, support, and protect an injured arm, shoulder or wrist).During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 9 diagnoses included autistic disorder ( a condition related to brain development ), unspecified dislocation of right shoulder joint ( ball-shaped top of the upper arm bone has popped out of its socket, causing severe pain, swelling, and inability to move), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (persistent, excessive fear or worry that interferes with life).During a review of Resident 9's Change in Condition (COC-a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 1/6/2026 timed at 12:02 p.m., the COC indicated Resident 9 was complaining of pain to right shoulder due to dislocation ( a joint injury where bones are forced out of their normal positions). The COC indicated Resident 9's physician ordered to transfer Resident 9 to GACH to manage the right shoulder dislocation.During a review of Resident 9's general acute care hospital (GACH) 1 Hospital Records titled, General History of Present Illness (HPI-detailed and chronological description of the development pf the patient's present illness) dated 1/6/2026 at 5:15 p.m., the HPI indicated Resident 9 came to the emergency room for right shoulder pain from Skilled Nursing Facility (SNF). The HPI indicated Resident 9 was assaulted in another GACH.During a review of Resident 9's GACH 1 Medical Records titled, X-ray of Right Shoulder, dated 1/6/2026 timed at 6:50 p.m., the x-ray of the right shoulder indicated there is no fracture (broken bone) or dislocation and mild soft tissue swelling (a slight temporary buildup of fluid in the tissue causing puffiness) was present.During a review of Resident 9's Care Plan titled, The Resident has Alteration in comfort related to Dislocation of Right Shoulder Joint, initiated on 1/14/2026 and revised on 1/15/2026, the Care Plan indicated to monitor pain every shift, administer pain medicine and Resident 9 will wear sling for his right shoulder as ordered.During a review of Resident 9's Rehabilitation Screening ( a quick initial checkup if a person needs specialized therapy to improve their daily functioning such as mobility) dated 1/15/2026, the Rehabilitation Screening indicated no Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) or Physical Therapy ( healthcare service that helps a resident move better and restores physical function after an injury, surgery or disease) was warranted. The Rehabilitation Screening indicated Resident 9 had a non-weight bearing ( no weight, contact or pressure is applied on the affected area) to right upper arm with soft sling.During a review of Resident 9's History and Physical (H&P) dated 1/16/2026, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS- resident assessment tool) dated 1/25/2026, the MDS indicated Resident 9 had an intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 9 required supervision or touching assistance (helper provides verbal cues and contact guard assistance as the resident completes an activity) with transfer to and from a bed to chair, toilet transfer, oral hygiene, toileting hygiene and dressing.During a review of Resident 9's Radiology Report of right shoulder x-ray dated 2/23/2026, the right shoulder x-ray report indicated greater tuberosity (large lateral bony prominence on the upper arm bone ) minimally comminuted fracture (bone broken into 3 or 4 pieces) and acute appearing humeral head fracture (a new, sudden break in the long bone of the upper arm usually caused by a fall, accident or direct blows).During a review of Resident 9's COC Evaluation dated 2/23/2026, the COC indicated Resident 9 had a humeral fracture (broken bone in the upper arm, between the shoulder and elbow) and would be transferred to GACH 2 for orthopedic evaluation (a comprehensive assessment by a specialist to find the cause of pain or limited movement).During a review of Resident 9's Care Plan titled, The resident had a humeral head fracture, initiated 2/24/2026, the Care Plan interventions included orthopedic evaluation and administration of anti-inflammatory (medicine that decrease swelling and pain) pain medications.During an interview on 2/26/2026 at 1:52 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 9 was transferred to a GACH on 1/6/2026 because Resident 9 was not compliant with the use of a sling. RNS 1 stated she became aware on 2/23/2026 that Resident 9 had sustained a humeral fracture. She stated she did not know how the fracture occurred, and the injury was not investigated to rule out abuse or neglect. RNS 1 stated Resident 9's right humerus fracture should have been investigated and reported to the California Department of Public Health immediately per facility's policy and procedure titled Abuse, Neglect, and Injury Reporting Policy.During an interview on 2/27/2026 at 1:08 p.m., RNS 1 stated Resident 9 was admitted to the facility on [DATE] for a right shoulder dislocation and was transferred to a GACH on 1/6/2026. RNS 1 stated the right shoulder X ray taken on 1/6/2026 showed no fracture or dislocation, with only mild tissue swelling noted. RNS 1 stated a subsequent X ray obtained on 2/23/2026 revealed a fracture of the right humerus, and she did not know how the resident developed the injury. RNS 1 stated the facility should have initiated an investigation on 2/23/2026 when the fracture was discovered, as the cause of the injury was unknown. She stated the facility sent Resident 9 to GACH on 2/23/2026 for evaluation, and the resident returned early in the morning of 2/24/2026. RNS 1 stated the facility needed to determine what occurred, how it occurred, and why the fracture developed, and that an investigation should have been started immediately to rule out abuse or neglect. RNS 1 stated she did not know why an investigation was not initiated. RNS 1 stated the fracture should have been reported to the California Department of Public Health (CDPH) immediately because it met the definition of an injury of unknown origin under the facility's policy and required investigation to determine whether abuse occurred. RNS 1 stated she did not know what happened between 1/6/2026 and 2/23/2026 that could have resulted in the fracture. RNS 1 stated she informed the Director of Nursing (DON) of the fracture on 2/23/2026 but did not discuss initiating an investigation or reporting the incident to CDPH. She stated the facility should have investigated the injury to ensure Resident 9's safety, protect other residents, and prevent potential abuse.During an interview on 2/27/2026 at 1:34 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 9 was screened for Joint Mobility on 1/15/2026 and no OT and PT were provided because of the sling on his right shoulder and Resident 9 required non- weight bearing on the right arm while moving. The DOR stated RNS 1 approached her to obtain recommendation for mobility (movement) regarding Resident 9's right shoulder dislocation on 2/23/2026. The DOR stated she consulted OT who recommended an orthopedic consultation (specialized appointment with a bone and joint physician to diagnose and treat issues with muscles, bones, joints and ligaments). The DOR stated the DON stated to obtain an x-ray of the right shoulder first before getting an orthopedic consultation for Resident 9.During an interview on 2/26/2026 at 4:26 p.m. and on 2/27/2026 at 1:08 p.m., with the DON and a record review of the facility's policy titled Abuse, Neglect, and Injury Reporting Policy (undated), the DON stated Resident 9 was admitted to the facility on [DATE] with a dislocated right shoulder and was wearing a sling. The DON stated she did not know how Resident 9 developed a right humeral fracture on 2/23/2026. The DON stated she neither reported the incident to the California Department of Public Health (CDPH) nor initiated an investigation to rule out abuse. The DON stated she had been sidetracked and that it was her mistake, explaining it did not occur to her that the fracture was an injury of unknown origin. The DON stated she did not notify the Administrator when Resident 9 was found to have a right humeral fracture on 2/23/2026. She stated the Administrator was aware of the prior shoulder dislocation but not of the newly identified humeral fracture on 2/23/2026. The DON stated the right humeral fracture should have been reported to CDPH immediately so that an investigation could be initiated promptly to rule out abuse or neglect.During a review of facility's P&P titled, Abuse, Neglect, and Injury Reporting Policy, undated, the P&P indicated injuries of unknown origin will be promptly evaluated and reported in accordance with federal and California regulations. The P&P indicated an injury of unknown origin is considered when the injury was not observed by staff, injury is inconsistent with the resident's clinical condition, or there is insufficient information to determine the cause after assessment. Cross reference F607 and F610

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to investigate an injury of unknown origin (cause of injury was not observed by any person or could not be explained by the resident) for one of 20 sample resident (Resident 9).The facility failed to:1. Investigate Resident 9's injury of unknown origin. Resident 9 was admitted to the facility on [DATE] with no documented fracture (broken bone) to the right shoulder, as confirmed by X ray (imaging that create images of structures inside the body) results dated 1/2/2026 and 1/6/2026. While under the facility's care, Resident 9 developed a humeral fracture (a break in the upper arm bone connecting the shoulder and elbow) on 2/23/2026.This failure had the potential to prevent the facility from determining whether Resident 9's injury resulted from abuse or neglect.Findings:During an observation on 2/24/2026 at 10:14 a.m. with Resident 9, observed Resident 9's right arm was on a sling (a supportive device typically a strap or cloth used to immobilize, support, and protect an injured arm, shoulder or wrist).During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 9 diagnoses included autistic disorder ( a condition related to brain development ), unspecified dislocation of right shoulder joint ( ball-shaped top of the upper arm bone has popped out of its socket, causing severe pain, swelling, and inability to move), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (persistent, excessive fear or worry that interferes with life).During a review of Resident 9's Change in Condition (COC-a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 1/6/2026 timed at 12:02 p.m., the COC indicated Resident 9 was complaining of pain to right shoulder due to dislocation ( a joint injury where bones are forced out of their normal positions). The COC indicated Resident 9's physician ordered to transfer Resident 9 to GACH to manage the right shoulder dislocation.During a review of Resident 9's general acute care hospital (GACH) 1 Hospital Records titled, General History of Present Illness (HPI-detailed and chronological description of the development pf the patient's present illness) dated 1/6/2026 at 5:15 p.m., the HPI indicated Resident 9 came to the emergency room for right shoulder pain from Skilled Nursing Facility (SNF). The HPI indicated Resident 9 was assaulted in another GACH.During a review of Resident 9's GACH 1 Medical Records titled, X-ray of Right Shoulder, dated 1/6/2026 timed at 6:50 p.m., the x-ray of the right shoulder indicated there is no fracture (broken bone) or dislocation and mild soft tissue swelling (a slight temporary buildup of fluid in the tissue causing puffiness) was present.During a review of Resident 9's Care Plan titled, The Resident has Alteration in comfort related to Dislocation of Right Shoulder Joint, initiated on 1/14/2026 and revised on 1/15/2026, the Care Plan indicated to monitor pain every shift, administer pain medicine and Resident 9 will wear sling for his right shoulder as ordered.During a review of Resident 9's Rehabilitation Screening ( a quick initial checkup if a person needs specialized therapy to improve their daily functioning such as mobility) dated 1/15/2026, the Rehabilitation Screening indicated no Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) or Physical Therapy ( healthcare service that helps a resident move better and restores physical function after an injury, surgery or disease) was warranted. The Rehabilitation Screening indicated Resident 9 had a non-weight bearing ( no weight, contact or pressure is applied on the affected area) to right upper arm with soft sling.During a review of Resident 9's History and Physical (H&P) dated 1/16/2026, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS- resident assessment tool) dated 1/25/2026, the MDS indicated Resident 9 had an intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 9 required supervision or touching assistance (helper provides verbal cues and contact guard assistance as the resident completes an activity) with transfer to and from a bed to chair, toilet transfer, oral hygiene, toileting hygiene and dressing.During a review of Resident 9's Radiology Report of right shoulder x-ray dated 2/23/2026, the right shoulder x-ray report indicated greater tuberosity (large lateral bony prominence on the upper arm bone ) minimally comminuted fracture (bone broken into 3 or 4 pieces) and acute appearing humeral head fracture (a new, sudden break in the long bone of the upper arm usually caused by a fall, accident or direct blows).During a review of Resident 9's COC Evaluation dated 2/23/2026, the COC indicated Resident 9 had a humeral fracture (broken bone in the upper arm, between the shoulder and elbow) and would be transferred to GACH 2 for orthopedic evaluation (a comprehensive assessment by a specialist to find the cause of pain or limited movement).During a review of Resident 9's Care Plan titled, The resident had a humeral head fracture, initiated 2/24/2026, the Care Plan interventions included orthopedic evaluation and administration of anti-inflammatory (medicine that decrease swelling and pain) pain medications.During an interview on 2/26/2026 at 1:52 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 9 was transferred to a GACH on 1/6/2026 because Resident 9 was not compliant with the use of a sling. RNS 1 stated she became aware on 2/23/2026 that Resident 9 had sustained a humeral fracture. She stated she did not know how the fracture occurred, and the injury was not investigated to rule out abuse or neglect. RNS 1 stated Resident 9's right humerus fracture should have been investigated and reported to the California Department of Public Health immediately per facility's policy and procedure titled Abuse, Neglect, and Injury Reporting Policy.During an interview on 2/27/2026 at 1:08 p.m., RNS 1 stated Resident 9 was admitted to the facility on [DATE] for a right shoulder dislocation and was transferred to a GACH on 1/6/2026. RNS 1 stated the right shoulder X ray taken on 1/6/2026 showed no fracture or dislocation, with only mild tissue swelling noted. RNS 1 stated a subsequent X ray obtained on 2/23/2026 revealed a fracture of the right humerus, and she did not know how the resident developed the injury. RNS 1 stated the facility should have initiated an investigation on 2/23/2026 when the fracture was discovered, as the cause of the injury was unknown. She stated the facility sent Resident 9 to GACH on 2/23/2026 for evaluation, and the resident returned early in the morning of 2/24/2026. RNS 1 stated the facility needed to determine what occurred, how it occurred, and why the fracture developed, and that an investigation should have been started immediately to rule out abuse or neglect. RNS 1 stated she did not know why an investigation was not initiated. RNS 1 stated the fracture should have been reported to the California Department of Public Health (CDPH) immediately because it met the definition of an injury of unknown origin under the facility's policy and required investigation to determine whether abuse occurred. RNS 1 stated she did not know what happened between 1/6/2026 and 2/23/2026 that could have resulted in the fracture. RNS 1 stated she informed the Director of Nursing (DON) of the fracture on 2/23/2026 but did not discuss initiating an investigation or reporting the incident to CDPH. She stated the facility should have investigated the injury to ensure Resident 9's safety, protect other residents, and prevent potential abuse.During an interview on 2/27/2026 at 1:34 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 9 was screened for Joint Mobility on 1/15/2026 and no OT and PT were provided because of the sling on his right shoulder and Resident 9 required non- weight bearing on the right arm while moving. The DOR stated RNS 1 approached her to obtain recommendation for mobility (movement) regarding Resident 9's right shoulder dislocation on 2/23/2026. The DOR stated she consulted OT who recommended an orthopedic consultation (specialized appointment with a bone and joint physician to diagnose and treat issues with muscles, bones, joints and ligaments). The DOR stated the DON stated to obtain an x-ray of the right shoulder first before getting an orthopedic consultation for Resident 9.During an interviews on 2/26/2026 at 4:26 p.m. and on 2/27/2026 at 1:08 p.m., with the DON and a record review of the facility's policy titled Abuse, Neglect, and Injury Reporting Policy (undated), the DON stated Resident 9 was admitted to the facility on [DATE] with a dislocated right shoulder and was wearing a sling. The DON stated she did not know how Resident 9 developed a right humeral fracture on 2/23/2026. The DON stated she neither reported the incident to the California Department of Public Health (CDPH) nor initiated an investigation to rule out abuse. The DON stated she had been sidetracked and that it was her mistake, explaining it did not occur to her that the fracture was an injury of unknown origin. The DON stated she did not notify the Administrator when Resident 9 was found to have a right humeral fracture on 2/23/2026. She stated the Administrator was aware of the prior shoulder dislocation but not of the newly identified humeral fracture on 2/23/2026. The DON stated failing to investigate could place Resident 9 at risk for fear, isolation, and unsafe conditions if abuse or neglect had occurred.During a review of facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, undated, the P&P indicated to take appropriate actions when abuse, or neglect is suspected. The P&P indicated the facility will consider factors indicating possible abuse, neglect and exploitations of residents the following possible indicators such as physical injury of a resident from unknown source.During a review of facility's P&P titled, Abuse, Neglect, and Injury Reporting Policy, undated, the P&P indicated injuries of unknown origin will be promptly evaluated and reported in accordance with federal and California regulations. The P&P indicated an injury of unknown origin is considered when the injury was not observed by staff, injury is inconsistent with the resident's clinical condition, or there is insufficient information to determine the cause after assessment.Cross reference F607 and F609

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one of one sampled residents (Resident 78) was assisted with eating during meals.This failure had the potential to place Resident 78 at risk for weight loss. Findings:During an observation on 2/24/2026 at 12:24 p.m. in the dining room, Resident 78 was seated in wheelchair, rocking back and forth and holding spoon in his right hand for 10 minutes before spooning food into his mouth while staff being observed by facility staff.During an observation on 2/24/2026 at 12:48 p.m. in the dining room, Resident 78 was observed with 75% of his meal still on his plate and not eaten after 30 minutes without staff assistance.During an observation on 2/24/2026 at 12:54 p.m. in Resident 78's room, Certified Nursing Assistant (CNA) 4 was observed assisting Resident 78 with his meal after not being assisted in the dining room for 30 minutes.During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses including lack of coordination, heart failure(heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (abnormal high levels of fats in the blood), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety (emotion characterized by feelings of tension, worried thoughts).During a review of Resident 78's History and Physical (H&P), dated 10/17/2025, the H&P indicated Resident 78 had the capacity to understand and make decisions.During a review of Resident 78's Minimum Data Set (MDS- a resident assessment tool) dated 1/22/2026, the MDS indicated Resident 78 was dependent (helper does all the effort) on nursing staff with showering. The MDS indicated Resident 78 needed setup or clean-up assistance with eating.During an interview on 2/24/26 at 1243 p.m. with Resident 78, Resident 78 was asked if he needed assistance with eating, and Resident 78 stated yes.During an interview on 2/25/2026 at 2:21 p.m. with CNA 4, CNA 4 stated Resident 78 takes more than a one hour to feed himself. CNA 4 stated when Resident 78 feeds himself, he takes a long time and his food gets cold. CNA 4 stated Resident 78 needs help with eating because he is unstable and rocks back and forth.During an interview on 2/25/2026 at 2:55 p.m. with CNA 5, CNA 5 stated Resident 78 eats slow and takes too long for him to finish the food due to the movement it takes resident takes an hour to eat. CNA 5 stated when she assists Resident 78 with eating, he finishes in less than hour. CNA 5 stated Resident 78 will benefit from help and assistance with eating.During an interview on 2/26/2026 at 10:40 a.m. with Registered Nursing Supervisor, (RNS) 1, RNS 1 stated Resident 78 could have a potential for weight loss with an inability to feed himself if not assessed properly.During an interview on 2/27/2026 at 2:41 p.m. with the Director of Nursing (DON), the DON stated a negative outcome for weight loss could result in actual mental health issues, muscle loss, and nutrient deficiencies, for Resident 78 due to his lack of coordination with feeding.During a review of the facility's policy and procedure (P&P), titled Activities of Daily Living (ADLs), undated, The P&P indicated The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to bathe, dress, and groom, transfer and ambulate, toilet, eat and use speech, language or other functional communication systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide one of 18 sample residents (Resident 63) with activities or regular room visits as part of an ongoing program to support the resident's chosen activities. This failure had the potential to negatively impact on Resident 63's sense of self-worth and psychosocial well being, including feelings of usefulness, social connection, and personal satisfaction.Findings:During review of Resident 63's admission Records, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), major depression ( mood disorder that causes a persistent feeling of sadness and loss of interest) and muscle weakness (loss of muscle strength).During a review of Resident 63's Minimum Data Set (MDS- resident assessment tool) dated 02/22/2026, the MDS indicated Resident 63's cognitive (ability to think, understand, learn, and remember) skills for daily decisions making was moderately impaired. The MDS indicated Resident 63 required setup or clean up assistance (helper set up or clean up; resident completes activity) from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During an observation on 02/24/2026 at 11:11 a.m., Resident 63 was observed lying quietly in bed on his side.During a concurrent observation and interview on 02/25/2026 at 10:44 a.m. with Resident 63, Resident 63 was observed lying quietly in bed, staring at the walls of the room. Resident 63 stated, no one regularly brought him books, and it only happened occasionally during his stay. Resident 63 stated he does not like going out for activities due to personal reasons. He stated he preferred his television in his room to be working so he could watch programs. Resident 63 also stated that his wife had recently passed away, and he often feels bored.During a concurrent observation and interview on 02/25/2026 at 11:55 a.m. with the Activity Director (AD), the AD stated she was not aware that Resident 63's room television was not working. The AD stated the Resident 63 had not reported the issue, but acknowledged that it is the responsibility of all staff to observe and ensure that resident rooms are maintained in a homelike manner. The AD stated she does not provide in room activities herself and primarily conducts rounds. The AD stated she will in service staff to ensure resident needs were addressed before leaving their rooms and will increase the frequency of rounds to better identify and meet residents' in room needs.During a concurrent interview and record review on 02/26/2026 at 7:55 a.m. with the Activity Assistant (AA),the activity participation logs were reviewed, including room visit and independent activity codes. The activity participation logs indicated the in room activity option coded as V4 (movies/TV) was not offered to Resident 63 according to his preferences throughout the month of February 2026. The AA stated she thought Resident 63 did not like to watch television. The AA stated she could not recall the last time she checked whether Resident 63 wanted to watch television or movies. She stated she should be asking Resident 63 during each activity visit about his preferred activities and provide it to Resident 63 to help maintain a homelike environment for the resident.During an interview on 02/27/2026 at 1:20 p.m. with the Director of Nursing (DON), the DON stated activities should be encouraged for all residents, and that if a resident refuses one activity, staff should offer an alternative aligned with the resident's preferences. The DON stated resident preferences should be obtained, and any refusals or actions taken should be documented.During a review of the facility's policy and procedures (P&P) titled, Activities, undated. The P&P indicated, Facility to provide an ongoing program of activities designed to meet the interest's choice and preference as well as to meet the interests of and support the physical, mental and psychological well-being of each resident, encouraging both independence and interaction in the community , as well as the physical, Mental and psychological well-being of each resident, encouraging both independence and interaction in the community. Activities will be designed with intent to promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 48) was offered functional hearing aids available for use. This failure resulted in Resident 48 not being able to hear adequately and communicate appropriately for care, safety needs and basic services for hygiene.Findings:During a review of Resident 48's admission Record (Face Sheet- front page of the chart), the admission Record indicated Resident 48 was originally admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. Resident 48's diagnoses included hypertensive heart disease (heart damage leading to high blood pressure), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), cataracts (a common age-related eye condition involving the clouding of the eye's normally clear lens) and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 48's History and Physical (H&P) dated 6/18/2025, the H&P indicated Resident 48 was self responsible. The H&P indicated Resident 48 had hearing loss and difficulty. The H&P indicated Resident 48 could read lips. The H&P indicated Resident 48 understands if you write the questions or statements then show it to him.During a review of Resident 48's Minimum Data Set (MDS-a resident assessment tool), dated 1/7/2026, the MDS indicated Resident 48 needed substantial to maximal assistance (helper does all the effort) with toileting, showering, dressing and taking off shoes. The MDS indicated Resident 48 needed partial to moderate assistance (helper does half the effort) with eating, oral hygiene, personal hygiene, transferring and walking.During a concurrent observation and interview on 2/24/2026 at 10:43 a.m., Resident 48 was observed hard of hearing. Resident 48 stated he had hearing aids but does not wear them because the hearing aids are too big.During an interview on 2/25/2026 at 11:04 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 48 is unable to hear. CNA 3 stated he types messages on his phone or gives Resident 48 paper to write down what he wants when he needs to communicate with Resident 48. CNA 3 stated Resident 48 does not have hearing aids and had not seen any hearing aids at Resident 48's bedside. CNA 3 stated he is not aware of anything being done to improve Resident 48's hearing.During an interview on 2/25/2026 at 11:47 a.m. with Restorative Nurse Aide (RNA) 1, RNA 1 stated Resident 48 is hard of hearing so you must speak loudly in his ear or pull your mask down so he can read your lips. RNA 1 stated Resident 48 can not understand or hear you when you are speaking with a mask on. RNA 1 stated Resident 48 would benefit from hearing aids.During a concurrent interview and record review on 2/25/2026 at 1:33 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 48's Care Plan, dated 12/19/2025 was reviewed, the Care Plan indicated Resident 48 required hearing aids to communicate. The Care Plan indicated to ensure availability and functioning of adaptive communication equipment. The Goal of the Care Plan indicated Resident 48 will be able to put on and work hearing aids. LVN 2 stated Resident 48 has difficulty hearing and has never seen Resident 48 with any hearing aids. LVN 2 stated Resident 48 would have a breakdown in communication and a problem hearing what is being said without his hearing aids.During an interview on 2/26/2026 at 11:27 a.m. with the Social Worker (SW), the SW stated her responsibility is to make sure residents have hearing aids. The SW stated Resident 48 has bilateral hearing aids that are kept in the medication cart. The SW stated the licensed staff are supposed to offer Resident 48 his hearing aids. The SW stated there is no system to check if Resident 48 is being offered his hearing aids. The SW stated Resident 48's hearing aids were not working and need to have the batteries replaced. The SW stated Resident 48 will not be able to communicate properly and would not be able to listen properly. The SW stated due to miscommunication Resident 48 may hear something different than what is said. During an interview on 2/27/2026 at 2:10 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 48's hearing aids are kept in medication cart. RNS 1 stated Resident 48 would not be able to understand the care rendered without his hearing aid.During an interview on 2/27/2026 at 2:39 p.m. with the Director of Nursing, the DON stated Resident 48 would not be able to communicate his needs with hearing aids that are not working.During a review of the facility's policy and procedure (P&P), titled Ancillary Services, undated, the P&P indicated the Purpose is to ensure residents receive ancillary services in a timely, coordinated, and safe manner to support their highest practicable, mental and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide effective pain management for one of four sampled residents (Resident 9). The facility failed to:1. Ensure Resident 9 was provided with pain medicine based on his assessed pain level.This failure had the potential to result in Resident 9 having unrelieved pain or overmedication (receiving too much medication and taking excessively high doses). Findings:During an observation on 2/24/2026 at 10:14 a.m. with Resident 9, observed Resident 9's right arm was on a sling (a supportive device typically a strap or cloth used to immobilize, support, and protect an injured arm, shoulder or wrist).During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 9 diagnoses including autistic disorder ( a condition related to brain development ), unspecified dislocation of right shoulder joint ( ball-shaped top of the upper arm bone has popped out of its socket, causing severe pain, swelling, and inability to move), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (persistent, excessive fear or worry that interferes with life).During a review of Resident 9's Care Plan titled, Alteration in Comfort related to dislocation of right shoulder joint, initiated on 1/14/2026 and revised on 1/15/2026. The Care plan goals indicated Resident 9 will not have an interruption in normal activities due to pain. The Care plan interventions included to monitoring of pain every shift and administering Ibuprofen ( medicine used to reduce fever, pain, and inflammation) and monitoring for its side effects (unwanted or unexpected reactions to medicine or treatment).During a review of Resident 9's History and Physical (H&P) dated 1/16/2026, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS- resident assessment tool) dated 1/25/2026, the MDS indicated Resident 9 had an intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 9 required supervision or touching assistance (helper provides verbal cues and contact guard assistance as the resident completes an activity) with transfer to and from a bed to chair, toilet transfer, oral hygiene, toileting hygiene and dressing.During a review of Resident 9's Medication Administration Report (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of January and February 2026, the MAR indicated an order of Ibuprofen 600 milligrams(mgs.-unit of measurement) dated 1/15/2026 to administer 1 tablet by mouth every 12 hours as needed for moderate pain ( pain rating using numerical rating of 1 to 10 that quantifies pain intensity from 0- no pain,1-3 mild pain, 4-6 moderate pain and 7 to 10 is severe pain). The MAR indicated Resident 9 received Ibuprofen 600 mgs. on the following days:On 2/2/2026 at 9:00 a.m. for a pain level of 2/10.On 2/5/2026 at 8:43 a.m. for a pain level of 9/10.On 1/25/2026 at 2:30 p.m. for a pain level of 2/10.On 1/27/2026 at 9:23 a.m. for a pain level of 2/10.During a concurrent interview and record review on 2/26/2026 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 9's MAR for February 2026 was reviewed. LVN 1 stated that Resident 9 would sometimes receive ibuprofen for mild discomfort. LVN 1 stated he should have notified the physician when Resident 9's pain level reached 9, because ibuprofen was ordered only for moderate pain levels of 5 to 7. LVN 1 stated he assessed Resident 9's pain level after giving the ibuprofen but did not document. LVN 1 stated he did not call Resident 9's physician regarding pain level of 9/10. LVN 1 stated that not providing pain medication appropriate for the assessed pain level could result in uncontrolled pain and ineffective pain management.During an interview on 2/26/2026 at 4:26 p.m. with the Director of Nursing (DON), the DON stated the licensed nurse should have notified the physician when Resident 9's pain level was 9/10 because Ibuprofen would not be enough to relieve the pain. The DON stated Resident 9 can be at risk for unrelieved pain because the licensed nurse administered pain medicine not appropriate to the assessed pain level of the resident.During a review of facility's policy and procedure (P&P) titled, Pain Assessment and Management, undated, the P&P indicated the facility will identify pain in the resident and will develop interventions consistent with the resident's goals and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Antibiotic Stewardship Program ( process for improving how antibiotics [medication used to treat infection] are prescribed and used by residents) was implemented for one of three residents (Resident 90). The facility failed to monitor antibiotic use and review the appropriateness of the prescribed antibiotic.This failure had the potential to put Resident 90 at risk for antibiotic resistance (ability of bacteria and other microorganisms to withstand the effects of antibiotics, rendering them ineffective) or inappropriate use of antibiotic.Findings:During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was initially admitted to the facility on 1/13/2023 and was readmitted on [DATE]. The admission Record indicated Resident 90 diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), anxiety disorder(persistent, excessive fear or worry that interferes with life), diabetes mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 9's General Acute Hospital (GACH) Record titled, Urinalysis ( laboratory test that analyzes a sample of urine to check for signs of health issue), dated 2/6/2026 at 6:30 a.m., the Urinalysis indicated presence of white blood count (WBC presence of white blood count in urine often signals infection) 25 to 50 A ( A- level of WBC in the urine and normal reference range is 0) in the urine.During a review of Resident 9's GACH Record titled, Urine Culture, dated 2/6/2026 timed at 11:10 a.m., the Urine Culture (laboratory test that is used to see if germs specifically bacteria or yeast grow from the sample of the urine) indicated normal genitourinary flora (laboratory found harmless bacteria that normally live in the skin or genital area) and presence of 25,000 colony forming units per milliliter( cfu/ ml- measurement of how many bacteria grew from the sample) in the urine sample.During a review of Resident 90's Physician Order dated 2/9/2026 timed at 2:21 p.m., the Physician Order indicated an order of Ciprofloxacin Hydrochloride (antibiotic used to treat serious bacterial infections like UTI) 500 milligrams (mgs. - unit of measurement) 1 tablet by mouth two times a day for UTI for 4 days.During a review of Resident 90's Minimum Data Set (MDS- a resident assessment tool) dated 2/16/2026, the MDS indicated Resident 90 had moderately impaired cognitive skills ( a person has trouble remembering, thinking, learning and making decisions). The MDS indicated Resident 90 required partial/moderate assistance with eating, oral hygiene, bathing and toilet transfer ( ability to get on and off a toilet or commode).During a concurrent interview and record review on 2/26/2026 at 9:57 a.m. with the Infection Preventionist Nurse (IPN), Resident 90's physician order for Ciprofloxacin dated 2/9/2026, Resident 90's urinalysis and urine culture obtained from GACH on 2/6/2026, were reviewed. The IPN stated she did not verify whether a urine culture had been obtained prior to initiating Ciprofloxacin for Resident 90. The IPN indicated that the urine culture from 2/6/2026 showed a bacterial count below the threshold required to start antibiotic therapy. She stated the culture also did not include sensitivity testing, which identifies which antibiotics would be effective for the specific bacteria. The IPN stated that, according to McGeer Criteria (standardized, evidence based definitions used in long term care facilities to determine true infections and ensure antibiotics are prescribed only when appropriate) a urine culture should show greater than 100,000 CFU/mL to indicate a urinary tract infection. The IPN acknowledged she should have confirmed whether a urine culture was obtained and clarified the order with the physician before starting the antibiotic. The IPN stated Ciprofloxacin was initiated in the facility for Resident 90, who received the full course of the medication. She stated it was her responsibility to track and monitor antibiotic use to ensure compliance with the Antibiotic Stewardship Program. The IPN stated that implementing the Antibiotic Stewardship Program was important to prevent the development of multidrug resistant organisms (MDRO- bacteria that have become resistant to multiple antibiotic making infections difficult to treat) in the facility.During an interview on 2/27/2026 at 2:08 p.m. with the Director of Nursing (DON), the DON stated Resident 90 will develop resistance to most antibiotic leading to MDRO if an antibiotic was administered without proper indication.During a review of facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, undated, the P&P indicated the program includes antibiotic use protocols and a system to monitor antibiotic use including laboratory testing will be used in accordance with current standards of practice. The P&P indicated antibiotic orders obtained upon admission, new admissions or readmission to the facility will be reviewed for appropriateness,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dental services in a timely manner for two of five sampled residents (Resident 32 and Resident 59). The facility failed to:1.Ensure appropriate follow up for Resident 59's denture needs.2.Provide a dental check up and evaluation for Resident 32, who was admitted with missing and broken teeth.These failures had the potential to result in discomfort and impaired chewing ability, which could lead to decreased appetite and weight loss for both Resident 32 and Resident 59. Findings:1.During a review of Resident 59's admission Record, the admission Record indicated Resident 59 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 69 with diagnoses including heart failure( chronic condition where the heart muscles becomes too weak or stiff to pump blood efficiently in our body), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and anxiety disorder(mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life).During a review of Resident 59's Care plan titled, Nutritional Status Risk for significant weight change due to behavior problem and mechanically altered diet related to pureed and mildly thick consistency (liquids thicker than water but easily pourable) initiated on 1/10/2026. The Care Plan interventions included monitoring tolerance to diet texture, consistency and notifying the physician if difficulties are noted.During a review of Resident 59's Minimum Data Set (MDS-a resident assessment tool) dated 1/17/2026, the MDS indicated Resident 59 had moderately impaired cognitive skills (a person is having trouble with thinking, memory, and learning). The MDS indicated Resident 59 required substantial/maximal assistance (helper does more than half the effort) with eating and oral hygiene.During a concurrent observation and interview with Resident 59 on 2/24/2026 at 10:02 a.m., observed Resident 59 had no lower teeth. Resident 59 stated he only had upper teeth and had been waiting for his lower denture for six months. Resident 59 stated he was on a pureed diet foods blended into a smooth, thick, pudding-like texture with no lumps, chunks, or seeds) because he was unable to chew regular texture foods (normal, everyday, solid foods that require standard chewing and swallowing) due to the absence of his lower teeth. Resident 59 stated he would like to occasionally eat a sandwich or have regular texture foods.During an interview on 2/25/2026 at 3:03 p.m., with the Social Worker (SW) , the SW stated that in December 2025 the dentist made an impression for Resident 59's lower denture, but she did not follow up on its status. The SW stated it was her responsibility to follow up and determine the cause of the delay. She stated without the lower denture, Resident 59 would be unable to eat well, which could lead to weight loss.2. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted on [DATE] to the facility with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder.During a review of Resident 32's Order Summary Report dated 1/8/2026, the Order Summary Report indicated an order of Dental Consult with treatment as needed and as indicated.During a review of Resident 32's Oral/Dental assessment dated [DATE], the Oral/Dental Assessment indicated Resident 32's had missing and unclean teeth.During a review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32 had intact cognition (thought process) and required supervision or touching assistance (helper provides verbal cues and contact guard assistance as the resident completes the activity) with eating and oral hygiene.During a concurrent observation and interview on 2/24/2026 at 12:32 p.m. and subsequent interview on 2/25/2026 at 3:43 p.m. with Resident 32, Resident 32 was eating lunch in his room. Observed missing and broken teeth on his lower and upper mouth. Resident 32 stated sometimes his teeth hurt and unable to eat harder food like apple.During an interview with the SW on 2/25/2026 at 2:49 p.m., and again during a follow up interview on 2/27/2026 at 11:42 a.m., the SW stated newly admitted residents are typically seen by a dentist within a couple of weeks. The SW stated she must have missed arranging the dental appointment for Resident 32 due to her workload, which resulted in the resident not being seen in a timely manner. The SW stated that Resident 32 may experience discomfort while eating, which could prevent him from consuming solid or harder foods.During an interview on 2/27/2026 at 2:08 p.m. with the Director of Nursing (DON), the DON stated that Resident 32 and Resident 59 could develop toothaches and experience discomfort while eating, which may lead to weight loss.During a review of facility's policy and procedure(P&P) titled, Ancillary Services, undated, the P&P indicated The facility will assess, arrange, coordinate and monitor ancillary services like dental services based on the resident's needs, physician orders, and interdisciplinary care plan.During a review of facility's P&P titled, Dental Services, undated, the P&P indicated dental needs of each resident are identified through physical assessment and identified needs as specified in resident's plan of care. The P&P indicated the facility will assist the resident with making dental appointments and obtaining routine and emergency dental care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients) for one of five sampled residents (Resident 48) who was prescribed an antibiotic drug without meeting the McGeers Criteria (a set of clinical definitions used for surveillance to define the resident symptoms and other clinical criteria that are used to meet infection surveillance definitions).This failure had the potential to result in Resident 48 developing antibiotic resistance (when bacteria develop defenses against the antibiotics designed to kill them) from unnecessary or inappropriate antibiotic use. Findings:During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 48's diagnoses included hypertensive heart disease (heart damage leading to high blood pressure), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), cataracts (a common age-related eye condition involving the clouding of the eye's normally clear lens) and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 48's History and Physical (H&P) dated 6/18/2025, the H&P indicated Resident 48 was self responsible.During a review of Resident 48's Minimum Data Set (MDS-a resident assessment tool), dated 1/7/2026, the MDS indicated Resident 48 needed substantial to maximal assistance (helper does all the effort) with toileting, showering, and dressing. The MDS indicated Resident 48 needed partial to moderate assistance (helper does half the record) with eating, oral hygiene, personal hygiene, transferring and walking.During a concurrent interview and record review on 2/26/2026 at 1:05 p.m., with the Infection Preventionist Nurse (IPN), Resident 48's Order Summary, dated 1/10/2026, was reviewed. The Order Summary indicated Resident 48 had an order for metronidazole external cream (an antifungal antibiotic cream) to treat rosacea (a chronic long-term inflammatory skin) 0.75 percent ([%] unit of measurement) for 30 Days. The IPN stated today is the first-time she has heard about Resident 48's order for the antibiotic. The IPN stated the McGeer's criteria were not followed because it was not communicated that Resident 48 was on antibiotics. The IPN stated Resident 48 could develop a Multi Drug Resistant Organism (MDRO-bacteria or germs resistant to multiple types of antibiotics) if there is no monitoring if the antibiotic is effective.During an interview on 2/26/2026 at 3:29 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated on 10/31/2025 Resident 48 developed redness on the face and scalp. LVN 3 stated the doctor ordered the metronidazole external cream 0.75 %, on 12/12/2026, 1/10/26, and 2/13/2026. LVN 3 stated she did not notify the IPN Resident 48 was taking metronidazole cream, because she thought she only had to inform the IPN for antibiotics taken by mouth. LVN 3 stated Resident 48 was not monitored for effectiveness of metronidazole cream.During an interview on 2/27/2026 at 1:57 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated metronidazole cream is an anti-fungal medication and needed to be monitored for Resident 48 for side effects to see if the skin infection was getting better. RNS 1 stated all skin issues should be documented, to know the condition of the skin.During a review of the facility's policy and procedure (P&P), titled, Unnecessary Drugs-Without Adequate Indication for Use, undated, the P&P indicated, each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements dose, duration of use, indications for use, adequate monitoring, presence of adverse consequences which indicate the dose should be reduced or discontinued, any combination of the reasons stated above. The P&P indicated the use of any drug will be documented in the medical record to facilitate adequate care planning, including appropriate monitoring and resident centered care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that the attending physician was notified of a change in condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death ) for one of three sampled residents (Resident 1), after Resident 1 reported being struck and expressed fear, indicating a psychosocial change ( shifts in a person's thoughts, feelings, behaviors, and relationships) in condition. This failure had the potential to delay or prevent medical and mental health evaluation, resulting in unaddressed psychosocial distress, continued fear, lack of appropriate interventions, and increased risk to resident safety and well-being.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities). During a review of Resident 1's History and Physical (H&P) dated 10/18/2025, the H&P indicated Resident 1 had the capacity to understand and make own decisions. During a review of Resident 1's Minimum Data Set ([MDS]resident assessment tool) dated 11/19/2025, the MDS indicated Resident 1 had moderate cognitive impairment (problems with memory and thinking and dependent (helper does all of the effort, resident does none of the effort to complete the activity) for oral care, toileting hygiene, and shower/bathe self. During an interview on 12/16/2025 at 8:32 a.m. with Resident 1, Resident 1 stated that he could not recall the allegation of an unknown black male striking him in the stomach and was unable to provide additional details related to the reported incident. Resident 1 stated I feel safe while you were here, but I won't feel safe when you leave, because he believes nothing will be done to address his concerns when surveyor leave. During a concurrent interview and record review on 12/16/2025 at 10:10 a.m. with License Vocational Nurse (LVN) 1, Resident 1's Care Plan was reviewed, the Care Plan indicated that there was no documentation indicating Resident 1's care plan was reviewed or updated in response to the resident's reported allegation of unknown black male striking him in the stomach. LVN 1 stated that he was first made aware of the alleged allegation on 12/9/2025 at approximately 9:00 a.m. to 10:00 a.m. by the ombudsman (an official appointed to investigate individuals' complaints). LVN 1 stated that the ombudsman informed him that Resident 1 reported that an unknown black man struck him, in the stomach, and that the date of the alleged incident could not be verified. LVN 1 stated that if a resident reports being struck and expressing fear, it would be considered a change in condition including a psychosocial change. LVN 1 stated that when a resident experiences a change in condition, the primary physician should be notified, the notification should be documented, and the resident's care plan should be reviewed and updated to address the identified concern. LVN 1 stated that failure to notify the physician and update the care plan could result in the residents' needs not being addressed, including unresolved fear, psychosocial distress, and lack of appropriate medical or mental health interventions. LVN 1 stated that he did not notify Resident 1's physician or document the incident because he believed it was not required, explaining that the resident has a history of making similar statements or allegations and that he therefore did not feel documentation was necessary. During an interview on 12/16/2025 at 10:30 a.m. with Registered Nurse Supervisor (RNS), the RNS stated that she was first made aware of the alleged incident on 12/9/2024 at approximately 2:00 p.m. by the Social Service Director (SSD). The RNS stated that the SSD stated that Resident 1 had reported that a black man came into his room and hit him in the stomach. The RNS stated that a resident reporting being struck and expressing fear would be considered a change in condition, including a psychosocial change. The RNS stated that when a resident experiences a change in condition, residents' physician should be notified, the notification should be documented, and the resident's care plan should be reviewed and updated to reflect the identified needs. The RNS stated that failure to follow these procedures could result in the residents' needs not being appropriately addressed, including continued fear, unresolved psychosocial distress, delay in medical or mental health evaluations, and staff being unaware of interventions necessary to ensure the resident's safety and well-being. The RNS stated that it was her role and responsibility to ensure that staff review and update resident's care plans. During an interview on 12/16/2025 at 11:00 a.m. with the Director of Nursing (DON), the DON stated that her role and responsibilities includes oversight of nursing operations, including supervision of nursing staff, ensuring compliance with facility policies and procedures, and ensuring appropriate follow-up when residents experience a change in condition. The DON stated that if a resident reports being struck and expressing fear a change in condition would be considered, including a psychosocial change. The DON stated that when a resident has a change in condition, physician should be notified, the notification should be documented, and the resident's care plan should be reviewed and updated to reflect the identified needs. The DON acknowledged that the change in condition was not documented, Resident 1's physician was not notified, and the resident's care plan was not reviewed or updated as required. The DON stated that these actions should have occurred in accordance with the facility's policies and procedures. The DON stated that she believed this represented a system failure, rather an isolated individual failure, due to a breakdown in communication and follow-through among nursing staff. The DON stated that failure to document a change in condition, notify the physician, and update the care plan could result in delayed medical or mental health evaluation, unaddressed psychosocial distress, lack of appropriate interventions, and increased risk to resident safety and well-being. During a review of Resident 1's Psychological Consultation, dated December 2025, the Psychological Consultation, indicated that Resident 1 shared that he feels unsafe and persecuted by others based on race. Resident 1 shared that he believes that people of a darker skin color were conspiring against him to harm him. During a review of the facility's policy and procedure (P&P) tilted, Change in a Resident's Condition or Status, [undated], the P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights etc.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the comprehensive care plan (a personalized, written guide detailing a patient's health status, specific needs, goals, and the nursing actions [interventions]) was developed and implemented for one of three sampled residents (Resident 1) following a change in condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death), when Resident 1 reported being struck and expressed fear, indicating a psychosocial change ( shifts in a person's thoughts, feelings, behaviors, and relationships) in condition. This deficient practice had the potential to result in staff being unaware of the residents' psychosocial and safety needs leading to inconsistent care, lack of protective interventions, continued fear, unaddressed psychosocial distress, and increased risk to resident safety and well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities). During a review of Resident 1's History and Physical (H&P) dated 10/18/2025, the H&P indicated Resident 1 had the capacity to understand and make own decisions. During a review of Resident 1's Minimum Data Set ([MDS]resident assessment tool) dated 11/19/2025, the MDS indicated Resident 1 had moderate cognitive impairment (problems with memory and thinking and dependent ( helper does all of the effort, resident does none of the effort to complete the activity) for oral care, toileting hygiene, and shower/bathe self. During an interview on 12/16/2025 at 8:32 a.m. with Resident 1, Resident 1 stated that he could not recall the allegation of an unknown black male striking him in the stomach and was unable to provide additional details related to the reported incident. Resident 1 stated I feel safe while you were here, but I won't feel safe when you leave, because he believes nothing will be done to address his concerns when surveyor leave. During a concurrent interview and record review on 12/16/2025 at 10:10 a.m. with License Vocational Nurse (LVN) 1, Resident 1's Care Plan was reviewed, the Care Plan indicated that there was no documentation indicating Resident 1's care plan was developed and implemented after Resident 1's reported allegation of an unknown black male striking him in the stomach. LVN 1 stated that he was first made aware of the alleged allegation on 12/9/2025 at approximately 9:00a.m. to 10:00 a.m. by the ombudsman (an official appointed to investigate individuals' complaints). LVN 1 stated that the ombudsman informed him that Resident 1 reported that an unknown black man struck him, in the stomach, and that the date of the alleged incident could not be verified. LVN 1 stated that if a resident reports being struck and expressing fear that it would be considered a change in condition including a psychosocial change. LVN 1 stated Resident 1's care plan should be reviewed and updated to address the identified concern. LVN 1 stated that failure update the care plan could result in the residents' needs not being addressed, including unresolved fear, psychosocial distress, and lack of appropriate medical or mental health interventions. During an interview on 12/16/2025 at 10:30 a.m. with Registered Nurse Supervisor (RNS), the RNS stated that she was first made aware of the alleged incident on 12/9/2024 at approximately 2:00 p.m. by the Social Service Director (SSD). The RNS stated that the SSD stated that Resident 1 had reported that a black man came into his room and hit him in the stomach. The RNS stated that a resident reporting being struck and expressing fear would be considered a change in condition, including a psychosocial change. The RNS stated that when a resident experiences a change in condition, resident's care plan should be reviewed and updated to reflect the identified needs. The RNS stated that failure to follow these procedures could result in the residents' needs not being appropriately addressed, including continued fear, unresolved psychosocial distress, delay in medical or mental health evaluations, and staff being unaware of interventions necessary to ensure the resident's safety and well-being. The RNS stated that it is her role and responsibility to ensure that staff review and update resident's care plans. During an interview on 12/16/2025 at 11:00 a.m. with the Director of Nursing (DON), the DON stated that if a resident reports being struck and expressing fear a change in condition would be considered, including a psychosocial change. The DON stated that when a resident has a change in condition, resident's care plan should be reviewed and updated to reflect the identified needs. The DON acknowledged that the change in condition was not documented, and the residents' care plan was not reviewed or updated as required. The DON stated that failure to update the care plan could result in delayed medical or mental health evaluation, unaddressed psychosocial distress, lack of appropriate interventions, and increased risk to resident safety and well-being. During a review of Resident 1's Psychological Consultation, dated December 2025, the Psychological Consultation, indicated that Resident 1 shared that he feels unsafe and persecuted by others based on race. Resident 1 shared that he believes that people of a darker skin color were conspiring against him to harm him. During a review of the facility's policy and procedure (P&P) titled, Reviewing and Revising the Care Plan, [undated], the P&P indicated, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow enhanced barrier precautions ([EBP] an infection control intervention designed to reduce transmission of multidrug- resistant organisms that employs targeted gown and gloves use during high contact resident care activities) for one sampled resident (Resident 4) when Treatment Nurse (TN) 1 did not wear a gown while providing care to Resident 4's wound. This deficient practice resulted in an increased risk for Resident 4's wound to become infected. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with a diagnosis of chronic (constantly recurring) osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the right ankle and foot and peripheral vascular disease ([PVD] a slow progressive narrowing of the blood flow to the arms and legs. During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool) dated 8/14/2025, the MDS indicated Resident 4's cognition was moderately impaired, and Resident 4 was dependent on facility staff to complete his activities daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 4's Physician's Order dated 8/7/2025, the Physician's Order indicated to use enhanced barrier precautions related to Resident 4's PVD and an ulcer (a small open sore or wound generally found in the stomach or on the skin) to Resident 4's right heel. During a review of Resident 4's Treatment Administration Record (TAR), dated 10/2025, the TAR indicated to cleanse Resident 4's left plantar (sole of the foot) foot with normal saline (a saltwater solution), pat dry, paint with povidone iodine (a solution used to clean and disinfect the skin), and cover with a dry dressing every day. During an observation outside of Resident 4's room on 10/21/2025 at 8:40 a.m., an EBP sign was observed to the left of the doorway to Resident 4's room. During an observation and interview on 10/21/2025 at 8:40 a.m., and 8:55 a.m., TN 1 was observed providing care to Resident 4's left plantar foot wound, wearing gloves only, no gown. TN 1 stated she was not aware a gown was required when providing wound care for residents who were on EBP. During an interview on 10/21/2025 at 11:56 a.m., the Infection Control Nurse (IPN) stated residents who have wounds, who were on dialysis, and had indwelling medical devices were placed on EBP to protect them from infection. The IPN stated facility staff should wear gowns and gloves during high contact activities such as transferring residents and dressing changes. During an interview on 10/21/2025 at 1:38 p.m., the Director of Nursing (DON) stated the purpose of EBP is to prevent the spread of infection especially for those residents who have indwelling medical devices and open wounds. The DON stated if the resident had an open wound, facility staff should wear gloves and gowns when providing wound care. During a review of the facility's Policy and Procedure (P/P) titled Enhanced Barrier Precautions dated 2024, the P/P indicated personal protective equipment ([PPE] - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for enhanced barrier precautions is only necessary when performing high contact care activities and may not need to be donned prior to entering the resident's room. The P/P indicated high contact resident care activities include wound care: any skin opening requiring a dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of abuse for one of two sample residents (Resident 1), when Resident 1 told Certified Nursing Assistant (CNA) 1, that Resident 2 threw water on her (Resident 1). This deficit practice resulted in the inability of the California Department of Public Health (CDPH) to conduct a timely investigation and had the potential for information to be lost and/or forgotten. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of hypertensive heart disease (a condition where the heart has been damaged by years of high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/10/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 1 was dependent on facility staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was severely impaired, and Resident 2 required partial/moderate assistance (helper does less than half the effort) to complete her ADLs. During an interview on 10/21/2025 at 9:04 a.m., Resident 1 stated while she was receiving ADL care from CNA 1, Resident 2 came over and poured water on her face, and the water went down her throat. During the interview Resident 1 was observed crying and stated she felt like she was drowning when the water was going down her throat. Resident 1 stated Resident 2 did not like her voice and had told her in the past, to shut the f*ck up and facility staff were present in the room when this happened. During an interview on 10/21/2025 at 9:56 a.m., and a subsequent interview at 12:24 p.m., CNA 1 stated while providing ADL care to Resident 1, she (CNA 1) left the room to follow up on Resident 1's treatment. CNA 1 stated when she returned to the room she heard Resident 1 screaming. CNA 1 stated Resident 1 informed her that Resident 2 threw water on her. CNA 1 stated Resident 1 was crying, and her upper body was soaking wet. CNA 1 stated the Director of Nursing (DON) came to the room to find out why Resident 1 was screaming, that's when she (CNA 1) reported to the DON about the allegation made by Resident 1 against Resident 2. During an interview on 10/21/2025 at 11:43 a.m., the DON stated she was not aware of any incident occurring between Resident 1 and Resident 2. The DON stated she did not go to Resident 1's room and CNA 1 did not report Resident 1's allegation to her. The DON stated CNA 1 should have reported the allegation of abuse to the charge nurse, to her (DON) or the ADM, so they could investigate, report to CDPH, and the ombudsman. During a review of the facility's undated Policy and Procedure (P/P) titled Reporting Abuse to Facility Management the P/P indicated employees must immediately report any suspected abuse or incidents of abuse to the DON. The P/P indicated any individual observing resident abuse or suspecting resident abuse must immediately report such incident to the ADM or DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was not subject to abuse when Resident 2, who has history of schizophrenia (a mental illness that is characterized by disturbances in thought), and sudden mood changes threw water on Resident 1. This deficient practice resulted in Resident 1 feeling like she was drowning when the water that Resident 2 threw on her, covered her face, went into her mouth and down her throat.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of hypertensive heart disease (a condition where the heart has been damaged by years of high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/10/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 1 was dependent on facility staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was severely impaired, and Resident 2 required partial/moderate assistance (helper does less than half the effort) to complete her ADLs. During an interview on 10/21/2025 at 9:04 a.m., Resident 1 stated while she was receiving ADL care from CNA 1, Resident 2 came over and poured water on her face, and the water went down her throat. During the interview Resident 1 was observed crying and stated she felt like she was drowning when the water was going down her throat. Resident 1 stated Resident 2 did not like her voice and had told her in the past, to shut the f*ck up and facility staff were present in the room when this happened. During an interview on 10/21/2025 at 9:45 a.m., Resident 3 stated she saw Resident 2 pour water on Resident 1's face. Resident 3 stated it looked like attempted murder, and it was intentional, like Resident 2 was drowning someone who could not move. Resident 3 stated the facility should have called the police, but they did not. During an interview on 10/21/2025 at 9:56 a.m., and a subsequent interview at 12:24 p.m., CNA 1 stated while providing ADL care to Resident 1, she (CNA 1) left the room to follow up on Resident 1's treatment. CNA 1 stated when she returned to the room she heard Resident 1 screaming. CNA 1 stated Resident 1 informed her that Resident 2 threw water on her. CNA 1 stated Resident 1 was crying, and her upper body was soaking wet. CNA 1 stated there were times when Resident 1 feared Resident 2 because when Resident 1 watched her television, Resident 2 would get mad at Resident 1 for having the volume up. CNA 1 stated on the same day, before the incident with the water pitcher, she saw Resident 2 move Resident 1's bedside table to her (Resident 2) side of the room, which made Resident 1 upset and caused her to cry. CNA 1 stated she had to remind Resident 2 that it was not her bedside table. During an interview on 10/21/2025 at 11:43 a.m., the Director of Nursing (DON) stated she was not aware of any incident occurring between Resident 1 and Resident 2. The DON stated if Resident 2 poured water on Resident 1, that would be considered abuse and had the potential for Resident 1 to be harmed. During a review of the facility's undated Policy and Procedure (P/P) titled Abuse, Neglect and Exploitation the P/P indicated each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P/P indicated a resident must not be subject to abuse by anyone, including but not limited to other residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment for one of three sampled residents (Resident 1). This deficient practice had the potential to expose residents to unsanitary conditions and increase the risk of transmission of disease-causing organisms. Findings: During review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), hyperlipidemia ( a condition where both cholesterol and triglycerides are elevated in the blood) , and lack of coordination (refers to jerky, uncoordinated movements and balance problems caused by an issue with the part of the brain that controls muscle coordination). During a review of Resident 1's Minimum Data Set (MDS -resident assessment tool), dated 09/19/2025, the MDS indicated Resident 1's cognitive (ability to think, understand, learn, and remember) skill for daily decision-making was intact. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half of the effort. Helpers lift or hold the trunk or limbs and provide less than the effort) in oral hygiene, toilet hygiene, shower/bath self, upper body dressing, lower body dressing, putting on /taking off footwear and personal hygiene. During a concurrent observation on 11/19/2025 at 9:30 a.m., with Resident 1. Resident 1's room was observed to be in an unsanitary condition. Resident trash was overflowing from the bedside trash can, brown substances were scattered on the floor near the bed, the wall beside the bed had visible juice-like stains, and the restroom had multiple black stains on the floor and around the toilet. During an interview on 11/19/2025 at 11:21 a.m., with Certified Nurse Assistant (CNA) 1 , CNA 1 stated she had not yet called housekeeping, as she was waiting to assist Resident 1 out of the room. CNA 1 stated she should have picked up the trash and cleaned the area, even while attending to other residents.During an interview on 11/19/25 at 1:42 p.m. with Housekeeper (HK), HK stated she was working her way down the hallway and had not yet reached Resident 1's room HK stated resident rooms were cleaned once per shift and as needed. During an interview on 11/19/25 at 1:54 pm with the Housekeeping Supervisor (HS), HS stated that rooms are cleaned daily, and housekeepers were expected to make rounds of their assigned areas before leaving. HS acknowledged the restroom stains and stated that facility management was working on replacing the old flooring. During an interview on 11/19/25 at 2: 13 p.m. with the Director of Nursing (DON) the DON stated she was unaware of the room's condition and acknowledged that all rooms were undergoing remodeling. The DON stated she will address the issue with housekeeping and provide in-service training. During a review of the facility's policy and procedure (P&P) titled Safe and home like Environment (undated) the P&P indicated In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment.

Based on observation, interview, and record review, the facility failed to ensure that window blinds were intact and provided adequate visual privacy for 5 of 18 sampled residents. This deficient practice resulted in residents' exposure to the parking lot and sunlight and a potential violation of residents' rights to visual privacy in five resident rooms.Findings: During a concurrent observation and interview on 11/19/2025 at 09:30 a.m. with Resident 1, Resident 1 room window blinds were missing slats, allowing sunlight and visibility from the parking lot. Resident 1 stated, I turn to the opposite side and cover my head when the sun rises. During a concurrent observation and interview on 11/19/2025 at 10:06 a.m., with Resident 4 in Resident 4's room, observed missing pieces of the window blinds. Resident 4 was exposed to the parking lot and sunlight was penetrating in the room on Resident 4 face. Resident 4 stated that the blinds had been broken for a long time and no one had come to fix them. During an interview on 11/19/25 at 2: 13 p.m. with the Director of Nursing (DON), the DON stated she was aware of the missing blinds. The DON stated she would conduct rounds to ensure such issues were addressed promptly. During an interview on 11/19/2025 at 2:35 pm with Maintenance Director (MD), the MD stated the broken window blinds had been brought to his attention, but he had failed to follow up. The MD stated it was his responsibility to conduct daily rounds. The MD stated he would implement a task log to ensure follow-up. The MD confirmed that the missing blinds exposed residents to the parking lot and sunlight and reported that replacement parts had been ordered and repairs were underway. During a review of the facility's policy and procedure (P&P) titled Resident Right, (undated), the P&P indicated, The residents have a right to a safe, clean, comfortable and homelike environment. During a review of the facility's P&P titled Safe and home like Environment (undated), the P&P indicated In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 was competent and reported a Change of Condition (COC) for one out of three sampled residents (Resident 1) who experienced new right hip pain and decreased right hip range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) to the director of nursing (DON) for further assessment.
As a result of this deficient practice, Resident 1 had the potential for delays in care and on 5/4/2025 Resident 1 was found to have a right hip fracture (broken bone).
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of encounter for orthopedic (a branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the skeleton and structures (as tendons and ligaments) closely associated with it) aftercare, epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive (lowering of a person ' s mood) lows to manic (extremely elevated and excitable mood) highs).
During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 had no functional limitations in ROM for the upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities.
During a review of Resident 1 ' s Nursing Note dated 4/28/2025, the note indicated Resident 1 complained of pain in the right hip radiating (pain that travels from one body part to another) to the right knee. The note indicated Resident 1 had trouble the morning of 4/28/2025 performing activities of daily living (ADLs, refer to the basic skills necessary for individuals to independently care for themselves) and required assistance from the certified nursing assistant (CNA) 1 to complete the tasks. The note indicated Resident 1 was unable to perform ROM on the right leg and was complaining of pain 6 out of 10 on the pain scale (measures patients pain levels, on a zero out of 10-pain scale, zero meant no pain and 10 meant the worst pain imaginable).
During a review of Resident 1 ' s Nursing Note dated 4/28/2025, Resident 1 was transferred to a general acute care hospital (GACH) for an unrelated incident (not related to the right hip pain or limited ROM) due to hypotension (low blood pressure).
During a review of Resident 1 ' s GACH Progress Note- Orthopedic Medicine dated 5/7/2025, the note indicated Resident 1 was initially admitted to the GACH 4/28/2025 for right sided weakness and a stroke (blocked blood flow in the brain) workup but was found to have a right hip fracture on 5/4/2025 requiring surgery.
During a review of Resident 1 ' s Nursing Note dated 5/8/2025, the note indicated Resident 1 was admitted back to the facility from the GACH with a diagnosis of a hip fracture (right hip).
During an interview on 5/15/2025 at 1:31 p.m., CNA 1 stated Resident 1 was usually able to walk and get himself dressed but on 4/28/2025 he had a change in condition (COC). CNA 1 stated the morning of 4/28/2025 she noticed Resident 1 was not out of bed to go smoke so she went to check on him and he stated he could not move which was a change from his baseline. CNA 1 stated it took two people to change him that morning when he could usually do it by himself. CNA 1 stated Resident 1 was unable to move his right leg, so she called the charge nurse (licensed vocational nurse (LVN) 1) to come and assess Resident 1. CNA 1 stated she was unsure how the patient became injured.
During an interview on 5/15/2025 at 1:55 p.m., LVN 1 stated Resident 1 complained of right hip pain on 4/28/2025. LVN 1 stated CNA 1 informed her that Resident 1 required extra assistance for ADLs the morning of 4/28/2025. LVN 1 stated she assessed Resident 1 and did not see any bruising or swelling on the right leg, so she thought maybe he slept on his leg wrong causing the pain, so she gave him Tylenol (pain medication). LVN 1 stated Resident 1 was able to lift the right leg but not as much as the left leg and he was signaling (patient hard to understand) his right leg was painful. LVN 1 stated the decrease in ROM of the right leg and the new pain was new for Resident 1. LVN 1 stated Resident 1 was hard to understand but she asked him if he hit himself or got hurt and he kept shaking his head no. LVN 1 stated the director of nursing (DON) was the supervisor for the day, but she did not tell the DON about the COC for decreased ROM or new right hip pain for Resident 1. LVN 1 stated they usually tell the supervisors about COCs to get a second set of eyes assessing the resident, but she did not tell the DON that day because Resident 1 was just complaining of pain and thought he would be better after the Tylenol. LVN 1 stated she did not think it was a big problem. LVN 1 stated she did inform Resident 1 ' s physician (MD) 1 about Resident 1 ' s situation and he just ordered (Ibuprofen, a medication used to treat mild to moderate pain) but did not order an X-ray (a photographic or digital image of the internal composition of something, especially a part of the body).
During an interview on 5/15/2025 at 3:28 p.m., the DON stated she was made aware of the right hip fracture when Resident 1 was readmitted to the facility on [DATE] but she could not understand how the fracture happened. The DON reviewed Resident 1 ' s Nurses Note from 4/28/2025 and stated she was not made aware Resident 1 was having the right hip pain or decreased ROM of the right hip on 4/28/2025, the day he was transferred to the GACH. The DON stated LVN 1 did not inform her Resident 1 had a COC or she would have gone to assess Resident 1 herself and recommended a right hip X-ray be ordered by MD 1. The DON stated it was important that the supervisor was made aware of COCs so a comprehensive assessment could be done, appropriate interventions could be placed, and an investigation into the cause of the injury could be conducted. The DON stated LVN 1 was not competent in reporting COCs to the supervisor based on this incident. The DON stated Resident 1 ' s right hip fracture was an injury of unknown origin because the pain and decreased ROM began prior to his discharge to the GACH, and they did not know how the injury occurred.
During a review of the facility ' s Charge Nurse Job description revised in 2023, the job description indicated the LVN was to report any incidents or unusual occurrences to the supervisor, unit manager, or DON and participate in the investigative process as needed.
During a review of the facility ' s P/P titled Injury of Unknown Origin Policy undated, the P/P indicated an injury of unknown origin was any injury where: the cause or circumstances are not witnessed or reported, the resident is unable to explain how the injury occurred, and the injury is not consistent with the resident ' s known condition or typical behavior. The p/p indicated department leadership was to be notified as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an injury of unknown origin (an injury whose source was not observed by any person or cannot be explained by the individual) to the State Department per the facility ' s policy and procedure (P/P) titled Abuse, Neglect and Exploitation for one of three sampled residents (Resident 1) when Resident 1 who was complaining of right hip pain and was experiencing decreased range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point), was found to have right hip fracture (broken bone).
As a result of this deficient practice, Resident 1 had the potential for delay in care and investigation into the cause of Resident 1 ' s fractured right hip.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility 1/31/2019 and was readmitted [DATE] with diagnoses of encounter for orthopedic (a branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the skeleton and structures (as tendons and ligaments) closely associated with it) aftercare, epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive [lowering of a person ' s mood] lows to manic [extremely elevated and excitable mood] highs).
During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 had no functional limitations in range of motion for the upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities.
During a review of Resident 1 ' s Nursing Note dated 4/28/2025, the note indicated Resident 1 complained of pain in the right hip radiating (pain that travels from one body part to another) to the right knee. The note indicated Resident 1 had trouble the morning of 4/28/2025 performing activities of daily living (ADLs, refer to the basic skills necessary for individuals to independently care for themselves) and required assistance from the certified nursing assistant (CNA) 1 to complete the tasks. The note indicated Resident 1 was unable to perform ROM on the right leg and was complaining of pain 6 out of 10 on the pain scale (measures patients pain levels, on a zero out of 10-pain scale, zero meant no pain and 10 meant the worst pain imaginable).
During a review of Resident 1 ' s Nursing Note dated 4/28/2025, Resident 1 was transferred to a general acute care hospital (GACH) for an unrelated incident (not related to the right hip pain or limited ROM) due to hypotension (low blood pressure).
During a review of Resident 1 ' s GACH Progress Note- Orthopedic (branch of medicine dealing with the treating of deformities of bones or muscles) Medicine dated 5/7/2025, the note indicated Resident 1 was initially admitted to the GACH on 4/28/2025 for right sided weakness and a stroke (blocked blood flow in the brain) workup but was found to have a right hip fracture on 5/4/2025 requiring surgery.
During a review of Resident 1 ' s Nursing Note dated 5/8/2025, the note indicated Resident 1 was admitted back to the facility from the GACH with a diagnosis of a hip fracture (right hip).
During an interview on 5/15/2025 at 1:31 p.m., CNA 1 stated Resident 1 was usually able to walk and get himself dressed but on 4/28/2025 he had a change in condition (COC). CNA 1 stated the morning of 4/28/2025 she noticed Resident 1 was not out of bed to go smoke so she went to check on him and he stated he could not move which was a change from his baseline. CNA 1 stated it took two people to change him that morning when he could usually do it by himself. CNA 1 stated Resident 1 was unable to move his right leg, so she called the charge nurse (licensed vocational nurse (LVN) 1) to come and assess Resident 1. CNA 1 stated she was unsure how the patient became injured.
During an interview on 5/15/2025 at 1:55 p.m., LVN 1 stated Resident 1 complained of right hip pain on the morning of 4/28/2025. LVN 1 stated CNA 1 informed her that Resident 1 required extra assistance for ADLs the morning of 4/28/2025. LVN 1 stated she assessed Resident 1 and did not see any bruising or swelling on the right leg, so she thought maybe he slept on his leg wrong causing the pain, so she gave him Tylenol (pain medication). LVN 1 stated Resident 1 was able to lift the right leg but not as much as the left leg and he was signaling (patient hard to understand) his right leg was painful. LVN 1 stated the decrease in ROM of the right leg and the new pain was new for Resident 1. LVN 1 stated Resident 1 was hard to understand but she asked him if he hit himself or got hurt and he kept shaking his head no. LVN 1 stated the director of nursing (DON) was the supervisor for the day, but she did not tell the DON about the COC for decreased ROM or new right hip pain for Resident 1. LVN 1 stated they usually tell the supervisors about COCs to get a second set of eyes assessing the resident, but she did not tell the DON that day because Resident 1 was just complaining of pain and thought he would be better after the Tylenol. LVN 1 stated she did not think it was a big problem. LVN 1 stated she did inform Resident 1 ' s physician (MD) 1 about Resident 1 ' s situation and he just ordered (Ibuprofen, a medication used to treat mild to moderate pain) but did not order an X-ray (a photographic or digital image of the internal composition of something, especially a part of the body).
During an interview on 5/15/2025 at 3:28 p.m., the DON stated she was made aware of the right hip fracture when Resident 1 was readmitted to the facility on [DATE] but she could not understand how the fracture happened. The DON reviewed Resident 1 ' s Nurses Note from 4/28/2025 and stated she was not made aware Resident 1 was having the right hip pain or decreased ROM of the right hip on 4/28/2025, the day he was transferred to the GACH. The DON stated LVN 1 did not inform her Resident 1 had a COC or she would have gone to assess Resident 1 herself and recommended a right hip X-ray be ordered by MD 1. The DON stated it was important that the supervisor was made aware of COCs so a comprehensive assessment could be done, appropriate interventions could be placed, and an investigation into the cause of the injury could be conducted. The DON stated Resident 1 ' s right hip fracture was an injury of unknown origin because the pain and decreased ROM began prior to his discharge to the GACH, and they did not know how the injury occurred. The DON stated injuries of unknown origin should be reported to the state department, but it was not done because she was not made aware. The DON stated it was important to investigate and report injuries of unknown origin because the facility does not know how the injury occurred and there was a possibility it happened due to an altercation with another resident or another unknown reason.
During an interview on 5/16/2025 at 10:50 a.m., the DON stated Resident 1 ' s right hip fracture (injury of unknown origin) should have been reported to the state department at the time of the incident. The DON stated she found out about the fracture on 5/8/2025 and the incident should have been reported, and they did not report the incident because she found out about the injury of unknown origin after the fact. The DON reviewed the facility ' s P/P titled Abuse, Neglect and Exploitation and stated per the facility policy the injury of unknown origin should have been reported to the state agency. The DON stated in the future injuries of unknown origin will be reported to the state agency as soon as they are discovered, even if it was after the fact.
During a review of the facility ' s P/P titled Abuse, Neglect and Exploitation undated, the P/P indicated the facility must ensure all alleged violations including injuries of unknown source (injuries of unknown origin) must be reported immediately but not later than two hours after the allegation is made, if the events result in serious bodily injury, to the facility administrator and the State Survey Agency.
During a review of the facility ' s P/P titled Injury of Unknown Origin Policy undated, the P/P indicated an injury of unknown origin was any injury where: the cause or circumstances are not witnessed or reported, the resident is unable to explain how the injury occurred, and the injury is not consistent with the resident ' s known condition or typical behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate an injury of unknown origin (an injury whose source was not observed by any person or cannot be explained by the individual) for one of three sampled residents (Resident 1) when Resident 1 was found to have right hip fracture (broken bone).
As a result of this deficient practice, Resident 1 had the potential for delay in care and investigation into the cause of Resident 1 ' s injury.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility 1/31/2019 and was readmitted [DATE] with diagnoses of encounter for orthopedic (a branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the skeleton and structures (as tendons and ligaments) closely associated with it) aftercare, epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive (lowering of a person ' s mood) lows to manic (extremely elevated and excitable mood) highs).
During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 had no functional limitations in range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) for the upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities.
During a review of Resident 1 ' s Nursing Note dated 4/28/2025, the note indicated Resident 1 complained of pain in the right hip radiating (pain that travels from one body part to another) to the right knee. The note indicated Resident 1 had trouble the morning of 4/28/2025 performing activities of daily living (ADLs, refer to the basic skills necessary for individuals to independently care for themselves) and required assistance from the certified nursing assistant (CNA) 1 to complete the tasks. The note indicated Resident 1 was unable to perform ROM on the right leg and was complaining of pain 6 out of 10 on the pain scale (measures patients pain levels, on a zero out of 10-pain scale, zero meant no pain and 10 meant the worst pain imaginable).
During a review of Resident 1 ' s Nursing Note dated 4/28/2025, Resident 1 was transferred to a general acute care hospital (GACH) for an unrelated incident (not related to the right hip pain or limited ROM) due to hypotension (low blood pressure).
During a review of Resident 1 ' s GACH Progress Note- Orthopedic Medicine dated 5/7/2025, the note indicated Resident 1 was initially admitted to the GACH 4/28/2025 for right sided weakness and a stroke (blocked blood flow in the brain) workup but was found to have a right hip fracture on 5/4/2025 requiring surgery.
During a review of Resident 1 ' s Nursing Note dated 5/8/2025, the note indicated Resident 1 was admitted back to the facility from the GACH with a diagnosis of a hip fracture (right hip).
During an interview on 5/15/2025 at 1:31 p.m., CNA 1 stated Resident 1 was usually able to walk and get himself dressed but on 4/28/2025 he had a change in condition (COC). CNA 1 stated the morning of 4/28/2025 she noticed Resident 1 was not out of bed to go smoke so she went to check on him and he stated he could not move which was a change from his baseline. CNA 1 stated it took two people to change him that morning when he could usually do it by himself. CNA 1 stated Resident 1 was unable to move his right leg, so she called the charge nurse (licensed vocational nurse (LVN) 1) to come and assess Resident 1. CNA 1 stated she was unsure how the patient became injured.
During an interview on 5/15/2025 at 1:55 p.m., LVN 1 stated Resident 1 complained of right hip pain on the morning of 4/28/2025. LVN 1 stated CNA 1 informed her that Resident 1 required extra assistance for ADLs the morning of 4/28/2025. LVN 1 stated she assessed Resident 1 and did not see any bruising or swelling on the right leg, so she thought maybe he slept on his leg wrong causing the pain, so she gave him Tylenol (pain medication). LVN 1 stated Resident 1 was able to lift the right leg but not as much as the left leg and he was signaling (patient hard to understand) his right leg was painful. LVN 1 stated the decrease in ROM of the right leg and the new pain was new for Resident 1. LVN 1 stated Resident 1 was hard to understand but she asked him if he hit himself or got hurt and he kept shaking his head no. LVN 1 stated the director of nursing (DON) was the supervisor for the day, but she did not tell the DON about the COC for decreased ROM or new right hip pain for Resident 1. LVN 1 stated they usually tell the supervisors about COCs to get a second set of eyes assessing the resident, but she did not tell the DON that day because Resident 1 was just complaining of pain and thought he would be better after the Tylenol. LVN 1 stated she did not think it was a big problem. LVN 1 stated she did inform Resident 1 ' s physician (MD) 1 about Resident 1 ' s situation and he just ordered (Ibuprofen, a medication used to treat mild to moderate pain) but did not order an X-ray (a photographic or digital image of the internal composition of something, especially a part of the body).
During an interview on 5/15/2025 at 3:28 p.m., the DON stated she was made aware of the right hip fracture when Resident 1 was readmitted to the facility on [DATE] but she could not understand how the fracture happened. The DON reviewed Resident 1 ' s Nurses Note from 4/28/2025 and stated she was not made aware Resident 1 was having the right hip pain or decreased ROM of the right hip on 4/28/2025, the day he was transferred to the GACH. The DON stated LVN 1 did not inform her Resident 1 had a COC or she would have gone to assess Resident 1 herself and recommended a right hip X-ray be ordered by MD 1. The DON stated it was important that the supervisor was made aware of COCs so a comprehensive assessment could be done, appropriate interventions could be placed, and an investigation into the cause of the injury could be conducted. The DON stated Resident 1 ' s right hip fracture was an injury of unknown origin because the pain and decreased ROM began prior to his discharge to the GACH, and they did not know how the injury occurred. The DON stated injuries of unknown origin should be reported to the state department, but it was not done because she was not made aware. The DON stated it was important to investigate and report injuries of unknown origin because the facility does not know how the injury occurred and there was a possibility it happened due to an altercation with another resident or another unknown reason. The DON stated if she was made aware of Resident 1 ' s right hip injury a thorough investigation would have been done to deep dive into what could have happened to Resident 1.
During an interview on 5/16/2025 at 10:50 a.m., the DON stated Resident 1 ' s right hip fracture (injury of unknown origin) should have been reported to the state department at the time of the incident. The DON stated she found out about the fracture on 5/8/2025 and the incident should have been reported, and they did not report the incident because she found out about the injury of unknown origin after the fact. The DON reviewed the facility ' s P/P titled Abuse, Neglect and Exploitation and stated per the facility policy the injury of unknown origin should have been reported to the state agency. The DON stated in the future injuries of unknown origin will be reported to the state agency as soon as they are discovered, even if it was after the fact. The DON stated an investigation was not conducted for Resident 1 ' s Injury of unknown origin of the right hip.
During a review of the facility ' s P/P titled Abuse, Neglect and Exploitation undated, the P/P indicated the facility must ensure all alleged violations including injuries of unknown source (injuries of unknown origin) must be reported immediately but not later than two hours after the allegation is made, if the events result in serious bodily injury, to the facility administrator and the State Survey Agency. The facility was to ensure alleged violations were thoroughly investigated and the facility was to prevent further potential abuse or mistreatment while the investigation was in progress.
During a review of the facility ' s P/P titled Injury of Unknown Origin Policy undated, the P/P indicated an injury of unknown origin was any injury where: the cause or circumstances are not witnessed or reported, the resident is unable to explain how the injury occurred, and the injury is not consistent with the resident ' s known condition or typical behavior. The P/P indicated the investigation was to include a review of recent care provided, staffing assignments, and resident routines. Interview staff who interacted with the resident during the shift(s) prior to the injury and evaluate the environment for potential hazards or contributing factors

Based on interview and record review, the facility ' s Quality Assurance (Q A)/ Quality Assurance and Performance Improvement (QAPI) (a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee failed to address , maintain, and develop an effective plan to correct identified problems after the deficient practices were identified related to abuse and accident on 4/28/2025 during an investigation of a facility reported incident (FRI- process by which a healthcare facility documents and reports an event that occurred within the facility and potentially affected the safety of residents, staff or the facility itself).
This failure resulted into a repeated deficient practice about abuse and supervision which could affect the health and safety of the residents.
Findings:
During an interview on 6/6/2025, at 11:50 a.m. with the Director of Nursing (DON), the DON stated she did not address the identified problems related to abuse and smoking supervision in their QAPI/QA Committee agenda. The DON stated it did not dawn on me to do it and did not have to wait for a quarterly meeting in July for the identified problems with regards to abuse and smoking supervision. The DON stated the facility had a QAPI meeting last April 2 but did not address identified problems concerning abuse and smoking supervision. The DON stated the facility conducts meeting every three months. The DON stated QAPI was important to prevent reoccurrences of abuse providing a safe environment for the residents. The DON stated the facility should have enough staff to cover supervision of residents to prevent occurrences of abuse.
During an interview on 6/6/2025, at 1:57 p.m. with the Administrator (ADM) , the ADM stated that the facility includes the issue of abuse , smoking and supervision on their next QAPI meeting. The ADM stated the facility will review issues in the facility , will plan and address the issues affecting the facility like monitoring residents , smoking and abuse.
During a review of facility ' s policy and procedure (P&P) titled, QAPI Change Process, undated, the P&P indicated the facility will establish and utilize a systematic approach to performance improvement activities to ensure changes are effective and improvements are sustained. The P &P indicated once the root cause of a problem is identified, QAA committee will develop appropriate corrective actions plans and will continue to track performance to ensure that improvements are sustained.
Based on interview and record review, the facility ' s Quality Assurance (Q A)/ Quality Assurance and Performance Improvement (QAPI) (a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee failed to address , maintain, and develop an effective plan to correct identified problems after the deficient practices were identified related to abuse and accident on 4/28/2025 during an investigation of a facility reported incident (FRI- process by which a healthcare facility documents and reports an event that occurred within the facility and potentially affected the safety of residents, staff or the facility itself).
This failure resulted into a repeated deficient practice about abuse and supervision which could affect the health and safety of the residents.
Findings:
During an interview on 6/6/2025, at 11:50 a.m. with the Director of Nursing (DON), the DON stated she did not address the identified problems related to abuse and smoking supervision in their QAPI/QA Committee agenda. The DON stated it did not dawn on me to do it and did not have to wait for a quarterly meeting in July for the identified problems with regards to abuse and smoking supervision. The DON stated the facility had a QAPI meeting last April 2 but did not address identified problems concerning abuse and smoking supervision. The DON stated the facility conducts meeting every three months. The DON stated QAPI was important to prevent reoccurrences of abuse providing a safe environment for the residents. The DON stated the facility should have enough staff to cover supervision of residents to prevent occurrences of abuse.
During an interview on 6/6/2025, at 1:57 p.m. with the Administrator (ADM) , the ADM stated that the facility includes the issue of abuse , smoking and supervision on their next QAPI meeting. The ADM stated the facility will review issues in the facility , will plan and address the issues affecting the facility like monitoring residents , smoking and abuse.
During a review of facility's policy and procedure (P&P) titled, QAPI Change Process, undated, the P&P indicated the facility will establish and utilize a systematic approach to performance improvement activities to ensure changes are effective and improvements are sustained. The P &P indicated once the root cause of a problem is identified, QAA committee will develop appropriate corrective actions plans and will continue to track performance to ensure that improvements are sustained.

Based on observation, interview and record review , the facility failed to observe infection control practice by failing to ensure four of ten sampled staff members wear a mask when the facility was in a Covid outbreak( two or more linked cases of the same illness caused by Covid 19 virus[infectious and contagious disease caused by coronavirus]).
This failure had the potential to spread and transmit infection to the residents and other staff.
Findings:
During a concurrent observation and interview on 6/5/2025, at 8:00 a.m. and subsequent interview on6/6/2025, at 9:00 a.m. with Certified Nursing Assistant (CNA 2) who was the screener for Covid 19 signs and symptoms was not wearing a mask. Observed a housekeeper (HSK 1) vacuuming the carpet at the lobby of the facility not wearing a mask. CNA 2 stated there were residents who were positive for Covid 19 in the facility. CNA 2 stated she did not wear a mask because she thought it was not mandatory to wear mask even there was a Covid 19 outbreak.
During an initial tour observation of the facility on 6/5/2025, at 8:20 a.m., observed several residents not wearing a mask in the hallway. Observed the Administrator, and some facility staff members were not wearing masks in the nursing station and resident care areas. Observed rooms designated the two Covid 19 residents.
During an interview on 6/6/2025, at 7:31 a.m. with Licensed Vocational Nurse (LVN 3), LVN 3 agreed she did not wear a mask while in the resident care areas yesterday (6/5/2025). LVN 3 stated she did not wear a mask because she felt hot. LVN 3 stated she should have always worn a mask to prevent spread of infection among the vulnerable residents in the facility and staff.
During an interview on 6/6/2025, at 9:05 a.m., with Housekeeping Supervisor (HKS), HKS stated HSK 1 should have worn a mask while vacuuming the lobby for the safety of residents and staff. HKS stated not wearing a mask during a Covid 19 outbreak had the potential to spread the infection.
During an interview on 6/6/2025, at 9:20 a.m. with Infection Preventionist Nurse (IPN), IPN stated the facility had a Covid 19 outbreak that started on 5/28/2025 when both residents were presenting cough, and nasal congestion(nasal passages were swollen with excess fluid and mucus ) and tested positive for Covid 19. IPN stated she always reminded the staff to wear a mask and was communicated to the charge nurses during huddle in the morning because the facility had an outbreak of Covid 19. IPN stated maybe the staff thought Covid 19 illness was normal according to their perception. IPN stated she should explain the risks and consequences of not wearing mask to help prevent spread of infection.
During an interview on 6/6/2025, at 12:40 p.m. with the Director of Nursing (DON) , the DON stated the facility had a Covid 19 outbreak and everyone should be wearing a mask to prevent spread of infection. The DON stated elderly people like their residents have a great risk of contracting the Covid 19 infection.
During an interview on 6/6/2025, at 1:33 p.m., with the Administrator (ADM), the ADM stated he did not wear a mask yesterday (6/5/2025) in the nursing station because he forgot to wear a mask. The ADM stated he wears a mask when he goes to the resident areas.
During a review of facility ' s Covid 19 Mitigation Plan Manual, undated, the Covid 19 Mitigation Plan Manual indicated facility staff should wear recommended personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for care of all residents when there are Covid-19 cases identified in the facility in line with the most recent California Department of Public Health PPE guidance. The Covid 19 Mitigation Plan indicated All staff should wear a facemask while in the facility.
Based on observation, interview and record review , the facility failed to observe infection control practice by failing to ensure four of ten sampled staff members wear a mask when the facility was in a Covid outbreak( two or more linked cases of the same illness caused by Covid 19 virus[infectious and contagious disease caused by coronavirus]).
This failure had the potential to spread and transmit infection to the residents and other staff.
Findings:
During a concurrent observation and interview on 6/5/2025, at 8:00 a.m. and subsequent interview on6/6/2025, at 9:00 a.m. with Certified Nursing Assistant (CNA 2) who was the screener for Covid 19 signs and symptoms was not wearing a mask. Observed a housekeeper (HSK 1) vacuuming the carpet at the lobby of the facility not wearing a mask. CNA 2 stated there were residents who were positive for Covid 19 in the facility. CNA 2 stated she did not wear a mask because she thought it was not mandatory to wear mask even there was a Covid 19 outbreak.
During an initial tour observation of the facility on 6/5/2025, at 8:20 a.m., observed several residents not wearing a mask in the hallway. Observed the Administrator, and some facility staff members were not wearing masks in the nursing station and resident care areas. Observed rooms designated the two Covid 19 residents.
During an interview on 6/6/2025, at 7:31 a.m. with Licensed Vocational Nurse (LVN 3), LVN 3 agreed she did not wear a mask while in the resident care areas yesterday (6/5/2025). LVN 3 stated she did not wear a mask because she felt hot. LVN 3 stated she should have always worn a mask to prevent spread of infection among the vulnerable residents in the facility and staff.
During an interview on 6/6/2025, at 9:05 a.m., with Housekeeping Supervisor (HKS), HKS stated HSK 1 should have worn a mask while vacuuming the lobby for the safety of residents and staff. HKS stated not wearing a mask during a Covid 19 outbreak had the potential to spread the infection.
During an interview on 6/6/2025, at 9:20 a.m. with Infection Preventionist Nurse (IPN), IPN stated the facility had a Covid 19 outbreak that started on 5/28/2025 when both residents were presenting cough, and nasal congestion(nasal passages were swollen with excess fluid and mucus ) and tested positive for Covid 19. IPN stated she always reminded the staff to wear a mask and was communicated to the charge nurses during huddle in the morning because the facility had an outbreak of Covid 19. IPN stated maybe the staff thought Covid 19 illness was normal according to their perception. IPN stated she should explain the risks and consequences of not wearing mask to help prevent spread of infection.
During an interview on 6/6/2025, at 12:40 p.m. with the Director of Nursing (DON) , the DON stated the facility had a Covid 19 outbreak and everyone should be wearing a mask to prevent spread of infection. The DON stated elderly people like their residents have a great risk of contracting the Covid 19 infection.
During an interview on 6/6/2025, at 1:33 p.m., with the Administrator (ADM), the ADM stated he did not wear a mask yesterday (6/5/2025) in the nursing station because he forgot to wear a mask. The ADM stated he wears a mask when he goes to the resident areas.
During a review of facility's Covid 19 Mitigation Plan Manual, undated, the Covid 19 Mitigation Plan Manual indicated facility staff should wear recommended personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for care of all residents when there are Covid-19 cases identified in the facility in line with the most recent California Department of Public Health PPE guidance. The Covid 19 Mitigation Plan indicated All staff should wear a facemask while in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents who were smoking on the patio were supervised and monitored for two of three sampled residents (Resident 1 and Resident 2). The facility failed to:
1. Ensure Resident 1 and Resident 2, who were assessed as needed supervision at all times, were supervised while smoking on the patio on 4/12/2025, at around 3:45 a.m. in accordance with the facility's policy and procedure titled, Smoking Policy-Residents and Resident 1's and Resident 2's Smoking Assessment Forms.
2. Ensure Resident 2's aggressive behavior was monitored and addressed on 4/12/2025. Resident 2 had been manifesting aggressive behavior and asking staff for a cigarette all night before the incident happened on 4/12/2025 at 3:35 a.m.
These failures resulted in Resident 1 and Resident 2 unsupervised smoking on 4/12/2025 at 3:35 a.m. leading to Resident 2 and Resident 1 having arguments resulted in Resident 2 punching Resident 1 multiple times on the mouth and face. Resident 1 sustained a cut / tear at the mid left corner of the bottom lip and swelling.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia(a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and chronic obstructive pulmonary disease(COPD-a chronic lung disease causing difficulty in breathing).
During a review of Resident 1's History and Physical (H&P- the process of a healthcare provider obtaining a thorough medical history from a patient and performing a physical examination) dated 8/16/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/19/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to think, understand, learn, and remember). The MDS indicated Resident 1 was independent in walking, rolling left to right on the bed, and transferring to and from a bed to a chair.
During a review of Resident 1's Smoking Assessment Form (a questionnaire used to understand a person's current smoking habits, their interest in quitting, their level of nicotine [an addictive chemical found in tobacco] dependence) dated 2/7/2025, the Smoking Assessment Form indicated Resident 1 utilized tobacco, must be supervised at all times and had to wear a protective non-flammable apron ( designed to protect the user from ash or other cigarette debris that could be a danger to resident) when smoking.
During a review of Resident 1's Body assessment dated [DATE], the Body Assessment indicated Resident 1 had a cut on the lower lip.
During a review of Resident 1's Change in Condition (COC-a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional condition) Evaluation dated 4/12/2025 at 4:21 a.m., the COC Evaluation indicated Resident 1 was hit in the face by Resident 2 and sustained a cut / tear at the mid left corner of the bottom lip. The COC Evaluation indicated Resident 1 was in distress when he reentered the facility from the patio, where he was smoking. The COC Evaluation indicated Resident 1 stated he was hit by Resident 2 on the mouth and face after an argument and Resident 1's mid left corner of his lip had minimal bleeding.
During a review of the facility's Incident Report dated 4/12/2025 and timed at 3:45 a.m., the Incident Report indicated Resident 1 was smoking on the patio near the lobby at 3:45 a.m. The Incident Report indicated Resident 1 verbalized to Licensed Vocational Nurse (LVN 1) that Resident 2 hit him due to argument over a cigarette. The Incident Report indicated Resident 2 hit Resident 1 multiple times in the face and Resident 1 had lost his balance.
During a review of Resident 1's Care Plan, titled Resident 1 has the potential for injury related to smoking, initiated on 4/28/2025, the Care Plan indicated the interventions included maintaining within line of sight of personnel supervising smoking schedule, strict implementation of smoking schedule and maintain safety at all times.
During a review of Resident 2's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] to the facility with diagnosis that included bipolar disorder, major depressive disorder(mental health disorder characterized by persistently depressed mood or loss of interest causing impairment in daily life) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).
During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 2 was independent in walking, rolling left to right on the bed, and transferring to and from a bed to a chair.
During a review of Resident 2's Smoking Assessment Form dated 3/7/2025, the Smoking Assessment Form indicated Resident 2 utilized tobacco, must be supervised at all times, and had to wear a protective non-flammable apron when smoking.
During a review of Resident 2's COC Evaluation dated 4/12/2025, timed at 4:19 a.m., the COC Evaluation indicated on 4/11/2025, at 11:00 p.m. Resident 2 asked staff at the nursing station, which was facing the facility lobby, to smoke in the patio The COC Evaluation indicated the licensed nurse (unknown) observed Resident 2 pacing the hallways and nursing station on 4/12/2025 at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m. and 3:30 a.m. The COC indicated at around 3:45 a.m. Resident 1 entered the facility from the patio and was distressed. The COC indicated Resident 1 stated that Resident 2 punched him in the face multiple times and Resident 1 sustained a cut with a small amount of blood on Resident 1's lip.
During a review of Resident 2's Care Plan titled, The Resident 2 has a behavior problem (fluctuations of emotions [changes in mood or feelings] from pleasant to angry) related to bipolar disorder, initiated on 4/8/2025, the Care Plan indicated a goal for Resident 2 was to have fewer episodes of fluctuations of emotions by review date on 7/8/2025. The Care Plan indicated the interventions included monitoring behavior episodes of fluctuations of emotions from pleasant to angry and attempting to determine underlying cause.
During a telephone interview on 4/28/2025, at 8:25 a.m. with Certified Nursing Assistant (CNA 1), CNA1 stated she was assigned to Resident 1 and Resident 2 on 4/12/2025 but did not know that they had a resident-to-resident altercation and did not remember that it happened that day of 4/12/2025. CNA 1 stated there were no smoking breaks for residents at night, on 11 p.m. to 7 a.m. shift. CNA 1 stated the last smoking time for the residents was at 7:30 p.m. daily. CNA 1 stated Resident 1 and Resident 2 were both ambulatory (able to walk and move around) and independent.
During an interview on 4/28/2025, at 11:00 a.m. with CNA 2, CNA 2 stated she was assigned as a Smoking Monitorer on 4/28/2025 and her responsibilities were to provide cigarettes, smoking aprons, lighting the cigarette and monitoring the residents while smoking for safety. CNA 2 stated the facility provides Resident 1 and Resident 2 cigarettes during regular smoking schedule. CNA 2 stated there were no smoking times at night from 11:00 p.m. to 7:00 a.m. shift.
During an interview on 4/28/2025, at 11:39 a.m. with Activity Assistant (AA 1), AA 1 stated the Smoking Monitorer was in charge of passing out cigarettes, providing smoking aprons to residents, ensure residents do not have a lighter in their possession for safety. AA 1 stated the residents cannot smoke whenever they want, and facility staff should supervise residents while residents were smoking.
During a telephone interview on 4/28/2025, at 9:07 a.m. with LVN 1, LVN 1 stated Resident 2 was getting aggressive at the start of 11 p.m. to 7 am. shift on 4/11/2025, around 11:00 p.m. LVN 1 stated Resident 2 kept coming to the nursing station and demanding to smoke, threatening to leave the facility if he did not get a cigarette to smoke. LVN 1 stated Resident 2 was having hallucination (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real) when he stated there was a guy giving him Methamphetamine (stimulant [substance that raises nervous activity in the body] that is highly addictive). LVN 1 stated Resident 2 was pacing in and out the patio and around the facility, yelling and demanding to have a cigarette. LVN 1 stated she was at the nursing station on 4/12/2025 and saw Resident 1 going out to the patio to smoke but did not see Resident 2 going out to the patio. LVN 1 stated Resident 1 came inside from the patio and told LVN 1 that Resident 2 was trying to beat him up. LVN 1 stated Resident 1 had a cut on his lip with redness and slight swelling. LVN 1 stated it was all about Resident 2 getting cigarettes and throwing tantrums. LVN 1 stated she does not know where Resident 1 got his cigarette to smoke on 4/12/2025, at around 3:45 a.m.
During a telephone interview on 4/28/2025, at 9:30 a.m. and subsequent telephone interview, at 10:57 a.m. with LVN 2, LVN 2 stated the incident happened between 3:30 a.m. and 4:00 a.m. on 4/12/2025. LVN 2 stated Resident 1 had been going out to smoke on the patio at random times during the night and carried his own cigarettes. LVN 2 stated Resident 1 was not supervised when he goes out to smoke and smokes by himself because Resident 1 was independent and could pretty much do it on his own. LVN 2 stated Resident 2 was agitated and had been yelling, walking around the facility and asking random staff members for a cigarette during that night (4/12/2025). LVN 2 stated LVN 1 instructed him to go back to his room and gave Resident 2 a cigarette on 4/11/2025, at 11:30 p.m. LVN 2 stated on 4/12/2025 at around 3:30 a.m., she heard a sound coming from the glass door, leading to the patio, when Resident 1 walked in with blood on his mouth while Resident 2 followed him behind. LVN 2 stated Resident 2 was talking loudly and was agitated while Resident 1 was trying to explain to staff what happened.
During a concurrent interview and record review on 4/28/2025, at 12:40 p.m. with the Director of Staff Development (DSD), Resident 1's and Resident 2's Smoking Assessment Forms dated 3/7/2025, were reviewed. The DSD stated Resident 1 and 2 required supervision while smoking. The DSD stated Resident 1 should have staff supervision on 4/12/2025 at around 3:00 a.m. and 4:00 a.m. when Resident 1 went out to the patio to smoke for safety. The DSD stated the CNAs should be making rounds every two hours to ensure the whereabouts of each resident. DSD stated the CNAs should be aware where their residents were to prevent fall, any change in condition, injury and elopement (the act of leaving the facility unsupervised and without prior authorization). The DSD stated the residents (in general) were not allowed to have cigarettes in their possession because the residents could burn, hurt themselves or an altercation can occur between residents.
During an interview on 4/28/2025, at 1:10 p.m. with the Director of Nursing (DON), the DON stated residents do not smoke at night and if the residents carry a cigarette, the staff should confiscate their lighter and cigarette. The DON stated the licensed nurse should have assigned a CNA to monitor Resident 2's aggressive behavior and notify the physician to manage his behavior. The DON stated there should have been a staff supervising Resident 1's while smoking to prevent the risk of injury. The DON stated this incident was avoidable and preventable if only staff supervised Resident 1 when he went out to smoke on the patio, and the licensed nurse identified and managed Resident 2's aggressive behavior.
During a review of facility's policy and procedure (P&P) titled, Accidents and Supervision, undated, the P&P indicated the resident's environment should remain free of accident hazards and each resident receives adequate supervision to prevent accidents.
During a review of facility's P&P titled, Smoking Policy- Residents, undated, the P &P indicated smoking articles for residents without independent smoking privileges may not have or keep any type of smoking articles, including cigarettes, tobacco except when they are under direct supervision. The P &P indicated any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member at all times while smoking.
Cross referenced F600

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor resident for signs and symptoms of neurological decline (brain and nervous system are not working correctly which can lead to problems with thinking, memory, movement or change in level of consciousness[loc-person ' s awareness and responsiveness to their surroundings]) for one of three sampled residents (Resident 4) after being struck on the face by Resident 5.
This deficient practice had the potential to lead to serious life-threatening effect that could go unnoticed without a neurological assessment (assessment of a patient ' s mental status , level of consciousness, changes in pupil size and reaction to external stimulus , motor strength, sensation and movement of arms and legs).
Findings:
During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including human immunodeficiency virus disease (HIV- virus that attacks the body ' s immune system [ defends the body against disease causing microorganism and harmful substances]), morbid obesity ( patient weight is significantly higher than what is considered healthy) , schizophrenia (a mental illness that is characterized by disturbances in thought), and left and right knee contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion).
During a review of Resident 4 ' s History and Physical (H&P) dated 4/18/2025, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.
During a review of Resident 4 ' s Minimum Data Set (MDS- a resident assessment tool) dated 5/8/2025, the MDS indicated Resident 4 had moderately impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision makingand was dependent (helper completed all the activities for the resident) on staff with bathing, dressing, toileting hygiene, transfer to and from a bed to chair and bed mobility.
During a review of Resident 4 ' s Change in Condition ( COC- a sudden clinically important deviation from a patient ' s baseline in physical, cognitive, behavioral or functional condition) Form dated 5/30/2025 and timed at 8:45 a.m., the COC Form indicated on 5/30/2025, at 5:30 a.m. Resident 4 was found with five centimeters (cm-unit of measurement) long laceration above his left eyebrow with minimal bleeding and slight swelling.
During an observation and interview on 6/5/2025, at 10 a.m. in the activity room and subsequent interview with Resident 4 on 6/6/2025, at 4:30 p.m., Resident 4 was observed sitting in a recliner chair. Resident 4 was observed with purplish discoloration around his left eye and a dressing above the left eye. Resident 4 stated on 5/30/2025 at 5:30 a.m., he was asleep when he was awakened when Resident 5 hit him on the face. Resident 4 stated Resident 5 punched him on the face once. Resident 4 stated after he was hit, Resident 5 remain in the room looking at him, then walked back to his bed. Resident 4 stated he did not know why he did not ask for help when Resident 5 hit him.
During a concurrent interview and record review on 6/5/2025, at 2:55 p.m. with RNS 1, Resident 4 ' s EHR was reviewed. RNS 1 stated there was no neurological check and observation of Resident 4 ' s neurological status after Resident 4 came back from general acute care Hospital (GACH) on the same day the incident occurred (5/30/2025).
During an interview on 6/6/2025, at 7:31 a.m., with LVN 3, LVN 3 stated staff should have checked Resident 4 ' s neurological status after being struck on his face. LVN 3 stated Resident 4 could die from possible bleeding in the brain.
During a concurrent interview and review of Resident 4 ' s medical record on 6/5/2025, at 12:40 p.m. with the DON, the DON stated the staff initiated the neurological check on 5/30/2025 before Resident 4 was transferred to the GACH but was not continued after he came back from the hospital on 5/30/2025 at 7:49 p.m. The DON stated Resident 4 could have serious injury to the brain after being hit on the face. The DON stated the staff should have performed a neurological check to monitor if the resident ' s brain function was affected like change in level of consciousness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident was free from physical abuse and was not punched on the face multiple times by another resident for one of three sampled residents (Resident 1).
The facility failed to:
1. Supervise Resident 1 and Resident 2 who were smoking on the patio and having an argument on 4/12/2025 at 3:45 a.m. as indicated in both residents' Smoking Assessment Form.
2. Assess and monitor Resident 2 when he was restless and had an escalating behavior manifested by yelling and demanding staff for a cigarette to smoke, pacing (to walk in one direction and then back again) back and forth at the facility's nursing station and hallways on 4/12/2025, from 12:00 a.m. to 3:30 a.m.
3. Ensure Certified Nursing Assistant (CNA) 1 knew the whereabouts of Resident 1 and Resident 2 while she was assigned to care for them on 4/12/2025.
4. Inform Resident 2's physician when Resident 2 was exhibiting behavior manifested by yelling, demanding staff to give him cigarettes, pacing in the hallways and verbalizing that a guy was giving him Methamphetamine (stimulant [substance that raises nervous activity in the body] that is highly addictive).
.
These failures resulted in Resident 1 and Resident 2 smoking unsupervised on 4/12/2025 at 3:35 a.m. leading to Resident 2 and Resident 1 having an argument resulted in Resident 2 punching Resident 1 multiple times on the mouth and face. Resident 1 sustained mid left corner of the lower lip a cut/tear on his mid left corner of the lower lip and swelling.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia(a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and chronic obstructive pulmonary disease(COPD-a chronic lung disease causing difficulty in breathing).
During a review of Resident 1's History and Physical (H&P the process of a healthcare provider obtaining a thorough medical history from a patient and performing a physical examination) dated 8/16/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/19/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to think, understand, learn, and remember). The MDS indicated Resident 1 required set up or clean-up assistance (helper sets up or cleans up) with eating, oral hygiene, toileting hygiene, bathing, dressing, and personal hygiene. The MDS indicated Resident 1 was independent in walking, rolling left to right on the bed, and transferring to and from a bed to a chair.
During a review of Resident 1's Smoking Assessment Form (a questionnaire used to understand a person's current smoking habits, their interest in quitting, their level of nicotine [an addictive chemical found in tobacco] dependence) dated 2/7/2025, the Smoking Assessment Form indicated Resident 1 utilizes tobacco, must be supervised at all times and had to wear a protective non-flammable apron ( designed to protect the user from ash or other cigarette debris that could be a danger to resident) when smoking.
During a review of Resident 1's Body assessment dated [DATE], the Body Assessment indicated Resident 1 had a cut on the lower lip.
During a review of Resident 1's Change in Condition (COC-a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional condition) Evaluation dated 4/12/2025 at 4:21 a.m., the COC Evaluation indicated Resident 1 was hit in the face by Resident 2 and sustained a cut /tear at the mid left corner of the lower lip. The COC Evaluation indicated Resident 1 was in distress when he reentered the facility from the patio where he was smoking. The COC Evaluation indicated Resident 1 stated he was hit by Resident 2 on the mouth and face after an argument with Resident 2. The COC indicated Resident 1 sustained a cut to mid-bottom corner of his lip with a minimal bleeding. The COC indicated LVN 1 applied ice pack.
During a review of Resident 1's Care Plan, titled Resident 1 has the potential for injury related to smoking, initiated on 4/28/2025, the Care Plan indicated the interventions included maintaining the resident within line of sight of personnel supervising smoking schedule, strict implementation of smoking schedule (start at 8 a.m. and ends at 7:30 p.m.) and maintain safety at all times.
During a review of Resident 2's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including bipolar disorder, major depressive disorder(mental health disorder characterized by persistently depressed mood or loss of interest causing impairment in daily life) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).
During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition. The MDS indicated Resident 2 was independent in walking, rolling left to right on the bed, and transferring to and from bed to a chair.
During a review of Resident 2's Smoking Assessment Form dated 3/7/2025, the Smoking Assessment Form indicated Resident 2 utilizes tobacco, must be supervised at all times and had to wear a protective non-flammable apron when smoking.
During a review of Resident 2's COC Evaluation dated 4/12/2025, timed at 4:19 a.m., the COC Evaluation indicated on 4/11/2025, at 11:00 p.m. Resident 2 asked the licensed nurse at the nursing station to smoke in the patio which was facing the facility's lobby. The COC Evaluation indicated Licensed Vocational Nurse (LVN 1) observed Resident 2 pacing the hallways and nursing station on 4/12/2025 at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m. and 3:30 a.m. The COC indicated at around 3:45 a.m. Resident 1 entered the facility from the patio and was distressed. The COC indicated Resident 1 stated that Resident 2 punched him in the face multiple times and Resident 1 sustained a cut with small amount blood on Resident 1's lip.
During a review of Resident 2's Care Plan titled, Resident 2 has a behavior problem (fluctuations of emotions from pleasant to angry) related to diagnosis of bipolar disorder initiated on 4/8/2025.,the Care Plan indicated a goal for Resident 2 was to have fewer episodes of emotional fluctuations by review date on 7/8/2025. The Care Plan indicated the interventions included to assist the resident to develop appropriate methods of coping and interacting with others, monitoring behavior episodes of fluctuations of emotions from pleasant to angry every shift, considering time, location, time of the day, persons involved and situations.
During a telephone interview on 4/28/2025, at 8:25 a.m. with Certified Nursing Assistant (CNA 1), CNA1 stated she was assigned to Resident 1 and Resident 2 on 4/12/2025 but did not know that they had a resident-to-resident altercation and did not remember that altercation happened that day of 4/12/2025. CNA 1 stated there were no smoking breaks for residents at night. CNA 1 stated the last daily smoking time for the residents was scheduled at 7:30 p.m. CNA 1 stated Resident 1 and Resident 2 were both ambulatory (able to walk and move around) and independent.
During a telephone interview on 4/28/2025, at 9:07 a.m. with LVN 1, LVN 1 stated Resident 2 was getting aggressive at the start of the 11 p.m. to 7 a.m. shift on 4/11/2025, at around 11:00 p.m. LVN 1 stated Resident 2 kept coming to the nursing station and demanding a cigarette to smoke threatening to leave the facility if he did not get a cigarette to smoke. LVN 1 stated Resident 2 was having hallucination (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real) when he stated there was a guy giving him methamphetamine. LVN 1 stated they were able to redirect his behavior several times during the night. LVN 1 stated Resident 2 was pacing in and out of the patio and around the facility, yelling and demanding to have a cigarette. LVN 1 stated she was in the nursing station and saw Resident 1 went out to the patio to smoke but did not see Resident 2 going out to the patio LVN 1 stated Resident 1 came inside from the patio and told her Resident 2 was trying to beat him up. LVN 1 stated Resident 1 had a cut on his lip with redness and slight swelling.
During a telephone interview on 4/28/2025, at 9:30 a.m. and subsequent telephone interview, at 10:57 a.m. with LVN 2, LVN 2 stated the incident between Resident 1 and Resident 2 happened around 3:30 a.m. to 4:00 a.m. on 4/12/2025. LVN 2 stated Resident 1 had been going out to smoke on the patio at random times during the night and carried his own cigarettes. LVN 2 stated Resident 1 was not supervised when he goes out to smoke and smokes by himself because Resident 1 was independent and could pretty much do it on his own. LVN 2 stated on 4/12/2025 the patio was dim and the only light that could be seen was the light coming from the nursing station and the lobby. LVN 2 stated Resident 2 was agitated and had been yelling walking around the facility and asking random staff members for a cigarette during that night (4/12/2025). LVN 2 stated LVN 1 instructed him to go back to his room and gave Resident 2 a cigarette on 4/11/2025, at 11:30 p.m. LVN 2 stated on 4/12/2025 at around 3:30 a.m., she heard a sound coming from the patio door when Resident 1 walked in with blood on his mouth while Resident 2 followed him behind. LVN 2 stated Resident 2 was talking loudly and was agitated while Resident 1 was trying to explain what happened to LVN 1.
During an interview on 4/28/2025, at 12:40 p.m. with the Director of Staff Development (DSD), the DSD stated she provided an in-services related to resident-to resident abuse that happened between Resident 1 and Resident 2 on 4/12/2025. The DSD stated if a resident was going to smoke outside on the patio from 3:00 a.m. to 4:00 a.m., the staff must be present to supervise and monitor the residents for safety. The DSD stated the CNAs should be making rounds every two hours to ensure the whereabouts of each resident. The DSD stated the CNAs should be aware where their assigned residents were to prevent falls, any change in condition, injury and/or elopement (the act of leaving the facility unsupervised and without prior authorization). The DSD stated residents unsupervised smoking could lead to injury and physical abuse. The DSD stated the residents (in general) were not allowed to have cigarettes in their possession because the residents could burn, hurt themselves, or hurt other residents.
During an interview on 4/28/2025, at 1:10 p.m. with the Director of Nursing (DON), the DON stated residents do not smoke at night and if the residents carry a cigarette, the staff should confiscate their lighter and cigarette. The DON stated the licensed nurse should have assigned a CNA to monitor Resident 2's aggressive behavior and notify the physician to manage his behavior on 4/12/2025. The DON stated there should be staff supervising Resident 1 and Resident 2's while smoking to prevent the risk of injury. The DON stated this incident was avoidable and preventable if only the staff supervised Resident 1 when he went out to smoke in the patio, and the licensed nurse identified and managed Resident 2's aggressive behavior.
During a review of facility's policy and procedure (P&P), titled Abuse, Neglect and Exploitation (undated), the P&P indicated Each resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P&P indicated the residents must not be subject to abuse by anyone in the facility and will make efforts to protect the residents. The facility will observe residents' behavior and their reaction to other residents, and train staff about appropriate interventions to deal with aggressive reactions by residents. The P&P indicated the facility will assess, monitor and develop appropriate plans of care with needs and behaviors which might lead to conflict or neglect like residents with history of aggressive behaviors to prevent abuse, neglect and exploitation of residents.
During a review of facility's P&P titled, Resident Smoking, (undated), the P&P indicated Residents who smoke will be further assessed using Resident Safe Smoking Assessment to determine if the resident would need supervision or not or will be allowed to smoke in designated smoking areas, at designated times and in accordance with the resident's care plan. The P&P indicated smoking materials of residents requiring supervision will be maintained by nursing staff.
Cross referenced F689

Based on observation and interview, the facility failed to ensure three of three outside grey garbage dumpsters were covered.
This deficient practice had a potential to harbor and attract flies, insects, mice, rats, and other animals to the garbage containers. This deficient practice also had the potential for those pests to enter the facility which could lead to the spread of infectious diseases to the residents, staff, and visitors.
Findings:
During a concurrent observation and interview on 3/14/2025 at 2:26 p.m., with the Director of Nursing (DON), three outside grey garbage dumpsters were observed uncovered. The DON confirmed the dumpsters were uncovered and without their lids. The DON stated that the lids to the dumpsters should be on when not in use because it may attract unwanted animals and/or pests.
During an interview on 3/14/2025 at 3 p.m. with the Administrator (ADM), the ADM stated the dumpster lids should be on when not in use and that the facility staff are aware to keep the dumpsters completely covered with lids to avoid attracting unwanted animals.
During a review of the undated facility's policies and procedures (P&P) titled, Disposal of Garbage and Refuse, the P&P indicated garbage and refuse containers should be free from cracks or leaks and covered when not in use. Refuse containers and dumpsters kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded. Dumpsters should be emptied according to the facility contract; garbage should not accumulate or be left outside the dumpster.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of six sample residents (Resident 1) was not physically assaulted by another resident while under the facility ' s care.
This deficient practice resulted in Resident 1 being assaulted by her roommate (Resident 2) when during an unprovoked attack, Resident 2 hit Resident 1 with her fist then her shoe. Resident 1 sustained a contusion (a bruise) to her left upper and lower eyelid. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 2/4/2025 for evaluation and treatment where an ice pack was applied.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with unspecified dementia (loss of cognitive [thinking process] functioning, remembering, and reasoning to such an extent that it interferes with a person ' s daily life and activities) and schizophrenia (a mental illness which can affect a person ' s thoughts, mood and behavior).
During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/1/2024, the MDS indicated Resident 1 had severe cognitive impairment.
During review of Resident 1 ' s History and Physical (H&P) dated 1/17/2025, the H&P indicated Resident 1 was alert and oriented to person only, with episodes of confusion.
During a review of Resident 1 ' s Nursing Progress note dated 2/4/2025 and timed at 2:07 p.m., the Nursing Progress note indicated Resident 1 was lying in bed asleep when Certified Nursing Assistant (CNA) 1 walked by Resident 1 ' s room and saw Resident 1 ' s roommate (Resident 2) assault Resident 1. The Nursing Progress note indicated Resident 1 was noted with a bruise on her left upper and lower eyelid.
During a review of Resident 1 ' s Skin assessment dated [DATE] and timed at 2:33 p.m., the Skin Assessment indicated Resident 1 had a contusion on her left upper and lower eyelid.
During a review of Resident 1 ' s Physician ' s Order Summary dated 2/4/2025, the Physician ' s Order Summary indicated to transfer Resident 1 to a GACH for further evaluation.
During a review of Resident 1 ' s Nursing Note dated 2/4/2025 and timed at 10:59 p.m., the Nursing Note indicated Resident 1 was transported by ambulance to the GACH on 2/4/2025 at 6:05 p.m.
During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation) and paranoid schizophrenia (a type of mental illness where someone experiences intense beliefs that others are actively trying to harm them, often accompanied by delusions [false beliefs] and hallucinations [seeing or hearing things that aren't there], making it difficult for them to distinguish reality from their distorted perceptions).
During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment.
During a review of Resident 2 ' s undated H&P, the H&P indicated Resident 2 had a fluctuating capacity to understand and make decisions.
During a review of the GACH ' s Emergency Department (ED) Physician ' s note dated 2/19/2025 and timed at 12:10 p.m., the ED Physician ' s note indicated Residents 1 presented to the emergency room (ER) for head trauma secondary to being assaulted by another resident at her facility. The ED Physician ' s note indicated Resident 1 was evaluated for a minor isolated blunt head trauma and left periorbital (the area surrounding the eye socket) ecchymosis (bruising). The ED Physician ' s note indicated Resident 1 was treated with an ice pack.
During a review of GACH ' s Clinical Discharge summary dated [DATE] and timed at 12:30 p.m., the Clinical Discharge Summary indicated Resident 1 had a contusion of the left orbital (eye socket) tissue and was provided with discharge instructions to apply ice on the injury for 20 minutes two to three times daily for the first one to two days.
During a review of Resident 1 ' s Nursing Note dated 2/5/2025 and timed at 9:24 a.m., the Nursing Note indicated Resident 1 was readmitted to the facility from the GACH on 2/5/2025.
During an interview on 2/18/2025 at 3:20 p.m., CNA 1 stated she was walking down a hallway when she saw Resident 2 sitting in a wheelchair near Resident 1, hitting Resident 1 in her face with her fist.
During an interview on 2/19/2025 at 9:27 a.m., Resident 1 stated Resident 2 hit her in the face with her shoe, it was unprovoked, and she (Resident 1) had no idea why Resident 2 assaulted her, she must have been having a bad day.
During an interview on 2/19/2025 at 3:14 p.m., the Director of Nursing (DON) stated the day of the incident (2/4/2025) CNA 1 called for her help. The DON stated when she entered Resident 1 ' s room she observed Resident 1 with a red mark to her left eye. The DON stated CNA 1 informed her Resident 1 was hit by Resident 2.
During an interview on 2/19/2025 at 4:20 p.m., the Administrator (ADM) stated it was impossible to monitor all corners of the facility and it was the responsibility of all facility staff to ensure resident safety.
During a review of the facility's Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation with no date, the P&P indicated that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone including but not limited to; facility staff, other residents, consultants, contractors, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain infection control practices for four of six sampled residents (Resident 20, 27, 54, and 73) by failing to:
1)
Ensure the humidifier was changed for Resident 73.
2)
Ensure staff wore appropriate Personal Protective Equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environment) while providing passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) exercises and applying splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to Resident 20, who had Enhanced Barrier Precautions ([EBP] an approach of targeted gown and glove use during high contact care activities to reduce transmission of infections).
3)
Ensure facility staff implemented infection prevention and hand hygiene precautions before administering eye drops to Residents 27 and 54.
These failures had the potential to result in the transmission of infectious microorganisms and increase the risk of infection for Residents 20, 27, 54, and 73.
Findings:
1.During a review of Resident 73's admission Record, the admission Record indicated Resident 73 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease ({COPD}- a chronic lung disease causing difficulty in breathing) and cardiomegaly (heart is larger than normal).
During a review of Resident 73's Minimum Data Set ({MDS}- resident assessment tool), dated 11/18/2024, the MDS indicated Resident 73 had moderate cognitive impairment (a noticeable decline in thinking abilities, problem-solving, and judgment). The MDS indicated Resident 73 required partial/moderate assistance (helper does less than half the effort) with toileting, dressing, and transferring.
During a concurrent observation and interview on 12/17/2024 at 9:53 a.m., in Resident 73's room, Licensed Vocational Nurse (LVN) 5 stated Resident 73's humidifier was dated 12/8/2024. LVN 5 stated the humidifier should be changed weekly.
During an interview on 12/17/2024 at 9:58 a.m. with LVN 2, LVN 2 stated its important to change the humidifier to prevent the resident from getting an infection.
During an interview on 12/19/2024 at 8:41 a.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated the treatment nurse is responsible for changing the humidifier every Sunday because if the water dries up, it can dry up the resident's nostrils and for infection prevention.
During an interview on 12/19/2024 at 3:27 p.m. with the Infection Prevention Nurse (IPN), the IPN stated it's important to change the residents humidifier because if it is not changed, bacteria can form, and the resident could potentially be hospitalized for an infection.
During an interview on 12/20/2024 at 1:23 p.m. with the Director of Nursing (DON), the DON stated if the humidifiers are not changed weekly, it could cause an infection for the resident.
During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Equipment, undated, the P&P indicated, Resident-care equipment is categorized based on the degree of risk for infection involved in the use of the equipment. Semi-critical items are exposed to mucous membranes (i.e. respiratory therapy equipment) or non-intact skin.
During a review of the facility's P&P titled, Oxygen Administration, undated, the P&P indicated, Other infection control measures include: change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer.
2. b. During a review of Resident 20's admission Record, the facility admitted Resident 20 on 9/5/2023 with diagnoses including epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), parkinsonism (group of conditions with symptoms including slow movements, stiffness, tremors, and balance issues), and attention to gastrostomy ([G-tube] surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems).
During a review of Resident 20's physician orders, dated 9/6/2023 and revised 11/18/2024, the physician's orders indicated a RNA program to provide exercises (unspecified) to both arms, apply both hand rolls or rolled washcloth for five hours, and provide passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) to both legs followed by application of both ankle splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for two hours, five times per week.
During an observation on 12/19/2024 at 9:00 a.m. with RNA 1, Resident 20's RNA session was observed. An orange sign titled, Enhanced Barrier Precautions, was observed posted on the wall next to the doorway prior to entering Resident 20's room. The back of the EBP sign indicated Resident 20 was on EBP. RNA 1, who was already wearing a face mask, was observed washing hands and wearing disposable gloves prior to providing PROM to Resident 20's hips and shoulders. RNA 1 placed a rolled hand towel in Resident 20's hands and applied both ankle splints. RNA 1 did not wear a protective gown while providing Resident 20 with PROM exercises and applying the splints.
During an interview on 12/19/2024 at 9:32 a.m. with RNA 1, RNA 1 stated Resident 20 was on EBP due to having a G-tube. RNA 1 stated EBP meant staff had to wear a face mask, gloves, and gown while providing care to Resident 20. RNA 1 stated wearing the gown was optional since Resident 20 did not have an active infection.
During an interview on 12/19/2024 at 3:28 p.m. with the IPN, the IPN stated residents with any bodily openings, including but not limited to G-tubes, wounds, urinary catheters (a hollow tube inserted into the bladder to drain or collect urine), and surgical sites were on EBP to prevent infections. The IPN stated the facility staff was supposed to perform hand hygiene (washing hands or rubbing hands with an alcohol-based hand sanitizer), wear gloves, and wear a protective gown while providing high contact activities with residents on EBP. The IPN stated performing ROM exercises with a resident on EBP was considered a high contact activity, requiring the use of gloves and a gown.
During an interview on 12/20/2024 at 1:47 p.m. with the DON, the DON stated staff was supposed to wear a face mask, glove, and gown when providing care to residents on EBP to prevent infection.
During a review of the facility's undated Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, the P&P indicated EBP referred to the use of gown and gloves for use during high-contact resident care activities known to be infected with a multidrug-resistant organism ([MDRO] germ resistant to many antibiotics) and those at increased risk of acquiring MDROs. The P&P indicated residents with wounds and indwelling devices, such as G-tubes, should be on EBP even if the resident was not known to be infected with a MDRO.
3. During a review of Resident 27's admission Record, dated 12/18/2024, the facility originally admitted Resident 27 on 11/8/2019 and readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), hypotension (low blood pressure) and epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).
During a review of Resident 27's Order Summary Report (a document containing a summary of all active physician orders), dated 12/19/2024, the order summary report indicated:
Artificial Tears (eye drops solution used to relieve burning and irritation in eyes due to dry eyes) Ophthalmic (eye) Solution 1%, instill 1 drop in both eyes three times a day for dry eyes, order date 4/10/2023, start date 10/8/2024.
During an observation of medication administration on 12/18/2024 at 8:45 a.m. in Resident 27's room with LVN 1, LVN 1 administered the list of prepared medications below to Resident 27. LVN 1 used a hand sanitizer and wore gloves before entering Resident 27's room. LVN 1 administered oral medications first to Resident 27. LVN 1 was observed touching bedside cart, medication tray, medicine cups and other resident care areas. LVN 1 did not wash hands, perform hand hygiene and/or change gloves prior to administering Artificial Tears eye drops to Resident 27.
During a review of Resident 54's admission Record, dated 12/18/2024, the facility originally admitted Resident 54 on 3/24/2022 and readmitted Resident 54 on 9/18/2024 with diagnoses including hypertensive (a condition described as high blood pressure) heart disease without heart failure (a condition when heart cannot pump enough blood and oxygen to the body's organs) and Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with other specified complication.
During a review of Resident 54's Order Summary Report, dated 12/19/2024, the order summary report indicated:
Artificial Tears Ophthalmic Solution, instill 1 drop in both eyes two times a day for dry eyes, order date 10/1/2024, start date 10/8/2024
During an observation of medication administration on 12/18/2024 at 9:10 a.m. in Resident 54's room with LVN 1, LVN 1 administered the following prepared medications to Resident 54 while the resident was sitting in her wheelchair. LVN 1 wore gloves before administering oral medications. LVN 1 was observed touching bedside cart, medication tray, medicine cups and other resident care areas. After administering oral medications to Resident 54, LVN 1 administered Artificial Tears eye drops to Resident 54 without performing hand hygiene.
1. One drop of Artificial tears in both eyes
During an interview on 12/18/2024 at 12:21 p.m. with LVN 1, LVN 1 stated she should have washed hands before and after administration of artificial tears eye drops to Residents 27 and 54. LVN 1 stated although she washed her hands before starting medication pass, it was important to wash hands as well as change gloves before administering eye drops to prevent infection in eyes.
During an interview on 12/19/2024 at 3:39 p.m. with the DON, the DON stated facility staff should wash hands before and after administering eye drops to prevent infection.
During a review of the facility's P&P titled, Medication Administration - Eye Drops, dated 5/2016, the P&P indicated, To administer solution into eye in a safe and accurate manner.Procedures: Refer to Section Medication Administration .Perform hand hygiene.
During a review of the facility's P&P titled, Handwashing During Medication Administration, undated, the P&P indicated, The facility requires all staff involved in medication administration to adhere to strict hand hygiene practices before, during, and after the process to prevent contamination and ensure resident safety. The P&P indicated, When to perform Handwashing: Before Medication Administration: Wash hands before preparing or administering any medications. Wash hands before touching a resident or any equipment involved in the medication process. After Medication Administration: Wash hands immediately after medication administration for a resident. Wash hands after removing gloves or handling used medication packaging or equipment. The P&P indicated, gloves are not a substitute for hand hygiene. Wash hands before donning gloves and after removing them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident's call light was within reach for one of 20 random sampled residents (Resident 42).
This deficient practice had a potential for the resident not able to call for assistant as needed.
Findings:
During review of Resident 42's admission record, indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hypertension (high blood pressure), type 2 diabetes mellitus (a group of diseases that result in too much sugar in the blood), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest
During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool), dated 10/08/2024, indicated Resident 42's cognitive skills for daily decision-making were intact. The MDS indicated Resident 42's required extensive assistance from staff for transfer, dressing, toilet use, bathing, and personal hygiene.
During a concurrent observation and interview on 12/17/24 at 11:10 a.m. with Resident 42, Resident 42's complains of distress, coughing and unable to reach the call light. Call light was observed wrap at the back of the bed rails on the left side.
During an interview on 12/17/24 at 11:21 a.m. with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated she was assigned to resident 42's but forget to place the call light within reach after cleaning up the Resident 42's.
During an interview on 12/19//24 at 11:22 a.m. with Licensed vocational Nurse (LVN 2), LVN 2 stated resident's should be able to reach call light at all times. LVN 2 stated it is very import in case of emergency so r Resident be able to reach the call light and it hard for resident not to get help when they needed help.
During an interview on 12/20/24 at 08:35a.m. with the Director of staff Development (DSD). DSD stated call light should be within reach of Residents, not on the side rails or where Resident can't reach the call light. DSD stated if residents is not able to reach the call light, they could not get help if they need too.
During an interview with The Director of Nursing (DON) on 12/20/24 at 1:54 p.m. DON stated Call light should be always within reach. DON added if call light is not within reached, we would not be able to reach the resident needs.
A review of the facility's policy and procedure -of undated, titled Answering the Call Light, indicated when the resident is in bed or confined to a chair to be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) for five of seven residents (Residents 5, 21, 36, 65, and 68).
These failures had the potential to result in causing a conflict with Resident 5, 21, 36, 65, and 68's wishes regarding their health care.
Findings:
During a review of Resident 5's admission Record, Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities) and chronic obstructive pulmonary disease ({COPD}- a chronic lung disease causing difficulty in breathing).
During a review of Resident 5's Minimum Data Set ({MDS}- resident assessment tool), the MDS indicated Resident 5 had moderate cognitive impairment (a noticeable decline in thinking abilities, problem-solving, and judgement). The MDS indicated required substantial/maximal assistance (helper does more than half the effort) with personal hygiene, toileting, and bathing.
During a review of Resident 5's advance directive acknowledgement of receipt, the advance directive acknowledgement of receipt was completed by the Interdisciplinary Team ({IDT}- a group of professionals from different disciplines who work together to achieve a common goal) on 6/17/2019 and was signed by the Physician on 10/28/2021.
During a review of Resident 21's admission Record, Resident 21 was admitted to the facility 12/8/2014 and readmitted on [DATE] with diagnoses that included epilepsy (a chronic brain condition that causes seizures {sudden uncontrolled body movements and changed in behavior that occur because of abnormal electrical activity of the brain}) and hypertensive heart disease (heart problems that occur because of high blood pressure).
During a review of 21's MDS, dated [DATE], the MDS indicated Resident 21 had severe cognitive impairment (someone with significant difficulty with thinking, remembering, making decisions, and understanding things). The MDS indicated Resident 21 required partial/moderate assistance (helper does less than half the effort) with dressing, personal hygiene, and transferring.
During a review of Resident 21's advance directive acknowledgement of receipt, the advance directive acknowledgement of receipt indicated there was no decision checked whether to formulate an advance directive or not and there was no physician signature.
During a review of Resident 36's admission Record , the admission record indicated Resident 36 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to schizophrenia (a mental illness that is characterized by disturbances in thought), epilepsy , and COPD.
During a review of Resident 36's History and Physical (H&P), dated 7/5/2024, the H&P indicated, Resident 36 did not have the capacity to understand and make decisions.
During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36 needed substantial to maximal assistance with transferring to a chair, shower, and toilet. The MDS indicated Resident 36 needed partial to moderate assistance dressing, personal hygiene, rolling from left to right, sitting, standing, and lying. The MDS indicated Resident 36 was independent with eating, and oral hygiene.
During a review of Resident 36's Acknowledgment of Receipt Advance Directive/Medical Treatment Decisions, dated 6/28/2021, the Acknowledgment of Receipt Advance Directive/Medical Treatment Decisions did not have a witnessed dated signature and did not indicate a reason that Resident 36 is unable to sign name. The Acknowledgment of Receipt Advance directive/Medical Treatment Decisions did not have a physician's dated signature and no documentation Resident 36's diagnoses, prognosis and mental condition was discussed. The Acknowledgment of Receipt Advance Directive/Medical Treatment Decisions did not indicate Resident 36's mental condition was consistent with the Advance Directive/Preferred Intensity of Care. The Acknowledgment of Receipt Advance directive/Medical Treatment Decisions did indicate documentation of Acknowledgment of Durable Power of Attorney (a legal document that allows someone you designate (called an agent) to make financial and legal decisions on the resident's behalf, even if the resident becomes incapacitated or unable to make decisions for themselves due to illness or injury) or dated signature.
During a review of Resident 65's admission Record, the admission record indicated Resident 65 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to dementia (a progressive state of decline in mental abilities), schizophrenia, and bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).
During a review of Resident 65's H&P, dated 7/17/2024, the H&P indicated, Resident 65 had fluctuating capacity to understand and make decisions.
During a review of Resident 65's MDS, dated [DATE], the MDS indicated, Resident 65 needed partial to moderate assistance with showering, dressing, personal hygiene, and transferring in an out of the shower. The MDS indicated Resident 65 needed supervision or touching assistance with oral hygiene, toileting, and putting on and taking off footwear. The MDS indicated Resident 65 needed supervision or touching assistance with rolling from left to right, changing positions from sitting to lying and changing positions from lying to sitting. The MDS indicated Resident 65 needed supervision or touching assistance with changing positions from sitting to standing and transferring to a chair or toilet.
During a review of Resident 65's Acknowledgment of Receipt Advance directive/Medical Treatment Decisions , dated 1/31/2023, indicated the Acknowledgment of Receipt Advance directive/Medical Treatment Decisions did not have a physician's dated signature. The Acknowledgment of Receipt Advance directive/Medical Treatment Decisions did not indicate documentation Resident 65's diagnoses, prognosis and mental condition was discussed. The Acknowledgment of Receipt Advance directive/Medical Treatment Decisions did not indicate Resident 65's mental condition is consistent with the Advance Directive/Preferred Intensity of Care. The Acknowledgment of Receipt Advance directive/Medical Treatment Decisions did indicate documentation of Acknowledgment of Durable Power of Attorney signed and dated.
During a review of Resident 68's admission Record, the admission record indicated Resident 68 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to acute kidney failure (a sudden loss of kidney function that occurs within a few hours or days), schizophrenia, and bipolar.
During a review of Resident 68's H&P, dated 8/4/2024, the H&P indicated, Resident 68 had fluctuating capacity to understand and make decisions.
During a review of Resident 68's MDS , dated 11/19/2024, the MDS indicated, Resident 68 needed substantial to maximal assistance with lower body dressing. The MDS indicated Resident 68 needed partial to moderate assistance with upper body dressing, showering, toileting, oral hygiene, personal hygiene, and putting on and taking off footwear. The MDs indicated Resident 68 needed supervision with rolling from left to right, sitting, lying, and standing. The MDS indicated Resident 68 was independent with eating.
During a review of Resident 68's Acknowledgment of Receipt Advance directive/Medical Treatment Decisions , dated 8/2/2024, did not indicated a check mark regarding Resident 68's right to choose to formulate any Advance Directive. The Acknowledgment of Receipt Advance directive/Medical Treatment Decisions did indicate documentation of a physician's dated signature or an Acknowledgment of Durable Power of Attorney.
During a phone interview on 12/19/2024 at 10:16 a.m. with the Social Services Director (SSD), the SSD stated she is responsible for ensuring the Advance Directives are accurately completed. SSD stated if there is no physician signature or if a physician signature is dated two years after the advance directive was completed, it is considered incomplete. SSD stated its important that the advance directives are completed because it represents the residents preferences and wishes for their care and if not, their wishes may not be met.
During a concurrent interview and record review on 12/19/2024 at 10:52 a.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 5's and Resident 21's advance directives were invalid because they were not completed accurately. RNS stated an invalid advance directive can cause a delay in care or treatment for the residents.
During an interview on 12/20/2024 at 1:40 p.m. with the Director of Nursing (DON), the DON stated it is important that the advance directives are accurately completed so they can follow the resident's wishes. The DON stated if the resident were to transfer to the hospital and the advance directive was incomplete, things may or not be done that the residents may or may not have wanted done.
During a review of the facility's policy and procedure (P&P) titled, Advance Directives, undated, the P&P indicated, The Director of Nursing or designee will notify the Attending Physician if advance directives so that appropriate orders can be documented in the resident's medical record and plan of care.
During a review of the facility's Social Services Director- Job Description, undated, the Job Description indicated, The Social Services Director will oversee the process of Advance Care Planning for each resident upon admission, and make sure that any Advance Directives are reviewed with the resident/resident representative on a regular basis.
During a review of the facility's policy and procedure (P&P), titled Advance Directives, undated, the P&P indicated, Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record .The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident 81 bed was not broken for 1 out of 3 Residents.
This deficient practice had the potential to put Resident 81 at risk for accidents while in bed.
Findings:
During a review of Resident 81's admission Record dated 12/19/24, indicated Resident 81 was admitted on [DATE] and readmitted on [DATE] with diagnoses of hypertensive heart, psychosis (loss of contact with reality), glaucoma (a group of eye diseases that cause blindness), muscle weakness.
During a review of Resident 81's History and Physical (H&P), dated 6/12/24 indicated, Resident 81 does have the capacity to understand and make decisions.
During a review of Resident 81's Minimum Data Set (MDS- a resident assessment tool) dated 11/22/24 the MDS indicated Resident 81 has moderate cognitive impairment. The MDS also indicated Resident 81 needed partial/moderate assist with activities of daily living (ADL's- activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated Resident 81 needed supervision or touch assistance with bed mobility (the ability to move around in bed).
During a review of Resident 81's Care plan dated 12/11/2024 indicated Resident 81 had a moderate risk for falls due to gait (the way a person walks) imbalance. The care plan also indicated Resident 81 needs a safe environment bed in lowest position at night and handrails.
During a review of the Maintenance Report log dated 11/20/24 indicated that Resident 81's bed does not work it does not go up and down.
During an observation on Resident's 81 room and interview on 12/17/24 at 9:54 a.m., Resident 81 stated I have been in this room for about 3 months and the bed was broken from the day I came here, the bed remote control does not work, and my bed is leaning to the left side. Resident 81 stated he told the nurses, and he told maintenance a few times.
During an observation and interview on 12/19/24 with Certified Nursing Assistant (CNA) in Resident 81's room, CNA 1 stated the bed is not working and it is leaning to the left side. CNA 1 stated that if a bed is not working, she would tell charge nurse and put it in the maintenance log. CNA1 stated resident 81 is at risk for falls if the bed is not working properly.
During an observation and interview on 12/19/24 with LVN 2 in Resident 81's room, LVN2 stated she was aware Resident 81's bed is broken and that she told maintenance it was broken a few weeks ago. LVN 2 stated that residents should not have a broken bed and that there is a safety issue resident could fall and get injured.
During a concurrent observation and interview on 12/19/24 at 10:08 a.m. with Maintenance supervisor (MS), in Resident 81's room, MS tested the remote control and Resident 81's bed remote was not working and the bed leaned to the left side.
During a concurrent interview on 12/19/24 at 11:08 a.m. and record review on Maintenance Report log with Maintenance Supervisor (MS). MS stated that He is responsible on reviewing the maintenance report log daily and that on 11/20/24 there was an entry in the maintenance report log that resident 81's bed was not working. MS stated that residents in the facility should not have broken beds because this is their home, and residents could get injured when the bed is not working properly.
During an interview on 12/20/24 at 1:00 p.m. with Administrator (ADM), ADM stated that residents need to have beds that work and that their quality of life could be affected when their bed is broken.
During a review of the facility's undated Policy & Procedure (P&P) titled Bed maintenance and inspection, the P&P indicated, that it is the policy of this facility to conduct regular inspections of all bed frames, mattresses, and bed rails, as part of a regular maintenance program. Bed frames mattress, and bed rail inspection will be conducted upon each item entering the facility and then placed on a regularly scheduled inspection and maintenance cycle according to the manufacturer's requirements. If bed equipment is found to be outside of the manufacturer's requirements for any reason the facility will perform maintenance to the bed equipment or remove from use if not able to bring specs to the manufacturer's requirements. The maintenance department or other designated employee will keep records of bed inspections and maintenance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to record dates on the Minimum Data Set ([MDS] a resident assessment tool) to indicate the start and end of therapy services since most recent entry (admission) to the facility for three of nine sampled residents (Resident 14, 21, and 26) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move).
This failure resulted in incomplete information submitted to the Federal database.
Findings:
a. During a review of Resident 14's admission Record, the facility admitted Resident 14 on 8/27/2024 with diagnoses including lack of coordination, type 2 diabetes mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 14's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 8/28/2024, the OT Evaluation indicated reasons Resident 14 would benefit from OT services, including to improve activity tolerance and independence with activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility). The OT Plan of Treatment for Resident 14 included therapeutic exercises (movement prescribed to correct impairments and restore muscle function), neuromuscular reeducation (technique used to restore movement patterns through repetitive motion to retrain the brain), therapeutic activities (tasks that improve the ability to perform ADLs), and self-care management training, five times per week for four weeks.
During a review of Resident 14's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, the PT Evaluation indicated reasons Resident 15 would benefit from PT services, including to promote safety awareness, minimize falls, improve leg strength and ROM, increase coordination, and increased independence with gait (manner of walking). The PT Plan of Treatment for Resident 14 included therapeutic exercises, neuromuscular reeducation, therapeutic activities, and wheelchair management training (training on proper positioning and ability to propel the wheelchair), five times per week for four weeks.
During a review of Resident 14's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 14 reached the highest level of functional independence.
During a review of Resident 14's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 14 reached the highest level of independence.
During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14's entry date was on 8/27/2024. Section O of Resident 14's MDS did not indicate the start and end dates for PT and OT services since Resident 14's most recent entry on 8/27/2024.
During a concurrent interview and record review on 12/19/2024 at 1:26 p.m. with the Director of Rehabilitation (DOR), the DOR reviewed Resident 14's PT and OT records. The DOR stated Resident 14 received PT and OT Evaluations on 8/28/2024 and was discharged from PT and OT on 10/1/2024.
During an interview on 12/20/2024 at 11:33 a.m. with the MDS Coordinator (MDSC), the MDSC stated the MDS collected information on each resident, including any special treatments a resident received.
During a concurrent interview and record review on 12/20/2024 at 11:41 a.m. with the MDS Coordinator (MDSC), Resident 14's PT Evaluation, dated 8/28/2024, OT Evaluation, dated 8/28/2024, PT Discharge summary, dated [DATE], OT Discharge summary, dated [DATE], MDS, dated [DATE], and the RAI Manual, dated 10/2023, were reviewed. The MDSC stated Resident 14's therapy dates were not included in the MDS, dated [DATE]. The MDSC stated there was another MDS for the Medicare payment system which included Resident 14's PT and OT Evaluation and discharge date s. The MDSC reviewed the RAI manual and stated she did not know the therapy start and end dates were supposed to be recorded in the quarterly MDS.
During an interview on 12/20/2024 at 1:47 p.m. with the Director of Nursing (DON), the DON stated the MDS (in general) was an assessment to determine a resident's care and to indicate the care provided to the resident. The DON stated the MDS information was submitted to the Federal database. The DON stated the MDS provided an incomplete picture of a resident if the start and end dates for therapy were not included in the MDS.
b. During a review of Resident 21's admission Record, the facility admitted Resident 26 on 5/3/2024 with diagnoses including bipolar disorder, major depressive disorder, and epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking).
During a review of Resident 21's OT Evaluation and Plan of Treatment, dated 5/4/2024, the OT Evaluation indicated reasons Resident 21 would benefit from OT services, including, to improve activity tolerance, improve safety awareness, and maximize independence with ADLs to enhance Resident 21's quality of life. The OT Plan of Treatment for Resident 21 included therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care management training, five times per week for four weeks.
During a review of Resident 21's PT Evaluation and Plan of Treatment, dated 5/5/2024, the PT Evaluation indicated reasons Resident 21 would benefit from PT services, including to promote safety awareness, improve balance, minimize falls, improve leg strength and ROM. The PT Plan of Treatment for Resident 21 included therapeutic exercises, neuromuscular reeducation, therapeutic activities, wheelchair management training, five times per week for four weeks.
During a review of Resident 21's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 21 reached the highest practical level.
During a review of Resident 21's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 21 reached the highest practical.
During a review of Resident 21's MDS, dated [DATE] (annual) and 10/30/2024 (quarterly), the MDS indicated Resident 21's most recent entry date was on 5/3/2024. Section O of Resident 21's MDS did not indicate the start and end dates for PT and OT services since Resident 21's most recent entry on 5/3/2024.
During a concurrent interview and record review on 12/19/2024 at 1:09 p.m. with the DOR, the DOR reviewed Resident 21's PT and OT records. The DOR stated Resident 21 received an OT Evaluation on 5/4/2024, PT Evaluation on 5/5/2024, and was discharged from PT and OT on 7/17/2024.
During a concurrent interview and record review on 12/20/2026 at 12:03 p.m. with the MDSC, Resident 21's OT Evaluation, dated 5/4/2024, PT Evaluation, dated 5/5/2024, PT and OT Discharge Summaries, dated 7/17/2024, MDS, dated [DATE] and 10/30/2024, and RAI Manual were reviewed. The MDSC stated Resident 21's therapy dates were not included in the MDS, dated [DATE] and 10/30/2024. The MDSC stated there was another MDS for the Medicare payment system which included Resident 21's PT and OT Evaluation and discharge date s.
During an interview on 12/20/2024 at 1:47 p.m. with the DON, the DON stated the MDS (in general) was an assessment to determine a resident's care and to indicate the care provided to the resident. The DON stated the MDS information was submitted to the Federal database. The DON stated the MDS provided an incomplete picture of a resident if the start and end dates for therapy were not included in the MDS.
c. During a review of Resident 26's admission Record, the facility admitted Resident 26 on 5/3/2024 with diagnoses including contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) of both knees and the left ankle, type 2 DM, bipolar disorder, and major depressive disorder.
During a review of Resident 26's OT Evaluation and Plan of Treatment, dated 5/4/2024, the OT Evaluation indicated reasons Resident 26 would benefit from OT services, including, to improve activity tolerance, improve safety awareness, and maximize independence with ADLs to enhance Resident 26's quality of life. The OT Plan of Treatment for Resident 26 included therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care management training, five times per week for four weeks.
During a review of Resident 26's PT Evaluation and Plan of Treatment, dated 5/6/2024, the PT Evaluation indicated reasons Resident 26 would benefit from PT services, including to promote safety awareness, minimize falls, improve leg strength and ROM, and develop a Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) Program. The PT Plan of Treatment for Resident 26 included therapeutic exercises, neuromuscular reeducation, therapeutic activities, manual therapy (hands-on treatment involving techniques to treat muscles and joints), and orthotic (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) management and training, five times per week for four weeks.
During a review of Resident 26's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 26 achieved the maximum potential.
During a review of Resident 26's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 26 achieved the maximum potential.
During a review of Resident 26's MDS, dated [DATE] (quarterly) and 10/12/2024 (annual), the MDS indicated Resident 26's most recent entry date was on 5/3/2024. Section O of Resident 26's MDS did not indicate the start and end dates for PT and OT services since Resident 26's most recent entry on 5/3/2024.
During a concurrent interview and record review on 12/19/2024 at 12:56 p.m. with the DOR, the DOR reviewed Resident 26's PT and OT records. The DOR stated Resident 26 received an OT Evaluation on 5/4/2024, PT Evaluation on 5/6/2024, and was discharged from PT and OT on 7/5/2024.
During a concurrent interview and record review on 12/20/2026 at 12:16 p.m. with the MDSC, Resident 26's OT Evaluation, dated 5/4/2024, PT Evaluation, dated 5/6/2024, PT and OT Discharge Summaries, dated 7/5/2024, MDS, dated [DATE] and 10/12/2024, and RAI Manual were reviewed. The MDSC stated Resident 26's therapy dates were not included in the MDS, dated [DATE] and 10/12/2024. The MDSC stated there was another MDS for the Medicare payment system which included Resident 26's PT and OT Evaluation and discharge date s.
During an interview on 12/20/2024 at 1:47 p.m. with the DON, the DON stated the MDS (in general) was an assessment to determine a resident's care and to indicate the care provided to the resident. The DON stated the MDS information was submitted to the Federal database. The DON stated the MDS provided an incomplete picture of a resident if the start and end dates for therapy were not included in the MDS.
During a review of Page O-23 in the Long-term Care Facility Resident Assessment Instrument Manual ([RAI Manual] guidance on the completion of the MDS), dated 10/2023, the RAI Manual indicated to record a resident's most recent therapy start and end dates since the most recent entry to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a preadmission screening and annual resident review (PASARR) was accurately documented for five of eight residents (Resident 19, 21, 45, 65, and 84).
This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident's 19, 21, 45, 65, and 84.
Findings:
During a review of Resident 19's admission Record, Resident 19's admission Record indicated Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought) and anemia (a condition where the body does not have enough healthy red blood cells).
During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 10/7/2024, the MDS indicated Resident 19 was cognitively intact. The MDS indicated Resident 19 had delusions (having false or unrealistic behaviors).
During a review of Resident 19's care plan initiated 9/2024, the care plan focus was, Resident 19 was at high risk to experience complications related to the use of psychotropic medications with goals that included minimal to no side effects of the medication. Interventions for Resident 19 included to monitor resident's mood state and evaluate the effectiveness and side effects of the medication.
During a review of Resident 19's Order Summary Report, the Order Summary Report indicated an order was placed 5/24/2021 for Zyprexa (medication to treat schizophrenia).
During a review of Resident 19's PASARR Level I document, dated 7/30/2020, the PASARR document indicated a negative Level I screening. The PASARR I indicated Resident 19 had a mental illness and was prescribed psychotropic (affecting the mind or mental process) medication.
During a review of Resident 21's admission Record, Resident 21's admission Record indicated Resident 21 was admitted to the facility 12/8/2014 and readmitted [DATE] with diagnoses of schizophrenia and bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs).
During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21 had severe cognitive impairment (someone with significant difficulty with thinking, remembering, making decisions, and understanding things). The MDS indicated Resident 21 required partial/moderate assistance (helper does less than half the effort) with dressing, personal hygiene, and transferring.
During a review of Resident 21's Order Summary Report, the Order Summary Report indicated an order was placed 11/5/2024 for Risperidone (medication to treat schizophrenia).
During a review of Resident 21's PASARR Level I screening, dated 7/18/2024, the PASARR Level I screening indicated a positive Level I screening requiring a PASARR Level II screening to be completed. Resident 21's PASARR Level II's screening was not completed because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening.
During a review of Resident 45's admission Record, Resident 45's admission Record indicated Resident 45 was admitted [DATE] and readmitted [DATE] with diagnoses of schizophrenia, bipolar disorder, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review Resident 45's MDS, dated [DATE], the MDS indicated Resident 45 has moderate cognitive impairment. The MDS indicated Resident 45 experiences hallucinations (when you see, hear, smell, taste, or feel something that seems real but isn't actually there).
During a review of Resident 45's Order Summary Report, the Order Summary Report indicated an order was placed 6/19/2024 for Risperdal (medication to treat schizophrenia).
During a Review of Resident 45's PASARR Level I screening, completed 1/17/2023, the PASARR Level I screening indicated a positive Level I screening requiring a PASARR Level II screening to be completed. No PASARR Level II screening was completed.
During a review of Resident 65's admission Record, the admission record indicated Resident 65 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to dementia (a progressive state of decline in mental abilities), schizophrenia, and bipolar (.
During a review of Resident 65's History and Physical (H&P) dated 7/17/2024, the H&P indicated Resident 65 had fluctuating capacity to understand and make decisions.
During a review of Resident 65's MDS dated [DATE], the MDS indicated, Resident 65 needed partial to moderate assistance with showering, dressing, personal hygiene, and transferring in an out of the shower. The MDS indicated Resident 65 needed supervision or touching assistance with oral hygiene, toileting, and putting on and taking off footwear. The MDS indicated Resident 65 needed supervision or touching assistance with rolling from left to right, changing positions from sitting to lying and changing positions from lying to sitting. The MDS indicated Resident 65 needed supervision or touching assistance with changing positions from sitting to standing and transferring to a chair or toilet.
During a concurrent interview and record review on 12/19/2024 at 2:02 pm with Infection Preventionist Nurse (IPN), Resident 65's PASRR Level I Screening, dated 7/19/2024. The PASRR Level I Screening indicated Resident 65 had a positive diagnosis of a serious mental illness. IPN stated Resident 65 needs a Level II screening (Level II Mental Health Evaluation is required when the Level I Screening result is positive) mental health evaluation. IPN stated she missed the Level II screening and never followed up.
During a review of Resident 84's admission Record, Resident 84's admission Record indicated Resident 84 was readmitted to the facility 8/13/2024 with a diagnosis of Hyperlipidemia (high cholesterol), type 2 diabetes mellitus (body does not produce enough insulin), extrapyramidal and movement disorder (involuntary movement side effects of antipsychotic medications (EPS).
During a review of Resident 84's History and Physical (H&P), dated 8/15/24 the H&P indicated Resident 84 does not have the capacity to understand and make decisions.
During a review of Resident 84's MDS dated [DATE] the MDS indicated Resident 84 has moderate cognitive impairment. The MDS also indicated Resident 84 was independent with activities of daily living ({ADL's}- activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated Resident 84 was taking antipsychotic medication.
During a review of Resident 84's All Active Orders dated 12/19/24 indicated resident 84 had orders for Zyprexa (antipsychotic medication) 5mg two times a day for the diagnosis of psychosis manifested by (M/B) mumbling to self-talking to walls and making gestures that she is talking on the phone with someone,
During a review of Resident 84's PASSAR Level1 Screening dated 12/17/2024 indicated, Resident 84 has no serious mental illness and is not taking any psychotropic medications.
During an interview on 12/19/2024 at 1:43 p.m. with the Infection Prevention Nurse (IPN), the IPN stated ensuring the PASARR is documented accurately and a PASARR II is completed if indicated is important to the residents will get the appropriate care they need at the appropriate level.
During a continued interview and record review on 12/19/2024 at 1:43 p.m. with the IPN, the IPN stated Resident 19's PASARR II should have been done because he had a positive Level I PASARR. The IPN stated Resident 21's PASARR II was not done because the facility was not responsive to the calls and now the case is closed and now a new Level I PASARR is required. IPN stated Resident 45's PASARR Level II was not done and should have been done because the PASARR Level I was positive.
During an interview on 12/20/2024 at 1:26 p.m. with the Director of Nursing (DON), the DON indicated it is important that the PASARR Is accurately documented and that a PASARR II is completed if indicated so the resident receives the care and services they need and deserve.
During a review of the facility's policy and procedure (P&P) titled Resident Assessment - Coordination with PASARR Program, undated, the P&P indicated, The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person focused care plan for two of three sampled residents (Resident 6 and 339) by failing to:
1.
develop a comprehensive care plan that will address Resident 339's fabrication (making something up) of stories.
2.
develop and implement care plan for skin redness and swelling of the right eye and right cheek for Resident 6.
These failures placed Resident 6 and Resident 339 at risk for a delay of care and treatment.
Findings:
1.During a review of Resident 339's admission Record, the admission Record Resident 339 was admitted to the facility 10/9/2020 with diagnoses including bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 339's Minimum Data Set ({MDS}- resident assessment tool), dated 10/9/2024, the MDS indicated Resident 339 is moderately cognitively impaired. The MDS indicated Resident 339 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene, dressing, and bathing.
During a review of Resident 339's care plan, dated 7/24/2024, the care plan focus was Resident 339's was at risk for behaviors for a diagnosis of anxiety (a feeling of fear, dread, or uneasiness that can be a normal reaction to stress). The goal for Resident 339 was to minimize the episodes of irritability with interventions including monitoring behaviors and notify the physician for any significant changes in behaviors and when interventions are ineffective.
During a concurrent interview and record review on 12/19/2024 at 7:51 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 339 can make up stories at times and this should be included in the care plan because its important to communicate with the staff who care for him, so they are aware of his behavior. LVN 2 verbally confirmed there is no care plan that addresses Resident 339's fabrication of stories.
During an interview on 12/20/2024 at 1:06 p.m. with the Director of Nursing (DON), the DON stated Resident 339 is known for making up stories and there should be a care plan for this, so the staff know what to expect when they are taking care of him.
2. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder and hypertensive heart disease (a condition that occurs when the heart is damaged by long-term high blood pressure).
During a review of Resident 6's History and Physical (H&P), dated 7/17/2024, the H&P indicated, Resident 6 had fluctuating capacity to understand and make decisions.
During a review of Resident 6's MDS dated [DATE], the MDS indicated, Resident 6 needed set-up or clean-up assistance with eating. The MDS indicated Resident 6 needed partial to moderate assistance with oral hygiene, personal hygiene, and rolling from left to right. The MDS indicated Resident 6 needed partial to moderate assistance with changing positions from sitting to lying and changing positions from lying to sitting. The MDS indicated Resident 6 needed substantial to maximal assistance with transferring to the toilet and chair. The MDS indicated Resident 6 needed substantial to maximal assistance with toileting, showering, and dressing.
During an observation on 12/17/2024 at 11:03 pm, Resident 6 had redness, swelling on the right side of the face and a small bump under the right eye.
During an interview on 12/19/2024 at 9:51 am with Licensed Vocational Nurse (LVN) 6, LVN 6 stated on 12/17/2024 Resident 6 had redness on the right side of the eyes and right cheek. LVN 6 stated he did not document a care plan for the redness on Resident 6's right cheek and eye. LVN 6 stated Resident 6 could experience infection, neglect, or hospitalization when care plan is not done since there is no intervention in placed.
During an interview on 12/20/2024 at 1:00 pm with the Director of Nursing (DON), DON stated the licensed nurses are responsible for developing and implementing Care Plans. DON stated licensed nurses formulate a plan of care to determine if the resident condition is improving or deteriorating.
During a review of the facility's policy and procedure (P&P) titled, Reviewing and Revising the Care Plan, undated, the P&P indicated, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.
During a review of the facility's P&P titled, Care Plans- Comprehensive, undated, the P&P indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to incorporate identified problem areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident was provided care and services to maintain good grooming and personal hygiene by failing to clean and cut Resident 29 fingernail for one of three sampled residents (Resident 29).
This deficient practice resulted in Resident 29 not receiving fingernail care and can potentially impact Resident 29's self-esteem
Findings:
During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest),bipolar disorder (; mood swings that range from the lows of depression to elevated periods of emotional highs)
During a review of Resident 29's Minimum Data Set ([MDS], a resident assessment tool) dated 10/23/2024, the MDS indicated Resident 29 cognitive for skills and daily decision making is severely impaired. The MDS also indicated the resident required extensive assistance or was totally dependent on staff for ADL's including bed mobility, transfer, eating, toilet use, personal hygiene, and dressing.
During observation on 12/17/2024 at 10:06 a.m. with Resident 29, Resident 29 was observed to have long and dirty fingernails on both hands.
During an observation on 12/18/24 at 12:14 pm Resident 29 was observe in bed lying down quietly. Resident was able to stretch out his hands and observed to have fingernails long with brown looking stuff around his fingers.
During an interview on 12/18/2024 at 2:50 p.m. with the Certified Nursing Assistant (CNA 3), CNA3 stated she did not clean Resident 29 nails today because he refused, CNA 3 stated it was not documented that Resident 29 refused. CNA 3 also stated she supposed to notify the charge Nurse about resident refusal of care.
During an interview with licensed Vocational Nurse (LVN 2) on 12/19/24 at 11:22 a.m. LVN 2 stated treatment nurses were trained to assist with trimming resident's fingernails and was not sure why this was not done for Resident 29. LVN 2 stated it was important to ensure Fingernail care was provided to promote resident's quality of life, prevent skin breakdown, and maintain self-esteem.
During an interview with The Director of Nursing (DON) on 12/20/24. DON stated CNA supposed to clean and cut nails during ADLs, and treatment nurse also can assist with cutting of the nails, DON stated Resident would get sick if they used dirty nails to eat and CNA should document right after caring for the resident
During a review of the facility's undated P&P titled, Quality of Care: Dignity , the P&P indicated residents should be groomed as they wish to be groomed (hair styles, nails etc.) Residents shall be always treatment with dignity and respect by maintaining his or her self-esteem and self-worth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident 6 who had redness on the right side of the cheek was monitored and received treatment for one of 22 sampled residents.
This failure had the potential for Resident 6 not receiving necessary care and treatment.
Findings:
During a review of Resident 6's admission Record (face Sheet) , the Face Sheet indicated Resident 6 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), gastro-esophageal reflux disease (a digestive condition where stomach contents flow back up into the esophagus, the tube connecting the mouth to the stomach) and hypertensive heart disease (a condition that occurs when the heart is damaged by long-term high blood pressure).
During a review of Resident 6's History and Physical (H&P), dated 7/17/2024, the H&P indicated, Resident 6 had fluctuating capacity to understand and make decisions.
During a review of Resident 6's Minimum Data Set (MDS -a resident assessment tool) , dated 10/11/2024, the MDS indicated, Resident 6 needed set-up or clean-up assistance with eating. The MDS indicated Resident 6 needed partial to moderate assistance with oral hygiene, personal hygiene, and rolling from left to right. The MDS indicated Resident 6 needed partial to moderate assistance with changing positions from sitting to lying and changing positions from lying to sitting. The MDS indicated Resident 6 needed substantial to maximal assistance with transferring to the toilet and chair. The MDS indicated Resident 6 needed substantial to maximal assistance with toileting, showering, and dressing.
During a concurrent observation and interview on 12/ 17/2024 at 11:03 am in Resident 6's room, Resident 6 had redness and swelling to the right eye and small bump with redness below the right eye. Resident 6 stated she had a bug bite on the right eye and reported it to nursing staff.
During an interview on 12/19/2024 at 9:37 a.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated while bathing the residents she checks the skin and reports to the treatment nurse or charge nurse if there is redness, rashes, skin tears and skin changes she has not seen before and documents it on the skin inspection sheet. CNA 5 stated on 12/17/2024 she noticed Resident 6 had redness on the right eye but did not document or report it to anyone.
During an interview on 12/19/2024 at 9:51 am with Licensed Vocational Nurse (LVN) 6, LVN 6 stated on 12/17/2024 Resident 6 had redness on the right cheek. LVN 6 stated redness on the right side of Resident 6's cheek has change of condition. LVN 6 stated he did not do a change of condition (COC- internal document), a care plan or notify the doctor for the redness on Resident 6's right cheek LVN 6 stated he missed on reporting Resident 6's skin changes and tried to take a short cut by assuming it was her glasses that left a red mark on Resident 6's face. LVN 6 stated a change of condition needs to be done to alert staff to check and address the resident's problem. LVN 6 stated the doctor and the family need to be notified.
During an interview on 12/19/2024 at 10:09 am with Registered Nurse Supervisor (RNS) 1, RNS 1 stated when there is a new skin finding the treatment nurse is notified to do a skin assessment, and the doctor is notified for any new orders or a wound consult. RNS 1 stated there is no documentation on 12/17/2024 of a skin inspection, a skin assessment, a care plan, or a change of condition for Resident 6's redness to the right eye or right cheek,.
During an interview on 12/20/2024 at 1:00 pm with the Director of Nursing (DON), DON stated any skin issue need to be checked and reported to the supervisor, documented in the nurses' progress notes, and the notify the doctor. DON stated a COC and a care plan needs to be done by the licensed nurses. DON stated a COC is anything out of the ordinary and is important to document so the resident's condition can be monitored on the resident's condition.
During a review of the facility's policy and procedures (P&P) titled, Skin Audits by Nursing Assistants, undated, the P&P indicated, Nursing assistants shall inspect all skin surfaces during bath/shower and report any concerns to the resident's nurse immediately after the task . Skin conditions that shall be reported include, but are not limited to redness, bruising, swelling, rashes, hives blisters (clear or blood-filled) skin tears, open areas, ulcers, lesions. Notification shall be made to the nurse verbally or in writing.
During a review of the facility's policy and procedures (P&P) titled, Change in a Resident's Condition or Status, undated, the P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative {sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to three of nine residents (Resident 5, 20, and 68) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to:
1. Provide Resident 5 with passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) to both arms from 12/1/2024 to 12/19/2024 in accordance with the physician's order and care plan.
2. Provide PROM to Resident 5's ankles on 12/19/2024 in accordance with the physician's order and care plan.
3. Provide PROM to Resident 20's elbows, wrists, hands, knees, and ankles in accordance with the physician's order and care plan.
4. Provide PROM to Resident 20's hands and ankles prior to applying rolled hand towels (rolled towel placed in the palm) and ankle splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion).
5. Position Resident 20's right rolled hand towel through the thumb's webspace
6. Ensure Resident 20's rolled hand towels were positioned securely in both hands.
7. Provide PROM to Resident 68's left hand in accordance with the physician's orders and care plan.
These deficient practices have a potential for Resident 5 unable to get the exercises at risk to develop contractures or limitation on both arms.
The deficient practice of not applying the hand towels correctly and not providing appropriate exercises has a potential for Resident 20 decline in ROM.
Findings:
a. During a review of Resident 5's admission Record, the facility admitted Resident 5 on 5/7/2024 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue) and dementia (a progressive state of decline in mental abilities).
During a review of Resident 5's Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs), dated 5/8/2024, the JMA indicated Resident 5 had ROM limitations in both arms and legs, including moderate (50 to 75 percent [%] available ROM) limitations in the left shoulder, moderate/severe (25 to 50% available ROM) limitation in the right shoulder, minimal (75 to 100% available ROM) limitation in both elbows, moderate limitation in both wrists, severe (0-25% available ROM) limitation in both hands, and severe limitation in both knees. The JMA indicated the ROM in Resident 5's hips and ankles were within functional limits ([WFL] sufficient movement without significant limitation).
During a review of Resident 5's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Discharge summary, dated [DATE], the OT Discharge recommendations indicated for Resident 5 to receive a Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) Program for PROM to both arms, five times per week.
During a review of Resident 5' Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge summary, dated [DATE], the PT Discharge recommendations indicated for Resident 5 to receive RNA Program for PROM to both legs and application of splints to both knees.
During a review of Resident 5's care plan titled, Rehab to RNA Care Plan, dated 7/11/2024, the care plan indicated a plan to provide PROM to both arms, five times per week, and PROM of both legs followed by application of both knee splints to prevent decline in ROM.
During a review of Resident 5's physician orders, dated 7/11/2024, the physician's orders indicated to provide PROM to both arms to resident's tolerance, five times per week. Another physician's order, dated 7/11/2024 and revised 11/18/2024, indicated to provide Resident 5 with PROM to both legs followed by the application of both knee splints, five times per week.
During a review of Resident 5's Minimum Data Set ([MDS] a resident assessment tool), dated 11/12/2024, the MDS indicated Resident 5 had clear speech, expressed ideas and wants, clearly understood others, and was moderately impaired for cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 5 had ROM limitations in both arms and legs and required substantial/maximal assistance (helper does more than half the effort) for oral hygiene, toileting, bathing, lower body dressing, rolling to both sides in bed, and chair/bed-to-chair transfers.
During a review of Resident 5's RNA treatment record, dated 11/2024, the RNA treatment record included PROM to both arms and legs followed by the application of both knee splints, five times per week.
During a review of Resident 5's RNA treatment record, dated 12/2024, the RNA treatment record included PROM to both legs followed by application of both knee splints, five times per week. The RNA treatment record did not include PROM to both arms.
During an observation on 12/18/2024 at 12:51 p.m. in Resident 5's room, Resident 5 was awake while side lying in bed. The joints of Resident 5's elbows, wrists, hands, hips, and knees were observed in a flexed (bent) position. Both of Resident 5's hands were positioned in closed fists with the left wrist bent sideways, away from Resident 5's body. Resident 5 was observed to partially move both shoulders upward and extended both elbows. Resident 5 was unable to fully extend both elbows which continued to be bent. Resident 5 was observed to attempt to straighten both legs, which resulted slight movement at Resident 5's hip joint.
During an observation on 12/19/2024 at 8:50 a.m. in Resident 5's room, Restorative Nursing Aide 1 (RNA 1) stood on the left side of the bed. RNA 1 performed PROM to both of Resident 5's legs, including hip extension (straightening the leg at the hip joint away from the body) with knee extension, hip flexion (bending the leg at the hip joint toward the body) with knee flexion, and hip abduction (moving the leg at the hip joint away from the body). RNA 1 did not provide PROM to both ankles and both arms.
During an interview on 12/19/2024 at 8:56 a.m. with RNA 1, RNA 1 stated Resident 5's physician orders for RNA was to provide PROM to both legs. RNA 1 stated Resident 5 received PROM to extend, bend, and abduct both legs. RNA 1 stated both knee splints would be applied after Resident 5 was changed.
During an interview on 12/19/2024 at 9:32 a.m. with RNA 1, RNA 1 stated she forgot to provide PROM to Resident 5's ankles.
During a concurrent interview and record review on 12/19/2024 at 11:09 a.m. with the Director of Rehabilitation (DOR), Resident 5's JMA, dated 5/8/2024, OT Discharge summary, dated [DATE], and PT Discharge summary, dated [DATE], and RNA treatment record, dated 11/2024 and 12/2024. The DOR stated Resident 5's JMA indicated Resident 5 had ROM limitations in both shoulders, elbows, wrists, hands, and knees. The DOR stated Resident 5's OT Discharge recommendations indicated for RNA to provide PROM to both arms. The DOR stated Resident 5's PT Discharge recommendations indicated for RNA to provide PROM to both legs followed by application of both knee splints. The DOR stated PROM exercises (in general) prevented further decline in ROM. The DOR reviewed Resident 5's RNA treatment record for 11/2024 and 12/2024. The DOR stated PROM to both arms was not included in the RNA treatment record for 12/2024 when the facility transitioned to the new electronic documentation system.
During a telephone interview on 12/19/2024 at 11:38 a.m. with Physical Therapist 1 (PT 1), PT 1 stated the RNAs were expected to provide ROM exercises at the shoulder, elbow, wrist, finger, hip, knee, and ankle joints to prevent any decline in ROM.
During a concurrent interview and record review on 12/19/2024 at 11:47 a.m. with the Director of Medical Record (DMR), Resident 5's physician orders, dated 7/11/2024 to provide PROM to both arms and RNA treatment records, dated 11/2024 and 12/2024, The DMR stated the physician's order to provide Resident 5 with PROM to both arms was not included in the RNA treatment record for 12/2024.
During a concurrent interview and record review on 12/19/2024 at 11:49 a.m. with the DOR, Resident 5's RNA treatment records, dated 11/2024 and 12/202, the DOR stated the facility did not provide Resident 5 with PROM to both arms for 12/2024.
During an interview on 12/19/2024 at 11:58 a.m. with the DOR, the DOR stated the residents (in general) had an increased possibility for developing contractures and experiencing a decline in ROM if ROM was not performed to the joints.
During a review of the facility's undated Policy and Procedure (P&P) titled, Prevention of Decline in Range of Motion/Joint Mobility, the P&P indicated the facility shall establish and utilize a systemic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care. The P&P further indicated interventions will be documented in a resident's care plan and will monitor for consistent implementation of the care plan interventions.
b. During a review of Resident 20's admission Record, the facility admitted Resident 20 on 9/5/2023 with diagnoses including epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), parkinsonism (group of conditions with symptoms including slow movements, stiffness, tremors, and balance issues), and attention to gastrostomy ([G-tube] surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems).
During a review of Resident 20's Functional Maintenance Program - OT, dated 9/6/2023, the Functional Maintain Program indicated for the RNA to provide PROM to both arms, five days per week as tolerated, and to apply both hand rolls or rolled washcloths for five hours, five days per week as tolerated.
During a review of Resident 20's Functional Maintenance Program - PT, dated 9/6/2023, the Functional Maintenance Program indicated for the RNA to provide gentle PROM to both legs followed by application of both ankle splints for two to four hours or as tolerated.
During a review of Resident 20's physician orders, dated 9/6/2023 and revised 11/18/2024, the physician's orders indicated RNA program to provide exercises (unspecified) to both arms, apply both hand rolls or rolled washcloth for five hours, and provide PROM to both legs followed by application of both ankle splints for two hours, five times per week.
During a review of Resident 20's care plan for limitations in joint mobility, dated 9/2024, the care plan indicated Resident 20 had limitations due to contractures (stiffening/shortening at any joint that reduces the joint's range of motion) in both shoulders, both elbows, both wrists, both hands, and both ankles. The treatment plan included RNA orders to provide Resident 20 with PROM to both arms and legs, five times per week; apply hand rolls or washcloths, five times per week; and apply both ankle splints for two hours, five times per week.
During a review of Resident 20's undated JMA, the JMA indicated Resident 20 had ROM limitations in both arms and legs, including severe (0 to 25% available ROM) limitation in both shoulders, elbows, wrists, hands, and ankles. The JMA indicated Resident 20 had WFL ROM in both hips and knees. The undated JMA indicated to continue with RNA.
During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20 had moderately impaired cognition and ROM limitations in both arms and legs. The MDS also indicated Resident 20 was dependent for oral hygiene, toileting, bathing, dressing, rolling to both sides in bed, and chair/bed-to-chair transfers.
During an observation on 12/18/2024 at 12:38 p.m. in Resident 20's room, Resident 20 was lying in the bed with visible tremors (small, rapid movements) in both arms and unclear speech. Both of Resident 20's shoulder joints were turned inward toward the body, both elbows were bent (flexed), and both wrists were bent downward. Resident 20's right-hand fingers were observed bent into a closed fist. Resident 20's left-hand large knuckles were bent upward (hyperextension) while the tips of the fingers were bent downward. Resident 20's legs laid flat on the bed's surface.
During an observation on 12/19/2024 at 9:00 a.m. in Resident 20's room, Resident 20's knees were fully extended while both legs rested on the bed. Both of Resident 20's ankles were positioned in plantarflexion (ankle bent away from the body). RNA 1 stood on the left side of the bed to provide PROM to both of Resident 20's legs, including hip flexion with the knee extended and hip abduction with the knee extended. RNA 1 covered Resident 20's legs with a sheet and proceeded to perform PROM to Resident 20's arms. RNA 1 provided Resident 20 with PROM into shoulder flexion (lifting the arm upward at the shoulder joint) and abduction (lifting the arm up and away from the body at the shoulder joint). Resident 20's right-hand fingers were observed bent into a closed fist. RNA 1 placed a rolled hand towel in Resident 20's palm underneath the middle, ring, and small fingers. Resident 20's left-hand large knuckles were bent in hyperextension while the tips of the fingers were bent downward. RNA 1 placed a rolled hand towel in Resident 20's left-hand underneath the tips of the bent fingers. RNA 1 applied both ankle splints. RNA 1 did not perform PROM on both of Resident 20's elbows, wrists, hands, knees, and ankles.
During an interview on 12/19/2024 at 9:16 a.m. with RNA 1, RNA 1 stated she provided PROM to both hips, shoulders, and elbows (not observed). RNA 1 stated she provided PROM to Resident 20's legs, including leg raises (hip flexion) and abduction. RNA 1 stated PROM was not provided to Resident 20's knees since both knees did not bend. RNA 1 stated Resident 20 also received PROM to both arms, including arm raises (shoulder flexion), abduction, gentle stretches to the elbows, and hand rolls were placed in both hands. RNA 1 was asked to demonstrate the gentle stretches to Resident 20's elbows. RNA 1 extended both of Resident 20's elbows, which continued to have a 90-degree bend when the elbows were extended. RNA 1 stated Resident 20 tolerated wearing both ankle splints for one to two hours. RNA 1 stated both hand towel rolls did not stay in Resident 20's hands for long, including the amount of time indicated in the physician's order (5 hours) due to the positioning of both hands.
During an interview on 12/19/2024 at 9:32 a.m. with RNA 1, RNA 1 stated PROM to both of Resident 20's ankles, wrists, and hands should have been done but was not done due to RNA 1 feeling nervous. RNA 1 stated she should have performed PROM to both of Resident 20's ankles and hands prior to placing the rolled hand towels in both hands and prior to applying both ankle splints.
During an interview on 12/19/2024 at 10:39 a.m. with the DOR, the DOR stated ROM exercises should be performed to increase mobility prior to the application of splints.
During a telephone interview on 12/19/2024 at 11:38 a.m. with Physical Therapist 1 (PT 1), PT 1 stated the RNAs were expected to provide ROM exercises at the shoulder, elbow, wrist, finger, hip, knee, and ankle joints to prevent any decline in ROM.
During an interview on 12/19/2024 at 11:58 a.m. with the DOR, the DOR stated the residents (in general) had an increased possibility for developing contractures and experiencing a decline in ROM if ROM was not performed to the joints during ROM exercises.
During a concurrent interview and record review on 12/19/2024 at 12:13 p.m. with the DOR, Resident 20's Functional Maintenance Program for OT and PT, dated 9/6/2023, the physician's orders for RNA, dated 9/6/2023, and undated JMA were reviewed. The DOR stated Resident 20 was readmitted to the facility on [DATE] and received a JMA on 9/6/2023, which indicated Resident 20 had severe ROM limitations in both shoulders, elbows, wrists, hands, and ankles. The DOR stated the JMA indicated Resident 20's hips and knees had WFL ROM. The DOR stated Resident 20's Functional Maintenance Program - PT, dated 9/6/2023, indicated for the RNA to provide PROM to both legs followed by application of both ankle splints. The DOR stated Resident 20's Functional Maintenance Program - OT, dated 9/6/2023, indicated a recommendation for RNA to provide PROM to both arms followed by application of hand rolls or rolled washcloths. The DOR stated the rolled washcloth was a rolled-up face towel placed in the hands and the hand roll had a strap to maintain the roll in the hands. The DOR stated the facility usually used the rolled washcloth, which should be positioned through the thumb webspace and in the palm of the hand to prevent further decline in ROM of the fingers. The DOR stated the rolled washcloth was useless if it was not placed through the thumb webspace. The DOR stated Resident 20 would benefit more from a hand roll with a strap to prevent the roll from falling out of both hands due to the positioning of Resident 20's fingers. The DOR stated the undated JMA was supposed to be for 9/2024, which indicated Resident 20 had severe ROM limitations in both shoulders, elbows, wrists, hands, and ankles and WFL ROM in both hips and knees.
During a concurrent interview and record review on 12/20/2024 at 9:25 a.m. with PT 1, PT 1 reviewed Resident 20's undated JMA. PT 1 stated Resident 20's undated JMA was from 9/2024. PT 1 stated the JMA indicated Resident 20 had WFL ROM in both hips and ankles. PT 1 stated WFL in both knees indicated Resident 20 had sufficient movement in both knees into flexion and extension.
During a concurrent observation and interview on 12/20/2024 at 10:09 a.m. with PT 1 in the dining room, Resident 20 was sitting in a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) but did not want PT 1 to move both legs. PT 1 stated Resident 20 bent both knees during the JMA in 9/2024. PT 1 stated it was not reported to PT 1 that Resident 20 could not bend both knees.
During a review of the facility's undated P&P titled, Prevention of Decline in Range of Motion/Joint Mobility, the P&P indicated the facility shall establish and utilize a systemic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care. The P&P further indicated interventions will be documented in a resident's care plan and will monitor for consistent implementation of the care plan interventions. The P&P indicated general guidelines for ROM included moving each joint through its ROM.
c. During a review of Resident 68's admission Record, the facility admitted Resident 68 on 8/2/2024 with diagnoses including hemiplegia (weakness of the arm, leg, and trunk on the same side of the body) and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area).
During a review of Resident 68's JMA, dated 8/15/2024, the JMA indicated Resident 68's left shoulder was limited to 90 degrees for shoulder abduction and flexion and the left elbow had ROM limitations between mild and moderate. The JMA indicated Resident 68 had WFL ROM in the right shoulder, right elbow, both wrists, both hands, both hips, both knees, and both ankles.
During a review of Resident 68's Functional Maintenance Program - OT, dated 8/5/2024, the recommendation indicated for the RNA to provide Resident 68 with active range of motion ([AROM] performance of ROM of a joint without any assistance or effort of another person) to the right arm and PROM to the left arm, five times per week as tolerated, to maintain ROM, maintain strength, and to prevent contractures.
During a review of Resident 68's care plan titled, Rehab to RNA Care Plan, dated 8/5/2024, the care plan indicated for Resident 68 to received RNA for AROM to the right arm and PROM to the left arm, five times per week as tolerated, to maintain ROM, maintain strength, and prevent contractures.
During a review of Resident 68's physician orders, dated 8/5/2024, the physician's orders indicated for RNA to provide AROM to the right arm and PROM to the left arm, five times per week as tolerated.
During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68 was moderately impaired for cognition and had impairment in one arm. The MDS also indicated Resident 68 required setup or clean up assistance for eating, supervision (verbal uses and/or touching/steadying assistance) for rolling to both sides, sitting at the edge of the bed to lying down, and lying down to sitting at the edge of the bed, and partial/moderate assistance (helper does less than half the effort) for toileting, bathing, upper body dressing, and chair/bed-to-chair transfers.
During a concurrent observation and interview on 12/18/2024 at 1:13 p.m. in Resident 68's room, Resident 68 was lying in bed and partially awake. Resident 68 stated the left arm and leg were weak and was observed to slowly move the left arm and leg.
During an observation on 12/19/2024 at 9:24 a.m. with RNA 1 in Resident 68's room, Resident 68 transferred from lying down to sitting at the edge of bed without any physical assistance by hooking the right leg underneath the left leg to carry the left leg over the edge of the bed. Resident 68 transferred from the edge of the bed to the manual wheelchair, which was positioned on Resident 68's right side without any physical assistance. Resident 68 performed exercises with RNA 1 while seated in the wheelchair. RNA 1 demonstrated AROM exercises for Resident 68 to perform at the left shoulder and elbow joints. RNA 1 was observed performing PROM on Resident 68's left shoulder, elbow, and wrist joints. RNA 1 did not perform PROM to Resident 68's left hand.
During an interview on 12/19/2024 at 9:32 a.m. with RNA 1, RNA 1 stated Resident 68 performed AROM exercises at the left shoulder and elbow joints. RNA 1 stated she performed PROM exercises to Resident 68's right shoulder, elbow, and wrist joints. RNA 1 stated she forgot to perform PROM to Resident 68's right hand.
During a concurrent interview and record review on 12/19/2024 at 11:58 a.m. with the DOR, Resident 68's JMA, dated 8/5/2024, and Functional Maintenance Program - OT, dated 8/5/2024, was reviewed. The DOR stated the JMA indicated Resident 68's left shoulder ROM was limited to 90 degrees, the left elbow ROM was between minimal and moderate limitations, and all other joints were WFL. The DOR stated the Functional Maintenance Program - OT indicated recommendations for RNA for PROM to the left arm and AROM to the right arm. The DOR stated PROM to the left arm should include the shoulder, elbow, wrist, and hand joints. The DOR stated the residents (in general) had an increased possibility for developing contractures and experiencing a decline in ROM if ROM was not performed to the joints during ROM exercises.
During a review of the facility's undated P&P titled, Prevention of Decline in Range of Motion/Joint Mobility, the P&P indicated general guidelines for ROM included moving each joint through

Based on observation, interview, and record review, the facility failed to ensure the facility's Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) staff were competent to provide range of motion ([ROM] full movement potential of a joint [where two bones meet]) exercises and apply splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to three of nine residents (Resident 5, 20, and 68) with limited ROM and mobility (ability to move) in accordance with the facility's undated job description titled, Restorative Aide.
This failure had the potential for Resident 5, 20, and 68 to develop further ROM limitations.
Findings:
1. During a review of Resident 5's admission Record, the facility admitted Resident 5 on 5/7/2024 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue) and dementia (a progressive state of decline in mental abilities).
During a review of Resident 5's physician orders, dated 7/11/2024 and revised 11/18/2024, the physician's orders indicated for RNA to provide Resident 5 with passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) to both legs followed by the application of both knee splints, five times per week.
During a review of Resident 5's care plan titled, Rehab to RNA Care Plan, dated 7/11/2024, the care plan indicated a plan to provide PROM of both legs followed by application of both knee splints to prevent decline in ROM.
During an observation on 12/19/2024 at 8:50 a.m. in Resident 5's room, Restorative Nursing Aide 1 (RNA 1) stood on the left side of the bed. RNA 1 was observed providing PROM to both hips and knees. RNA 1 did not perform PROM to both ankles.
During an interview on 12/19/2024 at 8:56 a.m. with RNA 1, RNA 1 stated Resident 5's physician orders for RNA was to provide PROM to both legs. RNA 1 stated both knee splints would be applied after Resident 5 was changed.
During an interview on 12/19/2024 at 9:32 a.m. with RNA 1, RNA 1 stated she forgot to provide PROM to Resident 5's ankles.
2. During a review of Resident 20's admission Record, the facility admitted Resident 20 on 9/5/2023 with diagnoses including epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), parkinsonism (group of conditions with symptoms including slow movements, stiffness, tremors, and balance issues), and attention to gastrostomy ([G-tube] surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems).
During a review of Resident 20's physician orders, dated 9/6/2023 and revised 11/18/2024, the physician's orders indicated an RNA program to provide exercises (unspecified) to both arms, apply both hand rolls or rolled washcloth for five hours, and PROM to both legs followed by application of both ankle splints for two hours, five times per week.
During a review of Resident 20's care plan for limitations in joint mobility, dated 9/2024, the care plan indicated Resident 20 had limitations due to contractures (stiffening/shortening at any joint that reduces the joint's range of motion) in both shoulders, both elbows, both wrists, both hands, and both ankles. The treatment plan included RNA orders for PROM to both arms and legs, five times per week; apply hand rolls or washcloths, five times per week; and apply both ankle splints for two hours, five times per week.
During an observation on 12/19/2024 at 9:00 a.m. in Resident 20's room, Resident 20's knees were fully extended while both legs rested on the bed. Both of Resident 20's ankles were positioned in plantarflexion (ankle bent away from the body). RNA 1 was observed providing PROM to Resident 20's hips and shoulders. Resident 20's right-hand fingers were observed bent into a closed fist. RNA 1 placed a rolled hand towel in Resident 20's palm underneath the middle, ring, and small fingers. Resident 20's left-hand large knuckles were bent upward (hyperextension) while the tips of the fingers were bent downward. RNA 1 placed a rolled hand towel in Resident 20's left-hand underneath the tips of the bent fingers. RNA 1 then applied both ankle splints. RNA 1 did not provide PROM on both elbows, wrists, hands, knees, and ankles.
During an interview on 12/19/2024 at 9:16 a.m. with RNA 1, RNA 1 stated Resident 20 received PROM to both legs and arms. RNA 1 stated both of Resident 20's knees did not bend. RNA 1 stated PROM should have been provided to both of Resident 20's ankles and hands prior to placing the rolled hand towels in both hands and prior to applying both ankle splints.
During an interview on 12/19/2024 at 9:32 a.m. with RNA 1, RNA 1 stated PROM to both of Resident 20's ankles, wrists, and hands should have been done but was not provided due to RNA 1 feeling nervous.
3. During a review of Resident 68's admission Record, the facility admitted Resident 68 on 8/2/2024 with diagnoses including hemiplegia (weakness of the arm, leg, and trunk on the same side of the body) and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area).
During a review of Resident 68's physician orders, dated 8/5/2024, the physician's orders indicated for RNA to provide AROM to the right arm and PROM to the left arm, five times per week as tolerated.
During a review of Resident 68's care plan titled, Rehab to RNA Care Plan, dated 8/5/2024, the care plan indicated for the RNA to provide Resident 68 with AROM to the right arm and PROM to the left arm, five times per week as tolerated, to maintain ROM, maintain strength, and prevent contractures.
During an observation on 12/19/2024 at 9:24 a.m. with RNA 1 in Resident 68's room, Resident 68 performed exercises with RNA 1 while seated in the wheelchair. RNA 1 demonstrated AROM exercises for Resident 68 to perform at the left shoulder and elbow joints. RNA 1 was observed performing PROM exercises to Resident 68's left shoulder, elbow, and wrist. RNA 1 did not perform PROM to Resident 68's left hand.
During an interview on 12/19/2024 at 9:32 a.m. with RNA 1, RNA 1 stated Resident 68 performed AROM exercises at the left shoulder and elbow joints. RNA 1 stated she provided PROM exercises to Resident 68's right shoulder, elbow, and wrist. RNA 1 stated she forgot to perform PROM to the right hand.
During an interview on 12/19/2024 at 10:39 a.m. with the DOR, the DOR stated ROM exercises should be performed to increase mobility prior to the application of splints.
During a telephone interview on 12/19/2024 at 11:38 a.m. with Physical Therapist 1 (PT 1), PT 1 stated the RNAs were expected to provide ROM exercises at the shoulder, elbow, wrist, finger, hip, knee, and ankle joints to prevent any decline in ROM.
During an interview on 12/19/2024 at 11:58 a.m. with the DOR, the DOR stated the residents (in general) had an increased possibility for developing contractures and experiencing a decline in ROM if ROM was not performed to the joints during ROM exercises.
During an interview on 12/19/2024 at 2:51 p.m. with the DSD, RNA 1 and RNA 2's competencies, dated 12/10/2024, were reviewed. The DSD stated the RNAs were observed while providing restorative tasks, including PROM exercises and the application of splints.
During an interview on 12/20/2024 at 9:37 a.m. with the DOR, the DOR reviewed in-services provided to the RNAs. The DOR stated an in-service provided to the RNAs for the application of splints was on 5/6/2021 (3 years ago) and for ROM exercises was on 2/18/2022 (2 years ago). The DOR stated the DSD was not present during both in-services.
During an interview on 12/20/2024 at 1:47 p.m. with the Director of Nursing (DON), the DON stated the therapy staff established the RNA program for the residents. The DON stated the DSD completed the RNA competencies. The DON stated the DSD would not know the therapists' expectations for providing ROM exercises and applying splints if the DSD did not attend the therapists' in-services. The DON stated the residents (in general) could develop limitations in ROM and function if the RNAs were not competent.
During a review of the In-service Attendance Sheet titled, Proper Application of B (both) Ankle Plantarflexion (ankle bent away from the body) Splint(s), dated 5/6/2021, the training included a review of splint application, including premedication prior to application and nurse notification if the resident had complaints of pain.
During a review of the Inservice Training Attendance Record titled, ROM and Transfers, dated 2/18/2022, the training objectives indicated to refresh knowledge on ROM and transfers.
During a review of Restorative Nursing Aide 1's (RNA 1) and RNA 2's Certified Nurse Aide (CNA)/RNA Competency, dated 12/10/2024, the CNA/RNA Competency indicated the Director of Staff Development (DSD) completed their competencies.
During a review of the facility's undated Policy and Procedure (P&P) titled, Prevention of Decline in Range of Motion/Joint Mobility, the P&P indicated general guidelines for ROM included moving each joint through its ROM.
During a review of the facility's undated job description titled, Restorative Aide, the job description indicated major duties and responsibilities, including performing RNA services in accordance with care plans and facility policies and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Administer risperidone (a medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), calcium (a supplement used to treat low level of calcium) and vitamin D (a vitamin used to treat low level of vitamin D) in accordance with physician's orders affecting one of four sampled residents during medication administration (Resident 54).
2. Clarify dose and frequency of physician's order for docusate sodium (a medication used to relieve constipation) affecting one of four sampled residents (Resident 440).
3. Accurately account for the administration of Vimpat (generic name - lacosamide, a controlled substance [a medication with a high potential for abuse] used to treat seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and lorazepam (a controlled substance used to treat anxiety) on Controlled Drug Record (CDR - a log signed by the nurse with the date and time each time a controlled substance is given to a resident) for two residents (Residents 23 and 13) in one of two inspected medication carts (South Medication Cart).
These deficient practices failed to administer medications in accordance with the physician orders or professional standards of practice, and provide accurate accountability for controlled substances, increasing the risk for hospitalization due to inappropriate treatment of mental disorders, constipation, and had a potential to result in misuse, drug loss and/or diversion of controlled substances.
Findings:
1. During a review of Resident 54's admission Record (a document containing demographic and diagnostic information), dated 12/18/2024, the facility originally admitted Resident 54 on 3/24/2022 and readmitted Resident 54 on 9/18/2024 with diagnoses including, but not limited to, hypertensive (a condition described as high blood pressure) heart disease without heart failure (a condition when heart cannot pump enough blood and oxygen to the body's organs), Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with other specified complication, vitamin D deficiency, anxiety disorder and bipolar disorder.
During a review of Resident 54's History and Physical, dated 9/20/2024, the document indicated Resident 54 had fluctuating capacity to understand and make decisions.
During a review of Resident 54's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 9/30/2024, the MDS indicated Resident 54's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was moderately impaired. The MDS indicated Resident 54 needed setup or cleanup assistance for eating and oral hygiene. The MDS indicated Resident 54 needed maximal assistance with lower body dressing, and moderate to supervision assistance for other activities of daily living such as shower, toileting, upper body dressing and personal hygiene.
During a review of Resident 54's Order Summary Report (a list of all currently active medical orders), dated 12/19/2024, the order summary report indicated the following medication orders:
a.
Artificial Tears (eye drops solution used to relieve burning and irritation in eyes due to dry eyes Ophthalmic (eye) Solution, instill 1 drop in both eyes two times a day for dry eyes, order date 10/1/2024, start date 10/8/2024
b.
Cholecalciferol (a dietary supplement used to treat low level of vitamin D) tablet 1000 unit (a unit of measurement for mass), give 1 tablet by mouth one time a day for vitamin D deficiency, order date 10/1/2024, start date 10/8/2024
c.
Oyster shell Calcium (a supplement used to treat lack of calcium) tablet 500 mg, give 1 tablet by mouth two times a day for supplement, order date 10/1/2024, start date 10/8/2024.
d.
Risperdal (generic name - risperidone), give 0.25 mg by mouth two times a day for psychosis m/b auditory hallucination stating, 'the voices are telling me not to go out of my room', order date 10/1/2024, start date 10/8/2024.
e.
Divalproex sodium (a medication used to treat seizure tablet delayed release 125 milligrams (mg - a unit of measure for mass), give 1 tablet by mouth two times a day for bipolar disorder manifested by (mb) fluctuations of emotions from pleasant to angry, order date 10/1/2024, start date 10/2/2024.
f.
DSS (docusate sodium) oral capsule 250 mg, give 1 capsule by mouth one time a day for bowel management hold for loose stools, order date 10/1/2024, start date 10/8/2024
g.
Duloxetine hydrochloride (HCl) (a medication used to treat depression [a mental disorder that can affect a person's thoughts, mood and sense of well-being], anxiety and nerve pain) 20 mg, give 1 capsule by mouth one time a day for depression m/b making negative statement such as of hopelessness, order date 10/11/2024, start date 10/13/2024.
h.
Gabapentin (a medication used to treat seizures and nerve pain) capsule 100 mg, give 1 capsule by mouth two times a day for neuropathy (nerve pain), order date 10/1/2024, start date 10/2/2024.
i.
Jardiance (generic name - empagliflozin [a medication used to treat high blood sugar]) oral tablet 25 mg, give 1 tablet by mouth in the morning for DM, order date 10/1/2024, start date 10/8/2024.
j. Lisinopril (a medication used to treat high blood pressure) tablet 5 mg, give 1 tablet by mouth one time a day for hypertension hold for systolic blood pressure ([SBP] - the pressure caused by heart while contracting) less than 110 or heart rate (HR) less than 60, order date 10/1/2024, start date 10/2/2024.
During an observation of medication administration on 12/18/2024 between 8:57 a.m. and 9:10 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared and administered following list of medications to Resident 54 that did not include risperidone 0.25 mg:
1. One drop of Artificial tears in both eyes
2. One tablet of vitamin D (a vitamin used to treat lack of vitamin D) 25 micrograms (mcg - a unit of measurement of mass), 1000 Internation Units (IU - a unit of measurement of mass) by mouth
3. One tablet of divalproex delayed release (DR) 125 mg by mouth
4. One tablet of Colace (generic name - docusate sodium) 250 mg by mouth
5. One capsule of duloxetine (a medication used to treat depression (low mood) and anxiety) 20 mg by mouth
6. One tablet of calcium 500 mg with vitamin D 5 mcg by mouth
7. One capsule of gabapentin (a medication used to treat nerve pain and epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) 100 mg by mouth
8. One tablet of Jardiance (generic name - empagliflozin, a medication used to treat high blood sugar) 25 mg by mouth
9. One tablet of lisinopril (a medication used to treat high blood pressure) 5 mg by mouth
During a medication reconciliation review on 12/18/2024 at 12:21 p.m. Resident 54's order summary report and observed administered medications list were reviewed. The order summary report indicated one tablet of risperidone 0.25 mg to be administered two times a day. The order summary report indicated separate physician orders for one tablet of calcium 500 mg two times a day and one tablet of vitamin D 1000 units one time a day.
During a concurrent interview and record review on 12/18/2024 at 12:21 p.m. with LVN 1, Resident 54's list of medications administered during medication pass observation and the container package label of calcium 500 mg with vitamin D 5 mcg (combination) were reviewed. LVN 1 stated it was her mistake because she remembered administering nine medications that did not include risperidone 0.25 mg. LVN 1 stated she made a mistake in administering a combination of calcium with vitamin D instead of only calcium 500 mg in addition to separate vitamin D3 (cholecalciferol) 25 mcg (1000 IU). LVN 1 stated it was important to follow physician orders to prevent medication errors that can negatively affect resident 54's health.
During an interview on 12/19/2024 at 3:39 p.m. with the Director of Nursing (DON), the DON stated facility nurse should have checked the stock calcium with vitamin D with physician order to prevent administering additional vitamin D from a combination bottle. DON stated the facility nurse should always follow physician orders. DON stated by not receiving risperidone 0.25 mg, Resident 54 could have experienced mental and behavioral episodes that could have negative impact on Resident 54's health.
2. During a review of Resident 440's admission Record, dated 12/18/2024, the admission record indicated the facility originally admitted Resident 440 on 10/11/2024 and readmitted Resident 440 on 12/2/2024 with diagnoses that included but not limited to major depressive disorder (a mental disorder that can affect a person's thoughts, mood, and sense of well-being).
During a review of Resident 440's History and Physical, dated 12/3/2024, the document indicated Resident 440 had the capacity to understand and make decisions.
During a review of Resident 440's MDS, dated [DATE], the MDS indicated Resident 440's cognition was moderately impaired. The MDS indicated Resident 440 needed moderate to maximal assistance from facility staff for toileting, showering, personal hygiene, and dressing, and needed clean up assistance for eating.
During a review of Resident 440's Order Summary Report, dated 12/19/2024, the order summary report indicated the following medication without dose and frequency:a. Docusate sodium oral tablet, give 1 tablet by mouth as needed for constipation, order date 12/2/2024, start date 12/2/2024.
During a concurrent interview and record review on 12/18/2024 at 12:54 p.m. with LVN 2, of the order details for Resident 440's docusate sodium, LVN 2 stated the docusate sodium order should have been clarified with the physician for dose and frequency. LVN 2 stated there was a risk for Resident 440 to be overtreated or undertreated with docusate sodium increasing the risk for hospitalization due to diarrhea and dehydration because of no hold parameters or dose and frequency specified on the order.
During an interview on 12/19/2024 at 3:39 p.m. with the DON, the DON stated facility staff should have called physician to clarify docusate for Resident 440. DON stated the order did not indicate specific dose, 50 mg or 100 mg or a frequency to be safely administered and there was a risk for diarrhea.
During a review of the facility's undated policy and procedure (P&P) titled, Medication Administration, , the P&P indicated, Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The P&P indicated, Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.
3a. During a review of Resident 23's admission Record, dated 12/29/2024, the admission record indicated the facility originally admitted Resident 23 on 1/31/2019 and readmitted Resident 23 on 8/15/2024 with diagnoses that included but not limited to, epilepsy, unspecified, without status epilepticus (a medical emergency that occurs when a person has a seizure that lasts longer than five minutes)
During a review of Resident 23's History and Physical, dated 9/11/2024, the document indicated Resident 23 had fluctuating capacity to understand and make decisions.
During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23's cognition was moderately impaired. The MDS indicated Resident 23 needed moderate to maximal assistance from facility staff for activities of daily living such as dressing, personal hygiene, toileting, and showering. The MDS indicated Resident 23 needed touching assistance for oral hygiene and clean up assistance for eating.
During a review of Resident 23's Order Summary Report, dated 12/19/2024, the order summary report indicated (not limited to) the following medication order:
a. Vimpat oral tablet 200 mg (lacosamide) give 1 tablet by mouth two times a day related to epilepsy, order date 9/8/2024, start date 10/8/2024.
During a concurrent inspection, interview and record review on 12/17/2024 at 3:34 p.m. with LVN 2 of South Medication Cart, Resident 23's medication card / bubble pack for lacosamide (generic for Vimpat) 200 mg, facility's CDR and the medication administration details. Resident 23's medication card / bubble pack for lacosamide 200 mg contained a quantity of 42 tablets remaining. The facility's CDR indicated a quantity of 43 tablets remaining with the last dose administered on 12/16/2024 at 5:00 p.m. The administration details indicated Vimpat oral tablet 200 mg (lacosamide) for Resident 23 was administered on 12/17/2024 at 10:17 a.m. LVN 2 stated lacosamide 200 mg was administered to Resident 23 on 12/17/2024 at 10:17 a.m. LVN 2 stated it was her mistake and the book (CDR) should have been documented and signed immediately after medication was administered. LVN 2 stated lacosamide was a controlled substance with a high potential for abuse and diversion. LVN 2 stated there was a possibility and risk for medication error leading to seizures, fall, injury and hospitalization.
3b. During a review of Resident 13's admission Record, dated 12/19/2024, the admission record indicated the facility originally admitted Resident 13 on 1/31/2024 and readmitted Resident 13 on 9/24/2024 with diagnoses that included, but not limited to, anxiety disorder.
During a review of Resident 13's History and Physical, dated 9/26/2024, the history and physical indicated Resident 13 had the capacity to understand and make decisions.
During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13's cognition was intact. The MDS indicated Resident 13 needed moderate assistance to supervision assistance from facility staff for personal hygiene, dressing, showering, toileting, oral hygiene and eating.
During a review of Resident 13's Order Summary Report, dated 12/19/2024, the order summary report indicated, but not limited to the following medication:
a. Ativan oral tablet 1 mg (lorazepam), give 1 tablet by mouth two times a day for anxiety manifested by (m/b) psychomotor agitation, irritability throwing himself to the floor angry and banging his head on the wall, order date 9/24/2024, start date 10/28/2024.
During a concurrent inspection, interview and record review on 12/17/2024 at 3:34 p.m. with LVN 2 of South Medication Cart, Resident 13's medication card / bubble pack for lorazepam (generic for Ativan) 1 mg, facility's CDR and the medication administration details were reviewed. Resident 13's medication card / bubble pack for lorazepam 1 mg contained a quantity of 14 tablets remaining. The facility's CDR indicated a quantity of 15 tablets remaining with the last dose administered on 12/16/2024 at 5:00 p.m. The administration details indicated Ativan oral tablet 1 mg (lorazepam) for Resident 13 was administered on 12/17/2024 at 8:51 a.m. LVN 2 stated lorazepam 1 mg was administered to Resident 13 on 12/17/2024 at 8:51 a.m. LVN 2 stated it was her mistake again and the book (CDR) should have been documented and signed immediately after medication was administered. LVN 2 stated lorazepam was a controlled substance with a high potential for abuse and diversion. LVN 2 stated there was a possibility and risk for medication error. LVN 2 stated Resident 13 would not be able to function properly and could suffer from angry outbursts and anxiety if the medication was not administered as prescribed by physician.
During an interview on 12/18/2024 at 4:28 p.m. with the DON, DON stated controlled substances should have been documented in the CDR immediately after they were administered to Residents 23 and 13 because otherwise there would not be a method to track the movement of controlled substance which increased the risk for medication discrepancies.
During a review of the facility's P&P titled, Controlled Substances, dated 11/2017, the P&P indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: (Note: Refer .proper storage) a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose.
During a review of the facility's P&P titled, Medication Administration, undated, the P&P indicated, Policy Explanation and Compliance Guidelines: If medication is a controlled substance, sign narcotic book.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor one of three sampled resident's (Resident 439) behaviors while prescribed with psychotropic medications (medications can alter brain chemistry, impact body functions, and modify a person's thoughts, moods, feelings, awareness, and perceptions).
This failure had the potential to result in unnecessary medications.
Findings:
During a review of Resident 439's admission Record, Resident 439's admission Record indicated Resident 439 was admitted on [DATE] and readmitted to the facility on [DATE] with a diagnosis of Atrial fibrillation (rapid heart rate), presence of a pacemaker, psychosis (loss of contact with reality)
During a review of Resident 439's History and Physical (H&P), dated 11/8/24 indicated, Resident 439 does not have the capacity to understand and make decisions.
During a review of Resident 439's Minimum Data Set ({MDS}- a resident assessment tool) dated 11/16/24 the MDS indicated Resident 439 has severe cognitive impairment. The MDS also indicated Resident 439 was dependent with activities of daily living ({ADL's}- activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated Resident 439 was taking antipsychotic medication and has a psychotic disorder.
During a review of Resident 439's Active Orders dated 12/19/24 indicated Resident 439 had orders for Risperdal (psychotropic medications) 0.5mg to be given two times a day for psychosis manifested by (m/b) auditory hallucinations the voices are telling me something I don't want to do .
During a review of Resident 439's Care plan dated 12/12/2024 indicated Resident 439 has a behavior problem of psychosis m/b auditory hallucination The voices are telling me something I don't want to do . The goal is that Resident 439 to have fewer episodes. The care plan also indicated Resident 439 intervention are to administer medications as ordered and monitor/document for side effects and effectiveness of the Risperdal.
During a concurrent interview and record review on 12/20/21 at 10:41 a.m. with Licensed Vocational Nurse LVN 2 of Resident 439's Active Orders dated 12/19/24. LVN2 stated anytime a resident is taking psychotropic medication we have to monitor for that specific behavior that the resident is taking the medications for. LVN2 stated she did not see that Resident 439's behavior was being monitored about hearing voices that are telling me something I don't want to do . LVN2 stated without the monitoring of that specific behavior you would not be able to see if the medication is working. LVN2 stated when the behavior monitoring is not being done the resident is at risk for receiving unnecessary medications.
During a concurrent interview and record review on 12/20/21 at 11:03a.m. with Registered Nurse supervisor (RNS), Resident 439's Active Orders dated 12/19/24 were reviewed. RNS stated she was unable to locate the symptoms monitoring for Resident 439's Risperdal use. RNS stated when not monitoring for the effectiveness of the medication, resident is at risk of receiving unnecessary medications.
During a concurrent interview and record review on 12/20/24 at 1:20 p.m. with Director of nursing (DON. DON stated that there was no monitoring of behaviors for the Risperdal use of Resident's 439. DON stated without the monitoring of the behaviors they would not be able to see if the medication was effective and the facility would not be able to do gradual dose reductions and that it could be considered an unnecessary medication.
During a review of the facility's undated policy and procedure (P&P) titled Use of Psychotropic medications indicated, the effects of the psychotic medications on a residents physical, mental, and psychosocial well-being will be evaluated on an ongoing basis. The residents response to the medications, including progress towards goals and presence/absence of adverse consequences shall be documented in the residents medical record.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for one of four sampled residents (Resident 54) by failing to provide risperidone (a medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), calcium (a supplement used to treat low level of calcium) and vitamin D (a vitamin used to treat low level of vitamin D) in accordance with physician's orders.
This deficient practice of medication administration error rate of 7.14% exceeded the five (5) percent threshold.
Findings:
During a review of Resident 54's admission Record (a document containing demographic and diagnostic information), dated 12/18/2024, the facility originally admitted Resident 54 on 3/24/2022 and readmitted Resident 54 on 9/18/2024 with diagnoses including, but not limited to, hypertensive (a condition described as high blood pressure) heart disease without heart failure (a condition when heart cannot pump enough blood and oxygen to the body's organs), Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with other specified complication, vitamin D deficiency, anxiety disorder and bipolar disorder.
During a review of Resident 54's History and Physical(H & P), dated 9/20/2024, the H &P indicated Resident 54 had fluctuating capacity to understand and make decisions.
During a review of Resident 54's Minimum Data Set (MDS- a resident assessment) dated 9/30/2024, the MDS indicated Resident 54's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was moderately impaired. The MDS indicated Resident 54 needed setup or cleanup assistance for eating and oral hygiene. The MDS indicated Resident 54 needed maximal assistance with lower body dressing, and moderate to supervision assistance for other activities of daily living such as shower, toileting, upper body dressing and personal hygiene.
During a review of Resident 54's Order Summary Report (a list of all currently active medical orders), dated 12/19/2024, the order summary report indicated the following medication orders:
1. Artificial Tears (eye drops solution used to relieve burning and irritation in eyes due to dry eyes Ophthalmic (eye) Solution, instill 1 drop in both eyes two times a day for dry eyes, order date 10/1/2024, start date 10/8/2024
2. Cholecalciferol (a dietary supplement used to treat low level of vitamin D) tablet 1000 unit (a unit of measurement for mass), give 1 tablet by mouth one time a day for vitamin D deficiency, order date 10/1/2024, start date 10/8/2024
3. Oyster shell Calcium (a supplement used to treat lack of calcium) tablet 500 mg, give 1 tablet by mouth two times a day for supplement, order date 10/1/2024, start date 10/8/2024.
4. Risperdal (generic name - risperidone), give 0.25 mg by mouth two times a day for psychosis m/b auditory hallucination stating, 'the voices are telling me not to go out of my room', order date 10/1/2024, start date 10/8/2024.
5. Divalproex sodium (a medication used to treat seizure tablet delayed release 125 milligrams (mg - a unit of measure for mass), give 1 tablet by mouth two times a day for bipolar disorder manifested by (mb) fluctuations of emotions from pleasant to angry, order date 10/1/2024, start date 10/2/2024.
6. DSS (docusate sodium) oral capsule 250 mg, give 1 capsule by mouth one time a day for bowel management hold for loose stools, order date 10/1/2024, start date 10/8/2024
7. Duloxetine hydrochloride (HCl) (a medication used to treat depression [a mental disorder that can affect a person's thoughts, mood and sense of well-being], anxiety and nerve pain) 20 mg, give 1 capsule by mouth one time a day for depression m/b making negative statement such as of hopelessness, order date 10/11/2024, start date 10/13/2024.
8. Gabapentin (a medication used to treat seizures and nerve pain) capsule 100 mg, give 1 capsule by mouth two times a day for neuropathy (nerve pain), order date 10/1/2024, start date 10/2/2024.
9. Jardiance (generic name - empagliflozin [a medication used to treat high blood sugar]) oral tablet 25 mg, give 1 tablet by mouth in the morning for DM, order date 10/1/2024, start date 10/8/2024.
10. Lisinopril (a medication used to treat high blood pressure) tablet 5 mg, give 1 tablet by mouth one time a day for hypertension hold for systolic blood pressure (SBP- the pressure caused by heart while contracting) less than 110 or heart rate (HR) less than 60, order date 10/1/2024, start date 10/2/2024.
During an observation of medication administration on 12/18/2024 between 8:57 a.m. and 9:10 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared and administered following list of medications to Resident 54 that did not include risperidone 0.25 mg:
1. One drop of Artificial tears in both eyes
2. One tablet of vitamin D (a vitamin used to treat lack of vitamin D) 25 micrograms (mcg - a unit of measurement of mass), 1000 Internation Units (IU - a unit of measurement of mass) by mouth
3. One tablet of divalproex delayed release (DR) 125 mg by mouth
4. One tablet of Colace (generic name - docusate sodium) 250 mg by mouth
5. One capsule of duloxetine (a medication used to treat depression (low mood) and anxiety) 20 mg by mouth
6. One tablet of calcium 500 mg with vitamin D 5 mcg by mouth
7. One capsule of gabapentin (a medication used to treat nerve pain and epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) 100 mg by mouth
8. One tablet of Jardiance (generic name - empagliflozin, a medication used to treat high blood sugar) 25 mg by mouth
9. One tablet of lisinopril (a medication used to treat high blood pressure) 5 mg by mouth
During a medication reconciliation review on 12/18/2024 at 12:21 p.m. Resident 54's order summary report and observed administered medications list were reviewed. The order summary report indicated one tablet of risperidone 0.25 mg to be administered two times a day. The order summary report indicated separate physician orders for one tablet of calcium 500 mg two times a day and one tablet of vitamin D 1000 units one time a day.
During a concurrent interview and record review on 12/18/2024 at 12:21 p.m. with LVN 1, Resident 54's list of medications administered during medication pass observation and the container package label of calcium 500 mg with vitamin D 5 mcg (combination) were reviewed. LVN 1 stated it was her mistake because she remembered administering nine medications that did not include risperidone 0.25 mg. LVN 1 stated she made a mistake in administering a combination of calcium with vitamin D instead of only calcium 500 mg in addition to separate vitamin D3 (cholecalciferol) 25 mcg (1000 IU). LVN 1 stated it was important to follow physician orders to prevent medication errors that can negatively affect resident 54's health.
During an interview on 12/19/2024 at 3:39 p.m. with the Director of Nursing (DON), the DON stated facility nurse should have checked the stock calcium with vitamin D with physician order to prevent administering additional vitamin D from a combination bottle. DON stated the facility nurse should always follow physician orders. DON stated by not receiving risperidone 0.25 mg, Resident 54 could have experienced mental and behavioral episodes that could have negative impact on Resident 54's health.
During a review of the facility's undated policy and procedure (P&P) titled, Medication Administration, the P&P indicated, Medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The P&P indicated, Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observation, interview, and record review, the facility failed to:
1. Ensure storage and/or labeling of brimonidine tartrate ophthalmic solution (a medication in form of eye drops used to treat high intraocular pressure [a term used to describe fluid pressure inside the eye]), bisacodyl (a medication used to treat constipation) suppositories (a medication designed to be inserted into the anus), and removal of expired Lantus ([generic name - insulin glargine] a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) Solostar Pen from medication refrigerator, in accordance with manufacturer requirements affecting at least two residents (Resident 34 and 51) in one of two inspected medication rooms (Medication Room).
2. Ensure removal of expired zinc sulfate (a mineral supplement used for wound healing and treat low level of zinc), vitamin D3 (a vitamin used to treat low level of vitamin D) and hydrogen peroxide (a product used as an antiseptic and for wound cleaning) from one of two inspected medication rooms (Central Supply Room).
3 and 4. Ensure storage, labeling and/or removal of expired medications including Fiasp (generic name - insulin aspart), Novolog (generic name - insulin aspart), latanoprost (a medication in form of eye drops used to treat high pressure in the eyes) eye drops, budesonide inhalation solution (a medication used to reduce swelling of airways for better breathing) and Serevent ([Generic name - Salmeterol] a medication used to relax airways for better breathing), in accordance with manufacturer requirement affecting eight residents (Residents 12, 49, 61, 64, 70, 76, 83 and 290) in two of two inspected medication carts (South Medication Cart and North Medication Cart 3).
These deficient practices had the potential to result in Residents 12, 34, 49, 51, 61, 64, 70, 76, 83, 290 and other facility residents receiving medications that had become expired, ineffective, or toxic due to improper storage or labeling possibly leading to health complications such as hyperglycemia (high blood glucose [simple sugar- the body's primary source of energy from food]), trouble breathing, eye complications and hospitalization.
Findings:
1.During a concurrent inspection and interview on 12/17/2024 at 12:13 p.m. with Licensed Vocational Nurse (LVN) 2 of the Medication Room, the following medications were found either expired or stored in a manner contrary to their respective manufacturer's requirements:
1a. 25 Bisacodyl Suppositories 10 milligrams (mg - a unit of measure for mass) found in the freezer of medication refrigerator with the refrigerator temperature at 42-degree Fahrenheit [(°F) is a unit of temperature] labeled with pharmacy label that indicated house stock.
According to the manufacturer's product labeling, bisacodyl suppositories should be stored at room temperature at 15-to-30 degree Celsius [(°C) is a unit of temperature] (59-to-86-degree Fahrenheit (°F), not to exceed 30° C (86°F).
LVN 2 stated they did not have a method to monitor freezer temperatures and bisacodyl suppositories were not stored according to manufacturer requirements. LVN 2 stated bisacodyl suppositories would not be safe and effective to use for residents.
1b. One sealed bottle of Brimonidine tartrate ophthalmic solution 0.2% 5 milliliters (mL - a unit of measurement for volume) for Resident 34 stored at 42°F in medication refrigerator.
According to the manufacturer's product labeling, Brimonidine should be stored at 15°C to 25°C or 59°F to 77°F.
LVN 2 stated the brimonidine eye drops for Resident 34 should not have been stored in the refrigerator. LVN 2 stated there would be a risk for eye redness, irritation, and worsening of eye condition if administered to Resident 34 as they would not be safe or effective to use due to improper storage.
1c. One opened Lantus Solostar pen for Resident 51 that indicated date of 7/28 and stored at 42°F in medication refrigerator.
According to the manufacturer's product labeling, unopened / not in-use pen if stored at room temperature (a below 86°F [30°C]) and opened / in-use pen must be used within 28 days.
LVN 2 stated the Lantus Solostar for Resident 51 indicated opened date as 7/28/2024 and should have been discarded within 28 days after opening. LVN 2 stated Lantus Solostar had expired and would not be safe and effective if administered to Resident 51. LVN 2 stated there was a risk for Resident 51 to experience high blood glucose that could lead to hospitalization.
2. During a concurrent inspection and interview on 12/17/2024 at 1:38 p.m. with LVN 3 of the Central Supply Room, the following medication and products were expired:
2a. One sealed box of zinc sulfate 220 mg, quantity of 100 with an expiration date of 02/2024.
2b. One sealed bottle of hydrogen peroxide 3% 473 mL with an expiration date of 06/2022.
2c. Two sealed bottles of vitamin D3 125 microgram (mcg - a unit of measure for mass) 5000 international units (IU - a unit of measure for mass), quantity of 200 each, with expiration dates of 11/2024 on each bottle.
2d. One open bottle of vitamin D3 50,000 IU with an expiration date of 03/2020.
LVN 3 stated these products should have been discarded and disposed because they were expired. LVN 3 stated these products would not be safe and effective to administer or use for facility residents. LVN 3 stated there was a potential for side effects to residents such as inadequate wound healing, nausea, vomiting and other health complications.
3. During a concurrent inspection and interview on 12/17/2024 at 2:40 p.m. with LVN 2 of the South Medication Cart, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:
3a. One open vial of Fiasp 100 units/mL for Resident 290 with no opened date.
According to the manufacturer's product labeling, unopened / not in-use Fiasp vial should be stored between 2° to 8°C (36° to 46°F) in a refrigerator, and opened / in-use vial, stored at room temperature (a below 86°F [30°C]) must be used within 28 days.
3b. One open vial of insulin aspart 100 units/mL for Resident 83 with no opened date.
According to the manufacturer's product labeling, unopened / not in-use insulin aspart vial should be stored between 2° to 8°C (36° to 46°F) in a refrigerator, and opened / in-use vial, stored at room temperature (a below 86°F [30°C]) must be used within 28 days.
3c. One open vial of Novolog 100 units/mL for Resident 76 labeled with open date of 9/14.
According to the manufacturer's product labeling, unopened / not in-use Novolog vial should be stored between 2° to 8°C (36° to 46°F) in a refrigerator, and opened / in-use vial, stored at room temperature (a below 86°F [30°C]) must be used within 28 days. Resident 76's Novolog expired on 10/12/2024.
LVN 2 stated the expired insulin should have been removed from the medication cart to prevent medication errors. LVN 2 stated there was a risk for residents to receive the expired insulin which would increase the risk for high blood glucose.
3d. One bottle of latanoprost eye drops 0.005% for Resident 64 with no opened date.
3e. One bottle of latanoprost eye drops 0.005% for Resident 12 with opened date of 9/12/2024. Resident 12's latanoprost eye drops expired on 10/24/2024.
3f. One bottle of latanoprost eye drops 0.005% for Resident 49 with opened date of 10/11/2024. Resident 49's latanoprost eye drops expired on 11/22/2024.
According to the manufacturer's product labeling, unopened bottle(s) should be stored under refrigeration at 2°C to 8°C (36°F to 46°F) and open or in-use bottle should be stored at room temperature up to 25°C (77°F) for six weeks.
LVN 2 stated latanoprost eye drops were supposed to be labeled with an open date to be able to determine expiration date and should have been removed from the medication cart once they had expired. LVN 2 stated there was a risk for eye complications if expired and unlabeled latanoprost were administered to Resident 64, 12 and 49.
4. During a concurrent inspection and interview on 12/18/2024 at 3:01 p.m. with LVN 4 of the North Medication Cart 3, the following medications were found without an open date label as required by their respective manufacturer's specifications
4a. Five ampules Budesonide 0.5 mg/2 mL inhalation solution for Resident 61 with no opened date on foil package.
According to the manufacturer's product labeling, budesonide inhalation suspension ampules should be stored at controlled room temperature 20°C to 25°C (68°F to 77°F). The product labeling indicated when an envelope has been opened, the shelf life for unused is two weeks.
LVN 4 stated budesonide for Resident 61 was for breathing and if improperly stored, the medication would lose its potency and not be effective and safe to treat Resident 61 increasing the risk for troubled breathing and hospitalization.
4b. One blister pack of Serevent inhaler for Resident 70 removed from foil pouch with no opened date.
According to the manufacturer's product labeling, Serevent inhaler should be discarded six weeks after removal from moisture-protective foil pouch or after all blisters have been used (when the dose indicator reads 0.
LVN 4 stated Resident 70's Serevent was not labeled in accordance with manufacturer requirements. LVN 4 stated there was a risk for untreated troubled beathing and hospitalization for adverse reactions if Resident 70 received an expired inhaler.
During an interview on 12/19/2024 at 3:08 p.m. with the Director of Nursing (DON), DON stated the medications for facility residents such as bisacodyl suppositories, brimonidine eye drops, latanoprost eye drops, insulin, Serevent and budesonide inhalation solution were not stored in accordance with manufacturer requirements. DON stated there was a risk for untreated constipation, high blood glucose, breathing difficulties, medication errors, side effects, and hospitalization. DON stated the medications such as zinc sulfate, vitamin D and hydrogen peroxide were found expired in the central supply room should have been discarded because they were expired in order to prevent medication errors and health complications for facility residents.
During a review of the facility's policy and procedure (P&P) titled, Medication Storage, undated, the P&P indicated, It is the policy of this facility to ensure all medications hosed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure .security. The P&P indicated, Refrigerated Products: temperatures are maintained within 36-46 degrees F The P&P indicated, Unused medications: the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed Unused Drugs Policy. The P&P indicated, Light Protection: All drugs, which require light protection while in storage, remain in the original package, in closed drawers until the time of administration.
During a review of the facility's P&P titled, Insulin Labeling, undated, the P&P indicated, The facility shall ensure that all insulin vials, pens, and cartridges are properly labeled to maintain safety, prevent medication errors, and comply with regulatory requirements. The P&P indicated, Facility Labeling Upon Opening: once opened, insulin vials, pens, or cartridges, must be labeled with: The date opened. For multi-dose vials, follow the facility's policy for beyond-use dates (typically 28 days unless otherwise specified by the manufacturer). Storage of Labeled Insulin: opened insulin must be separated from unopened stock and clearly labeled to avoid confusion.
During a review of the facility's P&P titled, Expired Medications, undated, the P&P indicated, The facility shall ensure that all expired medications are promptly identified, removed from use, and properly disposed of in accordance with state and federal regulations to maintain resident safety and compliance with applicable laws.

Based on observation, interview, and record review the facility failed to ensure the food in the refrigerator are not outdated when:
a.
chicken stored in the refrigerator in a clear plastic container with a cracked lid dated 10/13/2024,
b.
seasoned hash brown potatoes stored in the refrigerator with an expiration date of 11/26/2024,
c.
potato salad stored in the refrigerator with an expiration date of 12/9/2024,
d.
macaroni salad stored in the refrigerator with an expiration date of 12/14/2024,
e.
tomatoes stored in the refrigerator a plastic container covered with plastic wrap dated 12/14/2024,
f.
bread stored in the refrigerator in a plastic container covered with foil dated 12/16/2024,
g.
lettuce stored in the refrigerator in a plastic container covered with plastic wrap dated 12/16/2024 and
h.
freezer burned meat stored in the freezer were discarded.
These failures have the potential to result in residents being exposed to food borne illnesses, any illness resulting from food spoilage or contaminated food and eating compromised quality of meat due to dryness and altered texture.
Findings:
During an observation on 12/17/2024 at 8:32 am in the kitchen refrigerator, there was chicken stored in a plastic container dated 10/13/2024, seasoned hash brown potatoes dated 11/26/2024, potato salad dated 12/9/2024 , macaroni salad dated 12/14/2024, tomatoes dated 12/14/2024, bread dated 12/16/2024, lettuce dated 12/16/2024 and freezer burned meat stored in the freezer.
During a concurrent observation and interview on 12/17/2024 at 8:43 am with, [NAME] (1), [NAME] (1) [NAME] (1) stated the dated tomatoes, bread and lettuce is only good for three days. [NAME] 1 stated food in the refrigerator are dated so we know when it is good or not.
During a concurrent observation interview on 12/17/2024 9:37 am with Dietary Manager (DM), there was chicken stored in a plastic container dated 10/13/2024, seasoned hash brown potatoes dated 11/26/2024, potato salad dated 12/9/2024 macaroni salad dated 12/14/2024, tomatoes dated 12/14/2024, bread dated 12/16/2024, lettuce dated 12/16/2024 and freezer burned meat. DM stated the food is outdated and should not be stored in the refrigerator.
During an interview on 12/20/2024 at 10:16 am with DM, DM stated the food is labeled the dated when it's opened, and the kitchen staff follow the expiration dates and discard food if it is expired. DM further addeduse by date means the date, we have to use the food by. DM stated it is important to discard expired food to prevent food borne illnesses.
During an interview on 12/20/2024 at 1:34 pm with the Director of Nursing (DON), DON stated the residents can get food poisoning and stomach sickness if they eat expired food. DON stated food with freezer burns is not acceptable to taste and is advisable to throw away.
During a review of the facility's policy and procedures (P&P) titled, Storage Of Food And Supplies, dated 2018, the P&P indicated, No food will be kept longer than the expiration date on the product .Do not store bread in the refrigerator .Food in unlabeled rusty, leaking broken containers or cans with side seams dents, rims dents or swells shall not be retained or used.
During a review of the facility's policy and procedures (P&P) titled, Procedure for Refrigerator Storage, dated 2020, the P&P indicated, Food that has been freezer burned must be discarded.

Based on observation, interview, and record review, the facility failed to ensure the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) treatment records for one of nine sample residents (Resident 12) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) was complete for the month of 10/2024.
This failure resulted in incomplete RNA records for the provision of passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) for Resident 12.
Findings:
During a review of Resident 12's admission Record, the facility admitted Resident 12 on 8/22/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and rhabdomyolysis (condition where muscle cells break down and release their contents into the bloodstream).
During a review of Resident 12's physician orders, dated 8/28/2024, the physician's order indicated for the RNA to provide PROM to the left leg, five times per week as tolerated. Another physician's order, dated 8/28/2024, indicated for the RNA to provide PROM to the right leg, five times per week as tolerated.
During a review of Resident 12's RNA treatment record, dated 10/2024, the RNA treatment record included Restorative Nursing Aide 2's (RNA 2) initials for providing PROM to the left leg, five times per week as tolerated. Resident 12's RNA treatment record was blank (no initials) for RNA to provide PROM to the right leg.
During a review of Resident 12's Minimum Data Set ([MDS] a resident assessment tool), dated 12/2/2024, the MDS indicated Resident 12 had clear speech and was significantly impaired for cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 12 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for eating, toileting, bathing, dressing, and rolling to both side while lying in bed.
During an observation on 12/19/2024 at 9:53 a.m. with Restorative Nursing Aide 2 (RNA 2) in Resident 12's room, Resident 12 was lying in bed with both hips and knees bent. Both of Resident 12's hips were rotated to the right side. RNA 2 performed PROM to the left hip, knee, and ankle. RNA 2 attempted to perform PROM to the right leg but Resident 12 refused the PROM exercises.
During a concurrent interview and record review on 12/20/2024 at 10:34 a.m. with RNA 2, Resident 12's RNA treatment record, dated 10/2024, was reviewed. RNA 2 stated she provided PROM to the right leg but did not initial on the RNA treatment record for the entire month.
During a concurrent interview and record review on 12/20/2024 at 10:35 a.m. with the Director of Medical Records (DMR), Resident 12's RNA treatment record, dated 10/2024, was reviewed. The DMR stated Resident 12's RNA treatment record was incomplete since the RNA treatment record was blank for the provision of PROM to the right leg for 10/2024. The DMR stated Resident 12 could potentially develop contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) if the RNA treatment record did not indicate the RNA provided PROM to the right leg.
During an interview on 12/20/2024at 1:47 p.m. with the Director of Nursing (DON), the DON stated a resident's medical record (in general) was the record of care providing to the resident. The DON stated the facility's Medical Record departments was supposed to check the resident's medical records for accuracy. The DON stated the facility could miss treatments or care provided to residents if the medical record was not accurate.
During a review of the facility's undated Policy and Procedure (P&P) titled, Charting and Documentation, the P&P indicated all services provided to the resident shall be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) on 9/5/2024 for evaluation and treatment related to abnormal laboratory (labs) results, was refused readmission to the facility after Resident 1 was treated and stabilized at the GACH on 10/1/2024.
This deficient practice resulted in Resident 1 remaining at the GACH for 11 days after Resident 1 was deemed appropriate for transfer back to the facility but was denied readmission by the facility. Resident 1 was subsequently transferred to a different facility (10/1102024), placing the resident at risk for confusion, disorientation related to displacement from a place that was considered Resident 1's home.
Findings:
During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (mania and depression combination), and extrapyramidal movement disorder (involuntary muscular movement caused by side effects of antipsychotic medications).
During review of Resident 1's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/5/2024, the MDS indicated Resident 1 had the ability to understand others, make himself-understood and required maximal assistance (helper does more than half the effort) 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 1's Change of Condition (COC) dated 9/5/2024 the COC indicated Resident 1's lab results were abnormal.
During a review of Resident 1's Physician's Order dated 9/5/2024 and timed at 5 p.m., the Physician's Order indicated to transfer Resident 1 to the GACH (GACH 1).
During a review of Resident 1's Nurse Progress Note dated 9/5/2024 and timed at 4:51 p.m., the Nurse Progress Note indicated Resident 1 was transferred to GACH 1 for further evaluation.
During a review of the facility's Daily Census, the following was indicated:
From 10/1/2024 through 10/7/2024 - there was one male bed available
From 10/8/2024 through 10/9/2024 - there were three male beds available
From 10/10/2024 through 10/11/2024 - there were four male beds available
During a review of GACH 1's admission Records (Face Sheet), the Face Sheet indicated Resident 1 was transferred to GACH 1 on 9/5/2024 and discharged to GACH 2 on 9/18/2024.
During a review of GACH 2's admission Record, GACH 2's admission Record indicated Resident 1 was admitted to GACH 2 on 9/18/2024 and discharged to skilled nursing facility (SNF 2) on 10/11/2024.
During a review of GACH 2's Case Management/Social Services assessment dated [DATE], the Case Management/Social Services Assessment indicated SNF 1 reported they had no available beds since 10/1/2024.
During an interview on 10/11/2024 at 11:15 a.m. the Director of Nurses (DON) stated Resident 1 contracted Candida auris ([C. auris] a yeast that can cause life-threatening infections an is a highly contagious in healthcare settings) at GACH 2 and she could not readmit Resident 1 to the facility because they had no available isolation beds.
During an interview on 10/17/2024 at 2:30 p.m., Registered Nurse 1 (RN 1) stated, she spoke to someone at GACH 2, who reported Resident 1 had C. auris. RN 1 stated they did not refuse to readmit Resident 1 to the facility (SNF 1), they did not have any isolation beds available.
During an interview on 10/17/2024 at 2:40 p.m., the Administrator (ADM) stated they could not readmit Resident 1 because there were no available beds.
During a telephone interview on 10/17/2024 at 4:30 p.m., the Social Worker (SW) from GACH 2 stated, she called the facility about Resident 1's discharge on [DATE] and was told by RN 1 that there were no available beds.
A review of an All Facility's Letter 24-15 (AFL 24-15), dated 6/13/2024, indicated as of 3/20/2024, all Skilled Nursing Facilities (SNFs) in compliance with the Centers for Medicare & Medicaid Services (CMS an agency that provides health coverage to more than 160 million) Enhanced Barrier Precautions ([EBP] an infection control strategy that uses personal protective equipment ([PPE] clothing and gear that medical professional wear to protect themselves from infection and injury to reduce the spread of Multidrug-resistant Organisms ([MDROs] bacteria that have become resistant to certain antibiotics in nursing homes) requirement, were able to admit and provide care for residents with MDROs. Thus, there was no basis for the facility to refuse admission of a Resident based on the resident's need for EBP or MDRO status. Residents on EBP do not require placement in a single-person room, even when known to be infected or colonized with an MDRO.
During a review of the facility's undated policy and procedure (P/P) titled Bed Hold Notice Upon Transfer, the P/P indicated a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan will be readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility and is eligible for Medicaid nursing facility services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a resident-to-resident altercation not later than two hours to the Ombudsman (public advocate who tries to resolve complaints) and the California Department of Public Health (CDPH) after the abuse allegation was made according to mandatory reporting requirements for two of four sampled residents (Resident 1 and 2).
This deficient practice had the potential to impede the safety of the residents and place the residents at risk for elder abuse.
Findings:
During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and low back pain.
During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 01/24/20024, the MDS indicated Resident 1's had ability to understand others and could make himself understood, Resident 1 had moderate cognitive impairment. The MDS indicated, Resident 1 had functional limitation of upper and lower extremities, uses a wheelchair for mobility, and needed moderate assistance with personal hygiene, upper body dressing, toileting hygiene and needs maximal assistance with lower body dressing.
During a review of Resident 1's nurses progress report, on 1/24/2024 at 8:30 a.m., the report indicated Resident 1 was heard yelling and screaming then Resident 1 stated, that lady (unnamed in report) scratched and hit me on my face, get that patient out of here or I will knock her down.
During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis including schizophrenia and unspecified psychosis (a symptom triggered by a mental illness, a physical injury or illness, substance abuse, or extreme stress).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's had moderate cognitive impairment. The MDS indicated Resident 2 needed moderate assistance with personal hygiene, lower body dressing and supervision for toileting hygiene, and upper body dressing.
During a review of Resident 2's nurses progress report, on 1/24/2024 at 8:30 a.m., the report indicated Resident 2 scratched and hit a resident (unnamed in report).
During a review of the incident report dated 1/24/2024, the report indicated the abuse between Resident 1 and 2 occurred at 8:30 am.
During a review of the fax cover sheet for reporting dated 1/24/2024 indicated the fax went through at 01/24/2024 at 4:55 p.m.
During an interview with Director of Nursing (DON) on 02/02/2024 at 01:47 p.m. the DON agreed the allegation between resident 1 and 2w was about physical abuse, pinching the cheeks and kicking the legs; and the DON stated the incident should have been reported to CDPH within 2 hours.
During a review of facility's policy and procedure titled Abuse, Neglect and exploitation, undated, the policy indicated, in response to allegation of abuse the facility must: ensure the allegation was reported immediately, but not later than 2 hours after the allegation was made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement resident-centered care plan for one of three sampled residents (Resident1).
This deficient practice had the potential to result in a delaying delivery of care and services.
Findings:
During a review of Resident 1 ' s admission record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE] with a diagnosis of schizophrenia, unspecified ( a serious mental health condition that affects 0a person thinks and communicate the way a person thinks and communicates with the outside world ), Bipolar disorder, unspecified ( significant, abnormal mood elevations ), and Anemia , unspecified ( a condition in which the blood doesn ' t have enough healthy red blood cells).
During a review of Resident 1 ' s history and physical (H&P) dated 11/30/2023, the H&P indicated Resident 1 has fluctuating capacity to understand and make decisions.
During a review of the Resident 1 ' s Minimum Data Set (MDS- a comprehensive assessment and care planning tool) dated 1/4/2024, the MDS indicated Resident 1 required partial moderate assistance (helper lifts, holds or supports trunk or limbs, but provides less than half the effort) in toilet hygiene, shower / bathe self, and personal hygiene.
During an interview and record review on 1/ 25/2024 at 12:39 p.m., with Director of Nursing (DON) , the DON stated when there ia an abuse allegation care plan should be initiated so we can intervene and be able to monitor how the resident feell after the incident. DON stated Resident 1 had no care plan initiated after the allege abuse because it is for patient ' s safety.
During an interview on 1/25/2024 at 1:56 p.m., the Registered Nursing Supervisor (RNS), RNS stated it is important to start a care plan for Resident 1 to make sure he is safe and Resident will get the right kind of care and services.
During a review of the facility ' s policy and procedure (P&P) revised 12/2009, the P&P indicated an individual comprehensive care plan that includes measurable objectives and timetables to meet the resident ' s medical, nursing, mental and psychological needs is developed for each resident.
Each resident ' s comprehensive care plan is designed to :
a. Incorporate identified problem areas.
b. Incorporate risk factors associated with identified problems.
c. Identify the professional services that are responsible for each element of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to submit a five-day investigative report for one of three sampled resident ' s (Resident 1).
This deficient practice resulted in an incomplete investigation and incomplete conclusion of the alleged abuse in the facility.
Findings:
During a review of Resident 1 ' s admission record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE] with a diagnosis of schizophrenia, unspecified ( a serious mental health condition that affects the a person thinks and communicate the way a person thinks and communicates with the outside world ), Bipolar disorder, unspecified ( significant, abnormal mood elevations ), and Anemia , unspecified ( a condition in which the blood doesn ' t have enough healthy red blood cells).
During a review of Resident 1 ' s history and physical (H&P) dated 11/30/2023, the H&P indicated Resident 1 has fluctuating capacity to understand and make decisions.
During a review of the Resident 1 ' s Minimum Data Set (MDS- a comprehensive assessment and care planning tool) dated 1/4/2024, the MDS indicated Resident 1 required partial moderate assistance (helper lifts, holds or supports trunk or limbs, but provides less than half the effort) in toilet hygiene, shower / bathe self, and personal hygiene.
During an interview and record review on 1/ 25/2024 at 12:39 p.m., with Director of Nursing (DON) , the DON verified there was no Five-Day Allegation of Abuse letter. The DON stated when there is an allegation of abuse allegation there must be an investigation and a follow up Five Day Abuse letter to report the results of the alleged abuse.
During an interview on 1/26/2024 at 4:10 p.m., with the Administrator (ADM), ADM stated it needs to have a conclusion letter to describe what follow up investigation was done for Resident 1, he further stated if it was not documented it was not done.
During a review of the facility ' s undated policy and procedure (P&P) titled Abuse, Neglect and Exploitation, the P&P indicated report the results of all investigation to the administrator or his or her designated representative and the other official in accordance with State law, including to the State survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The administrator should follow up with government agencies, during business hours to confirm the report was received, and to report the results of the investigation when final, as required by state agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to investigate and separate Resident 70 from Resident 9 to prevent further potential verbal and mental abuse.
These failures resulted in Resident 70 being verbally and mentally abused by Resident 7 for four months and felt depressed (a mood disorder that causes a persistent feeling of sadness and loss of interest) and stressed.
Findings:
During a review of Resident 70's admission Record (Face Sheet), the Face Sheet indicated Resident 70 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), epilepsy (sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), and neuropathy (nerve damage leads to pain, weakness, numbness or tingling in one or more parts of your body).
During a review of Resident 70's History and Physical (H&P), dated 6/9/23, indicated, Resident 70 had the capacity to understand and make decisions.
During a review of Resident 70's Minimum Data Set [(MDS), a standardized assessment and care screening tool), dated 10/5/23, indicated Resident 70 had impairment on both sides of the lower extremities.
During an interview on 1/2/24 at 11:22 a.m. with Resident 70 in the north hallway. Resident 70 stated for four months he had experienced Resident 9 (his roommate) calling him racial slurs. Resident 70 stated Resident 9 have called him a (f-----g Mexican) and continued to use derogatory (showing a critical or disrespectful attitude) words towards him. Resident 70 stated that he requested a room change in December (a month ago) from License Vocational Nurse (LVN - nurse name unknown). Resident 70 stated LVN 1 and Certified Nursing Assistant (CNA) 1 had witnessed Resident 9 calling him names (insult someone verbally). Resident 70 stated the verbal abuse made him feel stressed out and raised his blood pressure. Resident 70 stated he felt afraid in the facility.
During an interview on 1/3/24 9:46 a.m. with CNA 1, CNA 1 stated Resident 70 and Resident 9 do not get along. CNA 1 stated he witnessed verbal altercation between Resident 70 and Resident 9. CNA 1 stated Resident 9 was verbally aggressive, using derogatory language towards Resident 70 and called him names. CNA 1 stated calling Resident 70 racial slurs and named was considered verbal and mental abuse. CNA 1 stated Resident 70 could experience sadness, and depression due to verbal abuse from Resident 9. CNA 1 stated he reported the verbal abuse to LVN 1 but does not know what happened after he reported it.
During an interview on 1/4/24 at 9:20 a.m. with Director of Social Service (DSS), the DSS stated Resident 70 informed her that Resident 9 would say racial slurs to him. DSS stated a racial slur would be considered verbal abuse. DSS stated, being verbally abused could make Resident 70 feel sad, upset, and angry, especially because this was supposed to be Resident 70's home.
During an interview on 1/4/24 at 9:47 am with LVN 1, LVN 1 stated Resident 70 asked her to be moved to another room a month ago because Resident 9 was yelling at Resident 70. LVN 1 stated Resident 70 stated Resident 9 was too noisy and yells racial slurs to him. LVN 1 stated she never informed anyone of Resident 70's request and she failed to report it. LVN 1 stated she has received abuse training from the facility. LVN 1 stated racial slurs would be considered verbal abuse and should be reported immediately. LVN 1 stated Resident 70 could feel bad and upset from being called racial slurs.
During an interview on 1/4/24 at 11:19 a.m. with Administrator (ADM), the ADM stated, she was not aware of the allegation of verbal and abuse for Resident 70. ADM stated abuse should be reported immediately to her. ADM stated she was responsible for ensuring the safety and quality of care for the residents (in general) in the facility.
During a concurrent interview and record review on 1/5/24 at 5:10 p.m. with Registered Nurse Supervisor (RNS) 1, the RNS 1 stated a racial slur would be considered verbal abuse. RNS 1 stated according to the facility's policy and procedure (P&P), the P&P indicated abuse should be investigated and reported immediately to the administrator, and Resident 70 and 9 should be separated. RNS 1 stated Resident 70 probably feels bad from being called racial slurs and wanted to be removed from Resident 9 and have his room changed.
During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 2023, the P&P indicted, Response and Reporting of Abuse, Neglect and Exploitation- Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect, or exploitation is suspected, the Licensed Nurse should: A. Respond to the needs of the resident and protect them from further incident. B. Notify the Director of Nursing and Administrator.C. Initiate an investigation immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross referenced to F600
Based on observation, interview and record review, the facility failed to implement its abuse policies and procedure for three of four sample residents (Resident 27, Resident 70 and Resident 74 by failing to:
1.Intervene, report, and investigate resident to resident altercation between Resident 27 and 70.
2.Report and investigate Resident 70'[s verbal and mental abuse after reporting it to CNA 1 and after request of room change to Director of Social Service
Findings:
1.During a review of Resident 27's admission Record (Face Sheet), the Face Sheet indicated Resident 27 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including bipolar disorder (mental disorder that causes unusual shifts in person's mood, energy, activity levels and concentration which make it difficult to carry out day-to-day tasks. and human immunodeficiency virus ([HIV] virus that attacks the body's immune system).
During a review of Resident 27's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/10/2023, the MDS indicated Resident 27 had moderately impaired cognitive skills (when a person had trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required partial assistance (staff member does less than half the effort) with bed mobility, toileting hygiene and personal hygiene.
During a review of Resident 27's History and Physical (H&P) dated 8/18/2023 the H&P indicated Resident 27 had a fluctuating capacity to understand and make decisions.
During a review of Resident 74's Face Sheet, the Face Sheet indicated Resident 74 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes (high sugar level in the blood), osteoporosis( disease in which bones become brittle and fragile), schizophrenia (mental illness that affects how a person thinks, feels and behaves) and depression(mood disorder causes a persistent feeling of sadness and loss of interest).
During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had moderate cognitive impairment and required partial assistance with bed mobility, toileting and personal hygiene.
During an interview on 1/2/2024, at 4:31 p.m. with Activity Driver (AD), AD stated Resident 74 was talking to another resident during smoking time in the patio on 1/2/2024 around 3:30 p.m. AD stated he observed both residents were talking in a loud manner, but he did not do anything or report the incident to any staff member.AD stated he was busy because a lot of residents would like to smoke and did not report the incident because it was only a verbal exchange. AD stated if both residents had physical altercation or hurt each other, that would be an alleged abuse and should be reported to the Activity Assistant (AA)1.
During an interview on 1/3/2024, at 3:10 p.m. with AA 4, AA 4 stated Resident 74 who was sitting on his wheelchair was accusing Resident 27 of running the place and bullying other residents. AA 4 stated as the first resident approach the other resident he cut in into the conversation and told the residents to be civil with each other. AA 4 stated Resident 74 threw a cigarette butt to Resident 27. AA 4 stated the incident between Resident 74 and Resident 27 could be verbal abuse and could be an assault because Resident 74 threw the cigarette butt to Resident 27. AA 4 stated it was a verbal abuse because of the aggressive tones of their voices and exchange of nasty words. AA 4 stated he should have reported the incident to one of the nurses immediately because the incident could escalate and had the potential for Resident 74 and 27 to hurt each other.
During an interview on 1/3/2024, at 4:03 p.m. with RN Supervisor (RNS)1, RNS 1 stated for alleged resident to resident altercation, the facility would separate the residents, investigate, document a Situation, Background, Assessment and Recommendation ([SBAR] communication tool that can help healthcare team share information about the change in condition of a resident), notify and call the physician and family member.
During an interview on 1/5/2024, at 9: 30 a.m. with Resident 27, Resident 27 stated Resident 74 was jealous, accused him of bullying and threw a cigarette butt towards him. Resident 27 stated he was not afraid of Resident 74. Resident 27 stated Resident 74 told him he would kick his behind, but Resident 74 never came to talk to him after the incident in the patio.
During an interview on 1/5/2024, at 10:56 a.m., with Director of Social Services (DSS), DSS stated she monitors behavior and does wellness check on involved residents for alleged resident to resident altercation. DSS stated she had talked to Resident 74. DSS stated they monitor their behaviors to ensure they are safe and if medical treatment was needed but failed to document.
During a concurrent interview and record review on 1/5/2024, at 2:16 p.m. with Licensed Vocational Nurse (LVN) 3, reviewed Resident 27' s and Resident 74's Care Plan, SBAR and Nursing Progress Notes indicated alleged Resident 27 and Resident 74 altercation was not addressed, no documentation of SBAR and behavioral monitoring post alleged incident. LVN 3 stated there were no documentation about behavioral monitoring, SBAR, or Care Plan addressing the alleged resident to resident altercation. LVN 3 stated they monitor for hostile behavior but had not documented anything for Resident 74.
During an interview on 1/5/2024, at 5:09 p.m. with RNS 1, RNS 1 stated facility staff failed to follow their abuse policy and procedure with regards to intervention, reporting and investigating alleged abuse.
During an interview on 1/5/2924, at 3:04 p.m. with RNS 2, RNS 2 stated if there was no documentation in the Nursing Progress Notes regarding behavioral monitoring it meant it was not done. RNS 2 stated monitoring of behavior after an alleged resident to resident altercation would prevent physical fights which can result to injury.
2. During a review of Resident 70's admission Record (Face Sheet), the Face Sheet indicated Resident 70 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), epilepsy (sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), and neuropathy (nerve damage leads to pain, weakness, numbness or tingling in one or more parts of your body).
During a review of Resident 70's History and Physical (H&P), dated 6/9/23, indicated, Resident 70 had the capacity to understand and make decisions.
During a review of Resident 70's Minimum Data Set [(MDS), a standardized assessment and care screening tool), dated 10/5/23, indicated Resident 70 had impairment on both sides of the lower extremities.
During an interview on 1/2/24 at 11:22 a.m. with Resident 70 in the north hallway. Resident 70 stated for four months he had experienced Resident 9 (his roommate) calling him racial slurs. Resident 70 stated Resident 9 have called him a (f-----g Mexican) and continued to use derogatory (showing a critical or disrespectful attitude) words towards him. Resident 70 stated that he requested a room change in December (a month ago) from License Vocational Nurse (LVN - nurse name unknown). Resident 70 stated LVN 1 and Certified Nursing Assistant (CNA) 1 had witnessed Resident 9 calling him names (insult someone verbally). Resident 70 stated the verbal abuse made him feel stressed out and raised his blood pressure. Resident 70 stated he felt afraid in the facility.
During an interview on 1/3/24 9:46 a.m. with CNA 1, CNA 1 stated Resident 70 and Resident 9 do not get along. CNA 1 stated he witnessed verbal altercation between Resident 70 and Resident 9. CNA 1 stated Resident 9 was verbally aggressive, using derogatory language towards Resident 70 and called him names. CNA 1 stated calling Resident 70 racial slurs and named was considered verbal and mental abuse. CNA 1 stated Resident 70 could experience sadness, and depression due to verbal abuse from Resident 9. CNA 1 stated he reported the verbal abuse to LVN 1 but does not know what happened after he reported it.
During an interview on 1/4/24 at 11:19 a.m. with Administrator (ADM), the ADM stated, she was not aware of the allegation of verbal and abuse for Resident 70. ADM stated abuse should be reported immediately to her. ADM stated she was responsible for ensuring the safety and quality of care for the residents (in general) in the facility.
During an interview on 1/4/24 at 1:03 pm with Director of Staff Development (DSD), the DSD stated Resident 70 being verbally abused by Resident 9 probably makes him feel afraid. DSD stated abuse should be reported immediately and should be reported to the administrator and if the administrator was not available, she would notify the DON.
During a concurrent interview and record review on 1/5/24 at 5:10 p.m. with Registered Nurse Supervisor (RNS) 1, the RNS 1 stated a racial slur would be considered verbal abuse. RNS 1 stated according to the facility's policy and procedure (P&P), the P&P indicated abuse should be reported immediately to the administrator, and Resident 70 and 9 should be separated. RNS 1 stated Resident 70 probably feels bad from being called racial slurs and wanted to be removed from Resident 9 and have his room changed.
During a review of facility's policy and procedure (P&P) titled Abuse, Neglect and Exploitation revised 2020, the P/P indicated when abuse is suspected, the Licensed Nurse should respond to the needs of the resident, protect them from further incident and notify the attending physician, resident's family/ legal representative and Medical Director. The P&P indicated to monitor, document the resident's condition and response to medical interventions or nursing interventions. The P&P indicated to assess and monitor and develop appropriate plans of care for resident with needs and behavior which could lead to conflict.
During a review of the P&P titled, Abuse, Neglect and Exploitation, dated 2023, the P&P indicted, Response and Reporting of Abuse, Neglect and Exploitation- Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect, or exploitation is suspected, the Licensed Nurse should: A. Respond to the needs of the resident and protect them from further incident (document), B. Notify the Director of Nursing and Administrator (document), C. Initiate an investigation immediately.
2. During a review of Resident 70's admission Record (Face Sheet), the Face Sheet indicated Resident 70 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), epilepsy (sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), and neuropathy (nerve damage leads to pain, weakness, numbness or tingling in one or more parts of your body).
During a review of Resident 70's History and Physical (H&P), dated 6/9/23, indicated, Resident 70 had the capacity to understand and make decisions.
During a review of Resident 70's Minimum Data Set [(MDS), a standardized assessment and care screening tool), dated 10/5/23, indicated Resident 70 had impairment on both sides of the lower extremities.
During an interview on 1/2/24 at 11:22 a.m. with Resident 70 in the north hallway. Resident 70 stated for four months he had experienced Resident 9 (his roommate) calling him racial slurs. Resident 70 stated Resident 9 have called him a (f-----g Mexican) and continued to use derogatory (showing a critical or disrespectful attitude) words towards him. Resident 70 stated that he requested a room change in December (a month ago) from License Vocational Nurse (LVN - nurse name unknown). Resident 70 stated LVN 1 and Certified Nursing Assistant (CNA) 1 had witnessed Resident 9 calling him names (insult someone verbally). Resident 70 stated the verbal abuse made him feel stressed out and raised his blood pressure. Resident 70 stated he felt afraid in the facility.
During an interview on 1/3/24 9:46 a.m. with CNA 1, CNA 1 stated Resident 70 and Resident 9 do not get along. CNA 1 stated he witnessed verbal altercation between Resident 70 and Resident 9. CNA 1 stated Resident 9 was verbally aggressive, using derogatory language towards Resident 70 and called him names. CNA 1 stated calling Resident 70 racial slurs and named was considered verbal and mental abuse. CNA 1 stated Resident 70 could experience sadness, and depression due to verbal abuse from Resident 9. CNA 1 stated he reported the verbal abuse to LVN 1 but does not know what happened after he reported it.
During an interview on 1/4/24 at 11:19 a.m. with Administrator (ADM), the ADM stated, she was not aware of the allegation of verbal and abuse for Resident 70. ADM stated abuse should be reported immediately to her. ADM stated she was responsible for ensuring the safety and quality of care for the residents (in general) in the facility.
During an interview on 1/4/24 at 1:03 pm with Director of Staff Development (DSD), the DSD stated Resident 70 being verbally abused by Resident 9 probably makes him feel afraid. DSD stated abuse should be reported immediately and should be reported to the administrator and if the administrator was not available, she would notify the DON.
During a concurrent interview and record review on 1/5/24 at 5:10 p.m. with Registered Nurse Supervisor (RNS) 1, the RNS 1 stated a racial slur would be considered verbal abuse. RNS 1 stated according to the facility's policy and procedure (P&P), the P&P indicated abuse should be reported immediately to the administrator, and Resident 70 and 9 should be separated. RNS 1 stated Resident 70 probably feels bad from being called racial slurs and wanted to be removed from Resident 9 and have his room changed.
During a review of facility's policy and procedure (P&P) titled Abuse, Neglect and Exploitation revised 2020, the P/P indicated when abuse is suspected, the Licensed Nurse should respond to the needs of the resident, protect them from further incident and notify the attending physician, resident's family/ legal representative and Medical Director. The P&P indicated to monitor, document the resident's condition and response to medical interventions or nursing interventions. The P&P indicated to assess and monitor and develop appropriate plans of care for resident with needs and behavior which could lead to conflict.
During a review of the P&P titled, Abuse, Neglect and Exploitation, dated 2023, the P&P indicted, Response and Reporting of Abuse, Neglect and Exploitation- Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect, or exploitation is suspected, the Licensed Nurse should: A. Respond to the needs of the resident and protect them from further incident (document), B. Notify the Director of Nursing and Administrator (document), C. Initiate an investigation immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to protect residents right to be free from verbal and mental abuse including racial slurs (words or phrases that refer to members of racial and ethnic groups in a derogatory manner ), calling him names (insult someone verbally) and being yelled at for one of 19 sampled residents (Resident 70). The facility failed to:
1.Ensure Resident 9 did not continue to use racial slurs, yell and called Resident 70 names after Certified Nursing Assistant (CNA) 1 witnessed the incident and Resident 70 informed CNA 1 in December.
2.Report Resident 70 verbal and mental abuse after reporting it to CNA 1 and after request of room change to Director of Social Service
3.Investigate Resident 70 verbal and mental abuse from Resident 9 for the four months.
4.The facility failed to prevent further abuse and mistreatment from Resident 9 to Resident 70 by allowing Resident 9 to continue to be on the same room with Resident 70.
These failures resulted in Resident 70 being verbally and mentally abused by Resident 7 for a month while feeling depressed (a mood disorder that causes a persistent feeling of sadness and loss of interest), stressed.
Findings:
During a review of Resident 70's admission Record (Face Sheet), the Face Sheet indicated Resident 70 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), epilepsy (sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), and neuropathy (nerve damage leads to pain, weakness, numbness or tingling in one or more parts of your body).
During a review of Resident 70's History and Physical (H&P), dated 6/9/2023, indicated, Resident 70 had the capacity to understand and make decisions.
During a review of Resident 70's Minimum Data Set [(MDS), a standardized assessment and care screening tool), dated 10/5/2023, indicated Resident 70 had impairment on both sides of the lower extremities.
During an interview on 1/2/24 at 11:22 a.m. with Resident 70 in the north hallway. Resident 70 stated for four months he had experienced Resident 9 (his roommate) calling him racial slurs. Resident 70 stated Resident 9 have called him a (f-----g Mexican) and continued to use derogatory (showing a critical or disrespectful attitude) words towards him. Resident 70 stated that he requested a room change in December (a month ago) from License Vocational Nurse (LVN - nurse name unknown). Resident 70 stated LVN 1 and Certified Nursing Assistant (CNA) 1 had witnessed Resident 9 calling him names (insult someone verbally). Resident 70 stated the verbal abuse made him feel stressed out and raised his blood pressure. Resident 70 stated he felt afraid in the facility.
During an interview on 1/3/24 9:46 a.m. with CNA 1, CNA 1 stated Resident 70 and Resident 9 do not get along. CNA 1 stated he witnessed verbal altercation between Resident 70 and Resident 9. CNA 1 stated Resident 9 was verbally aggressive, using derogatory language towards Resident 70 and called him names. CNA 1 stated calling Resident 70 racial slurs and named was considered verbal and mental abuse. CNA 1 stated Resident 70 could experience sadness, and depression due to verbal abuse from Resident 9. CNA 1 stated he reported the verbal abuse to LVN 1 but does not know what happened after he reported it.
During an interview on 1/4/24 at 9:20 a.m. with Director of Social Service (DSS), the DSS stated Resident 70 informed her that Resident 9 would say racial slurs to him. DSS stated a racial slur would be considered verbal abuse. DSS stated, being verbally abused could make Resident 70 feel sad, upset, and angry, especially because this was supposed to be Resident 70's home. DSS stated, abuse should be reported immediately to the administrator.
During an interview on 1/4/24 at 9:47 am with LVN 1, LVN 1 stated Resident 70 asked her to be moved to another room a month ago because Resident 9 was yelling at Resident 70. LVN 1 stated Resident 70 stated Resident 9 was too noisy and yells racial slurs to him. LVN 1 stated she never informed anyone of Resident 70's request and she failed to report it. LVN 1 stated she has received abuse training from the facility. LVN 1 stated racial slurs would be considered verbal abuse and should be reported immediately. LVN 1 stated Resident 70 could feel bad and upset from being called racial slurs.
During an interview on 1/4/24 at 11:19 a.m. with Administrator (ADM), the ADM stated, she was not aware of the allegation of verbal and abuse for Resident 70. ADM stated abuse should be reported immediately to her. ADM stated she was responsible for ensuring the safety and quality of care for the residents (in general) in the facility.
During an interview on 1/4/24 at 1:03 pm with Director of Staff Development (DSD), the DSD stated Resident 70 being verbally abused by Resident 9 probably makes him feel afraid. DSD stated abuse should be reported immediately and should be reported to the administrator and if the administrator was not available she would notify the DON.
During a concurrent interview and record review on 1/5/24 at 5:10 p.m. with Registered Nurse Supervisor (RNS) 1, the RNS 1 stated a racial slur would be considered verbal abuse. RNS 1 stated according to the facility's policy and procedure (P&P), the P&P indicated abuse should be investigated reported immediately to the administrator, and Resident 70 and 9 should be separated. RNS 1 stated Resident 70 probably feels bad from being called racial slurs and wanted to be removed from Resident 9 and have his room changed.
During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 2023, the P&P indicted, The abuse coordinator in the facility is the Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: Administrator, other Officials in accordance with State Law, State Survey and Certification agency through established procedures. Observe resident behavior and their reaction to other residents, roommates, tablemates. Place residents in accommodations and environments that keep them calm. Temporary or permanent room or roommate change, where incompatibility creates the potential for abuse.
During a review of the facility's P&P titled, Residents Rights, dated 2023, the P&P indicated, Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
During a review of the facility's P&P titled, Quality of Life-Dignity, dated 2023, the P&P indicated, Treated with dignity means the resident will be assisted in maintain and enhancing his or her self-esteem and self-worth.
During a review of the P&P titled, Abuse, Neglect and Exploitation, dated 2023, the P&P indicted, Response and Reporting of Abuse, Neglect and Exploitation- Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect, or exploitation is suspected, the Licensed Nurse should: A. Respond to the needs of the resident and protect them from further incident. B. Notify the Director of Nursing and Administrator. C. Initiate an investigation immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the physician when one of 19 sampled residents (Resident 232) was complaining of painful urination (feel pain or a burning sensation when urinating).
This failure resulted in a delay of treatment and had the potential to put Resident 232 for unrelieved bladder discomfort.
Findings:
During a review of Resident 232's admission Record (Face Sheet ), the Face Sheet indicated Resident 232 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease ( occurs when nerve cells of the brain don't make enough of a body chemical which can affect mood and movement ), dysphagia(difficulty of swallowing), cachexia(condition that leads to extreme weight loss and muscle wasting due to the underlying illness)and chronic pain syndrome( pain remained long after an illness or injury had healed).
During a review of Resident 232's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 11/3/2023, the MDS indicated Resident 232 had moderately severe cognitive impairment (when a person had trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required maximal assistance with bed mobility, bed to chair transfer, personal hygiene and toileting hygiene.
During a review of Resident 232's Care Plan, titled Risk for altered comfort related to urinary retention( difficulty of urinating and completely emptying the bladder) and bladder spasm( bladder muscles contract or tighten which can cause urge to urinate often) or discomfort dated 10/23/2023 indicated goals including discomfort related to urinary retention or bladder discomfort would be minimized for theree months. The Care Plan's interventions included to monitor for urinary retention, spasm and discomfort and report to the physician for increasing discomfort, bladder spasm and urine retention.
During a review of Resident 232's Medication Administration Record (MAR) dated 1/3/24 for anti-anxiety monitoring of side effects indicated the resident was manifesting urinary retention during 7 a.m. to 3 p.m. shift on 1/3/24.
During a review of Resident 232's Nurses Progress Notes dated 1/3/2024 indicated no documentation of resident's discomfort in urination was addressed or the physician was notified.
During a subsequent interview on 1/4/2024, at 9:30 a.m. and at 9:53 a.m. with Resident 232, Resident 232 stated he was having a hard time passing out urine as if it was stuck since yesterday (1/3/24). Resident 232 stated he told Licensed Vocational Nurse (LVN) 3 on 1/3/24 and this morning (1/4/24) about his discomfort and difficulty of urinating.
During an interview on 1/4/2024, at 9:53 a.m. with LVN 3 , LVN 3 stated Resident 232 told her about his difficulty of passing urine on 1/3/24 and this morning (1/4/24). LVN 3 stated she notified RN Supervisor (RNS)1 on 1/4/24 to notify the physician.
During an interview on 1/4/2024, at 10:07 a.m. with RNS 1, RNS 1 stated she went to see Resident 232 on 1/4/24 morning and the Resident 232 told her about a stone in his urine but RNS 1 did not see anything on his urinal upon inspection. RNS 1 stated she told Resident 232 he was receiving medicine for his enlarged prostate gland (enlarged prostate may constrict the flow of urine and cause urinary retention) and did not assess him further as to why resident was experiencing discomfort in urinating. RNS 1 stated the facility would document in the Situation, Background, Action, Recommendation( [SBAR] communication tool that can help healthcare team share information about the change in condition of a resident) if there was a change of condition and would notify the family and the physician. RNS 1 stated it would be important to call the physician to obtain necessary medical intervention and treatment for Resident 232. RNS 1 stated Resident 232 would become agitated because his discomfort or pain was not addressed.
During a review of facility's policy and procedure(P&P) titled Notification of Changes revised 2023, the P&P indicated the facility would promptly consult the resident's physician and notifies when there is a change requiring notification. The P&P indicated circumstance that would require notification include circumstances that require a need to alter treatment such as acute condition and exacerbation of a chronic condition and significant change in the resident's physical, mental or psychosocial condition.
During a review of facility's P&P titled Change in a Resident's Condition or Status revised 2023, the P&P indicated a significant change of condition is a decline or improvement in resident's status that will not normally resolve itself without intervention by staff or by implementing clinical interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to:
1.Follow physician written orders and instructions regarding oxygen therapy (the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of low oxygen) for one of 19 sampled residents (Resident 39).
This failure resulted in Resident 39 receiving too much oxygen and potentially leading to complications such as headaches, lethargy (state of sleepiness or deep unresponsiveness), drowsiness, confusion, coma, and death.
2.Replace empty oxygen humidifier for Resident 15.
This deficient practice had the potential for respiratory infections for Resident 15.
Findings:
During a review of Resident 39's admission Record (Face Sheet), the Face Sheet indicated Resident 39 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic obstructive inflammatory lung disease that causes obstructed airflow from the lungs), diabetes (high blood sugar) , glaucoma (a serious eye condition that can lead to blindness), and hypertensive heart (a heart condition caused by high blood pressure over a long time).
During a review of Resident 39's Minimum Data Set (MDS- standardized assessment and care screening tool) dated 10/9/23 indicated, Resident 39 had the ability to express ideas and wants. The MDS indicated, Resident 39 required set up or clean-up assistance with eating. The MDS indicated Resident 39 required partial or moderate assistant from staff with oral hygiene, personal hygiene, positioning, sitting, and lying. The MDS indicated, Resident 39 required substantial or maximal assistance for upper body dressing, putting on and taking off footwear. The MDS indicated Resident 39 was dependent on staff for toilet hygiene, showering, lower body dressing and walking. The MDS indicated Resident 39 received oxygen therapy while a resident at the facility.
During a review of Resident 39's Physician Orders, dated 12/11/23, the Physician Orders indicated Resident 39 had an order for oxygen at two liters per minute (L/min) by nasal cannula ([NC]a device that delivers oxygen through two thin plastic tubes inserted into the nose) as needed for shortness of breath and low oxygen saturation.
During a review of Resident 39's Care Plan dated 12/11/23, the Care Plan indicated Resident 39's plan of care was oxygen at two L/min by nasal cannula as needed for shortness of breath.
During an observation on 1/2/24 at 10:23 a.m. in Resident 39's room, Resident 39 was lying in bed asleep receiving oxygen at three L/min.
During an observation on 1/2/ 24 at 2:25 p.m. in Resident 39's room, Resident 39 was lying in bed asleep receiving oxygen at three L/min.
During an observation on 1/3/ 24 at 9:11 a.m. in Resident 39's room, Resident 39 was lying in bed asleep receiving oxygen at three L/min.
During a concurrent observation, interview, and record review on 1/4/24 at 10:46 a.m. with Licensed Vocational Nurse (LVN) 4, Resident 39's Physician Orders were reviewed. The Physician's Order indicated Resident 39 was ordered oxygen at two L/min via nasal cannula. LVN 4 stated it was nursing staff's responsibility for administering oxygen to Resident 39 and making sure the correct amount of oxygen was being received by Resident 39. LVN 4 was asked to go to Resident 39's bedside to read the amount of oxygen Resident 39 was receiving. LVN 4 went to Resident 39's bedside and read the flowmeter on the oxygen and read three liters. LVN 4 turned down the oxygen level and stated it should be at two liters.
During an interview on 1/4/24 at 3:44 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 39 gets two liters of oxygen due to COPD. LVN 3 stated Resident 39 cannot get more than two liters of oxygen secondary to diagnosis of COPD. LVN 3 stated if Resident 39 get more than two liters of oxygen the carbon dioxide (Co2-a colorless, odorless gas produced by burning carbon and organic compounds and by respiration) level will increase and decrease the respiratory effort.
During an interview on 1/5/24 at 3:21 pm with Registered Nurse Supervisor (RNS) 1, RNS stated residents with COPD should not get more than two liters of oxygen due to the risk of complications.
2. During a review of Resident 15's admission Order (Face Sheet), the Face Sheet indicated Resident 15 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease ([COPD] a common lung disease causing restricted airflow and breathing problems]), hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time), and hyperlipidemia (elevated cholesterol level in the blood).
During a review of Resident 15's MDS dated [DATE] indicated Resident 15 had no cognitive impairment (ability to learn, understand, and make decisions) and requires partial assistance for oral hygiene, toileting, and dressing.
During an observation on 1/2/24 at 11:11 a.m., observed Resident 15's oxygen humidifier (aids in preventing a patient's airways from becoming dry) was empty.
During an interview on 1/4/24 at 9:46 a.m., with Resident 15, Resident 15 stated that he told the charge nurse regarding the empty oxygen humidifier but did not change the empty oxygen humidifier.
During an interview on 1/4/24 at 2:01 p.m., the Licensed Vocational Nurse (LVN) 4 stated oxygen humidifier must be change when it was almost empty and not totally empty because it can cause dryness and irritation to the Resident 15's nasal canal. Reviewed with LVN 4 a picture that was taken of the oxygen humidifier, LVN 4 stated that the oxygen humidifier was empty. LVN 4 stated that it should have been change.
During an interview on 1/4/24 at 3:48 p.m., LVN 3 stated that when resident was on oxygen with humidifier, licensed staff assigned should not wait when it was totally empty before changing the humidifier bottle. LVN 3 stated empty oxygen humidifier had the potential to cause nasal irritation that can lead to nasal bleeding.
During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, undated, The P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide necessary care and services to one of 19 sampled residents (Resident 10) to prevent complications of enteral feedings (method of supplying nutrients directly into the gastrointestinal tract) via gastrostomy tube ([G-tube] an artificial opening into the stomach to deliver medication, nutrition, and hydration) by failing to change the tube feed (liquid form of food that is carried through your body through a flexible tube called G-tube) and administration set (tubing used to deliver the enteral feeding) per facility's policy and procedure.
This failure had the potential to result in administering expired enteral formula which could lead to diarrhea, intolerance, dehydration, and weight loss to Resident 10.
Findings:
During a review of Resident 10's admission Record (Face Sheet), the Face Sheet indicated Resident 10 was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including diabetes( elevated sugar level in the blood), chronic obstructive pulmonary disease ([copd] group of lung diseases that block the airflow and make it difficult to breathe), gastrostomy( surgical opening into the stomach from the abdominal wall made for introduction of food) , and atrial fibrillation( irregular heartbeat).
During a review of Resident 10's Minimum Data Set ([MDS] standardized asssessment and care screening tool) dated 11/22/2023, the MDS indicated Resident 10 had moderately impaired cognitive skills(when a person had trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required substantial ( staff member provides more help than half the effort)assistance with bed mobility, bathing, toileting hygiene and personal hygiene.
During a review of Resident 10's Physician Orders dated 12/8/2023, the Physician Orders indicated an order for Glucerna 1.2 (liquid formula provided to residents who had diabetes) at 55 milliliter ([ml] unit of measurement) for 20 hours or until dose is completed to provide 1,100 ml. every day via G-tube.
During a review of Physician Orders dated 11/30/2023, the Physician Orders indicated an order to change feeding tubes and administration set every day.
During an observation on 1/2/2024, at 10:31 a.m., Resident 10's tube feeding formula bag was labeled with resident's name, room number, and rate of tube feed to be delivered to the resident, name of formula but the date was not included. The tube feed bag had a remaining volume of 600 ml. out of 1,500 ml.
During a concurrent observation and interview on 1/2/2024, at 10:35 a.m. with Licensed Vocational Nurse (LVN) 3), LVN 3 stated the tube feed bag was not dated and stated the tube feeding bag and administration set are changed every 24 hours. LVN 3 stated the tube feeding bag should be dated and timed by the staff member who hung it.
During an interview on 1/4/2024, at 3:30 p.m. with LVN 3, LVN 3 stated labeling the tube feed bag and administration set with date and time is important to ensure they are not providing the resident an expired or spoiled formula. LVN 3 stated expired formula could give the resident diarrhea ( a condition in which feces are discharged from the bowels frequently and in a liquid form) and stomachache.
During an interview on 1/5/2024, at 3:23 p.m. with RN Supervisor (RNS ) 2, RNS 2 stated tube feed bag and administration set are changed every 24 hours to prevent infection. RNS 2 stated there is a possibility of bacterial growth in the tube feed bag because it was an open system and expired formula could make a resident develop diarrhea, intolerance to the formula, dehydration which could lead to weight loss.
During a review of facility's policy and procedure (P&P) titled Enteral Feedings- Safety Precautions revised 2023, the P&P indicated to check the enteral nutrition label against the order before administration and on the formula label or document initials, date and time formula was hung or administered. The P&P indicated to initial the label to ensure it was checked against the physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide supervision and monitor residents who are on smoking list for three of 19 sampled residents (Resident 15, Resident 72 and Resident 11).
This deficient practice resulted to superficial right middle fingers burn to Resident 15, and Resident 11 and Resident 72 at risk for accidental burn due to unsupervised smoking.
Findings:
A. During a review of Resident 15's admission Record (Face Sheet), the admission Record indicated Resident 15's was initially admitted to the facility on [DATE] and re-admitted back to the facility on 8/07/2023, with diagnoses including chronic obstructive pulmonary disease ([COPD] a common lung disease causing restricted airflow and breathing problems]), hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time), and hyperlipidemia (elevated cholesterol level in the blood).
During a review of Resident 15's Minimum Data Set (MDS-a comprehensive assessment and care planning tool) dated 12/07/2023 indicated Resident 15 had no cognitive impairment (ability to learn, understand, and make decisions and requires partial assistance for oral hygiene, toileting, and dressing.
During a review of Resident 15's care plan (CP) for smoking dated 08/07/2023, Resident 15 requires observation and constant supervision while smoking.
B. During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of but not limited to COPD, diabetes (high blood sugar), and neuropathy (damage or disease affecting the nerves).
During a review of Resident 72's History and Physical (H&P), dated 9/27/2023, the H&P indicated, Resident 72 had the capacity to understand and make decisions and smoked five tobacco cigarettes a day.
During a review of Resident 72's MDS dated [DATE] indicated, Resident 72 required set-up clean-up assistance from staff with eating. The MDS indicated Resident 72 required supervision from staff for oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear, personal hygiene, positioning, lying, sitting, standing, transferring to a chair, transferring to the toilet and shower. Resident 72 required supervision with walking.
During an observation on 1/2/2024 at 8:30 am, Resident 72 was observed seated in a wheelchair smoking on the patio without wearing an apron (a fire-retardant apron designed to provide protection from dropped cigarettes and hot ashes) or staff supervision, a sign was posted in this patio area that indicated no smoking.
During a review of Resident 72's Resident Smoking Assessment Form, dated 9/19/23, the Resident Smoking Assessment Form indicated, Resident 72 can smoke supervised with a physician's order. The Resident Smoking Assessment Form indicated, for safety reasons residents may not store cigarettes, lighters, matches, pipes, tobacco, cigars, or any other smoking material at bedside, in their bedstand, in their closet, or in any drawers in their room. The Resident Smoking Assessment Form indicated, for everyone's safety, all smoking materials and paraphernalia must be stored by facility staff. The Resident Smoking Assessment Form indicated, Resident 72 must be always supervised and wear protective non-flammable smoking apron when smoking.
During an interview on 1/2/2024 at 11:53 am with Resident 72, Resident 72 stated she smokes on the patio unsupervised and keeps her own cigarettes and lighters. Resident 72 stated she is supposed to wear an apron to protect her clothing from being burned.
During an interview on 1/03/2024 3:11 pm with Activities Assistant (AA 4) stated he supervises residents while smoking and gives aprons to residents to wear while smoking. AA 4 stated he is unaware of residents being assessed for smoking. AA 4 stated residents on the patio area that indicates no smoking are allowed to smoke unsupervised without aprons. AA 4 stated he does not keep a list of residents who smoke. AA 4 stated he allows any residents to smoke who wants to smoke and has not read the facility's policy and procedures regarding smoking. AA 4 stated if residents are smoking unsupervised the residents have the potential for harm and injury due to burns.
During an interview on 1/3/2024 at 4:20 pm with Registered Nurse Supervisor (RNS 1), RNS 1 stated residents must wear an apron at all times when smoking. RNS 1 stated residents are not allowed to keep their own cigarettes and lighters. RNS 1 stated residents have certain hours of smoking and need supervision because the resident might burn themselves. RNS 1 stated residents are not allowed to smoke on the patio with the sign that indicates no smoking because nobody can supervise them.
C. During a review of Resident 11's admission Record indicated Resident 11's was initially admitted to the facility on [DATE] and re-admitted back to the facility on 8/25/2023, with diagnoses including COPD, hypertensive hearts disease without heart failure, and diabetes mellitus.
During a review of Resident 11's MDS dated [DATE] indicated Resident 11 had no cognitive impairment and requires partial assistance foe toileting, oral hygiene, dressing and personal hygiene.
During a review of Resident 11's CP for smoking dated 11/31/2023, Resident 11 requires observation and constant supervision while smoking due to potential for burning first and second digit because of smoking.
During a concurrent interview and record review (RR) on 01/03/2024 at 4:30 p.m., Resident 15 stated that he sustained superficial burned to his right middle finger from smoking and picture taken. RR indicated there was no documentation that change of condition (COC) was done and the incident was not documented.
During an observation and interview on 01/03/2024 at 4:35 p.m., both MDS Coordinator and Social Services Director (SSD) confirmed that the superficial skin burn was a result from smoking. MDS Coordinator stated that she was not aware about the incident that resulted to the superficial right middle finger burn of Resident 15.
During an interview on 01/04/2024 at 9:41 a.m., the Activity Assistant (AA1) stated that sometimes some resident smoke without any staff supervising them.
During an interview on 01/04/2024 at 9:46 a.m., Resident 15 stated that he sustained a superficial right middle finger skin burned from smoking and there was no staff supervising at the time when the incident happened and told the staff afterwards, but the staff did not do anything about the incident.
During a concurrent interview with RNS 1 and Record review of Resident 15's medical chart on 01/04/2024 at 10:28 a.m., RNS1 stated that in every smoking schedule, there must be a staff supervising all smoking residents for safety purposes. RNS 1 stated if the burn injury will not be treated right away it can get infected. RR with RNS 1 and indicated that it was not reported and there was no documentation for COC. RR indicated according to care plan (CP) for smoking, supervision must have been provided while smoking. RNS 1 stated that if it was reported to the charge nurse, COC should have been done and should have been documented.
During an interview on 01/04/2024 at 10:52 a.m., the AA 3 stated that every smoking schedule there must be a staff to supervise to prevent burn injury and even after the incident happened the assigned certified nursing assistant (CNA) will be able to identify through the skin checklist at the beginning of their shift and should report it to the charge nurse.
During an interview on 01/04/2024 at 11:04 a.m., the licensed vocational nurse (LVN 3) stated that burn must have been identified because the CNA's check every resident's skin overall daily when they will have received their assignments and will report to the charge nurse and the charge nurse will do the COC assessment.
During an interview on 01/04/2024 at 12:45 p.m., the CNA 7 stated that it is impossible that initially the assigned CNA will not be able to notice skin issues because whenever they received an assignment, they have a checklist to follow and notify the charge nurse for any skin problems like burns so that the charge nurse can do thorough skin assessment and make a COC evaluation.
During a telephone interview on 01/05/2024 at 9:50 a.m., the CNA 8 stated that she informed LVN 5 and Administrator regarding the incident on 12/23/2023 that Resident 15 sustained a superficial right middle finger skin burn from smoking.
During a telephone interview on 01/05/2024 at 9:55 a.m., LVN 5 stated that she did not do a COC assessment and admitted that it should have been a COC.
During an interview on 01/05/2024 at 10:34 a.m., the Administrator admitted that it was informed to her the incident on 12/23/2023 when Resident 15 sustained a cigarette burn on his right middle finger, but she has no answer why LVN 5 did not do the COC assessment and she does not have any reason or excuses why COC assessment was not done.
During a RR with RNS 3 on 01/05/2024 at 3:09 p.m., it indicated that there was no treatment done for cigarette burn for both Resident 15 and Resident 11 from December 2023.
During a review of facility's policy and procedure titled Resident Smoking undated indicated: This facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan.
During a review of the facility's policy and procedure (P&P) titled, Resident Smoking, undated, the P&P indicated, Safety protections apply to smoking and non-smoking residents. Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area sign will be prominently posted. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of 19 sampled residents ( Resident 74, 21 and 68) received Restorative Nursing Aide (RNA- assist the resident in performing task that restore or maintain physical function) services as ordered by the physician by failing to:
1.Provide active range of motion exercises ([AROM] occurs when a person use their muscles to help move their body) to upper and lower extremities (limbs) five days a week as ordered by the physician to Resident 74.
2.Resident 21 has hand rolls on both hands as ordered by the physician.
3.Resident 68 received Restorative Nursing Aide as ordered by the physician.
These failures had the potential to result in Resident 74, 21 and 68 developing contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and decreased mobility.
Findings:
During a review of Resident 74's admission Record (Face Sheet), the Face Sheet indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included diabetes (high sugar level in the blood), osteoporosis( disease in which bones become brittle and fragile), schizophrenia (mental illness that affects how a person thinks, feels and behaves), low backpain and depression(mood disorder causes a persistent feeling of sadness and loss of interest).
During a review of Resident 74's Minimum Data Set ([MDS] standardized screening tool) dated 10/25/2023, the MDS indicated the resident had moderate cognitive impairment (when a person had trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required partial assistance (staff member does less than half the effort) with bed mobility, toileting hygiene and personal hygiene.
During a concurrent observation and interview on 1/3/2024, at 10:18 a.m. with Resident 74, Resident 74 was sitting on his wheelchair and stated he had not seen a staff member came to provide exercises on his legs and arms and they were lying if the staff said they did come and do the exercises with him.
During a review of Resident 74's Physician order dated 11/9/2023, the Physician Orders indicated an order for RNA everyday five times a week for active range of motion exercises to bilateral(both)upper and lower extremities as tolerated.
During a review of Resident 74's Restorative Service Record for the month of December 2023, the Restorative Treatment Record indicated no treatment provided on 12/12/2023, 12/14/2023, 12/27/2023 and 1/4/2024.
During a review of Resident 74's RNA Care Plan dated 11/9/2023, the RNA Care Plan indicated Resident 74 had muscle weakness and impaired balance as problems. The Care plan goal was to maintain range of motion and strength on bilateral upper and lower extremities. The Care Plan's interventions include RNA everyday five times a week for active range of motion exercises on bilateral upper extremities and bilateral lower extremities as tolerated.
During a concurrent interview and record review of Resident 74's RNA Treatment Record for month of December 2023 on 1/4/2024, at 1:08 p.m. with Restorative Nursing Assistant (RNA1),. RNA 1 stated Resident 74 refused the arom exercises this morning and she did not document the resident's refusal or notified the charge nurse about Resident 74's refusal yet because she usually would start documenting at 2:00 p.m. RNA1 confirmed Restorative Treatment Record was not signed on 12/12/2023, 12/14/2023 , 12/27/2023 and 1/4/2024. RNA 1 stated if the Restorative Treatment Record was not signed meaning the arom exercises were not provided for Resident 74. RNA 1 stated not providing RNA exercises could cause contractures.
During an interview on 1/5/2024, at 1:52 p.m. with RNA 2, RNA 2 stated she was assigned on both stations on 12/12/2023 and forgot to chart. RNA 2 stated if it was not documented on the chart, it meant the treatment was not performed.
During an interview on 1/5/2024, at 3:23 p.m. with RN Supervisor (RNS 2), RNS 2 stated it could cause a decline in mobility and place residents at risk for contracture if RNA Treatment are not provided.
2. During a review of Resident 21's Face Sheet, the Face Sheet indicated Resident 21's was initially admitted to the facility on [DATE] and re-admitted back to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), and Bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration).
During a review of Resident 21's MDS) dated [DATE] indicated Resident 21 had moderate cognitive impairment and requires dependent assistance for all activities of daily living.
During a review of Resident 21's care plan (CP) dated 09/06/2023, Resident 21 requires application of hand rolls or rolled wash cloth on both hands' everyday times five days a week up to five hours as tolerated to prevent further decline in joint mobility.
During an observation on 01/02/2024 at 12:21 p.m., Resident 21 observed sitting in the wheelchair inside her room without hand rolls on both hands that are both contracted.
During an observation on 01/03/2024 at 9:43 a.m., Resident 21 lying in bed asleep and observed without hand rolls application on both hands.
During an observation on 01/03/2024 at 10:25 a.m., Resident 21 lying in bed asleep and observed without hand rolls application on both hands.
During an observation on 01/03/2024 at 10:25 a.m., Resident 21 lying in bed asleep and observed without hand rolls application on both hands.
During an observation on 01/03/2024 at 1:03 p.m., Resident 21 lying in bed asleep and observed without hand rolls application on both hands.
During an observation on 01/04/2024 at 10:51 a.m., Resident 21 lying in bed asleep and observed without hand rolls application on both hands.
During an interview on 01/04/25024 at 2:21 p.m., the RNA 2 stated if restorative nursing exercises are not provided in a regular basis as ordered, it can worsen the hand contractures.
During an interview on 01/05/2024 at 1:23 p.m., the RNA 1 stated when RNA services are not documented that means it was not done.
During a record review on 01/05/2024 at 1:25 p.m., RR of RNA notes indicated, there was no RNA signature that RNA exercises was done on 01/04/2024 and 01/05/2024.
3. During a review of Resident 68's admission Record (Face Sheet), the Face Sheet indicated, Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension (high blood pressure), hemiplegia (weakness on one entire side of the body), encephalopathy (damage or disease that affects the brain), and acute kidney failure (the kidneys become unable to filter waste products from the blood).
During a review of Resident 68's History and Physical (H&P), dated 2/15/23, the H&P indicated, Resident 68 had fluctuating (rising and falling irregularly in number or amount) capacity (the maximum amount that something can contain) to understand and make decisions.
During a review of Resident 68's Minimum Data Set ([MDS]- a standardized assessment and care screening tool) dated 11/23/23 indicated, Resident 68 did not have corrective lenses. The MDS indicated Resident 68 required setup and clean-up assistance with eating. The MDS indicated Resident 68 required partial and moderate assistance with oral hygiene, upper body dressing, putting on and taking off footwear, personal hygiene, positioning, sitting, lying, standing. The MDS indicated Resident 68 required substantial and maximal assistance with toileting hygiene, showering, lower body dressing, sitting, standing, transferring to a chair, bed, toilet, and shower. The MDS indicated Resident 68 was in the Restorative Nursing Program and received passive range of motion for five days and active range of motion for five days.
During a review of Resident 68's initial Joint Mobility Assessment document, dated 2/15/2023, the Joint Mobility Assessment indicated, Resident 68 required assistance in all aspects of his functional abilities and would benefit from RNA program once daily five times a week for Assisted Active Range of Motion (AAROM-the resident uses the muscles around a weak joint to complete stretching exercises with the help of a nurse, physical therapist or equipment) exercises on the left leg and Passive Range of Motion (PROM-the resident applies no effort to move the joint, which is moved through a variety of stretching exercises by a nurse, physical therapist or with the help of equipment) to the left arm daily five times a week as tolerated.
During a review of Resident 68's Physician Orders, for the month of 1/24, the Physician Orders indicated, Resident 68 had a physician order for RNA program once daily five times a week for AAROM on the left leg as tolerated. The Physician orders indicated, RNA order for PROM to the left arm daily five times a week as tolerated. The physician orders indicated the RNA services started on 2/25/2023.
During a review of Resident 68's Restorative Record, dated 12/23, the Restorative Record indicated, Resident 68 had an order to receive RNA program once daily five times a week for AAROM on the left leg as tolerated. The Restorative Record indicated, RNA order for PROM to the left arm daily five times a week. The Restorative Record indicated Resident 68 RNA services started on 2/15/2023.
During an interview on 1/4/24 at 1:18 pm with Resident 68 in Resident 68's room, Resident 68 stated he does not get physical therapy and did not have RNA services on 1/4/24.
During an interview on 1/4/24 at 1:20 pm with Restorative Nursing Aide (RNA) 1, RNA 1 stated Resident 68 gets range of motion for the arms and legs five times a week. RNA 1 stated, on 1/4/24, Resident 68 did not receive RNA 1 services because she worked as a certified nurse assistant. RNA 1 stated if Resident 68 was not receiving his RNA services, Resident 68 will become contracted. RNA 1 stated, if the restorative form was not signed it means the RNA services was not done.
During a concurrent interview and record review on 1/4/24 at 3:15 pm with the Director of Staff Development (DSD), Resident 68's Restorative Record (document that nursing staff initial to indicate RNA services were done) dated December 2023 and January 2024 was reviewed. The Restorative Record indicated, on 12/12/23, 12/14/23, 12/27/23, 12/28 23 and 1/1/24 there were no staff initial in the box for Resident 68's RNA services to demonstrate the RNA services were done. DSD stated there was no documentation on the Restorative Record dated December 2023 and January 2024 that indicated Resident 68 received RNA services on 12/12/2023, 12/14/2023, 12/27/2023, 12/28 2023 and 1/1/2024.
During an interview on 1/5/24 at 1:27 pm with Certified Nursing Assistant (CNA) 9, CNA 9 stated if RNA services were not documented it means the RNA services were not done.
During an interview on 1/5/24 at 1:52 pm with RNA 2, if the Resident 68 does not receive RNA services the resident's mobility and ability to move will decline.
During an interview on 1/5/24 at 2:59 pm with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 68 will lose his mobility and become weaker and weaker and lose his range of motion and Resident 68 will also be at risk for contractures if he was not receiving RNA services as ordered.
During an interview on 1/5/2024 at 3:23 pm with Registered Nurse Supervisor (RNS) 2, RNS 2 stated Resident 68 should be provided with RNA services as ordered by the physician. Resident 68 will be most likely to have a decline in ambulation and mobility and at risk for contractures.
During a review of facility's policy and procedure (P&P) titled Provision of Quality Care revised 2023 indicated: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.
During a review of the facility's P&P titled, Restorative Nursing Program, undated, the P&P indicated, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of 19 residents (Resident 68) received the proper assistive devices to maintain vision abilities by not assisting in providing of reading glasses. Resident 68 was recommended eyeglasses on 10/2/2023 and by 1/2/2024, the Director of Social Services (DSS) had not followed up in the delay of the reading glasses.
This failure resulted in Resident 68 not having his reading glasses and being unable to read or see small objects for three months.
Findings:
During a review of Resident 68's admission Record (Face Sheet), the Face Sheet indicated, Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension (high blood pressure), hemiplegia (weakness on one entire side of the body), encephalopathy (damage or disease that affects the brain), and acute kidney failure (the kidneys become unable to filter waste products from the blood).
During a review of Resident 68's History and Physical (H&P), dated 2/15/23, the H&P indicated, Resident 68 had fluctuating (rising and falling irregularly in number or amount) capacity (the maximum amount that something can contain) to understand and make decisions.
During a review of Resident 68's Physician Orders, dated 1/24, the Physician Orders indicated, Resident 68 had physician orders for an optometrist (a healthcare professional who provides primary vision care) consult and treatment as indicated to start on 2/15/2023.
During a review of Resident 68's Minimum Data Set (MDS- standardized assessment and care screening tool) dated 11/23/23 indicated, Resident 68 did not have corrective lenses. The MDS indicated Resident 68 required setup and clean-up assistance with eating. The MDS indicated Resident 68 required partial and moderate assistance with oral hygiene, upper body dressing, putting on and taking off footwear, personal hygiene, positioning, sitting, lying, standing. The MDS indicated, Resident 68 required substantial and maximal assistance with toileting hygiene, showering, lower body dressing, sitting, standing, transferring to a chair, bed, toilet, and shower.
During an interview on 1/2/24 at 1:16 pm with Resident 68, Resident 68 stated he had problems with vision.
During a review of Resident 68's Eye Consultation Record, dated 10/2/2023, the Eye Consultation Record indicated, Resident 68 was seen and examined by the optometrist on 10/2/2023 and had recommendations for new reading glasses.
During a concurrent interview and record review on 1/4/24 at 10:12 a.m. with Licensed Vocational Nurse (LVN) 4, Resident 68's Eye Consultation Record, dated 10/2/24 was reviewed. LVN 4 stated Resident 68 does not use glasses and Resident 68 was last seen by the optometrist on 10/2/23. LVN 4 stated Resident 68 had recommendations for new reading glasses. LVN 4 stated Resident 68's vision will worsen if he does not have his reading glasses and his risk for falls will increase if he cannot see.
During a review of the facility's Optometric Master List (a list of Residents in the facility examined by the eye doctor), dated 10/2/2023, the Optometric Master List indicated, Resident 68 was prescribed bifocal glasses.
During an interview on 1/04/24 at 12:34 pm with Director of Social Services (DSS), DSS stated Resident 68 used reading glasses and was seen by the eye doctor on 10/2/23 for new reading glasses. DSS stated she needs to follow up on the recommendation for new reading glasses and was supposed to follow up on the recommendation but did not. DSS stated if Resident 68 does not have reading glasses it can affect his eyesight for reading and watching TV, and Resident 68 could be at risk injury or falls.
During an interview on 1/5/24 at 3:20 pm with Registered Nurse Supervisor (RNS) 2 RNS 2 stated if Resident 68 does not have reading glasses he might not be able to see very well and at risk for fall.
During a review of the facility's policy and procedure (P&P) titled, Hearing and Vision Services, dated 2023, the P&P indicated, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The social worker/social service designee is responsible for assisting residents, and their families, in locating and utilizing any available resources .for the provision of the vision and hearing services the resident needs. Employees will assist the resident with the use of any devices or adaptive equipment needed to maintain vision or hearing. Assistive devices to maintain vision include, but are not limited to, glasses, contact lenses, and magnifying lens or other devices that are used by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of an allegation of abuse were reported to Department of Public Health (DPH) no later than 24 hours for three out of 19 sampled residents (Resident 27,70 and 74).
This failure had the potential to delay the investigation by the State agency and had the potential to place Resident 27, 74 and 70 at risk for further occurrence of abuse.
Findings:
During a review of Resident 27's admission Record (Face Sheet), the Face Sheet indicated Resident 27 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including bipolar disorder (mental disorder that causes unusual shifts in person's mood, energy, activity levels and concentration which make it difficult to carry out day-to-day tasks. and human immunodeficiency virus ([HIV] virus that attacks the body's immune system).
During a review of Resident 27's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/10/2023, the MDS indicated Resident 27 had moderately impaired cognitive skills (when a person had trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required partial assistance (staff member does less than half the effort) with bed mobility, toileting hygiene and personal hygiene.
During a review of Resident 27's History and Physical (H&P) dated 8/18/2023 the H&P indicated Resident 27 had a fluctuating capacity to understand and make decisions.
During a review of Resident 74's Face Sheet, the Face Sheet indicated Resident 74 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes (high sugar level in the blood), osteoporosis( disease in which bones become brittle and fragile), schizophrenia (mental illness that affects how a person thinks, feels and behaves) and depression(mood disorder causes a persistent feeling of sadness and loss of interest).
During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had moderate cognitive impairment and required partial assistance with bed mobility, toileting, and personal hygiene.
During a concurrent observation and interview on 1/2/2024, at 3:57 p.m. with Resident 74, observed Resident 74 talking in a loud and angry voice. Resident 74 stated there were residents (unknown name) who were bullying other residents. Resident 74 stated this resident would send another resident to ask him for cigarette or coffee.
During an interview on 1/2/2024, at 4:31 p.m. with Activity Driver (AD), AD stated Resident 74 was talking to another resident during smoking time in the patio on 1/2/2024 around 3:30 p.m. AD stated he observed both residents were talking in a loud manner, but he did not do anything or report the incident to any staff member.AD stated he was busy because a lot of residents would like to smoke and did not report the incident because it was only a verbal exchange. AD stated if both residents had physical altercation or hurt each other, that would be an alleged abuse and should be reported to the Activity Assistant (AA)1.
During an interview on 1/3/2024, at 3:10 p.m. with AA 4, AA 4 stated Resident 74 who was sitting on his wheelchair was accusing Resident 27 of running the place and bullying other residents. AA 4 stated as the first resident approach the other resident he cut in into the conversation and told the residents to be civil with each other. AA 4 stated Resident 74 threw a cigarette butt to Resident 27. AA 4 stated the incident between Resident 74 and Resident 27 could be verbal abuse and could be an assault because Resident 74 threw the cigarette butt to Resident 27. AA 4 stated it was a verbal abuse because of the aggressive tones of their voices and exchange of nasty words. AA 4 stated he should have reported the incident to one of the nurses immediately because the incident could escalate and had the potential for Resident 74 and 27 to hurt each other.
During an interview on 1/5/2024, at 9: 30 a.m. with Resident 27, Resident 27 stated Resident 74 was jealous, accused him of bullying and threw a cigarette butt towards him. Resident 27 stated he was not afraid of Resident 74. Resident 27 stated Resident 74 told him he would kick his behind, but Resident 74 never came to talk to him after the incident in the patio.
During an interview on 1/3/2024, at 4:03 p.m. with RN Supervisor (RNS)1, RNS 1 stated for alleged resident to resident altercation, the facility would separate the residents, investigate, document a Situation, Background, Assessment and Recommendation ([SBAR] communication tool that can help healthcare team share information about the change in condition of a resident), notify and call the physician and family member. RNS 1 stated she was not notified by any staff member on what happened between Resident 27 and Resident 74. RNS 1 stated alleged resident to resident altercation should be reported as soon as possible to monitor the conditions of the residents and to ensure residents safety. RNS 1 stated allegation of abuse should be reported to DPH within 24 hours.
During an interview on 1/3/2024, at 4:30 p.m. with the Administrator (ADM), the ADM stated AA 4 had just told her about the alleged resident to resident altercation between Resident 27 and Resident 74. ADM stated alleged incident of abuse should be reported to her immediately for residents' safety. ADM stated everyone in the facility was a mandated reporter and alleged incident of abuse should be reported to DPH within 24 hours if there was no injury. ADM stated reporting of alleged abuse as soon as possible to initiate an investigation of the incident and prevent escalation of harm among residents.
2. During a review of Resident 70's admission Record (Face Sheet), the Face Sheet indicated Resident 70 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), epilepsy (sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), and neuropathy (nerve damage leads to pain, weakness, numbness or tingling in one or more parts of your body).
During a review of Resident 70's History and Physical (H&P), dated 6/9/23, indicated, Resident 70 had the capacity to understand and make decisions.
During a review of Resident 70's Minimum Data Set [(MDS), a standardized assessment and care screening tool), dated 10/5/23, indicated Resident 70 had impairment on both sides of the lower extremities.
During an interview on 1/2/24 at 11:22 a.m. with Resident 70 in the north hallway. Resident 70 stated for four months he had experienced Resident 9 (his roommate) calling him racial slurs. Resident 70 stated Resident 9 have called him a (f-----g Mexican) and continued to use derogatory (showing a critical or disrespectful attitude) words towards him. Resident 70 stated that he requested a room change in December (a month ago) from License Vocational Nurse (LVN - nurse name unknown). Resident 70 stated LVN 1 and Certified Nursing Assistant (CNA) 1 had witnessed Resident 9 calling him names (insult someone verbally). Resident 70 stated the verbal abuse made him feel stressed out and raised his blood pressure. Resident 70 stated he felt afraid in the facility.
During an interview on 1/3/24 9:46 a.m. with CNA 1, CNA 1 stated Resident 70 and Resident 9 do not get along. CNA 1 stated he witnessed verbal altercation between Resident 70 and Resident 9. CNA 1 stated Resident 9 was verbally aggressive, using derogatory language towards Resident 70 and called him names. CNA 1 stated calling Resident 70 racial slurs and named was considered verbal and mental abuse. CNA 1 stated Resident 70 could experience sadness, and depression due to verbal abuse from Resident 9. CNA 1 stated he reported the verbal abuse to LVN 1 but does not know what happened after he reported it.
During an interview on 1/4/24 at 11:19 a.m. with Administrator (ADM), the ADM stated, she was not aware of the allegation of verbal and abuse for Resident 70. ADM stated abuse should be reported immediately to her. ADM stated she was responsible for ensuring the safety and quality of care for the residents (in general) in the facility.
During a review of facility's policy and procedure (P&P) titled Abuse, Neglect and Exploitation revised 2020, the P&P indicated the facility will consider factors indicating possible abuse including but not limited to verbal abuse of a resident overheard and anyone in the facility can report suspected abuse. The P&P indicated alleged violations involving abuse are reported immediately but not later than 2 hours, or not later than 24 hours if the advents that cause the allegations do not involve abuse and do not result in serious bodily injury to the administrator, and to other official including State Survey Agency and Adult Protected Services.
During a review of Resident 70's admission Record (Face Sheet), the Face Sheet indicated Resident 70 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), epilepsy (sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), and neuropathy (nerve damage leads to pain, weakness, numbness or tingling in one or more parts of your body).
During a review of Resident 70's History and Physical (H&P), dated 6/9/23, indicated, Resident 70 had the capacity to understand and make decisions.
During a review of Resident 70's Minimum Data Set [(MDS), a standardized assessment and care screening tool), dated 10/5/23, indicated Resident 70 had impairment on both sides of the lower extremities.
During an interview on 1/2/24 at 11:22 a.m. with Resident 70 in the north hallway. Resident 70 stated for four months he had experienced Resident 9 (his roommate) calling him racial slurs. Resident 70 stated Resident 9 have called him a (f-----g Mexican) and continued to use derogatory (showing a critical or disrespectful attitude) words towards him. Resident 70 stated that he requested a room change in December (a month ago) from License Vocational Nurse (LVN - nurse name unknown). Resident 70 stated LVN 1 and Certified Nursing Assistant (CNA) 1 had witnessed Resident 9 calling him names (insult someone verbally). Resident 70 stated the verbal abuse made him feel stressed out and raised his blood pressure. Resident 70 stated he felt afraid in the facility.
During an interview on 1/3/24 9:46 a.m. with CNA 1, CNA 1 stated Resident 70 and Resident 9 do not get along. CNA 1 stated he witnessed verbal altercation between Resident 70 and Resident 9. CNA 1 stated Resident 9 was verbally aggressive, using derogatory language towards Resident 70 and called him names. CNA 1 stated calling Resident 70 racial slurs and named was considered verbal and mental abuse. CNA 1 stated Resident 70 could experience sadness, and depression due to verbal abuse from Resident 9. CNA 1 stated he reported the verbal abuse to LVN 1 but does not know what happened after he reported it.
During an interview on 1/4/24 at 11:19 a.m. with Administrator (ADM), the ADM stated, she was not aware of the allegation of verbal and abuse for Resident 70. ADM stated abuse should be reported immediately to her. ADM stated she was responsible for ensuring the safety and quality of care for the residents (in general) in the facility.
During a review of facility's policy and procedure (P&P) titled Abuse, Neglect and Exploitation revised 2020, the P&P indicated the facility will consider factors indicating possible abuse including but not limited to verbal abuse of a resident overheard and anyone in the facility can report suspected abuse. The P&P indicated alleged violations involving abuse are reported immediately but not later than 2 hours, or not later than 24 hours if the advents that cause the allegations do not involve abuse and do not result in serious bodily injury to the administrator, and to other official including State Survey Agency and Adult Protected Services.

Based on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices for 88of 88 residents according to the facility's policy and procedure and manufacture' s instructions by failing to:
1.Ensure stored foods were labeled with an open date.
2.Ensure monitoring and documentation for sanitization bucket log.
3.Ensure oasis multi-quat sanitizer strips (to sanitize hard, non-porous food contact surfaces such as tables, counters, utensils and food processing equipment) and sanitation range testing kit (ensures the sanitizer agents are of the correct pH, strength and temperature to ensure equipment is sanitized effectively) were available.
These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (caused by consuming contaminated foods or beverages illness with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever) and can lead to other serious medical complications and hospitalization.
Findings:
1. During a concurrent observation and interview on 1/2/24 at 8:30 a.m. with Dietary Supervisor (DS) in the kitchen, the DS confirmed that the teriyaki sauce inside refrigerator was not labeled with an open date. DS stated it is important to have an open date so the facility will know when to discard the food, because the food needs to be used in a certain time frame. DS stated serving food that is too old can cause food borne illness which could cause the residents (in general) to become sick.
During a concurrent observation and interview on 1/2/24 at 8:38 a.m. with DS in dry storage area, the thickener (thickeners are commonly used to thicken sauces, soups, and puddings without altering their taste and often used for individuals who have difficulty swallowing) inside of bin was not labeled with a date. The DS confirmed that the thickener was not labeled with a date. The DS stated it is important to have a date, to ensure when the thickener needs to be discarded because it might not work, and the residents could have food that is not thicken to the consistency needed and the residents could choke or might not be able to eat the food because the consistency is too thick.
During a concurrent observation and interview on 1/2/24 at 9:15 a.m. with the DS in the kitchen, sliced cheese in refrigerator #4 not labeled with date. DS confirmed that the sliced cheese was unlabeled. DS stated the cheese should be labeled with a date per the facility's policy and procedure (P&P), because if the cheese is old it could cause the residents (in general) to become sick.
2. During a concurrent observation and interview on 1/2/24 at 9:20 a.m. with the DS in the kitchen, the DS stated the staff are responsible for changing and documenting the sanitizing buckets every 2 hours. The DS confirmed that there were missing entries on the Record of Sanitizer Bucket Log. The missing entries were as follow:
1. for 7:00 am., 9:00 am., 11:00 am., on 12/1/2023 up to 12/17/2023
18. for 7:00 am., 9:00 am., 11:00 am., 1:00 pm., 3:00 pm., 5:00 pm., 7:00pm., on 12/18/ 2023-12/31/2023.
3. During a concurrent observation and interview on 1/2/24 at 9:00 am with the DS in the kitchen, the DS confirmed the facility did not have the multi-quat sanitizer strips and sanitation range testing kit were unavailable. DS stated it is important to have the multi-quat sanitizer and sanitation range testing kit in order to ensure the that the sanitizer is working effectively in order to sanitize the kitchen's surfaces and equipment. DS stated if the sanitizer cannot be checked the facility will not know if the sanitizer is effective or not. DS stated if the sanitizer is not effective the surfaces and equipment cannot be cleaned properly, which could cause the residents to get a food borne illness (with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever) to the residents.
During a review of the facility's Policy & Procedure (P&P) titled, Food Receiving and Storage dated 2023, the P&P indicated Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date) .All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).
During a review of the facility's Policy & Procedure (P&P) titled, Preventing Foodborne Illness-Food Handling dated 2023, the P&P indicated Food will be stored prepared, handled and served so that the risk of foodborne illness is minimized.
During a review of the facility's Policy & Procedure (P&P) titled, Sanitation dated 2023, the P&P indicated The food service area shall be maintained in a clean and sanitary manner.
A review of the Oasis Multi-Quat Sanitizer instructions, the instructions indicated registered sanitizer for pre-cleaned use on hard, non-porous food prep surfaces and ware is effective against foodborne organisms as listed on product label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow up necessary dental services for two of 19 sampled residents (Resident 15 and Resident 74).
This failure had the potential to put Resident 15 and Resident 74 at risk for development of tooth decay and weight loss.
Findings:
During a review of Resident 15's admission Order (Face Sheet), the admission Record indicated Resident 15's was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease ([COPD] a common lung disease causing restricted airflow and breathing problems]), hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time), and hyperlipidemia (elevated cholesterol level in the blood).
During a review of Resident 15's MDS dated [DATE] indicated Resident 15 had no cognitive impairment and requires partial assistance for oral hygiene, toileting, and dressing.
During a review of Resident 15's Physician Orders dated 08/7/23 indicated an order for dental consult and follow up treatment as indicated.
During a review of Resident 74's admission Record (Face Sheet), the Face Sheet indicated Resident 74 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes (high sugar level in the blood), osteoporosis( disease in which bones become brittle and fragile),schizophrenia (mental illness that affects how a person thinks, feels and behaves) and depression (mood disorder causes a persistent feeling of sadness and loss of interest).
During a review of Resident 74's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 10/25/23, the MDS indicated Resident 74 had moderate cognitive impairment (when a person had trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required partial assistance (staff member does less than half the effort) with bed mobility, toileting hygiene and personal hygiene.
During a review of Resident 74's Physician Orders dated 10/13/23 indicated an order for dental consult and follow up treatment as indicated.
During an observation on 1/2/24, at 10:48 a.m. Resident 74 had missing upper and lower teeth.
During an observation on 01/2/24 at 11:11 a.m., Resident 15 had missing upper and lower teeth.
During an interview on 1/3/24 at 4:30 p.m., Resident 15 stated he told the Director of Social Services (DSS) about the dental consult and did not arrange any appointment with dental consult. Resident 15 stated sometimes his gums would hurt because he used his gums to chew his food.
During an interview on 1/3/24 at 4:41 p.m., the SSD admitted that she did not arrange any dental consult for Resident 15.
During an interview on 1/4/24, at 12:37 p.m. with Resident 74, Resident 74 stated the facility never checked his teeth or gums or had seen a dentist since admission. Resident 74 stated sometimes his gums would hurt because he used his gums to chew his food.
During a concurrent interview and record review on 1/4/2024, at 10:42 a.m. DSS, DSS confirmed there was no dental evaluation performed on Resident 74 since his admission on [DATE]. DSS stated it was her responsibility to follow up dental evaluation and did not know why it was not done. DSS stated she probably had forgotten about Resident 74's dental evaluation. DSS stated Resident 74's missing teeth on his upper and lower mouth would make him difficult to chew his food and could possibly cause weight loss.
During an interview on 1/5/24, at 3:01 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated dentist was in the facility every two months and dental evaluation and follow up was important because residents could develop tooth decay which could lead to weight loss.
During a review of facility's policy and procedure (P&P) titled Dental Services revised 2023, the P&P indicated the facility will assist residents in obtaining routine and emergency dental care. The P&P indicated the Social Services Director maintains contact information for providers of dental services that are available to the residents. The P&P indicated the facility will notify the physician, consult dietician for assessment of diet change for residents or resident representatives who do not wish to be referred for dental services, and resident's plan of care will be revised to reflect preferences.

Based on observation, interview, and record review the facility failed to:
1.Removed and discard one expired insulin (medication used to regulate blood sugar levels) Novolog (fast-acting insulin) vial for Resident 10, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart South.)
2.Store two insulin Basaglar (long-acting insulin) Kwikpens (type of insulin injection devise) for Resident 10, two insulin Humulin R (short-acting insulin) vials for Resident 58 and 74 at room temperature, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart South.)
3.Store one lorazepam (a medication used to treat anxiety and restlessness) oral concentrate (a solution with increased strength) bottle in the refrigerator for Resident 232 in accordance with the manufacturer's requirements in one of two inspected medication carts (Medication Cart South.)
4.Remove and discard seventeen expired acetaminophen (medication used to treat pain or fever) suppositories (form of medication used for rectal administration) for facility use, in accordance with manufacturer's requirements in one of one inspected medication room (Medication Room.)
These failures had the potential for harm to Residents 10,58, 74 and 232 and other residents residing in the facility due to the potential loss of strength of the medications, toxic due to improper storage or labeling, and the potential for the residents to receive ineffective medication dosages.
Findings:
During an observation on 1/3/2024 at 12:12 p.m., in Medication Cart South, in the presence of Licensed Vocational Nurse (LVN) 3, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies:
1.Two unopened insulin Basaglar Kwikpens for Resident 10 was found stored at room temperature without a label indicating when storage at room temperature began.
During a review of the manufacturer's product labeling, indicated unopened Basaglar Kwikpens should be stored in the refrigerator between 36- and 46-degrees Fahrenheit (°F temperature scale) and used or discarded within 28 days of opening or once storage at room temperature began.
2.One expired insulin Novolog vial for Resident 10 was found stored at room temperature with a label indicating that storage at room temperature began on 11/3/2023, and an additional label indicating to discard 28 days after opening.
During a review of the manufacturer's product labeling, opened Novolog vial should be stored at room temperature below 86 °F and used or discarded within 28 days of opening or once storage at room temperature began.
3.One open insulin Humulin R vial for Resident 58 was found stored at room temperature without a label indicating when storage at room temperature began, and an additional label indicating to discard 31 days after opening.
During a review of the manufacturer's product labeling, opened Humulin R vial should be stored at room temperature below 86 °F and used or discarded within 31 days of opening or once storage at room temperature began.
4.One open insulin Humulin R vial for Resident 74 was found stored at room temperature without a label indicating when storage at room temperature began, and an additional label indicating expires 31 days after opening.
During a review of the manufacturer's product labeling, opened Humulin R vial should be stored at room temperature below 86 °F and used or discarded within 31 days of opening or once storage at room temperature began.
5.One open lorazepam oral concentrate bottle for Resident 232 was found stored at room temperature and marked with blank ink indicating that storage at room temperature began on 12/27/2023. Additional blue label affixed to the front of the package indicated to refrigerate, and a separate pink label affixed to the side of the package indicated to keep medicine in refrigerator.
During a review of the manufacturer's product storage and labeling, opened lorazepam oral concentrate bottles can be stored in a refrigerator between 36- and 46 °F for up to 90 days.
During a concurrent interview with LVN 3, LVN 3 stated that the Basaglar Kwikpens for Resident 10 stored in the medication cart had no label indicating when it was opened, the Novolog vial for Resident 10 expired on 12/1/23, the Humulin R vials for Resident 58 and 74 stored in the medication cart had no label indicating when it was opened, and the lorazepam bottle for Resident 232 was stored at room temperature in the medication cart. LVN 3 stated Resident 10 received several doses of expired Novolog from 12/2/2023 to 1/3/2024. LVN 3 stated giving expired insulin to residents will cause harm by not controlling the blood sugar levels. LVN 3 stated the above insulins are considered ineffective and when used can cause very high or low blood sugar levels and potentially lead to resident's death.
During an interview on 1/5/2024 at 9:58 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated unopened insulin pens should be stored in the refrigerator, and opened pens and vials should be labeled with a date open to know when they expire and need to be discarded. RNS 1 stated she was unaware when the Basaglar Kwikpen and Humulin R vials expired since they were not labeled with a date when they came to use at room temperature. RNS 1 stated not knowing the expiration date can potentially lead to administration of insulin to residents beyond the expiration date. RNS 1 stated Resident 10 received expired Novolog from 12/2/2023 to 1/3/2024 from several licensed nurses who failed to remove and replace the expired insulin vial. RNS 1 stated giving expired insulin was not effective and can harm the resident by causing high or low blood sugar levels leading to unresponsiveness, coma (a state of deep unconsciousness caused by severe injury or illness) and hospitalization.
During an interview on 1/5/2024 at 9:58 a.m. with RNS 1, RNS 1 stated lorazepam's life span (length of use of the medication) was based on the storage of the medication. RNS 1 stated lorazepam oral concentrate needs to be refrigerated, and if not refrigerated the potency (amount of drug required to produce an effect) and integrity (safety and effectiveness) of the medication was affected and decreased. RNS 1 stated administering ineffective lorazepam oral concentrate to Resident 232 was not treating the resident's anxiety and can cause the resident to experience continued behaviors. RNS 1 stated there was inconsistency in the proper labeling and storage of medications in the facility.
During an observation on 1/3/2024 at 1:46 p.m., in Medication Room, in the presence of LVN 6, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements and to facility policies:
1.Eleven acetaminophen suppositories for facility stock in the refrigerator with an expiration date of 3/2023
2.Six acetaminophen suppositories for facility stock in the refrigerator with an expiration date of 6/2023
During an interview on 1/3/2024 at 2:09 p.m., with LVN 6, LVN 6 stated it was concerning to have expired acetaminophen suppositories in the refrigerator that licensed nurses can grab and use when in a hurry and overlook the expiration date. LVN 6 stated the facility should be free of expired medications to prevent accidental use. LVN 6 stated using expired acetaminophen was not affective in lowering the resident's temperature or relieving the pain.
During a review of the facility's policy and procedures (P&P), titled Medication Administration, dated 2022, the P&P indicated that Medications are administered by licensed nurses, .in accordance with professional standards of practice .Identify expiration date. If expired, notify nurse manager.
During a review of the facility's P&P, titled Multi-Dose Vials, [undated], the P&P indicated: The medication label will also include the date when opened. Discard the vial accordingly if the vial is out of date (past the beyond use date/manufacturer's expiration date) or is visibly contaminated. The charge nurse will perform random checks of opened multi-dose vials for appropriate dating.
During a review of the facility's P&P, titled Medication Storage, [undated], the P&P indicated that It is the policy of the facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregations, and security. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drug Policy.
During a review of the facility's P&P, titled Destruction of Unused/Expired Drugs, dated 2023, the P&P indicated All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 31) did not receive Ativan (a psychotropic medication [drug that affects brain activities associated with mental processes and behavior] used for anxiety, and categorized as a controlled medication {CM-medications which have a potential for abuse and may also lead to physical or psychological dependence}) without a physician order to renew after 14 days of initial order on 11/16/23 and medication bubble pack (a medication packaging system that contains individual doses of medication per bubble) of Ativan was removed from the medication cart (Medication Cart South.)
These failures resulted in Resident 31 to received Ativan beyond the date prescribed by Resident 31's physician and had the potential for increased risk for Residents 31 to experienced serious adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) of psychotropic medication therapy leading to an overall negative impact on their physical, mental, and psychosocial well-being.
Findings:
During a review of Resident 's 31 admission Record (Face Sheet) the Face Sheet indicated Resident 31 was admitted to the facility on [DATE] and readmitted om 11/16/2023 with diagnoses including schizophrenia (a mental disorder involving thought, emotion, and behavior) and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration, making it difficult to carry out day-to-day tasks), hypertensive heart disease (long-term condition that develops over many years in people who have high blood pressure) and heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs).
During a review of Resident 31's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated12/4/2023, the MDS indicated Resident 31 had severe cognitive (ability to learn, remember, understand, and make decision) impairment.
During a review of Resident 31's medication bubble pack for Ativan one milligram (mg-unit of measurement) indicated Resident 31 was prescribed Ativan one mg tablet to be given orally every 4 hours as needed for agitation for 14 days, starting 11/17/2023.
During a review of Resident 31's Medication Administration Record (MAR) for 1/2024, the MAR indicated Resident 31 was not prescribed Ativan 1mg.
During a concurrent observation and record review on 1/3/2024 at 12:12 p.m. with Licensed Vocational Nurse (LVN) 3, in Medication Cart South, reviewed the count between the Controlled Drug Record (inventory and accountability record for CM) form and the amount of medication remaining in the medication bubble pack for Resident 31. Observed one dose of Ativan (a CM used for anxiety and agitation) one mg tablet was missing from the medication bubble pack compared to the count indicated on the Controlled Drug Record form for Resident 31. The Controlled Drug Record form indicated the medication bubble pack should have contained a total of 20 Ativan 1 mg tablets, after the last administration of Ativan 1 mg documented/signed-off on 12/1/2023 at 5 p.m., however the medication bubble pack contained 19 Ativan 1 mg tablets and contained no other documentation of subsequent administrations.
During an interview on 1/3/2024 at 12:12 p.m. with LVN 3, LVN 3 stated she administered Ativan 1 mg tablet on 1/3/2024 to Resident 31 without checking the MAR and forgot to sign off the Controlled Drug Record form and the MAR after administration. LVN 3 stated the last Ativan order prescribed by Resident 31's physician was on 11/16/2023 with a duration of 14 days. LVN 3 stated the Ativan bubble pack for Resident 31 remained in the Medication Cart South after the 14-day duration of the medication. LVN 3 stated the Ativan bubble pack should have been removed on 12/1/2023 from the Medication Cart South after the 14 days of initial order. LVN 3 stated the 1/24 MAR indicated Resident 31 did not have an active order for Ativan. LVN 3 stated she failed to follow facility's policy of checking the MAR prior to medication administration, and not having the Ativan bubble pack removed from the Medication Cart South resulted in administering a dose of Ativan to Resident 31 beyond the prescribed duration of Ativan. LVN 3 stated it was important to have accountability of controlled medications to prevent accidental exposure and overdose (receiving more than the prescribed dose), which can cause harm to Residents 31 leading to respiratory (related to the lungs) depression (stoppage of breathing) and death.
During an interview on 1/3/2024 at 2:09 p.m., with LVN 6, LVN 6 stated it was important to have accountability of CM to ensure there was no abuse, diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use), and accidental exposure or overdose to residents.
During an interview on 1/5/2024 at 9:58 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated the 1/24 MAR for Resident 31 did not contain documentation that Resident 31 was prescribed Ativan. RNS 1 stated when a medication order was discontinued, the medication bubble pack should be removed from the medication cart to avoid accidental use. RNS 1 stated the Ativan medication bubble pack for Resident 31 should have been removed from Medication Cart South after the 14-day duration of the 11/16/2023 order. RNS 1 stated that LVN 3 failed to follow facility's policy of checking CM orders in the MAR prior to administration which resulted in LVN 3 accidentally administered Ativan to Resident 31, potentially causing harm to Resident 31 by overdosing and possibly leading to respiratory depression. RNS 1 stated administering medications without an order can further harm Resident 31 due to potential medication interactions (a negative reaction between two or more medications).
During a review of the facility's policy and procedures (P&P), titled Medication Administration, dated 2022, the P&P indicated that Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician .Review MAR to identify medication to be administered. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.
During a review of the facility's P&P, titled Destruction of Unused/Expired Drugs, dated 2023, the P&P indicated that All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations.
During a review of the facility's P&P, titled Use of Psychotropic Medication, dated 2023, the P&P indicated:
A psychotropic drug was any that affects brain activities associated with mental processed and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressant, anti-anxiety, and hypnotics (sleep inducing drug). Pro Re Nata ([PRN] - as needed) orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (that is14 days).
If the attending physician pr prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond the 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure it was free of not greater than five (5) percent (%) or below medication error rate, as evidenced by two medication errors out of 29 opportunities for error, which yield a 6.9 % medication error rate.
The medication errors were as follows:
1.Resident 38 received a dose of artificial tears (eye drops used to moisturize dry eyes) different from the one ordered by Resident 38's physician.
2.Resident 182 did not receive vitamin D3 (medication used as a dietary supplement to promote bone health) as ordered by Resident 182's physician.
These failures had the potential to result in Resident 38 and 182 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 38's and 182's health and well-being to be negatively impacted.
Findings:
During a review of Resident 38's admission Record (Face Sheet) indicated Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (a mental health condition that causes a constant depressed mood and a loss of interest in activities that once brought joy).
During a review of Resident 38's Order Summary Report, for 1/2024, the Order Summary Report indicated Resident 38 was prescribed artificial tears two drops to both eyes three times a day for dry eyes, starting 8/31/2023.
During a review of Resident 38's Medication Administration Record (MAR) for 1/2024, the MAR indicated Resident 38 was prescribed artificial tears two drops to both eyes three times a day to be administered at 9 a.m., 1 p.m. and 5 p.m.
During a review of Resident 182's Face Sheet, indicated Resident 182 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (long-term condition that develops over many years in people who have high blood pressure) and paranoid schizophrenia (a mental disorder involving thought, emotion, and behavior).
During a review of Resident 182's Order Summary Report for 1/24 indicated Resident 182 was prescribed vitamin D3 5000 international unit (IU- unit of measurement) daily, starting 12/13/2023.
During a review of Resident 182's MAR for 1/2024, the MAR indicated Resident 182 was prescribed vitamin D3 5000 IU to be administered orally at 9 a.m. daily. The MAR indicated no documentation for the administration of Vitamin D3 5000 IU on 1/2/2024 at 9 a.m.
During an observation on 1/3/24 at 9:23 a.m., in medication cart North, Licensed Vocational Nurse (LVN) 2 was observed administering artificial tears 1 drop to both eyes to Resident 38.
During an interview on 1/3/2024 at 11:43 a.m., with LVN 2, LVN 2 stated that she administered one drop of artificial tears to each eye of Resident 38 during the morning medication administration on 1/3/24 at 9:23 a.m LVN 2 stated that she failed to administer two drops of artificial tears to both eyes to Resident 38 as ordered by the physician. LVN 2 stated giving less than the ordered dose of artificial tears may not relieve Resident 38's dry eyes and the resident will need additional doses to keep the eyes hydrated.
During an observation on 1/3/2024 at 10:27 a.m., in medication cart South, LVN 3 was observed not administering vitamin D3 5000 IU to Resident 182. Resident 182 asked LVN 3 for the vitamin D3 5000 IU tablet and LVN 3 stated Resident 182 did not have orders to administer vitamin D3 5000 IU that morning.
During an interview on 1/3/2024 at 11:18 a.m., with LVN 3, LVN 3 stated that she overlooked to prepare and failed to administer the vitamin D3 5000 IU to Resident 182 during the morning medication administration on 1/3/24 at 10:27 a.m. LVN 3 stated vitamin D3 was a supplement used to maintain strong bones, and not administering Vitamin D3 to Resident 182 can affect the maintenance of strong bones.
During an interview on 1/5/2024 at 9:58 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated LVN 2 failed to administer 2 drops of artificial tears to Resident 38 as ordered by the physician. RNS 1 stated that LVN 2 administered the second drop after LVN 2 was made aware that the order indicated to administer 2 drops to both eyes. RNS 1 stated Resident 38 has very dry eyes and not administering artificial tears as ordered by the physician does not fully help hydrate Resident 38 eyes. RNS 1 stated LVN 3 should check medication orders prior to administration to prevent medication omissions (not receiving a medication). RNS 1 stated vitamin D3 was for bone supplement and osteoporosis (a condition where bones are fragile) and omitting vitamin D3 does not supplement for bone health for Resident 182 and can cause possible bone fractures (breaking).
Review of the facility's policy and procedures (P&P), titled Medication Administration, dated 2022, the P&P indicated that Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician .Review MAR to identify medication to be administered. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.
Review of the facility's P&P, titled Preventing Medication Errors, dated 2023, the P&P indicated that The facility must ensure that it is free of medication error rates of five percent or greater as well as any significant medication error.
Review MAR to identify medication to be administered. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Medication will be administered within 60 minutes prior or after scheduled times unless otherwise ordered by physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure:
1.Twenty-five Licensed Vocational Nurses (LVNs) and one Registered Nurse Supervisor (RNS) did not administer expired insulin (a medication used to regular blood sugar levels) to one of seven sampled residents observed (Resident 10.)
2.Five LVNs and one RNS did not administer lorazepam oral concentrate (a medication used to treat anxiety and restlessness) stored at room temperature to one of seven sampled residents observed (Resident 232.)
These failures resulted in Residents 10 received a total of one hundred-one doses (units) of expired insulin and Resident 232 received a total of twenty-one doses of inappropriately stored Lorazepam. These failures had the potential to cause Residents 10 to experience serious health complications due to uncontrolled blood sugar levels and Resident 232 unrelieved anxiety and continued behaviors, possibly resulting in hospitalization or death.
Findings:
During an observation on 1/3/2024 at 12:12 p.m., in Medication Cart South, with LVN 3, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies:
1.One expired insulin Novolog vial for Resident 10 was found stored at room temperature with a label indicating that storage at room temperature began on 11/3/2023, and an additional label indicating to discard 28 days after opening.
During a review of the manufacturer's product labeling, opened Novolog vial should be stored at room temperature below 86 °F and used or discarded within 28 days of opening or once storage at room temperature began.
2.One open lorazepam oral concentrate bottle for Resident 232 was found stored at room temperature and marked with blank ink indicating that storage at room temperature began on 12/27/2023. Additional blue label affixed to the front of the package indicated to refrigerate, and a separate pink label affixed to the side of the package indicated to keep medicine in refrigerator.
During a review of the manufacturer's product storage and labeling, opened lorazepam oral concentrate bottles can be stored in a refrigerator between 36- and 46 °F for up to 90 days.
During a review of Resident 10's admission Record (Face Sheet) indicated Resident 10 was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including type 2 diabetes mellitus (a disease characterized by an impairment of the body's ability to control blood sugar levels.)
During a review of Resident 232's Face Sheet indicated Resident 232 was admitted to the facility on [DATE] with diagnoses including Parkinsonism (a disease characterized by slowed, stiff bodily movements from deterioration of your brain and can potentially experience anxiety).
During an interview on 1/3/2024 at 12:12 p.m. with LVN 3, LVN 3 stated the insulin Novolog vial for Resident 10 expired on 12/1/2023 and the Lorazepam bottle for Resident 232 was stored at room temperature in the medication cart. LVN 3 stated Resident 10 received several doses of expired Novolog from 12/2/23 to 1/3/24, and Resident 232 received doses from inappropriately stored Lorazepam in 12/23 and 1/24. LVN 3 stated giving expired insulin to residents will cause harm by not controlling the blood sugar levels. LVN 3 stated the above insulin was considered ineffective and when used can cause very high or low blood sugar levels and potentially lead to resident's death.
During an interview on 1/5/2024 at 9:58 a.m., with RNS 1, RNS 1 stated Resident 10 received expired Novolog from 12/2/23 to 1/3/24 from several licensed nurses who failed to remove and replace the expired insulin vial. RNS stated Resident 232 received lorazepam from several nurses in 12/23 and 1/24 who failed to store the lorazepam oral concentrate in the refrigerator. RNS 1 stated giving expired insulin was not effective and can harm the resident by causing high or low blood sugar levels leading to unresponsiveness, coma (a state of deep unconsciousness caused by severe injury or illness) and hospitalization.
During the same interview, with RNS 1 stated that Lorazepam's life span (length of use of the medication) was based on medication storage. RNS 1 stated Lorazepam oral concentrate needs to be refrigerated, and if not refrigerated the potency (amount of drug required to produce an effect) and integrity (safety and effectiveness) of the medication was affected and decreased effectiveness. RNS 1 stated administering ineffective lorazepam oral concentrate to Resident 232 was not treating the Resident 232's anxiety and can cause the resident to experience continued behaviors.
During a review of Resident 10's Physician Orders for 1/ 2024, the Physician Order indicated Resident 10's physician prescribed insulin Novolog to be administered subcutaneously (under the skin) AC (before) meals and HS (at bedtime) per sliding scale (dosing plan whereby the amount of insulin administered depends on the resident's blood sugar level) starting 11/30/2023.
During a review of Resident 10's Medication Administration Record (MAR) dated 12/2023, the MAR indicated Resident 10's insulin Novolog was to be administered subcutaneously AC meals and HS per sliding scale, at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m. The MAR indicated Resident 10 received 94 doses of expired insulin Novolog from the following nurses on the following dates/times:
LVN 1 - 1 dose (at 9 p.m. on 12/12/23)
LVN 3 - 38 doses (at 11:30 a.m., 4:30 p.m. and 9 p.m. on 12/2/23, 12/3/23, 12/6/23, 12/13/23, 12/14/23, 12/16/23, 12/17/23, 12/20/23, 12/21/23; and at 11:30 a.m. and 4:30 p.m. on 12/7/23, 12/11/23, 12/18/23, 12/28/23, and at 11:30 a.m. on 12/4/23, 12/26/23, 12/27/23)
LVN 6 - 1 dose (at 11:30 a.m. on 12/25/23)
LVN 9 - 1 dose (at 6:30 a.m. on 12/2/23)
LVN 10 - 3 doses (at 6:30 a.m. on 12/14/23, and at 9 p.m. on 12/22/23, 12/25/23)
LVN 11 - 1 dose (at 6:30 a.m. on 12/15/23)
LVN 12 - 5 doses (at 6:30 a.m. on 12/3/23, 12/4/23, 12/5/23, 12/6/23, 12/7/23)
LVN 13 - 7 doses (at 11:30 a.m. on 12/5/23, 12/12/23, 12/15/23, 12/19/23, 12/22/23, and 4:30 p.m. on 12/12/23, 12/15/23)
LVN 14 - 3 doses (at 6:30 a.m. on 12/8/23, 12/9/23, 12/22/23)
LVN 15 - 7 doses (at 6:30 a.m. on 12/10/23, 12/14/23, and at 11:30 a.m. on 12/8/23, and at 4:30 p.m. on 12/5/23, 12/8/23, and at 9 p.m. on 12/5/23, 12/10/23)
LVN 16 - 2 doses (at 9 p.m. on 12/8/23, 12/15/23)
LVN 17 - 6 doses (at 11:30 a.m. and 4:30 p.m. on 12/9/23, 12/23/23, and at 9 p.m. on 12/18/23, 12/23/23)
LVN 18 - 1 dose (at 6:30 a.m. on 12/9/23)
LVN 19 - 1 dose (at 6:30 a.m. on 12/16/23)
LVN 20 - 1 dose (at 6:30 a.m. on 12/17/23)
LVN 21 - 1 dose (at 6:30 a.m. on 12/18/23)
LVN 22 - 1 dose (at 6:30 a.m. on 12/19/23)
LVN 23 - 1 dose (at 6:30 a.m. on 12/20/23)
LVN 24 - 1 dose (at 9 a.m. on 12/22/23)
LVN 25 - 1 dose (at 6:30 a.m. on 12/24/23)
LVN 26 - 2 doses (at 11:30 a.m. and 4:30 p.m. on 12/29/23)
LVN 27 - 1 dose (at 9 p.m. on 12/29/23)
LVN 28 - 1 dose (at 6:30 a.m. on 12/30/23)
RNS 3 - 7 doses (at 9 p.m. on 12/4/23, at 11:30 a.m. and 4:30 p.m. on 12/10/23, 12/24/23, 12/31/23).
During a review of Resident 10's 1/2024 MAR, the MAR indicated Resident 10's insulin Novolog was to be administered subcutaneously AC meals and HS per sliding scale, at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m. The MAR indicated Resident 10 received 7 doses of expired insulin Novolog from the following nurses on the following dates/times:
LVN 3 - 3 dose (at 11:30 a.m. on 1/2/24, 1/3/24, and 4:30 p.m. on 1/2/24)
LVN 10 - 1 dose (at 4:30 p.m. on 1/1/24)
LVN 29 - 1 dose (at 6:30 a.m. on 1/1/24)
LVN 30 - 1 dose (at 6:30 a.m. on 1/2/24)
RNS 3 - 1 dose (at 11:30 a.m. on 1/1/24)
During a review of Resident 232's MAR for 12/2023, the MAR indicated Resident 232's physician prescribed lorazepam 1 milligram ([mg] - a unit of measure of mass) to be administered sublingually (below the tongue) three times a day at 9 a.m., 1 p.m. and 5 p.m., starting 11/3/23. The 12/2023 MAR indicated Resident 232 received 15 doses of lorazepam oral concentrate stored at room temperature from the following nurses on the following dates/times:
LVN 1 - 2 doses (9 a.m. and 1 p.m. on 12/27/23)
LVN 3 - 4 doses (5 p.m. on 12/27/23 and 12/28/23, 9 a.m. and 1 p.m. on 12/30/23)
LVN 7- 2 doses (9 a.m. and 1 p.m. on 12/28/23)
LVN 8 - 3 doses (9 a.m., 1 p.m. and 5 p.m. on 12/29/23)
LVN 10 - 2 doses (5 p.m. on 12/30/23 and 12/31/23)
RNS 3 - 2 doses (9 a.m. and 1 p.m. on 12/31/23)
During a review of Resident 232's MAR, dated 1/24, the MAR indicated Resident 232 received 6 doses of lorazepam oral concentrate stored at room temperature from the following nurses on the following dates/times:
RNS 3 - 2 doses (9 a.m. and 1 p.m. on 1/1/24)
LVN 3 - 2 doses (9 a.m. and 1 p.m. on 1/2/24)
LVN 10 - 2 doses (5 p.m. on 1/1/24 and 1/2/24)
During a review of the facility's policy and procedures (P&P), titled Medication Administration, dated 2022, the P&P indicated that Medications are administered by licensed nurses, .in accordance with professional standards of practice .Identify expiration date. If expired, notify nurse manager.
During a review of the facility's P&P, titled Multi-Dose Vials, [undated], the P&P indicated: The medication label will also include the date when opened. Discard the vial accordingly if the vial is out of date (past the beyond use date/manufacturer's expiration date) or is visibly contaminated. The charge nurse will perform random checks of opened multi-dose vials for appropriate dating.
During a review of the facility's P&P, titled Medication Storage, [undated], the P&P indicated that It is the policy of the facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregations, and security. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drug Policy.
During a review of the facility's P&P, titled Destruction of Unused/Expired Drugs, dated 2023, the P&P indicated that All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer the pneumococcal vaccine (vaccine that helps prevent pneumonia (an infection that inflames the air sacs in one or both lungs) to one of 19 sampled residents.
This failure had the potential to result in Resident 19 acquiring and transmitting pneumonia to other residents, staff, and visitors.
Findings:
During a review of Resident 19's admission Record (Face Sheet), the Face Sheet indicated Resident 19 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses to but not limited to chronic obstructive pulmonary disease (COPD-a chronic obstructive inflammatory lung disease that causes obstructed airflow from the lungs), hypertensive heart (a heart condition caused by high blood pressure over a long time), and chronic kidney disease (a gradual loss of kidney function).
During a review of Resident 19's Physician admission Orders, dated 12/2/2023, the Physician admission Orders Indicated, resident 19 had an order for one dose of the pneumococcal vaccine.
During a review of Resident 19's Minimum Data Set (MDS- standardized assessment and screening tool) dated 12/25/2023 indicated, Resident 19 required partial or moderate assistance from staff for eating, oral hygiene, upper body dressing, personal hygiene, positioning, sitting, standing, walking, toilet transfer, and shower transfer. The MDS indicated, Resident 19 required substantial or maximal assistance for lower body dressing and putting on and taking off footwear. The MDS indicated Resident 19 was dependent on staff for toilet hygiene, and showering.
During a concurrent interview and record review on 1/3/2024 at 12:02 pm with Infection Preventionist Nurse (IPN), Resident 19's Immunization Record was reviewed. The Immunization Record indicated, on 10/15/2018 Resident 19 received the pneumococcal vaccine at another facility. IPN stated Resident 19 is due to receive the pneumococcal vaccine and was not given.
During an interview on 1/5/2024 at 12:25 pm with IPN, IPN stated the pneumococcal vaccine is given every five years and if the pneumococcal vaccine is due, it will be administered. The IPN stated the pneumococcal vaccine was not offered to Resident 19. The IPN stated resident are vulnerable to getting pneumonia if not vaccinated and can lead to health complications and death.
During a review of the facility's policy and procedure (P&P) titled, Pneumococcal Vaccine (Series), date revised 2019, the P&P indicated, It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one of 19 sampled residents (Resident 68) had a functioning call light.
This failure resulted in Resident 68 not being able to use his call light to get help or call for assistance from the nursing staff.
Findings:
During a review of Resident 68's admission Record (Face Sheet), the Face Sheet indicated, Resident 68 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of but not limited to hypertension (high blood pressure), hemiplegia (weakness on one entire side of the body), encephalopathy (damage or disease that affects the brain), and acute kidney failure (the kidneys become unable to filter waste products from the blood).
During a review of Resident 68's History and Physical (H&P), dated 2/15/2023, the H&P indicated, Resident 68 had fluctuating (rising and falling irregularly in number or amount) capacity (the maximum amount that something can contain) to understand and make decisions.
During a review of Resident 68's Minimum Data Set (MDS- standardized assessment and care screening tool) dated 11/23/2023 indicated, Resident 68 did not have corrective lenses. The MDS indicated Resident 68 required setup and clean-up assistance with eating. The MDS indicated Resident 68 required partial and moderate assistance with oral hygiene, upper body dressing, putting on and taking off footwear, personal hygiene, positioning, sitting, lying, standing. The MDS indicated, resident 68 required substantial and maximal assistance with toileting hygiene, showering, lower body dressing, sitting, standing, transferring to a chair, bed, toilet, and shower. The MDS indicated Resident 68 was in the Restorative Nursing Program and received passive range of motion for five days and active range of motion for five days.
During a concurrent observation and interview on 1/2/2024 at 10:35 am with Resident 68 in Resident 68's room, Resident 68's call light wire was cut in half and the call light was missing, Resident 68 stated his call light had been broken for a month.
During an observation on 1/3/2024 at 9:17 am in Resident 68's room, the call light wire was cut in half with the call light missing.
During an interview on 1/3/2024 at 10:18 am with Certified Nursing assistant (CNA 9), CNA 9 stated every staff can check call lights and report to maintenance or the supervisor, call lights should be checked daily on all shift to make sure they are working.
During a concurrent observation and interview on 1/3/2024 at 10:24 am with Certified Nursing Assistant (CNA 10) in Resident 68's room, Resident 68's call light was behind the bed with the wire cut in half and the call light was missing. CNA 10 stated Resident 68 can use the call light, everyone is responsible for making sure call lights are working. CNA 10 stated she checked Resident 68's call light at 9 am and stated the call light was working yesterday. CNA 10 stated when she saw the call light wire cut in half and the call light missing and stated she did not check Resident 68's call light yesterday or today.
During an interview on 1/3/2024 at 10:31 am with Licensed Vocational Nurse (LVN 4), LVN 4 stated everyone must check the call light to see if it is functioning well, nursing staff are supposed to check the call lights every day. LVN 4 stated Resident 68 is a high risk for fall and has weakness. LVN 4 stated Resident 68 should not have to come and get the nurse if he needs assistance.
During an interview on 1/3/2024 at 4:05 pm with Registered Nurse Supervisor (RNS 1), RNS 1 stated the nurses assigned to Resident 68 are supposed to check the call light every day and every shift and tell the charge nurse if the call light is not working. RNS 1 stated, maintenance also checks to make sure the call lights are working. RNS 1 stated if Resident 68 cannot use the call light or if the call light is not properly working then Resident 68 cannot tell the staff what he needs. RNS 1 stated she is not aware of issues with Resident 68's call light. RNS 1 stated, none of the staff taking care of Resident 68 reported any issues regarding the call light. RNS 1 stated she will follow up with nurses taking care of Resident 68 to find out what happen to Resident 68's call light.
During a review of the facility's policy and procedure titled, Answering the Call Light, undated, the P&P indicated, Report all defective call lights to the nurse supervisor promptly.
During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, date revised 2023, the P&P indicated, The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe operable manner at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to:
1.Account for four doses of controlled medication ([CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for four out of four sampled residents (Resident 31, 44, 58 and 60) in one of two inspected medication carts (Medication Cart South).
2.Document four doses of CM in the January 2024 Medication Administration Record ([MAR] - a record of mediations administered to residents) for Resident 31, 44, 58 and 60 in one of two inspected medication carts (Medication Cart South.)
These failures increased the opportunity for CM diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and increased the risk that Residents 31, 44, 58 and 60 could have delayed medication treatment and continuity of care due to lack of availability of the CM, and accidental exposure to harmful medications, possibly leading to physical and psychosocial harm.
Findings:
During a review of Resident 's 31 admission Record (Face Sheet) the Face Sheet indicated Resident 31 was admitted to the facility on [DATE] and readmitted om 11/16/2023 with diagnoses including schizophrenia (a mental disorder involving thought, emotion, and behavior) and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration, making it difficult to carry out day-to-day tasks.)
hypertensive heart disease (long-term condition that develops over many years in people who have high blood pressure) and heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs).
During a review of Resident 31's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated12/4/2023, the MDS indicated Resident 31 had severe cognitive (ability to learn, remember, understand, and make decision) impairment.
During a review of Resident 44's admission Record (Face Sheet) the Face Sheet indicated Resident 44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertensive heart disease and primary generalized osteoarthritis (a joint disease, in which the tissues in the joint break down over time, causing joint pain and stiffness.)
During a review of Resident 44's MDS dated [DATE], the MDS indicated Resident 44 had moderate cognitive impairment.
During a review of Resident 58's admission Record (Face Sheet) the Face Sheet indicated Resident 58 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertensive heart disease, type II diabetes mellitus without complications (a condition in which the body fails to metabolize (process) glucose (sugar) correctly) and idiopathic neuropathy (weakness, numbness, and pain caused from nerve damage.)
During a review of Resident 58's MDS dated [DATE], the MDS indicated Resident 58 had moderate cognitive impairment.
During a review of Resident 60's admission Record (Face Sheet) the Face Sheet indicated Resident 60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a mental disorder involving thought, emotion, and behavior.), epilepsy (a sudden, uncontrolled burst of electrical activity in the brain) and generalized osteoarthritis.
During a review of Resident 60's MDS dated [DATE], the MDS indicated Resident 60 had short term and long-term memory problem.
During a concurrent observation and record review on 1/3/2024 at 12:12 p.m. with Licensed Vocational Nurse (LVN) 3, in Medication Cart South, reviewed the count between the Controlled Drug Record (inventory and accountability record for CM) form and the amount of medication remaining in the medication bubble pack (a medication packaging system that contains individual doses of medication per bubble) for the following residents:
1.One dose of Ativan (a CM used for anxiety and agitation) 1 milligram ([mg]-unit of measure of mass) tablet was missing from the medication bubble pack compared to the count indicated on the Controlled Drug Record form for Resident 31. The Controlled Drug Record form indicated the medication bubble pack should have contained a total of 20 Ativan 1 mg tablets, after the last administration of Ativan 1 mg documented/signed-off on 12/1/2023 at 5 p.m., however the medication bubble pack contained 19 Ativan 1 mg tablets and contained no other documentation of subsequent administrations.
2.One dose of Norco (a combination CM used for pain) 5-325 mg tablet was missing from the medication bubble pack compared to the count indicated on the Controlled Drug Record form for Resident 44. The Controlled Drug Record form indicated the medication bubble pack should have contained a total of 11 Norco 5-325 mg tablets, after the last administration of Norco 5-325 mg documented/signed-off on 1/2/2024 at 6 p.m., however the medication bubble pack contained 10 Norco 5-325 mg tablets and contained no other documentation of subsequent administrations.
3.One dose of Tramadol (a CM used for pain) 50 mg tablet was missing from the medication bubble pack compared to the count indicated on the Controlled Drug Record form for Resident 58. The Controlled Drug Record form indicated the medication bubble pack should have contained a total of 13 Tramadol 50 mg tablets, after the last administration of Tramadol 50 mg documented/signed-off on 1/2/2024 at 9 p.m., however the medication bubble pack contained 12 Tramadol 50 mg tablets and contained no other documentation of subsequent administrations.
4.One dose of Ativan 1 mg tablet was missing from the medication bubble pack compared to the count indicated on the Controlled Drug Record form for Resident 60. The Controlled Drug Record form indicated the medication bubble pack should have contained a total of 21 Ativan 1 mg tablets, after the last administration of Ativan 1 mg documented/signed-off on 1/2/2024 at 5 PM, however the medication bubble pack contained 20 Ativan 1 mg tablets and contained no other documentation of subsequent administrations.
During an interview on 1/3/2024 at 12:12 p.m. with LVN 3, LVN 3 stated Ativan 1 mg tablet was administered to Resident 31, Norco 5-325 mg tablet to Resident 44, Tramadol 50 mg tablet to Resident 58, and Ativan 1 mg tablet to Resident 60 on 1/3/2024 in the morning and forgot to sign off the Controlled Drug Record forms and the MARs. LVN 3 stated she failed to follow the facility's policy of signing each CM dose on the Controlled Drug Record form after preparing the dose and failed to sign the MAR after administering the dose to each resident. LVN 3 stated it was important to have accountability of CM by documenting the Controlled Drug Record as the dose was prepared and document the MAR after the dose was administered. LVN 3 stated this ensures availability of doses to residents, prevents CM diversion and accidental exposure and overdose (receiving more than the prescribed dose), which can cause harm to Residents 31, 44, 58 and 60 leading to respiratory (related to the lungs) depression (stoppage of breathing) and death.
During an interview on 1/3/2024 at 1:12 p.m., with Resident 58 who has a Brief Interview for Mental Score (BIMS) of 11 (scores between 8 and 12 indicate moderate cognitive impairment), Resident 58 stated that LVN 3 administered Tramadol earlier that morning for her pain, and the pain was better.
During an interview on 1/3/2024 at 2:09 p.m., with LVN 6, LVN 6 stated it was important to have accountability of CM to ensure there was no abuse, diversion, and accidental exposure or overdose to residents.
During an interview on 1/3/2024 at 2:18 p.m., with Resident 44 who has a Brief Interview for Mental Score (BIMS) of 10 (scores between 8 and 12 indicate moderate cognitive impairment), Resident 44 stated that she asked LVN 3 for Norco that morning and received it from LVN 3, and that Resident 44's pain is relieved.
During an interview on 1/5/2024 at 9:58 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated LVN 3 failed to follow facility's policy and procedure (P&P) by not immediately documenting the Controlled Drug Record form for the CM preparation and the MAR for the CM administration the morning of 1/3/2024 for Residents 31, 44, 58 and 60. RNS 1 stated, as a result, LVN 3 accidentally administered Ativan to Resident 31, and can accidentally administer additional doses to Residents 44, 58 and 60, potentially causing harm by overdosing and possibly leading to respiratory depression. RNS 1 stated without proper documentation and accountability, there was also potential of diversion of CM's.
During a review of Resident 31's medication bubble pack for Ativan 1 mg, it indicated the Resident was prescribed Ativan 1 mg tablet to be given orally every 4 hours as needed for agitation for 14 days, starting 11/17/2023.
During a review of Resident 31's MAR for 1/ 2024, the MAR indicated Resident 31 was not prescribed Ativan 1mg.
During a review of Resident 44's Physician Orders for 1/2024, the Physician Order indicated Resident 44 was prescribed Norco 5-325 mg tablet to be given orally twice a day as needed for severe pain levels from 7 to 10 (tool that doctors use to help assess pain 0-no pain and 10 worst possible pain) starting 11/17/2023.
During a review of Resident 44's MAR for 1/2024, the MAR indicated there was no documentation for the Norco 5-325 mg administration on 1/3/2024.
During a review of Resident 58's Physician Orders for 1/2024, the Physician Order indicated Resident 58 was prescribed Tramadol 50 mg tablet to be given orally twice a day for severe pain, starting 12/24/23.
During a review of Resident 58's MAR for 1/2024, the MAR indicated Resident 58's dose of Tramadol 50 mg was due every day at 9 a.m. and 5 p.m., and there was no documentation for the Tramadol 50 mg administration for 9 a.m. on 1/3/2024.
During a review of Resident 60's Physician Orders for 1/2024, the Physician Order indicated Resident 60 was prescribed Ativan 1 mg tablet to be given orally twice a day for anxiety, starting 8/29/23.
During a review of Resident 60's MAR for 1/2024, the MAR indicated Resident 60's dose of Ativan 1 mg was due every day at 9 a.m. and 5 p.m., and there was no documentation for the Ativan 1 mg administration for 9 a.m. on 1/3/2024.
During a review of the facility's P&P, titled Medication Administration, dated 2022, the P&P indicated Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician .
Review MAR to identify medication to be administered.
Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.
Sign MAR after administered.
If the medication is a controlled substance, sign the narcotic book.
During a review of the facility's P&P, titled Controlled Substance Administration & Accountability, dated 2022, the P&P indicated:
All controlled substances are accounted for in one of the following ways:
All controlled substances obtained from non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided.
In all cases, the dose noted on the usage form or entered the automated dispensing system must match the dose recorded in the MAR, Controlled Drug Record, or other facility specified form and placed in the patient's medical record.
The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration.
The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedure regarding Trauma Informed Care (an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or response to behavioral health) for one of five sampled residents (Resident 60) by failing to screen Resident 60 for history of trauma on admission.
This failure had the potential to place Resident 60 at risk for not receiving adequate care and implement trigger specific interventions to meet Resident 60's psychosocial needs.
Findings:
During a review of Resident 60's admission Record (Face Sheet) , the Face Sheet indicated Resident 60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including epilepsy( brain disorder characterized by repeated seizures), schizophrenia ( mental illness that affects how a person, thinks, feels and behaves), and major depressive disorder (mental disorder characterized by persistent feeling of sadness, loss of interest and feelings of worthlessness which cause disruption in day-to-day tasks in life).
During a review of Resident 60's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 12/13/23, the MDS indicated Resident 60 had severely impaired cognitive skills (when a person had trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required substantial assistance from staff with bed mobility, bathing, toileting, and personal hygiene.
During a review of Resident 60's Initial Social Service assessment dated [DATE], the Initial Social Service Assessment indicated Resident 60 was not screened for history of trauma.
During a subsequent observation on 1/2/24 at 10:40 a.m. at Resident 60's room. Resident 60 was awake, with occasional episodes of crying and screaming and a Certified Nursing Assistant (CNA) was standing at the door of the room.
During an interview on 1/5/24, at 10:35 a.m. with the Director of Social Services (DSS), the DSS stated Resident 60 would have days she would be crying and screaming. DSS stated it was her behavior and did not know what could trigger her crying behavior. DSS stated she was not familiar with trauma informed care and did not do assessment on Resident 60 during admission regarding any history of trauma. The DSS stated it was important to assess Resident 60's behavior and find out what trigger her crying behavior to meet her psychosocial need. The DSS stated Resident 60 was quiet before and started to have the episodes of crying when she was in the facility.
During a concurrent interview and record review with the DSS of Resident 60's Quarterly Social Services assessment dated [DATE], the DSS stated Resident 60 behavior of crying was not addressed during the review.
During an interview on 1/5/24, at 2:16 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 60 would yell and cry when she was up in the chair or getting touched by staff member. LVN 3 stated she did not know why Resident 60 was crying or what would trigger the behavior and was not familiar with trauma informed care. LVN 3 stated Resident 60 was probably abused in the past, but she would not know how to deal or what to do with Resident 60's behavior.
During an interview on 1/5/24, at 3:04 p.m. with Registered Nurse Supervisor (RNS) 2, RNS 2 stated Resident 60 was confused, would yell and scream. RNS 2 stated Resident 60 might be scared and would not know what would trigger that kind of behavior. RNS 2 stated it was important to know what could trigger her crying and yelling behavior so we can help her better.
During a review of facility's policy and procedure (P&P) titled Trauma Informed Care revised 2023, the P&P indicated Each resident will be screened for a history of trauma upon admission by the facility social worker or designee. The P&P indicated if the screening showed the resident has a history of trauma or trauma related symptoms, a physician's order will be obtained for an evaluation of a mental health professional who is experienced in working with those exposed to trauma. The P&P indicated the facility will account resident's experiences, preferences, and cultural differences to eliminate or mitigate triggers that may cause re-traumatization of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a copy of medical records upon written request from an authorized conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) for one of three sampled residents (Resident 1) within two working days per the facility ' s policy and procedure (P/P) titled, Release of Medical Records.
This deficient practice violated Resident 1 and the conservator ' s (CON 1) rights to obtain a copy of the resident ' s medical record.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (heart problems which occur because of high blood pressure which is present over a long time), diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream], hyperlipidemia (high levels of fat particles in the blood), and schizophrenia (a disorder which affects a person's ability to think, feel, and behave clearly).
During a review of Resident 1 ' s History and Physical (H&P) dated 10/1/2022, indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/6/2023 indicated Resident 1 had the ability to understand and be understood by others.
During a review of Resident 1 ' s Conservatorship Documents dated 6/14/2022, indicated CON 1 was re-appointed as conservator for Resident 1 due to Resident 1 being gravely disabled (a condition in which a person, as a result of a mental disorder, was unable to provide for his or her basic personal needs for food, clothing, or shelter) from a mental health disorder (a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior).
During a review of Resident 1 ' s Authorization for use and Disclosure of Protected Health Information ([PHI] any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) form dated 11/10/2022, indicated CON 1 signed a release to disclose the protected health information for Resident 1. The Authorization for use and Disclosure of PHI indicated the authorization shall become effective immediately and shall expire upon Resident 1 ' s discharge from the facility.
During a review of request for medical records electronic mail ([e-mail] method of transmitting and receiving messages using electronic devices ) from CON 1 dated 1/6/2023 and timed at 12:02 p.m., indicated CON 1 sent an e-mail to the facility requesting a copy of Resident 1 ' s complete medical record including physician progress notes.
During a review of request for medical records e-mail from CON 1 dated 1/22/2023 and timed at 8:28 p.m., indicated CON 1 sent a follow-up e-mail regarding release of medical records request for Resident 1 initially requested on 1/6/2023.
During a review of request for medical records e-mail from CON 1 dated 8/10/2023 and timed at 1:03 p.m., indicated CON 1 sent a follow-up e-mail regarding release of Resident 1 ' s medical records request which was initially requested on 1/6/2023 and 1/22/2023. This was the third attempt made by CON 1 requesting release of Resident 1 ' s medical records.
During a review of e-mail correspondence from the facility ' s Administrator (ADM) to Resident 1 ' s CON 1 dated 8/31/2023 and timed at 12 p.m., indicated Resident 1 ' s entire medical record will be sent to CON 1 by the end of the business day.
During an interview on 12/11/2023, at 4:12 p.m., with the Medical Records Director, the Medical Records Director stated Resident 1 ' s complete medical record was sent via email to CON 1 on 8/31/2023 by the facility ' s Administrator (ADM).
During an interview on 12/11/2023, at 4:45 p.m., with the ADM, the ADM stated requests for copies of medical records should be completed within two working days and it was important for residents and their conservators to receive their requests for medical records in a timely manner because this was a resident ' s right.
During a review of the facility ' s P/P titled, Release of Medical Records, revised 2023, indicated the resident or his/her legal representative may receive a copy of his/her record within two working days after the request has been made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had an authorized conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) and had fluctuating capacity to understand and make decisions, a notice of discharge was provided to the CON 1.
This deficient practice resulted in Resident 1 being discharged to an assisted living facility ([ALF] housing facility for people with disabilities or for adults who cannot or choose not to live independently) and CON 1 being unaware of Resident 1 ' s discharge status and whereabouts. This deficient practice also denied Resident 1 ' s protection from being inappropriately discharged and had the potential to result in an unsafe discharge.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (heart problems which occur because of high blood pressure which is present over a long time), diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream], hyperlipidemia (high levels of fat particles in the blood), and schizophrenia (a disorder which affects a person's ability to think, feel, and behave clearly).
During a review of Resident 1 ' s History and Physical (H&P) dated 10/1/2022, indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/6/2023 indicated Resident 1 had the ability to understand and be understood by others.
During a review of Resident 1 ' s Conservatorship Documents dated 6/14/2022, indicated CON 1 was re-appointed as conservator for Resident 1 due to Resident 1 being gravely disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter) from a mental health disorder (a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior).
During a review of electronic mail ( e-mail -a communication method that uses electronic devices to deliver messages) between CON 1 and the Social Service Director (SSD) dated 12/27/2023 and timed at 9:30 a.m., indicated CON 1 sent an e-mail to the SSD inquiring when Resident 1 will be discharged and what the discharge process will include.
During a review of e-mail correspondence between CON 1 and the SSD dated 12/30/2023 and timed at 12:42 p.m., indicated CON 1 sent a follow-up e-mail to the SSD inquiring a second time when Resident 1 will be discharged and what the discharge process will include.
During a review of e-mail correspondence between CON 1 and the Director of Nursing (DON) dated 12/31/2023 and timed at 10:34 p.m., indicated CON 1 sent a follow-up e-mail to the DON inquiring a third time when Resident 1 will be discharged from the facility and what was the discharge plan.
During a review of e-mail correspondence between Resident 1 ' s Family Member (FM 1), CON 1, the DON, the SSD, and the Administrator (ADM), dated 1/3/2023 and timed at 6:47 p.m., indicated FM 1 and CON 1 sent a follow-up e-mail to the DON, SSD, and the ADM inquiring a fourth time regarding information on Resident 1 ' s discharge plan and date of discharge.
During a review of Resident 1 ' s Physician ' s Orders dated 1/4/2023 and timed at 3 p.m., indicated a physician ' s order was written to discharge Resident 1 in the morning. There was documentation provided by the licensed nurses indicating Resident 1 ' s CON 1 was notified of the order for discharge.
During a review of e-mail correspondence between SSD and CON 1, dated 1/4/2023 and timed at 6:18 p.m., indicated the SSD sent an e-mail to CON 1 indicating the licensed nurses were in the process of obtaining a discharge order for Resident 1.
During a review of e-mail correspondence between Resident 1 ' s FM 1, CON 1, the DON, the SSD, and the ADM, dated 1/4/2023 and timed at 6:39 p.m., indicated FM 1 and CON 1 sent a follow-up e-mail to the DON, SSD and ADM, inquiring how they (CON 1 and FM 1) will be involved in Resident 1 ' s transition to the Assisted Living Facility (ALF- facilities that provide both housing and personal care ).
During a review of e-mail correspondence between Resident 1 ' s FM 1, CON 1, the DON, the SSD, and the ADM, dated 1/5/2023 and timed at 5:05 p.m., indicated FM 1 and CON 1 sent an e-mail to the DON, SSD, and ADM inquiring on a clinical update prior to Resident 1 ' s discharge to determine if Resident 1 ' s discharge was appropriate.
During a review of Resident 1 ' s Nursing Progress Notes, dated 1/5/2023 and timed at 1:30 p.m., indicated Resident 1 reported to Registered Nurse 1 (RN 1) she (Resident 1) was not ready to be discharged . There was no documentation provided by RN 1 indicating Resident 1 ' s CON 1 was notified of the discharge.
During a review of Resident 1 ' s Nursing Progress Notes dated 1/6/2023 and timed at 7:30 a.m., indicated Resident 1 requested to be discharged in the afternoon. There was no documentation on the Nursing Progress Notes indicating CON 1 was notified of the discharge.
During a review of Resident 1 ' s Notice of Proposed Transfer/Discharge Form, dated 1/6/2023, indicated Resident 1 signed the proposed discharge form under the resident/responsible party section. There was no documentation indicating CON 1 was notified of the discharge.
During a review of Resident 1 ' s Post Discharge Plan of Care Form, dated 1/6/2023, indicated Resident 1 signed the post discharge plan of care under the resident/responsible party section. There was no documentation indicating CON 1 was notified of the discharge nor was the discharge plan of care discussed with CON 1.
During a review of Resident 1 ' s Nursing Progress Notes, dated 1/6/2023 and timed at 4 p.m., indicated Resident 1 was discharged from the facility. There was no documentation indicating CON 1 was notified of Resident 1 ' s discharge.
During an interview on 12/8/2023 at 3:57 p.m., with RN 1, RN 1 stated she (RN 1) thought Resident 1 had the capacity to understand the discharge summary and plan of care. RN 1 stated she (RN 1) was not aware Resident 1 had a CON nor was she (RN 1) aware of Resident 1 ' s H&P indicating Resident 1 having fluctuating capacity to understand and make decisions. RN 1 stated if a resident does not have the capacity to understand and make decision, then Resident 1 should not be signing documentation, especially regarding discharge because Resident 1 may not fully understand what they were reading or signing for. RN 1 stated she (RN 1) did not notify CON 1 of Resident 1 ' s discharge.
During an interview on 12/11/2023 at 10:04 a.m., with CON 1, CON 1 stated she (CON 1) was not aware of Resident 1 ' s discharge until she (CON 1) received a call from the ALF indicating Resident 1 had arrived at the ALF.
During a phone interview on 12/14/2023 at 9:34 a.m. with the DON, the DON stated when a resident does not have the capacity or has fluctuating capacity to understand and make decisions, the facility was responsible for notifying the responsible party regarding the resident ' s discharge and discharge plan of care.
During a review of the facility ' s undated policy and procedure (P/P) titled, Notification of Changes, indicated the purpose of this policy was to ensure the facility promptly informs the resident, consults with the resident ' s physician; and notifies, consistent with his or her authority, resident ' s representative when there was a change requiring notification when a transfer or discharge of the resident from the facility. The P/P indicated for a resident who was incapable of making decisions, the representative would make any decisions which have to be made.
During a review of the facility ' s P/P titled, Resident ' s Rights, revised 2023, indicated the resident representative has the right to exercise the resident ' s rights to the extent those rights are delegated to the resident representative.
During a review of the facility ' s P/P titled, Transfer and Discharge (including Against Medical Advice [AMA], revised 2023, indicated supporting documentation shall include evidence of the resident ' s or resident representative ' s verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview and record review the facility failed to ensure a resident (Resident 1) who had an appointed conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) was invited to participate in Resident 1 ' s care planning meetings upon admission and quarterly for one of three sampled residents (Resident 1).
This deficient practice resulted in Resident 1 ' s CON not attending the care planning meetings, and unable to participate in Resident 1 ' s care and treatment plans.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (heart problems which occur because of high blood pressure which is present over a long time), diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream], hyperlipidemia (high levels of fat particles in the blood), and schizophrenia (a disorder which affects a person's ability to think, feel, and behave clearly).
During a review of Resident 1 ' s History and Physical (H&P) dated 10/1/2022, indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/6/2023 indicated Resident 1 had the ability to understand and be understood by others.
During a review of Resident 1 ' s Conservatorship Documents dated 6/14/2022, indicated CON 1 was re-appointed as conservator for Resident 1 due to Resident 1 being gravely disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter) from a mental health disorder (a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior).
During a review of Resident 1 ' s Interdisciplinary ([IDT] a group of healthcare professionals who assess, coordinate, and manage each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) Team Meeting/Care Conference Notes dated 10/3/2022, indicated the conference was held to discuss Resident 1 ' s admission and plan of care. The IDT Meeting/Care Conference Notes indicated Resident 1 ' s CON 1 was not in attendance nor was there was documentation indicating she (CON 1) was notified of the conference. There was no documentation indicating CON 1 was updated on what was discussed at the conference.
During a review of Resident 1 ' s IDT Meeting/Care Conference Notes dated 1/3/2023, indicated the conference was held to discuss and review Resident 1 ' s care. The IDT Meeting/Care Conference Notes indicated Resident 1 ' s CON 1 was not notified of the conference nor was she (CON 1) updated on what was discussed at the conference.
During an interview on 12/11/2023 at 2:24 p.m., with Registered Nurse (RN) 2, RN 2 stated she (RN 2) was not aware Resident 1 had a CON; therefore, she (RN 2) did not notify CON 1 about the meeting nor did she (RN 1) notify CON 1 on Resident 1 ' s refusing to shower and participate in facility activities. RN 1 stated she did not notify CON 1 when she (RN 1) updated Resident 1 ' s care plan. RN 1 stated when a resident was conserved, it was important to notify the CON because the CON was responsible for the care of the resident.
During a telephone interview on 12/14/2023 at 9:34 a.m., with the Director of Nursing (DON), the DON stated whenever an IDT Meeting/Care Conference was held, it was the responsibility of the facility to notify the resident ' s responsible party or CON in writing or by telephone of the date and time of the conference. The DON stated the staff should document on the IDT Meeting/Care Conference form indicating who was contacted, when they were contacted, and the date of when the conference will be held. The DON stated it was important to notify the responsible party or CON of the conference because CON 1 was responsible for making decisions on the Resident 1 ' s care. The DON stated if the facility was not able to contact CON 1, the IDT meeting can still be held, however it was the responsibility of the facility to notify CON 1 if there are any adjustments needed in Resident 1 ' s care so the facility can obtain consent from CON 1.
During 1 review of the facility ' s undated policy and procedure (P/P) titled, Comprehensive Care Plan, indicated the comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to the resident and the resident ' s representative. The P/P indicated the physician, other practitioner, or professional will inform the resident and/or resident representative of the risk and benefits of proposed care, of treatment, and treatment alternatives/options. The P/P indicated the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident/and or resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident (Resident 1) who had an appointed conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) 1 was informed in advance, of the risks and benefits of psychoactive medications (a medication which changes brain function and results in alterations in perception, mood, consciousness or behavior) for one of three sampled residents (Resident 1).
This deficient practice violated the conservator ' s (CON 1) right to make an informed decision regarding the use of psychoactive medications for Resident 1 and placed Resident 1 at risk for making health care decisions she was not able to understand.
Findings:
A review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including hypertensive heart disease (heart problems which occur because of high blood pressure which is present over a long time), diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream], hyperlipidemia (high levels of fat particles in the blood), and schizophrenia (a disorder which affects a person's ability to think, feel, and behave clearly).
A review of Resident 1 ' s History and Physical (H&P) dated 10/1/2022, indicated Resident 1 had fluctuating capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/6/2023 indicated Resident 1 had the ability to understand and be understood by others.
A review of Resident 1 ' s Conservatorship Documents dated 6/14/2022, indicated CON 1 was re-appointed as conservator for Resident 1 due to Resident 1 being gravely disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter) from a mental health disorder (a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior).
A review of the facility ' s Consent to Treatment form dated 9/30/2023, indicated the facility shall contact the resident ' s legal representative to assist in making necessary decisions regarding the resident ' s care by the facility when the resident is incapable of making such decisions.
A review of Resident 1 ' s Physician ' s Orders, dated 9/30/2022 indicated Resident 1 was to receive the following medications:
1. On 9/30/2022, an order for Seroquel, an antipsychotic (a class of medicines used to treat psychosis [abnormal condition of the mind)]) 50 milligrams ([mg] a unit of measurement) one tablet at bedtime for verbal aggression and resistance to care.
2. On 9/30/2022, an order for Zyprexa (an antipsychotic medication which can treat several mental health conditions including schizophrenia by regulating a person ' s mood, behavior, and thoughts) 5 mg one tablet daily for verbal aggression and yelling.
3. On 9/30/2022, an order for Lexapro (medication used to treat depression [a mood disorder which causes a persistent feeling of sadness and loss of interest]) 10 mg one tablet daily for feelings of hopelessness and crying.
A review of Resident 1 ' s Informed Consent for Psychotherapeutic (medication used to treat problems in thought processes of individuals) Drugs dated 9/30/2022, indicated Resident 1 ' s physician (MD) obtained an informed consent for Seroquel, Zyprexa, and Lexapro. The informed consent indicated the consent was obtained by Resident 1. The informed consent did not indicate Registered Nurse (RN 2) verified with the CON 1 of the consent prior to the initiation of therapy.
A review of Resident 1 ' s Physician Orders dated 11/17/2022, indicated Resident 1 ' s Seroquel order was increased from 50 mg to 150 mg.
A review of e-mail correspondence from CON 1 to the Director of Nursing (DON) dated 12/1/2022 and timed at 2:34 p.m., CON 1 requested to speak to Resident 1 ' s MD to discuss her psychiatric medications.
During an interview on 12/11/2023 at 2:24 p.m., with RN 2, RN 2 stated she did not informed Resident 1 ' s CON 1 because she was not aware Resident 1 had a CON. RN 2 stated she was not able to provide documented evidence Resident 1 ' s CON 1 was notified of the change in medication dosage on 11/17/2022 and verification of an informed consent was obtained from the CON 1 prior to the initiation of therapy. The RN 1 stated when a resident is conserved, it is important to notify and obtain informed consent from the CON because the CON is responsible for the care of the resident.
A review of the facility ' s undated policy and procedure (P/P) titled, Notification of Changes, indicated when a resident is incapable of making decisions, the representative would make any decisions that have to be made.
A review of the facility ' s undated P/P titled, Consent-Informed, indicated informed consent is a decision made freely by the patient/resident/or a legally authorized representative after he/she has full knowledge and understanding of the risks, benefits, and available options about the various treatment alternatives. The P/P indicated the patient/resident or legal guardian signs and dates prior to treatment/procedure being performed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed ensure a resident (Resident 1) who had an appointed conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) request to change psychiatrist (a medical doctor [MD] who specializes in mental health [emotional, psychological, and social well-being]) was honored for one of three sampled residents (Resident 1).
This deficient practice resulted in the request for change in MD not being granted per the CON 1 ' s request and violated CON 1 ' s rights to change Resident 1 ' s MD.
Findings:
A review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including hypertensive heart disease (heart problems which occur because of high blood pressure which is present over a long time), diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream], hyperlipidemia (high levels of fat particles in the blood), and schizophrenia (a disorder which affects a person's ability to think, feel, and behave clearly).
A review of Resident 1 ' s History and Physical (H&P) dated 10/1/2022, indicated Resident 1 had fluctuating capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/6/2023 indicated Resident 1 had the ability to understand and be understood by others.
A review of Resident 1 ' s Conservatorship Documents dated 6/14/2022, indicated CON 1 was re-appointed as conservator for Resident 1 due to Resident 1 being gravely disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter) from a mental health disorder (a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior).
A review of Resident 1's Consent to Treatment form dated 9/30/2022, indicated the facility will permit the resident to use the attending physician of the resident's choice.
A review of e-mail correspondence from CON 1 to the Director of Nursing (DON) dated 11/21/2022 and timed at 2:40 p.m., the e-mail indicated CON 1 requested a MD change for Resident 1 from MD 2 to MD 3.
A review of e-mail correspondence from CON 1 to the DON dated 11/21/2022 and timed at 6:21 p.m., indicated CON 1 sent Resident 1 ' s Notification of Change of Attending Physician request form to the DON.
A review of e-mail correspondence from the DON to CON 1 dated 11/21/2022 and timed at 6:45 p.m., indicated DON informed CON 1 she (DON) will have MD 3 sign the Notification of Change of Attending Physician request form and change Resident 1 ' s MD from MD 2 to MD 3.
During an interview on 12/11/2023 at 10:04 a.m., with CON 1, CON 1 stated she was never informed of Resident 1 ' s MD change from MD 2 to MD 3 was completed.
During a phone interview on 12/14/2023 at 9:34 p.m., with the DON, the DON stated Resident 1 ' s did not have a change in MD from MD 2 to MD 3. The DON stated she could not remember why the change in MD was not completed and does not have any documentation notifying CON 1 on why the change in MD was not done.
A review of the facility ' s policy and procedure (P/P) titled, Resident's Right's, revised 2023 indicated the resident has the right to choose his or her attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident, who had a diagnosis of diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream], who was receiving Insulin (a hormone which lowers the level of glucose [a type of sugar in the blood]) every morning at 9 a.m., and blood glucose monitoring before meals and at bedtime, primary care doctor (MD 1) and appointed conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) was informed immediately after Resident 1 ' s refusal of medication on 1/5/2023 and 1/6/2023 and refusal of blood glucose monitoring on 1/5/2023 at 11:30 a.m. and on 1/6/2023 at 6 a.m.
This deficient practice resulted in the licensed nurse ' s inability to determine what Resident 1 ' s blood glucose level was on 1/5/2023 at 11:30 a.m. and on 1/6/2023 at 6 a.m. placing the resident at risk of hyperglycemia (blood sugar levels are too high, above 180 milligrams ([mg] a unit of mass or weight) per deciliter ([dL] a metric unit of capacity) and resulted in Resident 1 having hyperglycemia on 1/5/2023 at 4:30 p.m., on 1/5/2023 at 9 p.m., and on 1/6/2023 at 11:30 a.m.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (heart problems which occur because of high blood pressure which is present over a long time), diabetes mellitus (DM) type 2, hyperlipidemia (high levels of fat particles in the blood), and schizophrenia (a disorder which affects a person's ability to think, feel, and behave clearly).
During a review of Resident 1 ' s History and Physical (H&P) dated 10/1/2022, indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/6/2023 indicated Resident 1 had the ability to understand and be understood by others.
During a review of Resident 1 ' s Conservatorship Documents dated 6/14/2022, indicated CON 1 was re-appointed as conservator for Resident 1 due to Resident 1 being gravely disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter) from a mental health disorder (a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior).
During a review of Resident 1 ' s Physician Orders, dated 11/17/2023, indicated a physician ' s order for administration of Lantus (medication used to treat elevated blood sugar level) 10 units every morning at 9 a.m. for DM.
During a review of Resident 1 ' s Physician Orders, dated 11/17/2023, indicated a physician ' s order for administration of regular Insulin (short acting medication used to treat elevated blood sugar levels) before meals and at bedtime, per the sliding scale (varies the dose of insulin based on blood glucose level) as follows:
1. For blood sugar between 50-149 mg/dL no insulin required.
2. For blood sugar between 150-199 mg/dL administer two units of regular insulin.
3. For blood sugar between 200-249 mg/dL administer four units of regular insulin.
4. For blood sugar between 250-299 mg/dL administer six units of regular insulin.
5. For blood sugar between 300-349 mg/dL administer eight units of regular insulin.
6. For blood sugar between 350-399 mg/dL administer 10 units of regular insulin.
7. For blood sugar greater than 400 mg/dL administer 12 units of regular insulin and call MD.
During a review of Resident 1 ' s Medication Administrative Record, dated 1/2023, indicated Resident 1 refused Lantus 10 units on 1/5/2023 at 9 a.m., and on 1/6/2023 at 9 a.m. The Medication Administrative Record indicated the licensed nurses documented on 1/5/2023 at 9 a.m., Resident 1 refused the medication after two attempts and on 1/6/2023 at 9 a.m., the licensed nurses documented Resident 1 refused the medication after three attempts.
During a review of Resident 1 ' s Medication Administrative Record, dated 1/2023, indicated Resident 1 refused blood glucose monitoring on 1/5/2023 at 11:30 a.m. and on 1/6/2023 at 6:30 a.m.
During a review of Resident 1 ' s Medication Administrative Record, dated 1/2023, indicated the following blood sugar results and the amount of regular Insulin administered were as follows:
1. On 1/5/2023 at 4:30 p.m., Resident 1 ' s blood sugar was 205 mg/dL, and four units of regular insulin was administered.
2. On 1/5/2023 at 9 p.m., Resident 1 ' s blood sugar was 180 mg/dL, and two units of regular insulin was administered.
3. On 1/6/2023 at 11:30 a.m. Resident 1 ' s blood sugar was 192 mg/dL, and two units of regular insulin was administered.
During a review of Resident 1 ' s Nursing Progress Notes, dated 1/2023, indicated there was no documentation from the licensed nurses indicating Resident 1 ' s MD and CON 1 were notified of Resident 1 ' s refusal of blood sugar monitoring on 1/5/2023 at 11:30 a.m., on 1/6/2023 at 6:30 a.m., or upon refusal of Resident 1 ' s 9 a.m. dose of Lantus on 1/5/2023 and on 1/6/2023.
During an interview on 12/11/2023 at 2:24 p.m., with RN 2, RN 2 stated after Resident 1's refused medications and treatments, especially insulin, it was important to notify the MD so he/she was aware of the Resident 1's condition so additional monitoring can be done. RN 2 stated CON 1 should have been notified because the CON was responsible for the care of Resident 1. RN 2 stated because Resident 1 refused her blood sugar levels to be monitored and refused her morning insulin doses, there was a potential for the resident to have hyperglycemia and/or hypoglycemia (blood sugar level is lower than the standard range of 70 mg/dL), possible hospitalization and other complications because the licensed nurses don ' t know what her blood sugar levels were.
During a review of the facility ' s undated policy and procedure (P/P), titled Change in a Resident ' s Condition or Status, indicated our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident ' s medical/mental condition and or status. The P/P indicated the nurse supervisor/charge nurse will notify the resident ' s attending physician or on-call physician when there has been a refusal of treatment or medication (i.e., two or more consecutive times).