Based on interview and record review, the facility failed to report an allegation of abuse within the mandated timeframe for one resident (Resident 2) of two sampled residents when the facility submitted notification to the California Department of Public Health (CDPH) on 8/25/25 when the allegation of abuse was reported to a nurse on 8/24/25.This failure decreased the facility's potential to protect residents.Findings:A review of Resident 2's admission record indicated admission to the facility on 7/17/25 with diagnoses which included dementia (a progressive state of decline in mental abilities), mild cognitive impairment of unknown cause, and a need for assistance with personal care.A review of Resident 2's Minimum Data Set (an assessment tool) dated 7/20/25 indicated a Brief Interview for Mental Status (BIMS, a screening tool used to monitor cognitive function (the mental processes our brain uses to perceive, learn, remember, and reason)) score of 11 which indicated moderate cognition.A review of Resident 2's progress note dated 8/24/25 at 5:25 p.m. indicated, Resident's daughter .reported to desk nurse that [Resident 2] stated that she was 'slapped two times' .During the skin assessment, the resident stated that she was 'slapped twice on the face, 3 weeks ago'.A review of a fax confirmation receipt of an SOC 341 (a state form used in California for mandated reporters to report suspected elder and dependent adult abuse or neglect) sent to CDPH from the facility regarding Resident 2's allegation of abuse was received on 8/25/25 at 10:15 a.m.In an interview on 9/9/25 at 12:58 p.m., the Administrator (ADM) stated he was the Abuse Coordinator and acknowledged allegations of abuse were to be reported to CDPH within 2 hours. The ADM stated he had faxed the SOC 341 to CDPH again on 8/25/25 when he realized it had not been confirmed as received on 8/24/25. The ADM also stated he called CDPH and left a message notifying the Department of Resident 2's allegation of abuse.A review of CDPH's voice message log on 9/9/25 at 3:55 p.m. showed no evidence that a call was received from the facility on 8/24/25. A review of CDPH's fax log confirmed a document regarding Resident 2's allegation of abuse was received from the facility on 8/25/25.A review of the facility's policy and procedure titled Elder/Dependent Adult Abuse revised 5/31/19 indicated, All alleged violations of abuse .the mandated reporter shall .Make phone report immediately .(no later than (2) two hours) to the .licensing agencies of .obtaining knowledge of, or suspecting abuse .Fax within (2) two hours .written report (SOC 341) to .the licensing agency.

Based on interview and record review, the facility failed to honor a resident's desire to go outdoors when one of two sampled residents, Resident 1, was asked repeatedly by multiple staff members to go inside to his room where he was in isolation for COVID-19. This failure potentially resulted in an escalation of Resident 1's anxiety prompting a call to the police and Resident 1's subsequent arrest. Finding: On 3/25/25, the Department received a report from the facility that on 3/24/25 at approximately 11:30 a.m., [Resident 1] became agitated in his covid isolation room. He exited the room using his walker without shoes or a mask on and went to exit the facility, to get fresh air and sun. As he approached the exit of the facility, the [facility] receptionist let him know he was not wearing the proper PPE (personal protective equipment) and was supposed to stay in his isolation room. Once inside, Resident 1 became significantly more agitated, 911 was called, police arrived, and after he became physical with one of the police officer, Resident 1 was arrested and escorted to the county jail. During a record review on 4/22/25 at 2:45 p.m., Resident 1's face sheet revealed an admit date of 2/18/25 with multiple diagnoses including prostate cancer, anxiety disorder, difficulty in walking, and depression. Resident 1's face sheet also indicated he was his own responsible party. Review of Resident 1's MDS (minimum data set, an assessment tool) dated 2/23/25 indicated he had a BIMS score of 13 (Brief Interview for Mental Status, a score of 13 indicates intact cognition) and he had exhibited no behaviors in the past five days such as physical or verbal aggression or resisting care. During an interview on 4/22/25 at 1:25 p.m. with Director of Nursing (DON) and Administrator, DON stated that on 3/24/25 Resident 1 was in isolation because he had tested positive for COVID-19. DON stated Resident 1 had four days left of isolation. DON stated Resident 1had a roommate who was getting a therapy session that day (3/24/25) and Resident 1 had gotten tired of the therapy staff talking to his roommate. DON stated Resident 1 left his room and went outside. Administrator stated staff were trying to ask Resident 1 not to go out, he had no shoes and no mask on. Administrator stated two nurses went outside with Resident 1 because he was unsteady on his feet. Administrator stated DON and a nurse tried to calm Resident 1, but Resident 1 would not calm down, Resident 1 said he was tired of being on isolation. Administrator stated Infection Prevention Nurse (IPN) called 911. Administrator stated that while the police were here, Resident 1 got so worked up contact was made, Resident 1 was arrested for resisting arrest and assault on a police officer. When queried, DON stated that even though Resident 1 was already outside, Resident 1 could not remain outside because he was COVID-positive and was on isolation. During an interview on 4/22/25 at 1:51 p.m., IPN stated that on 3/24/25 someone came and told her that Resident 1 had left his room and she went outside to talk to Resident 1. IPN stated he was in the front of the building without shoes or a mask, just his walker. IPN stated Resident 1 was angry and he stated he felt hot. IPN stated she asked Resident 1 to go back to his room to talk, which he did. IPN stated that when they got to his room, Resident 1 told her the air purifier in his room was too noisy, the room was hot, and he said he wanted to get away from you f---ing people. IPN stated she told Resident 1 she would get him a fan, and Resident 1 asked for lorazepam (an antianxiety medication) which Resident 1's nurse, Licensed Staff B, gave to him. IPN stated that while she got the fan, Resident 1 left his room again. IPN stated Licensed Nurse C approached her and told her, We need to 5150 (an involuntary psychiatric hold) him. IPN stated DON told staff to call 911, which they did. IPN stated she spoke to the dispatcher and explained Resident 1's situation and told them a peace officer would be good to de-escalate Resident 1. IPN stated an officer came and talked to Resident 1 in the dining room. IPN stated the officer started yelling and shuffling around, and then called for backup and a second officer came. IPN stated the two officers tried to restrain Resident 1 and Resident 1 hit one of the officers. IPN stated the police escorted Resident 1 out and put him in the police car. IPN denied any visitors or residents were out in the front of the building during the time of this incident. When queried, IPN stated Resident 1 was never aggressive prior to this incident. IPN stated Resident 1 would let his needs be known, and he would let staff know if he was anxious, which was handled with lorazepam, and then she would talk to him about how he was doing. When queried, IPN stated any time a resident was on isolation the resident could be outside safely with PPE and the resident could take their mask off when outside to get fresh air. IPN stated she had not in-serviced the staff on how to let someone on isolation go outside safely. During an interview on 4/22/25 at 2:08 p.m., Receptionist A stated that on 3/24/25 Resident 1 was agitated, he was unmasked and COVID- positive. Receptionist A stated that when Resident 1 headed towards the door, he (Receptionist A) tried to approach Resident 1, but he bashed me with his walker. I got out of the way, and I got help from other staff members. Receptionist A stated Resident 1 said, F--- you. I'm going outside, I'm getting the f--- out of here, and Resident 1 went outside. Receptionist A stated, It happens (resident aggression towards staff), it's not the first time. I just roll with it. During an interview on 4/22/25 at 2:27 p.m., Licensed Nurse B verified he was Resident 1's nurse the day he went to jail. Licensed Nurse B stated Resident 1 was on isolation for COVID, and it was reported to him that Resident 1 was out of his room going to the main door to go out. Licensed Nurse B stated IPN guided Resident 1 back to his room. Licensed Nurse B stated Resident 1 was very anxious, Resident 1 was verbalizing that he was feeling isolated, and he was anxious and confused about what was going on. Licensed Nurse B stated he administered lorazepam to Resident 1 for his anxiety and then after that Resident 1 attempted again to get out of the room. Licensed Nurse B stated he was following Resident 1, letting him know he was on isolation, and he has to go back to the room. Licensed Nurse B stated Resident 1 went to the dining room and he and DON and were watching Resident 1 at that time. Licensed Nurse B stated Resident 1 was aggressive in the dining room, he put his leg on a box, and he was trying to grab something, and we were trying to get it away from him because we thought he might throw it. Licensed Nurse B stated Resident 1 was very anxious. When queried, Licensed Nurse B stated that was his first day working with Resident 1 and he did not know the plan for Resident 1's anxiety except to give the lorazepam as needed. When queried, Licensed Nurse B stated that what Resident 1 needed in that moment was to get out of the room. Licensed Nurse B stated Resident 1 could not be out of his room at that time because he was on isolation, so his (Licensed Nurse B's) understanding was that all activities, therapy, and visitation happened in his room. During a phone interview on 4/22/25 at 4:15 p.m., Licensed Nurse C stated that on 3/24/25 Resident 1 had COVID, no mask, no shoes, and no socks and had gone outside. Licensed Nurse C stated he tried to get Resident 1 to come inside, but Resident 1 was saying, I want to go, this is like a jail. Licensed Nurse C denied anyone else was outside at the time, except maybe staff. During an interview on 4/23/25 at 1:24 p.m., Social Services Director (SSD) stated Resident 1 did not have aggressive behaviors prior to 3/24/25, just frustrated behaviors. SSD stated Resident 1 found out about his cancer diagnosis just before he got here, he lost his ability to live independently and found out he was not going to be able to go home to the same situation, he lost his apartment, and then he got the COVID diagnosis, which delayed his transfer out, and all that compounding was a lot for him. During an interview on 4/24/25 at 3:32 p.m., Administrator stated yes, Resident 1 could absolutely go outside as long as he followed protocol for infection control. Administrator verified someone could have brought Resident 1 a chair and his shoes. During a record review on 4/23/25 at 4:05 p.m., Resident 1's medication administration record for March 2025 indicated Resident 1 had a physician order for lorazepam 0.5 mg (milligrams) every six hours as needed for anxiety and Licensed Nurse B documented a dose given to Resident 1 on 3/24/25 at 11:41 a.m. Review of Resident 1's nurse progress notes indicated a note written by IPN dated 3/20/25 at 11:51 a.m., Resident tested positive for COVID 19 on 3/20/2025. He presents with a low grade fever and overall feeling of weakness. No other documentation of COVID symptoms was noted. Review of Resident 1's vital signs (blood pressure, pulse, respiratory rate, and temperature) revealed no fever after 3/20/25. Review of facility policy Resident Self Determination and Participation, last revised 8/2022, indicated, Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to issue a written notice of bed hold when a resident transferred to a local hospital for 1 (Resident # 78) of 2 sampled residents reviewed for hospitalization. This failure resulted in a bed not being available upon discharge of the resident from the acute care hospital. Findings included: Review of a facility policy titled; Bed Hold Acknowledgement/Notification, revised 03/29/2018, indicated 1. facility will issue two notices related to bed-hold: a The first notice will be given upon admission to the facility. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility's policy were changed; b Second notice will be given at the time of transfer of a resident for hospitalization or therapeutic leave which specifies the duration of the bed-hold policy. An admission Record indicated the facility admitted Resident #78 on 09/19/2024. According to the admission Record, the resident had a medical history that included diagnoses of type I diabetes mellitus and personal history of transient ischemic attack (TIA) and cerebral infarction without residual effects. Per the admission Record, Resident #78 discharged (transferred) to an acute care hospital on [DATE]. A discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/09/2024, revealed Resident #78 had an unplanned discharge to a short-term general hospital on [DATE]. Resident #78's Progress Notes, dated 10/09/2024 at 2:55 PM, revealed the physician visited the resident related to ongoing complaints of nausea and uncontrolled pain. Per the Progress Note, there was a physician's order given to transfer the resident to an acute care hospital for further evaluation and treatment. Resident #78's medical record revealed no evidence to indicate the resident was provided a bed hold notice on transfer from the facility to the hospital on [DATE]. During an interview on 11/07/2024 at 9:01 AM, the Director of Admissions stated she was not responsible for the issuance of a second written bed hold notice to Resident #78 or the resident's responsible party on transfer from the facility and was not aware that was included in the facility policy. The Director of Admissions stated she was responsible for checking with the hospital discharge planner to determine if the resident would readmit to the facility. Per the Director of Admissions, after the resident transferred to the hospital, she spoke with resident's spouse and informed the spouse that the facility was at capacity and therefore did not have a bed available for the resident. The Director of Admissions stated she referred the resident's spouse to other local skilled nursing facilities. The Director of Admissions stated during the resident's hospitalization, the hospital staff reached out to her and she informed the hospital staff that the facility did not have any beds available for the resident. During an interview on 11/07/2024 at 9:40 AM, the Director of Social [NAME] stated the admissions team was responsible for the issuance of all bed hold notices during transfer from the facility. During an interview on 11/08/2024 at 8:23 AM, the Director of Nursing (DON) stated a member of the admission teams would provide the bed hold documentation to the resident and/or the resident's responsible party during the admission process. Per the DON, if the resident had a change of condition that required a transfer to the hospital, staff would ask the resident and/or the resident's responsible party, if they wished to have a bed hold, and that request and/or denial would be documented in the resident's medical record. During an interview on 11/08/2024 at 1:02 PM, the Administrator stated he expected the staff to follow the facility policy and procedures related to bed hold notification.

Based on record review, interview, and facility policy review, the facility failed to resubmit a Level I screening for 1 (Resident #6) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR, a tool to ensure residents are not inappropriately placed in nursing homes for long term care). This failure had the potential to affect the care the resident received. Findings included: An undated facility policy titled, Preadmission Screening and Resident Review, indicated 1. The facility will obtain/complete a Preadmission Screening and Resident Review timely. An admission Record indicated the facility admitted Resident #6 on 11/04/2019. According to the admission Record, the resident had a medical history that included diagnoses of adjustment disorder (an excessive reaction to stress), bipolar disorder (disorder characterized by mood swings between depressive lows and manic highs), and dementia. An quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/09/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had active diagnoses to include dementia and manic depression (bipolar disease), A letter from the State of California Department of Health Care Services, dated 10/26/2021, indicated Resident #6 had a positive Level I screening and a Level II mental health evaluation was required. A letter from the State of California Department of Health Care Services, dated 12/14/2021, indicated the Level II mental health evaluation was unable to be completed as Resident #6 was in isolation as a health and safety precaution. Per the letter, a new Level I screening must be submitted. Resident #6's medical record revealed no evidence to indicate a new Level I screening was submitted. During an interview on 11/06/2024 at 8:40 AM, the Director of Nursing (DON) stated she was able to retrieve a document that indicated a level II was attempted; however, Resident #6 was under isolation at the time of the attempt. The DON stated the facility did not attempt to file a new Level I screening after Resident #6 was removed from isolation. During an interview on 11/06/2024 at 9:10 AM, Licensed Vocational Nurse #1 stated the facility did not resubmit a new Level I screening for Resident #6 when the resident came off isolation. During an interview on 11/08/2024 at 12:53 PM, the Administrator stated he expected the staff to follow the PASARR policy for the completion of Level I screenings.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene when soiled gloves were removed and before a new pair of gloves were put on during the provision of wound care for 1 (Resident #4) 1 sampled resident reviewed for pressure ulcer/injury. This failure had the potential to cause the spread of infection between residents. Findings included: A facility policy titled, Handwashing/Hand Hygiene revised 08/2019, revealed This facility considers hand hygiene the primary means to prevent the spread of infections. The policy specified, 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handing an invasive device; f. Before donning (putting on) sterile gloves; g. Before handing clean or soiled dressings, gauze pads, etc.; h Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects in the immediate vicinity of the resident; m. After removing gloves; Per the policy, 8. The use of gloves does not replace hand washing/hand hygiene. An Transfer / Discharge Report indicated the facility admitted Resident #4 on 08/24/2021. According to the Transfer/Discharge Report, the resident had a medical history that included diagnoses of multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), quadriplegia (a form of paralysis that affects all four limbs), acquired absence of the right leg above the knee, and neuromuscular dysfunction of the bladder. A quarterly Minimum Data Set (MDS, an assessment tool), with an Assessment Reference Date (ARD) of 09/15/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS, a tool to assess cognition) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had one Stage 3 pressure ulcer (a deep wound when skin loss extends through the entire thickness of the skin into the underlying tissue, but not to muscle, tendon, or bone). Resident #4's Order Summary Report, that contained active orders as of 11/05/2024, revealed an order dated 08/17/2024 that directed staff to cleanse the resident's left buttock with cleanser, pat dry, and apply a thin layer of paste to the periwound (an area of tissue around a wound), and calcium alginate to the wound bed and cover with a foam dressing daily and as needed. During an observation of wound care for Resident #4 on 11/05/2024 at 2:26 PM, Licensed Vocational Nurse (LVN) #3 did not perform hand hygiene after she removed a soiled pair of gloves and before she applied a new pair of gloves. During an interview on 11/05/2024 at 2:48 PM. LVN #3 stated she was educated to perform hand hygiene and put on clean gloves between each step of wound care to include the removal of the old dressing, cleansing the wound, and the application of the clean dressing. LVN #3 confirmed she did not perform hand hygiene with hand sanitizer and/ or soap and water with gloves changes. During an interview on 11/07/2024 at 9:25 AM, the Infection Preventionist (IP) stated staff had been educated to perform hand hygiene during wound care whenever gloves were removed and a new pair was put on. The IP stated it was never acceptable to not perform hand hygiene. During an interview on 11/08/2024 at 8:12 AM, the Director of Nursing stated hand hygiene should be performed before applying gloves, with each glove change, and at the completion of the care provided.

Based on observation, interviews, and record reviews, the facility failed to ensure that one of two sampled residents, Resident 1, received an accurate reconciliation of medications (A process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that included the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care) during her discharge, when Resident 1 received three (3) over the counter medications that were ordered for another resident, Resident 2. This failure had the potential to result in a medication error and could affect the safety and well-being of Resident 1, if she accidentally took the medications that were not ordered for her. Findings: On 7/2/2024, at 1:51 p.m., the facility's DON (Director of Nursing) provided a list of residents who were discharged in June 2024. The list included Resident 1, who was discharged on 6/7/24. During a concurrent observation and interview on 7/2/24, at 11:26 a.m., with Licensed Nurse A, she stated she remembered discharging a resident who called her pharmacy because she was discharged with medications that did not belong to her. Licensed Nurse A confirmed that it was Resident 1. Licensed Nurse A stated that she drove to Resident 1's home and took back the medications that were ordered for Resident 2. Licensed Nurse A stated that she still has the medications kept in a transparent plastic bag which she showed this surveyor. This surveyor took pictures of the contents of the bag with labels indicating that these three medications were for Resident 2. Licensed Nurse A stated that she was taking responsibility for the incident. Licensed Nurse A stated that Resident 1 could be at risk if she was allergic to any of the three medications that were sent home with her during her discharge. Licensed Nurse A stated that she did not document the incident, but stated she might have verbally notified the DON. Licensed Nurse A stated that the over-the-counter medications were all sealed and unopened. This surveyor verified that the medications were unopened during inspection. A review of Resident 1's Progress Notes, dated 6/7/24, at 9:10 a.m., authored by Licensed Nurse A, indicated, Resident 1 is schedule to discharge home today as per MD (Doctor's) orders. All discharge instructions including medication regimen review with resident (Resident 1) who verbalized understanding .Resident 1 left the facility at this time .all belongings taken at this time. During an interview on 7/2/24, at 12:30 p.m., with the DON, she stated that it was her expectation that medications should be discharged to the right resident. The DON stated that if the resident was not alert as Resident 1, there would be a potential for harm if that resident accidentally took the medications. The DON stated that it was the facility's responsibility, not the pharmacy, to double check the medications being discharged to the residents. A review of a facility document titled, Discharge Instructions, dated 6/7/24, indicated, IMPORTANT: You (Resident 1) will be provided a discharge medication list before you leave the facility. It is important to continue with this medication list as prescribed by your physician at this facility until you see your regular doctor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep one of three sampled residents (Resident 1) safe from elopement (Leaving the facility without notice), when he had a history of attempting to elope from the facility and was able to walk without a wheelchair. The facility's intervention to prevent him from elopement included a wander guard (Bracelets that trigger alarms at exit monitored doors to prevent the resident from leaving unattended) placed on his wheelchair. As a result, Resident 1 eloped from the facility by foot, left the wheelchair at the facility, which did not trigger the wander guard system, fell during the process, and hitchhiked to a neighboring town 8.5 miles away. This failure had the potential to result in serious harm, including death, to Resident 1. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Nontraumatic Intracerebral Hemorrhage (Bleeding in the brain, not caused by trauma), Alcohol Abuse, Metabolic Encephalopathy (A neurological disorder that occurs when a chemical imbalance in the blood causes brain dysfunction), and Unsteadiness on Feet, according to the facility Face Sheet (Facility demographic). Record review of Resident 1's MDS (Minimum Data Sheet-An assessment tool) dated 3/29/24 indicated his BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 9, which indicated his cognition was moderately impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). Record review of Resident 1's care plan for elopement initiated on 3/29/24 indicated, ALARM (Wander guard) WAS PLACED ON THE HANDLE OF HIS WHEELCHAIR. Other interventions in this care plan included, DEVELOP AN ACTIVITIES PROGRAM TO DIVERT ATTENTION AND MEET NEEDS .DISCUSS WITH RESIDENT/FAMILY RISKS OF ELOPEMENT AND WANDERING. There was no mention of increased supervision, or another system other than the wander guard to prevent elopement. This care plan was not revised until 4/14/24, after Resident 1 eloped from the facility. Record review of a facility document titled, Elopement/Wondering Risk Assessment, dated 3/29/24 at 12:03 p.m., indicated Resident 1 had attempted to leave the building 1-2 times within a week, unattended. This document indicated Resident 1 was at risk for wandering, but the intervention was to place the wander guard device on his wheelchair. Record review of a nursing note dated 3/31/24 at 1:10 p.m., indicated, patient [Resident 1] exhibited increased agitation this afternoon and attempted elopement through the front doors of [Name of facility]. Re-direction was provided in the parking lot, and patient agreed to return inside. He states he is ready to walk to Gualala however he is unable to correctly state his current location, appears confused. During a phone interview with Licensed Staff A (Who wrote the note on 3/31/24 at 1:10 p.m., above) on 4/25/24 at 11:30 a.m., she stated that on 3/31/24 Resident 1 attempted to elope from the facility by foot, although he was walking unsteady on his feet. Licensed Staff A stated that when she saw Resident 1, he was outside in the parking lot of the facility with another staff member, attempting to walk off. Licensed Staff A stated staff brought out Resident 1's wheelchair, and he agreed to come back inside the building. Licensed Staff A stated a decision was made to place a wander guard on Resident 1's wheelchair, as he did not want it placed on his body. Record review of a note dated 4/02/24 at 4:54 p.m., indicated, [Resident 1] has attempted to leave facility three times .staff run outside of facility trying to persuade resident to return to facility. Resident receptive to return to facility. Record review of a report sent to the DEPARTMENT on 4/14/24 of an elopement that occurred that same day (On 4/14/24) indicated, Around 8:45 AM (Morning) we received a call from a concerned citizen that a Caucasian male jumped over the fence. Staff alerted to check all residents. All Staff checked inside and surrounding area and at this time resident in 17A [Resident 1] cannot be located. Staff called [Local police department] for assistance. At 9:20 AM, received a phone call from the person who gave resident [Resident 1] a ride to make us aware that resident is in [Name of neighboring town} area, Police Officer [Name of Officer] made aware of resident's whereabouts. SAFE team (mental health team) brought resident back to the facility. Upon resident's return, LN (Licensed Nurse) made a thorough assessment. Resident made comfortable. Medicated for pain as needed. MD/RP (Medical doctor/Patient Representative) notified. Resident had a wander guard on in WC (Wheelchair). Therapy made him independent in the facility yesterday (Saturday). Record review of a nursing note dated 4/14/24 at 13:22 p.m. indicated, Pt (Patient [Resident 1]) has eloped this morning .PT is alert and verbalized that he fell by sliding down when he jumped out of the fence and leaned to his left shoulder, Pt noted to have no injuries. Record review of Resident 1's care plan for elopement, revised after the elopement on 4/14/24 indicated, 4/14/24 Wander guard applied on left ankle. During an interview with Resident 1 on 4/18/24 at 1:30 p.m., he stated that on 4/14/24 he wanted to leave the facility, so he left by foot, leaving the wheelchair with wander guard inside the building, which did not trigger the alarm. Resident 1 stated he jumped over the fence of the facility, and fell in the process, scraping his knee, but managed to get back up on his feet, and was given a ride by a vehicle passing by. Resident 1 stated he was driven to [Neighboring town 8.5 miles away, according to Google maps]. During an interview with the Director of Nursing (DON) on 4/25/24 at 11:00 a.m., she stated that after the elopement attempt on 3/31/24, facility staff should have placed a wander guard on Resident 1's wheelchair, and another one on his body to prevent him from eloping again. Record review of an e-mail sent to the DON and Medical Records Staff B on 4/24/24 at 10:53 a.m., indicated the Surveyor requested the policy on wander guard use, among other documents. Other requested documents were e-mailed to the Surveyor by Medical Records Staff B on 4/24/24 at 1:50 p.m., but the policy on wander guard use was not provided. Record review of the facility policy titled, Elopements, last revised in December of 2007, indicated, If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner .Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises .When the resident returns to the facility, The Director of Nursing Services or Charge Nurse shall: e. Complete and file an incident report and f. Document relevant information in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to manage two of three resident's (Resident 1 and Resident 2) pain according to professional standards of practice and resident's preferences when residents were not properly educated about their pain medication management. This failure resulted in increased pain levels and had the potential to cause a delay in recovery, impair mobility, impair mood, disturb sleep, and diminish quality of life and wellbeing. Findings: During an interview on 10/31/23, at 3:03 p.m., Resident 1 stated she had pain on the lower back, neck, and her whole body. Resident 1 stated her scheduled pain medication was not given on time. The longest she had to wait was half hour, depending on the nurse on duty. Resident 1 stated she did not like to wait because it messed up her schedule and made her pain worse. Resident 1 stated, about two weeks ago, a night shift nurse refused to give her pain medication, because the previous nurse supposedly already gave her 11 p.m. pain medication. The night shift nurse told her she would give the medication at 3 a.m. but did not come back. Resident 1 stated she missed her 11 p.m., and 3 a.m. pain medication and finally received medication at 7a.m. Resident 1 stated she did not receive medication from the nurse who was supposed to give her pain medication at 11 p.m. Resident 1 stated her pain level was always 10 (numerical pain rating scale 0-10: where 0 is no pain and 10 is the worst pain imaginable), and it took twice as long to relieve the pain. The Nurse argued with her like she was crazy, or not stable, and did not know about her medication. Resident 1 stated she did not feel respected by that nurse. A review of Resident 1's admission Minimum Data Set (MDS - a federally mandated clinical assessment tool) dated 9/6/23 indicated she was admitted [DATE] with a Brief interview for Mental Status (BIMS – a tool to assess cognitive function) score of 13 indicating Resident 1 was cognitively intact. Resident 1's facesheet (resident demographics) indicated she was admitted with a diagnosis of cancer of the breast, pressure ulcer of the sacrum, diabetes, and depression among other medical conditions. A review of Resident 1's Medication Administration Record (MAR) for 9/23 and 10/23 indicated she was prescribed Morphine (narcotic pain medication) 30 milligram (mg - unit of measure equal to a thousandth of a gram) to be given one (1) tablet twice a day routinely and Oxycodone (another type of narcotic pain medication) 10 mg to be given one (1) tablet every four (4) hours as needed (PRN – to be administered when it is requested by, or as needed by, the patient; is not scheduled and not required on a regular basis) for moderate (level 4-6) and severe (level 7-10) pain. During a follow-up interview on 10/31/23, at 4:15 p.m., Resident 1 stated she expected the Oxycodone every four hours. Resident 1 did not understand the order for the medication was to be administered every 4 hours PRN (as needed/ requested by the patient). During an interview on 10/31/23, at 3:33 p.m., Resident 2 stated she had back pain on the right side, had level 7 pain, and she had to wait at least 30 to 45 minutes for her pain medication. By that time the medication arrived she would be in tears. Resident 2 stated except for the two nurses who gave her medication on time, the others did not. Resident 2 states she did not feel respected, she felt like she was so much baggage. A review of Resident 2's admission MDS dated [DATE] indicated she was admitted [DATE] with a BIMS score of 14, suggesting she was cognitively intact. She had moderate level pain and was on pain medication. A review of Resident 2's Medication Administration Records for 10/23 indicated she was prescribed Oxycodone 5 mg to be given 1 tablet every 4 hours PRN for moderate (level 4-6) pain, and 2 tablets every 4 hours PRN for severe (level 7-10) pain. During a follow-up interview on 10/31/23, at 4:23 p.m., Resident 2 stated she thought the pain medication order was for Oxycodone every 6 hours. Resident 2 did not understand the order for her pain medication was to be administered every 4 hours PRN (as needed/per patients request). During a concurrent observation and interview on 10/31/23, at 4:28 p.m. Licensed Nurse A was observed administering 2 tablets of Oxycodone to a resident. Licensed Nurse A stated she had not asked the resident's pain level before she administered the medication. Licensed Nurse A stated she was told by her Certified Nursing Assistant that the patient was in pain. During an interview on 12/12/23, at 1:45 p.m., when asked who provides information to the residents about their pain medication, the Director of Nursing stated nurses explain the pain medication order and time of administration schedule to residents. Nurses educate patients about routine and PRN medication – it is a standard of practice. In cases when a medication is given early, [brand name ] -the computer program used by the facility for medication administration-, gave nurses a warning of an early administration of medication, but they could administer as early as an hour before schedule, then the nurse would have to complete a supplemental documentation of the early medication administration. During an interview on 12/13/23, at 11:17 a.m., Licensed Nurse B was asked what information was provided to a resident about their pain medication. Licensed Nurse B stated, depending on the physician order, a routine medication the resident did not have to ask for, it was [NAME] to them; it was usually ordered for consistent pain. A PRN (as needed) medication, the resident had to ask for, and the nurses would assesses pain if controlled or not. It was a nurse's duty to assess pain. Routine medication education included how early the medication may be given. When asked when this information was provided to the resident, Licensed Nurse B stated, every day or every time the resident verbalized misunderstanding. When asked why information on medication was not provided to a resident, Licensed Nurse B stated, some nurses did not know their patient well – they had not observed when (pattern or time) the patient took their medication, had not assessed the effectiveness of the pain medication, were lazy, or had not reviewed the patient's medication order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide safety reminders, guidance, and assistance to one of four residents (Resident 1) before he tripped on a transition strip on the floor and fell while walking at the lobby of the facility. This failure resulted in Resident 1 sustaining a closed or incomplete fracture of the neck of the right thigh bone, pain, and hospitalization. Findings: A review of records indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of asthma, cognitive (natural skills including attention, memory, processing speed, reasoning, planning, problem solving, and multitasking) communication deficit, anxiety disorder, and major depressive disorder, among other conditions. Resident 1 ' s Minimum data set (MDS – federally mandated process for clinical assessment of each resident in Medicare and Medicaid certified nursing homes of their functional capabilities and help nursing home staff identify health problems) dated 6/3/23, indicated he had short term memory problem and required limited assistance (staff providing guided maneuvering of limbs or other non-weight-bearing assistance) while walking the corridors, moving between his room and adjacent corridor on the same floor, or moving to and from distant areas on the floor. A review of the Resident 1 ' s care plan dated 1/16/21, indicated interventions to prevent falls included providing the resident/family/caregivers safety reminders and a safe environment with even floors, etc. A review of facility documents titled: 1) SBAR Communication Form and progress Note V-3 (pneumonic for Situation-Background-Assessment-Recommendation a framework for communication between members of the health care team about a patient's condition) dated 6/3/23 indicated Resident 1 had a witnessed fall on 6/3/23, and; 2) Progress Notes dated 6/3/23 titled: Post Fall indicated Resident 1 was sent to the acute hospital for a closed or incomplete fracture of the neck of the right thigh bone. During an interview on 6/14/23, at 1:03 p.m., Licensed Nurse A (LN A) stated Resident 1 fell on 6/3/23, around 3:30 p.m. during change of shift. LN A stated she was inside the admission office when she heard a commotion at the lobby and when she went to check was informed by another Licensed Nurse and the Receptionist about Resident 1 ' s fall. LN A stated she had briefly assessed Resident 1 before he was moved using a Hoyer lift (a portable total body lift or a patient lift used to allow a person to be lifted and transferred with a minimum of physical effort) and returned to his room. LN A stated Resident 1 was alert and oriented, lying flat on his back, his right leg was slightly over his left leg, refused to bend his legs because his back hurt and denied he had hit his head during the fall. LN A stated Resident 1 was using his walker independently. During an interview on 6/14/23, at 1:18 p.m., Unlicensed Staff B (ULS B) stated Resident 1 was walking and was maneuvering his walker to go over the transition strip on the floor near the receptionist counter at the lobby. ULS B stated the slider on Resident 1 ' s walker got stuck on the lip of the transition strip between wood floor to tile, and Resident 1 fell backward to the right still holding on to his walker. ULS B stated she ran to Resident 1, told him not to move while she called for assistance. ULS B stated Resident 1 was forgetful, asking why he was in pain several times. A review of Activities of Daily Living (ADL) record of Resident 1 between 5/27 to 6/3/23, titled: Follow-up Question Report 5/28/23 - 6/3/23, indicated, Resident 1 required limited 1-person physical assistance on: 5/28/23 at 2:19 p.m., 5/31/23 at 8:14 a.m., 5/31/23 at 2:18 p.m., 6/2/23 at 10:37 a.m., 6/2/23 at 2:16 p.m., and 6/3/23 at 10:53 a.m. during the 7-day look back period. A review of the facility ' s policy titled: Falls-Clinical Protocol revised 9/2021, indicated under the subheading Treatment/Management: based on resident assessment, the staff and physician will identify pertinent interventions o try to prevent falls and to address risks of serious consequences of falling. A review of facility policy titled Fall risk assessment, revised 12/2007, indicated under policy interpretation and implementation: the staff with the support of the Attending Physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, ADL capabilities and identify environmental factors that may contribute to falling and will collaborate and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. The policy did not specifically discuss implementation of interventions, such as adequate supervision consistent with a resident ' s needs and ADL capabilities, goals, care plan and current professional standards of practice to eliminate the risk, if possible, and, if not, reduce the risk of an accident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dignity and respect for one resident (Resident 8), when the resident regularly requested his fingernails be neatly trimmed but facility staff did not schedule time to provide the requested service. This failure resulted in Resident 8's fingernails growing long, sharp, and dirty, which caused Resident 8 to feel bothered by the long nails and caused accidental injuries to the resident's skin, and had the potential to cause an infection. Findings: A review of Resident 8's face sheet indicated he was [AGE] years old, admitted to the facility on [DATE] with the diagnoses of Hemiplegia (a symptom that involves one-sided paralysis) Hemiparesis (a weakness or the inability to move on one side of the body), Diabetes Mellitus (DM--a condition that happens when the body cannot use blood sugar normally) and Gout (an inflammatory disease affecting joints that is painful). A review of Resident 8's Minimum Data Set assessment (MDS--an assessment tool), dated 9/1/22, indicated a Brief Interview for Mental Status (BIMS--a screening tool for cognition) score of 15, indicating intact cognition. During a concurrent observation and interview on 11/15/22, at 10:37 a.m., Resident 8 was noted with long fingernails. Resident 8 stated his fingernails had not been cut by the nurse despite multiple requests. Resident 8 stated he had made this request weeks ago. Resident 8 stated his long fingernails nails were bothering him. Resident 8 stated that he had accidentally scratched his arms at night that resulted in scrapes and scratches. During an interview on 11/16/22, at 9:23 a.m., Certified Nursing Assistant Q stated there was a weekly nail care for residents, every Sunday, where residents nails were cut per facility policy. She stated that not cutting residents regularly can result to long fingernails which can cause accidental wound opening and scratches. She stated residents can acquire infection because long fingernails can harbor bacteria. During an interview on 11/16/22 at 9:32 a.m., Treatment Nurse stated the facility policy was to cut residents nails weekly every Sunday and as needed. She stated residents having long nails had a potential effect on residents dignity due to dirty nails. She stated bacteria can build up under the nails which can result to wound, infection and skin scratches. During a concurrent observation and interview on 11/16/22 at 9:40 a.m., Treatment Nurse verified Resident 8's fingernails were long. She stated Resident 8's fingernails looks like it had not been cut for 2 weeks. During an interview on 11/16/22 at 9:48 a.m., the Director of Nursing (DON) stated the facility policy was to ensure nail care was done weekly every Sunday. She stated the expectation was residents nails were cut as needed and weekly. She stated if the residents nails were long, the facility policy was not followed. The DON stated bacteria could be concealed under long fingernails and could result to skin breakdown and infection. During an interview on 11/16/22 at 10:23 a.m., MDS Coordinator stated he expected residents to have short fingernails. He stated having long fingernails can affect residents psychosocially since fingernails that were long could be dirty. He stated having long fingernails nails could result to accidental self harm, wound and infection. During an interview on 11/17/22 at 1:38 p.m., the Infection Preventionist (IP) verified Resident 8's long fingernails suggested it was not cut for more than 3 weeks. IP stated the facility policy was to provide nail care weekly. She stated Sunday was nail care day. She stated it was expected for staff to cut residents nails every Sunday. IP stated If residents nails were long and dirty, the facility policy was not followed. IP verified that residents having long nails are at risk for skin infection and self inflicted injury. During a review of facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL's), Supporting, undated, the P&P indicated appropriate care and services will be provided for residents who were unable to carry out ADL's independently such as personal hygiene and grooming. During a review of facility's policy and procedure (P&P) titled, Care of Fingernails/Toenails, undated, the P&P indicated it's purpose was to ensure nail bed are clean, nails are trimmed to prevent infections. It stated nail care includes daily cleaning and regular trimming.

Based on interviews and record reviews, the facility failed to follow its policy and procedure on disclosure and release of information, when a request for records of one resident (Resident 1) by her legal representative on 9/6/22, was not processed and released within two days. This failure did not ensure resident rights and had the potential to adversely affect Resident 1's health, safety, and best interests. Findings: During a review of Resident 1's admission Record, dated 9/23/22, the admission record indicated Resident 1 had Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). During a review of Resident 1's completed Physician Orders for Life Sustaining Treatment, (POLST) form, dated 6/27/22, at 2:20 p.m., the POLST form indicated, Resident 1's son was designated as her legally recognized decision-maker. During a concurrent record review and interview on 9/23/22, at 11:30 a.m., with Management Staff K, she stated she receives request for records via phone call or fax. Management Staff K stated the facility process was to fulfill a request for records within 48 hours. Management Staff K stated that on 9/6/22, she did not receive a request via fax or U.S. Mail from Resident 1's legal representative. Management Staff K stated that on 9/20/22, she received a phone call from Resident 1's legal representative, in follow-up to a request sent on 9/6/22, on behalf of Resident 1. Management Staff K stated that after the phone call, she started working to get the requested records right away. Management Staff K presented a document, indicating Resident 1's legal representative sent the facility a request for Resident 1's records via fax on 9/6/22, at 10:31 a.m. Management Staff K stated that she did not know if any staff received a fax or mail regarding the request for Resident 1's records that day. Management Staff K stated that during the call on 9/20/22, she informed Resident 1's legal representative the facility could provide the requested records in a couple of days. During an observation on 9/23/22, at 1:40 p.m., Management Staff K provided a test fax, sent by the Department to the facility's fax number on 9/23/22, at 1:33 p.m., which indicated no fax transmission issues. During an interview on 11/3/22, at 10:30 a.m.,Management Staff K stated the facility had no process to ensure the faxes received by the facility reach their intended recipient. Management Staff K stated the facility Administrator was not aware of the phone call on 9/20/22, with Resident 1's legal representative. Management Staff K stated she sent the requested medical records to Resident 1's legal representative on 9/27/22, and the billing records were sent on 10/19/2022. During an interview on 11/3/22, at 10:35 a.m., the Administrator stated that he was not aware of the call regarding a renewed request for records that Management Staff K received on 9/20/22. During a review of a facility policy and procedure (P&P) titled, Health Information Record Manual, Chapter IV 4020 Disclosure/Release of Information/Authorization, dated 2/16/19, the P&P indicated, The facility will keep all information in the resident's records confidential, except when release is to the resident or the resident representative where permitted by applicable law, required by law (i.e. subpoena or regulatory reason) or for treatment, payment, or healthcare operations permitted and in compliance with HIPAA .The Health Information Department will be responsible for: Making electronic and manual medical records, protected health information, under the supervision of the Administrator and in consultation with the Health Information Consultant. When the information is in electronic format, the resident may direct the facility to transmit such copy directly to any entity or person designated by the [resident], provided that such choice is clear, conspicuous, and specific.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1) Ensure of one of one resident (Resident 280) was protected from potential abuse, when it discharged Resident 280 home with the suspected abuser on 10/22/22 without notifying Adult Protective Services (APS, a state-funded program that promote safety, independence, and quality-of-life of vulnerable adults). 2) Report the result of its abuse investigation for two of two residents (Residents 280 and 38) to the State Survey Agency (SSA), within 5 working days of the incident. These failures did not ensure residents' right to be protected from abuse, and did not comply with facility policy and procedure. Findings: 1) During a review of Resident 280's face sheet (demographics), it indicated she was [AGE] years old and was admitted to the facility on [DATE]. Her diagnoses included Parkinson's Disease (PD-a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and muscle weakness. During an interview on 11/16/22 at 11:08 a.m., IP stated that yelling, name calling, calling a person lazy was considered an abusive behavior. She stated name calling can be considered an emotional abuse if there was an emotional outcome. IP stated abuse between a family member and resident should be reported to APS. During a concurrent interview and nursing and social services note record review on 11/16/22 at 3:08 p.m., the Social Services Director (SSD) verified there was an incident reported by a nursing student teacher on 10/20/22 , a concern that Resident 280 might be being emotionally abused by her daughter. SSD stated a day after the report was made, Resident 280 requested to be discharged to home to her daughter that was allegedly abusing her. SSD stated that APS should had been contacted per facility policy. SSD verified that APS was not contacted when Resident 280 was discharged to home. SSD stated since this incident was not reported to APS, this could put Resident 280 at risk for further abuse at home. During an interview on 11/16/22 at 4:14 p.m., the Director of Nursing (DON) stated that this incident should have been reported to APS per facility policy. She verified that SSD/facility did not call APS about this incident. She stated that the facility policy was not followed when this incident was not reported to APS. She stated this placed Resident 280 at risk for further abuse at home. The DON also verified there was no 5 day investigative report completed and submitted to State Survey Agency (SSA) for Resident 280 During an interview on 11/17/22 at 11:40 p.m., the Administrator verified that on 10/20/20 Resident 280's daughter spoke to him and was really upset that the DON and the SSD felt she was abusing Resident 280. He stated Resident 280's daughter gives her tough love to get her better and that Resident 280's daughter even admitted she tells her mom like it is. Administrator stated Resident 280's daughter even recommended that he speaks with Resident 280 because she wants to sue the facility for accusing her daughter of abuse. The administrator verified APS was not notified of Resident 280's possible abuse from her daughter. The Administrator stated the facility should have contacted APS when Resident 280 was discharged to home with her daughter, the day after the facility reported the abuse. He stated APS notification was important to ensure Resident 280's safety. He stated that failure to report to APS could result to further abuse at home. He stated that APS could investigate further and follow up on the abuse allegation since Resident 280 was discharged to home with her daughter. During a review of facility's policy and procedure (P&P) titled, Elder/Dependent Abuse, revised 5/21/19, the P&P indicated the facility should control visits by family pending investigation by allowing only visits in presence of staff or denying access to the facility. During an interview on 11/17/22 at 11:40 a.m., the Administrator verified he did not complete nor submitted Resident 280's 5 day investigative report to SSA. The administrator stated he did not complete nor submitted to SSA the 5 day investigative report for Resident 280 because he was not aware it was needed. 2. During a review of Resident 38's face sheet (demographics), it indicated he was [AGE] years old and was admitted to the facility on [DATE]. His diagnoses included Parkinson's Disease (PD-a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Paraplegia (a partial or complete paralysis of both legs) and Bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). During a review of Resident 280's face sheet (demographics), it indicated she was [AGE] years old and was admitted to the facility on [DATE]. Her diagnoses included Parkinson's Disease (PD-a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and muscle weakness. During an interview on 11/16/22 at 4:14 p.m., the DON stated the facility did not complete or submit a 5-day investigative report to the State Survey Agency (SSA) regarding abuse allegedly suffered by Resident 280 and Resident 38. During an interview on 11/17/22 at 11:40 a.m., the Administrator verified the facility neither completed nor submitted 5-day investigative reports regarding the reports of abuse concerning Resident 280 and Resident 38 to SSA. The administrator stated he did not complete or submit reports because he was not aware it was needed. During a review of facility's policy and procedure (P&P) titled, Elder/Dependent Abuse, revised 5/21/19, the P&P indicated the facility will have evidence that all alleged violations were thoroughly investigated .that results of all investigations were submitted to the SSA within 5 working days of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet the activities' interests of one of 18 sampled residents (Resident 183) when Resident 183 enjoyed watching TV but was provided the remote control of another resident's TV. This failure did not support the well-being of Resident 183, which required the resident to watch TV looking sideways and caused the resident discomfort and neck pain. Findings: A review of Resident 183's facesheet indicated Resident 183 was admitted to the facility on [DATE] with diagnoses including depression and muscle weakness. During an observation on 11/14/22, at 10:10 a.m., Resident 183 was in his room. The room had two beds: one close to the door (Bed A) and one close to the window (Bed B). Each bed had a TV located in front of the bed. Resident 183 was lying in Bed A, but his head was turned to the left, and he was watching the TV placed in front Bed B. The TV placed in front of Resident 183's bed was turned off. During a concurrent interview, Resident 183 stated his TV was broken and for this reason he was watching the TV in front of the other bed, to his left. Resident 183 stated it was uncomfortable for him to turn his head to the left to watch TV and it caused him neck pain. A review of Resident 183's activities care plan, initiated on 11/09/22, and revised on 11/12/22, indicated Resident 183 enjoyed watching TV. During an interview an interview on 11/14/22, at 3:31 p.m., Resident 183 stated his favorite activities were sleeping and watching TV. During an observation on 11/15/22, at 1:45 p.m., Resident 183 was in his room lying in Bed A. During a concurrent interview, Certified Nursing Assistant (CNA) L was asked to turn on the TV in front of Resident 183's bed. CNA L removed a remote control from Resident 183's bedside table, pointed it towards the TV in front of his bed, and pressed the power button. The TV in front Bed A remained off but the TV in front of Bed B, to the left of Resident 183, turned on. During a concurrent interview, the Director of Maintenance (DM) explained both TVs were operational, but the remote controls had been inadvertently switched, so that Resident 183, who was on Bed A, had the remote control of the TV for Bed B and vice-versa. The DM stated this was a problem and happened often because the TV remote controls were identical and were not marked to which TV they belonged to. A review of facility policy titled Activities and Social Services, revised December 2006, indicated: Residents shall have the right to choose the types of activities and social events in which they wish to participate .

Based on observation and interviews, the facility failed to follow its policy and procedure in safe storage of food in the dry storage area when one expired item (seasoning sauce) was stored with other food items. The dietary staff wrote on the seasoning sauce container that it was opened on 10/26/21, and a used by date of 10/26/2022. The sauce container had a manufacturer's recommendation indicating it was best to use date by 7/31/2022. This failure had the potential to result in food borne illnesses to the residents of the facility. Findings: During a concurrent observation and interview on 11/16/22, at 9:55 a.m., with the Dietary Manager, at the kitchen's dry storage area, it was observed that a special sauce container with its content, was on the pantry along with other food items. The container had a hand-written date indicating it was opened on 10/26/21, and the use by date written was 10/26/22. Stamped on the sauce container was a manufacturer's recommendation that it was best to use by 7/31/22. A picture of the sauce container, along with the dates written on the container, was taken while the Dietary Manager was holding the container and also looking at the dates written and stamped on the sauce container. The Dietary Manager stated that the food item should have been discarded. The Dietary Manager was observed taking the expired sauce out of the dry storage area. During and interview on 11/16/22, at 10:31 a.m., with the Dietitian, he stated that the Dietary Manager and Dietary Staff A were responsible to check for expiration dates on the food items at the dry storage area at the end of each month. The dietitian stated that the expired sauce found on the pantry was missed and was not taken out of the storage area. A facility policy and procedure (P&P) titled, Canned and Dry Goods Storage, dated 2018, indicated, All the food and non-food items purchased by the Department of Food and Nutrition services will be stored properly. All open food items will have an open date and use-by-date per manufacturer's recommendation .New stock must be placed behind old stock so oldest items will be used first. Products should be dated to assure FIFO-First In-First Out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff demonstrated the appropriate use of PPE, when one direct care staff demonstrated inappropriate PPE re-use and santizing practices. These failure did not minimize the risk of spreading infection in the facility and did not comply with facility policy and procedure. Findings: During an interview on 11/17/22 at 1:38 p.m., the IP verified Human metapneumovirus (hMPV) is a common respiratory virus that causes an upper respiratory infection (like a cold or flu). She stated residents with hMPV should be placed on contact and droplet precautions (transmission-based precautions used when caring for patients whose illness may trasmit to other humans in contact with surfaces in a resident's room or when in close proximity to the resident) to prevent spread of infection. During a concurrent observation and interview in room [ROOM NUMBER] on 11/17/22, at 3:00 p.m., Certified Nursing Assistant (CNA) R was observed wearing two masks--a surgical mask placed atop of an N95 mask (a mask that offers the highest level of protection). CNA R stated she was double-masking and stated double-masking was the facility's policy. When not worn, CNA R stored her N95 and a face shield in a the brown bag. Unlicensed Staff stated she wiped down the inside and outside of the faceshield with santizing wipes, and placed the still-wet face shield inside the brown bag immediately after wiping it down. CNA R stated she did not know the contact time (e.g., the amount of time a disinfectant needs to sit on a surface, without being wiped away or disturbed, to effectively kill germs) for the santizing wipes she used. CNA R checked the package of the santitizing wipes and verified the wipes required 2 minutes contact time. CNA verified she did not wait for 2 minutes before placing the face shield inside the brown bag. During an interview on 11/17/22 at 3:30 p.m., the IP verified it was not the facility's policy to double mask. IP verified N95 is not even needed to be worn when caring for residents with an active infection of hMPV. IP stated a surgical mask should have sufficed. IP verified that the staff should have waited for 2 minutes before placing the face shield in the brown bag. She stated that brown bag were porous and placing a wet item inside the bag could compromise the integrity of the bag. She stated this could result to the brown bag getting ripped or torn easily, allowing bacteria to seep through the brown bag. IP stated the facility does not practice re using N95 since this requires staff to touch the mask frequently which could result to contamination. IP stated donning and doffing N95 frequently affects the over all fit of the mask which could affect the ability of the mask to adequately protect staff from virus. She stated this practice was an infection control issue and could result to residents or staff getting sick and acquiring infection. During a review of facility's policy and procedure (P&P) titled,Personal Protective Equipment- Face Mask, undated, the P&P indicated masks were used only once and discarded. During a review of facility's policy and procedure (P&P) titled, Isolation--Categories of Transmission based Precautions, undated, the P&P indicated that staff caring for residents on droplet precaution should wear a medical grade face mask.

Based on observation, interview and record review, the facility failed to ensure a comfortable environment for eight of 74 residents (Residents 19, 23, 31, 43, 47, 55, 60 and 182) when the ambient temperature at the facility was too cold for these residents. This failure resulted in Residents 19, 23, 31, 43, 47, 55, 60 and 182 reporting feeling cold and uncomfortable in their rooms. Findings: During an interview on 11/14/22, at 10:34 a.m., Resident 60 stated the temperature in his room was uncomfortably cold. During an interview on 11/14/22, at 10:36 a.m., Resident 182 stated the temperature in his room had been uncomfortably cold for the past two or three days. Resident 182 reported it was freezing in his room. During an interview on 11/15/22, at 9:30 a.m., Resident 55 stated the temperature in her room was uncomfortably cold. Resident 55 stated her room felt like an icebox. During observations on 11/16/22, starting at 8:30 a.m., with the Director of Maintenance (DM), the DM measured the ambient temperature of 32 of 34 resident rooms (room numbers 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 34, 35 and 36). During concurrent resident interviews, five residents, Residents 19, 23, 31, 43 and 47, reported the temperature in their rooms was uncomfortably cold. The DM measured the temperature in the rooms of these residents and, during a concurrent interview, stated it was 67° Fahrenheit (F) in Residents 19 and 43's room, 68° F in Resident 31's room and 69.5° F in Residents 23 and 47's room. The DM stated he set the facility's thermostats for 72° F throughout the facility. A review of facility policy titled Room Temperature, undated, indicated: It is the policy of this facility to provide a comfortable and safe temperature levels and that Facility shall maintain a safe a comfortable temperature levels or room temperature range of 71° - 81° F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 279's demographics indicated she was [AGE] years old, admitted to the facility on [DATE],with diagnoses of Muscle Weakness, Difficulty in Walking, Sciatica (aggravation of the sciatic nerve, which travels from butt to foot, causing pain along the nerve's pathway) and Spinal Stenosis (narrowing of space between spinal vertebrae) of the Cervical (neck) region. Resident 279 had an additional diagnosis of right ankle fracture on 1/14/22. Review of Resident 279's Minimum Data Set (MDS, an assessment tool), dated 12/14/22, indicated a Brief Interview of Mental Status (BIMS, a brief interview assessment for mental status) score of 11, indicating moderately impaired cognition. The MDS assessment also indicated Resident 279 required extensive assistance of 1 person when toileting and transferring. During a concurrent interview and skilled assessment charting review on 11/16/22 at 11:28 a.m., the Infection Preventionist (IP) verified facility staff completed a initial fall assessment for Resident 279 on 12/7/21. The Fall assessment indicated Resident 279 scored a total of 8, meaning the resident was a low risk for fall. IP stated the facility's protocol for managing residents with high fall risks included resident monitoring every 2 hours, low bed, fall mattress, room assignment (near nursing station). IP reviewed Resident 279's medical record including several fall incidents indicated therein. IP stated that based on these information from the record, the facility should have initiated scheduled toileting as an intervention for Resident 279. IP verified Resident 279 was not on scheduled toileting or a bladder and bowel (B/B) training program (e.g., a program aimed to minimize episodes of incontinence or urgency, and promote controlled bowel and bladder elimination) when she fell on 1/10/22. During a concurrent interview and record review on 11/17/22, at 10:13 a.m., the Director of Nursing (DON) stated Resident 279 was alert and oriented, but very impulsive. The DON verified Resident 279 fell while transferring commode unassisted, on 1/10/22. The DON also verified Resident 279 had three other falls between admission and readmission: [DATE], 12/30/21, and 3/16/22. The DON stated three of four falls occurred when the resident transferred to the commode unassisted to meet her toileting needs. The DON reviewed Resident 279's care plan that concerned the resident's risk of falling, dated 12/31/21. The DON stated the care plan indicated Resident 279 should have been on a B/B training program. Continuing the concurrent interview and record review, initiated on 11/17/22 at 10:13 a.m., the DON reviewed Resident 279's IDT- Incident Review for Fall, dated 12/30/22, which indicated a recommendation to enroll Resident 279 in the facility's B/B training program and for staff to verbally prompt with the resident every 2 hours about the resident's need to toilet. The DON stated that Resident 279's fall incident on 1/10/22 could have been prevented had Resident 279 called for help before self-transferrring to a commode without staff assistance. When asked what interventions were put in place to ensure Resident 279's risk of falling decreased prior to 1/10/22, DON was silent. DON stated Resident 279's fall care plans did not directly address the root cause of the resident's falls. The DON stated she expected the staff to assist Resident 279 during toileting based on her care plan and MDS assessment. The DON stated Resident 279's risk of falling on 1/10/22 would have decreased had the facility placed Resident 279 on a B/B program beforehand. During a concurrent interview and record review on 11/18/22, at 8:24 a.m., the OT / Assistant Rehabilitation Director (OT) stated Resident 279 consistently used the commode without asking staff for assistance. She stated her expectation was that clinical staff would assist Resident 279 when toileting, for safety. The OT verified that Resident 279's participation in the facility B/B training program began on 5/4/22. OT verified facility staff did not institute a toileting program prior to Resident 279's fall on 1/10/22, and after IDT's 12/30/22 recommendation to place the resident on B/B training program. During a review of facility's policy and procedure (P/P) titled Fall and Fall Risk- Managing revised 3/2018, the P&P indicated staff will identify residents specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .staff will try to minimize the serious consequences of falling .if resident continues to fall, staff will re-evaluate the situation and whether it was appropriate to continue or change the interventions. Based on observation, interview, and record review, the facility failed to minimize accident hazards for three of 24 sampled residents (Residents 41, 279, and 2), when facility staff did not: 1. For Resident 41, accurately indicate the resident's fall history, past medical history, and medication history when assessing the resident's risk of falling. 2. For Resident 279, plan the resident's bowel and blader care to include interventions to mitigate falls associated with the resident's toileting pattern. 3. For Resident 2, implement fall prevention interventions to mitigate the resident's fall risk. The failure associated with Resident 41 resulted in the facility not collecting sufficient data to plan for the resident's fall risk and safety, and had the potential to not prevent future falls. The failure associated with Resident 279 contributed to the resident's fall 1/10/22 that caused a right ankle fracture. The failures associated with Resident 2 resulted in the resident experiencing two falls on 2/17/22 and 10/25/22, the second causing a leg fracture. Findings: 3. A review of Resident 2's Facesheet indicated she was admitted to the facility on [DATE] for rehabilitation following a fracture and surgical repair of the left femur (the thigh bone). Resident 2's Facesheet indicated additional diagnoses of Alzheimer's (dementia), muscle weakness, abnormalities of gait and mobility, unsteadiness of feet, need for assistance with personal care and heart failure. During an observation and interview on 11/14/22, at 4:37 p.m., Resident 2 stated she was recovering from a fall where she broke her leg. Speaking about the fall, Resident 2 stated: It definitely hurt and It hurt really good. During an interview on 11/17/22, at 2:25 p.m., the Director of Nursing (DON) stated Resident 2 was originally admitted to the facility on [DATE], but was discharged to the hospital on [DATE] because of fall with injury. The DON stated Resident 2 returned to the facility on [DATE], for rehabilitation following surgical repair of a leg fracture sustained because of the fall. During the same interview on 11/17/22, at 2:25 p.m., the DON stated Resident 2 fell a total of three times since her original admission to the facility, 7/22/20. The DON stated Resident 2 fell on 1/11/22 while transferring from the bathroom to the bed, fell a second time on 2/17/22 also during a transfer from the bathroom to the bed and fell a third time on 10/25/22 while transferring from the bed to the bathroom. The DON stated Resident 2 had intermittent confusion because of a diagnosis of dementia. First Fall: 1/11/22 A review of Resident 2's Fall Risk assessment dated [DATE], the latest fall risk assessment completed prior to the first fall on 1/11/22, indicated Resident 2 was at low risk of falls. During a concurrent interview and record review on 11/17/22, at 2:25 p.m., the DON was present. The DON reviewed Resident 2's fall prevention care plan, created 6/7/21 and titled: Resident is at risk for falls r/t Deconditioning, Gait/balance problems, incontinence, poor communication/comprehension, psychoactive and opioid drug use, unaware of safety needs . The care plan indicated the following fall prevention interventions: (1) anticipate and meet the resident's needs; (2) ensure call light is within reach and encourage the resident to use it for assistance as needed; (3) encourage resident to participate in activities; (4) follow facility fall protocol; and (5) physical therapy to evaluate and treat as ordered. The care plan indicated these interventions were implemented starting 7/30/20. The DON confirmed this was the active care plan to manage Resident 2's risk of falls on 1/11/22, prior to the first fall. The DON stated these interventions were put in place on Resident 2's initial admission, or 7/22/20, and predated the creation of the fall care plan dated 6/7/21. During a review of Resident 2's record the report titled Interdisciplinary Team [(IDT)] Incident Review indicated a description of Resident 2's first fall on 1/11/22. The IDT Report indicated the fall occurred in the early morning of 1/11/22, at 3:00 a.m., and described the fall as follows: Resident called for assistance, when staff/LN [Licensed Nurse] arrived resident was found sitting in the bathroom floor and was trying to stand up on her own. Resident stated she hit her head and knees. Upon assessment found with some blood on forehead and claimed with pain on both knees. RP[Responsible Party] / MD [Medical Doctor] contacted. Resident was sent out to ER for eval[uation]. The IDT Report indicated the following contributing factors to the fall: (1) diagnoses of dementia and chronic pain; (2) impaired mobility; (3) cognitive impairment; and (4) use of assistive devices/equipment. Under the section, Impaired mobility comments, the IDT Report indicated the following: Weakness, uses [Front-Wheeled Walker] for stability but [due to] cog[nition] res[ident] forgets to [use Front-Wheeled Walker]. Under Cognitive Impairment the IDT Report indicated Alzheimer's Dementia and under Comments indicated Forgetful, needs reminding and under Interventions/Recommendations indicated Remind resident to call for assistance as needed, use well-fitting shoes or non-skid socks with ambulation, and under Additional Comments the IDT Report indicated De clutter bed space. A review of Resident 2's fall care plans indicated the facility updated the resident's fall care plan after the first fall on 1/11/22, with title Fall on 1/11/22 with minor scratch to forehead and the interventions of De clutter bedroom space . The fall care plan did not contain the intervention, recommended in the IDT Report dated 1/11/22, of ensuring resident wore well fitting shoes or non/skid socks with ambulation. During an interview on 11/17/22, at 2:25 p.m., the DON confirmed the IDT Report recommended that Resident 2 wear shoes or non-skid socks to prevent slipping on the floor and decluttering the room to prevent tripping over objects. The DON further stated that Resident 2 was evaluated and treated by Occupational Therapy after the first fall to improve mobility and that Resident 2 was discharged with an assessment that Resident 2 was able to ambulate and transfer independently, without staff assistance. During interviews on 11/17/22, at 4:40 p.m. and on 11/18/22, at 9:20 a.m., the Occupational Therapist and Director of Rehabilitations (OT/DH) stated she evaluated and treated Resident 2 after the first fall. The OT/DH stated Resident 2 received occupational therapy from 1/24/22 to 2/4/22 and was discharged with a functional level of Modified Independence, which the OT/DH described as meaning Resident 2 was able to safely transfer and ambulate with the assistance of mobility devices, such as a walker, but without the need for staff assistance. The OT/DH stated Resident 2 was not further evaluated or treated by the rehabilitation department after being discharged on 2/4/22, until she returned from the hospital on [DATE]. Second Fall: 2/17/22 A review of Resident 2's Fall Risk assessment dated [DATE], the latest fall risk assessment completed prior to the second fall on 2/17/22, indicated Resident 2 was at a high risk of falls. The Fall Risk Assessment indicated fall risk factors such as history of falls, decreased muscular coordination, jerking or unstable when making turns, use of assistive devices, use of medications and predisposing diseases. A review of progress note dated 2/17/22, at 10:32 p.m., titled Post Fall, written by Licensed Nurse M, indicated: Resident was found by LN on the floor of her bathroom, sitting on her buttocks with legs underneath her. She reported [NAME] slipped while trying to get up from the toilet. Resident reports was not wearing any footwear at the time . A review of the facility's Interdisciplinary Team Incident Review (IDT Report) for Resident 2's second fall, dated 2/17/22, indicated the fall occurred on 2/17/22, at 9:00 p.m. The second IDT Report described the fall as follows: Resident was found in the bathroom floor with her legs underneath her facing the sink. Resident claimed that her legs slipped and she ended up on the floor on her bottom. Resident denies hitting her head and denies pain. Upon assessment observed with quarter size purplish discoloration to left knee. Resident mechanically transferred to bed. Reminded to call for assistance as needed. The second IDT Report indicated the following contributing factors: (1) diagnoses of dementia and chronic pain; (2) impaired mobility; (3) cognitive impairment; (4) use of assistive devices/equipment and (5) history of falls. The second IDT Report further indicated under Impaired mobility comments the following: Weakness and with poor safety awareness. Under Cognitive Impairment and With Dementia . Does not always call for assistance . and under Comments indicated Resident does not call for assistance as needed, reality oriented as needed under Interventions/Recommendations indicated Reality orientation provided regarding safety reminded to call for assistance at all times if needed refer to therapy for eval post fall and Under Additional Comments indicated Monitor and check q2 hours [(every 2 hours)] for needs and comfort . A review of the Resident 2's clinical record indicated note titled Rehab Post Fall Assessment dated 2/18/22, indicating: OT [Occupational Therapy] completed fall risk assessment, recommended environmental modifications. Specifically, removing current shower chair over toilet and replacing with raised commode seat appropriately modified with correct height for patient to minimize patient risk for falls. Additionally, recommending 2-hour toileting program. During interviews on 11/17/22, at 4:40 p.m. and on 11/18/22, at 9:20 a.m., the Occupational Therapist and Director of Rehabilitations (OT/DH) stated she wrote Resident 2's Rehab Post Fall Assessment note, dated 2/18/22. The OT/DH stated Resident 2 fell on 2/17/22 because the shower chair over the toilet in her bathroom which she was using on 2/17/22 was too high for her. OT/DH stated the shower chair was not of an appropriate height and size for Resident 2 and stated Resident 2 required a toilet seat of lower height. The OT/DH stated the shower chair used by Resident 2 over the toilet on 2/17/22 belonged to another resident that was using the same bathroom. The OT/DH was asked if the shower chair contributed to the fall on 2/17/22. The OT/DH stated no, it caused of the fall of Resident 2. The OT/DH stated Resident 2 fell because the shower chair was not safe due to being the wrong size. During the same interviews on 11/17/22, at 4:40 p.m., and on 11/18/22, at 9:20 a.m., the OT/DH was asked why she recommended the 2-hour toileting program (e.g., an intervention where staff check on the resident every two hours to see if the resident needs toileting). The OT/DH stated it was for added staff supervision of Resident 2 while ambulating, to have an extra set of eyes on her. A review of progress note dated 2/18/22, at 2:37 p.m., titled Post Fall, written by Licensed Nurse N, indicated: Prior to this fall resident always non-compliant in using her walker and independently goes to the bathroom by herself without assistance. A review of Resident 2's fall care plans indicate it was updated after the second fall on 2/18/22, with the following fall prevention interventions: (1) Attend to resident promptly; (2) Call light within reach; (3) Encourage call for help; (4) Notify family / MD of any fall/injury; (5) Observe for potential adverse effects from medications . (6) Observe for signs/symptoms of Hypo/Hyperglycemia; (7) Offer/Assist with toileting before meals, before bedtime and PRN [as needed]; (8) OT [occupational Therapy] / PT [Physical Therapy] evaluation and treatment per MD order to improve functional mobility and safety; (9) Post fall assessment PRN; and (10) Provide clean, clutter free environment. Third Fall: 10/25/22 During a review of Resident 2's Fall Risk assessment dated [DATE], the latest fall risk assessment completed prior to the third fall on 10/25/22, indicated Resident 2 was a low risk of falls. The Fall Risk Assessment indicated Resident 2 had no balance or gait problems, though did indicate Resident 2's use of medications that increased the potential for falling. During a review of Resident 2's Order Review History Report, for the inclusive period of 10/1/22-10/31/22, the orders indicated Resident 2 received Fentanyl (a synthetic opioid for pain management that is 50-100 times stronger than morphine) dosed at 50 MCG/HR [Micrograms/Hour] every 72 hours (order dated 7/24/20) via patch, Duloxetine (a medication for depression) dosed at 30 MG [Milligrams] twice a day (order dated 10/23/22), and Donepezil (a medication to treat dementia) dosed at 10 MG (order dated 11/1/22). All medications could cause somnolence, dizziness and tremors, and increase the risk of falls. A review of Resident 2's Minimum Data Set (MDS - a comprehensive assessment of the resident), dated 10/18/22, indicated it was the most recent MDS assessment completed prior to the third fall. Section G of the MDS, Functional Status, indicated Resident 2 could not safely transfer independantly to and from the bed, walk in the room, toilet use or personal hygiene. The MDS indicated, for all those actions, Resident 2 needed Supervision - oversight, encouragement or cueing as well as One person [staff] physical assist. A review of the facility's Interdisciplinary Team Incident Review (IDT Report) for the third fall, dated 10/25/22, indicated the fall occurred on 10/25/22 at 8:40 a.m. The third IDT Report described the fall as follows: Resident had unwitnessed fall this morning in room. Found sitting up, bearing weight to left wrist and leaning on left hip. No bleeding or bruising noted. Severe pain noted to left hip. Unable to straighten left leg due to pain. Per son request, patient to go to hospital for further eval. MD notified . The third IDT report indicated the following were factors that contributed to Resident 2's fall: (1) behaviors (2) impaired mobility; (3) cognitive impairment; (4) use of assistive devices/equipment and (5) history of falls. The third IDT report indicated under Behaviors the following: Resident collects unnecessary things and brings more stuff from home brought in by son, cluttered area adjacent to bed which makes not enough space for resident to freely navigate area with FWW. Reality orientation provided to RP and Resident but not quite understanding safety and hazard, under Impaired mobility comments the following: unsteadiness to gait and balance, under Cognitive Impairment indicated dementia, forgetfulness ., and under Comments indicated, Resident is deemed independent in the room by therapy for toileting and ambulation. A review of progress note dated 10/25/22, at 10:48 a.m., titled Post Fall, written by Licensed Nurse O, indicated: Staff notified this LN that the patient was on the floor. Upon LN arrival, patient found sitting on floor on left side of bed. Patient was holding herself up with left wrist and leaning on left hip. States she was trying to ambulate to bathroom. Verbalized that she fell on her ass . Patient complaining of severe pain 9.5/10 [(e.g, zero to scale where zero mean no pain and 10 worst pain)] .911 called at 0845 [(8:45 a.m.)]. During an interview on 11/17/22, at 2:25 p.m., the DON stated a clinical nursing instructor supervising student nurses at the facility had found Resident 2 on 10/25/22, and alerted staff of her fall. The DON stated Resident 2 fell because of clutter around her bed. The DON stated Resident 2 filled the area around her bed with personal belongings leaving no space to move around with the walker. The DON stated Resident 2 attempted to transfer out of the bed using the walker but tripped on the clutter around her bed. The DON stated Resident 2 had a history of collecting personal objects and placing them around the bed which posed a safety hazard. The DON stated the clutter around her bed caused the fall. During the same interview on 11/17/22, at 2:25 p.m., the DON stated Resident 2 had been cleared by physical therapy to ambulate unassisted after being evaluated and treated following the first fall on 1/11/22. However, because Resident was at risk for falls, she had been placed on a Q2 [every two] hours toileting program. The DON explained a toileting program required certified nursing assistants (CNAs) to visually check and ask Resident 2, every two hours, if Resident 2 needed to use the toilet, and if the answer was positive, then CNAs assisted or supervised Resident 2 to the toilet. The DON stated the toileting program was a safety measure to prevent accidents such as falls. The DON stated every instance CNAs checked on residents who were on a toileting program they documented they did so on the resident's chart. During an interview on 11/18/22, at 1:21 p.m., the DON provided copies of the section of Resident 2's chart where CNAs documented the toileting program checks, titled Documentation Survey Report v2 . Intervention/Task - Scheduled toileting to minimize patient risk for falls. for October 2022. A review of this report for 10/25/22, the date of Resident 2's fall, indicated staff checked and offered toileting to Resident 2 on 10/25/22 only twice, at 11:32 a.m., and at 9:26 p.m. The DON stated staff should have checked on Resident 2 every two hours and documented the checks on the chart. A review of facility policy titled Falls and Fall Risk, Managing, revised 3/2018, indicated: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy also indicated: Fall Risk Factors . Environmental risk factors that contribute to the risk of falls include . footwear that is unsafe or absent .obstacles in the footpath . The policy additional indicated Resident conditions that may contribute to the risk of falls include: .delirium and other cognitive impairment . lower extremity weakness .medication side effects .functional impairments . and [m]edical factors that contribute to the risk of falls include: .heart failure .balance and gait disorders . Furthermore, the policy indicated The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Moreover, the policy indicated Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear . 1. During record review the admission Record for Resident 41 was reviewed. Resident 41 was admitted on [DATE] and had the following diagnoses: Left hip fracture, Dementia, Heart failure, and osteoarthritis. During an interview on 11/16/22, at 3:00 p.m., the DON stated she was present at the facility whe Resident 41 fell on [DATE]. The DON stated Resident 1 was alert and oriented at the time of the fall. The DON stated at the time of the fall she helped the bedside nurse by initiating the fall risk assessment for Resident 41. DON stated, I started the fall risk evaluation. I answered it as to how the resident was at the time of the fall. DON stated she started the form, but did not review the resident's medical records when answering the questions. DON stated the document was closed by other nursing staff. During record review of Resident 41's medical records, a SBAR Communication Form and Progress note dated 10/4/22 was reviewed. The SBAR documented that Resident 41 was found on the floor next to her bed on the morning of 10/4/22. It was documented that Resident 41 may have rolled out of bed, potential due to increased confusion. Resident 41's Fall Risk assessment dated [DATE] (day of admission) had a total score of 14, and was categorized as a high risk of falls. Question 7 indicated categories of medications. Resident 41 scored a 2, because she was on two categories of medication, a diuretic (water pill) and anti-hypertensive (for lowering blood pressure). Question 8 indicated twelve predisposing diseases including Arthritis, Osteoporosis (e.g., bone deterioration), fractures (broken bones), and dementia. Resident 41 scored a 2 for this question, as the resident had a history of fracture and dementia. Resident 41's Fall Risk Assessment, dated 10/4/22 had a total score of 9, categorized as a low risk for falls. Question 7 had a score of 0 to indicate resident was not on medications listed with the question. Question 8 was scored at 0 for no Predisposing diseases. Resident 41's Fall Risk assessment dated [DATE] had a total score of 20, categorized as High Risk for falls. Question 7 scored at a 4 due to three to four of the medication types listed were being given to Resident 41. These were diuretic, antihypertensive and narcotics. Question 8 was scored at a 4 due to three or more predisposing diseases were present, Arthritis, Fracture and Dementia.

Based on interview and record review, the facility failed to keep record of visits from the attending physician for one of three sampled residents, Resident 76. This failure resulted in Resident 76's caregivers and practitioners having no written record of his physician's examination, plan of care, or clinical decision-making for a six-month period of time. Findings: During a record review on 11/8/22 at 1:30 p.m., Resident 76's facesheet revealed an admit date of 2/18/22 and discharge date of 9/2/22. Review of Resident 76's paper and electronic medical records revealed there were no progress notes written by Resident 76's attending physician after 2/24/22. During a record review and concurrent interview on 11/8/22 at 2:55 p.m., Director of Nursing (DON) reviewed Resident 76's paper and electronic medical records with medical records staff and verified Resident 76's attending physician had not entered any progress notes since 2/24/22. DON stated the residents' physicians should write a progress note every 45 to 60 days. During an interview on 11/9/22 at 10:55 a.m., Physician A stated the facility had made her aware that Resident 76's medical record did not have any progress notes from her since February. Physician A stated she was trying to find any notes she may have written but had not faxed to the facility. Physician A stated Resident 76 would often approach her at the nurses' station and they would discuss his care. Physician A stated she did not always document those interactions. She stated, I should have. During an interview on 11/15/22 at 8:56 a.m., Medical Director stated it was his expectation that the residents' attending physicians write a progress note in the medical record once per month. Review of facility policy Physician Services, last revised 5/16/19, indicated, At each visit, the physician must: i. Review the resident's total program of care, including medications and treatments; ii. Write, sign and date progress notes . The facility will routinely review for ongoing physician compliance by means of a monitoring/auditing system that includes review for physician services/documentation upon: . Conducting required routine visits .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient staff to maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 18 sampled residents (Residents 44, 66, and 8), when nursing staff did not: 1. Timely respond to residents who triggered a call light 2. Follow the Facility Assessment's recommendation for nurse staffing. The call-light-response failure resulted in nurses taking between 12 and 38 minutes to respond to call lights, and caused Residents 44 and 66 to feel humiliated, as well as angry, helpless, and frustrated due to being left wet for an extended time. The failure to follow the Facility Assessment's staffing recommendation resulted in Resident 8 feeling bothered due to having untrimmed, long, dirty fingernails, and it did not allow the facility to meet the recommended total of nursing staff on multiple days. Findings: 1. A review of Resident 44's face sheet (demographics) indicated she was [AGE] years old, admitted to the facility on [DATE] with the diagnoses of Diabetes Mellitus ( DM - a condition that happens when the body can't use glucose (a type of sugar) normally), Pyonephrosis ( pus in the renal pelvis, the area at the center of the kidney) and Hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 44's MDS dated [DATE] indicated a BIMS score of 14 indicating intact cognition. A review of Residents 66 face sheet (demographics), indicated he was [AGE] years old, admitted to the facility on [DATE] with the diagnoses of Hypertension (a condition in which the blood vessels have persistently raised pressure), Acute Respiratory Failure (a serious condition that makes it difficult to breathe on your own. Respiratory failure develops when the lungs can ' t get enough oxygen into the blood) and Chronic Obstructive Pulmonary Disease (COPD - A type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe). A review of Resident 66's MDS dated [DATE] indicated a BIMS score of 12 indicating moderately impaired cognition. During an observation on 11/15/22 at 10:50 a.m., the call light in room [ROOM NUMBER] was on. Multiple staff (Licensed Nurse at 10:44 a.m., housekeeping at 10:58 a.m., administrator was at the hallway at 11:03 a.m., Certified Nursing Assistant M (CNA M) was at the nursing station 5 at 11:15 a.m., Treatment Nurse was sitting at nursing station 5 at 11:19 a.m.) passsed by the call light without responding to it. At 11: 28 a.m., staff responded to room [ROOM NUMBER]'s call light. The total wait time for staff to answer room [ROOM NUMBER]'s call light was 38 mins. No CNAs were observed in the Station 5 hallway between 10:50 a.m. and 11:14 a.m. During an observation on 11/15/22, at 10:57 a.m., room [ROOM NUMBER]'s call light was on. Multiple staff (Housekeeping at 10:58 a.m., administrator was at the hallway at 11:03 a.m., nursing station 5 charge nurse passing medications at 11:01 a.m.) were noted to pass by room [ROOM NUMBER], but no one answered the call light. The total wait time for staff to answer room [ROOM NUMBER]'s call light was 18 mins. During an interview on 11/17/22, at 11:00 a.m., the Director of Nursing (DON) stated the facility expected staff to answer call lights timely and promptly. DON stated timely meant staff should respond within 3 to 5 minutes. She stated a response beyond 5 minutes was unacceptable and meant the facility policy was not being followed. She stated not answering call light timely and promptly could lead to resident accidents and falls, and residents could hurt themselves. During an interview on 11/17/22 at 11:30 a.m., the Administrator stated the facility policy was to answer call light timely, or between 3 to 5 minutes. He stated call lights could be answered by any staff, but the type of help given would depend on the staff's scope of practice. The Administrator stated not answering call lights timely or promptly could result to resident falls and accidents. During an interview on 11/17/22 at 3:25 p.m., the Director of Staff Development (DSD) stated the facility expects staff to answer call light timely, between 7 to 10 minutes. DSD stated that anytime after a 10 minutes response time was not acceptable and meant that the facility policy was not followed. DSD stated answering a call light was the responsibility of everyone. She stated it was important for staff to answer call light timely to prevent falls, accidents or even death. During an observation on 11/18/22 at 11:05 a.m., the call light in room [ROOM NUMBER] was on, the Occupational Therapist Assistant (COTA) was noted documenting a few feet away from room [ROOM NUMBER] but did not answer the call light. During an observation on 11/18/22 at 11:10 a.m., the Physical Therapist (PT) presented to meet with a resident in room [ROOM NUMBER], but did not answer the call light in room [ROOM NUMBER]. During an observation on 11/18/22, at 11:10 a.m., room [ROOM NUMBER]'s call light was on. The Infection Preventionist (IP) passed by but did not answer the call light. The Administrator passed by a few seconds later but did not answer the call light either. During an observation on 11/18/22, at 11:17 a.m., room [ROOM NUMBER]'s call light was responded to by staff, total wait time was 12 minutes. During an observation on 11/18/22, at 11:18 a.m., Licensed Nurse N passed by room [ROOM NUMBER], but did not answer the call light. During an observation on 11/18/22 at 11:22 a.m., call light in room [ROOM NUMBER] was responded to by staff, total wait time was 12 mins. During an interview on 11/14/22 at 10:04 a.m., Resident 44 stated the facility did not have enough staff. Resident 44 stated yesterday, before lunch, she had to wait for over an hour for staff to answer her call light. Resident 44 stated I was left in bed, soaking wet in my urine. Resident 44 stated she felt the burning and stinging sensation on her buttocks and the back of her legs. Resident 44 stated she had to call an outside friend to call the facility to ask for help. Resident 44 stated she felt humiliated sitting in her urine. During an interview on 11/17/22 at 11:30 a.m., the Administrator stated Resident 44's friend had complaint about slow call light response time in the past. When asked what the administrator did with this complaint, Administrator stated the facility did what they could to answer the call lights timely. During a concurrent interview and assignment sheet review dated 11/13/22 on 11/18/22 at 9:02 a.m., the Staffing Coordinator verified that the morning shift CNA caring for Resident 44 had 11 residents under her care. When asked if she felt this was a lot for a CNA to care for, staffing coordinator was silent. During an interview on 11/15/22 at 1:45 p.m., Resident 66 verified he did have to wait for over 30 minutes before lunch time today when he was waiting for a staff to answer his call light. Resident 66 stated he pressed his call light so staff can come and empty his catheter. Resident 66 stated that this long wait for staff to answer his call light was ridiculous. He stated this long response time to call light also happened early in the morning today. Resident 66 stated he had to wait for over 30 minutes for someone to help him empty his catheter. Resident 66 stated it was frustrating and annoying. He stated at around 2:00 a.m. today, he had to wait for more than 30 minutes before someone came to help empty his catheter. He stated he ended up getting soaked in urine and staff having to change his clothing and his beddings. He stated he had a disrupted sleep because of this incident. He stated feeling frustrated, angry and helpless. During an interview on 11/16/22 at 12:20 p.m., Resident 66 stated that by the time staff answered his call light yesterday early morning, his urinary bag was so full, it has back flowed hence the soaking wet with the urine situation. He stated he was really angry when this occurred, he was humiliated and felt really helpless. He stated he also worries that in case a real emergency occurs, like a fall or accident, that staff could not come to help him timely. During a concurrent interview and daily staffing review on 11/18/22 08:54 a.m., the Staffing Coordinator verified that on 11/15/22, the night shift CNA taking care of Resident 66 had 18 residents under her care. During a review of facility's policy and procedure (P&P) titled, Answering the Call Light, revised 3/2021, the P&P indicated it's purpose was to ensure timely responses to the resident's requests and needs. 2. A review of Resident 8's face sheet indicated he was [AGE] years old, admitted to the facility on [DATE] with the diagnoses of Hemiplegia (a symptom that involves one-sided paralysis)/ Hemiparesis (a weakness or the inability to move one side of the body), Diabetes Mellitus (DM, a condition that causes uncontrolled blood sugars) and Gout ( a common form of inflammatory arthritis that was very painful). A review of Resident 8's Minimum Data Set assessment (MDS, an assessment tool), dated 9/1/22, indicated a Brief Interview for Mental Status (BIMS, a quick assessment of cognitive status) score of 15, indicating intact cognition. During a concurrent observation and interview on 11/15/22 at 10:37 a.m., Resident 8 showed me his fingernails. The fingernails on both hands were long, both of the thumb fingernails were about 1.5 centimeters (cm, a unit of measure) long. Resident 8 stated he requested facility nurses multiple times to cut his fingernails, but the nails were still not cut. Resident 8 stated he had made this request weeks ago. Resident 8 stated his long fingernails nails were bothering him. Resident 8 stated there were times he accidentally scratched his arms at night that resulted in scrapes/scratches. Resident 8 stated he felt there were not enough nurses or staff to help the residents at the facility. Resident 8 stated that nurses always said they were busy and could not accomodate residents' requests. During a concurrent observation and interview on 11/16/22, at 8:59 a.m. Resident 8's both fingernails remained untrimmed. Resident 8 repeated his frustration that he asked staff to cut his nails weeks ago. He stated it's very frustrating. I don't think they have enough people to help us here. Everyone says I'm busy. During an interview on 11/16/22, at 9:17 a.m., Licensed Nurse O stated she was not able to cut Resident 8's fingernails because she was busy. During a concurrent observation and interview on 11/16/22, at 10:33 a.m., the Director of Nursing (DON) verified Resident 8's fingernails were long. The DON verified it was probably more than two weeks ago when she had cut Resident 8's fingernails. DON stated she was not sure on why staff did not cut Resident 8's fingernails per his request. A review of daily staffing schedule indicated the facility was not meeting the staffing needs based on the Facility Assessment. During an interview on 11/17/22 at 3:44 p.m., the Staffing Coordinator reviewed the Facility Assessment staffing plan. The Staffing Coordinator stated, per the Facility Assessment, the facility did not schedule enough staff to be able to provide support and care for residents. Under guidance of the Facility Assessment, the Staffing Coordinator stated during the month of November 2022 the facility did not provide enough Certified Nursing Assistant (CNA) staff on 15 of 16 days, from 11/2/22 to 11/16/22. The Staffing Coordinator also stated the staffing needs for licensed nurses was not met from 11/1/22 to 11/16/22. During an interview on 11/17/22, at 3:52 p.m., DON was reviewed the Facility Assessment as it concerned staffing needs. The DON stated she was not aware that their Facility Assessment indicated the facility should staff 16 licensed nurses and 25 CNAs daily. The DON verified the Interdisciplinary Team reviewed the Facility Assessment in April 2022. The DON stated the Facility Assessment was accurate. The DON stated that based on the Facility Assessment, the facility needed to schedule 16 licensed nurses and 25 CNAs each day to provide care to their residents. During a concurrent interview and record review of daily staffing information on 11/18/22, at 8:54 a.m., the Staffing Coordinator verified that for the month of September, CNA staffing needs were not met on 21 out of 30 days--all days from 8/1/22 to 8/19/22, as well as 8/24/22 and 8/25/22. The Staffing Coordinator stated the facility did not staff sufficient licensed nurses to match the needs indicated for September in the Facility Assessment. The Staffing Coordinator stated that for the month of October, CNA staffing needs were not met on 12 out of 31 days--from 10/2/22 to 10/7/22, as well as 10/9/22, 10/16/22, 10/23/22, 10/28/22, 10/29/22 and 10/30/22. The staffing coordinator stated the facility did not staff sufficient licensed nurses in October on 25 of 31 days--from 10/1/22 to 10/7/22, 10/8/22, 10/9/22 to 10/14/22, 10/16/22, 10/21/22 to 10/23/22, and 10/25/22 to 10/31/22. During a review of facility's policy and procedure (P&P), titled, Activities of Daily Living (ADL's), Supporting, the P&P indicated residents who were unable to carry out activities of daily living independently will receive the services to maintain good grooming and personal hygiene. During a review of facility's policy and procedure (P&P), titled, Facility Assessment dated 4/27/22, the P&P indicated that on a daily basis, the facility needed 16 licensed nurses providing direct care and 25 nurse aides to provide competent support and care for their resident population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the bathrooms used by residents in 34 of 34 resident rooms had a call light system accessible to residents lying on the floor. This failure placed all the 74 facility residents at risk of being unable to alert staff via the facility's communication system if they fell in the bathroom and were unable to get up. One of 18 sampled residents fell twice in the bathroom in 2022 and had to verbally call for staff assistance (cross-reference to tag F-689). Findings: During observations and interviews on 11/16/22, starting at 8:30 a.m., with the Director of Maintenance (DM), the call light system installed in the bathrooms used by residents in 34 of 34 rooms (room numbers 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36) consisted of a button placed on the wall next to the toilet seat at elbow height (while seated on the toilet) and within reach of a person sitting on the toilet or standing in front of it. Pressing the button activated the light above the resident's room and relayed the request for assistance to staff. The DM measured the height of the call light button in the bathrooms and stated it was placed at a height of 37.75 inches, or approximately three feet, from the floor. The call light button in the bathrooms did not have a string attached to it reaching the floor, which could be used by a resident to activate it while lying on the floor on the bathroom. During an observation of the bathroom used by residents in room [ROOM NUMBER], the surveyor simulated a fall from the toilet and, while on the floor in front of the toilet, attempted to reach and press the call light button but the call light was out of reach from the position of a person sitting or lying on the floor. A review of facility policy titled Answering the Call Light, Revised March 2021, indicated a call light was available to residents in the bathrooms but did not indicate it needed to be accessible to residents lying on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, the facility failed to ensure one resident, (Resident (R)19), of three sampled residents whose clinical records were reviewed for participation in care planning, were invited to their care plan meetings. Eighty-one residents resided in the facility. Findings include: Review of the Medical Diagnoses and Minimum Data Set (MDS) sections of R19's electronic health record (EHR) revealed the facility originally admitted the resident on 11/27/18, with a recent readmission on [DATE]. R19's diagnoses included atherosclerotic heart disease, epilepsy, heart failure, hypothyroidism, acute kidney failure, and diabetes mellitus. Review of R19's significant change in status MDS, with an Assessment Reference Date of 04/27/19, documented the resident had a Brief Interview for Mental Status score of eight out of 15, which indicated she had moderate cognitive impairment. The resident required supervision with eating, and required extensive assistance with most other activities of daily living. The MDS indicated the resident received hospice services. Review of R19's care plan, reviewed/revised on 04/19/19, revealed the resident's problems included a self-care deficit, risk for pain related to end of life, risk for falls, and need for hospice services. Appropriate goals and interventions for the problems were addressed in the care plan. Review of R19's paper chart and EHR documentation, including the Progress Notes, Interdisciplinary Team (IDT) Notes, Assessments, Miscellaneous, and Care Plan tabs, for documentation of care plan meetings and attendees, revealed no documentation to indicate the resident and/or her responsible party were invited to, or had attended, an IDT care plan meeting. Review of an IDT progress note, dated 05/13/19 at 9:50 AM, documented the IDT met to discuss R19's medical and care issues on 05/09/19. The list of attendees did not include R19 and/or her responsible party. During an interview on 07/15/19 at 10:56 AM, R19 stated she was not invited to her care plan meetings. During an interview on 07/16/19 at 1:08 PM, the Social Services Director (SSD) was asked for documentation, which indicated the resident and/or her responsible party had been invited to, and/or attended, a care plan meeting. The SSD reviewed R19's paper chart and EHR documentation and stated that the care plan meeting records had been purged. During a telephone interview on 07/16/19 at 3:11 PM, the resident's responsible party stated she had not been invited to a care plan meeting, and had not attended a care plan meeting for R19. During an interview on 07/17/19 at 11:39 AM, the SSD stated she could find no documentation which indicated R19 and/or her responsible party had been invited to the resident's care plan meetings. During an interview on 07/18/19 at 10:19 AM, the SSD stated it was an oversight that R19 and/or her responsible party had not been invited to R19's care plan meetings. She stated she had impromptu meetings with the resident and her responsible party when her responsible party was in the facility visiting. She stated she did not have documentation of care issues having been discussed with the resident and her responsible party during those impromptu meetings. Review of the facility's policy titled, Resident/Family Participation - Assessment/Care Plans, revised 12/2016, revealed: Each resident and his/her family members are encouraged to participate in the development of the resident's comprehensive assessment and care plan. The resident and his/her family, and/or the legal representative (sponsor), are invited to attend and participate in the resident's assessment and care planning conference.