Every finding on record at Alvarado Care Center

Based on interview and record review, the facility failed to ensure a significant change in condition was appropriately assessed, reported, documented, and incorporated into the comprehensive care plan for one of three sampled residents (Resident 1).This failure resulted in lack of direction for staff to address Resident 1's left knee pain and swelling, and had the potential to result in delayed or inadequate care.During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of hepatic encephalopathy (a reversible decline in brain function occurring in people with severe liver disease, such as cirrhosis or liver failure), cirrhosis of liver (a type of liver damage where healthy cells are replaced by scar tissue), reduced mobility, cellulitis of left leg (an infection of the deeper layers of skin and underlying tissue. This infection and spread quickly and become life threatening), thrombocytopenia (occurs when your bone marrow doesn't make enough platelets. Platelets are blood cells that form blood clots to help stop bleeding), and muscle weakness.During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 3/15/2026, indicated, Resident 1 had intact cognitive skills for daily decision making. The MDS indicated Resident 1 was independent to perform oral hygiene, eating, upper body dressing, putting on footwear, personal hygiene, roll left and right, sit to lying, and lying to sitting on side of bed. Resident 1 required supervision assistance for toileting, and set up assistance to shower, lower body dressing, and chair/bed to chair transfer.On 4/14/2026 at 8 AM, a voicemail was received from Resident 1 reporting concerns related to left knee pain and associated issues. Resident 1 stated that she had experienced a fall and reported left knee pain to the nurse; however, she indicated that the nurse did not accurately document the event.Resident 1 expressed dissatisfaction with facility staff not managing her care needs; however, specific details could not be further clarified due to inability to establish direct communication with Resident 1. At the time of entrance to the facility, Resident 1 had already been discharged from the facility, making an in-person interview not feasible. Two attempts were made to contact Resident 1 via telephone on 4/20/2026 at 10:44 AM and 4/21/2026 at 11:29 AM. No response was received, and voicemails were left requesting a return call.During a concurrent interview and record review on 4/20/2026 at 1 PM with Registered Nurse Supervisor (RNS), the RNS verified record review titled Results from the electronic medical record (EMR) revealed that on 2/17/2026, Resident 1 developed pain and swelling to the left knee, and a physician order was obtained for an X-ray to rule out fracture, indicating a significant change in condition. The RNS stated facility process for reporting a change in condition is for Certified Nursing Assistants to report any unusual circumstances to the licensed nurses, write it in the Change of Condition Binder at the nursing station, and the licensed nurses check the binder to ensure prompt and completed assessment of residents. Further review of the medical record showed:No documented assessment identifying the cause of the knee swellingNo documented incident or investigation related to a possible fall or injuryNo evidence of notification or clear documentation of change in condition in the electronic medical record (EMR)No updated or revised care plan addressing pain, altered mobility, or risk for further injury During an interview on 4/20/2026 at 1:30 PM with the Director of Nursing (DON), the DON stated that licensed nurses are responsible for:Assessing and documenting changes in conditionReporting and documenting incidents such as fallsUpdating the care plan in the EMR to reflect current needs, goals, and interventionsDespite this stated process, the facility failed to ensure that Resident 1's change in condition was properly assessed, reported, documented, and care planned. During a review of the facility's policy and procedure titled Change of Condition Notification dated October 1, 2023, indicated the licensed nurse will document the following:Date, time, and pertinent details of the incident and the subsequent assessment in nursing notes.The time the attending physician was contacted, method of contact, response time, and orders received.Update the Care Plan to reflect the resident's current status.The incident and brief details in the 24 hour report.Each shift for at least 72 hours.Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the 24 hour report.

Based on interview and record review, the facility failed to develop and implement an updated, person-centered care plan following a significant change in condition for one of three sampled residents (Resident 1).This failure resulted in lack of clear interventions and monitoring to address Resident 1's left knee pain and swelling, impaired mobility, or risk for further injury, and had the potential to result in delayed or inadequate care.During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of hepatic encephalopathy (a reversible decline in brain function occurring in people with severe liver disease, such as cirrhosis or liver failure), cirrhosis of liver (a type of liver damage where healthy cells are replaced by scar tissue), reduced mobility, cellulitis of left leg (an infection of the deeper layers of skin and underlying tissue. This infection and spread quickly and become life threatening), thrombocytopenia (occurs when your bone marrow doesn't make enough platelets. Platelets are blood cells that form blood clots to help stop bleeding), and muscle weakness.During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 3/15/2026, indicated, Resident 1 had intact cognitive skills for daily decision making. The MDS indicated Resident 1 was independent to perform oral hygiene, eating, upper body dressing, putting on footwear, personal hygiene, roll left and right, sit to lying, and lying to sitting on side of bed. Resident 1 required supervision assistance for toileting, and set up assistance to shower, lower body dressing, and chair/bed to chair transfer.On 4/14/2026 at 8 AM, a voicemail was received from Resident 1 reporting concerns related to left knee pain and associated issues. Resident 1 stated that she had experienced a fall and reported left knee pain to the nurse; however, she indicated that the nurse did not accurately document the event. Resident 1 expressed dissatisfaction with facility staff not managing her care needs; however, specific details could not be further clarified due to inability to establish direct communication with Resident 1. At the time of entrance to the facility, Resident 1 had already been discharged from the facility, making an in-person interview not feasible. Two attempts were made to contact Resident 1 via telephone on 4/20/2026 at 10:44 AM and 4/21/2026 at 11:29 AM. No response was received, and voicemails were left requesting a return call.During a concurrent interview and record review on 4/20/2026 at 1 PM with Registered Nurse Supervisor (RNS), the RNS verified record review titled Results from the electronic medical record (EMR) revealed that on 2/17/2026, Resident 1 developed pain and swelling to the left knee, and a physician order was obtained for an X-ray to rule out fracture, indicating a significant change in condition.Further review of the medical record showed:No documented assessment identifying the cause of the knee swellingNo documented incident or investigation related to a possible fall or injuryNo evidence of notification or clear documentation of change in condition in the electronic medical record (EMR)No updated or revised care plan addressing pain, altered mobility, or risk for further injury During an interview on 4/20/2026 at 1:30 PM with the Director of Nursing (DON), the DON stated that the Care Plan is essential to guide staff in implementing interventions for resident's health problems, make a goal to prioritize interventions for residents and prevent the issues from reoccurring. Licensed nurses are responsible for documenting changes in condition, completing appropriate assessments, and updating the care plan in the electronic medical record (EMR) to guide goals and interventions to meet residents' needs.During a review of the facility's policy and procedure titled Care Planning dated October 1, 2023, indicated the facility will develop a person-centered Care Plan for each resident within 48 hours of admission. The Care Plan will include initial goas, physician orders, therapy services, dietary orders, social services, summary of medications, treatments and services to be administered. The Interdisciplinary Team will revise the Care Plan as needed to address changes in behavior and care, and as dictated by changes in resident's condition.

Based on observation and interview, the facility failed to ensure that call light systems were functioning properly and that staff consistently verified functionality to promote timely response to resident needs for one of three sampled residents (Resident 2).This failure resulted in inconsistent implementation of monitoring practices, resulting in a non-functioning call light for Resident 2, and had the potential to result in delayed care and unmet resident needs.During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of type 2 diabetes (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel), hypoglycemia (a condition characterized by blood sugar levels falling below normal. Common in people with diabetes, often due to excess insulin, inadequate food intake, or intense exercise. Symptoms include shakiness, dizziness, sweating, and confusion. Severe cases can lead to seizures or loss of consciousness), and osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes. This can lead to a decrease in bone strength that can increase the risk of broken bones) with fracture (broken bone).During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool), dated 3/15/2026, indicated, Resident 2 had intact cognitive skills for daily decision making. The MDS indicated Resident 2 required supervision from staff for oral hygiene and eating, substantial assistance for toileting, showering, lower body dressing, personal hygiene, and putting on taking off footwear. Resident 2 required partial assistance from staff for upper body dressing, to roll left and right, sit to lying, sit to stand, and sitting on side of bed.During a concurrent observation and interview on 4/20/2026 at 12:21 PM with Resident 2, in Resident 2's room, Resident 2 was eating her lunch and activated her call light; however, the call light failed to illuminate at the nurse's station, indicating the system was not functioning properly. Resident 2 reported that staff response times are sometimes delayed and stated that at times the call light does not work, contributing to delays in assistance.During an interview on 4/20/2026 at 12:24 PM with Certified Nursing Assistant 1 (CNA1), the CNA1 confirmed that the call light cable was not fully connected. CNA 1 stated she had forgotten to check the call light connection during morning rounds.During an interview on 4/20/2026 at 1:30 PM with the Director of Nursing (DON), the DON stated that department heads are expected to conduct daily rounds to ensure call lights are functioning properly to support timely response to resident needs and prevent delays in care.During a review of the facility's policy and procedure titled Communication - Call System dated February 20, 2026, indicated the facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting facilities. If the primary call system becomes inoperable for any reason, the facility shall provide a bell for each resident room. Additionally, resident safety check rounds shall be conducted at least hourly and documented until the primary call system is operable again.

Based on interview, and record review, the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident's needs for two of sixteen sampled residents (Resident 54, and Resident 69), by failing to: 1. Create and implement an at risk for falls care plan for Resident 54 on 11/11/25 after the resident suffered a fall.2. Create and implement a care plan for Resident 69 requiring supervision or touch assistance with meals.3. Create and implement a care plan for Resident 69's specific behaviors defined as aggressive or disruptive related to the use of Depakote (a prescription medication used as a mood stabilizer) and Risperdal (a prescription antipsychotic medication used to treat serious mental health conditions). These failures had the potential for Resident 9, Resident 54, and Resident 69 to receive inadequate care and for Resident 69 activities associated with mental processes and behavior) increased the risk that Resident 69 could have experienced adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication (medications that affect brain activities associated with mental processes and behavior), possibly leading to a decline in her quality of lifeFindings: 1.During a review of Resident 54's admission Record, the admission Record indicated the facility re-admitted the resident on 11/09/2025 with diagnoses that included lack of coordination (poor muscle control that causes clumsy movements), muscle weakness, cognitive communication deficit (an impairment in communication caused by the disrupted ability to think, understand, reason, and remember), other abnormalities of gait (the pattern of walking) and mobility (movement), and dementia (a progressive state of decline in mental abilities). During a review of Resident 54's Fall Risk Assessment (a standardized questionnaire test used by healthcare professionals to evaluate and score an individual's likelihood of falling) dated 11/11/2025, the Fall Risk Assessment indicated Resident 54 had a fall risk score of 80 and was at high risk of falling (a score of 45 and higher indicated there was a high risk of falls). The Fall Risk Assessment indicated Resident 5 had fallen before, had more than one diagnosis on his chart, used crutches, a cane, or a walker, had a weak gait (balance), and overestimated or forgot his limits. During a review of Resident 54's Change in Condition Evaluation dated 11/11/2025, the Change in Condition Evaluation indicated the resident had a fall. The Change in Condition Evaluation indicated staff had witnessed Resident 54 in the hallways bending over from a standing position, raised his head up, the resident lost his balance, fell on his bottom, and hit his back on the closed door. The Change in Condition Evaluation indicated Resident 54 complained of mild pain to the back and sacrum (tailbone area) after the fall. The Change in Condition Evaluation indicated Resident 54 did not have any obvious injuries. During a review of Resident 54's Minimum Data Set (MDS, a resident assessment tool) dated 12/19/2025, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 54 normally used a walker. The MDS indicated Resident 54 required partial/moderate assistance (helper does less than half the effort) for toileting hygiene, showering/bathing himself, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) for eating and oral hygiene. During a review of Resident 54's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 54 had a fall risk score of 80 and was at high risk of falling (a score of 45 and higher indicated there was a high risk of falls). The Fall Risk Assessment indicated Resident 5 had fallen before, had more than one diagnosis on his chart, used crutches, a cane, or a walker, had a weak gait (balance), and overestimated or forgot his limits. During a review of Resident 54's Change in Condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) Evaluation dated 1/9/2026, the COC Evaluation indicated the resident had a fall. The COC Evaluation indicated Resident 54 had lost his balance and fell to his right side, landing on his right hip and leg. During a review of Resident 54's Care Plan Report revised 1/9/2026, the Care Plan Report indicated the resident had an actual fall on 11/11/2025 with minor injury due to poor balance and unsteady gait. The Care Plan Report indicated Resident 54 had another actual fall on 1/9/2026 with no injuries due to poor balance and unsteady gait. The Care Plan Report indicated a goal for Resident 54 was to resume usual activities without further incident through the review date. The Care Plan Report indicated interventions (specific actions the nursing staff takes to help a resident meet their health goals, like giving medication, repositioning them, or providing education, all detailed in their personalized care plan to ensure consistent, effective care) to continue the interventions on the at-risk plan; determine and address causative factors of the fall; monitor, document, and report as needed for 72 hours any signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, and agitation to Resident 54's physician. During a review of Resident 54's Care Plan Report for all active care plans, the report indicated Resident 54 did not have a specific care plan for being at-risk for falls. During a concurrent interview and record review on 1/22/2026 at 12:26 PM with Licensed Vocational Nurse 3 (LVN 3), Resident 54's Care Plan Report revised 1/9/2026 was reviewed. LVN 3 stated Resident 54 had fallen on 11/11/2025 and 1/9/2026. LVN 3 stated Resident 54 had a care plan for the resident's actual fall on 11/11/2025 and 1/9/2026. LVN 3 stated Resident 54's actual fall care plan had an intervention to continue the interventions on the at-risk for falls care plan. LVN 3 stated and verified that Resident 54 did not have an at-risk for falls care plan. LVN 3 stated Resident 54 was at high risk of falling because the resident was forgetful, needed stand-by assistance (a form of care where a caregiver remains within arm's reach of an individual providing supervision and safety monitoring without offering direct physical aid unless needed) with walking, and the resident used a walker. LVN 3 stated Resident 54 should have had an at risk for falls care plan with interventions to educate Resident 54 to use the call light for assistance before getting out of bed, to have the resident wear non-skid socks, and to ensure the resident's room was clean and free of clutter. LVN 3 stated an at-risk for falls care plan was a guide that had interventions that the nurses (in general) used to monitor the residents and reduce the resident's chances of the falling again. LVN 3 stated if there was no at-risk for falls care plan there wouldn't be guidance for the nurses (in general) of what to do to prevent the resident from falling. LVN 3 stated if Resident 54 did not have an at-risk for fall care plan, there was a potential for the resident to fall again. During a concurrent interview and record review on 1/22/2026 at 2:02 PM with Registered Nurse 1 (RN 1), Resident 54's Care Plan Report revised 1/9/2026 was reviewed. RN 1 stated Resident 54 had a fall on 11/11/2025 and 1/9/2026. RN 1 stated Resident 54 had a care plan for his falls on 11/11/2025 and 1/9/2026. RN 1 stated Resident 54's care plan for his falls on 11/11/2025 and 1/9/2026 had an intervention to continue interventions on the resident's at-risk care plan. RN 1 stated and verified that Resident 54 did not have a care plan for being at risk for falls. RN 1 stated Resident 54 should have had a care plan for being at risk of falls. RN 1 stated and verified that Resident 54 was at high risk of falling. RN 1 stated Resident 54's at risk of falls care plan should have had interventions that would help prevent the resident from falling again, such as placing call light within the resident's reach, educating the resident ambulate with walker, having the resident wear non-skid socks, keeping the bed low, and educating the resident to call for help before getting out of bed. RN 1 stated a care plan was a plan that told nurses (in general) about the care the residents needed. RN 1 stated that if there was no care plan for being at risk for falls, Resident 54 could fall again because the nurses (in general) would not know to provide interventions to prevent falls. During a concurrent interview and record review on 1/23/2026 at 10:16 AM with the Director of Nursing (DON), Resident 54's Care Plan Report revised 1/9/2026 was reviewed. The DON stated Resident 54 required supervision and utilized a walker when ambulating (walking). The DON stated Resident 54 was at high risk for falls. The DON stated Resident 54 fell on [DATE] and 1/9/2026. The DON stated and verified that Resident 54 had a care plan for the residents' falls on 11/11/2025 and 1/9/2026 which had an intervention to continue the interventions on the resident's at-risk plan. The DON stated and verified that Resident 54 did not have a care plan for being at risk for falls. The DON stated if Resident 54 had a history of falls the resident should have had an at risk for falls care plan. The DON stated the care plan for at risk for falls should have included interventions for monitoring Resident 54 for safety, a physical therapy evaluation, an occupational therapy evaluation, and ensuring the resident was utilizing the walker. The DON stated a care plan was important because it contained goals and interventions to help deal with issues and help Resident 54 prevent injuries. The DON stated if Resident 54 did not have a care plan for being at risk for falls, there would be no interventions in place to help prevent falls. The DON stated if there was no care plan for being at risk for falls the nurses (in general) would not know how to help Resident 54 from falling. During a review of the facility's Policy and Procedure (P&P) titled Fall Management Program dated 2/17/2025, the P&P indicated The Nursing staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls. The interdisciplinary team will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall. Interventions will be implemented or changed based on the resident's condition and response. During a review of the facility's P&P titled Care Planning revised 2/17/2025, the P&P indicated A Comprehensive Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs.Each resident's Comprehensive Care Plan will describe the following: services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment; any specialized services including rehabilitative service as a result of PASARR recommendations. If the facility disagrees with PASARR findings, rationale will be notated in the resident's medical record; the resident's goals for admission and desired outcomes; and discharge plans as appropriate. 2.A review of Resident 69's admission Record (a record containing diagnostic and demographic resident information), dated 1/22/26, the admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included unqualified visual loss( a significant loss of vision in one or both eyes where the specific cause[blindness category, underlying disease] has not been clearly identified) both eyes, unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance (acting out, agitated, aggressive or mood/personality changes), psychotic disturbance(hallucinations or strong delusions), mood disturbance (disruptive sadness, irritability), and anxiety (excessive worry, fear, and nervousness), other lack of coordination(the brain struggles to coordinate muscles, leading to jerky, unsteady, or inaccurate movements), dysphagia (difficulty swallowing), oral(mouth) phase and cognitive communication deficit (struggling with talking, listening, or understanding because of problems with thinking skills[cognition], rather than a physical speech or language issue). During a review of Resident 69's Minimum Data Set (MDS – a resident assessment tool) dated 10/14/2025, the MDS indicated Resident 69 had severely impaired vision ( no vision or sees only light, colors or shapes; eyes do not appear to follow objects), did not use corrective lenses (contacts, glasses, or magnifying glass), had normal cognition (ability to think, understand, learn, and remember), had limitation in range of motion (ROM-the full distance and direction a joint[where two or more bones meet] can move, measured by how far it can bend, straighten, or twist) in the upper extremity(shoulder, elbow, wrist, hand) on one side and required supervision or touching assistance (helper provides verbal cues[short spoken words used as a guide] and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating . During a review of Resident 69's Optometry Exam Consult notes dated 8/13/2025, the notes indicated Resident 69 had vision loss in both eyes and had an inability to adapt to bifocals (eyeglasses with split into two parts to correct both far and near vision in one frame). The Optometry Exam Consult indicated Resident 69 had cataracts (a clouding of your eyes' natural lens, like looking through a foggy window, which makes vision blurry and hazy). During a review of Resident 69's Speech Therapy note dated 11/7/2025, the note indicated Resident 69 required set up and intermittent cues (occasional reminders) for identification location of food items on meal tray due to have been diagnosed of being legally blind (severe uncorrectable vision loss) and benefitted from verbal cues upon meal tray set up and also finger foods. During a review of Resident 69's Dietary Profile dated 1/13/2026, the dietary profile indicated Resident 69 was blind and was able to feed self with supervision and maximum assist. During an observation on 1/20/2026 at 12:55 PM, Resident 69 was observed in the dining room sitting in a wheelchair and eating lunch unassisted by staff. Resident 30 was observed sitting beside Resident 69 and intermittently was scooping up Resident 69's food into mounds on the plate and Resident 69 preceded to scoop up another spoonful of food to eat. Certified Nurse Assistant (CNA) 1 was observed sitting at the same table and was assisting another resident with their meal. During an interview on 1/20/2026 at 1:17 PM with Resident 69, Resident 69 stated I cannot see, I only see light in my eyes. I have cataracts in my eyes. I needed help but no other person had assisted me. During a concurrent interview and record review on 1/20/2026 at 1:23 PM, with Infection Preventionist (IP), Resident 69's Dietary Profile dated 1/13/2026 and complete Care Plan Report were reviewed. The IP stated any staff member that was in the dining area could have assisted Resident 69. The IP stated she did not have staff available to assist Resident 69 with eating. The IP stated she (IP) informed Resident 30 he could not help Resident 69 with her meals and he stopped. The IP stated Resident 69's Dietary Profile indicated Resident 69 required maximum assistance and supervision with eating. The IP stated and verified there was no care plan for Resident 69 requiring assistance with eating and there was not any documentation of Resident 69 refusing assistance with her meals. The IP stated if Resident 69 did not have a care plan, facility staff would not know how to take care of Resident 69 and the resident should have had a care plan, and a care plan was not created. During an interview on 1/20/2025 at 2:2 PM, with Certified Nurse Assistant (CNA)1, CNA 1stated and verified she did not assist Resident 69 and was sitting beside her but not assigned to assist the resident on that day (1/20/2025). CNA 1 stated Resident 69 could only see shadows. CNA 1 stated I saw the other resident helping her and he was not supposed to do that. During a concurrent interview and record review on 1/21/2026 at 12:21 PM, with Registered Nurse (RN) 1, Resident 69's complete care plan and the facility's policy and procedure (P&P) titled, Care Planning dated 2/17/2025 was reviewed. RN 1 stated Resident 69 could only see shadows and required verbal cues during meals for location of food. RN 1 stated and confirmed there was no care plan for Resident 69 needing supervision or touch assistance with meals. RN 1 stated any licensed nurse could have created a care plan. RN1 did not want to answer if the facility was following the policy on care planning. During a concurrent interview and record review on 1/21/2026 at 12:46 PM with the Director of Nursing (DON) the facility's policy and procedure (P&P) titled, Care Planning dated 2/17/2025 was reviewed. The DON stated it was not appropriate for another resident to help Resident 69 with her meals. The DON stated staff should have assisted Resident 69 with her meal. The DON stated there was no care plan for Resident 69 requiring supervision or touch assistance with meals. The DON stated the consequence of not having had a care plan would have been not identifying Resident 69's needs to better help Resident 69. The DON stated any licensed nurse could have created a care plan. The DON stated the purpose of a care plan was to have interventions in place to address problems and have planned resident care with goals in mind. The DON stated the facility was not following policy on care planning since a care plan was not created for Resident 69's needs as indicated in the policy. During a review of the facility's policy and procedure (P&P) titled, Care Planning dated 2/17/2025, the P&P indicated A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/MDS guidelines. The P&P indicated Each Resident's Comprehensive Care Plan will describe the following: Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 3.A review of Resident 69's admission Record (a record containing diagnostic and demographic resident information), dated 1/22/26, the admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness characterized by hearing or seeing things that are not there.) A review of Resident 69's History and Physical (H&P – a record of a physician's comprehensive medical assessment and plan) dated 4/10/25, the H&P indicated this resident had capacity to understand and make medical decisions. A review of Resident 69's Order Summary Report (a summary of all current physician orders), dated 1/22/26 indicated Resident 69's attending physician prescribed the following psychotropic medication therapy: 1. Depakote 750 milligrams (mg, unit of measurement) by mouth three times daily for schizophrenia manifested by aggressive behavior on 9/29/25. 2. Risperdal 2 mg by mouth twice a day for schizophrenia manifested by disruptive behavior on 4/9/25. A review of Resident 69's active care plans, last revised 1/15/26, indicated there were no care plans created to address Resident 69's disruptive behavior or aggressive behavior related to a diagnosis of schizophrenia. Further review of the available care plans indicated the care plans for the use of Risperdal and Depakote to treat aggressive behavior and disruptive behavior did not provide any specific examples of Resident 69's manifestations of the problematic behaviors, no individualized non-pharmacological approaches to address these behaviors, or any Resident-centered therapeutic goals for the reduction of these behaviors related to the use of psychotropic medications. During an interview on 1/22/26 at 11:52 AM with the Director of Nursing (DON), the DON stated the facility failed to care plan any specific behaviors defined as aggressive or disruptive related to the use of Depakote and Risperdal or any non-pharmacological interventions to address the problematic behaviors. The DON stated failure to care plan target behavior and non-pharmacological interventions could result in longer courses or higher doses of psychotropic medications possibly leading to a decline in the quality of life from medication adverse effects. A review of the facility's policy titled Psychotherapeutic Drug Management, revised 5/19/25, indicated The care plan will reflect an individualized team approach emphasizing person-centered interventions with measurable goals, timetables and specific interventions for the management of behavioral and psychological symptoms.

Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS - a comprehensive resident assessment tool) assessment Section I (active diagnoses) by failing to include diagnoses of bipolar disorder (a mental illness characterized by having rapid changes in mood from depression to mania) and depression (a mental illness characterized by depressed mood, insomnia, and lack of energy or interest in usually enjoyable activities) per information in the medical record for two of five residents sampled for unnecessary medications (Resident 1 and Resident 69).The deficient practice of failing to accurately assess active diagnoses and complete MDS Section I increased the risk that Resident 1 and Resident 69 may not have received care planning and treatment according to their needs possibly leading to a decline in their overall health and well-being. Findings:During a review of Resident 1's admission Record (a record containing diagnostic and demographic resident information), the admission Record indicated the facility admitted Resident 1 on 9/14/2011 and readmitted Resident 1 on 12/21/2025 with diagnoses including dementia (a loss of mental ability that affects memory, thinking, and behavior to the point that it interferes with daily life). During a review of Resident 1's History and Physical (H&P - a record of a physician's comprehensive medical assessment and plan) dated 12/23/2025, the H&P indicated Resident 1 had capacity to understand and make decisions. During a review of Resident 1's follow-up psychiatric note dated 12/27/2025, the follow-up psychiatric note indicated Resident 1's diagnosis related to the use of Risperdal was schizoaffective disorder (a mental illness characterized by seeing or hearing things that are not there, paranoid delusions, and mood swings. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) assessment (a periodic comprehensive resident assessment performed by facility staff), dated 12/28/2025, Section I (active diagnoses) indicated Resident 1 did not have a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder. During a review of Resident 1's Order Summary Report (a summary of all current physician orders) dated 1/22/2026, the Order Summary Report indicated Resident 1's attending physician prescribed Risperdal 1.5 milligrams (mg - a unit of measure for mass) by mouth one time a day for bipolar disorder (a mental illness characterized by extreme mood swings ranging for depressed lows to manic highs) manifested by throwing objects, fighting with staff on 12/22/2025. During a review of Resident 1's care plan related to the use of Risperdal, last revised 1/7/2026, indicated on 10/27/2022 Resident 1 was using Risperdal to treat a diagnosis of schizophrenia and was later updated on 12/11/2024 to bipolar disorder. During an interview on 1/22/2026 at 12:05 PM with the Director of Nursing (DON), the DON stated Resident 1's MDS dated [DATE] was inaccurate as the MDS did not indicate any of the psychiatric diagnoses included in Resident 1's clinical record related to the use of Risperdal. The DON stated failure to accurately assess Resident 1's challenges could result in care plans which were inadequate to address Resident 1's needs, possibly leading to a decline in his quality of life. During a review of the facility's policy titled RAI Process, revised 5/19/2025, the policy indicated All information recorded withing the MDS assessment must reflect the resident's status at the time of the Assessment Reference Date (ARD). b. During a review of Resident 69's admission Record, the admission Record indicated the facility admitted Resident 69 on 4/9/2025 with diagnoses including schizophrenia (a mental illness characterized by hearing or seeing things that are not there). During a review of Resident 69's H&P dated 4/10/2025, the H&P indicated Resident 69 had capacity to understand and make medical decisions. During a review of Resident 69's MDS assessment Section I dated 10/14/2025, the MDS Section I indicated Resident 69 did not have a diagnosis of depression. During a review of Resident 69's care plan related to the use of sertraline last revised 1/18/2026, the care plain indicated Resident 69 used sertraline related to depression manifested by excessive crying for her husband. During a review of Resident 69's Order Summary Report dated 1/22/2026, the Order Summary indicated Resident 69's attending physician prescribed sertraline (a medication used to treat depression) 25 mg by mouth one time a day for depression manifested by uncontrollable crying for husband. During an interview on 1/22/2026 at 11:52 AM with the DON, the DON stated Resident 69's MDS assessment dated [DATE] was inaccurate as it omitted a diagnosis of depression despite evidence of treatment for depression in Resident 69's clinical record. The DON stated failing to complete resident assessments correctly, including all information available in the medical record, could lead to care plans which don't adequately address a resident's needs possibly leading to an inability to reach their highest practicable level of functioning (in general).

Based on interview and record review, the facility failed to:-Ensure Risperdal (a medication used to treat mental illness) was used to treat a medical diagnosis clearly documented in the medical record for one of five residents (Resident 1) sampled for unnecessary medications-Define specific problematic behaviors related to the use of Risperdal and Depakote (a medication used to treat mental illness) for one of five sampled residents (Resident 69) for unnecessary medications (Resident 69).-Monitor for adverse effects (unwanted or dangerous medication-related side effects) related to the use of Cymbalta (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 69.)The deficient practices of failing to define specific problematic behaviors, ensure medication was used to treat a resident's specific, diagnosed condition, and monitor adverse effects related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) increased the risk that Residents 1 and 69 could have experienced adverse effects related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.Findings:a. During a review of Resident 1's admission Record (a record containing diagnostic and demographic resident information), the admission Record indicated the facility admitted Resident 1 on 9/14/2011 and readmitted Resident 1 on 12/21/2025 with a diagnosis of dementia (a loss of mental ability that affects memory, thinking, and behavior to the point that it interferes with daily life). During a review of Resident 1's History and Physical (H&P - a record of a physician's comprehensive medical assessment and plan) dated 12/23/2025, the H&P indicated Resident 1 had capacity to understand and make medical decisions. During a review of Resident 1's follow-up psychiatric note, dated 12/27/2025, the follow-up psychiatric note indicated Resident 1's diagnosis related to the use of Risperdal was schizoaffective disorder (a mental illness characterized by seeing or hearing things that are not there, paranoid delusions, and mood swings. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) assessment (a periodic comprehensive resident assessment performed by facility staff), dated 12/28/2025, the MDS Section I (active diagnoses) indicated Resident 1 did not have a diagnosis of bipolar disorder. During a review of Resident 1's care plan related to the use of Risperdal, last revised 1/7/2026, the care plan indicated on 10/27/2022 Resident 1 was using Risperdal to treat a diagnosis of schizophrenia and was later updated on 12/11/2024 to bipolar disorder. During a review of Resident 1's Order Summary Report (a summary of all current physician orders) dated 1/22/2026, the Order Summary indicated Resident 1's attending physician prescribed Risperdal 1.5 mg by mouth one time a day for bipolar disorder (a mental illness characterized by extreme mood swings ranging for depressed lows to manic highs) manifested by throwing objects, fighting with staff on 12/22/2025. During an interview on 1/22/2026 at 12:05 PM with the Director of Nursing (DON), the DON stated the facility failed to ensure Resident 1's Risperdal was used for a clear diagnosis as documented in the clinical record. The DON stated the clinical record included diagnoses of bipolar disorder, schizophrenia, and schizoaffective disorders all tied to his use of Risperdal. The DON stated this makes the true use of the medication unclear. The DON stated not having a clearly defined diagnosis related to the use of psychotropic medication increases the risk that Resident 1 may experience a decline in the quality of life because of medication-related adverse effects. During a review of the facility's policy titled Psychotherapeutic Drug Management revised 5/19/2025, the policy indicated The psychotherapeutic medication order will include the following information. diagnosis for the medication. indications and manifestations of the disorder treated (i.e. auditory hallucinations, hitting others, refusing to eat, etc.) Nursing responsibility. will monitor psychotropic drug use daily noting any adverse effects (i.e. EPS, Tardive dyskinesia, excessive dose or distressed behavior). b. During a review of Resident 69's admission Record, the admission Record indicated the facility admitted Resident 69 on 4/9/2025 with diagnoses including schizophrenia (a mental illness characterized by hearing or seeing things that are not there.) During a review of Resident 69's H&P dated 4/10/2025, the H&P indicated Resident 69 had capacity to understand and make medical decisions. During a review of Resident 69's follow-up psychiatric note (a record of a psychiatric provider's psychiatric assessment and plan) dated 12/8/2025, the follow-up psychiatric note indicated there was no discussion of Resident 69's problematic behaviors or specific examples related to her diagnosis of schizophrenia but that staff should report any unwanted behavior and continue monitoring the patient closely. During a review of Resident 69's available care plans (a plan of care individualized to a resident's specific needs), last revised 1/15/2026, indicated there were no care plans created to address Resident 69's disruptive behavior or aggressive behavior related to a diagnosis of schizophrenia. Further review of the available care plans indicated the care plans for the use of Risperdal and Depakote to treat aggressive behavior and disruptive behavior did not provide any specific examples of Resident 69's manifestations of the problematic behaviors, no individualized non-pharmacological approaches to address these behaviors, or any Resident-centered therapeutic goals for the reduction of these behaviors related to the use of psychotropic medications. During a review of Resident 69's Order Summary Report dated 1/22/2026, the Order Summary indicated Resident 69's attending physician prescribed the following psychotropic medication therapy:1.Risperdal 2 mg by mouth twice a day for schizophrenia manifested by disruptive behavior on 4/9/2025.2. Cymbalta 30 mg by mouth at bedtime for phantom limb pain (nerve-related pain due to an amputation) on 5/720/25.3.Depakote 750 mg by mouth three times daily for schizophrenia manifested by aggressive behavior on 9/29/2025. During a review of Resident 69's Medication Administration Record (MAR - a daily record of medications administered, and monitoring performed for a resident) for January 2026, the MAR indicated there were no specific examples of aggressive or disruptive behaviors defined in the behavioral monitoring orders to allow licensed staff to effectively monitor and quantify the problematic behaviors. Further Review of the MAR indicated there was no monitoring done for adverse effects related to the use of Cymbalta. During an interview on 1/22/26 at 11:52 AM with the DON, the DON stated the behaviors for Resident 69's Risperdal and Depakote are vague and should be defined more specifically so nursing staff could monitor appropriately for the problematic behaviors. The DON stated the failure to adequately define problematic behaviors related to the use of psychotropic medication could lead to Resident 69 being on Risperdal or Depakote longer than necessary possibly leading to a decline in her quality of life due to medication adverse effects. The DON stated the facility also failed to monitor adverse effects related to the use of Cymbalta. The DON stated Cymbalta and other psychotropics must be monitored for adverse effects to continually ensure that the benefits of the medication outweigh the risks. The DON stated failing to monitor adverse effects of psychotropic medications could result in Resident 69 experiencing more adverse effects than necessary possibly leading to a decline in her quality of life.

Based on observation, interview, and record review, the facility failed to revise the care plans for three of 10 sampled residents (Resident 2, Resident 5, Resident 8) by failing to: -Ensure to revise(update) Resident 2's care plan for impaired cognition (having difficulties with thinking, learning, remembering, concentrating, solving problems, or making decisions) related to dementia (a progressive state of decline in mental abilities). -Ensure to revise Resident 5's care plan for falls. -Ensure to revise Resident 8's care plan for smoking. These failures had the potential to impact Resident 2's provision of care and services and placed Resident 5 and Resident 8 at risk for injuries related to falls and smoking. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility re-admitted Resident 2 on 1/29/2025 with diagnoses that included dementia (a progressive state of decline in mental abilities). During a review of Resident 2' Minimum Data Set (MDS, a resident assessment tool) dated 11/4/2025, the MDS indicated the resident had severe cognitive impairment (decreased ability to think, understand, and reason). The MDS indicated the resident was dependent (helper does all the effort) on help for eating, oral hygiene, toileting hygiene, showering/bathing himself, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 2's Care Plan Report dated 12/10/2025, the Care Plan Report indicated the resident had impaired cognitive function or impaired thought processes related to dementia. The Care Plan Report indicated goals for Resident 2 to be able to communicate basic needs on a daily basis, to maintain a current level of decision-making ability, and to remain oriented to person, place, situation, and time through the review date. The Care Plan Report indicated one intervention: Cognition: Resident is able to remember one/two/three instructions, find room, read, sit and participate in activities of choice. During a concurrent interview and record review on 1/22/2026 at 12:40 PM with Licensed Vocational Nurse 3 (LVN 3), Resident 2's Care Plan Report dated 12/10/2025 was reviewed. LVN 3 stated Resident 2 had a diagnosis of dementia. LVN 3 stated Resident 2 had a care plan for dementia, however, the care plan only had one intervention that indicated Cognition: Resident is able to remember one/two/three instructions, find room, read, sit and participate in activities of choice. LVN 3 stated Resident 2's care plan for dementia was not appropriate and was not personalized to the resident's needs for his diagnosis. LVN 3 stated Resident 2's care plan for dementia should be revised to include more interventions tailored to the resident's needs for dementia. LVN 3 stated Resident 2's care plan for dementia should include interventions such as establishing a routine for the resident, hanging a calendar in the resident's room, reminding him what day and date it was, bringing the resident out of his room to the activity room, encouraging the resident to do activities that he enjoys, and making the resident's environment familiar to him. LVN 3 stated the care plan helped the nurses (in general) monitor the resident. LVN 3 stated the care plan created interventions and guided the nurses (in general) on how to help the resident. LVN 3 stated that if Resident 2's care plan was not revised and personalized to meet the resident's needs for dementia there was potential for Resident 2 to not get the care he needed. During a concurrent interview and record review on 1/22/2026 at 2:15 PM with Registered Nurse 1 (RN 1), Resident 2's Care Plan Report dated 12/10/2025 was reviewed. RN 1 stated Resident 2 had a diagnosis of dementia. RN 1 stated Resident 2 had a care plan for dementia; however, the care plan was not appropriate for the resident. RN 1 stated Resident 2's care plan for dementia only had one intervention that indicated Cognition: Resident is able to remember one/two/three instructions, find room, read, sit and participate in activities of choice. RN 1 stated Resident 2's care plan for dementia should be revised to include personal interventions such as making sure the resident was monitored for safety, ensuring to speak to the resident clearly, and ensuring the resident's environment was familiar with things he recognized. RN 1 stated it was important for Resident 2 to have a personalized care plan with interventions for the resident's diagnosis of dementia. RN 1 stated there was a potential for Resident 2 not to get the appropriate care for his dementia needs if the resident's care plan was not revised. RN 1 stated the nurses (in general) would not know what type of care and interventions to provide Resident 2 without a personalized care plan. During a concurrent interview and record review on 1/23/2026 at 10:16 AM with the Director of Nursing (DON), Resident 2's Care Plan Report dated 12/10/2025 was reviewed. The DON stated Resident 2 had a diagnosis of dementia. The DON stated Resident 2 had a care plan for dementia that had three goals and only one intervention that indicated Cognition: Resident is able to remember one/two/three instructions, find room, read, sit and participate in activities of choice. The DON stated Resident 2's care plan for dementia was not appropriate for the resident. The DON stated Resident 2's care plan for dementia should be revised to have personalized interventions, at least one intervention for each goal. The DON stated Resident 2's care plan should have interventions such as monitoring for changes in condition, activities, a neurology consult, monitoring for increased confusion, and labs. The DON stated if Resident 2's care plan was not appropriate and revised to include personalized interventions there was potential for the resident to receive inadequate care for his diagnosis of dementia. The DON stated the nurses (in general) would not know what kind of care to provide if there were not any interventions in place on Resident 2's care plan for dementia. During a review of the facility's Policy and Procedure (P&P) titled Management of Residents with Dementia dated 2/17/2025, the P&P indicated The care plan will reflect an individualized team approach emphasizing person-centered interventions with measurable goals, timetables and specific interventions for the management of behavioral and psychological symptoms.The Care Plan will include the problem/symptoms the resident is experiencing, goals for the resident, a sticker or note describing the side effects of the drug, non-pharmacologic interventions to help the resident cope with the problem i.e., quiet environment, comfort items nearby, frequent supportive visits by staff etc. Interventions by nursing, activities, social services, and other departments as indicated will also be included on the care plan. During a review of the facility's P&P titled Care Planning dated 2/17/2025, the P&P indicated Purpose: To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.A Comprehensive Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. Each resident's Comprehensive Care Plan will describe the following: services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment; any specialized services including rehabilitative service as a result of PASARR recommendations. If the facility disagrees with PASARR findings, rationale will be notated in the resident's medical record; the resident's goals for admission and desired outcomes; and discharge plans as appropriate.The IDT will revise the Comprehensive Care Plan as needed at the following intervals: Per RAI schedules; as dictated by changes in the resident's condition; in preparation for discharge; to address changes in behavior and care; and other times as appropriate or necessary. b. During a review of Resident 5's admission Record, the admission Record indicated the facility originally admitted Resident 5 on 6/24/2024 and re-admitted Resident 5 on 7/20/2025 with diagnoses that included wedge compression fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing (a healing break in the first lower back bone); unsteadiness on feet (difficulty keeping balance while on their feet), and muscle weakness(Generalized weakness in many muscles throughout the body). During a review of Resident 5's History and Physical (H&P) dated 7/24/2025, the H&P indicated Resident 5 had the capacity to understand and make decisions. During an interview on 1/22/2026 at 1:40 PM with the Director of Nursing (DON), the DON stated that to identify if a resident was at high risk for falls an assessment was done upon admission and quarterly. The DON stated the Fall Risk post fall assessment was documented by a Registered Nurse (in general) within 24 hours or as soon as possible. The DON stated that the Falling Star Program (a structured educational and exercise program for older adults designed to reduce the risk of falling) was for residents who were identified as high risk for falls and a yellow star was placed at the door next to the resident's name. The DON stated that if a resident (in general) fell, the resident was placed right away in the falling star program. During a concurrent interview and record review on 1/22/2026 at 2:15 PM with the DON, Resident 5's Progress Notes dated 12/15/2025 were reviewed. The DON stated the Progress Notes indicated the DON discontinued Resident 5 from Falling Star Program because Resident 5 had not fallen in three months. During a concurrent interview and record review on 1/22/2026 at 2:15 PM with the DON, Resident's 5 Nursing Quarterly assessment dated [DATE] was reviewed. The DON stated the Nursing Quarterly Assessment indicated Resident 5 was a high risk for falls. The DON stated he (DON) was not aware of Resident 5's Nursing Quarterly assessment dated [DATE] when he (DON) took Resident 5 off the fall list star program on 12/15/2025. The DON stated that he (DON) should not have taken Resident 5 off from the falling star program because the Nursing Quarterly Assessment indicated Resident 5 was still at high risk for fall precautions. During a concurrent interview and record review on 1/22/2026 at 2:15 PM with the DON, Resident's 5 care plan, titled, RISK FOR FALL: The resident is at risk for falls r/t confusion, Gait/balance and Hx [history] of falls problems, dated 10/30/25, indicated Resident 5 had an intervention to Follow facility fall protocol. The DON stated he (DON) did not follow Resident 5's care plan when he (DON) took Resident 5 off fall precautions on 12/15/2025. During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 2/17/2025, the P&P indicated, The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment, and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments. c. During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted Resident 8 on 5/19/2025 and readmitted Resident 8 on 12/26/2025 with diagnoses that included hereditary idiopathic neuropathy (a group of different inherited medical conditions that cause nerve damage, pain, numbness, tingling, or weakness usually in the hands or feet), diabetes type 2 s (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with polyneuropathy (nerves throughout the body are damaged, causing weakness, numbness, tingling, and pain, usually starting in the feet and hands and often occurring symmetrically on both sides), lack of coordination, reduced mobility (move around), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 8's History and Physical (H&P) dated 12/27/2025, the H&P indicated Resident 8 had contractures of both hands (a condition where tissue in the palm tightens, thickens, and scars, causing one or more fingers to curl permanently toward the palm making it difficult to grip, hold, or pick up objects, and creates challenges for tasks like putting hands in pockets or washing faces) and needed assistance with personal care (non-medical, hands-on assistance with daily tasks such as bathing, brushing teeth, hair and skin care, and shaving). The H&P indicated Resident 8 had the capacity (ability) to understand and make decisions. The H&P indicated Resident 8 was a smoker. During a review of Resident 8's Nursing admission Assessment 5.5, dated 12/2025 at 8:20 PM, the Nursing admission Assessment 5.5 indicated Resident 8 required supervision for smoking. The Nursing admission Assessment 5.5 box marked Resident currently smokes and is able to hold physical the smoking device while smoking was not checked indicated Resident 8 could not hold a smoking device. The Nursing admission Assessment 5.5 box marked Resident can light and smoke cigarette or other smoking device while demonstrating safe technique or putting out matches or lights and disposing ashes was not checked indicated Resident 8 could not smoke safely or dispose of ashes. The Nursing admission Assessment 5.5 indicated the box marked Resident is a safe smoker and can perform function independently was not checked indicated Resident 8 was not an independent smoking (able to smoke without supervision). During a review of Resident 8's Minimum Data Set (MDS – a resident assessment tool) dated 1/2/2026, the MDS indicated Resident 8 had the ability to make himself understood and had the ability to understand others. The MDS indicated Resident 8 was dependent (helper does all of the effort and resident does none of the effort to complete activity) for upper and lower body dressing, for personal hygiene (comb hair, shaving, washing/drying face and hands) and for toileting. During a review of Resident 8's Care Plan titled At risk for injury related to smoking, dated 1/2/2026 indicated an intervention for Smoking apron offered during smoking time, respect residents preference and an intervention for Supervised smoking at all times. During a review of Resident 8's Physician Progress Notes dated 1/7/2025, the Physician Progress Notes indicated Resident 8 had decreased functional capacity (a measure of what a person can physically and mentally do in their daily life), fluctuating cognitive capacity (a person's practical ability to use their thinking skills like memory, focus, planning, and judgment to manage everyday tasks independently), and coordination deficits (a person has difficulty making smooth, precise, and purposeful body movements). During a review of Resident 8's Progress Notes dated 1/1/2026 to 1/20/2026, the Progress Notes indicated no documentation the facility offered Resident 8 a smoking apron (a fire-resistant protective cover worn over the chest and lap, primarily for wheelchair users or bedridden individuals to act as a safety shield to catch falling ashes to prevent burns to clothing, skin, or furniture). The Progress Nites indicate there was no documentation that Resident 8 refused a smoking apron. During a concurrent observation and interview on 1/20/2026 at 10:31 AM with Certified Nursing Assistant 1 (CNA 1) in the facility's designated smoking area, Resident 8 was observed smoking without a smoking apron using his contracted hand/fingers to wipe away excess ashes from his cigarettes with the ashes falling directly on Resident 8. CNA 1 stated he (CNA 1) would only offer a smoking apron if a resident (in general) could not independently smoke. During a concurrent observation and interview on 1/20/2026 at 10:38 AM with Licensed Vocational Nurse 3 (LVN 3), Resident 8 was observed smoking without a smoking apron. LVN 3 stated Resident 8 could burn himself if he could not hold his (Resident 8) cigarette safely with his (Resident 8) contracted hands/fingers. LVN 3 stated Resident 8 would also be at risk for burning himself if Resident 8 used his (Resident 8) fingers to remove excess ash from his (Resident 8) cigarette and allow the ash to fall on himself (Resident 8) without a smoking apron. LVN 3 stated if Resident 8 refused to use a smoking apron, the facility would need to document the refusal to follow his (Resident 8) individualized person-centered care plan (customized roadmap for support built specifically around a person's unique needs, goals, and preferences). During a concurrent interview and record review on 1/20/2026 with the Social Services Director (SSD), Resident 8's Smoking assessment dated [DATE] was reviewed. The Smoking Assessment indicated Resident 8 was not an independent smoker and required supervision. The SSD stated it was recommended for Resident 8 to use a smoking apron. The SSD stated if Resident 8 did not use a smoking apron, the ashes from Resident 8's cigarette could fall on him (Resident 8) and cause a burn. The SSD stated she (SSD) or the licensed nurses would have been responsible for creating a smoking care plan for Resident 8. During a concurrent interview and record review on 1/22/2026 at 8:16 AM with Registered Nurse 1 (RN 1) and LVN 3, Resident 8's Progress Notes dated 1/1/2026 to 1/22/2026 were reviewed. LVN 3 stated there was no documentation of the facility offering Resident 8 a smoking apron or documentation Resident 8 was using his fingers to wipe the excess ashes from his (Resident 8) cigarette (reference observation and interview on 1/20/2026 at 10:31 AM with CNA 1). LVN 3 stated CNA 1 did not report any issues with Resident 1's smoking/ashes on himself (Resident 8) on 1/20/2026 or she (LVN3) would have documented Resident 8's smoking issues and refusal to use a smoking apron. RN 1 stated Resident 8 could have had an injury if Resident 8 was allowed to have ashes fall on him (Resident 8) without a smoking apron on. RN 1 and LVN 3 stated the facility did not document any interventions from Resident 8's smoking care plan. During a concurrent interview and record review on 1/22/2026 at 8:22 AM with the Director of Nursing (DON), Resident 8's Smoking assessment dated [DATE] was review. The Smoking Assessment indicated the question Resident can light and smoke a cigarette or other smoking device while demonstrating safe technique or putting out matches or lights and disposing ash was not checked. The DON stated Resident 8 was not able to safely dispose of cigarette ashes according to the Smoking Assessment. During a concurrent interview and record review on 1/22/2026 at 8:22 AM with the DON, Resident 8's Care Plan titled At risk for related to smoking dated 1/2/2026 and Progress Notes dated 12/23/2025 to 1/22/2026 were reviewed. The DON stated there was no indication that the staff (unidentified) documented any interventions from Resident 8's care plan. During a concurrent interview and record review on 1/22/2026 at 8:22 AM with the DON, the facility's policy and procedure (P&P) titled, Smoking, dated 2/17/2025 was reviewed. The P&P indicated the following sections: B. If necessary, a referral to PT (physical therapy - helps you move better, reduce pain, and get back to your daily activities after an injury, surgery, or illness by using movement, exercise, and hands-on care, acting like a movement doctor to fix problems with your muscles, joints, and balance so you can live more independently and confidently) /OT (occupational therapy - helps people do the everyday activities they need and want to do, like getting dressed, cooking, working, or playing, when an illness, injury, disability, or developmental challenge makes it hard for them) to assess for the necessary eye-hand coordination and cognitive skills (the brain's core tools used to think, learn, remember, pay attention, and solve problems) for safe smoking may be required. IX. Residents who smoke shall wear a smoking apron if they are found not to be safe (i.e., drop lit cigarettes or do not handle the ashes properly). During an interview on 1/22/2026 at 9:30 AM with the DON, the DON stated he (DON) could not find a PT/OT evaluation for Resident 8's smoking. During an interview on 1/22/2026 with the facility's Administrator (ADM), the ADM stated the facility did not refer Resident 8 for a PT/OT evaluation to assess Resident 8's necessary eye-hand coordination and cognitive skills per the facility's policy. The ADM stated the PT/OT evaluation was not done. During a review of the facility's policy and procedure titled, Smoking, dated 2/17/2026, the P&P indicated the purposed of the policy was To respect resident/employee choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers. The P&P indicated The Facility discourages smoking by residents and ensures that those residents who choose to smoke do so safely. The P&P indicated Residents who want to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke independently in these areas. The P&P indicated Residents who are not able to smoke independently and safely will be accompanied by Facility Staff while smoking. The P&P indicated Residents who smoke shall wear a smoking apron if they are found not to be safe (i.e., drop lit cigarettes or do not handle the ashes properly.) If clothing is found to have cigarette burn holes the smoker must wear an apron to protect themselves from burns regardless of whether the resident is assessed as independent for smoking.

Based on observation, interview, and record review, the facility failed to ensure resident safety for two five sampled residents (Resident 8 and Resident 56) by failing to:-Ensure to implement safety smoking precautions for Resident 8. -Ensure to complete a post fall neurological assessment for the fall on 9/2025 and 12/2025 and Interdisciplinary Team (IDT- group of healthcare staff from different disciplines involved in the care of the resident), met, reviewed, and/or revised Resident 56's care plans after the fall on 09/10/2025 and 12/24/2025 to implement fall precautions for Resident 56. These failures had the potential for Resident 8 to have injuries related to unsafe smoking practices and for Resident 56 to sustain an injury from preventable fall.Findings: a. During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted Resident 8 on 5/19/2025 and readmitted Resident 8 on 12/26/2025 with diagnoses that included hereditary idiopathic neuropathy (a group of different inherited medical conditions that cause nerve damage, pain, numbness, tingling, or weakness usually in the hands or feet), diabetes type 2 s (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with polyneuropathy (nerves throughout the body are damaged, causing weakness, numbness, tingling, and pain, usually starting in the feet and hands and often occurring symmetrically on both sides), lack of coordination, reduced mobility (move around), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 8's History and Physical (H&P) dated 12/27/2025, the H&P indicated Resident 8 had contractures (a condition where tissue in the palm tightens, thickens, and scars, causing one or more fingers to curl permanently toward the palm making it difficult to grip, hold, or pick up objects, and creates challenges for tasks like putting hands in pockets or washing faces)of both hands and needed assistance with personal care (non-medical, hands-on assistance with daily tasks such as bathing, brushing teeth, hair and skin care, and shaving). The H&P indicated Resident 8 had the capacity (ability) to understand and make decisions. The H&P indicated Resident 8 was a smoker. During a review of Resident 8's Nursing admission Assessment 5.5, dated 12/2025 at 8:20 PM, the Nursing admission Assessment 5.5 indicated Resident 8 required supervision for smoking. The Nursing admission Assessment 5.5 box marked Resident currently smokes and is able to hold physical the smoking device while smoking was not checked indicated Resident 8 could not hold a smoking device. The Nursing admission Assessment 5.5 box marked Resident can light and smoke cigarette or other smoking device while demonstrating safe technique or putting out matches or lights and disposing ashes was not checked indicated Resident 8 could not smoke safely or dispose of ashes. The Nursing admission Assessment 5.5 indicated the box marked Resident is a safe smoker and can perform function independently was not checked indicated Resident 8 was not an independent smoking (able to smoke without supervision). During a review of Resident 8's Minimum Data Set (MDS – a resident assessment tool) dated 1/2/2026, the MDS indicated Resident 8 had the ability to make himself understood and had the ability to understand others. The MDS indicated Resident 8 was dependent (helper does all of the effort and resident does none of the effort to complete activity) for upper and lower body dressing, for personal hygiene (comb hair, shaving, washing/drying face and hands) and for toileting. During a review of Resident 8's Care Plan titled At risk for injury related to smoking dated 1/2/2026, the Care Plan indicated an intervention for Smoking apron [a fire-resistant protective cover worn over the chest and lap, primarily for wheelchair users or bedridden individuals to act as a safety shield to catch falling ashes to prevent burns to clothing, skin, or furniture] offered during smoking time, respect residents preference and an intervention for Supervised smoking at all times. During a review of Resident 8's Physician Progress Notes dated 1/7/2025, the Physician Progress Notes indicated Resident 8 had decreased functional capacity (a measure of what a person can physically and mentally do in their daily life), fluctuating cognitive capacity (a person's practical ability to use their thinking skills like memory, focus, planning, and judgment to manage everyday tasks independently), and coordination deficits (a person has difficulty making smooth, precise, and purposeful body movements). During a review of Resident 8's Progress Notes dated 1/1/2026 to 1/20/2026, the Progress Notes indicated there was no documentation the facility offered Resident 8 a smoking apron. The Progress Notes indicated there was no documentation that Resident 8 refused a smoking apron. During a concurrent observation and interview on 1/20/2026 at 10:31 AM with Certified Nursing Assistant 1 (CNA 1) in the facility's designated smoking area, Resident 8 was observed smoking without a smoking apron using his contracted hand/fingers to wipe away excess ashes from his cigarettes with the ashes falling directly on Resident 8. CNA 1 stated he (CNA 1) would only offer a smoking apron if a resident (in general) could not independently smoke. During a concurrent observation and interview on 1/20/2026 at 10:38 AM with Licensed Vocational Nurse 3 (LVN 3), Resident 8 was observed smoking without a smoking apron. LVN 3 stated Resident 8 could burn himself if he could not hold his (Resident 8) cigarette safely with his (Resident 8) contracted hands/fingers. LVN 3 stated Resident 8 would also be at risk for burning himself if Resident 8 used his (Resident 8) fingers to remove excess ash from his (Resident 8) cigarette and allow the ash to fall on himself (Resident 8) without a smoking apron. LVN 3 stated if Resident 8 refused to use a smoking apron, the facility would need to document the refusal to follow his (Resident 8) individualized person-centered care plan (customized roadmap for support built specifically around a person's unique needs, goals, and preferences). During a concurrent interview and record review on 1/20/2026 with the Social Services Director (SSD), Resident 8's Smoking assessment dated [DATE] was reviewed. The SSD stated the Smoking Assessment indicated Resident 8 was not an independent smoker and required supervision. The SSD stated it was recommended for Resident 8 to use a smoking apron. The SSD stated if Resident 8 did not use a smoking apron, the ashes from Resident 8's cigarette could fall on him (Resident 8) and cause a burn. The SSD stated she (SSD) or the licensed nurses (in general) would have been responsible for creating a smoking care plan for Resident 8. During a concurrent interview and record review on 1/22/2026 at 8:16 AM with Registered Nurse 1 (RN 1) and LVN 3, Resident 8's Progress Notes dated 1/1/2026 to 1/22/2026 were reviewed. LVN 3 stated there was no documentation of the facility offering Resident 8 a smoking apron or documentation that Resident 8 was using his fingers to wipe the excess ash from his (Resident 8) cigarette (reference observation and interview on 1/20/2026 at 10:31 AM with CNA 1). LVN 3 stated CNA 1 did not report any issues with Resident 1's smoking/ashes on himself (Resident 8) on 1/20/2026 or she would have documented Resident 8's smoking issues and refusal to use a smoking apron. RN 1 stated Resident 8 could have had an injury if Resident 8 was allowed to have ashes fall on him (Resident 8) without a smoking apron on. RN 1 and LVN 3 stated the facility did not document any interventions from Resident 8's smoking care plan. During a concurrent interview and record review on 1/22/2026 at 8:22 AM with the Director of Nursing (DON), Resident 8's Smoking assessment dated [DATE] was review. The DON stated the Smoking Assessment indicated the question Resident can light and smoke a cigarette or other smoking device while demonstrating safe technique or putting out matches or lights and disposing ash was not checked. The DON stated Resident 8 was not able to safely dispose of cigarette ashes according to the Smoking Assessment. During a concurrent interview and record review on 1/22/2026 at 8:22 AM with the DON, Resident 8's Care Plan titled At risk for related to smoking dated 1/2/2026 and Progress Notes dated 12/23/2025 to 1/22/2026 were reviewed. The DON stated there was no indication that the staff (in general) documented any interventions from Resident 8's care plan. During a concurrent interview and record review on 1/22/2026 at 8:22 AM with the DON, the facility's policy and procedure (P&P) titled, Smoking, dated 2/17/2025 was reviewed. The P&P indicated the following: B. If necessary, a referral to PT (physical therapy - helps you move better, reduce pain, and get back to your daily activities after an injury, surgery, or illness by using movement, exercise, and hands-on care, acting like a movement doctor to fix problems with your muscles, joints, and balance so you can live more independently and confidently) /OT (occupational therapy - helps people do the everyday activities they need and want to do, like getting dressed, cooking, working, or playing, when an illness, injury, disability, or developmental challenge makes it hard for them) to assess for the necessary eye-hand coordination and cognitive skills (the brain's core tools used to think, learn, remember, pay attention, and solve problems) for safe smoking may be required. IX. Residents who smoke shall wear a smoking apron if they are found not to be safe (i.e., drop lit cigarettes or do not handle the ashes properly.) XVI. Response to resident non-compliance with smoking rules include: A. First offense: A written letter issued to the resident and/or family regarding noncompliance (breaking rules or failing to follow instructions and safety procedures). B. Second offense: A written letter issued to the resident and/or family referencing the first offense letter and advising that a third offense results in the loss of smoking privileges. C. Third offense: A written letter Issued to the resident and/or family outlining the noncompliant behavior. At this time the resident loses their smoking privileges. D. Residents observed smoking following revocation of smoking privileges Is Issued a 30-day notice of discharge if their non-compliant behavior endangers other individuals (e.g. continuing to smoke in areas where oxygen is in use). The clinical/behavioral status of the resident endangering other individuals at the Facility will be documented by an associated physician in accordance with Policy No. - AD - 04 - Transfer and Discharge. During a concurrent interview and record review on 1/22/2026 at 8:22 AM with the DON, the DON stated he (DON) would need to investigate if Resident 8 had a PT/OT evaluation. The DON stated the facility did not give Resident 8 a noncompliance letter when Resident 8 did not comply with the facility's policy. The DON stated the facility was not following their Smoking policy. During an interview on 1/22/2026 at 9:30 AM with the DON, the DON stated he (DON) could not find a PT/OT evaluation for Resident 8's smoking. During an interview on 1/22/2026 with the facility's Administrator (ADM), the ADM stated the facility did not refer Resident 8 for a PT/OT evaluation to assess Resident 8's necessary eye-hand coordination and cognitive skills per the facility's policy. The ADM stated the PT/OT evaluation was not done. During a review of the facility's policy and procedure titled, Smoking, dated 2/17/2026, the P&P indicated the purposed of the policy was To respect resident/employee choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers. The P&P indicated The Facility discourages smoking by residents and ensures that those residents who choose to smoke do so safely. The P&P indicated Residents who want to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke independently in these areas. The P&P indicated Residents who are not able to smoke independently and safely will be accompanied by Facility Staff while smoking. 2.During a review of Resident 56's admission Record, the admission record indicated Resident 56 was initially admitted to the facility on [DATE], with diagnoses including Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), extrapyramidal and movement disorder (involuntary or uncontrollable body movements) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 56's Minimum Data Set (MDS – resident assessment tool) and care screening tool) dated 12/11/2025, MDS indicated that Resident 56's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. MDS indicated Resident 56 required moderate to maximal assistance from staff for activities of daily living (ADLs – toileting hygiene, shower/bathing). During a concurrent observation and interview of Resident 56 on 1/20/2026 at 1:11 p.m., Resident 56 observed awake, sitting in the wheelchair and unable to respond to questions. During a review of Resident 56's records titled Progress notes dated 9/10/2025, Licensed Vocational Nurse 4 documented at around 11:48 a.m., Resident 56 was walking on the hallway without assistance, lost his balance and slowly fell on his buttocks. Resident 56 usually has unsteady gait/use wheelchair for locomotion. Noted with 2 small redness marks on the right mid lateral side of back area (1x2cm and 1x1.5cm). During a review of Resident 56's records titled eINTERACT Change of Condition (COC) Evaluation dated 12/24/2025, COC indicated that Resident 56 had unwitnessed fall. Director of Nursing (DON) documented seen by staff and was able to help with assisting resident back up for assessment. During a review of Resident 56's Care Plan (CP) Report titled falling star program initiated on 1/02/2026. CP interventions included: Assist resident to participate in activities. By joining activities, residents will be around staff for assistance. Encourage resident to use wheelchairs to move around the facility. During a subsequent review of Resident 56's Care Plan Report titled risk for falls initiated and revised on 11/26/2024. CP indicated goals that Resident 56 will be free of falls and minor/serious injury with interventions included: Anticipate and meet The resident's needs. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night, handrails on walls, personal items within reach. During a concurrent observation and interview with Certified Nursing Assistant 6 (CNA 6) on 1/20/2026 at 1:18 p.m., CNA 6 assisted Resident 56 back to bed and placed bed in lowest position. CNA 6 stated that Resident 56 is high-risk for fall and currently on falling star program. During a concurrent interview with Registered Nurse 1 (RN 1) and review of Resident 56's medical records, RN 1 stated that Resident 56 is non-verbal, has an unsteady gait, and is able to ambulate with assistance. RN 1 added that Resident 56 is at high risk for falls and is unable to use the call light. Staff rely on non-verbal cues such as restlessness, fidgeting, grimacing, and reaching for objects to identify needs. RN 1 explained that when a resident is assessed as high risk for falls, they receive an evaluation from a physical therapist and are placed on the Falling Star Program. This program includes interventions such as keeping the bed in a low position, using floor mats, performing frequent checks, and providing assistance during ambulation. RN 1 stated that according to the Change of Condition (COC) assessment, Resident 56 experienced falls on 09/10/2025 and 12/24/2025. RN 1 described the post-fall protocol as including a resident assessment, completion of a post-fall assessment, a 72-hour neurological assessment, updating the care plan, and notifying the physician and responsible party. RN 1 reported that for the fall on 09/10/2025, Resident 56 sustained minor injuries consisting of two small areas of redness on the right lateral side of the back. An X-ray of the right hip and pelvis was ordered but not completed because the resident refused. RN 1 indicated that there was no documentation of a post-fall assessment for the 12/24/2025 incident. RN 1 also stated that there are no 72-hour neurological assessment documentation for post fall on 9/10/2025 and 12/24/2025. RN 1 stated that the fall on 12/24/2025 might have been avoidable if staff had reviewed Resident 56's medications, provided physical therapy, and relocated the resident closer to the nurse's station following the 09/10/2025 fall. During a concurrent interview with the DON and a review of Resident 56's records on 1/22/26 at 1:40 p.m., DON stated the importance of conducting fall risk assessments to identify high-risk residents. DON added that assessments are done upon admission, quarterly, and within 24 hours post-fall. DON also stated that high-risk residents are placed in the Falling Star Program, which includes placing floor mats, bed in lowest positions, and providing frequent visual checks. DON stated that the nurses should have completed a 72-hour neurological assessment done post fall for Resident 56 but failed to do. DON stated an IDT, consisting of the resident, DON, family, and PT meets within three days after a COC. DON indicated that reassessment is crucial to continue identifying fall risks and adjusting interventions and medications. DON stated he failed to reassess Resident 56 on 12/24/2025. DON stated that there should be an update on Resident 56's care plan post fall on 12/24/2025. DON stated there is no documentation of IDT for post fall on 9/10/2025 and IDT was done on 1/2/2026 which is past three days from the fall on 12/24/2025. DON stated that he did not adhere to the policy of meeting with the IDT team. DON indicated the importance of the IDT discussing actions to prevent further falls, identifying the cause of the fall, and implementing patient-centered care. During a review of facility's Policy & Procedure (P&P) titled Fall Management Program revised on 2/17/2025, P&P indicated that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. During a review of facility's Policy & Procedure (P&P) titled Response to Falls revised on 2/17/2025, P&P indicated in the post fall assessment and monitoring, following each resident fall, the licensed Nurse will complete an incident report and perform a Post-Fall Assessment & Investigation. The licensed Nurse will also complete the Neurological Flow Sheet for any un-witnessed fall or witnessed fall with known head injury for 72 hours following the fall.

Based on observation, interview, and record review, the facility failed to administer five doses of Adderall (a medication used to treat mental illness) per the physician's order between 1/19/2026 and 1/21/2026 in one resident randomly sampled for medication errors (Resident 34). The deficient practice of failing to administer five doses of Resident 34's Adderall increased the risk that Resident 34 could have experienced medical complications from missing scheduled doses of her medication and caused Resident 34 to feel overwhelmed and anxious about the potential impact to her physical and mental health as a result or missing her medication. Findings:During an observation on 1/21/2026 at 11:19 AM of Station 1 Medication Cart, an empty bubble pack (unit dose packaging from the pharmacy containing individual doses of medication) for Resident 34's Adderall was observed in the locked compartment of the medication cart. During a review of Resident 34's Controlled Drug Record (a log for controlled drugs [medications with a high potential for abuse] indicating the time and date each dose was administered) for Adderall indicated the last dose from the empty bubble pack was administered to Resident 34 on 1/19/2026 at 2 PM. During a review of Resident 34's admission Record (a record containing diagnostic and demographic resident information), the admission Record indicated the facility admitted Resident 34 on 7/28/2025 and readmitted her on 1/6/2026 with diagnoses including major depressive disorder (a mental illness characterized by depressed mood, difficulty sleeping, and lack of energy and interest in usually enjoyable activities). During a review of Resident 34's History and Physical (H&P - a record of a physician's comprehensive medical assessment and plan) dated 1/6/2026, the H&P indicated Resident 34 also had a diagnosis of attention deficit hyperactivity disorder (ADHD - a neurological condition that affects how the brain manages focus, impulses, and energy levels.) Further review of the H&P indicated this resident did have the capacity to understand and make decisions. During a review of Resident 34's Order Summary Report (a summary of all current physician orders) dated 1/22/2026, the Order Summary Report indicated Resident 34's attending physician prescribed Adderall ER (Extended Release - a dosage form that releases the dose over a 24 hour period) 15 milligrams (mg - a unit of measurement for mass) to give two capsules by mouth two times a day for ADHD on 1/6/2026. During a review of Resident 34's Medication Administration Record (MAR - a record of all medications administered for a resident) dated January 2026, the MAR indicated Resident 34 missed (or received partial) doses of Adderall on 1/19/26, 1/20/2026, and 1/21/2026.A review of the corresponding nurse progress notes on the dates above indicated the following notes regarding the administration of Adderall:1/19/2026 at 9:12 AM - Refill requested from pharmacy.1/19/2026 at 1:48 PM - Gave resident half the dose.1/20/2026 at 7:59 AM - Out of stock. Awaiting pharmacy delivery.1/20/2026 at 2:56 PM - Out of stock. Awaiting authorization from pharmacy.1/21/2026 at 7:24 AM - Out of stock. Will follow up with pharmacy.1/21/2026 at 1:45 PM - Resident is out at appointment. During an observation and concurrent interview on 1/22/2026 at 9:08 AM of Station 1 Cart with Licensed Vocational Nurse 4(LVN 4), Resident 34's Adderall was observed to be available in the medication cart with the delivery manifest indicating delivery was made on 1/21/2026 at 7:39 PM. LVN 4 stated Resident 34's dose of Adderall from the afternoon of 1/21/2026 was missed not only because Resident 34 was out of the facility but also because the medication had not yet been delivered. LVN 4 stated the progress notes were incomplete and did not indicate that the medication was still out of stock at that time. During an interview on 1/22/2026 at 9:18 AM with the Director of Nursing, the DON stated there were administrative hurdles obtaining approval for the refill of Resident 34's Adderall. The DON stated refills should be requested at least three to five days in advance and possibly longer for controlled medications. The DON stated this time frame would allow the facility time to address any administrative hurdles in obtaining the resident's refill to allow continuity of care for the resident's medications (in general). The DON stated that since the refill was requested on 1/19/2026, the same day Resident 34 received her last dose of medication, the facility failed to follow their policy regarding requesting refills sufficiently in advance. The DON stated this caused Resident 34 to miss five doses of her Adderall. The DON stated missing doses of psychotropic medications may cause medical or psychiatric complications resulting in an exacerbation of behaviors treated by the medication possibly leading to a decline in Resident 34's quality of life. During an interview on 1/22/2026 at 9:20 AM with Resident 34, Resident 34 stated she (Resident 34) only got half the dose of her Adderall on 1/19/2026 in the afternoon because that was all they (facility) had left. Resident 34 stated she (Resident 34) then missed two doses on 1/20/2026 and two doses on 1/21/2026. Resident 34 stated the facility routinely would delay her prescription refills with multiple medications, including her inhalers and other maintenance medications, to the point where she needed to sometimes take extra steps to manage obtaining her medications herself. Resident 34 stated having to manage her missing medications and thinking about the potential impact to her health causes her to feel overwhelmed and anxious.During a review of the facility's policy Medication Ordering and Receiving from Pharmacy revised January 2022, the policy indicated Reorder medication five days in advance of need to assure an adequate supply is on hand.During a review of the facility's policy Medication - Administration revised 2/17/2025, the policy indicated Medication will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner.

Based on observation, interview, and record review the facility failed to:1. Remove one expired insulin aspart pen (a medication used to control high blood sugar) affecting Resident 67 from the medication cart in one of two inspected medication carts (Station 1 Medication Cart). 2. Remove two vials of expired injectable lidocaine (a medication used to treat pain) and one vial of expired haloperidol (a medication used to treat mental illness) from the emergency kit (E-kit - a kit containing a limited supply of medication to be used on an emergency basis) in one of one inspected medication rooms (Medication Room). 3. Label one opened Arnuity Ellipta inhaler (a medication used to treat breathing problems) with an open date per the manufacturer's requirements affecting Resident 83 in one of two inspected medication carts (Station 2 Medication Cart). The deficient practices of failing to remove expired medications from the medication carts and E-kits and label open medication according to the manufacturer's requirements, increased the risk that Resident 67 and Resident 83 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.Findings:During a concurrent observation and interview on 1/21/2026 at 11:19 AM of Station 1 Medication Cart with Licensed Vocational Nurse 4 (LVN 4), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One opened insulin aspart pen was found in the medication cart labeled with an open date of 12/16/2025. According to the product labeling, insulin aspart pens should be used or discarded withing 28 days of opening. During a concurrent interview, LVN 4 stated Resident 67's insulin aspart was expired. LVN 4 stated the open date was 12/16/2025 and it was only good for 28 days once opened. LVN 4 stated this should have been removed from the cart and replaced on the day it expired. LVN 4 stated administering insulin after expiration could cause it to be less effective at controlling high blood sugar which may ultimately lead to medical complications requiring hospitalization. During a concurrent observation and interview on 1/21/2026 at 11:31 AM of the Medication Room with LVN 4, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:1. Two vials of injectable lidocaine were observed in the E-kit with a manufacturer's expiration date on 12/2025. 2. One vial of injectable haloperidol was observed in the E-kit with a manufacturer's expiration date of 12/2025. According to the product labeling, salmeterol/fluticasone inhalers should be used or discarded within one month of removal from the protective foil pouch. During a concurrent interview on 1/21/2026 at 11:31 AM, LVN 4 stated the lidocaine and haloperidol injectables from the E-kit expired last month. LVN 4 stated lidocaine was used to treat pain and if given when expired could be less effective at controlling pain that a resident might experience. LVN 4 stated that injectable haloperidol was usually used for behavioral control and if it was expired could cause a safety risk to an affected resident, other residents, or facility staff if it fails to help control behaviors. During a concurrent observation and interview on 1/21/2026 at 11:43 AM of Station 2 Medication Cart with LVN 3, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One opened Arnuity Ellipta inhaler was found without a labeled open date. According to the product labeling, Arnuity Ellipta inhalers should be used or discarded within six weeks of removing them from the protective foil pouch. During a concurrent interview 1/21/2026 at 11:43 AM, LVN 3 stated the Arnuity Ellipta for Resident 83 was opened but not labeled with an open date. LVN 3 stated this inhaler expired six weeks after opening per the manufacturer's requirements and thus needs an open date to know when it would expire. LVN 3 stated this medication (Arnuity) was used to prevent breathing problems due to asthma and could cause Resident 83's asthma to worsen if it was given after expiration possibly leading to medical complications requiring hospitalization. During a review of the facility's policy titled Medication Storage in the Facility revised January 2025, the policy indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications. are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists.

Based on observation, interview and record review the facility failed to ensure the lunch menu was followed on 1/20/2026, when:1. One Dietary aide (DA2) did not communicate the allergies listed on two of three (the gluten free meal ticket [lists resident's food preferences, allergies, and the food items on the menu to be served and portions] and the lactose intolerant meal ticket) meal tickets.2. [NAME] 2 did not prepare the non-breaded plain hamburger patty replacement for the gluten free diets. As a result, the cooks served pureed country fried steak (breaded beef patty) containing gluten on a tray for a resident who was allergic to gluten, and potato gratin (sliced potatoes in creamy sauce) prepared with milk served on a tray for a resident who was lactose intolerant (milk intolerant). This deficient practice had the potential to result in decreased meal satisfaction, decreased caloric intake and residents experiencing symptoms associated with intolerance in two residents who had gluten intolerance and two residents who had lactose intolerance.Findings: A review of the facility lunch menu for the regular diet on 1/20/2026 indicated the following items would be served: Country fried steak (breaded beef patty); Au gratin Potatoes (sliced potatoes in creamy sauce); green beans, dinner roll/margarine; dessert and beverages. A review of the facility lunch menu for the Gluten free diet on 1/20/2026 indicated the following items would be served: hamburger; baked potatoes quarters; green beans, Gluten free bread/margarine; dessert and beverage A review of the facility lunch menu for the Lactose intolerance diet on 1/20/2026 indicated the following items would be served: same as regular but eliminate the potato au gratin. During the tray line (tray line-a system of food preparation, in which trays move along an assembly line) observation on 1/20/2026 at 12:30PM, the service of trays for residents who were on gluten free diet and lactose intolerance diet was observed. DA2 was observed not communicating the diet orders written on the meal during lunch service to the cooks serving the food. The meal ticket located on one tray indicated an order for a lactose intolerant diet to be served by eliminating the potato au gratin. The meal ticket on the tray with the for the gluten free pureed diet indicated a hamburger was to be served instead of country fried steak, and a baked potato instead of potato au gratin. During the same lunch service observation, the tray for gluten free and pureed texture received pureed country fried steak (breaded beef patty) with gravy and the tray for lactose intolerance received the potato au gratin. During a concurrent observation and interview with Dietary Supervisor (DS) on 1/20/2026 at 12:35PM, DS checked the meal carts before they left the kitchen. DS verified the cooks served the wrong food to residents on gluten free diet. DS stated DA2 did not follow the resident's preference list, diet orders, and menu when calling out the diets to be served. During an interview with Cook1 and Cook2 on 1/20/2026 at 12:40PM, Cook1 stated he did not prepare the hamburger for the gluten free diet per the menu. Cook1 stated facility did not have gluten free bread or dinner rolls. Cook2 stated the potato au gratin contained milk and one tray indicating lactose intolerance was served potato au gratin. Cook1 stated if the residents received the incorrect diet, they would have symptoms of the allergies and get sick. During an interview with DA2 on 1/20/2026 at 12:45PM, DA2 stated he was nervous and forgot to look at resident allergies and the food listed on the meal ticket. DA2 stated if residents received the wrong food, they could get sick. During a review of the facility's recipe titled Country Fried Steak (dated 2026) the recipe listed Allergens (triggers an allergic reaction in sensitive individuals) for: egg, gluten, soy, wheat. During a review of the facility's recipe titled Au Gratin Potatoes (dated 2026) the recipe listed allergens for: gluten, milk, soy and wheat. During a review of the ingredients listed on the gravy mix packaging, it indicated it contained wheat and gluten. During a review of the facility's diet manual titled lactose Controlled diet (dated 9/2025), the diet manual indicated, this diet is designed to reduce the symptoms of bloating, gas and diarrhea associated with consumption of lactose. Lactose intolerance is not an allergy. Foods that should be limited are milk and milk products During a review of the facility's diet manual titled Gluten Restricted Diet (dated 9/2025), the diet manual indicated, the diet aims to eliminate symptoms, such as diarrhea, weight loss, indigestion and bloating, caused by sensitivity to gluten. If a resident is admitted with a gluten allergy it is highly suggested, they are served this diet. Grains not allowed on a gluten restricted diet are wheat, flour, gravy etc. During a review of the facility policy titled Therapeutic Diets (dated 10/2023), the policy indicated dietary manager is responsible for ensuring, the correct type and amount of food is purchased to meet the needs of resident receiving therapeutic diets. During a review of the facility policy titled Menus (dated 10/2023), the policy indicated Food served should adhere to the written menu.When a substitution is requested, the substitute items should be compatible in nutritional value taking into consideration vitamins, minerals, and calories.

Based on observation, interview and record review, the facility failed to ensure: The minced and moist diet (diet for residents who experience biting, chewing or swallowing limitations. Food is soft and moist; the size of the lumps should be approximately 4 mm in size fits through gaps of fork prongs.) Au gratin potatoes (sliced potatoes in creamy sauce) were served in a form that was in accordance with the international Dysphagia Diet initiative (IDDSI - a framework made up of levels and describes food textures and drink thickness) Level Five (Minced and Moist foods) when breaded beef patties were chopped and not minced and the texture of the minced and moist was not small (minced) did not fit through the gaps of fork prongs and breaded beef patty was dry. This failure had the potential to result in meal dissatisfaction and increased choking risk for ten residents on the minced and moist diet.During an observation in the facility's kitchen on 1/20/2026 at 10:00AM, Cook1 removed a portion of baked breaded beef patties from the oven and placed them on a chopping board. Cook1 started cutting the baked breaded beef patties using a knife into pieces varying in size, some pieces of the beef were larger about 1 inch, and some were smaller. Cook1 stated that it was preparation for the minced and moist diet. Cook1 stated the baked breaded beef patties were chopped into small pieces and then would be served with gravy for moistness. Cook1 stated the kitchen staff did not use the food processor because it made the food mushy and sticky. During an observation of the tray line (tray line-a system of food preparation, in which trays move along an assembly line) service for lunch 1/20/2026 at 12:30PM, the minced and moist country fried steak looked dry and over cooked as the edges of the breading that covered the beef patty were brown; it was chopped into inconsistent size and not minced, there were some larger pieces of breaded patties and was not moist. During the serving of the minced and moist food observed the potato au gratin was not minced. During a concurrent interview with Dietary Supervisor (DS) and [NAME] 1 on 1/20/2026 at 12:30PM, Cook1 stated, the breaded patties were chopped and not minced, and Cook1 did not prepare minced and moist potato au gratin because the potato was already soft. Cook1 stated gravy would be added on top of the chopped patties during serving. During a concurrent observation and test tray (a process of tasting, temping [measuring the temperature of food to ensure it is safe to eat] and evaluating the quality of food) of the minced and moist country fried steak breaded beef patty and potato au gratin with DS, Cook1 and Cook2 on 1/20/2026 at 12:50PM, Cook1 stated the size of the food should have been very small. DS stated the food was supposed to fit through the gaps of the fork prongs. [NAME] 1 was asked to demonstrate the test to make sure the minced and moist food meets the specification of the minced and moist diet per the IDDSI guidelines. Cook1 stated kitchen staff used a fork to press on the food to make sure it was soft and fit between the gaps of the fork with no runny juices. Cook1 pressed on the Breaded patties with fork and then stated the patty piece was too large, not soft and the food did not fit between the prongs. Cook2 stated the cooks should have put the food in the food processor and pulse twice to achieve the minced consistency. Cook1 stated the pieces were also dry and needed to be mixed with gravy for moistness. DS stated it was important to follow the recipe for minced and moist diet because if the texture was not correct it could be a potential for choking and residents could end up in the hospital. During a review of the facility's recipe titled Country Fried Steak (dated 2026) the recipe indicated, Minced and Moist Level 5: Mince regular cooked portions. With no separate thin liquid prior to service (4mm, approximately 1/8th inch) use slot between fork prongs to determine whether minced pieces are correct size. Reheat to 165F. serve with gravy. During a review of the facility's recipe titled Au Gratin Potatoes (dated 2026) the recipe indicated, Minced and Moist Level 5: Mince regular cooked portions. With no separate thin liquid prior to service (4mm, approximately 1/8th inch) use slot between fork prongs to determine whether minced pieces are correct size. Reheat to 165F. serve with gravy. During a review of the facility's diet manual titled Minced and Moist texture IDDSI Level 5 -MM5 (dated 9/2025), the diet manual indicated, the diet used to management of dysphagia with the food texture prepared as minced and moist; some people on this diet may be able to bit off a large piece of food but they are unable to chew it into small enough pieces that are safe to swallow. All recipes should be tested prior to service to ensure the texture and piece size meet the IDDSI guidelines. During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated that Level 5 Minced and Moist is usually eaten with spoon or fork, for people who cannot bite off pieces of food safely but have some basic chewing ability. It is important that food is not sticky. You should be able to scoop food onto a fork, with no liquid dripping and no crumbles falling off the fork. Size of the food is 4mm, which is about the gap between the prongs of a standard dinner fork. Food testing method: Spoon tilt test and Fork drip test.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1.Clean and sanitized resident trays and cups were stored on the counter next to the handwashing sink and in the splash zone (the area within roughly 3 feet of a handwashing sink or drain, where water spray and particles from handwashing can contaminate surrounding surfaces). 2. The floor in the dry storage area located in the kitchen was not kept clean, food debris, a hair net, a lighter, condiments packages and plastic wrappers were on the floor. 3. Expired food was stored in the dry storage area. One unsealed bag of chocolate chips with no date, one bag of powder/ground graham crackers stored with the bag opened and received date of 8/30/2024 (expired), one container of Worcestershire sauce with a use by date (the final recommended date for safe consumption, indicates when food is at peak quality and should be treated as a safety deadline) of 3/21/2025, and one container of sesame oil with a use by date of 11/20/2025 (expired) were stored in the dry storage area. 4. Nutrition supplement/shakes labeled store frozen with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. One box containing 30 single serving containers of chocolate flavored high calorie nutrition shakes were stored in the walk-in refrigerator with no thaw date. 10 single serving containers of vanilla flavored high calorie shakes were stored in the reach in refrigerator with no thaw date. This deficient practice had the potential to result in foodborne illness in 14 residents who receive nutritional shakes during lunch and snacks. 4. Food brought to residents from outside of the facility was stored in the resident's food refrigerator located in the nurse's station with no label and not monitored for the expiration date. There was one paper bag with open packages of deli meat (ham and bologna) and sliced cheese with no resident name; one subway sandwich dated 1/19/2026 and one bag of tamales and taco brought in on 1/19/2026 exceeding storage period for outside food; four yogurt smoothies with manufactures expiration dates of 10/11/2025 expired and stored in the resident refrigerator. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 62 out of 68 residents who received food from the facility and including residents who had food stored in the resident refrigerator.Findings: 1. During an observation in the facility's kitchen on 1/20/2026 at 8:20AM, resident food trays and cups were observed stored on the dish washing area counter and adjacent (next to) to the handwashing sink in the splash zone. During a concurrent observation and interview with Dietary Supervisor (DS) on 1/20/2026 at 8:30AM, DS verified that the trays and cups had been washed and stored on the counter to air dry. DS stated there was a potential to splash on the dishes next to the sink. During an interview with the Maintenance supervisor (MS) and DS on 1/20/2026 at 10:15AM, DS agreed that the dishes were in the splash zone and should have been covered to prevent cross contamination of the clean and sanitized dishes. MS stated there should have been a divider placed to prevent splashes on the clean dishes. During a review of the 2022 U.S. Food and Drug Administration Food Code, code 4-903.11 titled Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. code indicated, (A) cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. 2. During a concurrent observation in the dry storage area of the facility's kitchen and interview on 1/20/2026 at 8:35AM, the floor behind the shelf was observed to be dirty with trash. Food debris, a hair net, a lighter, condiments packages and plastic wrappers were observed on the floor. The DS stated there was trash on the floor. DS stated staff swept the floor every day. DS stated the floor had to be clean to prevent attracting pests. During a review of facility cleaning schedule and checklist dated January 2026, the cleaning schedule indicated weekly cleaning of the kitchen pantry. The schedule did not indicate cleaning the dry storage area. During the same observation and interview in the dry storage area on 1/20/2026 at 8:40AM, there was one unsealed bag of chocolate chips with no date, one bag of powder/ground graham crackers stored with the bag open and a received date of 8/30/2024 expired, one container of Worcestershire sauce with a use by date of 3/21/2025, and one container of sesame oil with a use by date of 11/20/2025 expired and stored in the dry storage area. During a concurrent observation and interview with DS on 1/20/2026 at 8:40AM, DS stated the powdered graham cracker was not used anymore and should have been discarded. DS verified the powdered graham cracker was expired and not sealed. The DS was then observed discarding the expired powdered graham cracker. DS stated the facility received a new shipment of chocolate chips for baking and then discarded the unsealed bag of chocolate chips with no date. DS stated once the bags were opened, they had to be dated and labeled then sealed tight to prevent cross contamination. DS stated all seasonings that were expired would be discarded. DS stated the bottle of oil and sauce had been at the facility for a long time. DS stated when seasonings were expired, they lost quality and taste. During a review of facility's policy titled Food storage (dated 10/1/23) the policy indicated, Dry storage guidelines: The walls, ceiling and floor should be maintained in good repair and regularly cleaned, any opened products should place in storage containers with tight fitting lids, label and date storage products and rotate stock. 3. During an observation in the kitchen on 1/20/2026 at 9:00AM, 30 single-serve cartons of chocolate flavored nutrition supplements/shakes stored inside the walk-in refrigerator with no date were observed. During a concurrent observation and interview with DS on 1/20/2026 at 9:00AM, DS stated the shakes were delivered frozen and they were stored in the freezer. DS did not know the expiration date of the nutrition shakes. The label on the nutritional shake indicated to store frozen and once thawed use within 14 days. The DS did not know when the nutritional shakes were removed from the freezer. During an observation of the kitchen's tray line refrigerator on 1/20/2026 at 9:15AM, 10 single serve cartons of vanilla flavored nutrition shake with no date were observed. DS did not know when the shakes were thawed. DS stated there should have been a date to monitor the thaw date. DS stated nutrition shakes were like milk and could go bad and cause residents to have stomach pain. 4. During an observation in the resident refrigerator located in the nurse's station on 1/21/2026 at 9:00AM, one paper bag with open packages of deli meat (ham and bologna) and sliced cheese with no label were observed stored in the resident refrigerator. One bag with a subway sandwich and one bag with a leftover taco and tamale with a date of 1/19/26 were observed stored in the resident refrigerator. Four expired yogurt smoothies with manufacturer expiration dates of 10/11/2025 were observed stored in the resident refrigerator. During a concurrent observation and interview with IP nurse on 1/21/2026 at 9:00AM; IP nurse stated residents families took food to the facility or the residents would order food from outside the facility. The IP stated leftovers were labeled with resident name and the date the food was brought in and then stored in the refrigerator for 72 hours. IP stated it was important to date, label, and discard items before they went bad. IP stated the yogurt smoothies were expired and should have been discarded because residents could get sick. During an interview with RN1 on 1/21/2026 at 9:30AM, RN1 stated nursing staff checked for expired items and discarded the items appropriately. RN1 verified the smoothies were expired and stated the smoothies should have been discarded. RN1 stated leftovers were stored for 72 hours but would confirm the policy and discard the food accordingly. RN1 stated outside food was monitored before resident consumption to prevent risk of aspiration, choking and to discard any expired items. During a review of facility's policy titled Food Brought in by Visitors (dated 10/1/23), the policy indicated, Perishable food requiring refrigeration will be discard after two hours at bedside, and if refrigerated, it will be labeled, dated and discarded after 48hours.

Based on interview and record review, the facility failed to obtain an informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to the treatment with Cymbalta (a medication used to treat mental illness) in one of five sampled residents (Resident 69) for unnecessary medications.The deficient practice of failing to obtain an informed consent prior to initiating treatment with a psychotropic (medications that affect brain activities associated with mental processed and behavior) medications could have prevented Resident 69 from exercising her right to decline treatment with Cymbalta. This increased the risk that Resident 69 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to Cymbalta leading to impairment or decline in her mental or physical condition or functional or psychosocial status. Findings: During a review of Resident 69's admission Record (a record containing diagnostic and demographic resident information), the admission Record indicated the facility admitted Resident 69 on 4/9/2025 with a diagnosis of schizophrenia (a mental illness characterized by hearing or seeing things that are not there). During a review of Resident 69's History and Physical (H&P - a record of a physician's comprehensive medical assessment and plan) dated 4/10/2025, the H&P indicated Resident 69 had capacity to understand and make medical decisions. During a review of Resident 69's Order Summary Report (a summary of all current physician orders) dated 1/22/2026, the Order Summary indicated on 5/7/2025, Resident 69's attending physician prescribed Cymbalta 30 milligrams (mg - a unit of measure for mass) by mouth at bedtime for phantom limb pain (nerve-related pain due to an amputation.) During a review of Resident 69's available informed consent documentation and clinical record indicated there was no documentation that Resident 69 or any responsible party received education regarding the risks and benefits of Cymbalta prior to its initiation on 5/7/2025. During an interview on 1/22/2026 at 11:52 AM with the Director of Nursing (DON), the DON stated the facility failed to obtain informed consent for the use of Resident 69's Cymbalta prior to its use. The DON stated he (DON) was unaware Cymbalta needed an informed consent as it was not being used for behavioral management. The DON stated failure to obtain an informed consent could deprive Resident 69 of her right to decline psychotropic treatment possibly leading to a decline in her quality of life. During a review of the facility's policy Psychotherapeutic Drug Management, revised 5/19/2025, the policy indicated When obtaining consent for the use of psychotherapeutic drugs, the resident will be informed of the risks and benefits for the use of these medications.

Based on interview and record review the facility failed to provide feeding assistance during meals for one of three sampled residents (Resident 69). This deficient practice had the potential not to meet Resident 69's specific needs and had the potential for Resident 69's activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) to decline.Findings:During a review of Resident 69's admission Record, the admission Record indicated the facility admitted Resident 69 on 4/9/2025 with diagnoses that included unqualified visual loss (a significant loss of vision in one or both eyes where the specific cause[blindness category, underlying disease] has not been clearly identified) both eyes, unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance (acting out, agitated, aggressive or mood/personality changes), psychotic disturbance(hallucinations or strong delusions), mood disturbance (disruptive sadness, irritability), and anxiety (excessive worry, fear, and nervousness), other lack of coordination(the brain struggles to coordinate muscles, leading to jerky, unsteady, or inaccurate movements), dysphagia (difficulty swallowing), oral (mouth) phase and cognitive communication deficit (struggling with talking, listening, or understanding because of problems with thinking skills[cognition], rather than a physical speech or language issue). During a review of Resident 69's History and Physical dated 4/10/2025, the H&P indicated Resident 69 had the capacity (ability) to make medical decisions. During a review of Resident 69's Optometry Exam Consult dated 8/13/2025 indicated Resident 69 had vision loss in both eyes and had an inability to adapt to bifocals (eyeglasses with split into two parts to correct both far and near vision in one frame). The Optometry Exam Consult indicated Resident 69 had cataracts (a clouding of your eyes' natural lens, like looking through a foggy window, which makes vision blurry and hazy). During a review of Resident 69's Minimum Data Set (MDS - a resident assessment tool) dated 10/14/2025, the MDS indicated Resident 69 had severely impaired (reduced) vision (no vision or sees only light, colors or shapes; eyes do not appear to follow objects), did not use corrective lenses (contacts, glasses, or magnifying glass), had normal cognition (ability to think, understand, learn, and remember), had limitation in range of motion (ROM-the full distance and direction a joint[where two or more bones meet] can move, measured by how far it can bend, straighten, or twist) in the upper extremity (shoulder, elbow, wrist, hand) on one side and required supervision or touching assistance (helper provides verbal cues[short spoken words used as a guide] and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating . During a review of Resident 69's Speech Therapy note dated 11/7/2025 indicated Resident 69 required set up and intermittent cues (occasional reminders) for identification location of food items on meal tray due to have been diagnosed of being legally blind (severe uncorrectable vision loss) and benefitted from verbal cues upon meal tray set up and also finger foods. During a review of Resident 69's Dietary Profile dated 1/13/2026 indicated Resident 69 was blind and was able to feed self with supervision and maximum assist. During an observation on 1/20/2026 at 12:55 PM Resident 69 was observed in the dining room sitting in a wheelchair and eating lunch unassisted by staff. Resident 30 was observed sitting beside Resident 69 and intermittently scooping up Resident 69's food into mounds on the plate and Resident 69 preceded to scoop up another spoonful of food to eat. Certified Nurse Assistant 1 (CNA 1) was observed sitting at the same table and was assisting another resident (unidentified) with their meal. CNA 1 did not assist Resident 69. During an interview on 1/20/2026 at 1:17 PM with Resident 69, Resident 69 stated I cannot see, I only see light in my eyes. I have cataracts in my eyes. I needed help but no other person had assisted me. During a concurrent interview and record review on 1/20/2026 at 1:23 PM, with the Infection Preventionist (IP), Resident 69's Dietary Profile dated 1/13/2026 was reviewed. The IP stated, any staff member that was in the dining area could have assisted [Resident 69], but I did not have anyone that helped her today with her meal. The IP stated I had asked [Resident 69] if she wanted assistance with her meal, but [Resident 69] stated she did not want any help. The IP stated Resident 69 would usually refuse assistance with her meal. The IP stated she (IP) informed Resident 30 he (Resident 30) could not help Resident 69 with her meal, and he (Resident 30) stopped. The IP stated Resident 69's Dietary Profile indicated Resident 69 required maximum assistance and supervision with eating. The IP stated there was not any documentation of Resident 69 refusing assistance with meals. During an interview on 1/20/2025 at 2:24 PM, with CNA1, CNA 1stated he (CNA1) did not assist Resident 69 and was not assigned to Resident 69. CNA 1 stated Resident 69 could only see shadows. CNA 1 stated he (CNA1) saw the other resident (Resident 30) helping her (Resident 69). During a concurrent interview and record review on 1/21/2026 at 12:14 PM, with the IP, the facility's policy and procedure (P&P) titled, Care Planning dated 2/17/2025 and the facility's policy and procedure (P&P) titled, Resident Rights-Accommodation of Needs dated 2/17/2025 were reviewed. The IP stated an interdisciplinary team meeting (IDT, a collaborative group of diverse health care professionals from different fields who work together) should have been done for Resident 69's accommodation of requiring assistance with her meals as indicated on the policy. The IP stated there was no IDT done for Resident 69's accommodation of having needed assistance and to find out why the resident was refusing assistance for meals that needed to be addressed. The IP stated the policies for care planning and resident accommodation were not followed as indicated since a care plan was not developed and Resident 69 was not assisted during meals. During a concurrent interview and record review on 1/21/2026 at 12:21 PM, with Registered Nurse 1 (RN1), the facility's policy and procedures (P&P) titled, Care Planning dated 2/17/2025 and the facility's policy and procedure (P&P) titled, Resident Rights-Accommodation of Needs dated 2/17/2025 and Resident 69's complete Care Plan Report were reviewed. RN 1 stated Resident 69 could only see shadows and was able to feed herself but required verbal cues during meals for location of food which was considered an accommodation. RN 1 stated there was no IDT done for Resident 69 having required accommodation of supervision or touch assistance with meals. RN 1 stated an IDT needed to have been done and it was important to have known the results of the IDT for Resident 69's care. RN 1 stated an IDT was not done for Resident 69's to have needed assistance during meals or having refused assistance. RN 1 stated there was no care plan for Resident 69 accommodation needing supervision or touch assistance with meals. RN 1 did not want to answer if the facility was following the policy and procedure on accommodation needs and care planning. During a concurrent interview and record review on 1/21/2026 at 12:46 PM, with the Director of Nursing (DON), the facility's policy and procedures (P&P) titled, Care Planning dated 2/17/2025 and the facility's policy and procedure (P&P) titled, Resident Rights-Accommodation of Needs dated 2/17/2025 were reviewed. The DON stated it was not appropriate for another resident to help Resident 69 with her meal; the staff should have assisted Resident 69, that was part of the resident's accommodation. The DON stated there was no IDT done for Resident 69 needing accommodation for assistance with meals or having refused assistance. The DON stated the IDT was members of every department meeting to have assessed concerns for residents and to have created a person-centered care plan per policy. The DON stated there was not a care plan for Resident 69 indicating Resident 69 required supervision or touch assistance with meals or a care plan for that accommodation. The DON stated the consequence of not having a care plan was that there would not be an identification of resident's needs to better help Resident 69. The DON stated any licensed nurse could create a care plan and the IDT could have created a care plan based on the policy; the IDT could have addressed the reason behind Resident 69's refusal of assistance with meals. The DON stated the purpose of a care plan was to have interventions in place to have problems addressed and plan for resident care with goals in mind. The DON stated we needed to accommodate Resident 69's needs in her ADL's, especially with meals since that is very specific and can lead to an alteration in the resident's nutrition. The DON stated the facility did not follow policies on care planning or resident accommodation of needs. During a review of the facility's policy and procedure (P&P) titled, Care Planning dated 2/17/2025, the P&P indicated The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan. The P&P indicated A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/MDS guidelines. The P&P indicated Each Resident's Comprehensive Care Plan will describe the following: Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. During a review of the facility's policy and procedure (P&P) titled, Resident Rights-Accommodation of Needs dated 2/17/2025, the P&P indicated To ensure that the Facility provides an environment and services that meet residents' individual needs. The P&P indicated Facility Staff interacts with the residents in a way that accommodates the physical or sensory limitations of the residents.

Based on interview and record review, the facility failed to ensure that a Pre-admission Screening and Resident Review (PASRR - a federal requirement ensuring people with mental illness, intellectual disabilities, or related conditions are not inappropriately placed in nursing homes) was done for one of five sampled residents (Resident 42) diagnosed with a mental illness prior to admission in the facility. This failure had the potential for Resident 42 not to receive the necessary and appropriate psychiatric evaluation (is a comprehensive mental health assessment by a professional to diagnose emotional, behavioral, or cognitive conditions, guide treatment, and understand a person's overall mental state) and level of treatment at the facility.Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility admitted Resident 42 on 8/18/2025 with diagnoses that included end stage renal disease (ESRD - irreversible kidney failure), essential (primary) hypertension (HTN - high blood pressure), hyperlipidemia (too much fat such as cholesterol in the blood), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool) dated 11/25/2025, the MDS indicated Resident 42 had the ability to make himself understood and had the ability to understand others. During a concurrent interview and record review on 1/21/2026 at 3:25 PM with the facility's Director of Nursing (DON), Resident 42's electronic medical record (EMR - a digital version of a patient's paper chart, storing health information like medical history, diagnoses, medications, and test results on a computer) was reviewed. The DON stated Resident 42 had a diagnosis of bipolar disorder and schizophrenia. The DON stated he (DON) could not locate Resident 42's PASRR in the EMR. During a concurrent interview and record review on 1/21/2026 at 3:25 PM with the facility's DON, the PASRR, DHS.CA.GOV website (a website where you can find PASRR information for someone) was reviewed. The DON logged onto the PASRR.DHR.CA.GOV website and stated he (DON) could not locate a PASRR for Resident 42. During a concurrent interview and record review 1/21/2026 at 3:25 PM with the facility's DON the facility's policy and procedure (P&P) titled Pre-admission Screening and Resident Review (PASRR), dated 2/17/2025 was reviewed. The P&P indicated I. All individuals, regardless of payer source, seeking admission to a Medi-Cal-certified SNF (Skilled Nursing Facility) must have a PASRR Determination by the Department of Health Care Services (DHCS - a state agency that manages and funds health programs for low-income residents, primarily operating Medi-Ca) or Department of Development Services (DDS- a state agency that helps Californians with developmental disabilities [such as autism, epilepsy, cerebral palsy, and intellectual disabilities] live independent, productive lives) prior to the Facility accepting the admission. II. The Facility ensures that PASRR Level I (a mandatory, quick, initial screening for anyone entering a Medicaid-certified nursing home to check for mental illness, intellectual disabilities or related developmental conditions) is completed either by the transferring general acute care hospital [GACH - a facility providing 24/7, short-term, in-patient care for severe, sudden, or urgent health conditions] or by the Facility for all applicants, regardless of payor, prior to admission to determine if they have a serious mental illness (SMI) and/or intellectual disability (ID -significant limitations in both mental functioning and adaptive skills needed for daily life, such as communication and self-care), developmental disability (DD - a lifelong condition, appearing before age [AGE], that affects a person's physical, learning, language, or behavior areas) or related condition(s) (ID/DD/RC). A. All potential resident of the Facility, whether or not they receive or are eligible for Medical, receive the Level I screening.Ill. The Facility also conducts PASRR Level I screening for current residents who have a mental illness or intellectual disability and experience a significant change in their condition based on MOS 3.0 guidelines.IV. A negative PASRR Level I screen permits admission to proceed and ends the PASRR process unless a possible SMI or ID/DD/RC arises later. A positive PASRR Level I screen necessitates an in-depth evaluation of the individual by a Level II Contractor, known as PASRR Level II (an in-depth, personalized assessment conducted when a preliminary screen [Level 1] suggests a nursing home applicant has a mental illness or intellectual disability, which must be conducted prior to admission.The DON stated there was no proof of a PASRR was done for Resident 42. The DON stated the facility would not be able to properly treat Resident 42's mental health conditions without performing a PASRR. During an interview on 1/23/2026 at 10:50 AM with the facility's Administrator (ADM), the ADM stated she (ADM) would investigate to see if Resident 42 had a PASRR performed by the general acute care hospital (GACH) before transferring the facility. The ADM was not able to provide proof Resident 42 had a PASRR.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 79) reviewed for skin care received the care required to prevent pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to: -Ensure to set Resident 79's low air loss mattress (LALM - a medical bed surface designed for immobile patients to prevent or treat bedsores) according to Resident 79's weight. This failure had the potential for Resident 79 to develop pressure injuries and/or worsen skin wounds (injury that break the skin or other body tissues).Findings: During a review of Resident 79's admission Record, the admission Record indicated the facility originally admitted Resident 79 on 1/22/2019 and readmitted Resident 79 on 1/15/2026 with diagnoses that included cerebral palsy (a lifelong condition that leads to problems with movement, balance, and posture, like a broken communication line between the brain and muscles), type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified protein-calorie malnutrition (a person is not getting enough food, specifically protein and total calories, to keep their body functioning properly, but the exact cause or specific type is not defined), unspecified intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), unspecified convulsions (sudden, involuntary muscle spasms, shaking, or rigid body movements lasting seconds to minutes, where the exact cause or specific type is not immediately determined), heart failure (your heart isn't pumping as well as it should, failing to deliver enough oxygen-rich blood to meet the body's needs, causing fatigue, shortness of breath, and fluid buildup), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 79's Minimum Data Set (MDS - a resident assessment tool) dated 12/25/2025, the MDS indicated rarely/never could make himself (Resident 79) understood and rarely/never had the ability to understand others. The MDS indicated Resident 79 was dependent (helper does all of the effort and resident does none of the effort to complete activity) for oral hygiene (clean teeth), toileting, showering/bathing, upper/lower body dressing, personal hygiene (comb hair, shaving, washing/drying face and hands), rolling to the left, rolling to the right, moving from sitting to lying position transferring from chair to bed, and going to the toilet. During a review of Resident 79's Dietary Profile, dated 1/16/2026, the Dietary Profile indicated Resident 79 weighed 79 pounds. During a review of Resident 79's Progress Note dated 1/16/2026 at 3:48 PM, the Progress Note indicated Resident 79 had a left middle back surgical wound measuring 12 centimeters (cm a unit of measurement) x 18 cm x utd (undetermined). The Progress Note indicated Resident 79's skin was fragile. During a review of Resident 79's History and Physical (H&P), dated 1/18/2026, the H&P indicated Resident 79 did not have the capacity (ability) to understand and make decisions). The H&P indicated Resident 79 had a large ulcer (a small open sore or wound generally found in the stomach or on the skin) upper back. The H&P indicated Resident 70 had stiffness and contraction (permanent tightening or shortening of muscles, tendons, or skin, causing joints to become stiff, bent, and fixed in one position) on his (Resident 79) back and extremities. During a concurrent observation, and interview on 1/20/2026 at 11:31 AM with Licensed Vocational Nurse 3 (LVN 3), Resident 79's LALM was observed to be set for a weight between 300 and 350 pounds. LVN 3 stated the LVNs (in general) were responsible for checking to ensure the LALM settings were set correctly. LVN 3 stated Resident 79's LALM weight setting was set too high. LVN 3 stated Resident 79's back wound could get worse if the LALM was set too high. LVN 3 stated the LALM should have been set according to Resident 79's weight. During a concurrent interview and record review on 1/20/2026 at 11:31 AM with LVN 3, Resident 79's electronic medical record (EMR - a digital version of a patient's paper chart, storing health information like medical history, diagnoses, medications, and test results on a computer) weight record dated 1/16/2026 was reviewed. LVN 3 stated Resident 79's weight was 79 pounds. During an interview on 1/20/2026 at 11:42 AM with Registered Nurse 1 (RN 1), RN 1 stated Resident 79's back wound could worsen if Resident 79's LALM weight setting was too high. RN 1 stated Resident 79's LALM settings should be set based on Resident 79's weight. During a review of Resident 79's Order Summary Report, dated 1/21/2026, the Order Summary Report indicated an order for Resident 79 to have a LALM for Resident 79's wound management. The LALM order indicated for the LAM to match Resident 79's weight. During an interview and record review on 1/23/2026 at 10:19 AM with the Director of Nursing (DON), the facility's user manual titled Med-Aire 8 (inch) Alternating Pressure Mattress Replacement System With Low Air Loss User Manual Item #14027 (undated), was reviewed. The user manual indicated The analog control unit (a method of managing devices using continuous, smooth, and variable signals like a [NAME] switch or volume knob) includes an easy-to-use dial that is adjustable to the patient's weight and comfort. The DON stated the facility's staff would not be able to tell what setting was comfortable for Resident 79 because Resident 79 could not verbalize (say) to staff what level setting on the LALM was comfortable. The DON stated the facility should have used Resident 79's weight for the LALM settings. The DON stated setting the LALM too high could make the LALM surface harder, increasing Resident 79's risk for pressure injury or could make Resident 79's back wound worse. During a review of the facility's user manual titled Med-Aire 8 Alternating Pressure Mattress Replacement System With Low Air Loss User Manual Item #14027 (undated), was reviewed. The user manual indicated the following: This analog control unit includes an easy-to-use pressure dial that is adjustable to the patient's weight and comfort.

Based on observation, interview and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system, your kidneys, ureters, bladder and urethra) for one of two sampled resident (Resident 9) by failing to:1. Provide an on-going assessment of the use and removal of Resident 9's indwelling foley catheter (foley catheter - a hollow tube left implanted in a body canal or organ, especially the bladder, to promote drainage).2. Review and revise the individualized care plan when Resident 9 had UTI on 3/24/2025 and 09/15/2025.3. Initiate an interdisciplinary team (IDT) review when Resident 9 had UTI on 3/24/2025 and 09/15/2025 and a change of condition on 11/30/2025.These deficient practices has caused Resident 9 to develop catheter associated urinary tract infection (CAUTI - an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder [an organ inside the body that stores urine until it can be excreted]), pain and had potential to result in serious complications including sepsis (a potentially life-threatening complication of an infection).During a review of Resident 9's admission Record, the admission record indicated Resident 9 was initially admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), end stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis) with dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream). During a review of the Minimum Data Set (MDS - a resident assessment) dated 11/20/2025, MDS indicated that Resident 9's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 9 required maximal assistance from staffs for activities of daily living (ADLs - toileting hygiene, shower/bathing). The MDS also indicated that Resident 9 had an indwelling foley catheter. During a concurrent observation and interview with Resident 9 on 1/20/2026 at 10:50 a.m., Resident 9 had a foley catheter with yellow, cloudy urine noted in the tubing and started having it for over a year without knowing why. During an interview with LVN 4 on 1/21/2026 at 2:20 p.m., LVN 4 stated that there was no order for monitoring of urine output. LVN 4 stated that the urine had moderate amount and unable to answer amount in milliliter (ml- unit of measurement). During a review of Resident 9's laboratory urine culture resulted on 03/24/2025 indicated that Resident 9 had extended spectrum beta-lactamase (ESBL - an enzyme found in some strains of bacteria that can't be killed by many of the antibiotics that doctors use to treat infections) in the urine. During a review of Resident 9's records titled Surveillance Data Collection Form dated 3/25/2025, Infection Preventionist (IP) indicated that Resident 9 had Healthcare-Associated Infection (HAI) and was on contact isolation (separation of residents with an infection from residents without an infection) for ESBL in the urine. IP documented Resident 9 complained of pain around shaft of penis, foley in place, noted also with foul smell. Medical Doctor (MD) notified and ordered urinalysis with culture and sensitivity. Resident 9 continuous to have recurrent UTIs. During a review of Resident 9's records from General Acute Care Hospital 1 (GACH 1) on 9/13/2025, History and Physical (H&P) indicated that Resident 9 was admitted for a missed dialysis session and had a complicated urinary tract infection needing intravenous (IV -fluids given directly into the blood stream) antibiotics (medication used to fight bacterial infection). The laboratory urinalysis result collected on 9/13/2025 indicated that white cells in urine (indicate an infection or inflammation within the urinary tract) had Too Numerous To Count (TNTC) and bacteria in urine had many. During a review of Resident 9's records titled Surveillance Data Collection Form dated 9/16/2025, IP documented that Resident 9 had Healthcare-Associated Infection (HAI) and was on Enhanced Barrier Precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs - bacteria that are resistant to more than one antibiotic and can cause serious infections in nursing facilities]). IP documented that Resident 9 reported pain around the shaft area, and Resident 9's catheter was found to be clogged. Resident 9 missed his dialysis appointment. Resident 9 was sent out and returned with a prescription for Ceftriaxone (an antibiotic used to treat a wide variety of severe bacterial infections) 1 gram (g-unit of measurement) IV daily for five days to treat a urinary tract infection (UTI). During a review of Resident 9's records titled eINTERACT Change in Condition (COC) Evaluation dated 11/30/2025, Registered Nurse 2 (RN 2) documented that Resident 9 was screaming in pain with rate of 8/10 in his private area and added, Resident 9 is noted to have urinary catheter, no urine output, rigid abdomen. RN 2 documented that Nurse Practitioner (NP) was notified and ordered to transfer Resident 9 to General Acute Care Hospital 2 (GACH 2). During a review of GACH 2 Resident 9's records titled ED Summary of Care dated 11/30/2025, records indicated the reason for the visit was difficulty urinating. Resident 9 received one dose of morphine sulfate (a drug used to treat moderate to severe pain) 4 milligram (mg-unit of measurement) IV. During a concurrent interview with Registered Nurse 1 (RN 1) and record review of Resident 9's medical records on 1/22/2026 at 08:40 a.m., RN 1 stated that according to assessment tab of Resident 9's medical records, there was a change of condition (COC) for Resident 9 related to foley catheter on 3/24/2025 and 11/30/2025. RN 1 added that there was no COC assessment initiated for Resident 9 when he was readmitted back on the facility on 9/15/2025 with prescription for antibiotics but only for monitoring for readmission. RN 1 stated there were no documented Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) conference meeting for COC on 3/24/2025 and 11/30/2025. RN 1 added that there was an IDT documented on 9/16/2025 regarding readmission. During a review of Resident 9 records titled care conference IDT meeting, there were no documented records for COC on 3/24/2025 and 11/30/2025. During an interview with Infection Preventionist (IP) on 1/22/2026 at 12:09 p.m., IP stated responsibilities included monitoring foley catheter use, ensuring proper indications, and consulting urology when needed. IP added that foley catheters cannot remain indefinitely due to risks of infection and severe complications like sepsis (a life-threatening blood infection). IP stated that Resident 9 had two CAUTIs in 2025, linked to the use of a Foley catheter. IP also stated there was no documented care plan for educating Resident 9 on the catheter's indication. During a concurrent interview with Director of Nursing (DON) and record review of Resident 9's medical records on 1/21/2026 at 2:25 p.m., DON stated that Resident 9's foley catheter was initially inserted on 07/31/2024 and the facility has not attempted to remove the foley catheter. DON stated the physician order for foley catheter with an indication of obstructive bladder did not align with the facility's policy. DON stated that licensed nursing staff must monitor and evaluate the need for a foley catheter. DON stated, There should be a urology consultation for Resident 9. DON added that nurses are also responsible for following up with the doctor and arranging a urology consultation if necessary. DON stated that there are no records of Resident 9 having a urology consultation. During a review of facility's Policy & Procedure (P&P) titled Catheter-Care of revised on 2/17/2025 , P&P indicated that I. Each resident who is incontinent of urine is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible; II. Residents who enter the Facility without an indwelling catheter will not be catheterized, unless the resident's clinical condition demonstrates that catheterization is necessary. A. An indwelling catheter is not used unless there is valid medical justification During a review of facility's Policy & Procedure (P&P) titled Care Planning revised on 2/17/2025, P&P indicated its purpose is to ensure a comprehensive, person-centered care plan is developed for each resident based on their assessed needs. I. The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MOS guidelines. A Comprehensive Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs.

Based on observation, interview, and record review, the facility failed to ensure the necessary medication (Biktarvy) to treat Human Immunodeficiency Virus (HIV- a virus that attacks the body's immune system. HIV damages the immune system so that the body is less able to fight infection and disease. Without treatment, it can lead to acquired immunodeficiency syndrome- a chronic condition of the disease) was available and administered as ordered by physician for six consecutive days for one of three sampled residents (Resident 2).This failure resulted in an interruption and delay of treatment for Resident 2, causing emotional and psychological distress for Resident 2, and placed Resident 2 at risk of avoidable decline in health status.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of HIV.During a review of Resident 2's Order Summary (part of the resident's medical record that synthesizes all physician orders, ensuring that the resident, their representative, and all facility staff are aware of the comprehensive care plan), dated 10/24/2025, the Order Summary indicated give one tablet Biktarvy 50-200-25 milligram (mg- a unit of mass) by mouth one time a day for HIV.During a review of Resident 2's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 10/31/2025, the MDS indicated Resident 2 had intact cognitive skills for daily decision making. The MDS indicated Resident 2 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) in eating, oral hygiene, toileting, upper body dressing, putting on and taking off footwear, personal hygiene, rolling left and right, sitting to lying, lying to sitting on the side of bed, sitting to stand, chair bed transfer, and shower transfer from staff. The MDS indicated Resident 2 required partial assistance (helper does less than the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with lower body dressing and showering from staff. During a review of Resident 2's Medical Administration Record (MAR), the MAR indicated Resident 2 was not administered Biktarvy on:1. 11/9/2025, reason see progress note.2. 11/10/2025, reason see progress note.3. 11/11/2025, reason see progress note.4. 11/12/2025, reason see progress note.5. 11/13/2025, reason see progress note.6. 11/14/2025, reason see progress note.No documentation was found for the reason of the omission from 11/10/2025 thru 11/14/2025 in the medical chart.During a review of Resident 2's Nursing Progress Notes, dated 11/9/2025, the Nursing Progress Notes indicated Licensed Vocational Nurse 1 (LVN 1) spoke to the pharmacy regarding Resident 2's Biktarvy refill to be delivered to the facility by the next morning. No other documentation was found in Resident 2's medical chart regarding the omitted doses of Biktarvy from 11/10/2025 thru 11/14/2025, when the doses were omitted.During an interview on 12/9/2025 at 1 PM with Resident 2, while in Resident 2's room, Resident 2 was sitting down in bed and stated he was concerned about not having his medication Biktarvy available in the facility because he stated there had been many days when he did not take it due to the staff telling him the medication was not in stock at the facility. Resident 2 stated he had developed diarrhea (watery stools) and was also concerned about having an infection and getting treated for the diarrhea. Resident 2 stated he was supposed to have an appointment to see the doctor to prescribe the medication for his HIV. Resident 2 stated he was worried about the consequences of going without treatment. During a concurrent observation and interview on 12/9/2025 at 1:36 PM with Licensed Vocational Nurse 1 (LVN 1), the LVN1 verified that Resident 2 had five oral tablets left of Biktarvy in the medication cart. LVN 1 stated on 11/9/2025 Resident 2 was not administered Biktarvy due to a lack of supply and she had noted this on the progress notes of Resident 2's medical chart. LVN1 stated she believed the medication was very expensive and Resident 2's insurance did not cover the costs but was uncertain as to why he didn't have an alternative treatment for his HIV. LVN 1 stated facility protocol included to notify the physician if the medication was not in the facility to determine an alternative treatment. LVN 1 stated Resident 2 was required to have an appointment with his physician to refill the prescription, and it was important for the facility to follow up on setting up this appointment for Resident 2 to ensure the medication was available for Resident 2. LVN 1 stated typically the turn around time to get the medication from the pharmacy is one to two days, but it was important not to wait until the last minute to refill the medication to prevent interruption of treatment for Resident 2.During an interview on 12/9/2025 at 3:20 PM with the Director of Nursing (DON), the DON verified Resident 2's Order Summary, MAR, and progress notes, and stated the omission of the medication should have been documented, explained, and endorsed by the licensed nurses. The DON stated it was important to give Resident 2 the medication, because it causes HIV to go into remission (a lessening, reduction, or temporary disappearance of disease signs or symptoms) and omitted doses placed Resident 2 at risk of infections and health complications. During a review of the facility's policy and procedure titled Medication Errors, dated 10/1/ 2023, the policy indicated any medications which are not administered in accordance with prescriber orders, including any omission of medications, will require the Licensed Nurse to make an immediate assessment of the resident, and follow up notes will be written including the ongoing assessment of the resident. Medication errors are documented, reported, and reviewed by the facility's Quality Assurance Performance Improvement Committee.

Based on observation, interview, and record review, the facility failed to ensure that the necessary medication (Biktarvy) used to treat Human Immunodeficiency Virus (HIV- is a virus that attacks the body's immune system. HIV damages the immune system so that the body is less able to fight infection and disease. Without treatment, it can lead to acquired immunodeficiency syndrome- a chronic condition of the disease) was available and administered as ordered by the physician on six consecutive days for one of three sampled residents (Resident 2).This failure resulted in an interruption and delay of treatment for Resident 2, causing emotional and psychological distress for Resident 2, and placed Resident 2 at risk of avoidable decline in health status.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of HIV.During a review of Resident 2's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 10/31/2025, the MDS indicated Resident 2 had intact cognitive skills for daily decision making. The MDS indicated Resident 2 supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for eating, oral hygiene, toileting, upper body dressing, putting on taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair bed transfer, and shower transfer from staff. The MDS indicated Resident 2 required partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for lower body dressing and showering from staff.During a review of Resident 2's Order Summary (part of the resident's medical record that synthesizes all physician orders, ensuring that the resident, their representative, and all facility staff are aware of the comprehensive care plan), dated 10/24/2025, the Order Summary indicated to administer Biktarvy one tablet 50-200-25 milligram (mg- a unit of mass) by mouth one time a day for HIV.During a review of Resident 2's Medical Administration Record (MAR), the MAR indicated Resident 2 was not administered Biktarvy on the following dates:1. 11/9/2025, reason see progress note.2. 11/10/2025, reason see progress note.3. 11/11/2025, reason see progress note.4. 11/12/2025, reason see progress note.5. 11/13/2025, reason see progress note.6. 11/14/2025, reason see progress note.No documentation was found for the reason of the omission on 11/10/2025 thru 11/14/2025 in the medical chart.During a review of Resident 2's Nursing Progress Notes, dated 11/9/2025, the Nursing Progress Notes indicated Licensed Vocational Nurse 1 (LVN 1) spoke to the pharmacy regarding Resident 2's Biktarvy refill to be delivered to the facility by the next morning. No other documentation was found in Resident 2's medical chart for the omitted doses of Biktarvy from 11/10/2025 thru 11/14/2025, when the doses were omitted.During an interview on 12/9/2025 at 1 PM with Resident 2, while in Resident 2's room, Resident 2 was sitting down in bed and stated he was concerned about not having his medication Biktarvy available in the facility because he stated there had been many days when he did not take it due to the staff telling him the medication was not in stock at the facility. Resident 2 stated he had developed diarrhea (watery stools) and was also concerned about having an infection and getting treated for the diarrhea. Resident 2 stated he was supposed to have an appointment to see the doctor to prescribe the medication for his HIV. Resident 2 stated he was worried about the consequences of going without treatment. During a concurrent observation and interview on 12/9/2025 at 1:36 PM with Licensed Vocational Nurse 1 (LVN 1), LVN1 verified that Resident 2 had five oral tablets left of Biktarvy in the medication cart. LVN 1 stated on 11/9/2025, Resident 2 was not administered Biktarvy due to a lack of supply and she had noted this on the progress notes of Resident 2's medical chart. LVN1 stated she believed the medication was very expensive and Resident 2's insurance did not cover the costs but was uncertain as to why he didn't have an alternative treatment for his HIV. LVN 1 stated the facility protocol would be to notify the physician if the medication was not in the facility to determine alternative treatment. LVN 1 stated Resident 2 was required to have an appointment with his physician to refill the prescription, and it was important for the facility to follow up on setting up this appointment for Resident 2 to ensure the medication was available for Resident 2. LVN 1 stated typically the turn around time to get the medication from the pharmacy is one to two days, but it was important not to wait until the last minute to refill the medication to prevent interruption of treatment for Resident 2.During an interview on 12/9/2025 at 3:20 PM with the Director of Nursing (DON), the DON verified Resident 2's Order Summary, MAR, and progress notes, and stated the omission of the medication should have been documented, explained, and endorsed by the licensed nurses. The DON stated it was important to give Resident 2 the medication, because it puts HIV in remission (a lessening, reduction, or temporary disappearance of disease signs or symptoms) and omitted doses placed Resident 2 at risk of infections and health complications. The DON stated it was the facility's responsibility to ensure medications are available in the facility for each resident, and the facility had failed to ensure Resident 2's Biktarvy medication was available in the facility on the dates of omission.During a review of the facility's policy and procedure titled Pharmacy Services, dated 10/1/ 2023, indicated it was the responsibility of the facility to educate facility staff regarding pharmacy services, conduct monthly reviews of each resident's drug regimen, including irregularities, and update previously noted irregularities, and review events such as errors of medication distribution, and use.

Based on interview and record review, the facility failed to prevent the development of pressure injuries and provided care and services consistent with professional standards of practice for one out of three sampled residents (Resident 1) by failing to: 1. Implement interventions to prevent PI (Pressure Injury - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) development for Resident 1 who was admitted without PI, by not repositioning according to the Care Plan (CP- a document that details an individual's health conditions, treatments, needs, and goals, serving as a blueprint for their healthcare and support services) for quadriplegia dated 6/27/25. No documentation repositioning was done. Resident bedbound.2. Provide pressure-relieving mattresses as indicated in the CP for quadriplegia dated 6/27/25.3. Accurately assess Resident 1 Risk for skin breakdown. Skin assessment done on 6/30/25 indicated friction and shear no apparent problem and the assessment scored zero (no risk for skin breakdown). Resident 1 is bed bound, who had multiple co-morbidities (incontinent, hip fracture) and was totally dependent on staff, placing him at increased risk for PI development.5. Implement recommendation of the wound care specialist for Low Air loss Mattress on 8/4/2025 upon discovery of the PI.6. The lack of assessing and measuring pressure ulcers to establish a baseline of wound conditions as well as providing care and treatment for pressure injuries resulted in the development of a DTI (Deep tissue Injury- damage to the underlying muscles and fatty tissue caused by prolonged pressure or trauma, but the skin on top remains intact).7. Ensure facility staff had the necessary competencies needed to identify, describe, care,and treat Residents 1's pressure injuries.8. Report an abnormal WBC level of 15.81 (4-11) on 8/7/2025 to the resident's physician as a sign of infection. As a result, the development of the hospital acquired pressure injury had a highly potentially led to a systemic infection (sepsis- a life-threatening organ dysfunction caused by a disorganized response to an infection), unnecessary hospitalization, organ failure, and death. On 8/11/2025, Resident 1 was unresponsive, requiring transfer to GACH (General Acute Care Hospital). Resident 1 was admitted to the hospital eventually FM decided on palliative care and expired on 8/14/2025.Findings:During a review of Resident 1's Record of Admission (undated), indicated, Resident 1 was initially admitted [DATE] and readmitted to the facility on [DATE] with diagnoses including fracture (a break in the bone) of right femur (The thigh bone), chronic atrial fibrillation (A type of long-lasting, irregular heartbeat where the heart's top chambers quiver instead of beating in a coordinated, regular way), and dysphagia (Difficulty swallowing) oropharyngeal phase (Second stage of swallowing when the food goes from the back of the mouth to into the esophagus [tube that connects the throat to the stomach]). During a review of the Resident 1's CP created 6/27/2025 with a focus on the diagnosis quadriplegia. The CP indicated interventions which included:Perform skin assessments every shift. Reposition every two hours using pressure-relieving mattresses or cushions (e.g., ROHO cushions- a soft, squishy seat made of air-filled bubbles that adjust to your body. It's used mostly by people who can't move around much, like those in wheelchairs, to help protect their skin and keep them comfortable). Use moisture-barrier creams and keep skin clean and dry. During a review of Resident 1's admission assessment dated [DATE], the assessment indicated Resident 1 was able to move in bed and chair independently with no apparent problems with friction and shear. The same assessment indicated Resident 1's skin was good/intact with no skin breakdown. The same assessment which includes the Braden scale (a widely used, evidence-based assessment tool in healthcare used to predict a patient's risk of developing pressure injuries) score was 0 (zero score would be invalid, as the lowest possible total score is 6, score ranges between 6 and 23 where the lower the score, the higher the risk). During a review of Resident 1's CP created 7/7/2025 with a focus on the diagnosis quadriplegia. The CP indicated interventions which included:Reposition is necessary to prevent skin breakdown. Prevent 90-degree flexion (bending a part of your body to create a right angle) to prevent circulation problems. During a review of Resident 1's History and Physical (H&P, a comprehensive medical assessment that includes a patient's medical history, a physical examination, and an assessment/plan), dated 7/9/2025 indicated, Resident 1 was having memory loss and had fluctuating capacity to make decisions. The same H&P indicated advance directives, and/or goals were discussed in detail with Resident 1's (Next of kin) and designated decision maker, FM1. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/25/2025, indicated that Resident 1 had moderate cognitive (ability to think, understand and make daily decisions) impairment. The same MDS further indicated Resident 1 was mostly dependent on staff for his activities of daily living (ADLs-toileting, shower/bathe self, lower body dressing, and putting on/taking off footwear). The same MDS indicated Resident 1 required substantial/maximal assistance (describe the level of help a patient requires to perform a task, the resident is highly dependent and requires extensive physical support to complete the task) for rolling left and right, sitting to lying, and lying to sit on side of the bed. During a review of Resident 1's wound care specialist notes dated 8/4/2025, the notes indicated Resident 1 had pressure induced deep tissue damage of sacral (the region of the human body at the base of the spine and top of the buttocks) region measuring 15 centimeter (cm, is a unit of length measurement), 3 x 5 cm ulceration (An open sore or wound that develops on the skin), moderate sanguineous drainage (A bright, red, and fresh-bleeding discharge from a wound, indicating damage to blood vessels and occurring normally in the early stages of wound healing), 26-50% slough (a type of non-viable (dead) tissue that forms in wounds), 26-50% epithelialization (the regeneration and migration of epithelial cells across the surface of a wound). The same notes indicated, recommend low air mattress. Spoke with nurse (unidentified) who will facilitate. During a review of Resident 1's physician order dated 8/4/2025 indicated, Sacrum DTI (A DTI is damage to deeper underlying structures overlaid with either intact or non-intact skin, occurring due to prolonged pressure at the bone-muscle interface): Cleanse wound with normal saline (NS, sterile mixture of salt and water that closely matches the salt concentration of human blood), pat dry, paint with betadine (a brand of antiseptic product that contains povidone-iodine to prevent and treat infections in minor wounds like cuts, scrapes, and burns), cover with foam dressing every day shift. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) dated 8/4/25 indicated, that the resident presented with a deep tissue injury (DTI) on the sacrum. Resident 1 was informed of the recommendation to initiate use of a low air loss (LAL) mattress (a specialized medical air mattress designed to promote skin integrity by providing continuous airflow to reduce moisture and heat, preventing bedsores and enhancing comfort for people with limited mobility). However, the resident, who has a designated Responsible Party (RP), declined the use of the LAL mattress. The facility initiated the appropriate treatment protocol for the DTI, and Resident 1 to be repositioned every two hours. During a review of Resident 1's CP created 8/4/2025 with a focus, The resident has DTI pressure ulcer in sacrum or potential for pressure ulcer development r/t (related to) immobility. The CP indicated interventions which included:Assess/record/monitor wound healing, measure length, width depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the medical doctor (MD).Educated the resident/family/caregivers as to the causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. During a review of Resident 1's Laboratory Results report dated 8/7/2025 and reported at 4:14 pm, the results indicated a white blood cell count (WBC - measure the total number of white blood cells in the blood, which are a crucial part of the immune system that fight infection and disease, and may indicate infection or inflammation if level is elevated) of 15.81 cells per microliter [cells/uL, unit of measurement] (normal level range 4-11 cells/uL). The MD was not notified. During a review of Resident 1's nursing notes dated 8/11/2025 at 8:39 am, indicated, Resident (Resident 1) seen in respiratory distress at around 8 AM during breakfast time. Resident (Resident 1) is difficult to arouse, even with a sternal rub. Accessory muscle use noted with a respiratory rate of 32 breaths per minute (normal is 12-20bpm). Resident's body temperature at 98.9F (Fahrenheit, temperature scale), normal range of (97 F to 99 F) blood pressure at 132/76, heart rate (HR) at fluctuating around 110~120 per min, and oxygen saturation at 88% (percent). Paramedics were called for assistance. Resident 1 left at 8:16 am (on 8/11/25) to GACH. Medical Doctor (MD) and Family Member (FM 1) notified. During a review of Resident 1's 911 (the universal emergency telephone number in the United States and Canada that you call for immediate help from the police, fire department, or emergency medical services) run sheet (report) date 8/11/2025 at 7:59 am, indicated the chief complaint as altered level of consciousness (ALOC -a condition where a person is not as awake, alert, or responsive as they normally would be ranging from mild to complete coma). Resident found fowlers (sitting up about 90 degrees) in bed, on oxygen (O2) via non-rebreather mask (NRB - a specialized medical mask with a connected reservoir bag that provides high concentrations of oxygen to patients who can breathe on their own but need more support) at 15 liters per minute (lpm-unit of measure for oxygen delivery), and Glasgow Coma Scale (GCS - a tool that doctors and nurses use to measure how awake and responsive a person is, especially after a head injury or if someone might be in a coma) of score of three (15 as fully awake and alert , 8 or below as serious condition, possibly a coma, 3 is no response at all, deep coma). Staff (unidentified) stated that Resident 1 was found to be unresponsive while doing rounds this morning with no time specified. Last known well for Resident 1 is sometime last night with no specific time stated by staff. Staff (unidentified) states that Resident 1 is normally alert oriented, able to effectively communicate, and GCS 15. Staff states no recent trauma, cold/flu symptoms, drug or alcohol use, or abnormalities in urine output. Resident 1 has no history of stroke (when there is blood interruption to the brain causing the cells to die) or seizure (a temporary, uncontrolled electrical disturbance in the brain that can cause changes in a person's awareness, behavior, sensations, and muscle control) according to facility paperwork. Resident 1 is tachycardic (elevated heart rate) and feels hot to the touch with normal color and dry skin. During an interview with Family Member (FM) 1, on 8/15/25 at 5:10 pm, FM 1 stated that Resident 1 was admitted to the facility in January 2024 while ambulatory and no skin abnormalities. FM 1 stated that Resident 1 suffered a right hip fracture in 6/2025 and returned to the facility 6/30/2025. FM 1 stated that Resident 1 required assistance from the facility staff after he returned to the facility which included toileting, turning, eating etc. On 8/4/2025, FM 1 received a call from nursing on the morning of on 8/11/2025 in telling her that Resident 1 had been transferred to GACH after Resident 1 was found unresponsive. FM 1 stated that she (FM 1) was very confused and asked what could have led to the sudden change and was at that point, the faculty staff notified FM 1 that Resident 1 had a pressure injury to his (Resident 1) buttocks which had opened up on 8/4/2025. FM 1 stated that she felt frustrated and asked why the facility had not notified her about the pressure injury being that she had Durable Power of Attorney for Health care (DPOA, a legal document where a trusted person [agent or health care proxy] to make medical decisions if one become mentally incapacitated) and the responsible party. FM 1 stated that Resident 1 had a history of dementia (A decline in cognitive function-such as memory, reasoning, language, and problem-solving-that is severe enough to interfere with daily life) and Parkinson's disease (a condition that affects the brain and makes it harder for a person to move their body the way they want to) which caused him to be confused and unable to make his own decisions which was the reason why she was designated DPOA. FM 1 stated that the facility as well as other health care providers called her (FM 1) regarding every decision pertaining to Resident 1's care. On the same interview FM 1 stated that the GACH healthcare personnel (unidentified) informed her that the PI was in bad shape and appeared infected. FM 1 stated that the GACH physician informed her that Resident 1 was septic with the PI as a possible source. FM 1 stated that Resident 1 was placed on comfort care on 8/12/2025, discharged to her home on 8/13/2025 and passed away on 8/14/2025. During an interview with Certified Nursing Assistant (CNA) 3 on 8/16/2025 at 11:31 am, CNA 3 stated that Resident 1 was bedbound after his surgery (right hip replacement) and readmitted on [DATE]. Resident 1 required total assistance for activities such as repositioning, feeding even though he was able to move his arms, changing his incontinence (unable to control both bladder and bowels) briefs, bed bath, and dressing. During an interview on 8/16/2025 at 11:58am, LVN 1 stated that skin assessments must be completed weekly by nursing. If a resident is found to have a stage 2 (partial-thickness skin loss involving the epidermis and dermis) or higher PI, a LAL mattress should be provided. Interventions to prevent skin breakdown included getting residents up out of bed to relieve pressure at least after breakfast and back to bed at lunch, frequent checking of the skin, and repositioning. During an interview with LVN 2 on 8/18/2025 at 11 am, LVN 2 stated that residents that are at risk of skin breakdown such as bedbound must have a CP to prevent skin breakdown and include interventions such as repositioning while in bed, keeping the residents nice and dry. LVN 2 stated the CP helps the team know how to care for the residents. LVN 2 stated skin assessment must be documented and done often/daily especially when non-ambulatory/non-verbal. LVN 2 stated that there are signs such as redness to the skin first before it develops to pressure injury or skin breakdown. LVN stated that if she had a resident who had changes in condition such as abnormal lab values, it must promptly be reported to the physician for directions on what actions to take next such as transfer the resident to the hospital. During an interview with Infection Prevention Nurse (IPN) on 8/18/2025 at 1 pm, the IPN stated that on 8/4/2025 a Certified Nursing Assistant (CNA) informed her that Resident 1 had a skin abnormality to his sacrum. The IPN stated that a consult for the wound care specialist was placed. The IPN stated that she assisted the wound care specialist with repositioning the resident to allow a clear view of the PI site for the wound care specialist. The IPN stated that she had leaned over to see the PI while holding Resident 1 on the side facing her (IPN). Resident 1's skin had a reddish/purple color to the sacrum. IPN stated that Resident 1's skin was intact with a small scratch and no drainage. The IPN stated that Resident 1's PI was classified as a DTI and may happen when a resident is not moving or repositioning. During an interview with the Registered Nurse Supervisor (RNS) on 8/18/2025 at 12:02 pm, the RNS stated that residents who are admitted with surgical wounds must have ongoing assessments with documentation describing the condition of the wound including size (measurements) and drainage upon admission and throughout admission until completely healed. RNS stated that there was no specific protocol for DTI, but that interventions such as repositioning every two hours, wound care specialist consults and daily skin assessments should be done. RNS stated that the facility refers to the PI policy. During a concurrent interview and record review of Resident 1's wound care specialist notes dated 8/4/2025 with the MDS nurse (also as treatment Nurse) on 8/18/2025 at 2:02 pm, the MDS nurse stated that when he completed Resident 1's dressing changes on 8/8/2025, the skin to Resident 1's sacrum had some reddish/ purple color but that the skin was intact with no drainage noted. The MDS nurse confirmed that he had not received specific training as a treatment nurse (a licensed nurse who specializes in providing direct care and expert assessments for wounds, skin conditions, and other therapeutic needs, including medication administration and treatment plan development, all under physician orders and facility guidelines) cause his main job is doing MDS. During an interview with the wound care specialist on 8/18/2025 at 2:10 pm, the wound care specialist stated that pressure ulcers usually have signs such as redness before breakdown and develop over time. He stated that Resident 1 had a DTI with an area of ulceration upon his assessment on 8/4/2025. Wound care specialist stated that an elevated WBC must be reported to either himself or the primary medical provider because it may indicate an infection process. The wound care specialist confirmed that he had not received any call from the facility regarding the elevated WBCs. The specialist stated that had he received a call about the elevated WBC, he would have ordered for a wound culture to be collected to rule out wound infection. The specialist stated that wound infection may lead to sepsis. During an interview with the DON on 8/19/2025 at 12:43 pm, the DON confirmed that the facility did not have a full-time treatment nurse. The DON stated that one of the requirements for treatment nurses was to complete a special treatment nurse training online. The DON confirmed that the facility staff (IPN, MDS, ADSD- assistant Director of staff Development) that were covering as a treatment nurse had not completed the training. During an interview with the DON on 8/19/2025 at 2 pm, the DON stated that Resident 1 had a care plan for quadriplegia based on documentation received upon the resident's readmission from the General Acute Care Hospital (GACH) on 6/30/2025. The DON further stated that the pressure injury risk assessment for Resident 1 was done inaccurately. The DON confirmed that there was no documented evidence that the interventions outlined in Resident 1's care plan, initiated on 6/27/2025 and 8/4/2025, were implemented. Specifically, there was no documentation of skin assessments being performed every shift, nor of repositioning every two hours using pressure-relieving mattresses or cushions. DON further stated these interventions, if consistently applied, may have prevented the development of pressure injury. During a review of a policy and procedures (P&P) titled, Pressure Ulcer Prevention, reviewed 5/19/2025, indicated to identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure ulcers and minimize complications. The same P&P indicated the following procedure:Risk Identification and Assessment:The Licensed Nurse will complete a Braden Scale Assessment upon admission and quarterly to identify residents at risk for skin breakdown. The Licensed Nurse will conduct a skin assessment for a resident upon admission, readmission, weekly, and as needed. Results of the weekly skin assessment will be documented in the medical record. (Results may be documented using the Weekly Skin Inspection form. Weekly Skin Inspection) .If the resident is identified as having a wound, refer to policy for Wound Management.If the resident is identified as having a wound upon admission, findings will be documented on the Resident admission Assessment. Each identified wound will be documented in the resident's clinical chart. During a review of a P&P titled, Change of Condition Notification, reviewed 5/19/2025, the P&P indicated, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The same P&P defined an acute change in condition (ACOC) as, is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death). The P&P's further indicated the following:The Licensed Nurse will notify the residents' Attending Physician when there is an:A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications.A need to alter treatment significantly (e.g. based on lab/x-ray results, a need to discontinue an existing form of treatment due to change of condition).

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of two sampled residents (Resident 1), when on 6/26/2024 Resident 2 hit Resident 1 on the nose causing pain and redness to the nose. Resident 1 was subjected to abuse and psychosocial (mental health) harm by Resident 2, while under the care of the facility. Findings: A review of Resident 2's admission record indicated the facility admitted the resident on 1/19/2024 with diagnoses including Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), psychosis (a mental disorder, collection of symptoms that affect the mind, where there has been some loss of contact with reality) and anxiety disorder. A review of Resident 2's Behavior Problem Care Plan, initiated 3/7/2024, indicated the resident had psychosis manifested by sudden outburst of anger. The goal was for Resident 2 to utilize acceptable methods of communicating needs and the interventions included to assist the resident in developing more appropriate methods of coping, interacting, and for caregivers to provide opportunity for positive interaction or attention. A review of Resident 2's Change in Condition (COC) form, dated 3/14/2024, indicated Resident 2 had an episode of physical aggression towards staff. Resident 2 hit the staff member on the chest. A review of the Activities, Cognitive Stimulation and Social Interaction care plan, developed 3/14/2024, indicated the resident was dependent upon staff for these activities. The care plan interventions indicated all staff were to converse with Resident 2 while providing care and Resident 2 needed one to one bedside/in-room visits and activities if unable to attend out of room events. According to a review of Resident 2's History and Physical (H&P), dated 4/19/2024, the resident was recently discharged from hospital due to confusion and agitation and was transferred to the hospital due to 5150 danger to self (the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, to himself or herself, or gravely disabled). The H&P indicated the resident was currently diagnosed with major depression (a common and serious medical illness severe low mood, sadness and despair), psychotic features (collection of symptoms that affect the mind, where there has been some loss of contact with reality), and was being followed by psychiatry(a medical practitioner specializing in the diagnosis and treatment of mental illness). The H&P further indicated Resident 2 lacked capacity to make medical decisions. A review of Resident 2's Minimum Data Set (MDS, an assessment and care planning tool) dated 4/27/2024, indicated the resident's cognitive skills of daily decision were intact. The MDS indicated Resident 2 did not have physical or verbal behavioral symptoms directed towards others, which was a discrepancy compared to the Behavior Problem Care Plan, initiated 3/7/2024 and the COC dated 3/14/2024. A review of Resident 2's Nursing Home Visit note, dated 5/6/2024, indicated the resident was seen for a psychiatric consultation (a medical practitioner specializing in the diagnosis and treatment of mental illness) at the request of the primary physician to assess the resident's behaviors and to review any psychotropic medications (a group of drugs that doctors may prescribe to treat a variety of brain conditions). The note indicated Resident 2 was having sudden outbursts of anger, inability to sleep, and episodes of aggressive behavior towards staff. A review of Resident 2's COC form, dated 5/14/2024 at 1:30 AM, indicated Resident 2 was noted grabbing and spitting on staff members. Resident 2's behavior care plan was not updated to reflect the resident's behavior of grabbing and spitting at staff. A review of Resident 2's Nursing Home Visit note, dated 6/6/2024, indicated Resident 2 continued to have sudden outbursts of anger. The note indicated the recommendation for a decrease in the resident's psychotropic medication dose was contraindicated because the benefits outweighed the risks for the resident and a reduction was likely to impair the resident's function and /or cause instability. A review of Resident 2's COC form, dated 6/26/2024 at 6:15 PM, indicated Resident 2 had physical aggression towards a roommate (Resident 1). The form indicated Resident 2 hit Resident 1's face, as Resident 2 was angry due to the roommate being very slow and Resident 2 needed to go to the restroom right away. The COC form indicated the psychiatrist ordered Resident 2 to transfer out of the facility on a 5150. A review of the Physician's Orders, dated 6/26/2024 (after the altercation), indicated the following: - monitor Resident 2 for 72 hours due to physical aggression - transfer Resident 2 on 5150 (which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) due to physical aggression towards another resident - place Resident 2 on one-to-one observation (used to reduce the risk and incidence of harm to the resident). A review of Resident 1's Admission Record indicated the facility admitted the resident on 5/31/2024 with diagnoses including schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms) and depression. According to a review of Resident 1's History and Physical, dated 6/1/2024, the resident had the capacity to understand and make decisions. A review of Resident 1's MDS dated [DATE], indicated the resident's cognitive skills of daily decision were intact. The MDS indicated Resident 1 had little interest or pleasure in doing things and Resident 1 was feeling down, depressed or hopeless. The MDS also indicated the resident required partial to substantial assistance with oral hygiene, toileting hygiene, showering/bathing, and dressing. A review of Resident 1's Resident Grievance/Complaint Investigation Report dated 6/24/2024 (two days before the altercation) indicated Resident 1 reported not getting along with his roommate (Resident 2). The report indicated Resident 1 and his roommate were offered a room change and both refused. A review of Resident 1's COC form, dated 6/26/2024 at 6:15 PM, indicated Resident 1 received physical aggression, the resident's nose was red, and staff applied an ice pack. The COC indicated the physician ordered Resident 1 to receive an x-ray. A review of the Physician's Orders, dated 6/26/2024, indicated to transfer Resident 1 to a general acute care hospital (GACH) for further evaluation of nasal pain and redness, Resident 1 was to receive a stat (immediate) x-ray of the face due to nasal pain and redness, and was to have a psychiatrist and psychologist consultation. According to a review of Resident 1's Telemedicine Visit note, dated 6/27/2024, the resident was recently involved in a physical altercation with another resident (Resident 2), in which Resident 1 was the victim. The note indicated Resident 1 continued to verbalize feelings of depression and the psychiatrist increased the resident's dose of Luvox (fluvoxamine - a medication used to treat unwanted repeated thoughts). During an interview on 7/10/2024 at 9:20 AM, Resident 1 stated while sitting in a wheelchair in their shared room (on 6/26/2024), Resident 2 walked past. Resident 1 stated Resident 2 then turned back around and hit Resident 1 in the face three times. During a phone interview on 7/10/2024 at 10:03 AM, Certified Nursing Assistant (CNA) 1 stated she heard Resident 2 screaming and yelling at Resident 1 on 6/26/2024. Resident 1 stated, Get away from me, to Resident 2. CNA 1 stated then she observed Resident 2 hit Resident 1 in the face twice. CNA 1 stated she then went to inform the charge nurse. CNA 1 stated Resident 2 tended to be 'grumpy'. During an interview on 7/10/2024 at 10:24 AM, Licensed Vocational Nurse (LVN) 1 stated about two weeks ago (on 6/26/2024), while administering medications, RN Supervisor (RNS) 2 stated Resident 1 and Resident 2 had a physical altercation. LVN 1 stated upon assessing Resident 1, Resident 1 had a small area of redness on the nose. LVN 1 stated Resident 1 stated it was painful but refused pain medication. LVN 1 further stated Resident 2 was placed on one-to-one observation. LVN 1 stated Resident 2 had a history of being verbally aggressive towards staff. On 7/10/2024 at 10:49 AM, during an interview, RNS 2 stated that on 6/26/2024 around 6 PM, RNS 2 heard a loud noise, and Resident 1 reported, I was too slow to move out of his way, I think he became impatient, so he hit me twice. RNS 2 stated Resident 2 had a red area on the nose and law enforcement was notified. RNS 2 stated law enforcement determined Resident 2 did not qualify for 5150 transfer and Resident 1 was moved to a different room. RNS 2 further stated Resident 2 had a sudden outburst of anger toward staff in the past and if you did not give Resident 2 attention he would become angry. During an interview on 7/10/2024 at 12:07 PM, RNS 1 stated we have to remind Resident 2 to use his call light instead of screaming. During a concurrent review of Resident 2's COC Evaluation, dated 5/14/2024, where Resident 2 was noted to spit on staff, RNS 1 stated the care plan for this incident of Resident 2 being physically aggressive with staff was initiated on 6/26/2024 (over one month later from the COC evaluation). RNS 1 further stated when Resident 2 was readmitted from the GACH on 7/3/2024 (after the altercation with Resident 1), the resident's dose of Seroquel (an antipsychotic medication that treats several kinds of mental health conditions) was increased from 25 milligrams (mg) to 50 mg. During a concurrent interview and record review on 7/10/2024 at 1:55 PM, Resident 1's Resident Grievance / Complaint Investigation Report, dated 6/24/2024, was reviewed. The Social Services Director (SSD) stated Resident 1 made a grievance against Resident 2 prior to the physical altercation (on 6/24/24). The SSD stated Resident 1's grievance against Resident 2 was regarding Resident 2's TV being too loud and Resident 2's extended time in the restroom. The SSD stated when speaking to Resident 2 regarding Resident 1's complaint, Resident 2 refused to move and stated they would work the situation out. During an interview on 7/10/2024 at 4:09 PM, the Administrator (ADM) stated she was in the building when the altercation between Resident 1 and Resident 2 occurred. The ADM stated she completed an investigation into the incident, and it was determined Resident 2 hit Resident 1. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, dated 10/1/2023, indicated the residents have the right to be free from abuse and neglect, or mistreatment. The policy indicated the facility was committed to protecting residents from abuse by anyone including staff, other residents, visitors, and others. A review of the facility's P&P titled, Resident - Resident Altercations, dated 10/1/2023, indicated the facility acts promptly and conscientiously to prevent and address altercations between residents. The policy indicated the facility staff monitors residents for aggressive or inappropriate behavior toward other residents, separates the residents and institute measures to calm the situation.

Based on observation, interviews, and record review, the facility failed to protect the resident's right to be free from physical abuse for of one of four sampled residents (Resident 3) in accordance with the facility's policy and procedures (P&P), dated June 2022, by failing to: 1. Ensure Resident 4 did not push Resident 3 on April 29, 2023. 2. Thoroughly investigate the incident when Resident 3 reported to Licensed Vocational Nurse 3 (LVN 3) that Resident 4 pushed her on 4/29/2023 for the potential for resident-to-resident abuse. 3. Implement safety measures to protect Resident 3 from potential further physical abuse from Resident 4 by not sharing or remain in the same room after the incident on April 29, 2023. These deficient practices resulted in Resident 4 subjecting Resident 3 to physical abuse and mental abuse. Resident 3 fall to the ground, hitting her head on the floor, and bled from the mouth after she was pushed by Resident 4. Resident 3 was visibly anxious and stated she feared for her life and could die if Resident 4 pushed her again. Findings: A review of Resident 3's admission record indicated the facility admitted Resident 3 on April 1, 2023, with diagnoses including Type 2 diabetes mellitus, (A long term condition that affects the way the body processes blood sugar), unsteadiness on feet, lack of coordination, dysphagia (Swallowing difficulties), and cataract (A condition where the lens of the eye becomes cloudy). A review of Resident 3's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated April 8, 2023, indicated Resident 3's cognitive skills (mental ability to make decisions of daily living) was intact, and was able to understand, and communicate her needs. The MDS indicated Resident 3 required staff assist when moving from seated to standing position, walking, turning around, moving on and off toilet, surface to surface transfer, for activities of daily living (ADL- grooming, bed mobility, personal hygiene, surface transfers) and had unsteady balance/gait (manner of walking). The MDS indicated Resident 3 required staff assist with mobility due to weakness in Resident 3's both arms. The MDS further indicated Resident 3 did not have any behavioral concerns/issues. The MDS indicated Resident 3 did not have any thoughts of hurting self. The MDS did not indicated Resident 3 was better off dead. A review of Resident 3's Psychiatry (The branch of medicine that deals with mental and behavioral disorders) and Neurology (The branch of medicine that deals with disorders of the nervous system) consultation progress notes dated April 29, 2023, indicated the psychiatrist consulted with Resident 3 via videoconference. The progress notes indicated, Psychiatry consult request as patient (Pt- Resident 3) is throwing herself on floor and falsely accusing peers and staff of assaulting her. The progress notes indicated Resident 3 did not have a history (hx) of schizophrenia (A mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) or psychosis (A mental health problem that causes people to perceive or interpret things differently from those around them). The progress notes indicated Resident 3 told the psychiatrist, I don't have problems, denied falsely accusing others, and denied throwing herself to the floor. The psychological consultation notes further indicated, Resident 3, Denies she is accusing others of harming her. Also denies falling on the floor. A review of Resident 3's Change of Condition Evaluation (COC- A sudden change in mental, physical, or behavioral status from a resident's normal status) report dated April 29, 2023, timed at 12 midnight, indicated LVN 4 documented that Resident 3 was, making false accusations towards resident and staff. The COC also indicated Resident 3's mental status was unchanged from baseline. A review of Resident 3's nursing progress notes dated, April 29, 2023, timed at 12:28 a.m., indicated that on April 28, 2023, at 11:30 p.m., Patient [Resident 3] noted to be at nurses station speaking to the charge nurse (CN) about her roommate [Resident 4] being too loud. A review of Resident 3's Psychiatry and Neurology consultation progress notes dated May 3, 2023, indicated the psychiatrist documented that Resident 3 stated, That Is crazy. Resident 3 was, Visibly anxious states she was pushed by roommate [Resident 4]. Repeating she [Resident 4] pushed me. No criteria for 5150 (The Welfare and Institutions Code number, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disable) met. Recommend room change . A review of Resident 3's Skilled Medicare Charting Record (SMCR), dated April 28, 2023, timed at 11:07 p.m., indicated Resident 3 was, alert and understands the situation, and is able to communicate with clear speech. A review of Resident 4's record titled Room Change Form, dated April 29, 2023, timed at 8:59 a.m., indicated Resident 4 remained in the room with Resident 3. The room change form further indicated room change was performed because Resident 3 was disturbing Resident 4. A review of Resident 4's admission record indicated the facility admitted Resident 4 on April 4, 2023, with diagnoses including unspecified psychosis (A severe condition in which thought and emotions are so affected that contact is lost with external reality), schizophrenia (A mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), anxiety disorder (tension, or uneasiness that stems from the anticipation of danger, which may be internal or external), insomnia (A sleep disorder in which a person has trouble falling and/or staying asleep), and psychoactive substance (Is a chemical substance that changes function of the nervous system, and results in alterations in perception, mood, cognition and behavior) abuse with unspecified psychoactive substance-induced disorder. A review of Resident 4's MDS dated [DATE], indicated Resident 4's cognitive skills was intact. Resident 4, able to walk independently with minimal assistance and supervision from staff. On May 2, 2023, at 1:20 p.m., during an interview, Resident 3 stated she informed LVN 3 that she [Resident 3] fell to the ground after Resident 4 pushed her. Resident 3 stated that LVN 3 assessed her, and that during the assessment, she [Resident 3] informed LVN 3 that Resident 4 pushed her to the floor. Resident 3 further stated LVN 3 ignored her report about the incident with Resident 4. Resident 3 stated she was terrified that she could die if Resident 4 pushed her again. Resident 3 stated that she did not know how to protect herself. Resident 3 stated that she told LVN 3 that Resident 4 pushed her. Resident 3 further stated that LVN 3 ignored her [Resident 3] statement that Resident 4 pushed her. Resident 3 stated LVN 3 told her to stand from the floor and go wash her [Resident 3] in the restroom. On May 2, 2023, at 1:34 p.m., during an interview, Resident 4 stated she pushed Resident 3 to the ground. Resident 4 also stated that a facility staff told her on the night of the incident with Resident 3, that everything would be okay, and not to worry. Resident 4 refused to provide more details concerning the conversation with the facility staff that reassured her. Resident 4 also declined to identify the facility staff who told her that everything would be alright. On May 3, 2023, at 7 a.m., during an interview, LVN 4 stated that on April 29, 2023, night, Resident 3 reported to him [LVN 4] that Resident 4 pushed her. LVN 4 stated he found Resident 4 asleep after Resident 3 reported the incident with Resident 4. LVN 4 stated Resident 3's allegation about Resident 4 was unsubstantiated (Not supported or proven by evidence). LVN 4 stated he did not implement any abuse policy and procedures to protect Resident 3 from further potential harm or abuse. LVN 4 stated Resident 4 slept all night, on April 29, 2023. LVN 3 stated further he was not familiar with Resident 3 and that he had never provided care to Resident 3. On May 3, 2023, at 10:07 a.m., during an interview, LVN 3 stated that she witnessed Resident 3 throw herself to the floor and bled from the mouth. LVN 3 stated she witnessed Resident 3 fall to the floor and hit her [Resident 3's] head on the floor. LVN 3 stated she instructed Resident 3 to stand up, go to the restroom and wash her [Resident 3] mouth and face, so that LVN 3 could better assessment Resident 3. LVN 3 stated Resident 3 refused to comply with LVN 3's instructions. LVN 3 stated she did not implement the facility's abuse policy and procedures because LVN 3 stated she was in the supply closet and witnessed Resident 3 throw herself to the ground. On May 3, 2023, at 10:27 a.m. during an observation, the supply closet was not directly opposite Resident 3's room. On May 3, 2023, at 12:20 p.m., during an interview with Resident 3 in the presence of the SSD, Resident 3 stated that her roommate [Resident 4] pushed her on April 29, 2023. The SSD stated she understood everything Resident 3 said. A review of the facility's document titled, Employee Interview Record, dated May 3, 2023, timed at 2 p.m., indicated the DON documented that LVN 3 stated Resident 3, Went to the other LVN about how she can't sleep due to roommate being loud. LVN was at the central supply room and heard someone yelling and noted resident threw herself onto the floor. and noted there was bleeding. LVN placed a four by four (4x4) gauze (wound care material) on resident's lip . A review of the facility's document titled, Employee Interview Record, dated May 3, 2023, timed at 2 p.m., indicated the DON documented that LVN 4 stated that Resident 3, came to the station and requested to move the roommate [Resident 4] out of the room. She [Resident 4] is not good. I want her out of the room. A review of the facility's document titled, Resident Interview Record, dated 5/3/2023, indicated the SSD documented that Resident 4 stated, She [Resident 4] was slamming the door to the room. All I remember was closing the door and she [Resident 3] fell . LVN [LVN 4] was in the hallway and saw [Resident 3] on the floor by her room. LVN [LVN 4 assessed her [Resident 3] and noted bleeding from the upper lip that looked like resident bit her lip. A review of the facility's document titled, Resident Interview record, dated 5/3/2023, indicated the SSD documented that Resident 3 stated, Verbalized Friday evening (4/28/2023) roommate [Resident 4] was pacing and not allowing her to rest. Reported to nurses' station, resulting in one of the charge nurses (LVN) to speak to roommate. Resident 3 alleged to be pushed . A review of the facility's policy and procedures, titled, Resident to Resident Altercation, released in December 2017, indicated, Fundamental Information: All altercations, including those that may represent resident-to-resident abuse, shall be thoroughly investigated and reported to the Nursing Supervisor, the Director of Nursing services and to the Administrator. Procedure: 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents. incidents shall be promptly reported to the Nurse Supervisor, the Director of Nursing services and to the Administrator. A review of the facility's policy and procedures (P&P), dated June 2022, titled, Abuse and Neglect Prohibition Policy, indicated, . It is the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents through the following: .; Prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Reporting of incidents, investigations, and the facility's response to the results of their investigations; protection of residents during investigations. The P&P further indicated, Physical Abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment. Mental Abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation . Willful is . means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Forms of abuse can be as follows: . 2. Resident to Resident Abuse of Any type 1. The following actions to prevent abuse, mistreatment, . will include: 4. The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff. D. Identification of possible incidents or allegations which need investigations: 3. If the suspected abuse is resident-to-resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation. 5. When an abuse is identified, the appropriate steps to protect residents from additional abuse will be implemented immediately, which will include: i. Conducting a thorough investigation of the alleged abuse ii. Taking steps to prevent further potential abuse iii. Take appropriate action that is reflected in the revise the care plan that addressed the resident's current medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse E. Investigation of incidents and allegations: 1. Initiate an investigation within 24 hours of an allegation of abuse that focuses on: i. Whether abuse or neglect occurred and to what extent; ii. Clinical examination for signs of injuries, if indicated; iii. Causative factors; and, iv. Interventions to prevent further injury. A review of the facility's Inservice (Education/training) titled, Abuse and Neglect lesson plan, dated January 19, 2023, included 12 types of abuse and Mandated Reporter, and that LVN 3 and LVN 4 attended the inservice. The lesson plan included lecture, and handouts of the facility policy entitled, Abuse and Neglect Prohibition Policy The course objectives were as follows: At the conclusion of the presentation, the participants will be able to: 1. Define what Abuse is and how it is preventable 2. Verbalize the and provide example of the 12 types of Abuse 3. Identify who Abuse Prevention Coordinator is 4. Identify Mandated Reports

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was assessed at risk for elopement (leaving without notice or permission), had an increased episode of wandering out of the facility, and had triggered the door alarm (a device that resident wear and when attempts to wander too close or through the doorway, the door monitor alarm sounds audibly) received adequate supervision to prevent elopement by failing to: 1. Respond immediately to door alarm when it was triggered on 3/21/19 at 7:49 p.m. and immediately check the immediate area for any resident that might have eloped. 2. Ensure the cause of the door alarm was immediately identified before resetting the alarm sound. 3. Ensure the video surveillance was immediately checked when door alarm was triggered to immediately identify possible elopement. These deficient practices resulted in Resident 1 eloping from the facility on 3/21/19 and was still missing and had the potential for 12 other residents identified by the facility as high risk for elopement to elope. Immediate jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called under F689 on 3/23/19 at 8:26 p.m. The facility administrator, Director of Nursing (DON), registered nursing supervisor (NS), and social services/activity director (SSD) were notified of the immediate jeopardy situation. The lack of supervision of Resident 1 who was assessed at risk for elopement, increased episodes of wandering out of the facility, and failure to immediately respond to the door alarm resulted to elopement of Resident 1. The above deficient practice had the potential for 12 other residents at risk for elopement to elope. An acceptable immediate written plan of action was accepted on 3/25/19 at 5:57 p.m.which included the following: - Hourly visual monitoring of residents with code alarm (a wander guard (wristband) - that when a resident wearing a wander guard attempts to wander too close or through the doorway, the door monitor alarm sounds audibly) by their respective certified nursing assistant (CNA) and will be documented in the code alarm clipboard. Immediate reporting of an incomplete head count to charge nurses by CNA. - Director of Nurses (DON) in-serviced all staff regarding need for immediate response to code alarms on 3/22/19. - Director of Nurses in-serviced charged nurses on 3/23/19 to be ultimately responsible for an immediate response by any nursing staff as soon as warning sound triggers. Charge nurses must ensure that the cause of the code alarm was not triggered by a resident before resetting the alarm sound. Charge nurses will also ensure that a visual check of the immediate area for any resident that might have eloped will be done. - Video surveillance monitor was installed in the medical records near the nurses' station and the charge nurses, registered nursing supervisor, DON and Administrator were in-serviced as to how to access the surveillance monitor. - Charge nurses must review video every time the code alarm is triggered. The immediate jeopardy was removed on 3/26/19 at 3 p.m., after the Evaluator verified through onsite observation, interview, and record review that the facility's written plan of action was implemented. Findings: On 3/23/19 at 12:47 p.m., an unannounced visit was made to the facility to investigate a facility-reported incident (FRI) regarding Resident 1 who walked out of the facility on 3/21/19, and was still missing. A review of Resident 1's Admission Record dated 3/22/19 indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1 [DIAGNOSES REDACTED]. The admission record indicated Resident 1's responsible party is a Public Guardian (PG, is a guardian appointed by a court and is deemed to be an officer of the court. A public guardian may be appointed as guardian for many incompetent or incapacitated persons). A review of Resident 1's history and physical examination [REDACTED]. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/23/19 indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 needed limited assistance and one-person physical assist for transfer, walk in room, walk in corridor, locomotion off unit and dressing. The MDS indicated that resident needed supervision for locomotion on unit. A review of Resident 1's Assessment Risk of Elopement/Wandering Review dated 2/11/19 indicated Yes on the following questions: 1. Is the resident cognitively impaired with poor decision-making skills (i.e. intermittent confusion, cognitive deficits or disorientation)? 2. Does the resident have a pertinent [DIAGNOSES REDACTED]. 3. Does the resident have a history of: Leaving the facility without informing staff? (Yes - multiple) 4. Has the resident verbally expressed the desire to go home or packed belongings to go home or stayed near exit door? A review of Resident 1's elopement care plan initiated 2/11/19 indicated resident had a tendency to wander out of the facility manifested by staying close to exit doors and history of leaving the facility. The care plan goal indicated for Resident 1 was to have less episodes of wandering out of the facility. The interventions included to obtain an order for [REDACTED]. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's Medication Administration Record [REDACTED]. The MAR for (MONTH) 2019 indicated Resident 1 started showing behavior of wandering out of the facility on 2/18/19 to 2/28/19: 7 a.m. to 3 p.m. shift = 10 episodes, 3 p.m. to 11 p.m. shift = 4 episodes, and 11 p.m. to 7 a.m. shift = 0 episode. A review of Resident 1's MAR for (MONTH) 2019 indicated the resident had documented episodes of wandering out of the facility on 7 a.m. to 3 p.m. shift on 3/17/19 = 3 episodes, 3/18/19 = 1 episode, 3/19/19 = 2 episodes, 3/20/19 = 1 episode, and 3/21/19 = 1 episode. A review of Resident 1's Nurse's Notes dated 3/21/19 at 8 p.m., indicated that physician was notified that Resident 1 left the facility. The notes indicated that law enforcement, PG, DON, and administrator were notified. A review of Resident 1's Incident Report dated 3/21/19 indicated that on 3/21/19 at 8 p.m., Resident 1 was noted not to be present in the facility. The report indicated that a search was conducted by two staff members. The report indicated that on 3/21/19 at 8:45 p.m., law enforcement and public guardian were notified. During an interview with the Nursing Supervisor (NS) on 3/23/19 at 3:50 p.m., NS stated he was the outgoing nursing supervisor on the day Resident 1 was missing. NS stated that Resident 1 had a wheelchair and can ambulate (walk) using the wheelchair. NS stated that resident has wander guard (code alarm) on his lower extremity. On 3/23/19 at 2:13 p.m, a review of the facility's video surveillance footages dated 3/21/19 of Resident 1 incident leaving the facility was done in the presence of the Administrator and a follow up review on 3/25/19 at 4:24 p.m., in the presence of the Administrator and Administrative Assistant revealed the following timeline highlights: 1. On 3/21/19 at 7:48:06 p.m., NS was seen walking towards right side of the building. At this time, Resident 1 was seen sitting on her wheelchair using her feet to propel. Resident 1 stopped by outside room [ROOM NUMBER] where Licensed Vocational Nurse (LVN) 1 was seen facing Resident 1 with the medication cart in between them. 2. At 7:48:36 p.m., Resident 1 was seen still sitting on her wheelchair and she turned right proceeding to door number 3, same direction where NS went. LVN 1 still seen outside room [ROOM NUMBER] with medication cart. 3. At 7:48:51 p.m., from outside surveillance camera, Resident 1 was seen inside the facility sitting on wheelchair propelling towards door number 3. She was seen opening the door and exiting from the building. 4. At 7:49:29 p.m., from outside surveillance camera, Resident 1 was seen outside the facility building and stayed momentarily near the metal post. 5. At 7:49:48 p.m., from outside surveillance camera, Resident 1 was seen standing up and went behind her wheelchair. 6. At 7:50:53 p.m., from outside surveillance camera, Resident 1 was seen walking by pushing her wheelchair in front of her leaving the facility parking lot. Then she turned left and disappeared from the video surveillance. 7. At 7:52:24 p.m., from inside surveillance camera, Certified Nursing Assistant 1 (CNA 1) and LVN 1 were seen coming out from room [ROOM NUMBER]. CNA 1 hurriedly went to check door number 3. 8. At 7:52:36 p.m., from inside surveillance camera, LVN 1 was seen walking towards the nursing station and appeared resetting the alarm. LVN 1 was seen walking back to the medication cart parked in front of room [ROOM NUMBER]. 9. At 7:53:02 p.m., from inside surveillance camera, LVN 1 was seen going back the second time to the nursing station and appeared resetting the alarm. 10. At 7:53:12 p.m., from inside surveillance camera, LVN 1 was seen going back the third time to the nursing station and appeared resetting the alarm. 11. At 7:53:37 p.m., from inside surveillance camera, CNA 1 was seen hurriedly going to the right side of the building where door number 3 was. 12. At 7:54:26 p.m., from inside surveillance camera, LVN 1 was seen going to the right of the building where door number 3 was. 13. At 7:55:15 p.m., from inside surveillance camera, CNA 1 was seen coming back from the right side of the building and was seen going to rooms [ROOM NUMBER]. On 3/23/19 at 3:25 p.m., during an inspection and demonstration of door number 3 where Resident 1 exited, on when and how far the door alarm will trigger. NS (the outgoing nursing supervisor at the time Resident 1 left the faciity on [DATE]) was holding a wander guard and the monitor alarm attached to the door sounded audibly eight feet away from the door and when the door was opened the same alarm sounded louder. There were two alarm sounds triggered: one from the door and another in the nursing station. The alarms continuously to sound loudly and to stop the alarms one has to put in the codes in the code pad attached to the door to stop the alarm in the door. Once the alarm in the door had stopped, one had to reset the alarm in the nursing station to stop the alarm sound in the nursing station. NS stated that the door alarm will be triggered when there is a resident wearing a wander guard close to exit door or opening the door. NS stated that all the facility three exit doors were automatically set to alarm when opened at 7:30 p.m. even without a wander guard. NS stated that for the alarm not to trigger, the staff had to enter the code number on the door code pad. During an interview with CNA 2 on 3/23/19 at 4:22 p.m., CNA 2 stated he heard the alarm sound off on 3/21/19. CNA 2 stated he was cleaning one of the residents when he heard the alarm and he did not respond immediately to see the reason why the door alarm was triggered. During a telephone interview with LVN 1 on 3/23/19 at 4:40 p.m., LVN 1 stated that on 3/21/19, at the time of the incident, she was passing medications when NS stated Goodbye and NS left. LVN 1 stated she heard the alarm was triggered, she assumed it was NS who triggered the alarm when he left the facility. LVN 1 stated she instructed CNA 1 to check and do a head count, but unable to tell the exact time she instructed CNA 1. A review of the facility's undated Policy and Procedure for Code Alert Monitoring System indicated that All facility personnel are to respond to alarming doors set off by resident activity trying to get out. Responsibility should primarily be on CNAs, however other department personnel are also required to monitor doors. A review of the facility's undated Policy and Procedure for Elopement indicated the following procedure: Identify resident for tendency to elope; obtain a physician's orders [REDACTED]. Policy indicated that in the event a resident is able to elope: search everywhere in the facility, then search outside vicinity of the facility; urgency on notification of local authorities; notify physician, family or public guardian; notify DHS of the elopement; document incident; and follow up calls will local authorities.