Every finding on record at Bethany Home Society San Joaquin County

Based on interview and record review, the facility failed to provide a drug regimen (a structured plan for taking medication, including dosage, frequency, and duration) that was free from unnecessary drugs for 5 of 22 sampled residents (Resident 5, Resident 8, Resident 35, and Resident 43) when:1. Resident 5 was administered blood pressure medication outside of the physician ordered vital sign parameters,2. Resident 8 was administered blood pressure medication outside of the physician ordered vital sign parameters, and3. Long term use of drugs known as Proton Pump Inhibitors (or PPI, used to treat bleeding stomach ulcer) were not assessed and addressed based on manufacturers, FDA (Food and Drug Administration, a federal agency regulated safe drug use) warnings and standards of practice to prevent adverse consequences in elderly population for 3 residents (Resident 5, Resident 35 and Resident 43) when:3a. Resident 5 had been prescribed a PPI drug called Protonix (or pantoprazole, stomach ulcer drug) since 1/30/24 with no documented clinical justification for long term use,3b. Resident 35 had been prescribed a PPI drug called omeprazole (or Prilosec, stomach ulcer drug) since 11/11/25 with no documented clinical justification for long term use, and3c. Resident 43 had been prescribed a PPI drug called Protonix since 10/25/24 with no documented clinical justification for long term use.These failures placed Resident 5 and Resident 8 at risk for hypotension and placed Resident 5, Resident 35, and Resident 43 at risk of adverse effects related to long term use of PPI in elderly population such as osteoporotic-related fractures (weak and brittle bone disease), Clostridium difficile infection (infection in the gut), pneumonia (lung infection), vitamin B12 deficiency, kidney disease, and magnesium deficiency in addition to drug-drug interactions. Findings: 1. A review of Resident 5's, admission Record indicated Resident 5 was admitted to the facility with diagnoses which included muscle weakness, anxiety disorder, essential hypertension (high blood pressure that develops over time without a single, clear medical cause. Where the force of blood pushing against your artery walls is too high). A review of Resident 5's care plan for hypertension dated 1/29/24, the care plan (a personalized, detailed outline of how a resident will be cared for on a daily basis) indicated, .administer medications as ordered. Monitor/document for side effects and effectiveness. During a concurrent interview and record review on 7/16/26, at 2:47 p.m., with the Assistant Director of Nursing (ADON), Resident 5's medication administration record (MAR, official legal documented used by healthcare professionals to track and record every medication administered to a resident) for the month of June 2026, and July 2026, was reviewed. The ADON verified Resident 5 had an order for metoprolol succinate (a blood pressure medication that slows the heart rate and lowers blood pressure, an extended-release medication that works over 24 hours) and the order indicated to hold the medication when Resident 5's heart rate (HR) was less than 60. The ADON verified Resident 5's metoprolol succinate was administered outside of the physician ordered parameters on 6/15/26 when Resident 8's HR was 58, on 7/7/26 when Resident 8's HR was 57, and on 7/8/26 when Resident 8's HR was 53. The ADON stated the physician orders were not followed for Resident 5 and Resident 5 was placed at risk of bradycardia (a slow heart rate), lethargy, and potentially passing out due to bradycardia when the metoprolol succinate was administered outside of physician ordered parameters. 2. A review of Resident 8's, admission Record indicated Resident 8 was admitted to the facility with diagnoses which included anxiety disorder, essential hypertension, and atherosclerosis of the heart (clogged or hardened arteries of the heart making it more difficult for blood to flow). A review of Resident 8's hypertension care plan dated 8/26/24, the care plan indicated, .I take cardiac medications as ordered.my vital signs will be taken per protocol. During a concurrent interview and record review on 7/16/26, at 2:36 p.m., with the ADON Resident 8's MAR for the month of June 2026 and July 2026 was reviewed. The ADON verified Resident 8 had an order for losartan hydrochlorothiazide (medication used to lower blood pressure by relaxing blood vessels) with parameters that indicated to take the medication daily and hold if Resident 8's HR was less than 60. The ADON verified Resident 8's losartan hydrochlorothiazide was administered out of the physician ordered parameters on 6/26/26 when Resident 8's HR was 57, 6/29/26 when Resident 8's HR was 57, and on 7/2/26 when Resident 8's HR was 57. The ADON stated it was his expectation for licensed nursing staff to follow Resident 8's physician orders and hold his blood pressure medication when indicated. The ADON further stated when Resident 8 received his blood pressure medication outside of the physician ordered parameters, Resident 8 was put at risk of adverse effects of the medication such as lethargy, bradycardia, and altered levels of consciousness. A review of the facility's policy and procedure (P&P) titled, Medication Administration dated 11/1/15, the P&P indicated, .Medications and treatments shall be administered as follows.Medications and treatments shall be administered as prescribed. 3a. A review of Resident 5's electronic medical record (EMR) under admission Record and diagnosis section, dated 7/17/26, the record indicated Resident 5 was admitted to the facility with the following diagnoses but not limited to diabetes mellitus (a condition where the body cannot control blood sugar levels), cerebral infarction (stroke – a part of the brain gets damaged because it did not receive enough blood and oxygen), and gastro-esophageal reflux disease (GERD – a condition where stomach acid frequently flows back into the food pipe) without esophagitis (swelling or irritation of the food pipe esophagus), as documented with onset date of 1/29/25. Resident 5's medical record indicated a diet of CCHO diet, Regular texture (CCHO means Consistent Carbohydrate), eating a stable amount of carbohydrates at each meal using normal, everyday foods with no special chewing or swallowing cuts. The record did not indicate any history of recent or current intestinal (stomach) bleeding or complaints. Review of Resident 5's Medication Administration Record (MAR), dated 7/2026, the record indicated an order for Protonix with start date of 1/30/24 as follows: Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Protonix, MG is milligram, a unit of measure); Give 40 mg by mouth one time a day for GERD (Give before breakfast) (Do not crush or chew) .; Active since:1/30/2024 During an interview with Resident 5 in his room on 7/15/26, at 4:48 PM, Resident 5 described his medical concerns, and stated difficulty sleeping at night and experiencing seasonal allergies. Resident 5 also confirmed that he had never had any issues related to stomach ulcers. A review of Resident 5's medical record, titled, History and Physical (H&P, a document listed the current diagnosis and medical conditions), written by Medical Doctor 1 (MD 1), dated 1/13/26, the record indicated past medical diagnosis and history of stroke with Left side weakness, diabetes, depression, anxiety, prostate cancer, and seizure disorder among others. The MD 1 did not include GERD or stomach ulcer as a current medical problem. A review of MD 1's progress notes for Resident 5, dated 5/12/26, 4/14/26, and 3/10/26, the record did not address any issues related to GERD or stomach ulcer. In a written communication via text, with facility's Consultant Pharmacist (CP), on 7/16/26 at 3:27 PM, CP stated he did not address pantoprazole use in MRR (medication Regimen review- a monthly review of drugs by a pharmacist). Rational- Resident has DX (diagnosis) of Dysphagia (unable to swallow solid food) following cerebral infarction (brain stroke). GERD may potentially contribute to reflux aspiration. Resident [was] administered Plavix (blood thinning drug) and PRN (as needed) meloxicam (a non-opioid pain reliver). Pantoprazole will provide protective benefit. The CP was not available to address Resident 5 did not have any restriction in his food intake due to dysphagia and the meloxicam PRN (as needed, non-narcotic pain reliver) for pain was barley used per medical record and MAR. 3b. A review of Resident 35's electronic medical record, under admission RECORD, dated 7/17/26, the record indicated Resident 35 was admitted to the facility with the following diagnoses but not limited to chronic pain taking multiple opioid pain medications, chronic obstructive pulmonary disease (COPD – progressive lung condition that makes it hard to breathe because airflow into and out of the lungs get blocked), heart failure, and gastro-esophageal reflux disease without esophagitis, and functional quadriplegia (inability to move limbs due to severe physical frailty, without any physical damage or injury to the spinal cord or brain), as documented with onset date of 2/7/24. The record further indicated a Regular diet with Regular texture. The record did not indicate any history of recent or current intestinal (stomach) bleeding or complaints. Review of Resident 35's Medication Administration Record (MAR), dated 7/2026, the record indicated an order for a PPI drug called omeprazole with start date of 11/10/25 as follows: Omeprazole Oral Capsule Delayed Release 40 MG (Omeprazole) Give 1 capsule by mouth one time a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE .; Active since: 11/11/25 A review of Resident 35's medical record, titled History and Physical, handwritten by MD 1, dated 12/5/25, the record indicated current medical issue was COPD exacerbation and past medical history included spine surgery, heart failure and GERD among others. The physical exam and symptom review did not indicate any acute GI issues or stomach problems. A review of MD 1's progress notes for Resident 35, dated 3/10/26, 4/14/26, and 5/12/26, the record documented issues with foley catheter (a flexible plastic tube used to drain urine from the bladder) and diet was changed from no added salt to a regular diet with no restriction. The monthly progress notes did not indicate any issues related to GERD or stomach ulcer. In a written communication via text, with facility's Consultant Pharmacist (CP), on 7/16/26 at 3:27 PM, regarding Resident 35, CP stated he Did not address Omeprazole use in MRR. Rational- DX of Quadriplegia and sleep apnea. Also administered prn (as needed) Tums (calcium containing antacid) on occasion. GERD control needed to mitigate aspiration/reflux complications tied to quadriplegia and sleep apnea (disorder where breathing repeatedly stops and starts during sleep). The CP was not available to address that Resident 35 was on a regular diet, did not use Tums, and how sleep apnea and functional quadriplegia could affect long term PPI use and GERD without symptoms. 3c. A review of Resident 43's admission record under the diagnosis section, dated 7/17/26, the record indicated Resident 43 was admitted to the facility with history of heart disease, kidney disease, diabetes, dementia, GERD without esophagitis and mental depression with dementia symptoms among others with onset dates of 8/16/24. The record indicated Diet: CCHO diet (consistent carbohydrate), with Mechanical Soft texture, Regular/Thin consistency. The record did not indicate any history of recent or current intestinal (stomach) bleeding or complaints. A review of Resident 43's medical record under, Medication Administration Record ( or MAR), dated 7/17/26, the MAR record indicated the following: . Pantoprazole Sodium Oral Tablet Delayed Release 40 MG . Give 1 tablet by mouth one time a day for GERD; Start Date 10/25/24 . and Apixaban (a blood thinner) for heart rhythm control since 10/16/25 and generic Maalox (an over-the-counter medicine used to treat heartburn, acid indigestion, and upset stomach) on as needed basis since 10/30/24 which was not used regularly. In a written communication via text, with facility's Consultant Pharmacist (CP), on 7/16/26 at 3:27 PM, was asked to see if he asked the medical doctor to assess or address long term use of Protonix. The CP did not address long term Pantoprazole use in MRR. During an interview on 7/16/26 at 3:54 PM with the Assistant Director of Nursing (ADON), the ADON stated that he would follow up with the consultant pharmacist to determine whether any recommendations had been made regarding the long-term use of Proton Pump Inhibitors (PPIs) for Resident 5, Resident 35, and Resident 43. The ADON acknowledged that Resident 5, Resident 35, and Resident 43 had no recent history of gastrointestinal (GI) bleeding. During the interview, the Infection Preventionist (IP), who was present, reviewed the FDA and manufacturer warnings regarding the long-term use of PPIs and stated that potential risks included hypomagnesemia (low magnesium levels), gastrointestinal infections, pneumonia or bone fracture. During a telephone interview with MD 1, on 7/16/26 at 5:31 PM, MD 1 stated that he had not reviewed all of the medications prescribed for Resident 5, Resident 35, and Resident 43. MD 1 further stated that he expected the consultant pharmacist to notify him of any medication-related concerns, including manufacturer or FDA warnings on potential risks, or other issues requiring his attention. Review of Beer's criteria (Beers Criteria, also known as the American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, a set of guidelines that help healthcare professionals identify medications that may be harmful or unnecessary for older adults), dated 4/2023, last accessed on 7/21/26 via https://www.americangeriatrics.org/media-center/news/many-older-adults-take-multiple-medications-updated-ags-beers-criteriar-will-help, and https://sbgg.org.br/wp-content/uploads/2023/05/1-American-Geriatrics-Society-2023.pdf, the document indicated, Treating GERD with a PPI for longer than 8 weeks should be avoided for most older adults. Rationale: Risk of C difficile infection, pneumonia, . bone loss and fractures . Recommendation: Avoid scheduled use for >8 weeks [more than 8 weeks] unless for high-risk patients . ; Strength of Recommendation: high . Review of the pantoprazole drug information, via FDA's DailyMed website, last accessed on 7/23/26 via https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=6b5ed424-2203-482f-bb85-2c97d9c356f2, the drug information indicated pantoprazole was indicated for Short-Term ((up to 8 weeks) Treatment of Erosive Esophagitis Associated with Gastroesophageal Reflux Disease (GERD) and Maintenance of Healing of Erosive Esophagitis (EE) where controlled studies did not extend beyond 12 months. The record further indicated warnings with long term use which included bone fracture, risk of Clostridium difficile-Associated Diarrhea (drug induced infection that disrupted the stomach's good bacteria), Cyanocobalamin (Vitamin B-12) Deficiency and Hypomagnesemia (low magnesium, with cardiac risk factors). Resident 5 and Resident 43 did not have Erosive Esophagitis (EE) documented in the medical record. Review of omeprazole drug information, via FDA's DailyMed website, last accessed on 7/23/26 via https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=a17e415e-a559-4a8d-a455-699184a01523, the drug information indicated omeprazole was indicated for Treatment of Symptomatic Gastroesophageal Reflux Disease (GERD) . for up to 4 weeks . and Maintenance of Healing of Erosive Esophagitis ( or EE) due to Acid-Mediated GERD with controlled studies did not extend beyond 12 months. Resident 35 did not have diagnosis of Erosive Esophagitis (EE) documented in the medical record. Review of an article published in the journal of Therapeutic Advances in Drug Safety, dated 5/19/17, titled Adverse effects of proton-pump inhibitor use in older adults: a review of the evidence, last accessed on 7/23/26 via https://pmc.ncbi.nlm.nih.gov/articles/PMC5557164/pdf/10.1177_2042098617715381.pdf the article's summary and conclusion indicated, Long-term PPI use in older adults links to increased risks of fractures, Clostridium difficile infection, pneumonia, vitamin B12 deficiency, kidney disease, and dementia. Many prescriptions are unnecessary, with guidelines recommended limiting use to under 8 weeks. Regular evaluation of ongoing needs was essential to minimize adverse effects and optimize safety in this vulnerable population . Review of the facility's policy, titled Pharmacy Services-Drug Regimen Review, dated 3/14/25, the policy indicated, .To provide expectation of pharmacy services around resident drug regimens to identify irregularities or unnecessary use . The policy further indicated, .The pharmacist must report any irregularities to the attending physician and the facility . Irregularities include, but not limited to, any drug that meets the criteria for an unnecessary drug .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food within the professional standards for food service and safety when:Five expired bottles of lime juice were stored in the walk-in refrigerator.Four expired bottles of lemon juice were stored in the walk-in refrigerator.Three expired whole milk ricotta cheese containers were stored in the walk-in refrigerator.Three bowls were chipped and without glaze; and,The dry storage temperature was not monitored and logged for the month of June 2026.These failures had the potential to lead to cross contamination (unintentional transfer of harmful bacteria, viruses, or allergens from one surface, food, or person to another) and food borne illness (any sickness caused by eating or drinking contaminated food or beverage that can result in nausea, vomiting, and/or diarrhea) for the 59 residents eating facility prepared meals.Findings:1. During a concurrent observation and interview on 7/14/26, at 8:57 AM, with the Certified Dietary Manager (CDM), during the initial kitchen tour, the walk-in refrigerator was observed with five bottles of lime juice with a best before date of 6/7/26. The CDM confirmed the five lime juice bottles were stored past the best before date and stated the lime juice should not have been stored in the walk refrigerator because the expired lime juice could potentially be served to the residents, causing illness. During an interview on 7/17/26, at 9:31 AM, with the Executive Chef (EC), the EC stated it was her expectation for the dietary staff to constantly check the quality of goods stored in the kitchen. The EC further stated the risk of storing lime juice past the best by date was a risk of food borne illness to the residents.2. During a concurrent observation and interview on 7/14/26, at 8:59 AM, with the CDM, during the initial kitchen tour, the walk-in refrigerator was observed with four bottles of lemon juice with a best buy date of 7/10/26. The CDM confirmed the four bottles were past the best buy date and stated they should not have been stored in the walk-in refrigerator because the lemon juice had the potential to be served to the residents. During an interview on 7/16/26, at 4:39 PM, with the Registered Dietitian (RD), the RD stated it was her expectation that the staff would check for expired goods daily. The RD further stated there was risk of serving food that was expired to residents, which could cause foodborne illness.3. During a concurrent observation and interview on 7/14/26, at 9 AM with the CDM, during the initial kitchen tour, the walk-in refrigerator was observed with three tubs that each weighed 3 pounds (lb. unit of measurement) and inside each tub had whole milk ricotta cheese, with a best if used by date of 7/4/26. The CDM confirmed the ricotta cheese should not have been kept past the best if used by date, because if it was served to the residents, they could have contracted a foodborne illness.During an interview on 7/16/26, at 4:39 PM, with the RD, the RD stated the whole milk ricotta cheese should not have been stored in the walk-in refrigerator. The RD further stated the risk of keeping food items past the best if used by date placed residents at risk for food poisoning.A review of the facility policy and procedure (P&P) titled, Food Storage, dated 2023, the P&P indicated, .Refrigerated food storage.All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their best by dates, or frozen (where applicable) or discarded.4. During a concurrent observation and interview on 7/14/26, at 9:06 AM, with the CDM, during the initial kitchen tour, three food bowls were observed to be chipped, visibly worn, and without glaze in the ready-to-use dish area next to the dishwashing station. The CDM confirmed there were three food bowls that were stored in the ready for use area.During an interview on 7/16/26, at 4:39 PM, with the RD, the RD stated bowls with chips and without glaze should not have been kept for use. The RD further stated that bowls should not have been kept when worn inside, chipped, and without glaze because they could not be thoroughly cleaned and the crevices in bowls could hold bacteria. The RD stated the risk to residents included exposure to bacteria and sickness.During an interview on 7/17/26, at 9:31 AM, with the EC, the EC stated it was her expectation for staff to monitor the utensils, plates, and bowls to ensure that quality was maintained. The EC further stated bowls that were chipped and without glaze were no longer safe and were compromised as they could not be cleaned thoroughly, potentially making the residents sick due to harbored bacteria. 5. During a concurrent observation and interview on 7/14/26, at 9:12 AM, with the CDM, during the initial kitchen tour, the dry storage area was observed with a dry storage temperature log posted that was dated 6/2026 (previous month's log). During an interview on 7/14/26 at 9:20 AM with the CDM, the CDM verified there was no dry storage temperature log for 7/2026. The CDM further stated it was important to monitor temperatures in the dry storage area to ensure spoiled food items are not served to residents. During an interview on 7/16/26, at 4:39 PM, with the RD, the RD stated it was important to monitor the temperature in the dry storage area. The RD stated if food in the dry storage area was exposed to high temperatures there was risk for food product spoilage and risk for food borne illness to the residents.A review of the facility P&P titled, Food Storage, dated 2023, indicated, .Dry storage rooms must be well ventilated and illuminated, with adequate temperature and humidity controls to prevent condensation of moisture and growth of mold. The storeroom temperature should be 50 degrees Fahrenheit (F, a unit of measurement for temperature). A thermometer will be present in the storeroom and will be monitored on a regular basis.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program for a census of 59 when:1. The facility did not fully develop, document, and implement a water management program (WMP -an active risk-management plan used to identify hazard conditions and minimize the growth and spread of these waterborne pathogens [tiny, disease-causing bacteria, viruses, or parasites that spread through contaminated water] in facility water systems) based on nationally accepted standards when they did not complete a facility wide assessment of potential Legionella (a type of bacteria found naturally in water that can multiply and cause serious lung infections if breathed in as a mist) growth to include: flow charts, control measures, a plan of corrective action when control measures were not met and a plan to mitigate Legionella if found in the facility.2. Resident 10 did not have a posted sign for enhanced barrier precautions (EBP -an infection control measure used in nursing homes to prevent the spread of multidrug-resistant organisms [MDRO- when the bacteria has become resistant to antibiotics] that require staff to wear a gown and gloves during high-contact care) at the entrance to the resident's room, and did not have personal protection equipment (PPE -gown, gloves, masks) available for use inside or near Resident 10's room.3. Resident 35's Continuous Positive Airway Pressure (CPAP) mask (a CPAP facemask connects to the CPAP machine by a flexible hose that delivers a steady stream of pressurized air to keep the airways open while sleeping) was not properly stored in a protective bag. 4. Resident 14 did not have a sign for contact precautions posted at the entrance to the room. In addition, staff providing care to Resident 14 were not wearing PPE and did not perform hand hygiene before entering and after exiting Resident 14's room; and,5. Resident 68 had perishable food at the bedside that was not labeled and sat at room temperature for over three hours.These failures placed the residents, staff, and visitors at risk of infection including, Legionella and other waterborne pathogen exposure. There was a potential for resident care supplies to become contaminated, and for infectious organisms to spread to the residents in the facility when staff failed to follow required infection control precautions. Findings: 1. During an interview on 7/16/26, at 9:46 AM, with the Infection Preventionist (IP), the IP confirmed she was on the Water Management Program Committee and met quarterly. The IP stated she attended the meetings but was not involved in and did not give input into the surveillance of Legionella or other waterborne pathogens to the committee. During an interview on 7/16/26, at 2:20 PM, with the Director of Facility Maintenance (MTD), the MTD stated he did not have the facility water flow system diagramed or mapped out with documented control measures. The MTD further stated that he did not have high risk areas where Legionella could grow mapped out with the measures that they used to control the growth. The MTD stated he only tested the water using a water test kit for aerobic bacteria (microorganisms that need oxygen to survive and grow) and placed filters on shower heads. The MTD explained that the facility did not test the water for Legionella. The MTD further explained the facility checked the water temperature of the hot water heaters and wanted the water temperature to be minimum of 105 degrees F ( degrees F = degrees -temperature measured in Fahrenheit) and maximum of 120 degrees F. The MTD stated that the facility did not monitor the temperature of cold water. The MTD could not verbalize what the control measures were for their WMP and confirmed he was part of the water management committee. The MTD stated he would defer to the Administrator (ADM) for the corrective plan if the water testing that he conducted was out of range. The MTD was unable to verbalize or show a written plan of corrective action if the water test kit the facility used was out of range. The MTD stated that he did not know whether the facility followed the guidelines of the Center for Disease Control and Prevention (CDC) Tool kit or the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE). The MTD further stated he did not conduct flushing of the water lines, did not hyper chlorinate (the process of adding a very high amount of chlorine to water for a long time to kill dangerous germs, bacteria, or parasites), did not use a disinfectant, did not monitor water pH (the process of measuring how acidic or basic the water is) and did not have temperature control for the water lines. The MTD further stated the only documentation of the water surveillance program he had was the outcome of their aerobic water testing and the location of the building that was tested. During a concurrent interview and record review on 7/16/26, at 5:11 PM, with the Administrator (ADM), the facility policy and procedure (P&P) titled, Water Management Program Policy and Procedure, revised 4/23/2025, was reviewed. The ADM confirmed the policy indicated the facility had a designated team and a flow diagram of the building. The ADM produced a flow diagram and the flow diagram produced was the example given by the CDC of how to create a flow diagram, with the facility logo added to it. The ADM stated some of the information was modified from the CDC to reflect their building, however, confirmed the diagram did not identify potential hazard conditions, what the hazard conditions were, what the interventions were to prevent the growth and spread of Legionella and the different types of monitoring that occurred at the potential hazard control points. Additionally, the diagram did not have documentation of the inlets and outlets of water flow of the building to include mixing valves and other high-risk contact points of Legionella growth. The ADM confirmed that the facility's water management program had not established a written protocol for when to intervene when control limits were not met. The ADM stated that they followed both ASHRAE and the CDC Toolkit for the prevention of Legionella and other waterborne pathogens. The ADM further stated the committee was supposed to meet quarterly but missed the January 2026 meeting this year due to the lack of committee members availability. A review of the facility P&P titled, Water Management Program Policy and Procedure, revised 4/23/2025, indicated, .To protect the health and safety of Skilled Nursing.residents by developing and implementing a Water Management Program to reduce the risk of growth and spread of Legionella in our building's water system.A Designated Team, appointed by the SNF Administrator, will be responsible for developing, implementing, and documenting all requirements of the Water Management Program./A water system flow diagram of the SNF building has been developed and will be used to identify potential hazard conditions and high-risk resident care areas.will follow the ANSI/ASHRAE Standard applicable to health care facilities, to include a Risk Management Plan. A review of the CDC's online guide titled, Monitoring Building Water, published March 15, 2024, indicated, .It's important to monitor the temperature, disinfectant residuals, and pH of building water, and identity areas where water moves slowly.Legionella grows best between 77 degrees F-113 degrees F.There's potential for Legionella growth in the absence of other Legionella controls under either of the following conditions: Cold water temperatures rise above 77 degrees F.Warm water temperatures fall below 120 degrees F.Hot water guidance.Store hot water temperatures above 140 degrees F.Ensure hot water in circulation doesn't fall below 120 degrees F and recirculate hot water continuously, if possible . https://www.cdc.gov/control-legionella/php/guidance/monitor-water-guidance.html A review of the CDC's online guide titled, Overview of Water Management Programs, published March 15, 2024, indicated, .Key Points.Many buildings need a water management program (WMP) for their building water system.WMPs identify hazardous conditions and outline steps to minimize the health impact of waterborne pathogens.Developing and maintaining a WMP is a multi-step process that requires continuous review.Seven steps of a Legionella WMP are to: 1. Establish a WMP team 2. Describe the building water systems 3. Identify areas where Legionella could grow and spread 4. Decide where to apply and how to monitor control measures 5. Establish interventions when control limits aren't met 6. Ensure the program runs as designed and is effective 7. Document and communicate all activities.the principle of effective water management include: Ensuring adequate disinfection.Maintaining devices to prevent.Sediment, Scale, Corrosion, Biofilm.Maintaining water temperatures to limit Legionella growth, preventing water stagnation.Once established, WMPs require regular monitoring of key areas for potentially hazardous conditions. The programs use predetermined responses to respond when control measures aren't met.Each program has to be tailored for each building at a particular point in time.In some settings, the entire building needs a WMP: Hospitals and long-term care facilities. https://www.cdc.gov/control-legionella/php/wmp/index.html 2. A review of Resident 10's care plan titled, [Resident 10] I have urine retention, dated 3/22/26, indicated in the intervention section, .CATHETER [a plastic tube]: I have a 18fr [French, 18 French equals 6 millimeters] foley catheter [a thin, flexible plastic tube inserted through the urethra into the bladder to drain urine into an external collection bag] . During a concurrent observation and interview on 7/14/26, at 9:17 AM, with Resident 10 and Resident 10's family member (FM) 2, in Resident 10's room. Resident 10 was observed with a foley catheter in place. FM 2 confirmed that he had not been told by facility staff if Resident 10 was on any special precautions. FM 2 explained that he was not told he needed to wear any protective equipment when feeding or assisting with bathing for Resident 10. FM 2 could not find any sign posted at the entrance to Resident 10's room that indicated the need for special precautions and could not find any personal protective equipment (PPE -wearing gown and gloves during close, high-contact care tasks to stop the spread of germs) in or near Resident 10's room. During a concurrent observation and interview on 7/14/26, at 9:38 AM, with the Assistant Director of Nursing (ADON), in Resident 10's room, the ADON confirmed Resident 10 did not have a sign posted for Enhanced Barrier Precautions (EBP - infection-control measures used in nursing homes to stop the spread of dangerous germs [like antibiotic-resistant bacteria]. The ADON stated caregivers needed to wear gown and gloves only during high-contact tasks (like bathing, dressing, changing linens for residents who have wounds, or indwelling devices like urinary catheters). The ADON further stated that any resident that had an indwelling catheter should have been on EBP due to the high risk of infections. The ADON confirmed there was no personal protective equipment (PPE) in or near Resident 10's room for staff or visitors to use. The ADON stated it was his expectation that all residents on EBP had signs posted at the entrance to the room to inform staff and visitors of the proper PPE to wear and when it was appropriate to wear it. The ADON confirmed it was expected that PPE be close to the room and be available for use for staff and visitors. During an interview on 7/16/26, at 9:49 PM, with the Infection Preventionist (IP), the IP stated when a resident was on EBP, it was the facility's policy to post the sign at the entrance of the room, including PPE supplies to be nearby and available to use prior to entering the room. The IP stated it was important to have signage posted outside of the rooms to notify staff and visitors that they needed to use PPE prior to certain resident care. The IP further stated the sign indicated which PPE to use and when. The IP stated that the risk to the residents was the risk of serious infection. A review of the facility provided P&P titled, Personal Protective Equipment, last updated 10/15/25, indicated, .Personal Protective Equipment will be used as indicated for preventing the spread of infections.Signs will be posted outside resident room/s indicating appropriate PPE for use in care of resident(s).PPE will be made available outside of the resident room.or as near as possible. 3. Review of Resident 35's admission RECORD, indicated Resident 35 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (lung disease that makes breathing difficult), chronic respiratory failure with hypoxia (long-term condition in which the lungs cannot provide enough oxygen to the body), functional quadriplegia (unable to move all four limbs because of severe weakness or illness, not because of a spinal injury), dependence on supplemental oxygen (requires extra oxygen to breathe), and obstructive sleep apnea (a condition in which breathing repeatedly stops during sleep) Review of Resident 35's Brief Interview for Mental Status, (BIMS - an assessment used to evaluate a resident's thinking and memory) dated 4/20/26, indicated Resident 35 had a BIMS score of 15, which indicated intact cognition (13 through 15 = intact, 8 through 12 = moderate impairment, 0 through 7 = severe impairment). During a concurrent observation and interview on 7/14/26, at 5 PM, with Resident 35 in Resident 35's room, Resident 35 was observed in bed and a CPAP (continuous positive airway pressure machine - machine that uses air pressure to help keep the airway open during sleep) was noted on the bedside table. The CPAP mask lay face down on top of an open cardboard box containing loose paper and no protective bag was noted. Resident 35 stated he used the CPAP machine while sleeping at night and that at 6 AM, a nurse entered the room to administer medications and placed the mask on the bedside table. Resident 35 further stated he needed staff assistance to place the CPAP mask on the bedside table because his weakness prevented him from reaching the table. During a concurrent observation and interview on 7/14/26, at 5:12 PM, with the IP, in Resident 35's room, Resident 35 remained in bed while the CPAP mask remained lying face down on top of an open cardboard box containing loose paper. The IP stated the CPAP mask should have been stored in a protective bag when not in use to prevent contamination. The IP acknowledged the CPAP mask could become contaminated when not stored in a protective bag because the open cardboard box could be contaminated with germs or bacteria, increasing Resident 35's risk of infection and contributing to the spread of germs. Review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, effective 11/28/16, indicated .to provide a safe, sanitary, and comfortable environment for residents, staff .to prevent the development and transmission of communicable diseases and nosocomial infections (infections acquired in a health care setting) . 4. Review of Resident 14's admission RECORD indicated Resident 14 was admitted to the facility with diagnoses including the need for assistance with personal care, aftercare following joint replacement surgery, diverticulitis (inflammation of the intestine), effusion left knee (fluid in the left knee), difficulty walking, and infection and inflammation reaction due to internal right hip prosthesis. Review of Resident 14's Care Plan initiated 5/18/26, in the section titled, Problem, indicated . [Resident 14] HAVE CARBAPENEM-RESISTANT KLEBSIELLA PNEUMONIAE [a bacteria resistant to multiple antibiotics] (URINE). In the section titled, Interventions, indicated, .[Resident 14] ON CONTACT PRECAUTIONS [special infection control measures to prevent the spread of germs or bacteria] AND STAFF WILL WEAR APPROPRIATE PPE [personal protective equipment – gloves, gowns, masks, or other protective equipment] WHEN IN ROOM AND DURING CARE. During a concurrent observation and interview on 7/14/26, at 4:44 PM, with the ADON, in the hallway outside Resident 14's room, Resident 14's room did not have a contact precautions sign posted outside the entrance to alert staff of the required personal protective equipment (PPE). Certified Nursing Assistant (CNA) 6 was observed in Resident 14's room wearing gloves while touching and adjusting Resident 14, who was in bed. CNA 6 removed the gloves, exited the room, and did not perform hand hygiene. CNA 6 gathered resident care supplies and a gown. CNA 6 re-entered the room and put on the gown without performing hand hygiene. CNA 6 stated he was going to provide care to Resident 14. The ADON confirmed Resident 14 was on contact precautions and that a contact precautions sign was not posted outside the room to alert staff of the required PPE. The ADON further confirmed CNA 6 failed to perform hand hygiene after exiting the room and before re-entering the room. The ADON stated that without a contact precautions sign indicating the required PPE, staff were at risk of entering the room without wearing the appropriate PPE. The ADON stated that failure to perform hand hygiene and wear the required PPE could result in the transmission of infection from Resident 14 to staff and other residents in the facility. During a concurrent interview and record review on 7/16/26, at 10:48 AM, with the ADON, Resident 14's undated Kardex (resident care instruction sheet for CNAs) was reviewed. The Kardex, in the section titled, Resident Care, indicated, .[Resident 14] ON CONTACT PRECAUTIONS AND STAFF WILL WEAR APPROPRIATE PPE WHEN IN ROOM AND DURING CARE. The ADON confirmed that Resident 14 was on contact precautions and should have had a contact precautions sign posted at Resident 14's room door. The ADON stated that even though there were no contact precautions sign posted at the door, CNA 6 was still expected to wear the appropriate PPE while in the room because the Kardex instructed staff that Resident 14 was on contact precautions and that appropriate PPE was required when in Resident 14's room. Review of the facility's undated policy and procedure (P&P) titled, Transmission-Based Precautions, indicated, .Transmissions-based precautions policy intends to prevent transmission of infectious agents which are spread through various mechanisms of contamination.Contact Precautions are put into place. Review of facility's P&P titled, Personal Protective Equipment, revised on 10/15/25, indicated, .Signs will be posted outside resident room/s indicating appropriate PPE for use in care of resident(s). Review of facility's P&P titled, Hand Washing/Hygiene, revised on 4/9/25, indicated .To prevent the spread of infection/contamination.Hand hygiene should be performed. 5. Review of Resident 68's admission RECORD, indicated Resident 68 was admitted to the facility with diagnoses of a left femur fracture (broken thigh bone), asthma, and a laceration (cut) to the right lower leg. Review of Resident 68's Brief Interview for Mental Status, (BIMS - assessment of thinking and memory) dated 7/14/26 indicated Resident 68 scored 14, which reflected intact cognition (13-15 = intact, 8-12 = moderate impairment, 0-7 = severe impairment). During a concurrent observation and interview on 7/14/26 at 12:15 PM in Resident 68's room, Resident 68 sat in a wheelchair with an overbed table next to him. A closed food container on the overbed table was not labeled with Resident 68's name or the date and time. Resident 68 opened the container and stated, it contained stuffed eggs (deviled eggs - hard-boiled eggs cut in half and filled with a creamy mixture). Resident 68 stated his daughter brought the stuffed eggs at approximately 9 AM. Resident 68 stated he had eaten one piece and planned to eat the remaining pieces later because he was full. During an observation on 7/14/26, at 12:30 PM, a staff member entered Resident 68's room carrying a lunch tray and delivered the meal to Resident 68. During a concurrent observation and interview on 7/14/26, at 12:36 PM, with the ADON, Resident 68 remained seated in the wheelchair with the overbed table next to him. The lunch tray remained on the overbed table next to the unlabeled container of stuffed eggs. The ADON confirmed with Resident 68 that the resident's daughter had brought the stuffed eggs at approximately 9 AM. The ADON stated staff were expected to label and date all perishable food brought from outside the facility so staff would know when to discard it. The ADON stated staff were also expected to check residents' bedside tables for perishable food when family members brought food into the facility, even if family members did not notify staff. The ADON acknowledged the staff member who delivered the lunch tray failed to identify the unlabeled perishable food. The ADON stated that the facility had a refrigerator to store perishable food if a resident could not finish it during one meal and that any remaining food not consumed by the next meal would be discarded. The ADON further stated the stuffed eggs had remained in Resident 68's room for approximately 31/2 hours and could become contaminated with bacteria if left at room temperature for more than 2 hours, placing Resident 68 at risk for foodborne illness, including diarrhea, nausea, vomiting, and fever. The ADON stated the stuffed eggs should have been discarded because perishable food should not remain at room temperature for more than two hours. During an interview on 7/16/26, at 4:57 PM, with the Registered Dietitian (RD), the RD stated perishable food brought from outside the facility should be served for one meal only, labeled with the resident's name, date, and time, consumed within 1 hour for safe food consumption, and not stored as leftovers. Review of the facility's policy and procedure titled, Food for Residents from Outside Sources, revised 11/2017, indicated, .To ensure the safety of food items brought from outside. Food items shall be labeled and dated. Prepared food will be consumed within the next meal time. Prepared food not consumed within the next meal time will be discarded.

Based on interview, and record review, the facility failed to implement and document individualized non-pharmaceutical interventions (NPI - drug-free approaches and resident-centered care interventions without use of drugs that may help with mental health issues) in the clinical records and comprehensive care plans for residents receiving psychotropic medications (mind-altering medications) for two of six residents reviewed for unnecessary psychotropic medication use (Resident 5 and Resident 35).This failure had the potential to result in unnecessary or prolonged use of psychotropic medications, reduce the use of individualized drug-free interventions, increase the risk of adverse medication effects, and negatively affect residents' quality of life.Findings:1a. A review of Resident 5's admission RECORD, indicated Resident 5 was admitted to the facility in early 2024 with diagnoses including major depressive disorder (a serious condition that causes long-lasting feelings of sadness and loss of interest), anxiety disorder (a mental condition where you experience excessive, persistent worry, fear or nervousness that doesn't go away and interferes with daily life), and insomnia (trouble falling asleep or staying asleep) among others.A review of Resident 5's electronic medical record (EMR) under the Medication Administration Record, (MAR - a written or electronic chart that tracks what medicines a person receives), dated 7/17/26, the MAR record indicated Resident 5 was on the following medications for depression and anxiety issues: Sertraline [antidepressant medication] HCl oral tablet 100 MG [milligram - a unit of measure].give 1 tablet by mouth one time a day for depression manifested by sad expressions.Start Date 7/26/25busPIRone [anti-anxiety medication] HCl oral tablet 15 MG.Give 15 mg by mouth three times a day for Anxiety m/b [manifested by] inability to relax.Start Date 11/18/25.The MAR record further indicated that the nursing staff were monitoring Resident 5's behaviors related to depression/anxiety and the side effects of medications used for depression and anxiety. The MAR record did not show any nursing documentation to help re-direct the resident with non-drug interventions for behaviors related to depression/anxiety that the medication may only partially treat.A review of Resident 5's EMR titled, Care Plan Report, dated 5/18/26, under the Problem section, indicated Resident 5 was taking sertraline for depression and the goal was to be free from discomfort or adverse reactions related to antidepressant therapy. The plan of care under the Interventions section did not address non-pharmaceutical interventions to help with feeling of depression. The Plan of care for anxiety under the Problem section indicated Resident 5 was taking buspirone for anxiety disorder and the goal was to be free from discomfort or adverse reactions related to anti-anxiety therapy. The plan of care under the Interventions section did not address non-pharmaceutical interventions to help with feeling of anxiety.During a concurrent interview and record review on 7/15/26, at 4:31 PM, with Licensed Nurse (LN) 8, Resident 5's EMR was reviewed. LN 8 stated that non-pharmaceutical interventions were performed and documented only when administering PRN (as needed) psychotropic (mind-alerting drugs) medications, and not for the routinely scheduled psychotropic medications. During the review of Resident 5's EMR, LN 8 was unable to locate any documented non-pharmaceutical interventions in the MAR or the resident's comprehensive care plan. LN 8 stated that she was not sure where those interventions would be documented.During a concurrent interview and record review on 7/16/26, at 2:25 PM, with LN 9, Resident 5's EMR was reviewed. LN 9 further reviewed Resident 5's MAR, care plan and nursing notes and could not locate a document or interventions for non-pharmaceutical interventions (or NPI). LN 9 stated there was no resident specific NPI in the record to help with feelings of depression/anxiety. LN 9 further stated a resident specific NPI would have helped the resident get distracted and would benefit their mood.1b. A review of Resident 35's admission RECORD, indicated Resident 35 was admitted to the facility in early 2024 with diagnoses including a history of chronic pain, heart failure, depression and anxiety disorder with a documented onset date of 2/7/24.Review of Resident 35's MAR, dated 7/2026, indicated the following medications for depression and anxiety: Xanax Oral Tablet 0.25 MG [Alprazolam, anxiety drug]: Give 0.25 mg by mouth in the afternoon for anxiety m/b [manifested by] restlessness, inability to redirect, overthinking -Start Date- 6/12/25 Xanax Oral Tablet 0.5 MG [Alprazolam]; Give 1 tablet by mouth at bedtime for anxiety -Start Date-5/24/25 Zoloft Oral Tablet 50 MG [Sertraline, drug for depression]; Give 50 mg by mouth one time a day for anxiety m/b restlessness and panic attack -Start Date-4/23/25The MAR record further indicated the nursing staff were monitoring Resident 35's behaviors related to depression/anxiety, and insomnia and the side effects of medications used for depression, anxiety and insomnia. The MAR record did not have any nursing documentation to help re-direct the residents with non-drug interventions during times resident was experiencing symptoms of anxiety or depression that the medication may only partially treat A review of Resident 35's medical record titled, Care Plan Report, dated 7/26, under the Problem section indicated Resident 35 was taking anti-anxiety medication for anxiety disorder and the goal was to be free from discomfort or adverse reactions related to anti-anxiety therapy. The plan of care under the Interventions section did not address non-pharmaceutical interventions to help with feeling of anxiety. Further record review under the Problem section indicated Resident 35 was taking an antidepressant medication for depression and the goal was to be free from discomfort or adverse reactions related to antidepressant therapy. The plan of care under the Interventions section did not address non-pharmaceutical interventions to help with feeling of depression and anxiety.During a concurrent interview and record review on 7/16/26, at 2:47 PM, with LN 9, Resident 35's EMR was reviewed related to the resident's use of three psychotropic medications: Xanax, Trazodone, and Zoloft. During the record review, LN 9 confirmed that there were no documented individualized non-pharmaceutical interventions in the resident's EMR, including the MAR or the comprehensive care plan. LN 9 stated that non-pharmaceutical interventions were important and should be attempted before administering psychotropic medications. LN 9 further stated that staff needed to be consistent in documenting non-pharmaceutical interventions, what worked best for each resident, and to know where those interventions should be documented.During an interview on 7/16/26, at 3:54 PM, with the Assistant Director of Nursing (ADON), the ADON stated that the facility implemented and documented non-pharmaceutical interventions only for residents receiving PRN (as needed) psychotropic medications and not for residents receiving routinely scheduled psychotropic medications. The ADON further stated that the facility did not have a consistent or standardized process for documenting non-pharmaceutical interventions in the EMR.A review of the facility policy and procedure titled, Psychotropic Drug Use, dated 11/28/17, indicated, .Purpose: To monitor for adverse or side effects of psychotropic medication and to prevent unnecessary use of medications. Procedure.All residents who receive psychotropic medication will be monitored.will have behavior monitoring documentation.will be done in the electronic health record by the Licensed Nurses and/or Certified Nursing Assistants.Documentation data will be recorded for each shift . Data collection for behaviors is recorded in the electronic health record. The policy did not address non-pharmaceutical interventions by nursing staff for residents with mood and emotional disorder while taking mind-altering medications.

Based on interview, and record review, the facility failed to transmit in a timely manner the required Minimum Data Set (MDS - federally required resident assessment) to the Centers for Medicare & (and) Medicaid Services (CMS - federal agency that oversees the Medicare and Medicaid programs) for 1 of 22 sampled residents (Resident 46) when, after Resident 46 was discharged from the facility on 1/30/26, the required Discharge Return Not Anticipated/End of PPS (Prospective Payment System) Part A Stay assessment (assessment completed when a resident is discharged from the facility or ends Medicare Part A skilled nursing services) remained in the completed status and was not accepted by CMS, which remained overdue for 166 days.This failure resulted in inaccurate and incomplete federally required resident assessment records, compromising the accuracy of data used for CMS quality measures.Findings:A review of Resident 46's admission RECORD, indicated Resident 46 was admitted to the facility with diagnoses including hypo-osmolality (condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia (low salt level in the blood), mood disorder (a mental health condition that long-term alters your everyday emotional state, extending far beyond normal sadness or bad moods), abnormalities of gait and mobility (difficulty walking and moving), and the need for assistance with personal care. Resident 46 was discharged from the facility on 1/30/26.A review of Resident 46's MDS Tracking screen, indicated the required Discharge Return Not Anticipated/End of PPS Part A Stay assessment with an Assessment Reference Date (ARD - date used to determine the assessment period) of 1/30/26 had a status of, completed, and remained 166 days overdue.During an interview on 7/15/26, at 3:38 PM, with the Minimum Data Set Coordinator Nurse (MDS nurse - responsible for completing resident assessments for care planning and reporting), the MDS nurse could not provide a validation report showing that Resident 46's required Discharge Return Not Anticipated/End of PPS Part A Stay assessment had been transmitted to CMS. The MDS nurse confirmed the required Discharge Return Not Anticipated/End of PPS Part A Stay assessment had not been transmitted to or accepted by CMS because its status remained, completed. The MDS nurse acknowledged that if the assessment had been successfully submitted to CMS, its status would have shown as, accepted. The MDS nurse stated she did not know when the assessment would be considered late for submission to CMS. During an interview on 7/15/26, at 3:52 PM, with the Assistant Director of Nursing (ADON), the ADON confirmed that Resident 46's Discharge Return Not Anticipated/End of PPS Part A Stay assessment remained in the completed status and had not been accepted by CMS since 1/30/26. The ADON stated this could mean that CMS was not aware Resident 46 had been discharged from the facility because the assessment had not been transmitted and accepted. The ADON further stated that late transmission of MDS assessments to CMS could affect the facility's Medicare payment reimbursement.A review of the facility's policy and procedure titled, MDS Policy for Clinical Practice and Guidelines, dated 11/28/16, indicated, .Assessments will be completed within the guidelines outlined in the RAI [Resident Assessment Instrument] Manual.These assessments will be completed in accordance with CMS requirements and the clinical practice guidelines.A review of the facility's policy and procedure titled, Resident Assessment Policy and Procedure, dated 11/28/26, indicated, .The MDS Coordinator will be responsible for the transmission of MDS assessment within the time frames outlined in the RAI manual, and for checking validation reports to assure acceptance of records sent.

Based on observation, interview, and record review, the facility failed to ensure the required Preadmission Screening and Resident Review (PASRR - required screening completed before nursing facility admission to identify serious mental illness, intellectual disability, or related conditions and ensure appropriate placement and services) was completed before admission to the facility for 1 of 22 sampled residents (Resident 69) when, Resident 69 was admitted to the facility on [DATE] without a current PASRR.This failure had the potential for Resident 69 not to receive a current PASRR determination, including a required Level II Mental Health Evaluation (a more detailed mental health assessment to determine whether the nursing facility would be the appropriate place for the resident and whether the resident needs specialized mental health services), if indicated, and recommendations necessary to ensure appropriate nursing facility placement and specialized mental health services based on the resident's current needs.Findings:A review of Resident 69's admission RECORD, indicated Resident 69 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that can affect a person's thinking, perception of reality, emotions, and behavior), dementia (a condition that causes memory loss and problems with thinking and daily activities), and parkinsonism (a neurological condition that causes tremors, stiffness, slowed movement, and balance problems).A review of Resident 69's Brief Interview for Mental Status, (BIMS - to assess a resident's thinking and memory) dated 7/3/26, indicated Resident 69 had a BIMS score of 15, which showed Resident 69 had intact cognition (13-15 = Intact, 8-12 = Moderate Impairment, 0-7 = Severe Impairment).During a concurrent observation and interview on 7/15/26, at 9:52 AM, with Certified Nursing Assistant (CNA 7) in Resident 69's room, Resident 69 was seated in a wheelchair yelling for CNA 7 to stay away because Resident 69 stated she did not need help going to the bathroom. Resident 69 refused assistance and independently propelled her wheelchair into the bathroom. CNA 7 remained outside the bathroom door and spoke calmly with Resident 69. CNA 7 stated Resident 69 was aggressive and refused assistance.During a review of the California Department of Health Care Services (DHCS) Notice of PASRR Level I Screening Results [an initial screening used to identify whether a resident may have a serious mental illness, intellectual disability, or related condition and requires further evaluation], dated 12/27/24, completed at [Hospital 2], the document indicated Resident 69's Level I screening result was positive for serious mental illness (SMI - a mental illness that seriously affects a person's thinking, emotions, behavior, or ability to function) and that a Level II Mental Health Evaluation was required.During an interview on 7/15/26, at 4 PM, with the Minimum Data Set Coordinator Nurse (MDS - nurse responsible for completing resident assessments for care planning and reporting), the MDS confirmed there was no PASRR Level II Mental Health Evaluation completed after the DHCS determination letter dated 12/27/24. The MDS further confirmed no new PASRR had been completed before Resident 69's admission on [DATE].During an interview on 7/16/26, at 10:58 AM, with the Assistant Director of Nursing (ADON), the ADON confirmed no new PASRR had been completed before Resident 69's admission on [DATE]. The ADON stated the facility was expected to complete a new PASRR upon admission if there was no current PASRR available for Resident 69. The ADON acknowledged Resident 69 had schizophrenia, exhibited aggressive behaviors, and that the only PASRR determination letter available was dated 12/27/24, more than 18 months before Resident 69's admission. The ADON stated that without a current PASRR, the facility could not determine whether Resident 69 required a Level II Mental Health Evaluation or obtain current PASRR recommendations to ensure appropriate nursing facility placement and specialized mental health services based on the resident's current needs.Review of the facility's policy and procedure titled, Resident Assessment Policy and Procedure, revised on 5/28/26, indicated, .RAI [Resident Assessment Instrument] shall include initial goals.and PASRR recommendations as identified at completion of PASRR.

Based on observation, interview, and record review, the facility failed to maintain an environment free of accident hazards and adequate supervision for 2 of 22 sampled residents (Resident 17 and Resident 22) when:1. A fall (floor) mat remained on the floor next to Resident 17's bed while Resident 17 was up in a wheelchair; and,2. On 7/8/26 Resident 43 approached Resident 22 and touched Resident 22's personal blanket wrapped around her shoulders. Resident 22 then swatted at Resident 43's hand to remove Resident 43's hand, and Resident 43 picked up a box of gloves and hit Resident 22 on the right shoulder with the box of gloves.These failures created an obstacle that interfered with Resident 17's ability to self-propel the wheelchair close to the bed and increased the risk of a fall while attempting to propel over or around the fall mat and had the potential to cause physical injury and psychosocial distress to Resident 22.Findings:1. Review of Resident 17's admission RECORD indicated Resident 17 was admitted to the facility with dementia (memory loss and problems with thinking), abnormalities of gait and mobility (difficulty walking and moving), weakness, and lumbar spinal stenosis with neurogenic claudication (narrowing of the lower spine that caused leg pain and weakness with walking). Review of Resident 17's Brief Interview for Mental Status, (BIMS - to assess a resident's thinking and memory) dated 6/19/26 indicated Resident 17's BIMS score was 6, which reflected severe cognitive impairment (13 through 15 = Intact, 8 through 12 = Moderate Impairment, 0 through 7 = Severe Impairment).During a concurrent observation and interview on 7/15/26 at 8:48 AM in Resident 17's room, Resident 17 sat in a wheelchair while a fall mat remained on the floor next to the left side of the bed. The right side of the bed was against the wall. Resident 17 self-propelled the wheelchair in the room and stated he did not want the fall mat on the floor next to his bed because it made it hard to move around the room and get close to the bed.During a concurrent observation and interview on 7/15/26 at 8:55 AM with Certified Nursing Assistant (CNA) 5 in Resident 17's room, Resident 17 remained in the wheelchair while the fall mat remained on the floor next to the bed. CNA 5 confirmed Resident 17 was a fall risk and that the fall mat was on the floor while Resident 17 was not in bed. During a concurrent observation and interview on 7/15/26 at 11:00 AM with the Assistant Director of Nursing (ADON) in the hallway, Resident 17 self-propelled the wheelchair about 150 feet from Resident 17's room without assistance while the fall mat remained on the floor in Resident 17's room next to Resident 17's bed. The ADON confirmed Resident 17 was not in bed and the fall mat remained on the floor next to Resident 17's bed. During a concurrent interview and record review on 7/16/26 at 8:45 AM with ADON, Resident 17's fall care plan, initiated on 11/22/22 and FALL RISK FORM V [version] 5.2, dated 3/13/26, were reviewed. Resident 17's fall care plan, in the section titled, Problem, indicated, . [Resident 17] AT RISK FOR FALLS. In the section titled Interventions, indicated, .place floor mat by bedside when in bed, monitor q [every] shift for placement. The ADON stated staff did not implement the care plan intervention to place the fall mat by the bedside only while Resident 17 was in bed because the fall mat remained on the floor while Resident 17 was not in bed. The ADON stated there was no monitoring process that was documented on paper, rather the nursing staff would do visual checks. Resident 17's FALL RISK FORM V [version] 5.2, indicated Resident 17 was at high risk for falls. The ADON stated leaving the fall mat on the floor while Resident 17 was in the wheelchair and not in bed created a safety hazard, especially because Resident 17 was assessed as being at high risk for falls. The ADON stated Resident 17 could push against the fall mat while trying to move closer to the bed, slide out of the wheelchair, and fall. The ADON further stated staff were expected to implement the interventions in the care plan to maintain resident safety.Review of the facility's policy and procedure (P&P) titled, Fall Prevention Program Policy and Procedure, revised in 11/2023, indicated .to increase staff awareness and sensitivity to the potential for accidents within the facility through an ongoing education program addressing hazards in the environment [things in the surroundings that could cause injury]. Factors taken into consideration for evaluating and preventing falls may include. Hazards in the environment.Arrhythmias [irregular heartbeats]. Lack of conditioning [poor physical strength]. Gait disturbance [difficulty walking]. History of falls. Cognition [thinking and memory]. Fall risk screening tools, such as the Morse Fall Risk [fall risk assessment tool], BIMS score. Safety measures will be included in the plan of care for residents identified as having fall risks.2. A review of Resident 22's minimum data set (MDS -a resident assessment and screening tool which identifies care needs) dated 7/22/26, under section titled, .Section C: Cognitive Patterns, - (an assessment of the mental abilities and functions the brain uses to think, learn, remember, pay attention, process information and solve problems) indicated Resident 22's Brief Interview for Mental Status (BIMS - a screening tool used in long-term care to assess a resident's cognitive function [the mental processes like thinking, memory, and perception, that a person uses to understand and respond to their environment]) was 03 out of 15 which indicated Resident 22 had severe cognitive impairment (a significant decline in mental abilities including memory).A review of Resident 22's Care Plan (a roadmap that details an individual's health needs, goals, and steps required by healthcare to achieve the goals) titled, .[Resident 22] I HAVE DX [diagnosis] OF DEMENTIA., revised 10/30/25, indicated, .I WILL REMAIN COMFORTABLE AND SECURE IN MY ENVIRONMENT.I AND MY FAMILY HAVE BEEN SCREENED FOR PAST TRAUMATIC EVENTS THAT MAY STILL AFFECT ME. I HAVE EXPERIENCED SOME TRAUMATIC EVENTS.STAFF WILL OBSERVE FOR AND REPORT ANY SIGNS OF DEPRESSION OR ANXIETY.During an interview on 7/14/26 at 10:03 AM, in Resident 22's room, when asked if Resident 22 recalled the incident with another resident last week, Resident 22 stated she had an encounter with a lady that was undone in the brain. Resident 22 further stated she had to swat Resident 43's hand away from her belongings. Resident 22 was unable to recall any other events related to the incident. Resident 22 was unable to answer whether she felt safe in the facility.During an interview on 7/17/26 at 9:32 AM, with Activities Assistant (AA), the AA stated that on 7/8/26 around 6:30 PM in the evening, she left the residents alone in the East dining room, including Resident 22 and Resident 43, who were gathered for an activity, to retrieve another resident. The AA further stated upon return she observed that Resident 43 had roamed in her wheelchair over to where Resident 22 sat and was observed touching Resident 22's blanket that was draped around Resident 22's shoulders. The AA explained she observed Resident 22 swat Resident 43's hand away. The AA added Resident 43 picked up the box of gloves that was in her lap and hit Resident 22 with the box on Resident 22's right shoulder. The AA stated that there were no other witnesses since the other residents were watching television and faced a different direction. The AA stated immediately after Resident 22 was smacked on the shoulder, Resident 22 became upset and grabbed her mouth with her hands. The AA explained Resident 22 calmed down after Resident 43 was removed from the room. The AA stated she was the only staff in the East Dining room. The AA further stated Resident 43 had previously hit another resident in the same East Dining room on 4/1/26 that the AA had also witnessed. The AA stated Resident 43 needed to be watched closely because she was unpredictable, fast, and roamed in her wheelchair. The AA added that Resident 43 was known to invade the space of other residents. The AA explained that Resident 43 was known to be up close and personal by touching staff and residents, usually in an innocent way, but added that sometimes other residents did not like having their personal space invaded. The AA stated the incident could have possibly been prevented if another staff member was in the room and the residents had not been left alone.During an interview on 7/16/26 at 9:25 AM, with Licensed Nurse (LN) 1, LN 1 confirmed the AA reported the physical abuse to her after it occurred on 7/8/26. LN 1 stated after the residents were separated both Resident 22 and Resident 43 were checked for injuries. LN 1 stated Resident 43 was agitated after the incident and Resident 22 was upset after the incident occurred. LN 1 explained when she attempted to interview the residents after the incident neither resident was able to verbalize what happened. LN 1 explained Resident 43 had previous aggressive behaviors with other residents, but that Resident 22 had not.During a concurrent observation and interview on 7/16/26 at 4:24 PM at the East Dining Room with Licensed Nurse (LN) 2, LN 2 stated Resident 43 was currently being monitored for aggression and irritability. LN 2 added that sometimes Resident 43 could become tearful and refuse care and had more aggressive behaviors in the evenings. LN 2 explained Resident 43 was very mobile in her wheelchair and was known to swat at other residents. LN 2 added that Resident 43 was known to be touchy feely and the staff were supposed to monitor Resident 43 closely when she was with other residents. At 4:34 PM LN 2 and this writer observed Resident 43 move quickly towards another resident in the East dining room. LN 2 stated she needed to intervene because she knew this resident did not like to be touched by Resident 43. Resident 43 was observed moving her wheelchair as close to this resident as possible. At that time, LN 2 intervened and redirected Resident 43 back to her table in the East dining room.During an interview on 7/17/26 at 9:21 AM, with the Social Services Director (SSD), the SSD confirmed she was aware of the incident between Resident 22 and Resident 43 and completed the investigation. The SSD stated that Resident 43 was known to have behaviors of aggression and the incident on 7/8/26 was not her first one. The SSD added that Resident 43 likes to be comforted by touching when she was upset. The SSD also added that Resident 22 liked her personal space and was very emotional at times. The SSD stated the incident could have been prevented if staff were present and kept a closer eye on Resident 43 when she was in the East dining room.During an interview with the Administrator (ADM) on 7/17/26 at 3 PM, the ADM confirmed that the incident that occurred between Resident 43 and Resident 22 physically hit each other, leading their facility to report it to the Department per Federal and State guidelines.A review of Resident 43's admission RECORD, indicated Resident 43 was admitted to the facility with diagnoses including encephalopathy (an umbrella term for any disease, damage, or malfunction that affects the brain function), dementia, depression, and anxiety (an emotional state that includes feelings of tension, worried thoughts, and physical changes).A review of Resident 43's MDS dated [DATE], under section titled, .Section C: Cognitive Patterns, indicated Resident 22's BIMS was 01 out of 15 which indicated Resident 22 had severe cognitive impairment.A review of Resident 43's Order Summary Report, dated 7/17/26, an order from Resident 43's physician dated, 12/3/25, indicated, .monitor [Resident 43] for aggressive behaviors such as: yelling, striking out, hitting and punching.every shift.A review of Resident 43's BEHAVIORS, monitoring schedule for May 2026 revealed out of 93 opportunities, Resident 43 had 21 documented observed behaviors related to aggression, with 5 blank/undocumented boxes.A review of Resident 43's BEHAVIORS, monitoring schedule for June 2026 revealed out of 90 opportunities, Resident 43 had 30 documented observed behaviors related to aggression, with 7 blank/undocumented boxes.A review of Resident 43's BEHAVIORS, monitoring schedule for July 1, 2026, through July 16, 2026, revealed out of 48 opportunities, Resident 43 had 10 documented observed behaviors related to aggression, with 2 blank/undocumented boxes.A review of Resident 43's Progress Notes, dated 4/2/26 at 3:09 PM, by the Assistant Director of Nursing (ADON), indicated, .On 4/1/26 [Resident 43] was noted tearful in her usual spot in the East dining room. Resident suddenly propelled her wheelchair toward another resident and started yelling at the resident. When the Activity Staff attempted to remove her, [Resident 43] slapped the other resident on his left shoulder.IDT recommendations: monitor resident for aggressive behaviors.A review of Resident 43's care plan titled, I have increased behaviors in the evening. I have potential to be physically/verbally aggressive r/t [related to] Poor impulse control. dated 1/16/26, indicated under the section titled, Goal, .I will demonstrate effective coping skills through the review date.I will not harm self or others.Interventions.Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document.Assess and anticipate [Resident 43's] needs: food, thirst, toileting needs, comfort level, body positioning.My triggers for physical aggression are being overly tired.A review of the facility provided policy and procedure titled, Freedom from Abuse, Neglect, Exploitation., revised 1/28/2019, indicated, .Each resident has the right to be free from abuse.Residents must not be subjected to abuse by anyone including.other residents.Physical abuse means assault, battery.this includes.hitting, slapping, punching, biting, or kicking.pinching, spanking, slapping of hands, flicking, or hitting with an object.All residents of [name of facility] shall be free from verbal, mental, sexual, physical abuse, and corporal punishment.staff will identify, correct and intervene in situations in which abuse.is likely to occur. This also includes the identification, ongoing assessment, care planning for appropriate intervention and monitoring of residents with needs and behaviors which might lead to conflict.

Based on observation, interview, and record review, the facility failed to implement trauma-informed care (a framework that recognizes the widespread impact of trauma and actively avoids re-traumatization) for 1 of 22 sampled residents (Resident 71), when Resident 71's trauma history and trauma triggers were not reassessed and staff failed to collaborate with Resident 71, her family, friends, and/or any other health care professionals (such as psychologists, mental health professionals) to develop and implement individualized interventions to avoid re-traumatization after the staff learned that her bed alarm triggered memories of the resident's childhood house fire. This failure resulted in repeated episodes of re-traumatization, fear, emotional distress, anxiety, agitation, and aggressive behaviors for Resident 71.Findings:A review of Resident 71's admission RECORD, indicated Resident 71 was admitted to the facility with diagnoses including dementia (memory loss and problems with thinking, and decision making), anxiety disorder, disorientation (confusion about time, place, or person), and need for assistance with personal care.Review of Resident 71's Brief Interview for Mental Status, (BIMS - an assessment of thinking and memory) dated 6/18/26, indicated Resident 71 had a BIMS score of 4, which reflected severe cognitive impairment (13 through 15 = Intact, 8 through 12 = Moderate Impairment, 0 through 7 = Severe Impairment).A review of Resident 71's Progress Notes, dated 4/21/26 through 6/19/26 were reviewed as follows:-The progress notes dated 4/21/26, at 2:50 PM, indicated Resident 71 returned to the facility from the hospital at approximately 2:08 PM following a left femur (thigh bone) surgery on 4/19/26. Resident 71's daughter requested a personal safety alarm on the bed for the resident's safety. The notes indicated Resident 71's mood was pleasant with some agitation observed.-The progress notes dated 4/22/26, at 5:30 PM, indicated that during dinner, Resident 71 was removing the hospital gown, safety alarm, and brief, and Resident 71 attempted to hit staff. -The progress notes dated 4/22/26, at 6:48 PM, indicated that at approximately 5:10 PM the same day, Resident 71 yelled for help, stated she was on fire, removed her personal alarm and gown, and struck staff while staff attempted to calm her.-The progress notes dated 4/23/26, at 8 AM, indicated Resident 71 refused to participate in the BIMS assessment and exhibited increased confusion. -The progress notes dated 4/23/26, at 2:58 PM, indicated that while staff were providing care, the bed alarm was activated and Resident 71 became agitated and yelled, Fire, and yelled for staff to call her daughter because it was hot.-The progress notes dated 4/23/26, at 5:43 PM, indicated Resident 71 removed the bed alarm and became agitated when it sounded. Resident 71's daughter informed staff that Resident 71's childhood home burned down when Resident 71 was a child and that the sound of the bed alarm reminded Resident 71 of the fire alarm heard during the childhood fire.-The progress notes dated 5/11/26, at 7:45 PM, indicated Resident 71 yelled, Fire, fire, help me, call the fire department. Resident 71 was inconsolable and became aggressive towards staff. -The progress notes dated 6/1/26, at 10:13 PM, indicated that at approximately 8 PM the same day, Resident 71 opened the door at the end of the hallway, attempted to leave, and expressed concern that there was a fire. Resident 71 was not consolable. -The progress notes dated 6/19/26, at 9:26 AM, indicated Resident 71 stated she occasionally felt down and depressed while staff were assessing Resident 71 for discharge.During an interview on 7/17/26, at 9:18 AM, with Resident 71's Responsible Party (RP), the RP stated Resident 71's childhood home burned down when Resident 71 was 3 years old. The RP stated the sound of the bed alarm reminded Resident 71 of the childhood fire and that the RP had shared this information with staff.During a concurrent interview and record review on 7/15/26, at 9:48 AM, with the Social Services Director/Activities Director (SSD/AD), Resident 71's TRAUMA INFORMED SOCIAL HISTORY FORM, dated 4/22/26, completed at [hospital name] was reviewed. Resident 71's TRAUMA INFORMED SOCIAL HISTORY FORM, indicated Resident 71 had no history of an adverse childhood event, no history of post-traumatic stress disorder (PTSD, a mental health condition that develops after experiencing or witnessing a terrifying life-threatening event), and no additional information shared by the Responsible Party. The SSD/AD confirmed the TRAUMA INFORMED SOCIAL HISTORY FORM, inaccurately documented that Resident 71 had no history of childhood trauma or PTSD despite Resident 71 exhibiting agitation, anxiety, and aggression related to the childhood house fire, which could indicate PTSD. The SSD/AD stated staff were expected to report trauma-related behaviors so the TRAUMA INFORMED SOCIAL HISTORY FORM, could be updated by the facility and appropriate trauma-informed interventions added to the resident's care plan. The SSD/AD further stated that an inaccurate TRAUMA INFORMED SOCIAL HISTORY FORM, could affect the resident's emotional well-being, sense of safety, and psychosocial needs (emotional and social needs). During a concurrent interview and record review on 7/15/26, at 10:05 AM, with the Assistant Director of Nursing (ADON), Resident 71's current care plan and progress notes, dated 4/2026 through 6/2026 were reviewed. The ADON stated the care plan did not include interventions addressing Resident 71's childhood house fire or the bed alarm as the identified trauma trigger. The ADON confirmed Resident 71's progress notes dated 4/21/26 through 6/19/26 documented repeated episodes of agitation, anxiety, and aggression triggered by the bed alarm after staff learned of Resident 71's childhood house fire. The ADON stated staff failed to reassess the resident's trauma history and develop trauma-informed care plan interventions, resulting in repeated trauma-triggered behaviors. The ADON further stated staff were expected to notify the SSD/AD so the trauma history could be reassessed to prevent recurrent behaviors, emotional distress, re-traumatization, and potential safety risks, including falls.Review of the facility's policy and procedure titled, Trauma Informed Care, revised on 11/18/19, indicated .[Facility Name] shall continue to improve systems for ensuring person-centered care for each resident by including trauma informed care principles in to each individualized plan of care.to provide comprehensive, person-centered care to assess each resident during pre-admission, admission and post admission time periods for history of any type of trauma as well as triggers which may cause re-traumatization.For those residents already in the care of [Facility Name], staff will make a good-faith effort to interview residents and or their representatives, regarding history of trauma, known triggers and historically effective methods of de-escalation for the individual.Care plans may be updated at such time that other information is made available.

Based on interview, and record review, the facility failed to ensure 1 of 22 sampled residents (Resident 37) was free of significant medication errors (one which could jeopardize the residents health and safety) when on 7/4/26, Resident 37 was administered a short acting insulin (insulin, a hormone produced by the pancreas that acts like a key so the body can absorb sugar [glucose] from the blood) instead of a long acting insulin. (Short acting insulin's onset occurs within one hour, peaks between two to four hours and has a duration of action up to eight hours. Long-acting insulin provides a steady, consistent release of insulin into the bloodstream for 24 hours or longer and maintains stable blood sugar levels between meals and overnight). This failure contributed to Resident 37 being sent out to a hospital for treatment and monitoring. In addition, this failure had the potential to result in seizures (a sudden, uncontrolled surge of electrical activity in the brain), aspiration (choking), altered mental status (confusion), and/or symptomatic hypoglycemia (when blood sugar drops below 70 mg/dL [mg/dL, a unit of measurement]) which includes, shakiness, sweating, rapid heartbeat, blurred vision, loss of consciousness, or coma (a deep, prolonged state of unconsciousness). Findings:A review of Resident 37's admission RECORD, indicated Resident 37 was admitted to the facility with diagnoses including type 2 diabetes mellitus (chronic condition where the body resists insulin or fails to produce enough). A review of Resident 37's Order Summary Report, dated 7/15/26, indicated, .Insulin lispro [short acting insulin] .inject per sliding scale: if 0-60 [blood glucose level] call MD [Medical Doctor, MDR]; 61-130 = 0 [units of insulin], 131-180 = 2 [units of insulin], 181-240 = 4 [units of insulin]; 241-300 = 6 units of insulin]; 301-350 = 8 [units of insulin]; 351-300 = 10 [units of insulin]; 401-999 notify MD .one time a day for DM2 [diabetes mellitus type 2] . Further review of the document indicated, .insulin glargine [long-acting insulin] .inject 25 unit .at bedtime for DM 2 .A review of Resident 37's Medication Administration Record, (MAR, official legal documented used by healthcare professionals to track and record every medication administered to a resident) dated 7/2026, indicated Resident 37 was on the following daily medications to manage type 2 diabetes mellitus: insulin lispro (fast acting insulin used to lower blood sugar quickly around meal time) and insulin glargine (long-acting insulin used to treat diabetes by keeping blood sugar levels steady over time). Further review of the document indicated on 7/4/26, the insulin glargine documentation noted the ordered medication was not administered at 8 PM and to review the progress note. During a concurrent interview and record review on 7/16/26, at 5:28 PM, with licensed nurse (LN) 4, Resident 37's record titled, Progress Notes dated 7/4/26, at 10:01 PM, was reviewed. LN 4 confirmed she wrote the progress note in Resident 4's electronic health record (EHR) and the progress note indicated on 7/4/26 at 7 PM, LN 5 administered 25 units of insulin lispro, instead of the ordered 25 units of insulin glargine to Resident 37. LN 4 stated she rechecked Resident 37's blood sugar level and got 170 mg/d L (high result, normal glucose range 72-99) before she notified the Medical Doctor (MDR) and received the order to send Resident 37 to the hospital for evaluation and treatment. LN 4 further stated the medication error was preventable, LN 5 stated she should have read the insulin bottle and verified it to Resident 37's physician order listed on the MAR.During an interview on 7/17/26, at 11:09 AM, with LN 5, LN 5 stated on 7/4/26, during the evening medication pass she accidently administered Resident 37's short acting insulin instead of the long-acting insulin. LN 5 further stated she should have double checked Resident 37's orders and compared it to the insulin bottle she was holding at the time. LN 5 stated Resident 37 did not show signs of hypoglycemia (low blood sugar) and was at her baseline, but was at risk of experiencing hypoglycemia symptoms, such as altered level of consciousness. During an interview on 7/17/26, at 9:19 AM, with Resident 37's Physician (MDR), MDR stated he was notified on 7/4/26 that Resident 37 had received 25 units of short acting insulin instead of the scheduled long-acting insulin. MDR further stated Resident 37 was at risk of becoming very hypoglycemic due to receiving the wrong insulin. MDR stated Resident 37 had to be transferred to an acute care setting for heavy monitoring and to treat Resident 37's blood sugar levels intravenously (medications given through the vein) if required. A review of Resident 2's, [Hospital Name] medical record document titled, Emergency/Urgent Care, dated 7/5/26, at 5:21 PM, indicated, .admission date: 07/24/26 .20:47 .[8:47 PM] .presenting from [Facility Name] after a medication error in which she was given 25 units of subcutaneous [located, used, or introduced under the skin, specifically in the fatty layer found between the skin and the muscles] Humalog [Humalog, short acting insulin also known as insulin lispro] instead of her usual 25 units of subcutaneous glargine at bedtime. She was brought in by ambulance for monitoring .blood sugar with EMS [Emergency Medical Services] and on arrival has been stable, with a fingerstick of 114 [blood sugar testing result] .07/04/26 21:50: [9:50 PM] Glucose 47 mg/dL [low- out of the normal range], patient asymptomatic [no symptoms], D50 [a concentrated 50% (percent) sugar solution used primarily to treat severe low blood sugar] administered IV [IV, intravenous, through the vein] .07/04/26 22:23 [10:23 PM]: Glucose 166/mg/dL [high- out of range], patient asymptomatic .07/04/26 23:36 [11:36 PM] Glucose 90 mg/dL [within normal range], no symptoms, neurologically at baseline .07/05/26 00:32=[12:30 AM] Glucose 92 mg/dL [within normal range], patient awake, alert, no new complaints .07/05/26 01:54 [1:54 AM] Glucose 105 mg/dL [slightly high] .07/05/26 03:57 [3:57 AM] Glucose 116 mg/dL [slightly high] .Discharge Time: 07/05/26 04:50:00 [4:50 AM] .Further review of Resident 2's same (Hospital Name) medical record document titled, Emergency/Urgent Care, dated 7/5/26, at 5:21 PM, under the medical decision-making section indicated, .I considered life-threatening complications, altered mental status, seizures, and aspiration. The patient was placed on continuous monitoring with hourly glucose checks for the expected duration of Humalog action .After prolonged observation period with stable glucose levels, absence of symptoms, and return to baseline, the patient was deemed safe for discharge back to her facility .During an interview on 7/17/26, at 10:46 AM, with the Assistant Director of Nursing (ADON), the ADON stated it was his expectation for licensed nursing staff to administer the five rights of medication administration (right resident, right medication, right dose, right time, right route). The ADON further stated the medication error was preventable and placed Resident 37 at risk of hypoglycemia.A review of the facilities policy and procedure titled, MEDICATION ADMINISTRATION, dated 11/25, indicated, .Medication shall be administered by Licensed Nursing staff according to.and good nursing procedure to limit error and to assure optimum desired effect from administered medications.Medications and treatment shall be administered as prescribed.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices in the medication refrigerator, medication cart and wound treatment cabinet for a census of 59 when:1. An Ativan solution bottle (or lorazepam, a controlled anxiety medication in liquid form) in the medication refrigerator was not dated upon opening and the bottle had yellow stains on the outer body of the bottle.2. An opened single use vial of injectable Ativan was not disposed of after used for a resident from the Emergency kit (or Ekit).3. Medication Cart #2 for North and B-hallway stored eye drops, and inhalers (a small, portable medical device used to breathe medicine directly into the lungs) with no marking for the date it was first opened due to short beyond use date (or BUD, date at which the product should not be used based on manufacturer specification). Medication Cart #2 additionally stored an expired bottle of melatonin liquid (non-prescription drug used for sleep) in the active storage area.4. Wound/Skin treatment cabinet in the D-hallway stored an unlabeled hazardous drug (medications that have the potential to cause cancer, genetic damage, birth defects, or reproductive harm) called fluorouracil cream (or Efudex, a cancer therapy drug used to treat cancerous skin lesions) with no protective hazardous tag or cover.These failed practices could contribute to unsafe medication use due to lower potency, not following manufacturer specification, and contributing to hazard exposure to staff and other residents.Findings:1. During a concurrent observation and interview, on 7/15/26 at 9:56 AM, with Licensed Nurse (LN) 6, in the ADON (Assisted Director of Nursing) office, the medication refrigerator stored a narcotic locked box storing Ativan (lorazepam) oral solution. One opened bottle of Ativan solution, labeled with a resident's name, was observed without an opening date. A yellow-colored residue was noted on the outside surface of the bottle, and yellow staining was also observed inside the manufacturer's box. The manufacturer's labeling on the box indicated, Discard opened bottle after 90 days. LN 6 stated the facility needed to obtain a new bottle and was unsure when the bottle was opened. LN 6 stated the drug may become ineffective if outdated.2. During a concurrent observation and interview, on 7/15/26 at 9:56 AM, with Licensed Nurse (LN) 6 in the ADON office, the narcotic box inside the medication refrigerator stored one opened single use vial of injectable Ativan without a label identifying the date vial was opened/punctured, when it was removed from Ekit and/or which resident it was used for. LN 6 was initially unable to locate the emergency kit (EKit) removal record but subsequently identified the resident for whom the medication had been used. LN 6 stated the medication was removed from the Ekit to give a resident 1 mg dose ( mg is milligram, a unit of measure) from the 2 mg vial, and the remaining 1 mg had been retained in the narcotic locked box since 4/27/26. Licensed Nurse (LN) 1 was present during the observation and confirmed the above findings stating it should have been destroyed along with other controlled drugs.3. During a concurrent observation and interview, on 7/14/26 at 4:05 PM, with Licensed Nurse (LN) 7, at the North/B Hall medication cart, the following undated and expired medications were observed:One bottle of Latanoprost ophthalmic solution (eye drop used to treat glaucoma eye disease) , labeled with a resident's name, was not dated when first opened. The manufacturer's instructions on the box indicated the medication was good for 42 days after opening and storage outside the refrigerator.Two Wixela brand inhalers (fluticasone and salmeterol drug combination for asthma), each labeled with a resident's name, were not dated when first opened. The manufacturer's labeling indicating the inhalers were good for 30 days after opening.One Budesonide/Formoterol aerosol inhaler (combination drug to treat asthma and shortness of breath), labeled with a resident's name, was not dated when first opened. The manufacturer's instructions indicating the inhaler were good for 90 days after opening and removal from the foil pouch.One bottle of Melatonin liquid (drug used for sleep) with an expiration date of 3/2026. LN 7 acknowledged the findings and stated the label warnings and open dates were not documented, and nurses could have ended up giving ineffective drugs.4. During a concurrent observation and interview, on 7/15/26 at 9:05 AM, with Licensed Nurse (LN) 3 at Nurses Station 2, the treatment storage cabinet contained one tube of Fluorouracil cream that did not have a resident-specific label, pharmacy prescription label and was not stored in a sealed zip-lock bag bearing a Hazardous Drug (HD) warning label. LN 3 initially stated the medication may have been a discontinued medication and upon further review, LN 3 identified the medication as belonging to Resident 20, who remained a current resident at the facility. LN 3 stated the hazardous status should have been kept on the medication tube so the nurses could use gloves when handling them.During an interview, on 7/15/26 at 10:50 AM, with the ADON, in his office, the ADON stated that nursing staff were hesitant to discard narcotic medications like Ativan and acknowledged that the opened Ativan vial should have been disposed of with other narcotics. The ADON further stated he was unsure why the Fluorouracil cream did not have a prescription label with resident name and hazard warning. The ADON stated he expected the nursing staff to follow the manufacturer labels for dating the products when first opened since it could affect drug effectiveness.Review of the facility's policy, titled Pharmacy Services, dated 2/26/19, the policy indicated the purpose was to ensure that medications are handled in this facility in a manner that protects the safety and welfare of the residents. The policy further indicated All medication obtained by prescription are labeled in compliance with state and federal laws governing prescription dispensing. The policy under section medication storage indicated, medication of each resident are kept and stored in their originally received containers medication are not transferred between containers. Licensed nurse will verify that medication have not expired at the time of the use. Expired medications will be removed from the Med cart; Nursing supervisor and a pharmacy representative, shall randomly check carts for expired medications The policy under section, disposal of Medications indicated, medications are not kept in stock beyond the expiration date on the label and no contaminated or deteriorated medication are allowed to be available for use.The facility did not have a policy on handling and storage of hazardous medications.

Based on interview, and record review, the facility failed to implement its Antibiotic Stewardship Program (ASP -a federally mandated program with goals of monitoring, optimizing antibiotic use, and reducing the misuse of antibiotics) for one of three sampled residents (Resident 34), when the facility continued to administer Macrobid (an antibiotic medication used to treat infections) for over 1.5 years to Resident 34 without a stop date (discontinue date), without documented clinical review, without documented signs or symptoms of infection, and without laboratory evidence to support the continued use.This deficient practice placed Resident 34 at risk of developing a serious infection due to antibiotic resistance (when bacteria adapt and change to survive the drugs meant to kill them, instead of being destroyed) and caused Resident 34 to take an unnecessary antibiotic without being monitored for potential side effects. Findings:A review of Resident 34's Order Summary Report, dated 7/15/26, indicated Resident 10 had a physician's order for Macrobid Oral Capsule 100 milligrams (MG - a unit of measure) which was ordered on 1/21/25 and started on 1/22/25, with no date listed as to when to stop the antibiotic.A review of Resident 34's Progress Notes, dated 1/21/25, at 11:58 AM, by LN 10, the nurses' progress note indicated, .New order received via fax from [Hospice (specialized care for individuals with a terminal illness) Provider Name]. Macrobid 100 mg daily routine for UTI prophylaxis [UTI -urinary tract infection, prophylaxis means taking steps to prevent a UTI before it starts]. Start once Cephalexin [antibiotic] is done. Noted and carried out.A review of Resident 34's Progress Notes, dated 1/21/25, at 11:50 AM, by LN 10, the order note indicated, .This order is outside of the recommended dose or frequency. Macrobid Oral Capsule 100 MG.Give 1 capsule by mouth one time a day.This dose fails a general dose range check based on drug inputs and/or the patient information provided. This drug's dose should be adjusted based on renal function. Manual screening is required.A review of Resident 34's clinical record document, HOSPICE DISCHARGE/TRANSFER SUMMARY, dated 5/17/25, indicated that Resident 34 was discharged from hospice service (special medical care that focuses on comfort, pain relief, and emotional support for people who are very sick and nearing the end of life) on 5/17/25.During a concurrent interview and record review on 7/16/26, at 10:34 AM, with the Infection Preventionist (IP), Resident 34's clinical record was reviewed (including nurses' progress notes, hospice notes, physician orders, weekly summaries, physician progress notes, lab values, and care plans) during the time period of 1/21/25 through 7/16/26, searching for any documentation that indicated the rationale as to why Resident 34 remained on the antibiotic without a stop date. The IP confirmed that Resident 34 was started on the antibiotic Macrobid for UTI prophylaxis (preventative care) by the hospice service on 1/21/25. The IP stated that she did not follow residents who were on antibiotics prophylactically. The IP was unable to state the rationale for why residents on prophylactic antibiotics were not followed by their facility and added, that was the way it had always been done. The IP further confirmed that Resident 34 was discharged from hospice service on 5/17/25 and was still taking the antibiotic daily since 5/17/25. The IP further reviewed Resident 34's clinical record and the clinical record failed to reveal documented evidence for the continued use of Resident 34's Macrobid after Resident 34 was discharged from hospice service. The IP reviewed laboratory results for Resident 34's blood work completed on 6/16/26 that indicated a white blood cell count (WBC -a test that measures white blood cells in your body, an elevated number can evidence of an infection) was normal. The IP further stated as a practice, the facility followed McGeer's Criteria (a standardized tool used in long-term care facilities to help determine whether a resident's signs and symptoms meet infection criteria) for their ASP. The McGeer's Criteria included measures that helped determine whether an antibiotic was clinically indicated, such as laboratory results that revealed an infection, a urinalysis or urine culture and sensitivity, or other clinical documentation to support for the continued use of the antibiotic for UTI prophylaxis. The IP confirmed that Resident 34 did not meet McGreer's Criteria to be on the antibiotic. The IP further confirmed there were no documented progress notes from the physician (MDR) or documented progress notes from nurses that indicated Resident 34 had of any signs or symptoms of a UTI since starting the antibiotic on 1/22/2025. The IP further reviewed Resident 34's clinical record that revealed no documentation of monitoring for adverse effects of antibiotic therapy. The IP stated it was important to monitor the residents on antibiotics because if the antibiotic was not needed the resident should not be taking it. The IP further stated the risk of Resident 34 not being monitored while on antibiotics was the risk of becoming resistant to the antibiotic. During an interview on 7/16/26 at 4:05 PM with Resident 34's physician and Medical Director (MDR), the MDR stated that Resident 34 was initially started on Macrobid by the hospice service, to help prevent a UTI. The MDR confirmed he started the Macrobid antibiotic based on the hospice service recommendation. The MDR stated the antibiotic should have been discontinued. The MDR confirmed Resident 34 had not shown any signs or symptoms of a UTI for a long time. The MDR further stated that the continued use of the antibiotic had been overlooked. The MDR explained the risk to Resident 34 for being placed on the Macrobid for so long was the development of a resistant infection or developing a UTI that was resistant to antibiotics.During a concurrent interview and record review on 7/17/26, at 8:07 AM, with the Assistant Director of Nursing (ADON), Resident 34's clinical record (including nurses' progress notes, hospice notes, physician orders, weekly summaries, physician progress notes, lab values, and care plans) during the time period of 1/21/25 through 7/16/26), were reviewed along with the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Policy and Procedure, revised 5/14/25. The ADON confirmed Resident 34 was not followed by the facility for the use of antibiotics because Resident 34 was under hospice care at the time when Macrobid was started by hospice and the facility did not complete lab work on hospice residents. The ADON further reviewed Resident 34's clinical record and confirmed Resident 34 was discharged from hospice in May 2025 and could not find any documentation that Resident 34 was being monitored by the facility nurses, the MDR, or the IP for the use of the antibiotic. The ADON confirmed Resident 34 remained on the antibiotic without monitoring for more than a year after Resident 34 was discharged from hospice. The ADON reviewed the facility policy titled, Antibiotic Stewardship Policy and Procedure, and confirmed the policy did not exclude residents who were on prophylactic antibiotics and confirmed the policy indicated the facility used the McGreer's Criteria for infections. The ADON further reviewed Resident 34's clinical record and confirmed there were no diagnostics completed, no signs or symptoms of a UTI documented, and no care plan that indicated Resident 34 was taking an antibiotic. The ADON confirmed that the MDR put in an order dated 7/17/26 to discontinue the Macrobid for Resident 34. The ADON stated it was his expectation for all residents in the facility that were ordered antibiotics were monitored by using the McGreer's Criteria, including prophylactic use. The ADON further stated that generally, antibiotics should have an end date and the risk to the resident's was that they could become resistant to antibiotics. The P&P titled, Antibiotic Stewardship Policy and Procedure, indicated, .Purpose: To promote the appropriate use of antibiotics and optimize the treatment of infections while reducing any adverse effects associated with antibiotic use.It is the policy of [facility name] to follow Industry Standards for Antibiotic Stewardship.All licensed staff should be in-serviced on the McGreer Criteria for Infections.The Infection Preventionist will do Antibiotic and MDRO [multi-drug resistant organism] tracking. This will include.Antibiotic use, dose, duration, type of infection.Culture report (if done) and organism.Resident identifier, onset date, antibiotic order date.Signs and symptoms, whether criteria was met.The findings will be reviewed monthly by the Medical Director.Review of an online document published by the Centers for Disease Control and Prevention (CDC) in 2015, titled, Core Elements of Antibiotic Stewardship for Nursing Homes indicated, .Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics [antibiotics that are taken to treat infections throughout the body] when followed over a year .studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate .Harms from antibiotic overuse are significant for the frail and older adults receiving care .These harms include risk of serious diarrheal infections from Clostridium difficile (a bacteria that causes diarrhea and inflammation of the colon-the longest part of the large intestines, which is an organ in the digestive system) increased adverse drug events (harm caused by appropriate or inappropriate use of a drug) and drug interactions (a change in the way a drug acts in the body when taken with certain other drugs), and colonization (when bacteria are present on or inside a person's body, growing and multiplying, but without causing any noticeable symptoms or illness) and/or infection with antibiotic-resistant organisms . https://www.cdc.gov/antibiotic-use/media/pdfs/core-elements-antibiotic-stewardship-508.pdf

Based on observation, interview, and record review the facility failed to ensure two of three residents (Resident 5 and Resident 8) were provided with a safe environment when:1. Resident 5 eloped (a resident leaving the premises or a secure area without authorization, supervision, or the knowledge of the staff) from the facility2. The C Hall exit door did not have an alarm activated during the day3. Resident 5 and Resident 8's [Brand Name] elopement bracelets (bracelet that can be placed on a resident and sets off a door alarm when the resident tries to exit through the door) were not checked at least daily for placement and function and not all exit doors at the facility were alarmed. These failures resulted in Resident 5 leaving the facility unsupervised and had the potential for Resident 8 to leave the facility unsupervised, with the potential for both Resident 5 and Resident 8 to experience getting lost and sustaining injuries, which had the potential to negatively affect their health, well-being, and psychosocial well-being.Findings:1. A review of Resident 5's clinical document titled, admission RECORD, date printed 4/15/26, indicated Resident 5 was admitted to the facility with diagnoses which included difficulty walking, mild cognitive impairment (a condition where individuals experience noticeable memory or thinking problems greater than typical for their age), and bilateral macular degeneration (an eye disease that can cause partial blindness).A review of Resident 5's clinical document titled, MDS Section E - Behavior . Section E0900 [Minimum Data Set Section E0900 - is a standardized assessment item that documents the presence and frequency of a nursing home resident wandering within the last 7 days], dated 10/21/25, indicated, . Wandering - Presence & [and] Frequency . Behavior of this type occurred 4- [to] 6 days .A review of Resident 5's clinical document titled, MDS Section E - Behavior . Section E0900, dated 1/7/26, indicated, . Wandering - Presence & Frequency . Behavior of this type occurred 4-6 days .A review of Resident 5's clinical document titled, MDS Section E - Behavior . Section E0900, dated 4/7/26, indicated, .Wandering - Presence & Frequency . Behavior of this type occurred 4-6 days .A review of Resident 5's clinical document titled, Care Plan Report [a written document that outlines a person's health needs, goals for treatment, and the specific actions healthcare providers will take to support them], dated 4/21/26, indicated, . Problem . I [Resident 5] am an elopement risk r/t [related to] frequent exit seeking with verbalizations of wanting to leave facility unattended, and impaired safety awareness . Date initiated 10/08/2025 . Goal . I will have reduced risk of leaving the facility unattended through the review date . Date Initiated 10/08/2025 . Interventions . Assess for fall risk . Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . WANDER ALERT . I have [Brand Name elopement] bracelet on right ankle .During an interview on 4/30/26 at 11:23 AM with the Director of Nursing (DON), the DON stated the facility did not only have elopement assessments for the residents. The DON explained residents at risk for elopement have the information in their care plans.During an interview on 4/30/26 at 8:34 AM, with the Dietary Aide/Cook (DA/Cook), the DA/Cook stated when she saw Resident 5, Resident 5 was in Independent Living Facility (a lifestyle that allows individuals to live on their own terms, maintaining personal autonomy and self-determination) not the Skilled Nursing Facility (SNF - a licensed, 24-hour medical facility that provides short-term rehabilitation or intensive nursing care for patients transitioning from the hospital to home). The DA/Cook explained Resident 5 was in the dining room of Independent Living Facility when she was approached by Resident 5. The DA/Cook Further explained Resident 5 requested help opening the front door because her daughter was going to pick her up, and the DA/Cook stated she opened the front door of the Independent Living Facility for Resident 5 and Resident 5 went outside.During an interview on 4/30/26 at 8:40 AM, with the DON, the DON stated neither her nor the nursing staff knew how long Resident 5 was in the Independent Living Facility before she approached the DA/Cook.During an interview on 4/30/26 at 8:43 AM with the DA/Cook, the DA/Cook stated she was told Resident 5 had been in line for Sunday church, went out of the line, and wandered to the Independent Living Facility. The DA/Cook explained from the SNF, Resident 5 would have had to exit C Hall and gone up the ramp into the Independent Living Facility.A record review of an e-mail sent on 4/30/26 at 10:33 AM, by the facility ADM to the Department, indicated Resident 5 went with residents from the SNF church services back to the Independent Living Facility around 10:45 AM on 3/15/26. The ADM's e-mail further explained residents started lining up for church services at 10 AM, which indicated Resident 5 could have been missing from 15 minutes to 1 hour.2. A review of the facility provided facility map indicated the C Hall exit had an alarm equipped.During an interview on 4/30/26 at 8:19 AM with the Administrator (ADM), the ADM stated all doors in the facility were equipped with alarms and the alarms were activated when opened. The ADM explained the alarm on the C Hall door was only turned on at night and off during the day, and all other alarms were on 24 hours a day, 7 days a week. The ADM further explained the entrance to the facility was the only door that had the [Brand Name] elopement alarm (the entrance door alarms only activated when a resident who was wearing the [Namee Brand] elopement bracelet passed through the doors).During an interview on 4/30/26 at 8:25 AM with the Director of Nursing (DON), the DON stated that her expectation for facility staff, if they witnessed a resident attempting to elope, was to immediately intervene, redirect the resident, and keep the resident safe by not allowing them to leave the facility. The DON explained that the risk to the residents was that they could elope, and the facility would not know if they were safe. Furthermore, the DON explained that the main concern was a loss of safety for the residents and not having anyone present to ensure their safety, placing the residents at risk of injury.3a. A review of Resident 5's clinical document titled, admission RECORD, date printed 4/15/26, indicated Resident 5 was admitted to the facility with diagnoses which included difficulty walking, mild cognitive impairment and bilateral macular degeneration.A review of Resident 5's clinical document titled, Progress Notes, dated 3/19/26, indicated, . On 3/15/26 approximately at 1100 [11 AM] resident [Resident 5] was found outside the facility in the parking lot by the maintenance office. Resident was spotted by the activity staff through the East dining room window . Per activity staff, resident was noted in the parking lot wheeling herself. Upon noticing the resident, activity staff rushed immediately outside and brought the resident back inside and notified the charge nurse. When asked about the incident, shestated [sic] to the nurse that she wheeled herself through the double doors leading into the breezeway between SNF [skilled nursing facility] and the [independent living facility] and asked dietary staff to help her make her way into the [independent living facility] because her daughter was waiting for her. Resident stated that the dietary staff pushed her through the second set of double doors into the [independent living facility] .During an interview on 4/15/26 at 10:37 AM with the Activities Aide (AA) 1, AA 1 stated he saw Resident 5 in the back parking lot on 3/15/26 at approximately 11 AM and went to get her. AA 1 explained once Resident 5 was back in the facility he informed his charge nurse of the incident.During a concurrent observation and interview on 4/15/26 at 11:29 AM with Resident 5, Resident 5 stated she left the facility one time (3/15/26). Resident 5 explained she was too scared to leave the facility by herself anymore and preferred if staff were with her. Resident 5's [Brand Name] elopement bracelet was noted to be on her right ankle.A review of Resident 5's clinical documents titled, Medication Administration Record [MAR - a document that contains the resident's ordered and administered medications], dated 3/1/26 through 3/31/26, and Treatment Administration Record [TAR] - a document that contains the resident's ordered and administered treatments], dated 3/1/26 through 3/31/26, did not indicate daily checks for placement and functioning of Resident 5's [Brand Name] elopement bracelet.3b. A review of Resident 8's clinical document titled, admission RECORD, date printed 4//17/26, indicated Resident 8 was admitted to the facility with diagnoses which included dementia (a decline in brain function that interferes with daily life, usually caused by progressive, irreversible brain damage) and osteoporosis (a common bone disease making bones thin, brittle, and highly prone to fractures).A review of Resident 8's clinical document titled, MDS Section E - Behavior . Section E0900, dated 12/27/21, indicated, .Wandering - Presence & Frequency . Behavior of this type occurred 1-3 days .A review of Resident 8's clinical document titled, MDS Section E - Behavior . Section E0900, dated 12/9/25, indicated, .Wandering - Presence & Frequency . Behavior of this type occurred 1-3 days .A review of Resident 8's clinical document titled, MDS Section E - Behavior . Section E0900, dated 3/10/26, indicated, .Wandering - Presence & Frequency . Behavior of this type occurred 1-3 days .A review of Resident 8's clinical document titled, Care Plan Report, dated 4/14/26, indicated, . Problem . I AM AN ELOPEMENT RISK R/T [related to] MY WANDERING BEHAVIOR . I HAVE A WONDER ALARM ON MY W/C [wheelchair] . Date Initiated: 04/27/2023 . Goal . I will not leave facility unattended . Interventions . Assess for fall risk . Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation . Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate . [Brand Name elopement bracelet] .A review of Resident 8's clinical documents titled, Medication Administration Record [MAR], dated 3/1/26 through 3/31/26, and Treatment Administration Record [TAR], dated 3/1/26 through 3/31/26, did not indicate daily checks for placement and functioning of Resident 8's [Brand Name] elopement bracelet.During an interview on 4/17/26 at 12:07 PM with Licensed Nurse (LN) 5, LN 5 stated she had not documented the placement or function of the [[NAME] Name] elopement bracelets in the past.During an interview on 4/17/26 at 12:20 PM with LN 6, LN 6 stated visual checks and daily documentation were supposed to be done on residents with [Brand Name] elopement bracelet devices.During a joint interview on 4/28/26 at 2:25 PM with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), the DON confirmed Resident 5 existed the facility with the assistance of kitchen staff. The ADON stated the exit door Resident 5 left the facility through only had the alarms activated at night, not during the day, so when Resident 5 was assisted by kitchen staff, the alarm was not activated. The DON confirmed there was no daily documentation in place for placement and functioning of Resident 5 and Resident 8's [Brand Name] elopement bracelets. The ADON stated the importance of having daily checks for placement and functioning of the [Brand Name] elopement bracelets were to prevent elopement and ensure resident safety. The ADON explained not having daily checks in place for placement and functioning of the [Brand Name] elopement bracelets placed Resident 5 and Resident 8 at risk of going outside unsupervised where an injury could occur.A review of the facility policy titled, [Brand Name Elopement Device] Policy, dated 3/13, indicated, POLICY: To alert staff of a potential elopement and provide a safe environment for residents . PURPOSE: . Any resident who has demonstrated a behavior of wandering without desire to elope purposefully may use a [brand name elopement device] . The [brand name elopement device] alarm is placed on wheel chair or walker and the alarm will sound if resident is within five feet of the front door, allowing staff to re-direct resident .

Based on interview and record review the facility failed to ensure one of three sampled residents' (Resident 1) drug regimen (a structured, prescribed plan for taking medication) was appropriately followed when Resident 1's prescribed narcotic pain medication (a strong, addictive, a regulated pain medication) that was prescribed for moderate to severe pain every six hours, was given without assessing Resident 1's pain level (the numerical pain scale 0 through 10; 0 indicates no pain,1 through 3 indicates mild pain; 4 through 6 indicates moderate pain; 7 through 10 indicates severe pain).This failure had the potential to result in Resident 1 being over-medicated and placed Resident 1 at risk for falls, negatively affecting Resident 1's health and well-being. Findings:A review of Resident 1's clinical document titled, admission RECORD, date printed 4/15/26, indicated Resident 1 was admitted to the facility with diagnoses which included dementia (a decline in brain function that interferes with daily life, usually caused by progressive, irreversible brain damage) and osteoporosis (a common bone disease making bones thin, brittle, and highly prone to fractures).A review of Resident 1's clinical document titled, Medication Administration Record [MAR-a document that contains the resident's orders and administered medications], dated 3/1/26 through 3/31/26, indicated, .HYDROcodone-Acetaminophen Oral Tablet 5-325 MG [milligrams - a unit of measurement] . Give 1 tablet by mouth every 6 hours for mod [moderate pain]- [to] severe pain . Start Date . 3/16/26 . D/C [discontinue] Date 3/23/26 . The above medication was administered every 6 hours for the duration of the order without documenting Resident 1's pain level.-3/16/26 at 6 PM-3/17/26 at 12 AM, 6 AM, 12 PM, 6 PM-3/18/26 at 12 AM, 6 AM, 12 PM, 6 PM-3/19/26 at 12 AM, 6 AM, 12 PM, 6 PM-3/20/26 at 12 AM, 6 AM, 12 PM, 6 PM-3/21/26 at 12 AM, 6 AM, 12 PM, 6 PM-3/22/26 at 12 AM, 6 AM, 12 PM, 6 PM-3/23/26 at 12 AM, 6 AM, 12 PM, 6 PMA review of Resident 1's MAR, dated 3/1/26 through 3/31/26, indicated, Pain Assessment every shift-rate on scale of 0- [through] 10, document location & [and] character of pain every 8 hours for pain screening . Start Date . 3/20/23 . D/C date 4/10/26 . From 3/16/26 to 3/24/26 there was one instance where Resident 1 had documented pain greater than 0, it was on 3/19/26 at 6 AM with a pain score of 3 (mild pain).During an interview on 4/29/26 at 1:34 PM with the Director of Nursing (DON), the DON stated a pain level of 0 through 3 indicated mild pain, 4 through 6 indicated moderate pain, and 7 through 10 indicated severe pain.During a concurrent interview and record review on 4/15/26 at 11:39 AM, with Licensed Nurse (LN) 1, Resident 1's MAR, dated 3/1/26 through 3/31/26 was reviewed. LN 1 confirmed Resident 1's pain level was not documented on the MAR and there was not a place to document on the MAR the resident's pain level score. LN 1 explained that Resident 1's pain level should have been assessed and documented prior to administering pain medication.During a concurrent interview and record review on 4/15/26 at 1:17 PM with the Assistant Director of Nursing (ADON), Resident 1's MAR, dated 3/1/26 through 3/31/26 was reviewed. The ADON stated before administering HYDROcodone medication, Resident 1's pain level should have been assessed. The ADON explained Resident 1 had a routine order for HYDROcodone and a pain assessment was needed prior to medication administration. The ADON further explained the indications for administration for the HYDROcodone was for moderate to severe pain and there should have been an assessment of Resident 1's pain level, and there was not. The ADON explained there was a risk of over medicating Resident 1 and an increased risk for falls.During a concurrent interview and record review on 4/15/26 at 3:34 PM, with the Director of Nursing (DON), Resident 1's MAR, dated 3/1/26 through 3/31/26 was reviewed. The DON stated Resident 1's pain level should have been assessed prior to administering the HYDROcodone. The DON explained the importance of knowing the pain level was to ensure pain medication was not administered if the resident was not experiencing pain.A review of the facility policy titled, Pain Management/Assessment Policy, dated 12/9/16, indicated, . Pain will be assessed Q [every] shift and any time that vital signs are taken . A review of the facility policy titled, MEDICATION ADMINISTRATION, dated 3/15, indicated, . Medications and treatment shall be administered as prescribed . Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded .

Based on interview and record review the facility failed to maintain complete and accurate records for one of two sampled residents (Resident 1) when Resident 1's document titled, Weekly Summary, (a weekly review of the resident's condition) for the week ending in 3/25/226, did not reflect Residents 1's current health status.This failure resulted in an inaccurate representation of Resident 1's current health status and had the potential to negatively impact Resident 1's health regarding wounds and pain management. Findings:A review of Resident 1's clinical document titled, admission RECORD, date printed 4/15/26, indicated Resident 1 was admitted to the facility with diagnoses which included dementia (a decline in brain function that interferes with daily life, usually caused by progressive, irreversible brain damage) and osteoporosis (a common bone disease making bones thin, brittle, and highly prone to fractures).A review of Resident 1's clinical document titled, Weekly Summary, dated 3/25/26, indicated, A. Skin Assessment . No wounds currently . Site . buttock . Type . MASD [Moisture-Associated Skin Damage, inflammation and erosion (a condition where the skin becomes red, swollen, and warm, followed by the breaking down or scraping away of its top layer of skin)] . Current treatment & [and] summary of effectiveness . [no response in box provided] . C. Pain Management . No Pain . Number of episodes of PRN [as needed] used in last 7 days [referring to pain medication] . none . Indicate type: (Pain Type-chronic, sharp, dull, etc.) (Medication Used) [no response in box provided] . A review of Resident 1's clinical document titled, Progress Notes, dated 3/21/26 indicated, . resident noted to have a MASD related fissure [a linear, superficial skin break or split that occurs within areas of MASD] to upper gluteal cleft [upper portion where buttocks separate]. the [sic] fissure measures 5x [by] 2cm [centimeters (cm, a unit of measurement)]. no s/sx [signs or symptoms] of infection noted. resident is incontinent [involuntary leakage of urine and stool] of bowel and bladder which increases the risk for skin damage. [Physician] made aware, and order received for Triad [topical medication to protect the skin] every shift .A review of Resident 1's clinical document titled, Progress Notes, dated 3/22/26, indicated, .Call out to MD [Medical Director] to change [HYDROcodone-Acetaminophen [Oral Tablet 5/325 MG prescribed narcotic (a strong, addictive, semisynthetic opioid pain medication used to treat moderate-to-severe pain)] pain medication tablet to liquid due to inadequate pain control. Resident noted to vocalized mild to moderate pain when touched or moved. Resident is refusing meds or having a difficult time taking crushed meds .A review of Resident 1's clinical document titled, Progress Notes, dated 3/23/26, indicated, . MD . called back with new orders for Morphine sulfate [a strong, addictive, opioid pain medication used to treat moderate-to-severe pain] oral solution .A review of Resident 1's clinical document titled, Medication Administration Record [MAR, a document that contains the resident's ordered and administrated medications], dated 3/1/26 through 3/31/26, indicated, . HYDROcodone-Acetaminophen Oral Tablet 5/325 MG . give every 6 hours . Start Date . 3/16/26 . Resident 1 received the medication every six hours from 3/16/26 at 6 PM through 3/23/26 at 6 PM for pain control for a total of 23 doses.A review of Resident 1's clinical document titled, Medication Administration Record, dated 3/1/26 through 3/31/26, indicated, Morphine Sulfate . every 4 hours as needed for Generalize pain and discomfort . Start date . 3/23/26 . Resident 1 received a dose of Morphine Sulfate on 3/24/26 at 10 AM and another dose on 3/25/25 at 9:45 AM.During a concurrent interview and record review with Licensed Nurse (LN) 1 on 4/15/26 at 11:39 AM, Resident 1's clinical document titled, Weekly Summary, for the week ending in 3/25/26 was reviewed. LN 1 confirmed she had not documented any wounds for Resident 1 in Resident 1's Weekly Summary, for the week ending 3/25/26, and she should have. LN 1 further confirmed she had not documented the new pain medication orders for hydrocodone and morphine or the new order for Triad cream in the Weekly Summary, and she should have. LN 1 further confirmed she should have documented when Resident 1 was experiencing pain. LN 1 explained the purpose of the Weekly Summary was to note any changes that occurred in the week prior, indicate new treatments and medications and document any changes in Resident 1's physical and mental condition. LN 1 further explained the risk to Resident 1 when the treatment and health changes were not documented in the Weekly Summary was the resident's health could have gotten worse due to poor communication and action between healthcare providers.During a concurrent interview and record review on 4/15/26 at 1:17 PM with the Assistant Director of Nursing (ADON), Resident 1's Weekly Summary, for the week ending in 3/25/26 was reviewed. The ADON stated the expectation was for the nursing staff to document skin issues and document new treatments and medications in the Weekly Summary. The ADON confirmed Resident 1'sWeekly Summary, dated 3/25/26 did not reflect these changes. The ADON stated the risk to Resident 1 was the MASD with a fissure could have gotten worse.During a concurrent interview and record review on 4/15/26 at 3:34 PM with the Director of Nursing (DON), Resident 1's clinical document titled, Weekly Summary, dated 3/25/26 was reviewed. The DON stated the LNs should have completed Resident 1's Weekly Summary after they retrieved the resident's vital signs (heart rate and respiration rate per minute, blood pressure, oxygen saturation percentage, and pain level) taken by the certified nursing assistants, reviewed the physician's orders, and documented any new orders in the Weekly Summary. The DON explained the LNs should have assessed Resident 1's skin to ensure there were not any new wounds. The DON confirmed Resident 1's Weekly Summary, dated 3/25/26 should have reflected Resident 1's new pain medication orders, new wounds and the size of the wound.A review of the facility policy titled, SKIN ASSESMENT AND TREATMENT, dated 11/14, indicated, .The licensed nurse is expected to be aware of any skin problem . on any of her residents. The licensed nurse is expected to observe, report and document any changed [sic] in these areas to the physician .A review of the facility policy titled, Pain Management/Assessment Policy, dated 12/9/16, indicated, . A review of the pain and medication used for the pain is done weekly on the weekly summary .

Based on interview and record review, the facility failed to ensure safe monitoring practices for high-risk medication (drugs with potential to cause harm without monitoring) use in one out of four residents (Resident 1) when:1. Resident 1 was prescribed metoprolol (a medication used to control heart rate and rhythm) without orders to monitor Resident 1's blood pressure or heart rate; and2. Resident 1's experienced syncopal episodes (a brief loss of consciousnesses caused by a temporary decrease in blood flow to the brain) during transfers, which were not adequately documented or addressed by the licensed nurse (LN).These failures had the potential to result in unsafe medication use and adverse consequences for Resident 1.1. Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with diagnoses that included but was not limited to atrial fibrillation (A-Fib; heart rhythm disorder) and hypertension (HTN; high blood pressure). During a concurrent interview and record review on 9/5/25 at 2:33 PM, Resident 1's Order Summary Report, dated 9/25 and Blood Pressure and Pulse Summary report, dated from 6/20/25 through 9/5/25, was reviewed with LN 1. LN 1 confirmed that Resident 1 had an order for .Metoprolol Succinate Oral Capsule ER [extended release] 24 Hour Sprinkle 50 MG [milligrams; a unit of measurement] (Metoprolol Succinate) Give 50 mg by mouth one time a day for A-fib. LN 1 confirmed Resident 1's metoprolol order did not include directions of when to hold or administer the medication based on the result of Resident 1's blood pressure or heart rate. LN 1 confirmed the following blood pressures (BP) and heart rate (HR) noted on Resident 1's vital summary report: 6/12/25 BP of 106/81, 6/27/25 HR of 128, 7/2/25 HR of 44, 7/4/25 HR of 113, 7/6/25 HR of 99 and BP of 99/60, 7/13/25 BP of 105/611, 7/18/25 BP of 106/70, 7/19/25 BP of 110/58, and 8/22/25 BP of 105/65. LN 1 stated that based on the review of Resident 1's blood pressures and heart rates, the results should have been reviewed with Resident 1's physician. LN 1 confirmed there was no documentation in Resident 1's electronic medical record that indicated that BP and HR results were reviewed with Resident 1's physician.During a concurrent interview and record review on 9/9/25 at 1:55 PM, Resident 1's physician order for Metoprolol Succinate, order dated 3/19/24, was reviewed with LN 2. LN 2 stated that Resident 1's physician order for the Metoprolol medication should have had parameters for blood pressure and heart rate monitoring and then, based on those parameters, the medication would then be administered or held. During a concurrent interview and record review on 9/15/25 at 3:10 PM, Resident 1's Consultant Pharmacist's Medication Regiment Review [an evaluation of a resident's entire medication list to ensure that the medication is safe, effective, and appropriate for their condition], dated 6/25, 7/25, and 8/25, were reviewed with the Pharmacy Consultant (PharmD). The PharmD stated that based on Resident 1's BP and HR results and with the history of syncope, he should have made a recommendation to the MD for Resident 1 to have daily monitoring of the blood pressure and heart rate prior to the administration of metoprolol.2. During a review of Resident 1's nurse progress notes, dated 6/26/25 and 6/27/25, indicated that Resident 1 became unresponsive while being transferred in the standing lift (a device designed to assist individual with limited mobility in going from a seated to a standing position) on 6/26/25 and 6/27/25.During an interview on 9/9/25 at 1:33 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Almost every time I work with [Resident 1], [Resident 1] becomes dizzy and lightheaded when I move [Resident 1] from a lying to sitting position or from sitting to standing using the standing lift. CNA 1 continued to state that Resident 1 must be sat back down or laid back down on the bed for fear that Resident 1 was going to pass out. CNA 1 stated that she did not always report these episodes to the licensed nurse (LN) because sometimes the episodes came and went very quickly.During a concurrent interview and record review on 9/5/25 at 2:33 PM, Resident 1's NURSES NOTE, dated 6/27/25, was reviewed with LN 1. LN 1 stated that Resident 1 had a history of syncopal episodes that occurred while in the standing lift. LN 1 confirmed there was no documentation that indicated that Resident 1 was assessed for orthostatic hypotension (form of low blood pressure that might cause dizziness, lightheadedness, or fainting when rising from sitting or lying down) or the possibility of completing orthostatic blood pressures (checking the BP and HR while lying, sitting, and standing) was discussed with Resident 1's physician. During an interview on 9/9/25 at 1:55 PM, LN 2 stated that Resident 1 did have a history of syncopal episodes that may be related to a drop in Resident 1's blood pressure or pulse from the Metoprolol medication. LN 2 stated that the licensed nurse should have initiated orthostatic blood pressures and heart rate checks after Resident 1's syncopal episode so that a more detailed and thorough report could have been given to Resident 1's physician.During a concurrent interview and record review on 9/9/25 at 4:04 PM with LN 3, Resident 1's NURSES NOTE, dated 6/27/25 was reviewed with LN 3. LN 3 stated that on 6/27/25, she assessed Resident 1 following a report that Resident 1 had become weak on the right side of the body then became confused during a transfer with the standing lift. LN 3 stated that Resident 1 had returned to baseline when LN 3 arrived in the room. LN 3 stated that she was aware of Resident 1's history of syncopal episodes during position changes between lying, sitting and standing and then stated that there was not a need to complete orthostatic blood pressure and heart rate checks since Resident 1 had returned to baseline at the time of LN 3's assessment. LN 3 further stated that a physician needed to add parameters for medication administration, not the licensed nurse and LN 3 had never seen a need to discuss that with Resident 1's physician even though there was a history of syncopal episodes.During an interview on 9/15/25 at 4:18 PM with LN 4, LN 4 confirmed that Resident 1 had a history of syncopal episodes. LN 4 stated that as a LN, she should have assessed Residents 1's blood pressure and heart rate further based on the syncopal episodes and the daily administration of metoprolol. LN 4 stated had that been done, the physician would have been able to make a more accurate assessment regarding the need for hold parameters on Resident 1's metoprolol order.During a concurrent interview and record review on 9/15/25 at 3:10 PM, Resident 1's Consultant Pharmacist's Medication Regiment Review, dated 6/25, 7/25, and 8/25, was reviewed with the PharmD. The PharmD stated if Resident 1 was having syncopal episodes during changes of position from lying, sitting and standing, then he would expect that the licensed nurse would check for orthostatic hypotension (low blood pressure) and report those results when reporting the syncopal episode to Resident 1's physician. PharmD further stated that since Resident 1 was having syncopal episodes it would have been beneficial to have parameters for blood pressure and heart rate monitoring along with the metoprolol medication order. PharmD stated that the licensed nurses had never notified him of these episodes during his drug regimen review while onsite at the facility, nor did he see the nurses progress notes regarding Resident 1's recent syncope episodes. PharmD stated if he had been notified, he would have made recommendations for blood pressure and heart rate monitoring and labs to help evaluate if the syncopal episode was related to the medication or another cause like dehydration.During a concurrent interview and record review on 9/8/25 at 3:56 PM, Resident 1's Order Summary Report, dated 9/25 and Blood Pressure and Pulse Summary report, dated from 6/20/25 through 9/5/25, was reviewed with the Director of Nursing (DON). The DON stated that the use of the standing lift to transfer Resident 1 was stopped on 7/2/25 not due to episodes of syncope, but due to a right shoulder dislocation (occurs when the ball-shaped top of the upper arm bone separates from the socket-shaped shoulder blade) and right humerus fracture (a break in the bone, located in the upper arm). The DON stated she was unaware that Resident 1 had multiple episodes of syncope, stating that she was only aware of one episode. During a review of Resident 1's blood pressure and heart rate entries, the DON acknowledged that Resident 1's did have high and low blood pressures and low heart rates that would have indicated a need to hold the Metoprolol, complete orthostatic blood pressures, and to notify the physician, especially if there was a history of syncope during transfers. The DON stated that the lack of further assessment into Resident 1's blood pressure and heart rate fluctuations by the nursing staff placed Resident 1 at risk for continued syncopal episodes which could result in a fall and further injury.During a review of the facility's policy and procedure (P&P) titled, Receiving Physician Medication Orders, dated 11/1/15, the P&P indicated, .Purpose: Clarification of Physician's orders - receiving orders for the medication for abnormal vital signs.B/P: Any abnormal B/P systolic > [greater than] 170 or < [less than] 100 diastolic [bottom number of BP reading] >90 or <40, physician notification is required.If an order is received, b/p parameters are to be included (i.e., Medication given for sbp [systolic blood pressure, top number of BP reading] >170 or hold medication for sbp <100).Pulse: Any abnormal pulse >100 or <60, physician notification is required.If an order is received for any medication, it must include the parameters.

Based on interview and record review, the facility failed to revise the restorative nursing program (RNP-nursing intervention to increase or maintain resident's mobility and to prevent further decline in mobility) for one of four sampled residents (Resident 1) when the RNP plan of care for passive range of motion (PROM - the movement of a joint through the range of motion with no effort from the patient) exercises to Resident 1's upper extremities was not revised following a right shoulder dislocation and fracture.This failure placed Resident 1 at risk for further injury, pain and discomfort to the right shoulder and right arm.Findings:During a review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses that included but were not limited to dementia (a decline in mental ability severe enough to interfere with daily life), displaced fracture of upper end of right humerus (arm bone), and unspecified dislocation of right shoulder (when the ball shaped head of the humerus bone (upper arm) comes out of the socket in the shoulder blade).During a review of Resident 1's physician orders, dated 9/25, the following orders were indicated as active orders . (R) [right] Shoulder Dislocation: CHECK for IMMOBILIZER [a type of arm sling used to hold the arm against the body, restricting movement of the shoulder and upper arm to promote healing from injuries like dislocation and fracture] PLACEMENT: Monitor for swelling, tenderness, numbness, tingling, discoloration and circulation. every shift for Dislocation.RA [restorative assistant] for Passive ROM to upper and lower extremities three times weekly as tolerated.During a concurrent interview and record review on 9/8/25 at 2:29 PM Resident 1's RNP order and the recorded Restorative Nursing Assistant (RNA) documentation to the upper and lower extremities three times a week as tolerated was reviewed with RNA 1. RNA 1 confirmed that Resident 1 received treatment from the RNA on the following dates: 7/1/25, 7/3/25, 7/6/25, 7/8/25, 7/10/25, 7/13/25, 7/15/25, 7/20/25, 7/22/25, 7/24/25, 7/27/25, 7/29/25, 7/31/25, 8/26/25, 8/28/25, 8/31/25, 9/4/25 and 9/7/25. RNA 1 confirmed that for the month of July of 2025 and for the period from 8/26/25 through 9/7/25, there was no documentation in Resident 1's electronic medical record that indicated that the PROM exercises to Resident 1's right upper arm was held. RNA 1 stated that the RNP order should have reflected that exercises to the right upper arm were not to be done and that the immobilizer was to remain in place except for bathing and dressing. During a concurrent interview and record review on 9/5/25 at 3:53 PM Resident 1's RNP meeting agenda, RNP care plan, and the RNP order were reviewed with the Director of Staff Development (DSD). The DSD stated that part of the DSD duties included overseeing the RNP which included updating the MD and physical therapist for order initiation of a RNP or revision of the current RNP and any need for physical or occupational therapy screening. The DSD stated that Resident 1's RNP had last been reviewed by the RNP team on 6/5/25 and no changes in Resident 1's plan were recommended at that time. The DSD confirmed that Resident 1's RNP had not changed and that the RNP for Resident 1 was not reviewed in the RNP meeting that was held in July or August of 2025 when Resident 1 returned from the acute hospital on 7/2/25 with the new diagnoses of dislocation of the right shoulder and fracture of the right humerus. The DSD stated that Resident 1 should have been referred to physical therapy for screening. The DSD stated that not updating the RNP for Resident 1 so that PROM to the right upper extremity was excluded, placed Resident 1 at risk for further injury, pain and discomfort. The DSD further stated that there had been no training on the immobilizer placement or techniques in positioning and transferring Resident 1 to avoid further injury. The DSD stated that providing that type of training to the Certified Nursing Assistants (CNA) and RNAs would have been beneficial to prevent further pain or injury to Resident 1.During an interview on 9/5/25 at 3:59 PM, the Director of Rehabilitation (DOR) stated that Resident 1 had not been screened by physical therapy when Resident 1 was readmitted from the acute hospital on 7/2/25 with new diagnoses of right shoulder dislocation and right humorous fracture. The DOR further stated that the physical therapist should have screened Resident 1's mobility, reassessed Resident 1's ordered RNP, and provided education to the CNAs and RNAs to ensure they were able to properly place the right arm immobilizer.During a concurrent interview and record review on 9/5/25 at 3:53 PM, Resident 1's physician order for the immobilizer to the right arm, dated 7/7/25, and Resident 1's RNP order for PROM to the upper and lower extremities three times weekly as tolerated, dated 2/25/20, were reviewed with the Director of Nurses (DON). The DON stated that since the immobilizer was on Resident 1's right arm, the expectation was that the RNAs would know not to perform the PROM exercises or to remove the immobilizer even though Resident 1's RNP order had not been updated upon Resident 1's return from the acute hospital on 7/2/25. The DON further stated that updating the RNP order to exclude PROM to the right upper arm, as well as providing training to the RNA and CNA on removing and placing the immobilizer, techniques in positioning Resident 1's right upper arm during care tasks such as bathing, dressing, bed mobility and transferring to and from her bed and wheelchair should have been done to help reduce the risk of further injury to Resident 1's right upper arm and shoulder.A review of the facility's job description titled, JOB DESCRIPTION RESTORATIVE NURSING ASSISTANT, dated 8/15, the record indicated, .documents on e-chart [electronic medical record] all activities performed in restorative program and the progress and changes that are observed.A review of the facility's policy and procedure (P&P) titled, RANGE OF MOTION, dated 11/15, the P&P indicated .All residents admitted to [facility name] LTC [long term care] will be screened for current mobility status within 7 days from admission.Residents identified as having a decline in ROM [range of motion] will be referred to PT/TO [physical therapy/occupational therapy] for screening and recommendations.

Based on interview and record review the facility failed to revise a comprehensive elopement (leaving a designated area, often a place of supervision or care, without permission) risk care plan (a guide that healthcare workers used to ensure Resident 1 received tailored care to his/her individual needs and goals) for one of two residents at risk for elopement (Resident 1), when Resident 1 was seen by facility staff sitting outside of the building unattended.This failure placed Resident 1 at risk for elopement and injury. Findings:During a review of Resident 1's clinical record titled, admission RECORD, (a document that contained the resident's demographic information) indicated Resident 1 was admitted to the facility with a diagnoses that included Dementia (a condition which caused a decline in memory, reasoning, and other thinking skills), tremors (shaking), dizziness, and hypertension (high blood pressure - the force of blood pushing against the artery walls).A review of Resident 1's clinical record titled, BRIEF INTERVIEW FOR MENTAL STATUS, (BIMS - a screening tool used to measure short term memory and orientation) dated 5/6/25, indicated Resident 1 had a BIMS score of 99 (99 is scored when the resident was unable to complete the interview).During a concurrent interview and record review on 7/17/25 at 3:03 p.m. with the Assistant Director of Nursing (ADON), Resident 1's clinical record titled, Progress Notes, dated 5/27/25, was reviewed. The progress note indicated Resident 1 was found outside of the facility building by the therapy office. The ADON stated Resident 1 was not supposed to be in the therapy rooms unattended and could have potentially wandered further away from the facility.During an interview with LN 2 on 7/17/25, at 2:42 p.m., LN 2 stated when Resident 1 eloped he was at risk of injury, such as being hit by a car, and/or getting lost.During a concurrent interview and record review on 7/17/25 at 4:05 p.m. with the Administrator (ADM), Resident 1's care plan titled, I AM AN ELOPEMENT RISK, revised on 8/20/24, was reviewed. The care plan indicated a goal was to maintain safety through the review date. The ADM stated the care plan was not revised after Resident 1 eloped and it was her expectation that care plans should have been revised after any assessment or change of condition. The ADM further stated the care plan should have accurately reflected interventions in place that maintained Resident 1's safety, and that the effectiveness of the interventions was monitored.A review of the facility's policy and procedure titled, Care Plan Policy and Procedure, dated 11/28/16, indicated, .New or additional problems, goals and approach will be added to the care plan by the appropriate discipline as they arise.Care planned long term problems will be evaluated for appropriateness.Each care plan will be reviewed quarterly at the interdisciplinary team (IDT) meeting and at the time of a change in condition.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision for one of two sampled residents (Resident 1), at risk for elopement (leaving a designated area, often a place of supervision or care, without permission), when Resident 1 was found outside of the physical therapy office back door on 5/27/25 at approximately 5:00 p.m.This failure placed Resident 1 at risk of serious injury and harm.Findings:During a review of Resident 1's clinical record titled, admission RECORD, (a document that contained the resident's demographic information) indicated Resident 1 was admitted to the facility with a diagnoses that included Dementia (a condition which caused a decline in memory, reasoning, and other thinking skills), tremor (shaking), dizziness, and hypertension (high blood pressure- the force of blood pushing against the artery walls).A review of Resident 1's clinical record titled, Progress Notes, dated 5/27/25 at 10:37 p.m., written by the Licensed Nurse (LN) 1, indicated at approximately 5:00 p.m., Resident 1 was found outside by the physical therapy door by an activities team member.A review of Resident 1's clinical record titled, BRIEF INTERVIEW FOR MENTAL STATUS, (BIMS - a screening tool used to measure short term memory and orientation) dated 5/6/25, indicated Resident 1 had a BIMS score of 99 (99 was scored when the resident was unable to complete the interview).A review of Resident 1's care plan (a document that contained the resident's individualized problems, goals, and interventions) titled, I AM AN ELOPEMENT RISK, dated 8/20/24, indicated Resident 1's goal was to maintain safety through review date.During an interview with LN 2 on 7/17/25, at 2:42 p.m., LN 2 stated when Resident 1 eloped he was at risk of injury, such as being hit by a car, and/or getting lost.During an interview with the Assistant Director of Nursing (ADON) on 7/17/25, at 3:03 p.m., the ADON stated the physical therapy office back door did not have an alarm to alert staff when Resident 1 was found outside. The ADON further stated Resident 1 was not supposed to be in those rooms unattended and that therapy staff were responsible for the therapy room doors to be locked when not in use.During an interview with the Administrator (ADM) on 7/17/25, at 4:05 p.m., the ADM stated someone from the physical therapy department left the room unlocked, and it was her expectation that the physical therapy room was locked when not in use. The ADM further stated Resident 1 was a safety risk if left unattended because he could wander further away, get lost, or injured.A review of the facility's policy and procedure (P&P) titled, Resident Rights Policy and Procedure, dated November 28, 2016, was reviewed. The P&P indicated, .The resident has a right to a safe, clean, and comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety.

Based on observation, interview, and record review, the facility failed to ensure documentation and monitoring of temperature range in one out of one medication refrigerator for a period of 6 months with resident census of 63. This failed practice may have contributed to unsafe storage of refrigerated medication resulting in altered potency and unusable medications based on manufacturer specification. Findings: During a concurrent observation and interview on 3/18/25, at 9:20 AM, with Licensed Vocational Nurse (LN) 4, the refrigerator at North hall station stored multiple containers of flu vaccine (flu same as influenza, an infection affecting the breathing system), resident's insulin (medication used to treat blood sugar disease), other refrigerated prescription medications, and Emergency Kit (or Ekit, a sealed container containing insulin and other refrigerated products for urgent use). The thermometer inside the refrigerator was within the approved and safe temperature range (36-to-46-degree Fahrenheit [a measure of temperature]). LN 4 was unable to provide North hall station refrigerator temperature log documentation. During a concurrent interview with LN 3 and record review of facility's temperature log document (for North Hall), titled NOC log (NOC is night shift documentation), on 3/19/25, at 9:45 AM, the temperature log for March 2025 was only documented once on 3/18/25 at 11:30 PM. LN 3 stated the refrigerator temperatures were not logged since October of 2024 and prior to that the temperature was logged once a day that went as far as January of 2024. LN 3 further stated, if vaccines were stored in the refrigerator, the temperatures should have been monitored twice a day for safe vaccines storage. LN 3 stated the vaccine would not have been safe to administer if the temperature were not within the range as it was not monitored. During an interview with the Director of Nursing (DON), on 3/19/25, at 2:30 PM, the DON stated there was a misunderstanding with staff who were filling out only partial portions of the refrigerator temperature log. The DON stated refrigerator temperature should have been monitored twice a day for consistency for proper medication and vaccine storage. A review of the facility policy and procedure (P&P) titled, Storage of Medications, last revision date of April 2019, indicated, .drugs and biologicals used in the facility are stored in locked compartments under proper temperature . A review of the facility P&P titled, Pharmacy Services, last revised 2/19/20, indicated, .Medications are stored at appropriate temperatures .Medications requiring refrigeration are stored in a refrigerator at a temperature between 36 degrees Fahrenheit and 46 degrees Fahrenheit . Review of Center for Disease Control (CDC, a federal public health protection agency) guidelines on safe storage of vaccine, [last accessed on 3/24/25, via https://www.cdc.gov/vaccines/hcp/storage-handling/resources.html#cdc_listing_res6-vaccine-temperature-monitoring, and https://www.cdc.gov/vaccines/hcp/downloads/storage-handling-toolkit.pdf ], indicated, .Failure to store and handle vaccines properly can reduce vaccine potency, resulting in inadequate immune responses in patients and poor protection against disease .Proper vaccine storage and handling play critical roles in efforts to prevent vaccine-preventable diseases. Vaccines exposed to storage temperatures outside the recommended ranges may have reduced potency, creating limited protection and resulting in the revaccination of patients and thousands of dollars in wasted vaccine . The CDC document further indicated, .Keep your storage units and vaccines within the appropriate temperature ranges. Check and record storage unit min/max temperatures at the start of each workday. If your device does not display min/max temperatures, then check and record current temperature a minimum of 2 times (at start and end of workday) .

Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from verbal abuse for one of sixteen sampled residents (Resident 44) when, Resident 44 was cursed at by Licensed Nurse (LN) 5. This failure had the potential to cause emotional distress and could negatively affect Resident 44's psychosocial well-being. Findings: Review of Resident 44's ADMISSION RECORD, indicated Resident 44 was admitted with diagnoses including depression (mental health condition characterized by persistent feelings of sadness) and anxiety (persistent worry) disorders. Review of Resident 44's Minimum Data Set [an assessment tool], dated 2/4/25, indicated Resident 44's Brief Interview for Mental Status score was 13 out of 15 suggesting an intact cognitive functioning (a person's mental processes, including thinking, learning, memory, and reasoning, are functioning normally and without any significant impairment). Review of Resident 44's IDT [Interdisciplinary Team; a group of healthcare professionals] Note, dated 11/13/24, indicated, .On 11/1/2024 [Resident 44] notified SSD [social services director] that he had a complaint of CN [charge nurse; LN 5] who cursed at him a couple of days ago. Resident could notrecall [sic] what the disagreement was about. On the same day CN approached DON [director of nursing] stating she was not getting along with resident and that a couple of days ago resident was following CN and interrupting her conversations she was having with CNA [certified nursing assistant], CN stated she tried to redirect him, and resident was angry and cursing at CN .CN then talked to SSD, asking resident not to bother CN during her shift .On 11/7/2024- A CNA notified DSD [director of staff development] that she had heard CN on 11/1/2024 telling another CNA that she cursed at the resident . During a concurrent observation and interview on 3/20/25, at 1:33 p.m., with Resident 44 in his room, Resident 44 stated he did not have any disagreement with any staff member and stated he felt safe in the facility and had been cared for. Resident 44 stated he did not want to answer any further questions. During a concurrent interview and record review on 3/20/25, at 3:04 p.m., with the Administrator (ADM) and Director of Nursing (DON), Resident 44's [Facility name] FACILITY EVENT REPORT [a detailed report regarding the investigation of the incident], dated 11/8/24, was reviewed. In the section of the facility event report titled, Describe Incident ., indicated, .the Social Services Director .notified the Administrator that [Resident 44] complained this morning about [LN 5] cursing at him a couple of days prior, saying I don't give a fuck at the end of a disagreement [LN 5] and [Resident 44] had. When [name of the SSD] had asked [Resident 44] what the disagreement was about, [Resident 44] could not remember .On the following Thursday afternoon, 11/7/24, a CNA confided to the DSD that she heard [LN 5] on 11/1/24 telling another CNA that she had told [Resident 44] to fuck off . The ADM explained, LN 5 admitted to Certified Nurse Assistant (CNA) 1 that she was working with at the time of the incident that LN 5 had used foul language toward Resident 44. The ADM stated, while LN 5 was explaining the events that had happened, CNA 2 had heard LN 5 admitting what she had done. The ADM further explained no staff had witnessed the disagreement between LN 5 and Resident 44. Further review of the facility event report in the section titled, What is the outcome?, indicated, .Through record review and interviews, it can now be substantiated that [LN 5] used a curse word in her interaction with [Resident 44]. Because of [Resident 44's] past propensity for using that sort of language toward staff and becoming demanding when patience is required, it was believed that there was a disagreement between [Resident 44] and [LN 5] and that [Resident 44] needed a break from [LN 5] providing care for him; however, with other staff reporting [LN 5's] admission to using that language with [Resident 44], though denying it when asked, [LN 5] will not be returning to work at [facility name] . During an interview on 3/21/25, at 10:05 a.m., the DON stated verbal abuse could have a negative effect on residents. The DON stated the residents should feel safe and comfortable in their own home and the facility was their home. The DON further stated verbal abuse could affect the residents psychologically, emotionally, and could manifest physical symptoms such as increased blood pressure and increased breathing. The DON stated residents needed to feel safe in the facility. Review of the facility's policy and procedure titled, Freedom from Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Policy and Procedure, revised 3/8/24, indicated, .Each resident has the right to be free from abuse .VERBAL ABUSE: Verbal abuse includes the use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families. This would include use of swear words, making demeaning remarks about a person's appearance or use of such slang expressions such as shut up or be quiet .All residents of [facility name] shall be free from verbal, mental, sexual, physical abuse .Residents must not be subjected to abuse by anyone, including, but not limited to facility staff .

F323 - Free Of Accident Hazards/supervision/devices - 42 CFR 483.25(h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.This citation was written as a result of an unannounced visit on 9/22/11 to investigate complaint number CA 318, a facility reported incident. The Department determined the facility failed to ensure Resident 1's sling was in good condition and securely attached to the mechanical lift prior to and during her transfer from the wheelchair to the bed resulting in her fall from the lift and a prolonged hospitalization and surgery. Resident 1 was a [AGE] year old admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. The lift was a manually operated lift that utilized a sling placed under the resident. The sling was then secured to the bars of the lift by four sling attachment clips. The resident was then lifted and transferred to another surface. On 6/14/10 Resident 1 was being transferred between the wheelchair and the bed by Certified Nurse Assistant (CNA) 1. A front clip on one corner of the sling used to transfer her became dislodged causing Resident 1 to fall to the floor. She landed in a face down position. Manufacturer guidelines, dated November 2005, for the use of the lift slings were reviewed. Number 2 under "During use" directs, "Always check that the sling attachment clips are fully in position before and during the commencement of the lifting cycle, and the tension as the resident's weight is gradually taken up."Licensed Personnel Weekly Progress Notes, dated 6/14/10 at 10:10 a.m., revealed Licensed Nurse (LN) 1 was "called into Residents room by CNA. During transfer out of bed Resident fell forward onto floor. Is alert answering questions appropriately. (Complained of) neck discomfort. Able to move all extremities. (Central Nervous System) good. Abrasion top (left) foot & lateral left ankle. Bruise top (left) foot. Stabilized her neck & log rolled onto her back. (Physician) notified. New order received & noted to transfer to (emergency room ) for evaluation. RN nursing supervisor notified. Notified (family member) per resident's request."Paramedics transferred Resident 1 to the acute care hospital emergency department. She arrived at the hospital at 11:20 a.m. on 6/14/10. The Emergency Department Chart indicated she complained of neck pain, right knee pain, and left ankle pain. She denied having a headache. There was no change in her level of consciousness. She had bilateral upper extremity contractures with the ability to use her hands. It was determined Resident 1 sustained a fracture to her spine at the second cervical vertebra - C2 (neck area of the spine) and an odontoid process fracture. The odontoid process is a tooth like upward projection at the back of the C2 vertebra. The odontoid process serves as the pivot point for turning the head. Resident 1 also sustained upper rib fractures and a fracture of her right femur (long bone of the upper leg) which required surgical repair.A CT scan of the cervical spine was completed on 6/14/10 at 12:55 p.m. The impression of the scan indicated, "There is a fracture involving the body of C2 with mild retropulsion (pushing) into the spinal canal. There is no (spinal) cord compression." A History and Physical, dated 6/14/10, indicated Resident 1 was admitted to the Neurological (Neuro) Intensive Care Unit of the hospital. According to the History and Physical, Resident 1 "has become hypotensive (low blood pressure) and has had (oxygen saturations) decreased into the 70s (normal is 90 - 100). She has been placed on nonrebreather mask (oxygen delivery mask that prevents rebreathing of exhaled air) and she is getting fluid boluses and (IV medication) therapy to stabilize her." A Progress Record, dated 6/15/10 at 8:30 a.m., had notations from the neuro physician. He reviewed the C-spine (neck, site of C2 injury) films and noted, "Although (fracture) is unstable some, will not require surgery." A Progress Record, dated 6/16/10 at 6 a.m., indicated Resident 1 required two units of blood because of low hemoglobin (red blood cells). A chest x-ray was taken on 6/24/10 which revealed a mild pleural effusion (an abnormal, excessive collection of fluid in the sack surrounding the lungs) with some atelectasis (partial collapsed lung). She became short of breath and was placed back on oxygen. She was started on antibiotics for pneumonia. Surgery had been scheduled for 6/24/10 to repair her femur fracture, but was cancelled due to her unstable medical condition at that point in time. Resident 1 was finally able to have surgical repair of her right leg on 6/30/10, 16 days after the fracture occurred. She had been medically unstable for surgery during the 16 days. A Discharge Summary from the acute care hospital, dated 7/5/10, indicated Resident 1 had final [DIAGNOSES REDACTED]. Resident 1 was discharged from the acute care hospital on [DATE].CNA 1 was interviewed on 6/15/10 by LN 2. In a written statement by LN 2, she indicated, "CNA 1 had the resident up in the total lift and was in the process of moving her to transfer her to the bed when she fell forward onto the floor. When (CNA 1) was asked how it happened, she stated she didn't know. When questioned further about details she stated that one of the front clips came off and the resident fell forward." In a second written statement by LN 2, dated 6/15/10, she indicated, "(CNA 1) verbalized to (LN 2) her knowledge of the correct way to attach total lift slings to the total lifts. However, she was visibly shaken and could not recall whether she heard them snap into place or not. (CNA 1) stated that the resident had been up in the sling for a while without any problems noted and then when she went to move the lift the resident fell forward out of it. She was not sure how it occurred but stated that one of the front clips had somehow detached and the resident fell forward." An Incident Description Form was completed by the representative from the lift company. The lift was inspected by the representative on 6/16/10. Under the section for Device Examination, he indicated the lift was in "good condition"; however, "The accessory sling that I saw and was told was in use at the time of the incident was in very poor condition, it was very worn and had stitching coming out." He also indicated, "The lifter seems to be functioning without any problem that I could see; however, the sling that was allegedly used at the time of the incident has a clip time stamp of 4/99. The sling appears to me to be very old and in an unsafe condition."An interview was conducted with the Director of Nursing (DON) on 6/15/10 at 11:59 a.m. She stated the sling "came undone...not too sure why." She stated the mechanical lift was operational. The sling used with Resident 1 "showed some wear" around the edges. It was immediately removed from use. An interview was conducted with the DON on 9/22/11 at 1:45 p.m. She stated prior to the accident all the slings were to be replaced. Resident 1 "preferred" the older sling and one was kept in the drawer at her bedside. She stated while CNA 1 was transferring Resident 1 from her bed, the strap "somehow came off and she fell ." She stated Administrative staff "did not know the sling was still being used." The Department determined the facility failed to ensure Resident 1's sling was in good condition and securely attached to the mechanical lift prior to and during her transfer from the wheelchair to the bed resulting in her fall from the lift and a prolonged hospitalization and surgery. These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom.