Every finding on record at Brookside Care Center

Based on interview, and record review, the facility failed to provide a safe discharge for two of three sampled residents (Resident 1, and Resident 2) who were given a notice of transfer (a formal written communication required when a nursing home or long-term care facility moves a resident to a different location or discharges them) when:1.There was no documentation in Resident 1's electronic medical record for a discharge plan that included if Resident 1's outpatient services were being arranged or obtained prior to being discharged from the facility, and;2. There was no documentation in Resident 2's electronic medical record that indicated Resident 2's health had improved and no longer required care and services provided by the facility.These failures had the potential to result in Resident 1 and Resident 2 being unsafely discharged to another location or did not meet their treatment plan goals. These failures also placed Resident 1 and Resident 2 at risk for psychosocial harm, injury, hospitalization, and possibly death.Findings:1. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses including cirrhosis of the liver (permanent scaring of the liver tissue that replaces healthy cells and blocks normal blood flow), presence of cardiac pacemaker (a small battery-powered medical device implanted under the skin to help regulate a slow or irregular heartbeat), psychoactive substance abuse (using mind-altering chemical substance in a way that harms health, causes social or professional problems, or leads to loss of control), type 2 diabetes mellitus (a long-term medical condition where the body does not make enough insulin or cannot use it the right way), and hypertensive heart (structural and functional heart damage cause by long-term unmanaged high blood pressure).A review of Resident 1's Minimum Data Set Record (MDS, a resident assessment tool used to guide care) dated 5/21/26, indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status exam (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, ability to register and recall information. A BIMS score of 13 to 15 is an indication of intact cognitive status).During a concurrent interview and a record review on 8/28/26, at 10:51 a.m., with the Assistant Director of Nursing (ADON), Resident 1's electronic medical record (EMR) was reviewed. The ADON confirmed a notice of transfer was provided to Resident 1 on 6/26/26. The ADON confirmed there was no discharge planning process documented in Resident 1's EMR and that Social Services did not set up home health nurse visits prior to and after the notice of transfer was given to Resident 1. The ADON further stated that nursing staff and Social Services should have taken steps to make sure the discharge was safe for Resident 1. The ADON explained there should have been a collaborative discussion between all the Interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) members. The ADON stated if proper discharge planning was not done, there was a risk that Resident 1 would return right back to the facility. The ADON further stated the facility should have considered Resident 1's past medical history and present condition during the discharge planning process. 2. A review of Resident 2's admission RECORD, indicated Resident 2's was admitted to the facility in 2026 with diagnoses including unsteadiness on feet (off balance, wobbly when standing or walking), repeated falls, depression (a common serious mood disorder that causes a persistent feeling of sadness and loss of interest in life), other symptoms and signs involving the musculoskeletal system (physical difficulties and limitations).A review of Resident 2's Minimum Data Set Record, dated 6/17/26, indicated Resident 2 had an intact cognitive status with a BIMS score of 14.During a concurrent interview and a record review on 8/28/26, at 10:51 a.m., with the ADON, Resident 2's EMR was reviewed. The ADON confirmed a notice of transfer was given to Resident 2 on 6/9/26.During an interview on 8/28/26, at 2:20 p.m., with Resident 2, in his room, Resident 2 stated the facility gave him a notice of transfer couple months ago, but he appealed and won. Resident 2 further stated he had told the facility he did not want to live with multiple people or at board and care, and that he wanted to live in an apartment. During a concurrent interview and a record review on 8/28/26, at 4:10 p.m., with the ADON, Resident 1 and 2's EMR were reviewed. The ADON confirmed she did not see a physician order in Resident 2's EMR to be discharged . The ADON further confirmed she did not see any notes from the physician that indicated Resident 2's health had improved and no longer required care and services provided by the facility. The ADON stated Resident 1 still required custodial care (non-medical assistance with basic everyday tasks that a person can no longer do safely on their own) while at the facility. A review of facility's policy and procedure (P & P) titled, Discharge Planning Process, dated 2025, indicated, .It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions.1. The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge.3. If discharge to community is determined to not be feasible, the facility will document in the clinical record who made the determination and why.4. In cases where the resident wishes be discharged to a setting that does not appear to meet his or her post discharge needs, or appears unsafe, the interdisciplinary team will treat this situation similarly to refusal of care.a. Discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location.b. offer other, more suitable, options of locations that are equipped to meet the needs of the resident. Document any discussions related the options represented.5. If discharge to community is a goal, an active discharge care plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative. The plan shall be documented in (list facility-specific form, comprehensive care plan, etc.).6. An active discharge care plan will address, at a minimum: a. Discharge destination, with assurances the destination meets the resident's health/safety needs and preferences. b. Identified needs, such as medical, nursing, equipment, educational, or psychosocial needs.c. Caregiver support person availability and the resident's or caregiver's/support person's capacity and capability to perform required care.7. The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modification.

Based on observation, interview, and record review, the facility failed to protect two of two resident's (Resident 1 and Resident 2) right to be free from physical abuse by a resident when, Resident 3, who had a history of known violent behaviors, entered the common area of the facility and pushed Resident 2 on 8/11/26 and on 8/12/26 walked up to Resident 1, slapped her on the face and pushed her to the ground.This failure resulted in Resident 1 feeling angry about the incident and Resident 2 sustaining bruising, pain, and a fracture (broken bone) of her right arm. As a result of the injuries Resident 2 required one person assistance for activities of daily living (ADL's- the basic, everyday self-care tasks you need to do on your own to live safely and independently) from her prior functional level of independence and has been unable to participate in activities she enjoyed participating in previously.Findings:1. A review of a document titled, admission RECORD indicated Resident 2 was admitted with medical diagnosis including depression (persistent feeling of sadness) and unsteadiness on the feet.Review of Resident 2's Minimum Data Set (MDS, an assessment tool), Brief Interview for Mental Status (BIMS), dated 6/18/26, indicated Resident 2 had a BIMS score of 14 which indicated intact cognition (a person's mental thinking abilities are fully functional, undamaged, and operating normally for their age; the assessment uses a points system that ranges from 0 to 15 points, 0 to 7 points suggests severe cognitive impairment, 8 to 12 points suggest moderate cognitive impairment, and 13 to 15 points suggest that cognition is intact).During an interview on 8/18/26 at 1:18 PM, Resident 2 stated he remembered the recent incident when Resident 3 pushed him but was not bothered by this incident as much as he was the previous attack in the earlier part of 2026 from Resident 3. Resident 2 explained, during the previous attack, Resident 3 hit him on the head multiple times with a ring-wearing fist, causing scalp punctures, bleeding, and painful scabs lasting several weeks. Resident 2 stated the incidents made him angry and frustrated that nothing legally could be done to Resident 3 because of his mental state.During an interview on 8/21/26 at 12:02 PM, Certified Nursing Assistant (CNA) 2 stated on the evening of 8/11/26 she observed Resident 2 walking towards the common area where Resident 3 was standing. CNA 2 stated she asked Resident 2 to avoid Resident 3 because they have a history of violent physical altercations, however CNA 2 stated she did not think Resident 2 heard her request. CNA 2 stated that Resident 2 walked by Resident 3, Resident 3 then pushed Resident 2 hard in the back; Resident 2 turned and asked Resident 3 why he hit him. CNA 2 further stated, although Resident 2 was pushed hard by Resident 3, Resident 2 did not fall because he was using a wheelchair as a walker. CNA 2 stated after the incident she checked on Resident 2, and he stated he was fine and went outside to smoke his cigarette. CNA 2 stated she reported this incident and both residents' history to the nurse on duty. CNA 2 then explained she was a witness to the previous incident between both Resident 2 and Resident 3 before, and Resident 3 was the aggressor and punched Resident 2 in the head until blood was drawn.During an interview on 8/26/26, at 10:14 AM, the Medical Doctor (MD) stated he does not remember being notified of the incident on 8/11/26 between Resident 2 and Resident 3 and if it was not documented he most likely was not notified. The MD stated if he was notified, he would have requested labs to make sure there was nothing physiologically (in the body) going on and would have been able to make some medication changes for Resident 3.A review of Resident 3's clinical record document titled, Progress Notes, dated 8/11/26, indicated, [Resident 3] was aggressive around 0400 [4 AM] and verbally abusive towards staff. Resident also pushed another resident [Resident 2] while he was trying to get out the courtyard door with his walker.A review of Resident 3's clinical record document titled, Care Plan Report, dated 1/10/26, indicated, .Patient has Episodes of verbal Aggressions. An additional care plan in Resident 3's clinical record, dated 8/10/26, indicated, .Resident had episode of sudden angry outburst.A review of Resident 3's clinical record titled, Progress Notes, dated 4/3/26, at 10 AM, indicated, Resident 3 was in an aggressive physical altercation with another Resident. Resident 3's progress note written on 6/21/26, at 2:43 PM, indicated, . Pt [patient] was noted to be physically and verbally aggressive during the AM shift .Resident also kicked a staff member. in chest, was being aggressive towards nursing staff stating Watch what I'm going to do to you, I am going to fuck you up. A review of Resident 3's progress notes indicated on 8/4/26 at 6:05 PM, Resident 3 was involved in another Resident-to-Resident altercation. Progress notes on 8/9/26 at 12:30 PM indicated, .Resident was agitated this morning and had a verbal altercation with another resident.2. A Review of a document titled, admission RECORD indicated Resident 1 was admitted to the facility with medical diagnosis of, but not limited to, difficulty in walking, dementia without behavioral disturbance (decline in thinking and memory skills that affects daily life, but without aggressive, agitated, or disruptive behavioral change), and depression. Review of Resident 1's MDS, BIMS, dated 5/5/26, indicated Resident 1 had a BIMS score of 7 which indicated she had severe cognitive impairment (major loss of mental capacity that prevents a person from living independently or caring for themselves safely).During concurrent observation and interview on 8/18/26 at 2:09 PM, with Resident 1, in Resident 1's bedroom, Resident 1 was observed sitting in a semi-Fowlers (35-degree angle) position in bed with her body leaning more to the right side in her bed. Resident 1's right arm exhibited discoloration, presenting as black and dark blue, accompanied by noticeable swelling. Resident 1 guarded her arm with her left arm and slightly hovered over that arm while her right arm lay on her lap without a sling. Resident 1 stated, about a week and a half or two weeks ago a guy here threw me to the ground and punched me a few times. Resident 1 further stated Resident 3 tried to throw her under the desk but the staff in the facility stopped him and that she was unable to move her arm because it hurt so bad. Resident 1explained the pain in her right arm went from the back of her head to her right shoulder down her right arm and to her fingertips. Resident 1 stated her pain was currently a 10 out of 10 on a pain scale (A pain rating scale used to determine the level of pain and scored on a scale of 0-10 with 0 being 'no pain' and 10 being the 'worst pain').During a concurrent observation and interview on 8/18/26 at 2:13 PM, in Resident 1's bedroom, Licensed Nurse 1 stated Resident 1's right arm was fractured when she was pushed by Resident 3 on 8/12/26. LN 1 described Resident 1's right arm as being black and blue with multiple skin tears and swelling. During the observation Resident 1 informed LN 1 that she had 10 out of 10 pain and that the pain radiated to her fingertips and up to the back of her head. Resident 1 was observed rocking back and forth. Resident 1 stated she rocked to distract herself from the pain because the pain had been bad. LN 1 stated Resident 1 had become more physically limited since the fracture occurred. LN 1 stated Resident 1 was previously independent for most of her care and because of the incident Resident 1 refused her scheduled showers stating that she had increased pain and discomfort. LN 1 left Resident 1's room and returned with a narcotic pain medication (powerful prescription drugs used to treat moderate to severe pain) to administer to Resident 1. During an interview on 8/20/26 at 12:22 PM, the Front Desk Personnel (FDP) stated she observed when the assault occurred on 8/12/26 between Resident 1 and Resident 3. The FDP stated Resident 3 walked by Resident 1 and asked her if she had a problem and Resident 1 stated, no I don't have a problem. The FDP stated Resident 3 continued to walk away from Resident 1 then suddenly stopped, turned around, and walked back to Resident 1. The FDP stated once Resident 3 approached Resident 1 he told her, You do have a problem, then he slapped Resident 1 on the face and then threw her on the ground. The FDP stated Resident 3 was about to kick Resident 1 while she was on the ground, but she was able to intervene. The FDP stated Resident 3 then turned his anger towards her and threw her against the front entry door multiple times before he exited the facility and staff followed behind him. The FDP stated when the assault occurred, Resident 3 did not have any staff with him to redirect or support him. The FDP stated, prior, Resident 1 used to sit next to her frequently by the front door, but since the incident, Resident 1 seemed more frustrated with herself and her new physical limitations and pain. The FDP stated Resident 1 appeared to get tired faster now than she did before the assault occurred.During an interview on 8/20/26 at 7:32 AM, Family Member (FM) 1 stated she visited Resident 1 daily and due to this incident, their visits had changed. FM 1 stated Resident 1 has since been in constant pain and no longer wants to leave her room. FM 1 stated they used to have lunch together in the dining room but Resident 1 did not want to go anymore. FM 1 stated Resident 1's entire arm is bruised, swollen, and remains broken because she had to see an orthopedic specialist (bone doctor). FM 1 stated Resident 1 told her that she was afraid that Resident 3 would come into her room and harm her. FM 1 stated since the incident she had observed Resident 3 still walking around the facility. FM 1 stated Resident 1 used to walk around the facility and did not hurt anyone but now she's in a wheelchair in pain with a broken arm. FM 1 stated that's just not fair that [Resident 3] gets to walk around normal and look at [Resident 1].During an interview on 8/19/26, at 11:46 AM, CNA 1 stated she had taken care of Resident 1 regularly prior to the assault. CNA 1 stated prior to the assault Resident 1 was able to walk around and was provided support on an as needed basis with limited assistance provided with ADL's. CNA 1 stated now that Resident 1 was unable to use her right arm she had become more dependent on the staff for assistance with her ADL's. CNA 1 stated Resident 1 needed assistance with bathing, showering, putting her clothing on and off, and other tasks that involve using her right arm. During an interview on 8/20/26, at 12:29 PM, the Activities Director (AD) stated since Resident 3 assaulted Resident 1, Resident 1's ability to participate in activities had decreased. The AD stated prior to the assault Resident 1 was active in activities and enjoyed the balloon toss, painting, coloring, and getting her nails done. The AD stated earlier that day she did Resident 1's nails in which different positions of painting her nails were attempted, and it was not enjoyable because Resident 1 stated she was in pain. The AD stated Resident 1's emotional impact had been significant, and that Resident 1 had noticeably shown increased sadness, agitation, and quick mood changes.During a concurrent interview and record review, on 8/19/26, at 3:47 PM, Resident 1's, Resident 2's, and Resident 3's Electronic Medical Records (EMR), were reviewed with the Director of Nursing (DON). The DON stated, on 8/12/26 at approximately 7 PM Resident 1 was assaulted by Resident 3. The DON stated after the assault Resident 1 complained of 10 out of 10 right shoulder pain. The DON stated Resident 1 was sent to the hospital and the hospital determined Resident 1's right arm was broken and provided Resident 1 with a brace to keep on until she was seen by an orthopedic surgeon. The DON stated Resident 1 returned to the facility on 8/13/26. The DON confirmed Resident 3's progress notes indicated Resident 3 had a history of physical abuse towards other residents in the facility. The DON reviewed Resident 2's and Resident 3's EMR and confirmed after Resident 2 was assaulted by Resident 3 on 8/11/26, there was no documentation in the record of the incident. The DON stated there was no change of condition documented, there was no staff Interdisciplinary Team Meeting (IDT- where different specialists meet about a resident's care and health) notes, no nursing progress notes, no social service notes, no record of a notification of the incident to the doctor, and there was no update or change to Resident 2's or Resident 3's care plans. The DON confirmed there was no IDT documentation in Resident 1's or Resident 3's chart following the abuse incident on 8/12/26. The DON stated after the incident on 8/11/26, between Resident 2 and Resident 3, the Medical Doctor (MD) was not notified regarding the incident. The DON stated this did not meet her expectations and stated the facility policy is that the MD is notified and this placed the residents at risk for delayed care. The DON stated the Social Services Director (SSD) did not see Resident 2 and Resident 3 after the incident on 8/11/26. The DON stated the risk of the SSD not visiting the residents after an incident occurred could result in the residents feeling worse emotionally and could result in symptoms of depression. The DON reviewed the care plans of Resident 1, Resident 2, and Resident 3 and confirmed abuse related care plans were not updated and/or created after the resident to resident incidents. The DON stated care plans were important individualized documents that identify the problems of the residents and how the facility will address those identified problems. The DON further stated the care plans address how the facility will help the residents to reach the goal as written.During a concurrent interview and record review, on 8/19/26 at 4:02 PM, Resident 3's progress notes were reviewed with the DON. The DON acknowledges Resident 3's previous known history of aggression towards residents and previous resident to resident altercations occurred on 4/3/36, 8/4/26, and 8/9/26, as well as an angry outburst on 8/10/26, then the abuse on 8/11/26 with Resident 2 and on 8/12/26 with Resident 1. During an interview on 8/20/26, at 10:17 AM, the DON stated that Resident 3 would get upset out of nowhere and the facility was unaware of what Resident 3's triggers were. The DON confirmed on 4/3/26 Resident 3 had an order from the MD to be monitored for physical behaviors towards staff and residents. The DON stated the facility reached out to a mental health agency (offers counseling, therapy, case management, and crisis response for adults with severe mental illness) to obtain services for Resident 3, but did not have documented evidence of the facilities attempt to provide this service to Resident 3. The DON stated she was not aware of what the facility did after each resident to resident incident (that occurred on 4/3/36, 8/4/26, and 8/9/26) because there was a lack of documentation in Resident 3's medical record. The DON stated, after the incident between Resident 3 and Resident 1 on 8/12/26, the facility placed Resident 3 on one-to-one supervision (one staff person assigned to be with Resident 3 at all times). During an interview on 8/20/26, at 11:04 AM, the Administrator in Training (AIT) stated she wished she had knew about the incident between Resident 2 and Resident 3 when it occurred on 8/11/26 because the facility could have implement a one-to-one intervention for Resident 3 before the incident occurred between Resident 3 and Resident 2 on 8/12/26. During an interview on 8/20/26, at 2:25 PM, the DON confirmed Resident 1 fell on 8/16/26 trying to get out of bed independently. The DON stated before this assault with Resident 3, Resident 1's bed mobility was independent and that she had no history of falls.During a concurrent interview and record review on 8/21/26 at 12:20 PM with the Social Services Director (SSD), the SSD stated after an abuse incident it was important for the residents to be seen by the social services department for the first 72 hours after the incident. The SSD stated the importance of the visit was to monitor behavioral changes and to assess for any referrals that may need to be initiated. The SSD added that these visits were important to ensure the residents feel safe in their environment. The SSD stated if the resident was not seen for the three visits in the 72 hours period post incident, the resident was at risk for psychosocial decline (the gradual loss of a person's ability to think clearly, manage emotions, and interact well with others). The SSD confirmed the social services department did not visit Resident 2 or Resident 3 at all after the abuse incident on 8/11/26. The SSD confirmed the social services department visited Resident 1 on day one and day two post abuse incident, but did not complete the third visit for Resident 1.A review of Resident 1's MDS, dated [DATE], in section GG- Functional Abilities, indicated, Resident 1 had no impairment in her upper extremities (arms) including her shoulder, elbow, wrist, and hand. The record also indicated Resident 1 did not use any mobility devices and Resident 1 needed either set up assistance or supervision assistance with her activities of daily living such as: eating, oral care, toileting, bathing, and upper and lower body dressing. A review of Resident MDS section J pain management indicated Resident 1 did not need pain management. A review of a document in Resident 1's clinical record of the nursing assistant documentation of the ADL care provided to Resident 1 throughout the day for the month of August 2026, indicated Resident 1's ADL care had increased since the assault. Resident 1 needed set up or clean up assistance only with dressing prior to 8/12/26 and post 8/12/26 Resident 1 was documented as being dependent or needing maximal substantial assistance (helper provides more than half of the effort) with occasional partial moderate assistance (helper provides less than half of the effort).A record review in Resident 1's clinical record titled, Care Plan Report, dated 8/19/26, indicated, .Resident has declined in ADL performance, related functional mobility [ability to move independently and safely through their environment to perform everyday tasks], balance, strength, and safety awareness. An additional care plan for Resident 1, dated 8/12/26, indicated, .Resident has 10/10 acute [short and sudden] right shoulder pain r/t [related to] Fall after push by another resident. A third care plan for Resident 1, dated 8/13/26, indicted, .Impaired mobility of right upper extremity [right arm] related to fracture, requiring sling immobilization [a fabric support or bandage suspended from the neck or shoulders to restrict the movement of an injured arm]. Resident 1's fall care plan, dated 8/16/26, indicated, .The resident is at risk for falls r/t Gait/balance problems [ physical conditions that disrupt your natural way of walking and your ability to stay upright] d/t [due to] weakness.A review of Resident 1's document from the hospital titled, [Acute Care Facility Name] Hospital ED [emergency department] note-physician [doctor], dated 8/12/26, indicated, .Chief Complaint: patient was involved in a physical altercation, was pushed, fell, +head -strike [head hit a surface].possible dislocation [a joint injury where the bones are forced out of their normal positions].The patient currently reports pain to the right shoulder and right upper arm, a headache and mild nausea [stomach upset].decreased range of motion to the right arm secondary to pain.Imaging: CT [Computed Tomography- imaging of inside of the body] scan of chest showed Fracture [broken] of the right humeral head and neck [upper arm bone] .During a review of an undated facility P&P titled, Resident Rights, the P&P indicated, .The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The resident has the right to a dignified existence, self-determination.During a review of an undated facility P&P titled, Abuse, Neglect and Exploitation, the P&P indicated, .It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Abuse means the willful inflection injury.resulting in physical harm, pain, or mental anguish which can include.resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse.Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Serious Bodily Injury means an injury involving extreme physical pain; involving substantial risk of death involving protracted loss or impairment of the function of a bodily member. requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to.Increased supervision of the alleged victim and residents.Provide emotional support and counseling to the resident during and after the investigation.Revision of the resident's care plan.

Based on observation, interview, and record review, the facility failed to implement care plan measures for three of four residents (Resident 2, Resident 3, and Resident 4) when:1. An abuse/behavior care plan was not created for Resident 2 or Resident 3 after Resident 3 assaulted Resident 2 on 8/11/26; and2. A transfer/discharge care plan was not created for Resident 4.This failure had the potential to place Resident 2 at risk for repeated abuse and emotional distress, Resident 3 at risk for emotional dysregulation, and Resident 4 at risk for an unsafe discharge.Findings:1. Review of Resident 2's admission RECORD indicated that Resident 2 was admitted with medical diagnosis including, but not limited to: depression (persistent feeling of sadness) and unsteadiness on the feet.Review of Resident 3's admission RECORD indicated Resident 3 was admitted to the facility with medical diagnosis including, but not limited to: severe dementia (the final stage of brain decline where a person loses all ability to care for themselves), chronic kidney disease (kidneys damaged and unable to filter), and generalized anxiety disorder (constant overwhelming fear and nervousness).During a concurrent interview and record review on 8/19/26 at 3:10 PM, with the Director of Nursing (DON), a review of Resident 2's and Resident 3's care plans were reviewed. The DON confirmed that both Resident 2 and Resident 3 did not have an abuse care plan related to the abuse incident that occurred on 8/11/26. The DON stated during the incident on 8/11/26 Resident 3 pushed Resident 2 on his back. The DON stated the development of a care plan was important to develop and identify individualized problems. The DON stated the care plans were important to help the residents reach their goals and if not implemented the residents were at a risk that the facility may not be able to provide the necessary support and treatments the residents needed. The DON stated her expectations were for the nurses to implement a care plan as the incident occurs and upon admission.2. A review of Resident 4's admission RECORD indicated that Resident 4 was admitted to the facility with the diagnosis including, but not limited to; chronic respiratory failure with hypoxia, diabetes mellitus (DM-too much sugar in the blood stream), hypertension (HTN- high blood pressure), hyperlipidemia (HLD- elevated levels of fat in the bloodstream), atherosclerotic heart disease (when the blood vessels become thick and stiff), and unsteadiness on the feet.During a concurrent interview and record review on 8/19/26 at 12:52 PM, Resident 4's NOTICE OF TRANSFER/DISCHARGE, dated 6/18/26, and Resident 4's care plans were reviewed with the DON. Resident 4's transfer notice indicated that Resident 4 was planned to be discharged from the facility on 7/16/26. The DON acknowledged Resident 4 did not have a discharge care plan. The DON stated the importance of a discharge care plan for Resident 4 was to ensure she had everything she needed prior to discharge and all of her supportive devices sent to her destination prior to her arrival. The DON stated the care plan played an essential role in Resident 4 to arrive and function safely in a new location. The DON stated it was important for Resident 4 to be involved in her discharge care plan beginning the day she arrived in the facility. The DON confirmed there was no documentation in Resident 4's clinical record of her being collaboratively involved in her discharge care. A record review of an undated facility provided policy and procedure titled, Comprehensive Care Plans, indicated, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.The comprehensive care plan will describe, at minimum, the following. The resident's goals for admission, desired outcomes, and preferences for future discharge . Discharge plans . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly.assessment.The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

Based on interview and record review, the facility failed to ensure an allegation of physical abuse was reported to the Department within 2 hours for two out of three sampled residents (Resident 2 and Resident 3), when Resident 3 pushed Resident 2 on 8/11/26 and the resident to resident incident was not reported to the Department until 8/12/26, which exceeded the 2-hour abuse reporting requirement.This failure delayed the investigation of the abuse, immediate protection of Resident 2, and placed Resident 2's physical safety at risk. In addition this failure placed Resident 2 and Resident 3 at risk for psychosocial decline.Findings:During an interview on 8/18/26 at 1:18 PM, Resident 2 acknowledged the recent incident on 8/11/26 when he was pushed by Resident 3. Resident 2 stated that he was upset that due to Resident 3's mental state he could not be held accountable for his actions. Resident 3 began to further discuss another incident when he was attacked by Resident 3 in the past. During an interview on 8/21/26 at 12:02 PM, Certified Nursing Assistant (CNA) 2 stated on the evening of 8/11/26 she observed Resident 2 walking towards the common area where Resident 3 was standing. CNA 2 stated she asked Resident 2 to avoid Resident 3 because they have a history of violent physical altercations, however CNA 2 stated she did not think Resident 2 heard her request. CNA 2 stated that Resident 2 walked by Resident 3, Resident 3 then pushed Resident 2 hard in the back. CNA 2 stated Resident 2 turned and asked Resident 3 why he hit him. CNA 2 further stated, although Resident 2 was pushed hard by Resident 3, Resident 2 did not fall because he was using a wheelchair as a walker. CNA 2 stated after the incident she checked on Resident 2, and he stated he was fine and went outside to smoke his cigarette. CNA 2 stated she reported this incident and both residents' history to the nurse on duty. CNA 2 then explained she was a witness to the previous incident between both Resident 2 and Resident 3 before, and Resident 3 was the aggressor and punched Resident 2 in the head until blood was drawn.During a telephone interview on 8/21/26 at 8:14 AM, with Licensed Nurse (LN) 2, LN 2 stated on 8/11/26 the nursing assistant for Resident 2 and Resident 3 informed her that Resident 3 pushed Resident 2. LN 2 stated she was advised by a senior colleague and other coworkers to just write a progress note on what happened. LN 2 stated she was not aware that it needed to be reported any further than the progress noted.During a concurrent interview and record review on 8/18/26 at 12:52 PM, with the Director of Nursing (DON), the DON stated the abuse between Resident 2 and Resident 3 was discovered during a chart audit and that is when the abuse was reported to the department. The DON stated her expectations of the nurses was to complete the facility abuse process including notifying the ombudsman, police, and the departments listed. The DON stated the risk to the residents of not following the facility's abuse process is delayed care. The DON stated this did not meet her expectations and the process of the facility. The DON stated that when an abuse is not reported in a timely manner the victim can get worse emotionally and go through extreme sadness. The DON stated the aggressor could also get worse as well. The DON added if the abuse is not reported properly the support needed for the resident's involved cannot be provided by the facility.During a review of the facility's undated policy and procedure titled, Abuse, Neglect and Exploitation., indicated, .It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies.Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.

Based on interview and record review, the facility failed to report a change of condition (COC, a change in the resident's normal physical, mental, or behavioral state) for two of three sample residents (Resident 2 and Resident 3) to the medical doctor (MD) when Resident 3 pushed Resident 2 on his back on 8/11/26.These failures eliminated the opportunity for the MD to participate in decisions regarding Resident 3's care prior to him assaulting another resident on 8/12/26 and prevented Resident 3 from being assessed for the necessary support.Findings:During an interview on 8/21/26 at 12:02 PM, Certified Nursing Assistant (CNA) 2 stated on the evening of 8/11/26 she observed Resident 2 walking towards the common area where Resident 3 was standing. CNA 2 stated she asked Resident 2 to avoid Resident 3 because they have a history of violent physical altercations, however CNA 2 stated she did not think Resident 2 heard her request. CNA 2 stated that Resident 2 walked by Resident 3, Resident 3 then pushed Resident 2 hard in the back. CNA 2 stated, Resident 2 turned and asked Resident 3 why he hit him. CNA 2 further stated, although Resident 2 was pushed hard by Resident 3, Resident 2 did not fall because he was using a wheelchair as a walker. CNA 2 stated she reported this incident to the charge nurse.During a telephone interview on 8/21/26 at 8:14 AM, with Licensed Nurse (LN) 2, LN 2 stated on 8/11/26 the nursing assistant for Resident 2 and Resident 3 informed her that Resident 3 pushed Resident 2. LN 2 stated she was advised by a senior colleague and other coworkers to write a progress note on what occurred and nothing further was needed. LN 2 stated she was not aware that the MD needed to be notified. LN 2 stated her training focused on blatant abuse when people were physically harmed and because in her observation Resident 3 was not physically harmed, she did not feel the need to do anything further. During a concurrent interview and record review on 8/18/26 at 12:52 PM, with the Director of Nursing (DON), the DON stated this abuse (resident to resident altercation between Resident 2 and Resident 3 on 8/11/26) was discovered during a chart audit. A concurrent review of Resident 3's progress note written on 8/11/26 at 6:54 AM, indicated that Resident 3 pushed Resident 2 at 4 AM on 8/11/26. The DON confirmed there was no indication that the doctor was notified of this incident between Resident 2 and Resident 3. The DON stated her expectation of the nurses was to notify the MD is there was any form of abuse. The DON stated the risk to the residents of not informing the MD would be delayed treatment and a missed opportunity to stop the behavior right away. The DON stated this did not meet her expectations and the process of the facility.During a concurrent interview and record review on 8/26/26 at 10:14 AM, with the MD, the MD stated he did not remember being notified of the incident between Resident 2 and Resident 3 that occurred on 8/11/26 and if it was not documented that he was notified, then he was not notified. The MD stated if he was notified of the incident, he would have ordered labs to be drawn on Resident 3 to rule out the possibility of an infection and would have been able to make some medication changes to support Resident 3 to possibly decrease his agitation and further aggression. The MD stated he should have been notified of Resident 3's continued agitation. The MD stated the staff should have contacted him when Resident 3's agitation was uncontrollable. During a review of an undated facility provided policy and procedure titled, Notification of Changes. indicated, The purpose of this policy is to ensure the facility promptly informs the resident, consults the residents physician.when there is a change requiring notification.Circumstances requiring notification include.Circumstances that required a need to alter treatment.this may include: New treatment.

Based on interview and record review, the facility failed to ensure the discharge planning process was properly followed for one of one sampled resident (Resident 4) when, the facility failed to provide sufficient preparation and orientation for Resident 4 to ensure a safe and orderly transfer and discharge from the facilityThis failure resulted in Resident 4 being at risk for an unsafe discharge and becoming anxious and scared of her future living situation. Findings:Review of Resident 4's admission RECORD, indicated Resident 4 was admitted to the facility with diagnosis including; chronic respiratory failure with hypoxia, diabetes mellitus (DM-too much sugar in the blood stream), hypertension (HTN- high blood pressure), hyperlipidemia (HLD- elevated levels of fat in the bloodstream), atherosclerotic heart disease (when the blood vessels become thick and stiff), and unsteadiness on the feet. Review of Resident 4 ' s Order Summary Report, dated 8/20/26, indicated the Resident 4 could understand her rights, responsibilities, and informed consent. Review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 7/2/26, indicated Resident 4 ' s cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. Resident 4's MDS further indicated Resident 4 needed substantial assistance/maximal assistance (helper does more than half of the effort), with toileting, upper and lower body dressing, putting on and taking off footwear, transferring in and out the shower, and with personal hygiene. Resident 4's MDS further indicated Resident 4 needed partial/moderate assistance (helper does less than half the effort), with sit to lying, roll left and right, lying to sit on side of bed, sit to stand, chair to bed transfer and toilet transfer. Resident 4's MDS indicated Resident 4's mobility was dependent on a wheelchair.During an interview on 8/18/26 at 2:33 PM, with Resident 4, Resident 4 stated in the middle of June of this year (2026) the facility issued her a document informing her that she had 30 days to relocate from the facility. Resident 4 stated when she received that document, she was surprised and shocked because she felt like she had not recovered enough to be discharged from the facility. Resident 4 stated she was unable to assist herself with activities of daily living (ADL)'s such as using the restroom without moderate assistance and bathing. Resident 4 stated she was not properly assessed by the physical therapy department, and the medical doctor had not assessed her prior to deciding if she was adequate to be discharged . During a concurrent interview and record review on 8/18/26 at 12:52 PM, with the Director of Nursing (DON), Resident 4's document titled, NOTICE TO TRANSFER/DISCHARGE, dated 6/16/26, indicated, Resident 4 was to be discharged with the effective date of 7/16/26. The DON confirmed this document was given to Resident 4 by the facility. The indication of discharge on this documented stated, .The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer require services provided by the facility. The DON confirmed there was no documentation of Resident 4 being assessed or evaluated by the medical doctor for discharge before or after the issuance of the notice of transfer/discharge issued to Resident 4. The DON confirmed Resident 4 did not have a discharge care plan in her clinical record. The DON confirmed the facility did not have an Interdisciplinary Team Meeting (IDT- a group of different medical and support staff who work closely together to create one unified care plan for a resident) for Resident 4's discharge or transfer plans from the facility. The DON confirmed there was not any documentation about the orientation and preparation process of Resident 4's discharge location and plans in Resident 4's electronic medical record (EMR). The DON stated the importance of initiating the discharge process according to the facility policy was to make sure that the facility was providing the residents with everything they needed to have a safe discharge and function at their new location. The DON stated it was important to have the residents involved in the decision-making process of the discharge so they could be aware of the process and goals as the discharge approaches. The DON stated the facility's discharge process started when the residents were first admitted to the facility. The DON stated the facility practice was to discuss the resident's goals, support system, and planned location of discharge upon admission. A record review of an undated facility provided document titled, Transfer and Discharge. indicated, .It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility.The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs.Orientation for transfer or discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand.A record review of an undated facility provided document titled, Documentation in Medical Record, indicated, .Each resident's medical record shall contain an accurate representation of the actual experiences of the residents and include enough information to provide a picture of the resident progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with the state law and facility policy.A record review of an undated facility provided document titled, Resident Rights. indicated, .The resident has the right to be informed of, and participate in, his or her treatment, including.The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to. The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.

Based on interview, and record review, the facility failed to follow its grievance process (the process for making a complaint and having the facility investigate and respond to it) and make prompt efforts to address and resolve a resident's reported concern regarding missing personal items for 1 of 4 sampled residents (Resident 1) when, Resident 1 reported missing personal items and her concerns were not addressed using the facility's grievance process.This failure resulted in Resident 1 expressing frustration and uncertainty regarding what actions had been taken by the facility to address her concern.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including an anxiety disorder (having too much worry or fear that interferes with daily life).A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status), dated 5/19/26, under Section C for Brief Interview of Mental Status (or BIMS, determines the individual's attention, orientation and ability to register and recall new information), indicated Resident 1 had a BIMS score of 13 (score of 13 to 15 means cognition is intact or normal thinking).During an interview on 8/11/26, at 10:50 AM, with Resident 1, in her room, Resident 1 stated that she had reported to facility staff that her batteries were missing. Resident 1 further stated that the batteries were used to operate her battery-operated candles. Resident 1 stated that after reporting the missing batteries to staff, no one returned to provide her with an update regarding the status of her reported concern, including whether the missing batteries had been located or what actions had been taken by the facility to address the concern. Resident 1 further stated that she felt frustrated because she had not received any follow-up regarding the missing items. Resident 1 stated that she expected someone from the facility to come to her room and provide her with an update regarding the status and outcome of her reported concern.During a concurrent interview and record review on 8/11/26, at 2:32 PM, with the Assistant Director of Nursing (ADON), Resident 1's electronic medical record (EMR), the facility's Grievance Binder (a file that keeps track of resident complaints, what the facility did about them, and how they were resolved), and the facility's Theft and Lost Binder (a file that keeps track of resident's lost or stolen belongings and what the facility did about them) were reviewed. The ADON confirmed that there was no documentation in the records reviewed regarding Resident 1's reported concern about missing personal items. The ADON reviewed Resident 1's progress notes and confirmed that there was no documentation indicating that the resident's concern had been reported, addressed, investigated, followed up, or resolved. The ADON stated that it was her expectation that whenever a resident reported a missing personal item, facility staff needed to complete the appropriate form documenting the concern and communicate the matter to the Social Services Director for follow-up. The ADON further stated that the grievance process was important to ensure that a resident's concern was documented, investigated, and followed through to resolution. The ADON explained the process also included the resident being informed of the status and outcome of the reported concern. The ADON confirmed that no such documentation was found for Resident 1.During a telephone interview on 8/12/26, at 12:27 PM, with the Social Services Director (SSD), the SSD stated that the last concerns received regarding Resident 1's missing personal items occurred in January of 2026. The SSD further stated that those concerns were followed up and resolved, including one incident that resulted in the issuance of a check to Resident 1 for missing items. The SSD stated that the most recent concerns known were a missing safe and batteries dated March 2026, both of which had been addressed, resolved, and documented. The SSD explained that after those incidents, no other additional reports, forms, or communication were received regarding Resident 1's missing personal items. The SSD stated that it was his expectation that any staff member who received a resident's concern regarding a missing personal item should complete the appropriate form documenting the concern and place the completed form in the designated Social Services box. The SSD further stated that upon receipt of the form, Social Services would initiate a follow-up and investigate the reported missing item, document the actions taken and outcome, update the appropriate facility binder, and provide the resident with updates regarding the status and resolution of the concern. The SSD stated that the process was necessary to ensure that residents' reported concerns were appropriately communicated, documented, investigated, followed up, and addressed through resolution.During an interview on 8/11/26, at 3:50 PM, with the Director of Nursing (DON), the DON stated that she was aware of Resident 1's concerns regarding missing personal items. The DON further stated her notes identified the reported missing items including a unicorn figurine, a Monopoly game, and a puzzle book. The DON stated that Resident 1's concerns regarding the missing items had been communicated to the Social Services Director approximately one week earlier and that the Social Services Director had taken a photograph of the information documented in the DON's notes. The DON further stated that it was her expectation that concerns regarding missing personal items be followed up to determine the status and outcome of the reported items. The DON stated that the appropriate documentation needed to be completed and maintained in the facility's Grievance Binder and Theft and Lost Binder. The DON explained that the resident's progress notes needed to reflect the reported concern, actions taken, follow-up, and resolution, as applicable. The DON stated that Resident 1 should have been provided with ongoing status updates regarding her concerns, including information about what actions the facility had taken to locate or otherwise address the reported missing items.A review of an undated facility policy and procedure (P&P) titled, [Name of Facility] Theft and Loss, indicated, .Policy - It is the policy of this facility to take reasonable steps to protect the personal property of residents.Procedure - Should the facility become aware that an item of resident's property is missing, the facility Social Service Director shall complete a Report of Missing Property form.The Social Service Director shall prepare a theft and loss report.Minor items reported as missing will be reported on Social Service Referral form and followed up by Social Service Director.The completed report form and documentation of the facility's theft and loss record shall be made available to the Department of Health Services.in response to a specific complaint regarding the loss or theft of a specific item.A review of an undated facility P&P titled, Resident Rights, indicated, .Grievances. The resident has the right to: a. Voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Such grievances include.other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of a resident's needs for 1 of 4 sampled residents (Resident 2), when Resident 2's call light was not placed within reach and was not accessible for use.This deficient practice resulted in Resident 2 being unable to independently access her call light to summon staff for assistance when needed.Findings:A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with diagnoses including age-related osteoporosis (weak and fragile bones caused by aging), and dizziness.A review of Resident 2's Minimum Data Set (MDS, a comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status), dated 6/20/26, under Section C for BRIEF INTERVIEW FOR MENTAL STATUS (BIMS - a short test used to check a person's memory and thinking abilities), indicated Resident 2 had a BIMS score of 12 (score of 8 to 12 means there is a moderate cognitive impairment).A review of Resident 2's clinical record titled, Care Plan Report, in the section titled, Focus indicated, .The resident is AT risk for falls . Further review of the clinical record in the section titled, Interventions, indicated, .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.During a concurrent observation and interview on 8/11/26, at 11:32 AM, with Resident 2, in her room, Resident 2 was observed lying in bed with a call bell noted on top of the overbed table positioned near the right side of Resident 2's bed. A call light was also observed wrapped around the side rail of Resident 2's bed. Both call devices were positioned outside of Resident 2's reach. Resident 2 stated that she needed to use the call light to summon staff for assistance when she needed to be changed and could not reach the call light. Resident 2 was then observed extending her right arm and attempting to reach the call light and was unable to reach either device.During a concurrent interview and record review on 8/11/26, at 11:35 AM, with Certified Nursing Assistant (CNA) 1, in Resident 2's room, CNA 1 confirmed the call bell positioned on top of the overbed table near Resident 2's bed and the call light positioned on Resident 2's side rail. CNA 1 stated that Resident 2 was unable to reach the call bell or call light from her position in bed. CNA 1 further stated that it was very important for Resident 2's call bell and call light to be kept within the resident's reach. CNA 1 explained that there would be an increased risk for a fall if Resident 2 attempted to get up or obtain assistance on her own.During an interview on 8/11/26, at 3:50 PM, with the Director of Nursing (DON), the DON stated that it was her expectation that a resident's call bell, or call light was to be kept within the resident's reach and accessible for use at all times. The DON further stated that all staff were responsible for ensuring that the call device was within a resident's reach. The DON stated that the call light system was an important means for residents to communicate their needs and summon staff for assistance. The DON further stated that when a call device was not within a resident's reach, the resident might be unable to communicate with staff. The DON explained that it could result in unmet or delayed care needs including assistance with hygiene, toileting, continence care, medication needs, changing, repositioning, or other requested care and services. A review of an undated facility policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, indicated, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside.to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.Policy Explanation and Compliance Guidelines.Staff will ensure that call light is within reach of resident.The call system will be accessible to residents while in their bed.

Based on interview and record review, the facility failed to ensure that one of three resident's (Resident 1) drug regimen (a detailed plan for taking medication) was free from unnecessary drugs, failed to obtain informed consent (ICO -process where a doctor explains a mind-altering medication, its risks, and benefits, alternatives, ensuring the patient or legal guardian agrees freely before treatment) for the use psychotropic medication (mind altering drugs) prior to Resident 1 starting the medications, failed to monitor for adverse side effects (ASE -harmful, negative, unintended reactions caused by medication treatment) of multiple psychotropic medications with black box warnings (BBW -life threatening risks), and failed to assess, intervene, and transfer Resident 1 to an acute care setting (hospital) until the evening of 8/13/26 when a family member/responsible party (RP) insisted that Resident 1 was transferred to the hospital due to a change in Resident 1's status.These failures resulted in Resident 1 being admitted to a general acute care hospital (GACH) intensive care unit (ICU - a special hospital room for people who are very sick and need close monitoring) where Resident 1 was treated for being over-medicated on benzodiazepines (prescription psychotropic central nervous system (CNS - the main control center of the body made up of the brain and spinal cord) medication depressant (slows down brain activity) to treat anxiety and other conditions) which required the use of the reversal agent medication that reversed the sedative effect of benzodiazepines and low blood glucose (when the levels of sugar in the blood drop below a normal range). Additionally, this failure resulted in the absence of Resident 1's and the RP's right to be informed of and consent to the treatment with the use of psychotropic medications.Findings: A review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (brain disorder that causes shaking, muscle stiffness and movement problems) bipolar disorder (mental health condition that causes shifts in mood) depression, (mood disorder that causes persistent feelings of sadness), dementia (mental decline that interferes with daily life), and anxiety (excessive worry and fear). A review of Resident 1's, Minimum Data Set, (MDS - a resident assessment tool), Section C - Cognitive Patterns (an assessment of the mental abilities and functions the brain uses to think, learn, remember, pay attention, and process information) dated 7/8/26, indicated Resident 1's BIMS (BIMS - Brief Interview for Mental Status - a screening tool used to assess a resident's cognitive function. Scoring = 13-15 indicates normal intact cognitive function, 8-12 moderate cognitive impairment, 0-7 signifies severe cognitive impairment) was 11 out of 15 which indicated Resident 1 had moderate cognitive impairment. A review of Resident 1's MDS, Section E - Behaviors, dated 7/8/26 indicated Resident 1 did not exhibit any physical behaviors directed towards others (hitting, kicking, pushing, or grabbing), or verbal behaviors directed towards others (threatening, screaming or cursing). A review of Resident 1's electronic medical record (EMR) under the Medication Administration Record, (MAR -a written or electronic chart that tracks what medications a person receives), dated July 2026, indicated Resident 1 was on the following psychotropic medications: Mirtazapine [antidepressant medication] Tablet 15 MG [milligram -a unit of measure] Give 1 tablet by mouth at bedtime for depression.Start Date 7/6/2026. QUEtiapine Fumarate [antipsychotic medication-mind altering drug typically used for the treatment of symptoms related to mental illness] Oral Tablet 25 MG.Give 0.5 [half] tablet by mouth at bedtime for manage bipolar.Start Date 7/2/26. Ativan [lorazepam -a benzodiazepine medication that slows down the central nervous system (CNS) to help treat anxiety] Oral Tablet 1 MG.Give 1 tablet by mouth two times a day for Anxiety m/b [manifested by] inability to Relax.Start date 7/9/26. Depakote [divalproex Sodium -a prescription medication used to treat bipolar disorder] Tablet Delayed Release 250 MG.Give 1 tablet by mouth three times a day for.mood stabilization.Start Date 7/9/26. A review of Resident 1's MAR record did not indicate any nursing documentation related to helping re-direct Resident 1 with non-pharmacological interventions (NPI -evidence based, non-medication attempts used to prevent and treat behavior) for anxiety, depression, and mood disorder that the medication may only partially treat. The MAR and EMR record did not reveal that informed consent (ICO) was obtained for these four medications prior to initiating the medications. A review of Resident 1's EMR titled, Care Plan Report, (a personalized document that outlines a resident's healthcare needs, goals, and interventions) dated 7/7/26, under the Focus section, indicated Resident 1 was prescribed one or more of medication with a Black Box Warning (BBW -quetiapine, mirtazapine, tramadol (pain medication)) with a goal that the adverse effects (undesired or harmful reactions of the medications) would be managed to prevent serious injury. An additional goal indicated that Resident 1 and RP 1 would be informed of the risks associated with BBW medications. The care plan Interventions section revealed that the medications should be administered as ordered when Resident 1 and RP 1 were informed of the warnings and potential side effects on Resident 1. Additionally, the interventions indicated that Resident 1 would be assessed weekly for any symptoms or changes possibly related to the BBWs and to notify the doctor of any changes to Resident 1's condition. A review of Resident 1's EMR titled, Care Plan Report, dated 7/13/26, indicated Resident 1 was on a mood stabilizer (Divalproex) with a goal that Resident 1 would be free from discomfort or adverse reactions related to anti-anxiety therapy. The plan of care under the Interventions section revealed Resident 1 would be monitored for side effects that included dizziness and drowsiness and to educate Resident 1 and RP 1 about the risks, benefits and side effects of the medication. A review of resident 1's EMR document titled, Care Plan Report, dated 7/7/26, indicated Resident 1 used psychotropic medications related to behavior management with a goal for Resident 1 to be free of psychotropic drug related complications which included behavioral impairment. The Interventions section revealed nursing staff would be monitoring each shift for side effects and to review Resident 1's behaviors. Additional review of the interventions revealed the staff were to educate Resident 1's family about the risks and benefits and the side effects. A review of Resident 1's EMR document titled, Progress Notes, dated 7/8/26 at 10:09 PM, under the, Physician's Order Note, the note text indicated, .Ativan Oral Tablet 1 MG [Lorazepam].Give 1 tablet by mouth two times a day for Anxiety m/b [manifested by] inability to Relax Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction.The system has identified a possible drug interaction with the following orders.Depakote [divalproex/valproic acid] Tablet Delayed Release 250 MG (milligrams).Severity: Severe.Interaction: Valproic acid may increase the serum concentration [the amount of a specific medicine present in the fluid part of the blood] of lorazepam. A review of Resident 1's EMR document titled, Interim Medication Regimen Review, (IMRR - a careful check of all the medicines a resident takes to find and stop harmful side effects, drug mixes, and dosing mistakes) dated 7/2/26, by the pharmacist consultant (PC) indicated in the section Action Required, that Resident 1 would need monitoring for CNS adverse effects such as drowsiness and the psychotropic medications quetiapine and mirtazapine required a consent form from Resident 1 or the RP. The document was signed by the physician (MD). During a telephone interview on 7/28/26 at 9:17 AM with Resident 1's responsible party, the RP stated that when Resident 1 was initially admitted to the facility she was doing well. The RP further stated that Resident 1 would get out of bed and sit at the nurse's station and socialize, was calm and happy. The RP stated on 7/8/26 at 9:52 PM she received a voice mail from the facility staff that stated Resident 1 had gotten agitated and aggressive and that the MD had recommended a new medication for her mood. The RP explained that she did not talk to anyone about the medication, they only left the voice mail message. The RP further stated she had never observed Resident 1 with aggressive behavior. The RP stated she went to see Resident 1 after the incident on 7/8/26 and the staff told her Resident 1 was now fine, and no other behavior occurred. The RP further stated the facility never explained or told her about the new medication or explained any risks or side effects. The RP added she was never asked to sign anything related to psychotropic medications or gave any verbal or written consent for any medications. The RP stated on 7/13/26 she visited Resident 1 at 9 AM and found Resident 1 lying in bed backwards (feet were at the head of the bed) and was very drowsy. The RP further stated Resident 1 would not open her eyes and could not speak, she only moaned when the RP tried to shake her shoulders and touch her to wake up. The RP stated Resident 1's condition alarmed and upset her so much that she made a video recording of trying to wake up Resident 1. The RP explained she went to get the Licensed Nurse (LN) 1. The RP stated LN 1 told her Resident 1 was drowsy from her medication and LN 1 would talk to the MD about Resident 1's condition. The RP stated LN 1 did not seem concerned with Resident 1's change in condition. The RP added she asked LN 1 to have the MD call her to discuss the medication that caused Resident 1 to be so drowsy. The RP stated she had to leave for work around 10:30 AM and trusted LN 1 to take care of Resident 1. The RP explained when she returned to the facility on 7/13/26 around 5 PM, she was upset to find Resident 1 on her hands and knees on the floor with her face up against the wall and was still very drowsy. The RP further explained she went to tell the nurse (LN 2) about Resident 1's condition and asked LN 2 to send Resident 1 out to the hospital since this was not normal for Resident 1. The RP explained that LN 2 came back and told her the MD said not to send Resident 1 to the hospital and to just monitor Resident 1 and the MD cut down her anxiety medication. The RP stated 2 staff members came in and helped Resident 1 get back into bed and checked her for injuries. The RP further stated Resident 1 was still very hard to wake up. The RP explained she was so upset that Resident 1's condition had not changed since the morning she insisted that LN 2 call 9-1-1 and send Resident 1 to the hospital. The RP further explained the ambulance came and had to give her medication to bring up her blood glucose, and then they transferred Resident 1 to the hospital. The RP explained at the hospital the hospital admitting physician (HMD) told the RP that Resident 1 had to be given medication to reverse the effects of the lorazepam and given more medication to get her blood sugar up to a normal level. The RP added Resident 1 was transferred into the ICU to be monitored. A review of Resident 1's EMR document title, Progress Note, dated 7/8/26 at 9:57 PM, by LN 3 indicated, . [Resident 1] exhibited combative and aggressive behavior during the shift. Resident was verbally aggressive and used profane language towards others, and repeatedly stated that she wanted to leave the place.Staff maintained a calm approach, provided verbal redirection and reassurance.The resident remainedin [sic] the facility, no injuries or adverse events occurred.MD.RP was made aware. Received new order for Ativan [lorazepam] 1 mg BID [twice a day] and Depakote [divalproex sodium] 250 TID [three times a day] .All needs attended and met by the staff. Resident is now resting comfortably in bed. During a concurrent interview and record review on 7/28/26 at 2:45 PM with LN 3, Resident 1's EMR was reviewed. LN 3 confirmed she documented a change in condition evaluation (CIC -formal medical functional assessment when a patient exhibits an unexpected shift in their health or behavior) dated 7/8/26 at 9:24 PM that indicated Resident 1 had become agitated and exhibited aggressive and combative behavior during the shift. LN 3 explained on 7/8/26 around 6:15 PM LN 3 observed Resident 1 walking towards the nurse's station while rolling a bedside table towards the nurse's station. LN 3 further explained Resident 1 kept saying she wanted to leave the facility. LN 3 explained once we attempted to re-direct Resident 1 to her room, and told her she could not leave, Resident 1 became very agitated and started yelling. LN 3 added that Resident 1 was not physically aggressive and did not try to hit anyone, but LN 3 feared Resident 1 would become physical due to being agitated. LN 3 explained that Resident 1 had approached the nurse's station quickly, so LN 3 thought Resident 1 was being aggressive and combative. LN 3 confirmed Resident 1 did not hit or strike and did not act like she would hit or strike anyone. LN 3 stated once Resident 1 was re-directed she was able to calm down. LN 3 stated it was unlike Resident 1 to be so verbally aggressive and yell at staff. LN 3 added that Resident 1 was normally calm and liked to sit at the nurse's station and visit with staff. LN 3 presented a text message on her personal cell phone that was sent to the MD on 7/8/26 at 6:28 PM, the MD responded via text message .please try to redirect., LN 3 responded via text message with, .We tries [sic] before texting you, she doesn't want to listen to anyone. The MD replied, Leave her alone and start Depakote [Divalproex/Valproic acid] 250 [MG] tid [three times a day] .Start Ativan [lorazepam] 1 mg bid [twice a day] routine . LN 3 stated that Resident 1 was not started on the medications until the next day 7/9/26 and was able to calm down after being left alone using NPI. LN 3 stated she then called Resident 1's RP and left a voice mail message. LN 3 confirmed she did not obtain informed consent (ICO -process where a doctor explains a mind-altering medication, its risks, and benefits, alternatives, ensuring the patient or legal guardian agrees freely before treatment) from the RP or Resident 1 to start the divalproex or lorazepam. LN 3 reviewed Resident 1's MAR and confirmed she gave Resident 1 the first dose of lorazepam on 7/9/26 at 5 PM. LN 3 stated she did not verify if informed consent to take the psychotropic medication was received and did not try to get informed consent. LN 3 stated Resident 1 did not display further aggressive behaviors after the incident on 7/8/26 and was not informed by other staff of any behaviors after 7/8/26. During an interview on 7/27/26 at 1:35 PM, with LN 1, LN 1 confirmed she was familiar with Resident 1. LN 1 recalled she admitted Resident 1 to the facility and that her baseline (normal state and awareness) was alert (fully awake), calm, cooperative, and confused. LN 1 added that on admission in early July 2026 Resident 1 had a baseline of confusion but was alert and interacted with staff and family and could hold a conversation and verbalize her needs. LN 1 explained Resident 1 worked with physical therapy to get stronger and would push a wheelchair or walker and walk to the nurse's station to visit with staff. LN 1 explained when she was told about Resident 1 being aggressive on 7/8/26, she was surprised because that was not common behavior of Resident 1. During a concurrent interview and record review on 7/27/26 at 1:55 PM with LN 1, Resident 1's EMR progress note dated 7/1/26 at 8 PM by LN 1 was reviewed. The progress note indicated, . [Resident 1] admitted to [facility name] .under [MD].Alert and oriented to self and confused, Able to move all extremities [arms and legs] .On regular diet able to feed herself. Able to make needs known.Oriented to her room. Further review of Resident 1's EMR, LN 1 confirmed Resident 1 was started on psychotropic medications on admission (Mirtazapine and QUEtiapine). LN 1 stated she did not get informed consent from Resident 1 or the RP and stated they were supposed to make sure it was done by the physician before starting the medications. Additional review of Resident 1's EHR progress note dated 7/13/26 at 3:17 PM by LN 1 indicated, .resident was awake and consumed this morning, resident eat [sic] 50-75% of her breakfast and lunch and took her mediation [sic] by mouth and resident came to visit the resident [sic] and resident was looking drowse [sic], Notified MD and got an order to hold (not administer) the lorazepam and depakote till [until] resident is not [sic] fully awake, then decrease Ativan [lorazepam] 0.5 mg bid [twice daily] from tomorrow.family is aware. LN 1 explained on the morning of 7/13/26 she came into work around 6:30 AM and observed Resident 1 sitting unclothed on the side of her bed. LN 1 stated she asked night shift staff to help Resident 1 get dressed and back to bed. LN 1 confirmed she thought that was odd behavior for Resident 1. LN 1 added around 9 AM that same morning she was approached by Resident 1's RP and told that Resident 1 was drowsy. LN 1 confirmed she went to check on Resident 1 and confirmed Resident 1 was drowsy and hard to wake up. LN 1 stated she told the RP that she would contact the MD before the RP left. LN 1 stated on 7/13/26 at 10:41 AM she sent a text message to the MD that indicated Resident 1 was drowsy due to her medication and that the RP wanted to talk to him and suggested that they may want to send Resident 1 out to the hospital. LN 1 shared the text message exchange; the MD responded back via text message to hold the lorazepam and depakote [divalproex] until Resident 1 was more awake and indicated to decrease the lorazepam. LN 1 stated she told the RP and held Resident 1's medication including the divalproex on 7/13/26 at 12:15 PM due to Resident 1 still being asleep. LN 1 further stated at the end of the shift around 3:30 PM she documented the progress note dated 7/13/26 at 3:17 PM and gave the on-coming nurse (LN 2) a review of the events with Resident 1 during the day shift (7AM - 3:30PM). During an interview on 7/27/26 at 2:34 PM with LN 2, LN 2 confirmed on 7/13/26 she was working the evening shift (3 PM - 11:30 PM) and was assigned to care for Resident 1. LN 2 stated that she observed Resident 1 sleeping at the beginning of her shift. LN 2 added that she was told by a Certified Nursing Assistant (CNA -unable to recall the which CNA) that Resident 1 had eaten dinner and added that the CNA did rounds around 5:30 to 6PM. LN 2 explained at around 6 PM Resident 1's RP came into the facility and found Resident 1 on the ground kneeling between the bed and the wall. LN 2 stated she went to Resident 1, assisted her back to bed, and assessed her for injuries. LN 2 further stated Resident 1 was sleepy but arousable to pain (woken up or made to react by applying physical pain stimulus). LN 2 explained that the RP was upset and wanted to know what medication Resident 1 had been given and requested LN 2 to contact the MD and send Resident 1 out to the hospital. LN 2 added that she contacted the MD, and he stated to just continue to monitor. LN 2 shared with the RP what the MD had suggested, and the RP insisted that Resident 1 be sent to the hospital. LN 2 explained that she called 9-1-1 and requested an ambulance to transport Resident 1 to the hospital. LN 2 added that Resident 1 was acting different from her baseline and stated that Resident 1 was usually up and walking around after dinner. A review of Resident 1's EMR document titled, RT- [Respiratory Therapy] Daily Treatment Note, dated 7/12/26 at 4:47 PM by Respiratory Therapist (RT) 1 indicated, .RT assessed pt [patient -Resident 1], difficult to arouse x2 [two times]. RT had to perform a sternal rub [medical technique of applying painful rub onto a person's sternum/chest to test a person's level of consciousness] to achieve arousal. Informed nurse, nurse stated difficulty to arouse due to recent admin [administration] of medication.RT will continue to monitor and assess as needed. MD/nurse informed. During a phone interview on 7/29/26 at 3:08 PM with RT 1, RT 1 confirmed he wrote the RT Daily Treatment Note dated 7/12/26 at 4:47 PM. RT 1 stated he did not remember the name of the nurse he informed and stated it was the evening shift nurse towards the end of his shift on 7/12/26 around 5:00 PM. RT 1 further stated he remembered this incident because it was not very common to have to try to wake someone with a sternal rub, usually people wake up to the sound of their name or a gentle touch. RT 1 added he wanted to make sure he checked on Resident 1 a second time and that was when the nurse told him that Resident 1 had difficulty waking up due to her medication. RT 1 stated he did not notify the MD even though his note indicated it, the process was he was supposed to notify the nurse who was supposed to notify the MD. A review of Resident 1's EMR document titled, RT- Daily Treatment Note, dated 7/13/26 at 4:08 PM by RT 2 indicated, .RT assessed pt [patient - Resident 1] difficult to arouse x3 [three times]. RT had to perform sternal rub to achieve arousal. Informed nurse, nurse stated difficulty to arouse due to recent admin. [administration] of medication.RT will continue to monitor and assess as needed. MD/nurse informed. During a phone interview on 7/29/26 at 3:30 PM with RT 2, RT 2 confirmed she wrote the RT -Daily Treatment Note dated 7/13/26 at 4:08 PM. RT 2 stated she informed Resident 1's nurse for the day shift about Resident 1's condition. RT 2 stated that LN 1 told her that Resident 1 was like that due to the medications she was taking. RT 2 explained that because she was not familiar with Resident 1 and her baseline, she checked her three times throughout the day and then notified the day shift nurse because it was not common for a person to be arousable only to pain. RT 2 explained that LN 1 acted like that was Resident 1's baseline (normal) when she was medicated. RT 2 stated Resident 1 was not combative, just difficult to arouse each time she attempted to work with her. RT 2 explained that Resident 1 was too drowsy and unable to participate in the respiratory practices RT 2 attempted to do with her. RT 2 further explained she documented she notified the MD/nurse because that was what the RT's were supposed to document. RT 2 added that by telling the nurse the condition of Resident 1, it was expected that LN 1 would notify the MD of Resident 1's condition. RT 2 could not confirm if the MD had been notified of Resident 1's difficulty in waking.A review of Resident 1's EMR document titled, eINTERACT Change in Condition (CIC) Evaluation, dated 7/13/26 at 7:55 PM by LN 2, indicated under the section, Mental Status Evaluation, indicated Resident 1 had an altered level of consciousness (ALOC - condition of the mind-such as sleeping that is significantly different from a normal state). In addition, the CIC indicated Resident 1 was .sleepy but arousable to pain. During a follow-up interview on 7/30/26 at 5:06 PM with LN 2, LN 2 confirmed she was working the evening shift on 7/12/26 and was assigned to Resident 1. LN 2 stated she was not alerted by an RT or anyone that Resident 1 was difficult to arouse on 7/12/26. LN 2 further stated she did not notify the MD since she did not recall being told this by an RT. LN 2 stated if she had been told she would have immediately assessed Resident 1 and notified the MD and recommended Resident 1 be sent out to a hospital for ALOC. LN 2 could not recall any significant change with Resident 1 on 7/12/26, stated she medicated her for pain, and recalled that Resident 1 was just sleepy. During a phone interview on 7/29/26 at 10:13 AM with the MD, the MD stated on 7/8/26 he was informed (by LN 3) that Resident 1 was confused and combative which was different from her baseline. The MD stated he did not assess Resident 1 on 7/8/26 and relied on nursing staff to give him accurate details of her behavior. The MD stated he did not start with the lowest dose possible of lorazepam or order it only as needed because he felt like Resident 1 already had anxiety and needed a stronger dose for agitation. The MD also stated on 7/8/26 he started Resident 1 on divalproex three times a day at the same time as the lorazepam to help manage Resident 1's moods. The MD confirmed that mirtazapine, quetiapine, divalproex, and lorazepam all had BBWs and when used together could cause sedation. The MD stated he was not informed by nursing staff that Resident 1 had calmed down prior to starting the medications. The MD confirmed he told LN 3 to redirect Resident 1 when he gave the orders for the lorazepam and divalproex. The MD confirmed Resident 1 did not have capacity to sign her own medical documents and expected the nurses to contact the resident's RP and read the consent form with the risk, benefits and alternatives (RBAs- harmful side effects, expected outcomes and other available treatment options like non-pharmacological interventions [NPIs]) to psychotropic medications. The MD stated if the nurses did not get the consent from the residents or the RPs prior to administration of the psychotropic drugs it did not meet his expectation. The MD stated he was not notified of a change in Resident 1's condition by the nurses or RT on 7/12/26. The MD stated he was notified in the evening of 7/13/26 that Resident 1 had a fall and was drowsy. The MD explained based on that information the facility could manage drowsiness and told the nurse to continue to monitor. The MD explained Resident 1's ALOC and waking only to painful sternal rub had not been communicated to him and had it been he would send Resident 1 out to the hospital. The MD added the nurses needed to document when they used NPI and what the interventions were so he could properly monitor the resident's responses to medication and justify the continued need for medication. The MD further added that the nurses needed to do better adverse side effect monitoring and communicating with him. The MD stated the risk to the residents if not properly monitored for ASE of medications could be worsening of condition and over sedation. During a concurrent interview and record review on 7/28/26 at 3:44 PM with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), Resident 1's EMR was reviewed. The ADON and DON reviewed Resident 1's entire EMR and were unable to locate any documentation or paper copies in medical records where Resident 1 or the RP was given informed consent for the psychotropic medication administered to Resident 1 that included lorazepam, divalproex, mirtazapine and quetiapine. The ADON confirmed all four medications required ICO prior to administration. The ADON and DON further reviewed Resident 1's MAR and confirmed there were no documented NPIs for the administration of lorazepam prior to giving the medication and during the medication administration from 7/9/26 to 7/13/26. The ADON added she was used to seeing a lower dose of lorazepam 0.5 MG once or twice a day as needed and stated it was unusual to start the medication as routine versus on an as needed basis. Resident 1's EMR documents titled, RT- Daily Treatment Note dated 7/9/26 at 4:37 PM, indicated, Resident 1 was, .Pleasant and cooperative. the ADON confirmed via MAR review this was documented prior to the first dose of lorazepam on 7/9/26 being given to Resident 1. During a continued review of Resident 1's EMR with the DON and ADON on 7/28/26 at 4:15 PM a review of the RT- Daily Treatment Notes dated 7/12/26 by RT 1 and 7/13/26 by RT 2 were reviewed with the ADON and DON. The DON stated it was her expectation when residents had a significant change in condition (CIC) like ALOC, the MD should be notified, and the cause should be evaluated. During a review with the DON and ADON of the facility policy and procedure titled, Use of Psychotropic Medication(s), the ADON and DON confirmed the facility policy was not followed for initiating psychotropic medications by educating Resident 1's RP of the RBAs to include the BBW, and the lack of EMR documentation of Resident 1's continued behaviors and NPI's after starting the medication. The ADON added the policy was not followed since the lowest dose possible was not used and the monitoring of ASE lacked continuity. A review of Resident 1's medical records from the [General Acute Care Hospital Name -GACH] by hospital admitting physician (HMD) in the section, History and Physicals, dated 7/13/26 at 23:45 [11:45 PM] indicated, .History of Present Illness [HPI -current medical problem] . [Resident 1] .presented to the ED [Emergency department] from her SNF [skilled nursing facility] due to altered mental status. She was late [sic] at her baseline mentation on Wednesday [7/8/26] as noted by [RP]. Reportedly that night she became verbally abusive.and additional medications were added. Since then she has become progressively more lethargic. They [RP] left and came back later that evening at approximately 1830 [6:30 PM] and found her on the floor.History is provide by [RP] at bedside.she [Resident 1] was reportedly hypoglycemic [low blood sugar] upon EMS [emergency medical services] arrival and was administered D10 [solution of 10 grams of sugar in water].blood sugar was initially 96 mg/dl [milligram per deciliter -normal blood sugar 70-110 mg/dl] however upon repeat it was 68.Urinalysis showed possible mild UTI [urinary tract infection].Urine toxicology [lab test that analyzes urine to detect the presence of legal or illegal drugs] was presumptively positive for benzodiazepines [prescription medicines that slow down your central nervous system like lorazepam] Medicine [HMD] was consulted for admission.Review of Systems.unable to be completed due to patient's mental status.General Appearance: Obtunded [reduced state of alertness], localizes the pain but not interactive.Neurological [relating to the nervous system, which includes the brain, spinal cord, and all the nerves in the body]: Obtunded, moves all extremities in response to pain.Pertinent Previous Studies personally reviewed: ED notes, SNF medication list.Assessment/Plan 1. Toxic metabolic encephalopathy [a temporary brain malfunction leading to confusion or changes in alertness from chemical imbalance] .due to polypharmacy [taking multiple medications at the same time] from lorazepam, Depakote [divalproex sodium], tramadol, Seroquel [quetiapine] exacerbated [worsened] by hypoglycemia.admission Status.2. Benzodiazepine intoxication [taking more sedative medication like lorazepam than the body can process] .4. Hypoglycemia.Continue D10 [dextrose 10 grams in water] for now.Suspect hypoglycemia is due to poor intake and poor mental status.Orders.flumazenil, 0.2 mg, IV, ONCE STAT [prescription medication injected intravenously to reverse the effects of benzodiazepine immediately].Dispo: [disposition -final plan] Admit to ICU.I expect that the patient's stay will require at least 2 midnights in workup and treatment of conditions above and will require interventions.and close monitoring that cannot occur at a lower level of care as the patient has a high likelihood of deteriorating without treatment. A review of the facility provided policy and procedure (P&P) titled, Use of Psychotropic Medication(s), dated 2026, indicated, .this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated.these medications should only be used to treat the resident's medical symptoms.without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is i

Based on interview and record review the facility failed to ensure the informed consent (ICO -when a resident or their legally authorized representative must agree, authorize, or be given the right to decline to take a prescribed mind-altering medication after being fully informed about its purpose, potential benefits, risks, and alternatives) for psychotropic medications (mind altering drugs that affect brain activities associated with mental processes, mood and behavior include the categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics to sleep) included the risks, side effects, the benefits and/or the Black Box Warnings (BBW -the most serious type of warning the U.S. Food and Drug Administration can require on a medication label) for two of three sampled residents (Resident 1 and Resident 2). This failure resulted in Resident 1, Resident 1's Responsibly Party (RP -authorized person to make healthcare choices for a patient who lacks the ability to make their own informed medical decisions and signs medical consents) and Resident 2 not being informed of the risks, benefits and alternatives (RBA -Risks are the potential harms or side effects, benefits are the expected positive outcomes, and alternatives are other choices or treatments options), not given the right to refuse, and not given the right to refuse participation in the psychotropic drug treatment.Findings: 1a. A review of Resident 1's electronic medical record (EMR -digital versions of paper charts that store a patient's medical history, diagnoses, progress notes and medications in an electronic format) under the Medication Administration Record, dated July 2026, the MAR record indicated Resident 1 was on the following psychotropic medications: Mirtazapine [antidepressant medication] Tablet 15 MG [milligram -a unit of measure] Give 1 tablet by mouth at bedtime for depression.Start Date 7/6/2026. QUEtiapine Fumarate [antipsychotic medication] Oral Tablet 25 MG.Give 0.5 [half] tablet by mouth at bedtime for manage bipolar [mood disorder] .Start Date 7/2/26. Ativan [lorazepam -a benzodiazepine medication that slows down the central nervous system (CNS) to help treat anxiety] Oral Tablet 1 MG.Give 1 tablet by mouth two times a day for Anxiety m/b [manifested by] inability to Relax.Start date 7/9/26. Depakote [divalproex sodium -a prescription medication used to treat bipolar disorder] Tablet Delayed Release 250 MG.Give 1 tablet by mouth three times a day for.mood stabilization.Start Date 7/9/26. During a phone interview on 7/28/26 at 9:17 AM with Resident 1's RP, the RP stated she was never informed by a Licensed Nurse (LN) or the Physician (MD) of any psychotropic medication given to Resident 1. The RP stated she was aware that Resident 1 was previously on mirtazapine for sleep and quetiapine for anxiety. The RP stated she was upset to find that Resident 1 had been given lorazepam and divalproex without being given the benefits, risks, and alternatives (RBA) or the right to decline or discuss other treatment options. The RP stated on 7/13/26 she found Resident 1 very drowsy and unable to wake up easily when the RP visited Resident 1. The RP stated that was when the nurse told her Resident 1 was taking the psychotropic medications. During a concurrent interview and record review on 7/28/26 at 3:44 PM with the Assistant Director of Nursing (ADON) and Director of Nursing (DON), Resident 1's EMR was reviewed. The ADON and DON were unable to locate any documentation or paper copies that documented Resident 1 or Resident 1's RP were given informed consent (ICO's) for the use of the psychotropic medication mirtazapine, quetiapine, lorazepam, and divalproex. The ADON stated she checked with the facilities medical records department, and they were also unable to find any physical record of the ICO's. The ADON and DON confirmed all four medications required ICO prior to administration to Resident 1, even when a resident came to the facility and had already been taking the medication, the facility was required to obtain ICO. 1b. A review of Resident 2's admission RECORD indicated Resident 2 was admitted to the facility with diagnoses which included fracture of the fifth lumbar vertebrae (a break in the fifth vertebra and lowest bone of the lower back above the tailbone), low back pain, depression, anxiety, difficulty in walking, and muscle weakness. A review of Resident 2's EMR under the Medication Administration Record, dated July 2026, the MAR record indicated Resident 2 was on the following psychotropic medications: DULoxetine HCl [a medication used to treat depression and anxiety] Oral Capsule Delayed Release Particles 30 MG.Give 1 capsule by mouth one time a day for depression.Start Date 5/19/2026. Sertraline HCl [a medication used to treat depression] Oral Tablet 100 MG.Give 1 tablet my mouth one time a day for depression.Start Date 5/19/2026. Lyrica [pregabalin -a seizure medication sometimes used for anxiety because it calms overactive nerve signals to the brain] Oral Capsule 50 MG [MG milligram -a unit of measure] .Give 1 capsule by mouth two times a day for anxiety.Start Date 5/30/2026. OLANZapine [an antipsychotic medication that alters the mood] Oral tablet 5 MG.Give 1 tablet by mouth two times a day for bipolar disorder [a mental health condition that causes extreme shifts in mood, energy and activity] .Start Date 5/19/2026. diazePAM [a benzodiazepine medication used to calm the nerves in the brain and treat anxiety] Oral Tablet 10 MG.Give 1 tablet orally every 6 hours as needed for Anxiety m/b [manifested by] inability to relax for 14 days.Start Date 6/29/26. A review of Resident 2's EMR document titled, Nurses Notes, dated 7/2/26 at 14:34 [2:34 PM] by LN 1 indicated, .Nurse [LN 1] received to the consent form to signed [sic] from the [FM -Responsible Party who is authorized to sign ICO], Nurse called the [FM] to get a verbal consent over the phone. [FM] said she will call the facility regarding the consent [ICO] form later today.endorsed to the upcoming shift . A review of Resident 2's EMR document titled, Nurses Notes, dated 7/2/26 at 20:43 [8:43 PM] by LN 3, indicated, .Followed up for getting verbal consent on psychotherapeutic drug from [Resident 2s FM]. [FM] said she is till [sic] waiting to get a call from attorney. Once she gets the call, she will call the facility and tell her decision. During an interview on 7/28/26 at 2:45 PM with LN 3, LN 3 confirmed she wrote the progress note dated 7/2/26 at 8:43 PM. LN 3 explained the forms (ICO) were passed to her from LN 1 and was told to call Resident 2's FM to get verbal consent for the psychotropic medications that Resident 2 was taking. LN 3 further explained Resident 2's FM told her she was waiting to talk to an attorney before deciding to agree to have Resident 2 take the medication. LN 3 stated when the nurses get phone consent for psychotropic medications, they put the call on speaker phone, and two nurses had to hear/witness the verbal consent and then they both sign the ICO that consent was granted. LN 3 could not recall what medications she was trying to obtain ICO for. During a concurrent interview and record review on 7/28/26 at 1:52 PM with the ADON and DON, Resident 2's EMR was reviewed. The ADON and DON reviewed Resident 2's MAR for the month of July 2026 and confirmed Resident 2 was taking the medications duloxetine, sertraline, pregabalin, olanzapine and diazepam for psychotropic purposes. The DON confirmed all 5 medications reviewed required ICO prior to administering the medication. The ADON provided two signed ICO for Resident 2 for the medication of sertraline and olanzapine. The ADON and DON searched Resident 2's EMR and were unable to locate ICO for duloxetine, pregabalin and diazepam. The ADON reviewed Resident 2's progress notes dated 7/2/26 by LN 1 and LN 3 and suggested they were attempting to obtain consent for the other three medications. The ADON stated the facility process was to wait for ICO prior to administering psychotropic medication. The ADON added it was important to obtain ICO because the side effects of the medication could be severe, the Resident or resident representative should be informed of the possible mental status changes or usual behaviors that could happen. The ADON explained the risk to the residents when not informed of the RBAs and their right to refuse or participate in the decision-making process was that the residents could be at risk of falls, confusion, or an altered mental status. During a phone interview on 7/29/26 at 10:13 AM, with the MD, the MD confirmed he was the MD for both Resident 1 and Resident 2. The MD stated it was his expectation that all psychotropic medications had the required ICO prior to initiating the medication. The MD stated he usually discussed the medications RBAs with the residents and had the nurses follow up and get the signature or verbal consent for the ICO. The MD stated he expected the nurses to read the ICO paperwork to the residents or family and have them sign the ICO. The MD further stated the nurses read the reason for the medication, what the probable side effects, risks associated with taking psychotropic medications, and the reasonable alternative treatment. The MD explained he believed he discussed Resident 2's ICO with Resident 2 and not the family. The MD stated he did not discuss ICO with Resident 1 or Resident 1's family. The MD stated he generally wrote the information on the ICO and expected the nurses to read about the RBAs to the family and have them sign the ICO. The MD added if the ICO's were not being completed it did not meet his expectation. The MD confirmed that psychotropic medications had a black box warning (BBW - is the strongest safety alert the U.S. Food and Drug Administration [FDA] requires for a medication) and had risks of sedation when used in the elderly. A review of the facility provided policy and procedure titled, Use of Psychotropic Medication(s) dated 2026, indicated, .8. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with the residents, their families and/or representatives, other professionals, and the interdisciplinary team. 9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. 10. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. 11. The facility will document that the resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline. (e.g., written consent form, narrative note, etc.) .

Based on observation, interview, and record review the facility failed to ensure safe and secure order communication among providers when medication orders were communicated via a text messaging system involving nursing staff's personal smart phone (a mobile phone that performs many of the functions of a computer, typically having a touchscreen and internet access) and the physician for one of three sampled residents (Resident 1) based on regulatory requirements on Protected Health Information (or PHI, any information in the medical record that can be used to identify an individual in the course of providing a health care services). This failure could violate residents' health information privacy and confidentiality.Findings:During a concurrent observation and interview on 7/28/26 at 2:45 PM with Licensed Nurse (LN) 3, LN 3 stated on 7/8/26 she had contacted Resident 1's (MD) because Resident 1 became agitated and combative. LN 3 shared her personal smart phone iMessage (text messages from an iPhone) and the following exchange with the MD and LN 3 on 7/8/26 at 6:28 PM was observed and indicated: . [Resident 1's first and last name and room number] we are sending her to the hospital because she very combative right now. She is trying to hit everyone staff plus residents. The MD responded via iMessage, Please try to redirect LN 3 responded via iMessage, We tries [sic] before texting you, she doesn't want to listen to anyone, The MD responded, Leave her alone and start depakote [divalproex -a mood stabilizing medication] 250 tid [three times a day] .Start Ativan [lorazepam] 1 mg [mg -milligram and unit of measure] bid [twice daily] routine.Give her tramadol [a medication for pain], if she has pain. LN 3 stated that was how she was taught to communicate with the MD. LN 3 stated it was common to take orders and give specific resident information on their personal smart phone via iMessage or text message so they could notify the MD when needed.During a concurrent observation and interview on 7/27/26 at 1:35 PM with (LN) 1, LN 1 stated on the morning of 7/13/26 Resident 1's family member (RP) approached her and told her that Resident 1 was drowsy, hard to wake up and wanted to speak to Resident 1's Physician (MD). LN 1 shared her personal smart phone iMessage text messages and the following exchange between LN 1 and the MD on 7/13/26 at 10:41 AM, was observed and indicated, .Hi DR CAN I CALL YOU.[Resident 1's first and last name] Dx [diagnosis] Bipolar [mood disorder that causes extreme shift in moods] Depression restless and weakness.She is little drowsy because of her medication. So maybe family wanna [sic] cut down some medicine and they wanna [sic] talk to you too. May be [sic] they wanna send her to the hospital. The MD responded via text message, Hold Ativan [lorazepam] and depakote [divalproex] till she is more awake, then decrease Ativan [lorazepam] to 0.5 mg [mg -milligrams, a unit of measure] bid [twice daily] from tomorrow.Please get cmp [comprehensive metabolic panel -a blood test that measures 14 different substances to check health] cbc [complete blood count -a blood test used to evaluate overall health] depakote levels [a blood test that shows the amount of divalproex in a person's system] .LN 1 stated that the only way the nurses had to communicate with the MD was by text message from their personal smart phones. LN 1 further stated she was not sure if it violated any privacy laws. LN 1 further stated that using their personal smart phones was the way it had always been done. LN 1 stated it was important to protect the residents' privacy and PHI and that the facility should provide a more secure way of communicating with the MD, if using text messaging was not secure.During an interview on 7/27/26 at 2:34 PM with LN 2, LN 2 stated it was common practice in the facility to communicate with the MD using their personal smart phones. LN 2 added she thought it could be a violation of the Health Insurance Portability and Accountability Act (HIPPA -a U.S. federal law designed to protect sensitive patient health information from being shared) but that the facility had not given them other secured options. LN 2 stated that this practice was just how the nurses communicated with the MD and added that it was not safe for the nurses or the residents because their PHI could possibly be seen by others.During an interview on 7/28/26 at 4:38 PM with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), the ADON stated that nurses were expected to use a landline (a phone system that connects to a network with wires, cables, rather than using cell towers) telephone only for communicating with the MD. The DON added that communication with the MD via text message related to Resident's PHI and taking orders via text message was not secure and prohibited. The DON added that the facility could not predict who had access to the nurses personal smart phones and that resident HPI should not be on their smart phones. The DON stated it was important to protect the residents PHI due to HIPPA.A review of the facility provided policy and procedure (P&P) titled, Confidentiality of Personal and Medical Records, dated 2026, indicated, This facility honors the residents' right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records.A review of the facility provided P&P titled, Personal Cell Phones, dated 2025, indicated, .1. This facility prohibits employees from using personal cell phones for any reason, on the nursing units or in working areas of the facility. 2. This includes calls, texts, social [NAME] or any other use of cell phones .A review of the facility provided P&P titled, Verbal Order, dated 2025, indicated, .Physician orders may be received by telephone. Verbal orders are those given to the nurse by the physician in person or by telephone.1. Repeat any prescribed orders back to the physician or health care provider.A review of a HIPPA journal, titled, Is iMessage HIPAA Compliant?, dated 3/30/2025, the article indicated .iMessage is not HIPAA compliant and should not be used to communicate Protected Health Information (PHI) . [Smart phone brand] does not have any control over how devices are configured, so does not take any responsibility for the privacy and security of PHI however it is created, received, stored, or transmitted by [Smart phone brand] devices. [smart phone brand] will not enter into Business Associate Agreements with covered entities and business associates and specifically states in its terms of service.the fact that [smart phone brand] will not take responsibility for the privacy and security of PHI - and will not enter into a Business Associate Agreement with covered entities and business associates - means it is not possible to use iMessages to communicate PHI.https://www.hipaajournal.com/is-imessage-hipaa-compliant/#:~:text=iMessage%20is%20not%20HIPAA%20compliant,in%20its%20Terms%20of%20Service

Based on interview and record review, facility failed to ensure accurate documentation of resident's medical records for one of three sampled residents (Resident 2) when Resident 2's nurse's progress notes were not being recorded consistently documenting the monitoring of Resident 2's condition for a medication error which occurred on 7/17/26. This failure placed Resident 2 at risk of potential harm and unnoticed side effects from the medication error.Findings:A review of Resident 2's admission RECORD, indicated Resident 2 was initially admitted to the facility in late 2025 with multiple diagnoses including chronic obstructive pulmonary disease with acute exacerbation (sudden worsening of lung disease), dementia with agitation (thinking skills decline and communication becomes hard, restlessness, verbal outbursts, and repetitive pacing), and generalized anxiety disorder.A review of Resident 2's record titled, eINTERACT Change in Condition Evaluation - V 5.2 - V 1 indicated that a medication error occurred on 7/17/2026.A review of Resident 2's record titled, Care Plan Report indicated .The resident has an alteration in neurological [mental] status r/t medication error Valproic Acid [seizure medication and/or mood stabilizer] taken from another resident.Monitor/document/report PRN [as needed] s/sx [signs and symptoms] of tremors [shaking], rigidity [muscle tightening], dizziness, changes in level of consciousness, slurred speech.During a concurrent interview and record review of Resident 2's medical record titled Progress Notes *NEW*, with the Assistant Director of Nursing (ADON) on 07/22/26, at 2:50 p.m., the ADON confirmed that there were no progress notes regarding the medication error on 7/18/26 pm shift, 7/18/26 night shift, 7/19/26 night shift, 7/20/26 am shift, 7/20/26 pm shift and 7/20/26 night shift. The ADON stated that she expected the licensed nurses to document monitoring in the progress notes every shift for 72 hours.During a telephone interview with Licensed Nurse (LN) 1 on 7/23/26 at 10:16 a.m., LN1 stated that on the night of 7/17/26 during the night shift at around 11pm, Resident 2 came to the medication cart and drank a little cup of valproic acid while he was looking to the other side. LN 1 continued that he had poured the medication for another resident. LN 1 further stated that he tried contacting the Medical Doctor and the Responsible Party for the resident and started her on monitoring as a standard procedure for 72 hours. LN 1 stated that he came in the next night as well but did not document the progress notes. LN 1 stated that he should have documented on Resident 2's status.During another interview with the ADON on 7/23/26 at 1:55pm, the ADON stated that documentation was very important and it was equally important to document correctly. The ADON added that not documenting could put the resident at risk for not being monitored when they should have been. A review of the facility's undated policy and procedure (P&P), titled Medication errors indicated, .Monitor and document the resident's condition, including response to medical treatment or nursing interventions.Document actions taken in the medical record.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who resided at the facility since 2013 and was transferred to a General Acute Care Hospital (GACH) in 4/2026, was readmitted to the facility after Resident 1 was cleared by the GACH to return to the facility on 6/4/2026.This deficient practice resulted in Resident 1 remaining at the GACH after Resident 1 was deemed appropriate for discharge back to the facility resulting in Resident 1's temporary loss of residence and had the potential for negative psychosocial outcomes.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was initially admitted to the facility in early 2013 and readmitted in July 2026 with multiple diagnoses including cholecystitis (the swelling and irritation of the gallbladder, most often caused by gallstones), resistance to carbapenem (bacteria that resist carbapenems, which are powerful last-resort antibiotics, making infections very hard to treat and is spread mainly from person to person through contact with wounds, stool, or unclean hands and medical equipment) and functional quadriplegia (the complete inability to move all four limbs due to severe debility, frailty, or end-stage chronic illness, occurring without direct physical injury or structural damage to the brain or spinal cord). During an interview on 7/23/26 at 10:40 AM, the Admissions Coordinator (AC) confirmed Resident 1 was at the GACH and was ready to come back to the facility on 6/4/26. The AC stated they did not have a male bed, or an empty room to accommodate Resident 1 as he needed isolation ( infection control practice that separates patients with contagious diseases from healthy people or other patients to stop the spread of infection) due to his diagnosis of resistance to carbapenem.During a concurrent interview and record review of the daily census for the month of June, with the Assistant Director of Nursing (ADON) on 7/23/26 at 10:54 AM, it was noted that on 6/21/26, room [ROOM NUMBER], which had two (2) beds, was empty. The ADON confirmed that the room was empty and stated that another resident was admitted to the facility on [DATE]. Upon further review it was noted that from 6/24/26 to 6/28/26, two rooms had only 1 occupant each and one empty bed and both the residents were females. The ADON stated that the facility could have tried to move those female residents to one room to accommodate Resident 1's need for isolation and admitted him at that time.During another interview on 7/23/26 at 1:00 PM, the AC stated that they could have brought Resident 1 back to the facility on 6/21 when room [ROOM NUMBER] was empty and could have been more strategic when 2 female rooms had only one occupant each, who could have been moved together, creating an isolation room for Resident 1.During another interview on 7/23/26 at 1:55 PM, the ADON stated they should have admitted Resident 1 back to the facility as soon as they had availability. The ADON further stated that this failure had a potential risk to cause stress and anxiety to Resident 1 and his family members. The ADON stated that it was important to readmit residents back to the facility, as soon as possible, as it was their right and their home.A review of the facility's undated policy and procedure (P&P) titled, readmission to Facility, the P&P indicated, .It is the policy of this facility to protect the resident's right to readmission by initiating a bed-hold and permitting each resident to return to the facility after they are hospitalized or placed on therapeutic leave, regardless of payment source.Residents who seek to return to the facility after the expiration of the bed-hold period [7 day period] or when state law does not provide for bed-holds, are allowed to return to their previous room if available or immediately to the first available bed in a semi private room .

Based on observation, interview, and record review, the facility failed to implement person centered interventions to ensure the safety of one of three sampled residents (Resident 1) who was an elopement (when a resident leaves the facility or a safe area without authorization) risk when Resident 1 removed her wanderguard (a device that alerts the staff when a resident at risk of elopement approaches a monitored exit door), eloped from the facility on 7/4/26, and upon return to the facility did not have interventions in place to prevent another elopement. This failure had the potential to contribute to another elopement from the facility that could have caused Resident 1 injury or harm. Findings:Review of an admission Record indicated, Resident 1 was admitted to the facility in late-2025 with multiple diagnoses including dementia (a loss of memory, reasoning, that interferes with daily life), generalized anxiety disorder (constant, uncontrollable worry about minimal), psychotic disorder with delusions (a person holds firmly to strong, false beliefs that are entirely disconnected from reality and cannot be changed by reasonable arguments), and major depressive disorder (an intense, long-lasting low mood).Review of Resident 1's active physician orders dated 5/22/26, indicated, .May have wanderguard to L [left] wrist r/t [related to] risk for elopement/active exit seeking behaviors. Check placement .every shift Notify Admin/Don of wanderguard is missing or expired, wanderguard must be replaced if missing or expired.Review of Resident 1's care plan dated 4/21/26, indicated. [Resident 1's name] is a high elopement risk and is a wanderer that is currently being monitored with the use of a wander guard r/t exit seeking. staff will report missing or dysfunctional wander guards.monitor wanderguard for proper placement daily and functionality every day.Review of Resident 1's Elopement Evaluation dated, 6/8/26 indicated, Resident 1 was at a high risk for elopement. During an interview on 7/8/26 at 10:28 AM, with Licensed Nurse (LN) 1, LN 1 stated on 7/4/26 while she was working an evening shift she heard someone say that Resident 1 had just left the facility. LN 1 stated she immediately ran outside of the facility to assist Resident 1. LN 1 stated when she set eyes on Resident 1, Resident 1 was past the facility parking lot and close to the street in front of the facility. LN 1 stated she attempted to bring Resident 1 back to the facility but Resident 1 refused. LN 1 stated Resident 1 became aggressive and threatening with her. LN 1 then stated she followed Resident 1 down the street until she lost sight of her. During an interview on 7/7/26 at 12:37 PM, with Resident 1, Resident 1 stated when she left the facility she walked right outside of the door. Resident 1 stated she cut the wanderguard off with scissors. Resident 1 stated at the time she left she did not feel safe here at the facility and that she told staff that there were people out to hurt her and she did not want to get hurt. Resident 1 further stated she walked about six to seven blocks from the facility while it was dark outside. Resident 1 further stated she began to get tired, she then found some bushes in front of an apartment complex, she laid on the bushes and went to sleep until the morning. Resident 1 stated in the morning she went to a gas station and asked them for some food because she did not have any money and she asked them to call the police. During a concurrent observation, interview, and record review, on 7/7/26, at 12:54 PM, with Licensed Nurse (LN) 2, Inside of Resident 1's bedroom LN 2 confirmed Resident 1 was not wearing her wanderguard. LN 2 stated Resident 1 cut the wanderguard off two weeks ago. Review of Resident 1's Medication Administration Record (MAR-A record of the residents medication that the nurses use for administration) LN 2 confirmed the order from the Medical Doctor (MD) indicating Resident 1 should have a wandergurad on her left wrist. LN 2 stated Resident 1 refused to have the wanderguard placed on her. LN 2 was unable to locate documentation of the refusal while reviewing Resident 1's clinical record progress notes. LN 2 stated she forgot to document the occurrence. LN 2 further verified Resident 1's elopement care plan, dated 4/21/26, indicated Resident 1 was supposed to have a wanderguard on at all times. LN 2 stated the care plan should have been updated to reflect Resident 1's current status. LN 2 stated the care plan should have been updated with interventions such as to monitor Resident 1 to ensure she remains in the facility. LN 2 stated if a resident elopes from the facility they could get hurt by other people, involved in an accident, and possibly forget how to return to the facility.During an interview on 7/7/26 at 2:07 PM, with LN 3, LN 3 stated Resident 1 was recorded missing at 10:30 PM on 7/4/26. LN 3 stated the police were called. LN 3 stated the police arrived and gathered information then left and returned at 2:15 AM and informed the facility they still had not found Resident 1. LN 3 stated around 6:00 AM the police department informed the facility that Resident 1 had been located at a gas station. LN 3 stated Resident 1's level of alertness was to person and place (alert and oriented X2), and stated Resident 1 was pleasantly confused. LN 3 stated Resident 1 did not have her wanderguard on at the time of the elopement and verified no alarms went off when Resident 1 exited the facility.During a concurrent interview and record review on 7/7/26 at 3:19 PM, with the DON, the DON stated she was aware of Resident 1's wanderguard going missing two weeks ago. The DON acknowledged that the facility did not replace the wanderguard. During a review of Resident 1's elopement care plan the DON stated she expected the care plan to have more interventions such are monitoring Resident 1 and her whereabouts in the facility. Review of a physician's order dated 4/16/26, indicated, monitor whereabouts of resident every 30 minutes. Location code:1. Bed 2. room [ROOM NUMBER]. Hallway 4. Activity RM [ROOM NUMBER]. Toilet . while reviewing the MAR for April 2026 the DON confirmed this order was not transferred to the MAR as the prescriber intended for it to be. The DON stated this placed Resident 1 at risk for elopement and placed her safety at risk. The DON stated she expected the doctors' orders to be carried out adequately. Review of Resident 1's progress notes for the month of June, the DON confirmed there was no documentation about Resident 1 being monitored or observed for elopement. The DON stated the staff should have assessed the placement of the wanderguard before signing the MAR. Following a review of Resident 1's July MAR, the DON acknowledged on 7/1/26 when a nurse signed that Resident 1 had a wanderguard on was not correct. The DON stated her expectations were for the nurses to document accurately. The DON stated she expected the nurses to go to Resident 1 and look at her wrist to see the wanderguard. The DON further stated when the wanderguard placement was not accurately assessed, it placed Resident 1 at risk for elopement and put the resident's safety at risk. Review of Resident 1's elopement risk evaluation document, the DON confirmed the last assessment , dated 6/8/26, indicated Resident 1 was at a high risk for elopement. The DON stated the intervention for the high-risk score for elopement was the wandergaurd for Resident 1. The DON stated the wanderguard should have been placed back on Resident 1 and if she refused it the staff should have documented it as well as updated Resident 1's care plan. The DON stated that due to no documentation on monitoring Resident 1's whereabouts, the elopement care plan not being followed or updated, a high risk elopement evaluation score, the multiple inconsistences in the MAR, and Resident 1's diagnosis of dementia with hallucinations (seeing and hearing things that are not there), the DON stated all of these issues collaboratively placed Resident 1 at high risk for elopement and placed her safety at risk. The DON stated this practice did not meet her expectations.Review of an undated facility's policy and procedure titled, Elopement and Wandering Residents indicated, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person centered plan of care addressing unique factors contributing to wandering or elopement risk.Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan.Adequate supervision will be provided to help prevent accidents or elopements.The effectiveness of the interventions will be evaluated, and changes will be made as needed.

Based on interview, and record review, the facility failed to provide routine and emergency drugs and biologicals for 1 of 3 sampled residents (Resident 1), when Resident 1 was prescribed Nitroglycerin (medicine to relieve chest pain) by her cardiologist (heart doctor) on 2/25/26, and it was not communicated to the facility's doctor until 3 days later.This failure resulted in a delay in ordering and having Resident 1's medication available. There was also a potential for a delayed medication administration that could result in unrelieved chest pain for Resident 1.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including heart failure (heart cannot pump blood efficiently enough to meet the body's daily needs), hypertension (high blood pressure), and Takotsubo syndrome (sudden, temporary weakening of the heart muscle causing chest pain and shortness of breath).A review of Resident 1's Progress Notes, dated 2/28/26, at 12:50 PM, indicated, .Resident is requesting for the nitro [nitroglycerin] prescribed by her heart doctor when she went out on the 25th.Called [medical doctor, MD] that resident is requesting for nitro and resident states that she saw the heart doctor and has prescribed a nitro but we do not have an order on file.Per [MD], resident needs to go the hospital, No nitro.[MD] informed that resident refuses to go to the hospital and resident states that she will call the ambulance herself if she is having a heart attack.Resident states on a raised, loud and almost shouting voice that her heart doctor prescribed her the nitro when she went to the appointment on the 25th and why do they not want to prescribe it.During a concurrent interview and record review on 6/25/26, at 3:50 PM, with the Assistant Director of Nursing (ADON), Resident 1's medication administration record (MAR) dated March 2026, was reviewed. The MAR indicated, .Nitroglycerin Tablet Sublingual [under the tongue].as needed for Chest Pain.Start Date- 2/28/2026 . The ADON stated nurses needed to check for documentation if there were any new orders from the clinic and/or hospital when residents went out for their appointments or went to the emergency room. The ADON further stated that the nurses need to call the facility doctor to notify and carry out the new order. The ADON stated that she expected nurses to also document as a note in the resident's electronic health record (EHR). During an interview on 6/26/26, at 5:08 PM, with Resident 1, Resident 1 stated she went to her cardiology appointment on 2/25/26, when her heart doctor prescribed Nitroglycerin, but the facility did not order it. Resident 1 further stated that she asked the nurse about her Nitroglycerin and was told that it was not ordered in the system. Resident 1 stated when she went to the appointment on 2/25/26, she came back on the evening shift and the Certified Nursing Assistant (CNA) who went with her, handed the documents from the cardiology appointment to the nurse on the evening shift. Resident 1 further stated that the nurse eventually found the paperwork from the appointment in another binder a few days later.During a concurrent interview and record review on 6/26/26, at 8:20 AM, with Licensed Nurse (LN) 2, Resident 1's Office Visit Progress Notes from Cardiology dated 2/25/26, was reviewed. LN 2 stated they had paperwork that residents needed to bring with them when they went out for medical appointments and the doctor's office would fill out that paperwork. LN 2 further stated that sometimes, the doctor's office would give their own paperwork to the resident that had information of their next appointment or prescribed medications or any other orders. LN 2 stated that it was their process to always ask the resident or the person who took the resident to their appointment to see the paperwork. LN 2 further stated the nurses would also document as a progress note about the appointment visit and notify the doctor if there were any new orders including if any medications were prescribed. LN 2 stated Resident 1 asked her for Nitroglycerin and told her that her heart doctor had prescribed it, but when she checked there was no order for it in Resident 1's EHR. LN 2 further stated that when Resident 1 came back from her cardiology appointment, whoever took her to the appointment, misplaced the paperwork. LN 2 stated she eventually found the paperwork that was placed in another binder for a different hallway. LN 2 further stated she called the cardiologist's office to verify the orders and then she notified the facility doctor and placed the order in the EHR. LN 2 confirmed Resident 1's order for Nitroglycerin was placed 3 days later after the appointment.During an interview on 6/26/26, at 10:43 AM, with the Director of Nursing (DON), the DON stated that she expected the nurse to notify the facility doctor, carry out the order and make a progress note once the resident came back to the facility even if there were no new orders. The DON further stated that if paperwork was not seen immediately or if the doctor was not notified of the new orders, there would be a delay in care. The DON confirmed that the order for Resident 1's Nitroglycerin was delayed for 3 days.A review of an undated facility policy and procedure titled, Medication Orders, indicated, .Written Transfer Orders (sent with a resident by a hospital or other health care facility) - Implement a transfer order without further validation, if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete, or the date signed is different from the date of admission.

Based on interview, and record review, the facility failed to report an allegation of physical abuse immediately to the Department for 2 of 3 sampled residents (Resident 2 and Resident 3), when a resident-to-resident altercation involving Resident 2 and Resident 3 occurred on 6/16/26.This failure resulted in a delay in the Department's investigation of a physical abuse allegation and decreased the facility's potential to protect residents from physical and psychosocial harm.Findings:During an interview on 6/25/26, at 1:22 PM, with the front desk receptionist (FDR) 1, FDR 1 stated she was at the front desk when she witnessed the physical altercation between Resident 3 and Resident 2 (on 6/16/26). FDR 1 further stated she and other staff separated both residents immediately.During an interview on 6/25/26, at 2:45 PM, with Licensed Nurse (LN) 1, LN 1 stated the incident between Resident 2 and Resident 3 was reported by FDR 1. LN 1 stated the facility's protocol when there was suspected abuse was for staff to immediately separate the residents, call the police about the incident, notify the Administrator (ADM), and the Director of Nursing (DON). LN 1 stated she filled out a form for the suspected the physical altercation and sent it to the Ombudsman (an advocate for residents in long term care), and the police department. LN 1 confirmed she did not fax the form to the Department. LN 1 stated she was not aware that she was supposed to fax the form to the Department. LN 1 further stated that it was important to report abuse allegations.During an interview with on 6/26/26, at 10:32 AM, with the Director of Staff Development (DSD), the DSD stated that he expected the nurses to report abuse allegations immediately to the police, the Ombudsman and to the Department. The DSD further stated he expected nurses to also inform the doctor, the DON, the ADM and the resident's responsible party. The DSD stated that he expected the nurses to fax abuse allegation reports to the Department on the same day immediately especially if there was an injury.During a concurrent interview and record review on 6/26/26, at 11:03 AM, with the DON, a SOC-341 form (the standard California form used to document and report suspected abuse) dated 6/16/26, was reviewed. The DON confirmed the form was not faxed to the Department. The DON stated that the nurse should have faxed it to the Department. The DON further stated that it was important to report, so that the facility and the Department could investigate the suspected abuse allegation. During an interview on 6/26/26, at 11:23 AM, with the ADM, the ADM stated that staff needed to report and follow the facility's protocol when an incident involved an allegation of abuse. The ADM further stated that staff needed to call the police and notify the Ombudsman and the Department by faxing the SOC-341 form. The ADM stated when a staff member did not fax the form to the Department, it was not acceptable, it was not their process, and it did not follow their facility's policy.A review of the facility's undated policy and procedure titled, Abuse, Neglect and Exploitation, indicated, .Employee Training.Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources.Reporting/Response.The facility will have written procedures that include 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies.within specified timeframes.Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or.Not later than 24 hours if the events that cause the allegation do not involve abuse and do no result in serious bodily injury.

Based on observation, interview, and record review the facility failed to ensure activities of daily living (ADL, personal care tasks which include bathing, dressing, eating, and transferring in and out of bed) were provided to maintain proper hygiene for two of four sampled residents (Resident 1 and Resident 4) when: 1. Resident 1 and Resident 4's fingernails were untrimmed and soiled; and, 2. Resident 1 did not receive his scheduled shower. These failures had the potential for Resident 1 and Resident 4 to sustain injury and/or infection related to having long, unclean fingernails and had the potential to cause psychosocial distress due to the lack of hygiene. Findings: 1a. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included paraplegia (partial or complete paralysis of the lower half of the body) and depression (mental health condition that causes ongoing sadness, low energy and loss of interest). During a review of Resident 1's clinical document titled, Care Plan Report, revised 2/10/26, the document indicated, .The resident has an ADL self -care deficit.PERSONAL HYGIENE: The resident requires (Substantial assistance) by (1) staff with personal hygiene. During a concurrent observation and interview on 6/4/26 at 11:46 AM, in Resident 1's room, Resident 1 stated his fingernails were digging into his contracted (fingers curled into the palm due stiffening and tightness) right hand and could cause his hand to bleed. Resident 1's fingernails on both hands were observed to be long and uneven with a thick brown substance under his right thumb nail. During a concurrent observation and interview on 6/4/26 at 1:51 PM, with licensed nurse (LN) 1, LN 1 stated she usually trimmed Resident 1's fingernails. LN 1 confirmed Resident 1's fingernails were long and soiled and needed to be trimmed. During a concurrent observation and interview on 6/5/26 at 10:10 AM, with LN 5, LN 5 confirmed Resident 1's hands were contracted and his nails were long and unclean. LN 5 stated there was the potential for injury and infection when Resident 1's fingernails were long and unclean. LN 5 further stated Resident 1's fingernails could dig into his contracted hands and cause wounds. LN 5 stated the facility could take preventative measures such as keeping Resident 1's fingernails trimmed and clean. 1b. A review of Resident 4's admission RECORD, indicated Resident 4 was admitted to the facility with diagnoses which included depression (mental health condition that causes ongoing sadness, low energy and loss of interest). During a review of Resident 4's clinical document titled, Care Plan Report, revised 11/11/25, the document indicated, .The resident has an ADL self -care deficit.PERSONAL HYGIENE: The resident requires (Substantial assistance) by (1) staff with personal hygiene. During a concurrent observation and interview on 6/4/26 at 3:46 PM, in Resident 4's room, Resident 4's fingernails on her right hand were observed to be long and unclean with a brownish substance under the nails. Resident 4 stated the facility staff did not cut her fingernails. During a concurrent observation and interview on 6/4/26 at 4:35 PM, in Resident 4's room, with LN 4, LN 4 stated the certified nurse's assistants (CNAs) usually trimmed residents' nails on Sundays. LN 4 further stated Resident 4's fingernails on her right hand did not appeared to have been trimmed or cleaned. LN 4 stated when Resident 4 had long, unclean nails she was at risk of scratching herself and getting an infection. During an interview on 6/5/26 at 11:16 AM with the Director of Nurses (DON), the DON stated she was aware of an issue with Resident 1's and Resident 4's fingernails being long and unclean. The DON further stated if Resident 4 received an injury from his long nails he would be at risk of delayed healing due to his medical condition and both Resident 1 and Resident 4 were at risk of injury and/or infection. During a review of a facility policy and procedure (P&P) titled, Nail Care, dated 2025, the P&P indicated, .The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health.Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis.Routine nail care, to include trimming and filing, will be included on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. 2. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included paraplegia (partial or complete paralysis of the lower half of the body) and osteoarthritis (joint pain and stiffness). A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) Section GG-Functional Abilities, dated 5/22/26 indicated, .Self-Care.Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self. the section was coded, .01.Dependent -Helper does ALL of the effort. Resident does none of the effort to complete the activity. During a concurrent observation and interview on 6/4/26 at 11:43 AM, in Resident 1's room, a sign pinned to Resident 1's bulletin board indicated, .shower schedule.Tuesday, Thursday and Saturday after lunch.Management 5/23/26. Resident 1 stated there were several times he did not receive a shower when scheduled on the evening shift. Resident 1 further stated the facility had adjusted the schedule to accommodate his needs and he would receive a shower after lunch today. During an interview on 6/4/26 at 3:07 PM with Resident 1, Resident 1 stated he had not received his shower because the CNA assigned to care for him was sent out of the facility to accompany another resident on an appointment. During an interview on 6/5/26 at 9:16 AM with CNA 4, CNA 4 stated Resident 1 preferred to receive his shower after lunch but she could not provide it after lunch on 6/4/26 because she was sent out with another resident. During an interview on 6/5/26 at 10:20 AM with the Director of Staff Development (DSD), the DSD stated CNA 4 was taken off her assignment with Resident 1 on 6/4/26 because she was one of the CNAs who agreed to go to appointments. The DSD further stated he did not check with Resident 1's nurse prior to removing CNA 4 from Resident 1's care. During an interview on 6/5/26 at 11:16 AM with the DON, the DON stated Resident 1 required a lot of assistance and she was not aware that CNA 4 had been removed from his care on 6/4/26. The DON further stated it was important for Resident 1 to receive his scheduled shower to remain clean and to prevent infection. The DON stated Resident 1 had the right to choose his shower schedule and to receive a shower on those days. During a review of a facility P&P titled, Resident Shower, dated 2026, the P&P indicated, .It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice.Residents will provided showers as per request or as per facility schedule protocols.

Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) remained free from abuse (willful infliction of injury, and/or intimidation resulting in physical harm, pain or mental anguish) when Resident 2 hit Resident 1 with his cane. This failure caused Resident 1 to feel threatened and fearful for his safety while residing in the facility and had the potential to result in emotional distress and ongoing fear. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included paraplegia (loss of movement or feeling of the lower half of the body) and depression (mental health condition that causes ongoing sadness, low energy and loss of interest). A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) Section C- Cognitive Patterns, dated 5/22/26, indicated, .Brief Interview of Mental Status (BIMS) [screening tool to assess cognitive impairment].BIMS Summary Score.15. (a score of 13 to 15 points suggests that cognition is intact). During an interview on 6/4/26 at 12:13 PM with Resident 1, Resident 1 stated he had previously argued with Resident 2 and Resident 2 came at me but was stopped by a staff member. Resident 1 further stated on 5/22/26 he was being pushed up the ramp into the van by two staff members when Resident 2 came running up behind him, cursed at him and stated he was going to kill him. Resident 1 stated Resident 2 was able to get in between the staff members and hit him on the head. Resident 1 stated after that he had requested a temporary restraining order against Resident 2. During an interview on 6/4/26 at 3:54 PM with the facility receptionist (FR), the FR stated on 5/22/26, she observed Resident 2 running up behind Resident 1 as he was being pushed into the van and she knew Resident 2 could be dangerous. The RF stated Resident 2 held his cane horizontally and hit hard at the back of Resident 1's high backed wheelchair. The RF stated she then stood in front of Resident 2 and talked to him until other staff arrived. During an interview on 6/4/26 at 2:54 PM with Resident 2, Resident 2 stated on 5/22/26 he was sitting out front and he heard Resident 1 verbally berate another resident, so Resident 2 slapped Resident 1. Resident 2 denied hitting Resident 1 with his cane. During a telephone interview on 6/16/26 at 11:26 AM with certified nurse assistant (CNA) 5, CNA 5 stated on 5/22/26 she pushed Resident 1, in his wheelchair, into the van and did not see Resident 2 come up behind them. CNA 5 further stated Resident 1 informed her he had been hit by Resident 2, then the FR came and stood with Resident 2. CNA 5 stated she proceeded to put Resident 1 in the van to prevent him from being hit. During a telephone interview on 6/17/26 at 11:42 AM the Director of Nursing (DON) stated the facility staff are taught to be aware of and intervene in situations that could lead to abuse. The DON further stated the facility had tried to prevent an altercation by assigning 1-1 staff to Resident 1 and Resident 2, but it made Resident 1 uncomfortable and Resident 2 became agitated with 1-1 staff, so they were monitored from a distance. The DON stated incidents of abuse had the potential to cause residents to feel depressed, unsafe, paranoid and fearful. During a review of a facility policy and procedure (P&P) titled Abuse, Neglect and Exploitation, dated 2025, the policy indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Identifying, correcting and intervening in situations in which abuse.is more likely to occur.and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms.

Based on interview and record review the facility failed to follow their discharge planning policy for one of four sampled Residents (Resident 1) when Resident 1's electronic health record (EHR) did not contain documentation of Resident 1's discharge goals and needs. This deficient practice had the potential to delay Resident 1's discharge and to not involve him in the planning process. Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in late 2025. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) Section C- Cognitive Patterns, dated 5/22/26, indicated, .Brief Interview of Mental Status (BIMS) [screening tool to assess cognitive impairment].BIMS Summary Score.15. (a score of 13 to 15 points suggests that cognition is intact). During an interview on 6/4/26 at 12:01 PM with Resident 1, Resident 1 stated he had no discharge plan and when he asked the social services director about a plan he was told they would return to discuss it, but they never came back. During a concurrent interview and record review on 6/5/26 at 10:24 AM with the interim social services director (ISSD), the ISSD confirmed there was no documentation in Resident 1's EHR to indicate a discharge plan had been created. The ISSD stated she would expect to see discharge planning notes on admission and on the social services evaluation. The ISSD further stated discharge planning was done to make sure the facility coordinated goal setting with the residents needs, identified any barriers, advised of realistic options and initiated any referrals that may be needed. During an interview on 6/5/26 at 11:16 AM with the Director of Nurses (DON), the DON stated it was her expectation that Resident 1 would have a discharge plan implemented. The DON further stated discharge planning should have started for Resident 1 on admission. During a review of a facility policy and procedure (P&P) titled, Discharge Planning Process, dated 2025, the P&P indicated, . Discharge planning is a process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge.The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge.The facility will determine the resident's expected goals and outcomes regarding discharge upon admission.subsequent assessment information and discharge goals will be included in the resident's comprehensive plan of care.

Based on interview, and record review, the facility failed to hold a residents' monthly resident council meeting for a census of 88 residentswhen, the resident council meeting was not held for the months of February 2026 and March 2026. This failure resulted in not honoring the residents' rights to meet for the resident council meeting and had the potential for residents' not to have their grievances or other concerns being heard and resolved. Findings: During the facility's resident council meeting on 5/11/26, at 10:37 AM, Residents 29, Resident 32, Resident 44, Resident 52, Resident 61, and Resident 66 voiced their concerns about not having a resident council meeting for the months of February 2026 and March 2026 despite their request to have a meeting. During a concurrent interview and record review on 5/11/26, at 8:46 AM, with the Activity Director (AD), resident council meeting minutes and monthly activities calendar were reviewed. The AD confirmed there was no evidence of a resident council meeting during both February of 2026 and March of 2026. The AD further confirmed the resident council meetings were scheduled for February 19th 2026 and March 19th 2026 as per monthly activities calendar but were not held. The AD stated the resident council meeting should be held monthly because it was the residents' right. During an interview on 5/13/26, at 10:07 AM, with the Administrator (ADM), the ADM confirmed the facility did not provide the residents' a resident council meeting for the months of February of 2026 and March of 2026. A review of the facility's policy and procedure titled, Resident Council Meetings, dated 2025, indicated, .This facility supports the rights of residents to organize and participate in resident groups, including a Resident Council. This policy provides guidance to promoting structure, order, and productivity in these group meetings. [Resident or family group] is defined as a group of residents.or family members that meet regularly to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life; support each other; plan resident and family activities; participate in educational activities; or for any other purpose.The residents meets.no less than determined by the group. The date, time, and location of the meetings are noted on the Activities Calendar.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with an environment free from accident hazards when certified nursing assistant (CNA) 1 provided care to Resident 1 alone, but based on Resident 1's assessed needs required two staff members, and Resident 1 had an air mattress (a mattress that works by using air chambers that redistribute pressure, improve blood flow, and reduce friction for residents with limited mobility) placed on his bed without a physician's order or monitors in place to ensure the correct settings were maintained. These failures resulted in Resident 1 falling from his bed and sustaining a broken bone in his right big toe on 9/25/25.Findings:A review of Resident 1's admission RECORD, indicated, Resident 1 was admitted to the facility with diagnoses of cerebral infarction (part of the brain does not get enough blood and oxygen causing brain tissue to die), left hemiplegia (little to no use of one side of the body), and severe obesity (significant excessive body weight that poses serious health risks).A review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool), dated 10/8/25, revealed a score of 14 out of 15 total points which indicated Resident 1 had normal memory, thinking, and understanding abilities. A review of Resident 1's Weight Summary, dated 9/1/25, indicated Resident 1's weight was 362.4 pounds.A review of Resident 1's Care Plan Report, revised 5/5/22, indicated, .The resident [Resident 1] has an ADL [activities of daily living] self-care performance deficit r/t [related to] left sided weakness.BED MOBILITY.The resident requires extensive assistance with 2+ [two or more] persons physical assist to turn and reposition in bed as necessary.date initiated 01/02/2023.Review of Resident 1's Progress Notes, dated 9/25/25, indicated Licensed Nurse (LN) 1 documented, .Called by the CNA [certified nursing assistant] in charge and he stated resident [Resident 1] slid from his bed now on the floor.found resident laying on his back on the floor.CNA [CNA 1] stated he turns on his left side then slid on the bed.A review of Resident 1's Radiology Results Report dated 9/26/25 indicated, .Reason for Study.ACUTE PAIN DUE TO TRAUMA.CONCLUSION: Acute fracture proximal phalanx right great toe [broken bone in the right big toe].During a phone interview with CNA 1 on 10/21/25 at 2:18 PM, CNA 1 stated that Resident 1's fall occurred when he was preparing to change Resident 1 and the mattress broke and he rolled out. At the time of the incident, CNA 1 stated he was positioned on the right side of Resident 1's bed and asked Resident 1 to roll over onto his left side. CNA 1 confirmed that the facility required two staff members to assist Resident 1 with Activities of daily living (ADLs, basic skills you need in regular daily life to care for yourself and/or others); however, he was alone at the time of the incident. CNA 1 reported that the air mattress, which had been installed the day prior, was unstable when Resident 1 turned. CNA 1 stated he was unsure who installed the air mattress for Resident 1 the day prior.During a concurrent observation and interview with Resident 1 in his room on 10/21/25 at 1:41 PM, it was observed that Resident 1 was able to move the right side of his body but was unable to move his left side. No air mattress was observed. Resident 1 stated on the day of the fall (9/25/25), CNA 1 assisted him with changing his brief (a disposable product used by people who cannot control their bladder and/or bowels). Resident 1 stated CNA 1 instructed him to turn to his left side but when he did so, the air mattress deflated on the left side, causing him to fall onto the floor. Resident 1 stated that only CNA 1 was present during the incident. Resident 1 further stated he can turn by himself, but since the fall, two staff members have now assisted him during care. Resident 1 stated the air mattress was removed on 9/25/25 after his fall. During an interview with the Director of Staff Development (DSD) on 10/21/25 at 2:09 PM, the DSD stated that the facility's protocol for a newly installed air mattress included verifying that the mattress settings were appropriate for the resident's weight and checking the overall firmness of the bed. Additionally, nurses were trained to ensure that the mattress remains properly inflated and is not flat. The DSD further stated that both he and the Director of Rehabilitation (DOR) trained staff on proper air mattress repositioning. They emphasized that residents who were immobile or morbidly obese should be turned with the assistance of two CNAs at a time. Regarding Resident 1, CNA 1 was the only staff member assisting him during the incident and was subsequently written up for not following the protocol. A review of the facility's memo titled, CORRECTIVE ACTION MEMO dated 9/25/25 indicated, .Type of Violation: Violation of Safety Rules.employee [CNA 1].failure to follow company protocol regarding repositioning or doing ADL's care for morbid obesity patients have to be 2 people assist to prevent fall.During a concurrent interview and record review with the Administrator (ADM) and the assistant director of nursing (ADON) on 10/30/25 at 12:15 PM, the air mattress invoices were reviewed. The ADM stated that an air mattress was ordered from their vendor on 9/19/25 for another resident (Resident 3). When Resident 3 was discharged from the facility, facility staff switched Resident 3's bed, including the air mattress, with Resident 1's bed. The ADON confirmed the settings for Resident 1's air mattress were never added to Resident 1's treatment or medication administration record so the nurses could verify the mattress settings every shift. During a concurrent interview and record review of Resident 1's medical record with the ADON on 10/30/25 at 2:15 PM, the ADON stated she was unsure who decided to move Resident 3's bed to Resident 1's room, as there was no physician order for an air mattress for Resident 1.During a phone interview with the ADON on 11/3/25 at 10:35 AM, the ADON stated that if an air mattress was applied to a resident's bed without a physician's order, there would be a risk of injury to the resident using the mattress.A review of the facility's Policy titled, Sufficient Staffing revised 10/2024 indicated, .Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. A review of the facility's undated Certified Nursing Assistant - Job Description indicated, .Major Duties and Responsibilities.Assist resident with or performs activities of daily living for resident in accordance with the care plans and established policies and procedures.Additional Assigned Tasks.Establish a culture of compliance by adhering to all facility policies and procedures.A review of the facility's policy titled, Assistive Devices and Equipment revised 10/2024 indicated, .Devices and equipment that assist with resident mobility safety and independence are provided for residents. These include.Specialty mattresses.The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment.Personal fit.equipment or device will be used according to its intended purpose and will be measured to.the resident's size and weight as much as possible.Requests or the need for special equipment should be referred to the appropriate Department.

Based on observation, interview, and record review, the facility failed to provide respiratory care (the diagnosis, treatment, and management of residents with breathing or other cardiopulmonary (heart and lung) disorders) consistent with professional standards of practice for two of two sampled residents (Resident 1 and Resident 2) with a tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) when: 1. Registered Nurses (RNs) provided care for Resident 1 and Resident 2 without documented competencies (measurable patterns of knowledge that enabled individuals to perform a skill successfully) for tracheal suctioning (a procedure that cleared mucus (a sticky substance produced by the body) and secretions (liquid substance produced by the body) from the trachea (a tube-like structure that allowed air to travel to and from the lungs) through a tracheostomy tube (a removable tube inserted in tracheostomy)), and tracheostomy care (maintaining a clean tracheostomy tube, that included cleaning the inner cannula; a removable tube that fits inside the larger outer cannula of a tracheostomy tube), and changing dressings (specialized medical dressing used to cover and protect the opening created in the neck to help manage secretions and prevent infection); 2. Tracheostomy care and tracheal suctioning care plans (a document that outlined a resident's health needs, goals, and the specific actions (interventions) a nurse took to achieve those goals) were not created for Resident 1 and Resident 2; and 3. RNs were not always available in the facility 24 hours a day, seven days a week from 7/28/25 through 8/7/25, to carry out Resident 1's and Resident 2's physician order for as needed tracheostomy suctioning (a respiratory task that falls within the scope of practice for trained healthcare professionals, particularly registered nurses and respiratory therapists). These deficient practices placed Resident 1 and Resident 2 at increased risk for the development of infection such as Pneumonia (when harmful germs enter the lungs, multiply, and cause illness), desaturation (a decrease in blood oxygen levels), aspiration (inhaling or drawing something into the lungs other than air), and acute respiratory distress (a serious lung condition that prevented enough oxygen from getting into the blood). This created a likelihood serious physical harm (significant injury or damage that could have long-lasting or potentially life-threatening consequences), hospitalization, and/or death would occur, if not corrected immediately. The Immediate Jeopardy (IJ-a threat to resident health or safety which requires immediate corrective action due to the likelihood of serious injury or harm) began on 7/28/25, when the facility failed to provide competencies to nursing staff regarding tracheostomy suctioning, no care plans were in place related to tracheostomy care, and the facility did not ensure a RN was on duty for an entire 24 hour period to provide tracheostomy suctioning as needed to Resident 1 and Resident 2. The Administrator (ADM) and Director of Nursing (DON) were notified of the IJ on 8/7/25, at 5:43 PM. On August 7th, 2025, at 8:01 PM, a removal plan was provided by the facility. The State Agency verified the facility's implementation of the removal plan while onsite at the facility. On 8/7/25, at 8:35 PM, the ADM and DON were notified that the IJ immediacy was removed. There was no non-compliance identified at a lower level upon removal.Findings: 1a. During a review of Resident 1's clinical document titled, admission RECORD, the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis which included respiratory failure (a serious condition that makes it difficult to breathe on your own), hypoxia (a condition where there was an inadequate supply of oxygen to the body's tissues), and the presence of a tracheostomy. A review of Resident 1's clinical document titled, Order Summary, dated 7/29/25, ordered by the Medical Director, (Med Dir - a physician who oversees resident care), the document indicated, .Perform suctioning via tracheostomy PRN [as needed] for audible secretions, visible mucus, increased work of breathing, or [oxygen saturation; the amount of oxygen you have circulating in your blood] < [less than] 92% [percent]. Use sterile technique [free from germs] with suction catheter [a sterile, flexible tube, used to remove secretions and other fluids from the airways of residents who cannot clear them on their own].pre oxygenate [the administration of oxygen to a resident before a procedure]. During a concurrent observation and interview on 8/7/25, at 9:15 AM, with Resident 1, in Resident 1's room, Resident 1 was observed to have a tracheostomy. Resident 1 stated she had asked the facility staff to please perform her tracheostomy care, stating the last time it was done was on 8/5/25, two days prior. Resident 1 stated the facility staff informed her that there was not anyone able to do her tracheostomy care. Resident 1 stated the last time she had tracheostomy care was on 8/5/25. During an interview on 8/7/25, at 12:47 PM, with Licensed Nurse (LN; a Licensed Vocational Nurse, LVN) 2, LN 2 stated she had asked Respiratory Therapist (RT) 2, on 8/5/25, if the RT staff would provide tracheostomy care for Resident 1. LN 2 stated RT 2 refused and stated she was leaving the facility and would no longer work for the facility. LN 2 stated she asked LN 4, a registered nurse on duty on 8/5/25, to provide tracheostomy care to Resident 1, but LN 4 told her that he did not know how to do tracheostomy care. LN 2 stated the RTs were only on duty on the day shift and RNs were not available when the residents with tracheostomy's were first admitted to the facility. 1b. During a review of Resident 2's clinical document titled, admission RECORD, the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included respiratory failure with hypoxia and the presence of a tracheostomy. A review of Resident 2's clinical document titled, Order Summary, dated 7/29/25, the document indicated, .Perform suctioning via tracheostomy PRN for audible secretions, visible mucus, increased work of breathing, or [oxygen saturation] < 92%. Use sterile technique with suction catheter.pre oxygenate. During an interview on 8/7/25, at 12:47 PM, with LN 2, LN 2 stated that the LVNs expressed concerns about caring for Resident 1 and Resident 2's tracheostomy needs because the facility had not provided the competencies needed to provide tracheostomy care. During an interview on 8/7/25, at 2:33 PM, with RT 1, RT 1 stated the RNs and RTs had not received any in-service (activities or training that take place while someone is employed, often to improve their skills or knowledge for their current role) training for tracheostomy care and tracheal suctioning. During a concurrent interview and record review on 8/7/25, at 2:47 PM, facility documents titled, Tracheostomy and T-Piece Care Competency Evaluation Form, dated 7/25, and the undated Suctioning In-Service Training, were reviewed with the Director of Nursing (DON). The DON confirmed both forms were blank (no names listed), which indicated there were no competencies completed for the RTs and LNs (both LVN's and RNs) for tracheostomy care and tracheal suctioning. The DON explained that the facility should have provided training for the RTs and LNs (both LVNs and RNs) to ensure the RTs and LNs had the competencies to provide safe tracheostomy and care and tracheal suctioning. During an interview on 8/7/25, at 2:54 PM, with RT 2, RT 2 stated she had not conducted or scheduled competencies with any of the licensed staff (additional RTs and/or RNs) to care for residents with tracheostomies (Resident 1 and Resident 2). RT 2 stated she did not work at the facility any longer. During an interview on 8/7/25, at 4:06 PM, with RT 1, RT 1 stated the RTs were not hired to do tracheostomy care and suctioning, they were hired to do incentive spirometer (a handheld medical device used to help residents breathe deeply and regularly, particularly after surgery or for those with lung conditions) and acapella (a handheld device that helped residents with respiratory conditions clear mucous; thick, slippery, and usually clear substance produced by the body to protect and lubricate various surfaces) from their lungs). RT 1 explained Resident 1 and Resident 2 were at risk for desaturation and pneumonia (infection in the lungs) when the facility did not have RNs who had the competencies to care for Resident 1 and Resident 2's tracheostomy care needs. During an interview on 8/8/25, 3:30 PM, with the Medical Director (Med Dir), the Med Dir stated the facility should have ensured they had staff that could care for, assess, and provide safe tracheostomy care and tracheal suctioning. The Med Dir stated that the facility should have ensured that staff received appropriate training and had the necessary competencies to care for residents with tracheostomies. The Med Dir further explained Resident 1 and Resident 2 were at risk of death because the staff did not have the appropriate training and competencies to manage tracheostomies. A review of the facility titled, Competency Evaluation, dated 2024, the document indicated, . Policy . It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skill for performing their job . Competency . a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual need to perform work roles or occupational functions successfully . A review of the facility policy titled, Tracheostomy Care-Suctioning, dated 2024, the document indicated, . Tracheal suctioning is performed by a Competent Registered Nurse and Respiratory Therapist to clear the throat and upper respiratory tract of secretions that may block the airway . A review of the facility policy titled, Tracheostomy Care, dated 2024, the document indicated, . The facility will ensure staff responsible for providing tracheostomy care including suctioning are trained and competent according to professional standards of practice . 2. During a concurrent interview and record review on 8/7/25, at 4:55 PM, Resident 1's and Resident 2's electronic medical record was reviewed with the DON. The DON confirmed no care plans and/or baseline care plan (care plans developed during the first 48 hours of the residents stay at the facility) had been developed for Resident 1 and Resident 2 regarding tracheostomy care and tracheal suctioning. The DON explained the importance of the care plans was to direct the care of the residents. A review of a facility policy titled, Comprehensive Care Plans, dated 2025, the document indicated, . The comprehensive care plan will describe, at a minimum . services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being . A review of the facility policy titled, Tracheostomy Care, dated 2024, the document indicated, . Based on the resident assessment, attending physician's orders, and professional standards of practice, the facility in collaboration with the resident/resident's representative will develop a care plan that includes appropriate interventions for respiratory care . 3. During a concurrent interview and record review, on 8/7/25, at 4:40 PM, the facility staffing sheets (documents that outline the number and types of staff scheduled to work at a facility on a given shift and/or day) from 7/28/25 through 8/7/25 were reviewed with the DON. The DON confirmed the following shifts (AM shift was 6:30 AM to 3 PM, PM shift was 2:30 PM to 11 PM, NOC (night) shift was 11 PM to 7 AM) and/or portions of shifts were without a RN assigned to work on the floor: 7/28/25 NOC shift, 7/29/25 NOC shift from 11 PM to 1 PM, 7/30/25 AM shift and PM shift, 7/31/25 AM shift and NOC shift, 8/1/25 AM shift and PM shift, 8/4/25 PM shift, 8/5/25 PM shift, 8/6/25 AM shift, and 8/7/25 AM shift. During a concurrent interview and record review, on 8/8/25, at 3:10 PM, the Facility Assessment (a comprehensive evaluation of a facility's ability to provide skilled nursing care, rehabilitation services, and other related health services to residents), dated 8/8/24, was reviewed with the Administrator (ADM). The ADM stated the facility had not met the facility assessment staffing plan which indicated .Based on the facility's resident population and their needs for care and support, the facility's general approach to staffing is to ensure that it has sufficient staff members with the appropriate competencies and skill sets to meet the needs of the residents. The ADM explained his expectations were whenever there was a resident in the facility with a tracheostomy the facility would have an RN in the building 24 hours a day to provide tracheostomy care, and that the staff would have the required competencies. The ADM also explained the risk to the residents with tracheostomies could have been a negative clinical outcome (an undesirable or unfavorable result for a patient receiving medical care).