Every finding on record at Burbank Healthcare & Rehab

Based on interviews and record reviews, the facility failed to ensure comprehensive and accurate Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling) were completed and updated to identify residents at risk for falls for three of three sampled residents (Resident 1, Resident 2, Resident 3), when: 1. The facility failed to complete Resident 1's quarterly Fall Risk Evaluation. 2. The facility failed to assess Resident 2's risk for a fall after Resident 2 had a fall on 7/9/2026. 3. The facility failed to accurately document Resident 3's Fall Risk Evaluation dated 6/21/2026. These failures placed Residents 1, 2, and 3 at increased risk for recurring falls and fall-related injuries by failing to accurately identify, reassess, and respond to changes in residents' fall risk status in accordance with professional standards of practice.Findings:a. During a review of Resident 1's Face Sheet (FS), the FS indicated the facility admitted Resident 1 on 10/18/2026 and readmitted the resident on 3/22/2026 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body)), and hemiparesis (muscle weakness or partial loss of strength on one side of the body, typically affecting the arm, leg, and face) following cerebral infarction (when a blood clot blocks blood flow, causing brain tissue to die from a lack of oxygen) affecting the right non-dominant side, dementia (a progressive state of decline in mental abilities), and osteoarthritis (progressive disorder of the joints, caused by a gradual loss of cartilage).During a review of Resident 1's Care plan (CP) created on 10/29/2024 and revised on 7/21/2026, the CP indicated Resident 1 was at risk for falls and injuries related to osteoarthritis, dementia and history of falls with interventions that included fall risk assessment upon admission, quarterly and as needed and place the resident on falling star program. During a review of Resident 1's History and Physical (H&P- a doctor's first complete checkup and interview to find out why you are sick and how to treat you) dated 3/24/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Change of Condition (COC) Assessment Form dated 7/9/2026 at 9:33 a.m., the COC Assessment Form indicated Resident 1 had a fall. During a review of Resident 1's Fall Risk Evaluation dated 7/9/2026, the Fall Risk Evaluation indicated Resident 1 had a fall risk score of 20 (a score 10 or greater the resident should be considered at high risk for potential falls).During a review of Resident 1's Fall Risk Evaluation dated 7/17/2026, the Fall Risk Evaluation indicated Resident 1's fall risk score was 14. The Fall Risk Evaluation section titled, Gait/Balance, and Medication, is noted to be blank. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/17/2026 the MDS indicated Resident 1 usually understood and was usually understood. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting, required partial assistance (helper does less than half the effort) with showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene, and required supervision (helper provides verbal cues, touching, steadying and or contact guard assistance as resident completes activity) with eating, and oral hygiene. During a concurrent interview and record review on 7/23/2026 at 1:41 p.m. with the Minimum Data Set Nurse (MDS) 1, of Resident 1's Fall Risk Evaluation, MDS 1 stated he (MDS 1) does the Fall Risk Evaluation. MDS 1 stated all sections of the Fall Risk Evaluation must be completed. MDS 1 stated if all the items are not reviewed and checked off then it is not a complete assessment. MDS 1 reviewed Resident 1's Fall Risk Evaluation dated 7/17/2026 and stated he (MDS 1) was the one to complete this assessment. MDS 1 stated the Fall Risk Evaluation dated 7/17/2026 was not completed. MDS 1 stated if not completed the score will be affected, MDS 1 stated Resident 1's fall risk score did change went from a score of 20 to a score of 14. MDS 1 stated there is a potential for the resident's care needs to change. MDS 1 stated can result in an inaccurate assessment of the resident and we will not capture the correct plan of care, can be a potential for a fall. During an interview on 7/23/2026 at 3:13 p.m. with the Director of Nursing (DON), the DON stated the MDS 1 informed her (DON) about Resident 1's Fall Risk Evaluation dated 7/17/2026, the DON stated the assessment was not complete. The DON stated the Fall Risk Evaluation should be complete and will be inaccurate if it is not completed. The DON stated there will be a potential to place Resident 1 at risk for another fall. b. During a review of Resident 2's FS, the FS indicated the facility admitted Resident 2 on 6/26/2026 with diagnoses including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), dementia, abnormalities of gait and mobility, and muscle weakness. During a review of Resident 2's H&P dated 6/29/2026 the H&P indicated Resident 2 had the ability to understand and make decisions. The H&P indicated Resident 2 is high risk for falls, aspiration, infection, sepsis, repertory arrest, cardiac arrest and sudden death. During a review of Resident 2's Fall Risk Evaluation dated 6/26/2026, the Fall Risk Evaluation indicated Resident 2 had a fall risk score of 8.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 needed partial assistance with toileting, showering, lower body dressing, putting on and taking off footwear, and personal hygiene, and required supervision with upper body dressing, and required set up assistance (helper sets up or cleans up, resident completes activity) with eating, and oral hygiene.During a review of Resident 2's COC Assessment Form dated 7/9/2026 at 10:18 p.m., the COC Assessment Form indicated Resident 2 slid off bed while reaching his drink. During a review of Resident 2's CP created on 7/14/2026 the CP indicated Resident 2 was at risk for falls and injury related to MS, dementia, and malignant neoplasm with interventions that included fall risk assessment upon admission, quarterly and as needed, and provide a safe and clutter free environment. During a concurrent interview and record review on 7/23/2026 at 3:13 p.m. of Resident 2's COC Assessment Form dated 7/9/2026 with the DON, the DON stated after a fall there should be another Fall Risk Evaluation. The DON reviewed Resident 2's COC Assessment Form dated 7/9/2026 and Resident 2's Fall Risk Evaluation and the DON stated there was no Fall Risk Assessment done after Resident 2 had the fall on 7/9/2026. The DON stated a Fall Risk Evaluation must be done to ensure staff reassess the residents' risk for all and implement other recommendations to prevent falls. The DON stated since there was no Fall Risk Assessment after Resident 2's fall on 7/9/2026 there can be potential for another fall.c. During a review of Resident 3's FS, the FS indicated the facility admitted Resident 3 on 5/5/2026 with diagnoses including muscle weakness, difficulty walking, and dyspnea (shortness of breath or difficulty breathing).During a review of Resident 3's Fall Risk Evaluation dated 5/5/2026 the Fall Risk Evaluation indicated Resident 3's fall risk score was a 6.During a review of Resident 3's H&P dated 5/6/2026 the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS dated [DATE] the MDS indicated Resident 3 had the ability to understand and be understood. The MDS indicated Resident 3 required substantial assistance with toileting, showering, lower body dressing, and putting on and taking off footwear, required partial assistance with upper body dressing and supervision with personal hygiene and setup with eating, and oral hygiene.During a review of Resident 3's CP created on 5/12/2026 the CP indicated Resident 3 was at risk for falls and injuries related to difficulty walking, generalized weakness, and history of falling with interventions that included to place Resident 3 on the Star program and fall risk assessments upon admission, quarterly and as needed. During a review of Resident 3's COC Assessment Form dated 6/21/2026 at 3:30 p.m., the COC Assessment Form indicated Resident 3 had a fall. During a review of Resident 3's Fall Risk Evaluation dated 6/21/2026 at 7:48 p.m. the Fall Risk Evaluation indicated Resident 3 had a fall risk score of 10. The Fall Risk Evaluation indicated Resident 3 had not had any falls in the past three months. During an interview on 7/23/2026 at 1:41 p.m. with MDS 1, MDS 1 stated if there is a fall on that day, the Fall Risk Evaluation would count that fall within the last three months. During a concurrent interview and record review on 7/23/2026 at 3:13 p.m. of Resident 3's Fall Risk Evaluation dated 6/21/2026 with the DON, the DON reviewed the Fall Risk Evaluation dated 6/21/2026 and the DON stated Resident 3's fall was not captured in the Fall Risk Evaluation. The DON stated the fall should be indicated on the Fall Risk Evaluation after the fall, this documentation is not accurate. The DON stated there is a risk for inaccurate fall risk score, there is a potential for a fall due to the inaccurate score. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, last reviewed on 2/20/2026, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident form falling and to try to minimize complications from falling. During a review of the facility's P&P titled, Falls-Clinical Protocol, last reviewed on 2/20/2026, the P&P indicated based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. During a review of the facility's P&P titled, Fall Risk Assessment, last reviewed on 2/20/2026, the P&P indicated nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. 1. Upon admission, the nursing will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling overtime.3. The nursing staff, attending physicians, and consultant pharmacists will review for medications or medication combinations that could relate to fall or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension.5. The nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions or sensory impairment that may predispose to falls.7. The staff, with the support of attending physicians, will evaluate functional and psychological factors that may increase the fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. During a review of the facility's Policy and Procedures (P&P) titled, Charting and Documentation, last reviewed on 2/20/2026, the P&P indicated documentation in the medical record will be objective, complete and accurate.

Based on interview and record review, the facility failed to ensure medications were available and administered as ordered for one of three sampled residents (Resident 2) when Resident 2 who had an active physician's order for Tramadol-Acetaminophen (a prescription medicine that combines two different pain relievers, tramadol and acetaminophen, to treat moderate to severe short-term pain) to be administered as needed for pain for 14 days, however the medication was unavailable, and Resident 2 went approximately two and a half days without access to the prescribed medication during the active order period. This failure had the potential to result in unmanaged pain and inadequate pain symptom control for Resident 2.Findings: During a review of Resident 2's Face Sheet (FS), the FS indicated the facility admitted Resident 2 on 6/26/2026 with diagnoses including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), dementia, abnormalities of gait and mobility, and muscle weakness. During a review of Resident 2's H&P dated 6/29/2026 the H&P indicated Resident 2 had the ability to understand and make decisions. The H&P indicated Resident 2 is high risk for falls, aspiration, infection, sepsis, repertory arrest, cardiac arrest and sudden death. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 needed partial assistance with toileting, showering, lower body dressing, putting on and taking off footwear, and personal hygiene, and required supervision with upper body dressing, and required set up assistance (helper sets up or cleans up, resident completes activity) with eating, and oral hygiene. During a review of Resident 2's Order Summary Report (OSR), dated 7/13/2026, the OSR indicated Tramadol-Acetaminophen tablet 37.5 to 325 milligram (mg- a unit of measurement) give one tablet by mouth every four hours as needed for severe pain of seven out of 10 for 14 days. During a review of Resident 2's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for July 2026, the MAR indicated Tramadol-Acetaminophen (a prescription medicine that combines two different pain relievers, tramadol and acetaminophen, to treat moderate to severe short-term pain) 37.5 to 325 mg give one tablet by mouth every four hours as needed for severe pain seven out of 10 for 14 days, was last given on 7/21/2026 at 8:36 a.m. for a pain of 8 out of 10. During a review of the facility provided record titled, Skilled Nursing Pharmacy Refill Request Only, form dated 7/21/2026 at 10 a.m., the Skilled Nursing Pharmacy Refill Request Only indicated a request for Resident 2's Tramadol-Acetaminophen 37.5 to 325 mg. During a review of Resident 2's Progress notes titled, Licensed Nursing Note, dated 7/23/2026 at 11:11 a.m. the Progress Note indicated per skilled nursing pharmacy verbalized tramadol with acetaminophen to be expedited and delivered possibly today on 7/27/2026, no exact time stated, since they are unable to provide an estimate time of arrival. During a review of the facility provided record titled, Urgent: Notice of Non-Covered/High-Cost Drug. Dated 7/23/2026 at 11:19 a.m. the Urgent: Notice of Non-Covered/High-Cost Drug indicated option one Tramadol-Acetaminophen 37.5 to 325 mg give one tablet by mouth every four hours as needed for severe pain seven out of 10 for 14 days, amount billed $76.65 quantity 42 for seven days. During an interview on 7/23/2026 at 11:15 a.m. with Resident 2 stated he takes Tramadol and he needs it at night. Resident 2 stated last night he did not get the tramadol. Resident 2 stated his pain is only at nighttime. Resident 2 stated when he gets the tramadol he sleeps from 10 p.m. to 8 a.m. and since not getting the tramadol has been having a hard time sleeping. Resident 2 stated he is restless. During an interview on 7/23/2026 at 2:31 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated is aware Resident 2 had concerns with not getting tramadol. LVN 1 stated Resident 2 has an order for the tramadol. LVN 1 stated she (LVN 1) followed up with pharmacy yesterday (7/22/2026) and the pharmacist stated Resident 2's tramadol was denied by the insurance company. LVN 1 stated she (LVN 1) called the pharmacy today and was told the pharmacy would send over a form for skilled nursing facility (SNF) to pay out of pocket. LVN 1 stated Resident 2 stated he has severe pain due to Resident 2 having MS. LVN 1 stated if Resident 2 went two and half days without his tramadol there is a potential for Resident 2 to be in pain, will not allow the resident to be able to do is daily activities of living due to pain, especially because Resident 2 gets rehab services. During an interview on 7/23/2026 at 3:13 p.m. with the Director of Nursing (DON), the DON stated was made aware of Resident 2's tramadol medication was not covered this morning. The DON stated staff should reorder medication five to seven days prior to the medication running out. The DON stated if there is an active order for the medication, the medication should not run out. The DON stated for pain medication Resident 2 is at risk for pain not being resolved because the tramadol is not being available. During a review of the facility's Policy and Procedures (P&P) titled, Pain Assessment and Management, last reviewed on 2/20/2026, the P&P indicated pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Review the medication administration record to determine how often the individual requests and receives as needed pain medication, and to what extent the administered medications relieve the resident's pain. Implementing Pain Management Strategies: 2. Pharmacological intervention may be prescribed to manage pain. During a review of the facility's P&P titled, Medication Ordering and Receiving From Pharmacy, last reviewed on 2/20/2026, the P&P indicated if not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ordered by peeling the bottom part of the pharmacy label and placing it in the appropriate area on the order from provided by the pharmacy for that purpose and ordered as follows: a. Reorder medication five days in advance of need to assure an adequate supply is on hand. Reorder a as needed medication five days in advance of anticipated need based on the current usage.

Based on interview and record review, the facility failed to maintain medical records in accordance with acceptable professional standards and practices for two of three sampled residents (Resident 1 and Resident 3) when:1. Resident 1's Fall Risk Evaluation (a comprehensive clinical assessment to identify the specific factors that increase a person's likelihood of falling), dated 7/17/2026, was incomplete.2. Resident 3 had a fall on 6/21/2026 and the Fall Risk Evaluation, dated 6/21/2026, did not reflect the resident's fall and was inaccurate.This deficient practice resulted in inaccurate documentation of Resident 1's and Resident 3's records. Findings: a. During a review of Resident 1's undated Face Sheet (FS - a single page summary document at the very front of a resident's chart), the FS indicated the facility admitted Resident 1 on 10/18/2026 and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial loss of strength on one side of the body, typically affecting the arm, leg, and face) following cerebral infarction (when a blood clot blocks blood flow, causing brain tissue to die from a lack of oxygen) affecting the right non-dominant side, dementia (a progressive state of decline in mental abilities), and osteoarthritis (progressive disorder of the joints, caused by a gradual loss of cartilage).During a review of Resident 1's Care plan (CP) Report, initiated on 10/29/2024, and revised on 7/21/2026, the CP Report indicated Resident 1 was at risk for falls and injuries related to osteoarthritis, dementia, and history of falls. The CP Report indicated interventions such as fall risk assessment upon admission, quarterly and as needed and place Resident 1 on falling star program (a clinical safety initiative designed to quickly identify and protect residents who have a high risk of falling). During a review of Resident 1's History and Physical (H&P - a clinical document that provides a comprehensive baseline assessment of a patient's medical past and current health status), dated 3/24/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Change of Condition (COC)/Interact Assessment Form, dated 7/9/2026 at 9:33 a.m., the COC/Interact Assessment Form indicated Resident 1 had a fall on 7/9/2026 at 9:15 a.m. During a review of Resident 1's Fall Risk Evaluation, dated 7/9/2026, the Fall Risk Evaluation indicated Resident 1 had a fall risk score of 20 (a score 10 or greater the resident should be considered at high risk for potential falls).During a review of Resident 1's Fall Risk Evaluation, dated 7/17/2026, the Fall Risk Evaluation indicated Resident 1's fall risk score was 14. The Fall Risk Evaluation sections titled Gait/Balance, and Medication were blank. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/17/2026, the MDS indicated Resident 1 had severe cognitive impairment. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting and required partial/moderate assistance (helper does less than half the effort) with showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During a concurrent interview and record review on 7/23/2026 at 1:41 p.m. with the Minimum Data Set Nurse (MDS) 1, Resident 1's Fall Risk Evaluation was reviewed. MDS 1 stated he (MDS 1) does the Fall Risk Evaluation. MDS 1 stated all sections of the Fall Risk Evaluation must be completed. MDS 1 stated if all the items are not reviewed and checked, then it is not a complete assessment. MDS 1 reviewed Resident 1's Fall Risk Evaluation, dated 7/17/2026, and stated that the Fall Risk Evaluation was not complete. MDS 1 stated the fall risk score will be affected if the evaluation is incomplete. MDS 1 stated Resident 1's fall risk score changed from a score of 20 to a score of 14 which can affect resident's care needs. MDS 1 stated incomplete evaluation can result in an inaccurate assessment of the residents and incorrect plan of care which can result in fall. During an interview on 7/23/2026 at 3:13 p.m. with the Director of Nursing (DON), the DON stated the MDS 1 informed her (DON) about Resident 1's Fall Risk Evaluation, dated 7/17/2026. The DON stated the Fall Risk Evaluation was not complete. The DON stated the Fall Risk Evaluation should be complete and will be inaccurate if it is not completed. The DON stated this will place Resident 1 at risk for another fall. b. During a review of Resident 3's undated FS, the FS indicated the facility admitted Resident 3 on 5/5/2026 with diagnoses including muscle weakness, difficulty walking, and dyspnea (shortness of breath or difficulty breathing).During a review of Resident 3's Fall Risk Evaluation, dated 5/5/2026, the Fall Risk Evaluation indicated Resident 3's fall risk score was a six.During a review of Resident 3's H&P Note, dated 5/6/2026, the H&P Note indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had intact cognitive function. The MDS indicated Resident 3 required substantial/maximal assistance with toileting, showering, lower body dressing, and putting on and taking off footwear. The MDS indicated Resident 3 required partial/moderate assistance with upper body dressing.During a review of Resident 3's CP Report, initiated on 5/12/2026, the CP Report indicated Resident 3 was at risk for falls and injuries related to difficulty walking, generalized weakness, and history of falling with interventions that included to place Resident 3 on the falling star program and fall risk assessments upon admission, quarterly and as needed. During a review of Resident 3's COC/Interact Assessment Form, dated 6/21/2026 at 3:30 p.m., the COC/Interact Assessment Form indicated Resident 3 had a fall. During a review of Resident 3's Fall Risk Evaluation, dated 6/21/2026 at 7:48 p.m. the Fall Risk Evaluation indicated Resident 3 had a fall risk score of 10. The Fall Risk Evaluation indicated Resident 3 did not have any falls in the past three months. During an interview on 7/23/2026 at 1:41 p.m. with MDS 1, MDS 1 stated if there was a fall on that day, the Fall Risk Evaluation would count that fall within the last three months. During a concurrent interview and record review on 7/23/2026 at 3:13 p.m. with the DON, Resident 3's Fall Risk Evaluation, dated 6/21/2026, was reviewed. The DON stated Resident 3's fall was not captured in the Fall Risk Evaluation, dated 6/21/2026. The DON stated the fall should be indicated on the Fall Risk Evaluation after the fall. The DON stated this documentation is not accurate. The DON stated that inaccurate fall risk score can be a potential for a fall. During a review of the facility's Policy and Procedures (P&P) titled, Charting and Documentation, last reviewed on 2/20/2026, the P&P indicated documentation in the medical record will be objective, complete and accurate.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) who complained of pain received medication according to the physician orders. This failure had the potential to result in unmanaged pain and inadequate pain symptom control for Resident 2.Findings: During a review of Resident 2's Face Sheet (FS), the FS indicated the facility admitted Resident 2 on 6/26/2026 with diagnoses including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), dementia, abnormalities of gait and mobility, and muscle weakness. During a review of Resident 2's H&P dated 6/29/2026 the H&P indicated Resident 2 had the ability to understand and make decisions. The H&P indicated Resident 2 was high risk for falls, aspiration, infection, sepsis, repertory arrest, cardiac arrest and sudden death. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 needed partial assistance with toileting, showering, lower body dressing, putting on and taking off footwear, and personal hygiene, and required supervision with upper body dressing, and required set up assistance (helper sets up or cleans up, resident completes activity) with eating, and oral hygiene. During a review of Resident 2's Order Summary Report (OSR), dated 7/13/2026, the OSR indicated Tramadol-Acetaminophen tablet 37.5 to 325 milligram (mg- a unit of measurement) give one tablet by mouth every four hours as needed for severe pain of seven out of 10 for 14 days. During a review of Resident 2's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for July 2026, the MAR indicated Tramadol-Acetaminophen (a prescription medicine that combines two different pain relievers, tramadol and acetaminophen, to treat moderate to severe short-term pain) 37.5 to 325 mg give one tablet by mouth every four hours as needed for severe pain seven out of 10 for 14 days, was last given on 7/21/2026 at 8:36 a.m. for a pain of 8 out of 10. During a review of the facility provided record titled, Skilled Nursing Pharmacy Refill Request Only, form dated 7/21/2026 at 10 a.m., the Skilled Nursing Pharmacy Refill Request Only indicated a request for Resident 2's Tramadol-Acetaminophen 37.5 to 325 mg. During a review of Resident 2's Progress notes titled, Licensed Nursing Note, dated 7/23/2026 at 11:11 a.m. the Progress Note indicated per skilled nursing pharmacy verbalized tramadol with acetaminophen to be expedited and delivered possibly today on 7/27/2026, no exact time stated, since they are unable to provide an estimate time of arrival. During a review of the facility provided record titled, Urgent: Notice of Non-Covered/High-Cost Drug. Dated 7/23/2026 at 11:19 a.m. the Urgent: Notice of Non-Covered/High-Cost Drug indicated option one Tramadol-Acetaminophen 37.5 to 325 mg give one tablet by mouth every four hours as needed for severe pain seven out of 10 for 14 days, amount billed $76.65 quantity 42 for seven days. During an interview on 7/23/2026 at 11:15 a.m. with Resident 2 stated he takes Tramadol, and he needs it at night. Resident 2 stated last night he did not get the tramadol. Resident 2 stated his pain is only at nighttime. Resident 2 stated when he gets the tramadol he sleeps from 10 p.m. to 8 a.m. and since not getting the tramadol has been having a hard time sleeping. Resident 2 stated he is restless. During an interview on 7/23/2026 at 2:31 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated is aware Resident 2 had concerns with not getting tramadol. LVN 1 stated Resident 2 has an order for the tramadol. LVN 1 stated she (LVN 1) followed up with pharmacy yesterday (7/22/2026) and the pharmacist stated Resident 2's tramadol was denied by the insurance company. LVN 1 stated she (LVN 1) called the pharmacy today and was told the pharmacy would send over a form for skilled nursing facility (SNF) to pay out of pocket. LVN 1 stated Resident 2 stated he has severe pain due to Resident 2 having MS. LVN 1 stated if Resident 2 went two and half days without his tramadol there is a potential for Resident 2 to be in pain, will not allow the resident to be able to do his daily activities of living due to pain, especially because Resident 2 gets rehab services. During an interview on 7/23/2026 at 3:13 p.m. with the Director of Nursing (DON), the DON stated was made aware of Resident 2's tramadol medication was not covered this morning. The DON stated staff should reorder medication five to seven days prior to the medication running out. The DON stated if there is an active order for the medication, the medication should not run out. The DON stated for pain medication Resident 2 is at risk for pain not being resolved because the tramadol is not being available. During a review of the facility's Policy and Procedures (P&P) titled, Pain Assessment and Management, last reviewed on 2/20/2026, the P&P indicated pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Review the medication administration record to determine how often the individual requests and receives as needed pain medication, and to what extent the administered medications relieve the resident's pain. Implementing Pain Management Strategies:2. Pharmacological intervention may be prescribed to manage pain. During a review of the facility's P&P titled, Medication Ordering and Receiving From Pharmacy, last reviewed on 2/20/2026, the P&P indicated if not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ordered by peeling the bottom part of the pharmacy label and placing it in the appropriate area on the order from provided by the pharmacy for that purpose and ordered as follows: a. Reorder medication five days in advance of need to assure an adequate supply is on hand. Reorder a as needed medication five days in advance of anticipated need based on the current usage.

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed when isolation linen cart (a dedicated mobile storage unit used to manage contaminated supplies specifically for residents under isolation precautions [a resident is placed on special safety restrictions to stop the spread of a contagious germ to others]) was overfilled, with bags of linen stacked above the rim of the cart and with trash overflowing during an observation on 7/17/2026.This failure had the potential to contaminate the care environment, increase the risk of cross contamination, and place residents at risk for infection.Findings:During observation on 7/17/2026 at 8:57 a.m., observed a red isolation linen cart in residents' room overfilled with bags of linen stacked above the rim of the cart and with trash overflowing.During a concurrent observation and interview on 7/17/2026 at 9 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that the red isolation linen cart should not be overflowing with trash and the nursing staff should not place bags of linen on top of the cart. LVN 1 stated that housekeeping is responsible for ensuring that the linen carts are emptied when full. LVN 1 stated that residents' (unspecified) in that room are on contact precautions (a resident has an infection that can spread easily through physical touch, requiring strict protective measures). During an interview on 7/17/2026 at 3:21 p.m. with Infection Control (IP) Nurse, the IP nurse stated that the red isolation linen cart should not overflow with trash and housekeeping is responsible for emptying the isolation linen cart when they become full. IP Nurse stated that staff should empty the isolation linen carts before it overflows to prevent the spread of infection. During an interview on 7/17/2026 at 3:34 p.m. with Assistant Director of Nursing (ADON), the ADON stated that the red linen cart should not overflow with trash or contain linen bags stacked above the rim of the cart. ADON stated that housekeeping is responsible for emptying the carts when they become full to maintain infection prevention. During a review of the facility's Policy and Procedure (P&P) titled, Laundry and Bedding, Soiled dated 2/20/2026, the P&P indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Linen carts are cleaned and disinfected whenever visibly soiled and according to the established schedule.

Based on observation, interview, and record review, the facility failed to implement physician order for fluid restriction (a medical directive that limits the total amount of liquid a person can drink or eat each day) for one of three sampled residents (Resident 1) receiving dialysis (a treatment to cleanse the blood from wastes and extra fluids artificially through a machine when the kidney(s) have failed) services when water pitcher was at resident's bedside during an observation on 7/17/2026.This failure had the potential to place Resident 1 at risk for fluid overload (a medical condition when there is too much fluid in the body's bloodstream and tissues) and edema (a medical term for swelling caused by excess fluid trapped in the body's tissues).Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD-irreversible kidney failure) and dependence on renal dialysis.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/7/2026, the MDS indicated Resident 1 had intact cognitive skills (ability to think, understand, learn, and remember) for daily decision making and needed moderate assistance (helper does less than half the effort) for toileting hygiene, upper/lower body dressing, and personal hygiene.During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 7/3/2026, the H&P indicated Resident 1 had capacity to understand and make decisions.During a review of Resident 1's Order summary Report (OSR), for the active orders as of 7/17/2026, the OSR indicated an order for [Dialysis] Fluid restriction; limited to no water pitcher at bedside, with an order date of 7/2/2026.During a concurrent observation and interview on 7/17/2026 at 9:37 a.m. inside Resident 1's room with Director of Staff Development (DSD), the DSD stated that Resident 1 had a yellow water pitcher at bedside despite a posted sign indicating the Resident 1 was on fluid restriction and should not have a water pitcher at the bedside. The DSD stated Resident 1 will be at risk for fluid overload, edema, and shortness of breath if they drink more fluids than ordered since Resident 1 was on fluid restriction and on dialysis. Observed a yellow pitcher was about half full.During a concurrent interview and record review on 7/17/2026 at 12:28 p.m. with the Assistant Director of Nursing (ADON), Resident 1's physician orders were reviewed. The ADON stated that Resident 1 receives dialysis and has a physician order for fluid restriction that indicates no water pitcher at bedside. The ADON stated that Resident 1 was on fluid restrictions to prevent him (Resident 1) from fluid overload. The ADON stated that nursing staff are responsible for implementing and following physician orders. During a review of the facility's Policy and Procedure (P&P) titled, End Stage Renal Disease, Care of Resident with dated 2/20/2026, the P&P indicated, Residents with end-stage renal disease (ESRD) will be cared for accordingly to currently recognized standards of care.

Based on interview and record review, the facility failed to prevent a fall and injury for one of three sampled residents (Resident 1), who was confused, identified as a fall risk, had difficulty in walking, and had repeated falls in the facility. The facility failed to:1. Provide supervision to Resident 1 when staff (unspecified) placed Resident 1 in the hallway unattended.2. Place resident (Resident 1) on areas visible by staff and within easy reach when they (Resident 1) get up in accordance with Resident 1's care plan titled, Actual Fall. with date initiated on 6/1/2026.As a result, Resident 1 fell in the hallway on 6/18/2026 at around 12:50 p.m., sustaining a scalp laceration (a torn, ragged cut or tear in the skin and tissue) with bleeding and severe pain in the left hip. On 6/18/2026 at 1:31 p.m., the facility transferred Resident 1 to the General Acute Care Hospital (GACH) for further evaluation and management, where Resident 1 was admitted with traumatic left periprosthetic shaft of femur fracture (the long bone in the left thigh has broken along its main midsection, right next to or surrounding an existing medical implant [a manufactured device placed inside or on the surface of the body]) and underwent open reduction and internal fixation (ORIF - surgical procedure used to repair severe, displaced, or complex bone fractures). Findings:During a review of Resident 1's undated admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/4/2026 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), history of falling, and difficulty in walking.During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool), dated 5/9/2026, the MDS indicated Resident 1 had severe impaired cognitive skills (a profound and persistent decline in memory, reasoning, language, and judgment that makes it impossible for a person to manage daily life without substantial help) for daily decision making and needed maximal assistance (helper does more than half the effort) when toileting, showers, lower body dressing, oral hygiene, and for personal hygiene.During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a person's medical history, performing a physical exam, and documenting their findings), dated 5/31/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Fall Risk Evaluation, dated 5/4/2026 and timed at 9:38 p.m., the Fall Risk Evaluation History of Falls indicated Resident 1 had one to two falls in the past three months. The Fall Risk Evaluation indicated Resident 1 had balance problems while standing and balance problems while walking. The Fall Risk Evaluation indicated Resident 1 was chairbound (refers to a person who is confined to a chair, typically a wheelchair, due to illness, injury, or physical incapacity). The Fall Risk Evaluation indicated Resident 1 was a risk for fall.During a review of Resident 1's Rehabilitation (Rehab - the process of restoring someone to a normal, healthy, or functional state) Fall Risk Assessment, dated 5/5/2026 and timed at 1:55 p.m., the Rehab Fall Risk Assessment indicated the reason for the review as initial assessment (the first comprehensive evaluation of a resident's health status) and that Resident 1 required extensive assistance (a resident cannot safely move from one surface to another on their own) when transferring and with ambulation (walking). The Rehab Fall Risk Assessment indicated Resident 1 did not demonstrate proper safety techniques during transfers, while using the assistive device (any tool, equipment, or product system used to increase, maintain, or improve a resident's functional abilities and independence), and Resident 1 did not show proper standing balance.During a review of Resident 1's Change of Condition (COC - a decline or improvement that requires assessment, often prompting a revision of the care plan)/Interact (Interventions to Reduce Acute Care Transfers) Assessment (a quality improvement program used in nursing homes to identify, evaluate, and communicate acute changes in a resident's health status) Form, dated 5/9/2026 and timed at 3:51 a.m., the COC/Interact Assessment Form indicated, that on 5/9/2026 at 3:45 a.m. (Resident 1 was) found lying on the floor, parallel (side by side) to the bed. The COC/Interact Assessment Form indicated that Resident 1 was confused and continued to get out of bed all evening.During a review of Resident 1's COC/Interact Assessment Form, dated 5/12/2026 and timed at 12:45 p.m., the COC/Interact Assessment Form indicated that CNA (unspecified) was inside another room when she heard a pad alarm (a pressure-sensitive sensor placed under a resident on a bed or chair that triggers an alert to caregivers when pressure is removed or applied helping staff quickly assist residents art risk for falls) sounding in the hallway, walked out of the room, and noted Resident 1 standing up but was unable to sustain a standing position and went down to the floor, landing on his buttocks. The COC/Interact Assessment Form indicated CNA (unspecified) was unable to reach resident (Resident 1) in time to prevent the fall incident. On 5/12/2026 at 1:45 p.m., a Certified Nursing Assistant (CNA, name not specified) notified Registered Nurse (RN) 1 that Resident 1 was on the floor in the hallway outside his (Resident 1's) room.During a review or Resident 1's Post Fall Evaluation, dated 5/12/2026 and timed at 12:45 p.m., the Post Fall Evaluation indicated the date and time of Resident 1's witnessed fall was on 5/12/2026 at 12:45 p.m., and the reason for the fall was Resident 1 stood up unassisted. During a review of Resident 1's Care Plan (CP) titled, Resident is at risk for fall and injury, initiated on 5/13/2026, the CP indicated a goal to Reduce risk of falls and injury daily. The CP indicated interventions that included to visibly observe resident (Resident 1) frequently and to provide resident with safe clutter free environment.During a review of Resident 1's COC/Interact Assessment Form, dated 6/1/2026 and timed at 3:10 p.m., the COC//Interact Assessment Form indicated that on 6/1/2026 at 3:15 p.m. writer (RN 2) came out of another room across the hallway when resident (Resident 1) was noted on the floor, right outside of his room laying on his right side. Writer (RN 2) called for helped and assessed resident . resident does not recall incident.During a review of Resident 1's Fall Risk Evaluation, dated 6/1/2026 and timed at 3:40 p.m., the Fall Risk Evaluation indicated Resident 1 had three or more falls in the past three months, had intermittent confusion (refers to episodes of disorientation or impaired thinking that come and go), and was chairbound/incontinent (having no or insufficient voluntary control over urination or defecation). The Fall Risk Evaluation indicated Resident 1 had balance problem while standing, balance problem while walking, and decreased muscular coordination (refers to the ability of the body to orchestrate multiple muscles working together in a controlled and purposeful manner, enabling smooth and effective movement in daily activities and complex physical tasks).During a review of Resident 1's CP titled, Actual Fall (found on the floor outside of the room lying on his right side) ., initiated on 6/1/2026, the CP indicated interventions that included to Place resident (Resident 1) in areas visible by staff and within easy reach when they (Resident 1) get up.During a review of Resident 1's COC/Interact Assessment Form, dated 6/18/2026 and timed at 12:50 p.m., the COC/Interact Assessment Form indicated that on 6/18/2026 at approximately 12:50 p.m., writer (RN 1) was notified by a CNA (unspecified) that resident (Resident 1) had sustained a fall. CNA (unspecified) was nearby and heard a thud sound and observed resident (Resident 1) on the floor. RN 1 immediately went to hallway and noted resident (Resident 1) sitting on the floor surrounded by multiple nursing staff (unspecified). According to staff (unspecified) interview, he (Resident 1) was lying on the floor on his left side with wheelchair behind him (Resident 1). The COC/Interact Assessment Form indicated Resident 1 verbalized severe pain to his left hip and left lower extremity (refers to the entire portion of the human body from the hip down to the toes) and was noted with laceration on top of scalp with bleeding. The COC/Interact Assessment Form indicated that on 6/18/2026 at approximately 1:31 p.m., the facility sent Resident 1 to the GACH for further evaluation and management per physician's order. During a review of Resident 1's GACH admission H&P report, dated 6/18/2026 timed at 7:09 p.m., the GACH admission H&P indicated Resident 1 was admitted with traumatic left periprosthetic shaft of femur fracture status post (after) fall at his (Resident 1) skilled nursing facility (SNF). The GACH admission H&P indicated Resident 1 was in his wheelchair in the hallway and got up from it while unattended and then fell forward injuring his head with laceration and his left leg. The GACH admission H&P indicated Resident 1 was in severe pain and his (Resident 1) left leg was noted to be shortened and externally rotated (outward rotation of a body segment away from the midline of the body or the center of a joint) suspicious for a fracture. The GACH admission H&P indicated Resident 1's impression (the healthcare provider's professional assessment or working diagnosis) was acute (recent injury) left femur closed (no open wound or surgical incision [a cut made through the skin or soft tissue]) periprosthetic fracture (the fracture occurs around the prosthesis [an artificial device designed to replace a missing part of the human body], meaning it is not through the bone itself but at the interface [at the point where two systems meet and interact] between the implant and the bone) with displacement (bone fragments are not aligned) - preoperative (patient is being evaluated before surgery) for ORIF. The GACH admission H&P indicated the plan was discussed with Resident 1's Family Member (FM) 1 who understood that Resident 1 was a moderate risk patient, that ORIF is a moderate risk surgery, and that there were risks that included significant bleeding, infection, and death.During an interview on 6/23/2026 at 8:30 a.m. with CNA 2, CNA 2 stated that Resident 1 frequently attempted to get up independently from both bed and wheelchair. CNA 2 stated that on 6/18/2026, CNA 2 had been assigned to care for Resident 1 and around lunchtime, Resident 1 should have been seated in the TV room so staff could watch Resident 1. CNA 2 stated an unidentified staff member placed Resident 1 in the hallway. CNA 2 stated that the facility made a mistake by leaving Resident 1 in the hallway rather than in the TV room. CNA 2 stated the fall incident could have been prevented if Resident 1 was in the TV room and was supervised by staff.During an interview on 6/23/2026 at 9:05 a.m. with CNA 3, CNA 3 stated that on 6/18/2026 before lunch, Resident 1 was in the hallway in his wheelchair and CNA 3 observed Resident 1 fell from the wheelchair to the floor. CNA 3 stated that Resident 1 was sitting in the wheelchair when he stood up from the chair and fell forward. CNA 3 stated that Resident 1 should have been in the TV room rather than in the hallway so he can be supervised. CNA 3 stated that Resident 1 was at a high risk for fall due to a history of multiple previous falls.During an interview on 6/23/2026 at 9:50 a.m. with CNA 4, CNA 4 stated that on 6/18/2026, at approximately lunchtime, she was in the hallway and was assisting another resident with lunch with her back to Resident 1 when she heard a loud noise. CNA 4 stated that she turned around and observed Resident 1 lying on the floor on his left side. CNA 4 stated that staff had left Resident 1 in the hallway unattended. CNA 4 stated that she attempted to assist Resident 1 into a sitting position but was unable to do so and she called RN 1 for assistance. CNA 4 further stated that, before observing Resident 1 on the floor, Resident 1 had attempted to rise from the wheelchair by grabbing the medication cart (a mobile workstation used by licensed nurses to securely store, organize, and transport medications directly to residents' rooms) positioned next to him. CNA 4 stated that she did not hear a chair pad alarm activate and did not believe the chair pad alarm on Resident 1's wheelchair was turned on. CNA 4 stated that Resident 1 should have been in the TV room rather than in the hallway. CNA 4 stated that staff closely monitored residents in the TV room and would have been within arm's reach to intervene when Resident 1 attempted to stand. CNA 4 stated that placing Resident 1 in the TV room may have prevented the fall.During an interview on 6/23/2026 at 11:26 a.m. with Licensed Vocational Nurse (LVN 1) stated that on 6/18/2026, around lunchtime, she observed Resident 1 sitting in the hallway. LVN 1 stated that when she was exiting another resident's (unspecified) room, she saw Resident 1 standing up from his wheelchair and attempting to grab the medication cart. LVN 1 stated Resident 1 was unable to reach the medication cart and fell forward onto his left side. LVN 1 stated that Resident 1 struck his head on the corner of the wall or door frame because Resident 1's head was bleeding. LVN 1 stated that she was not within easy reach from Resident 1 to prevent the fall. LVN 1 stated that Resident 1 was at high risk for falls because he frequently attempts to get out of bed.During an interview and concurrent record review on 6/23/2026 at 11:48 a.m. with Physical Therapist Assistant (PTA) 1, Resident 1's Physical Therapy Treatment Note, dated 6/17/2026, was reviewed. PTA 1 stated that Resident 1 required maximum assistance during transfers from sitting to standing, with two people providing 75 percent (per hundred) of the required support. The Physical Therapy Treatment Note indicated, posture remains stooped and stepping mechanism (the body's protective, automatic reflex of taking a quick step to catch yourself and maintain balance when you are pushed, tripped, or begin to fall) is impaired, as the patient ambulates (walks) on the balls of his feet (toe walking). Education and instruction provided for sit-to-stand performance with maximal assistance, as patient displays anxiousness with standing and fails to perform functional push-off (any movement that utilizes your lower body - particularly your glutes, calves, and feet - to propel your center of mass forward or upward) when prompted. PTA 1 stated that Resident 1's level of mobility (movement) fluctuates due to impaired cognition. PTA 1 stated that Resident 1 is on fall risk precautions because he frequently attempts to get up.During an interview and concurrent record review on 6/23/2026 at 1:31 p.m. with RN 1, Resident 1's COC dated 6/18/2026, fall risk evaluations (5/4/2026, 5/12/2026, 5/29/2026, 6/1/2026, and 6/18/2026), and care plan for actual fall (6/1/2026) were reviewed. RN 1 stated that on 6/18/2026, during lunchtime, CNA 4 notified her that Resident 1 had fallen in the hallway. RN 1 stated that when she arrived, Resident 1 was already sitting on the floor with wheelchair positioned on Resident 1's right side, and Resident 1 was bleeding from his head. RN 1 stated that once Resident 1 was placed in bed, she assessed his range of motion (the measurement of how far a specific joint can be comfortably move or rotate in its normal direction) and found that Resident 1 could not move his (Resident 1) left lower extremity. RN 1 stated she contacted Resident 1's physician and received orders to transfer Resident 1 to the GACH. RN 1 stated Resident 1 was a high fall risk because of his history of multiple falls. RN 1 stated that staff did not follow Resident 1's care plan initiated on 6/1/2026 after his previous unwitnessed fall (on 6/1/2026) in the hallway to place Resident 1 on areas visible by staff and within easy reach when they get up. RN 1 stated that staff did not place Resident 1 in a visible location and did not remain within reach when he (Resident 1) attempted to rise from the wheelchair. RN 1 further stated that Resident 1's fall could have been prevented if staff followed the care plan intervention.During an interview on 6/23/2026 at 3:10 p.m. with the Director of Nursing (DON), the DON stated that Resident 1 fell in the hallway on 6/18/2026 at 12:50 p.m. The DON stated that LVN 1 witnessed the fall. The DON stated that LVN 1 left Resident 1 in the hallway to check on another resident (unspecified). The DON stated that Resident 1 attempted to get up without assistance and fell. The DON stated that staff did not follow Resident 1's care plan because LVN 1 was not within reach of Resident 1 when he (Resident 1) attempted to stand. The DON stated that staff could have prevented Resident 1's fall by remaining within Resident 1's reach. The DON stated Resident 1's mental status was confused and fluctuating, Resident 1 was impulsive, and was a high fall risk resident.During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, last reviewed on 2/20/2026, the P&P indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision.4. Implementing interventions to reduce accidents risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring the interventions are implemented; and e. documenting interventions. Systems Approach to Safety . 2. Resident supervision is a core component of the system approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased . if there is a change in the resident's condition.During a review of the facility's P&P titled, Fall and Fall Risk, Managing, last reviewed on 2/20/2026, the P&P indicated that Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from failing and to try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk . 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Monitoring Subsequent Falls and Fall Risk . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the physician will help the staff reconsider possible causes that may not previously have been identified.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/20/2026, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9. Care plan interventions ae chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about resident's and the resident's condition change.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with physician orders and individualized care plan for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when the facility failed to: 1. Ensure physician's ordered wheelchair alarms (physical or electronic device that monitors resident movement and alerts the staff when movement is detected) stayed connected for Resident 1 and Resident 2 while they were seated in their wheelchairs.2. Implement Resident 3's care plan intervention for one-to-one (1:1) supervision for safety and close supervision. These failures increased the risk for falls and potential injury. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 the facility admitted Resident 1 on 6/2/2026 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities) and difficulty in walking. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 1 required moderate assistance (helper does less than half the efforts) for toileting hygiene, showers, upper/lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 required bed and chair alarm use daily. During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 6/12/2026, the H&P indicated Resident 1 can make needs known but cannot make medical decisions. During a review of Resident 1's Care Plan (CP) titled, Resident 1 is on sensory pad alarm. Resident requires sensory pad alarm when in wheelchair, initiated on 6/3/2026, the CP indicated a goal to Resident will be cooperative and participative during rehab treatment, safety education daily through the next assessment. The CP interventions indicated Apply sensor pad alarm as ordered. Monitor the alarm for good working conditions and proper placement as needed. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/10/2026 with diagnoses including difficulty in walking, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and history of falling. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making and required maximum assistance (helper does more than half of the efforts) for toileting hygiene, shower/bathe, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 2's H&P, dated 2/11/2026, the H&P indicated Resident 2 does not have the capacity to understand and make decisions. During a review of Resident 2's CP titled, Sensor pad alarm. Resident requires pad alarm when in wheelchair and bed to decrease potential for injury, initiated 2/11/2026, the CP indicated a goal to Resident will be cooperative and participative during rehab treatment, safety education daily through the next assessment. The CP interventions indicated Apply sensor pad alarm as ordered, Monitor the alarm for good working condition and proper placement. During a review of Resident 1's Order Summary Report, active orders as of 7/23/2026, the Order Summary Report indicated, Support & Safety Device - Pad alarm in bed/wheelchair as nursing intervention to alert staff for unassisted transfer, every shift Y = proper placement and it's in good working condition. During a concurrent observation and interview on 7/22/2026 at 3:09 p.m. with Activities Assistant 1, in the activities room, Resident 1 attempted to stand from her wheelchair. Staff did not receive an alert because the wheelchair alarm did not activate. Activities Assistant 1 stated that staff had disconnected Resident 1's wheelchair alarm from the wheelchair, preventing the alarm from sounding. During a concurrent observation and interview on 7/22/2026 at 3:14 p.m. with Infection Preventionist (IP) Nurse, inside the activity room, Resident 2 sat in a wheelchair with the wheelchair alarm disconnected. The IP Nurse stated that Resident 2's wheelchair alarm should remain connected because Resident 2 is part of the star program (a visual safety system used in nursing homes to easily identify residents who have a high risk of falling), which requires that the wheelchair alarm to remain activated whenever Resident 2 was seated in the wheelchair. The IP Nurse stated that disconnecting the wheelchair alarm prevented staff from receiving an alert if Resident 3 attempted to stand. During an interview on 7/22/2026 at 4:22 p.m. with Director of Activities (DA), the DA stated that activities department disconnects the wheelchair alarms when the activity department is fully staffed because residents become agitated by the alarm sound. b. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 3/22/2026 with diagnoses including dementia and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had severely impaired cognitive skills for daily decision making and required moderate assistance (helper does less than half of the efforts) for shower/bathe, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 3's H&P, dated 2/11/2026, the H&P indicated Resident 3 does not have the capacity to understand and make decisions. During a review of Resident 3's CP titled, Actual fall, initiated 7/9/2026, the CP indicated a goal to Minimize risk of falls/injury through appropriate interventions until the next assessment. The CP interventions indicated 1:1 supervision for safety and close supervision. During an observation on 7/22/2026 at 3:07 p.m. in the activity room, Resident 3 propelled herself in the wheelchair towards the wall without staff supervision. Resident 3 stated that she was going to the restroom. During an interview on 7/22/2026 at 4:22 p.m. with the DA, the DA stated that Resident 3 required 1:1 supervision. The DA stated staff left Resident 3 unsupervised in the activity room despite her need for 1:1 supervision. The DA further stated that Resident 3 moves constantly, has a high risk for falls, and requires continuous close supervision. During an interview on 7/23/2026 at 9:41 a.m. with the Director of Staff Development (DSD), the DSD stated that the facility assigns Certified Nurse Assistants (CNAs) to residents receiving 1:1 supervision. The DSD stated the assigned staff must remain with the resident at all times and obtain relief coverage before leaving because residents on 1:1 supervision cannot be left unattended. During a concurrent interview and record review on 7/23/2026 at 10:15 a.m. with the Director of Nursing (DON), Resident 1, Resident 2, and Resident 3's physician orders and care plans were reviewed. The DON stated that 1:1 supervision requires one staff member to provide continuous close supervision by always remaining within reach of the resident. The DON stated that wheelchair alarms notify staff when residents attempt to rise from their wheelchair. The DON stated that Resident 1 and Resident 2's wheelchair alarm should always remain on while the residents are seated in their wheelchair. The DON stated that staff did not follow physician orders for Resident 1's and Resident 2's because staff disconnected the wheelchair alarms while the resident were in the activity room. During a review of facility's policy and procedure (P&P) titled, Care Plans, comprehensive Person Centered, revised 2/20/2026, the P&P indicated A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. During a review of the facility's P&P titled, Safety and Supervision of Residents, revised 2/20/2026, the P&P indicated The care team shall target interventions to reduce individual risk related to hazards in the environment, including adequate supervision and assistive devices. Monitoring the effectiveness of interventions shall include the following: a. ensuring that interventions are implemented correctly and consistently; b. Evaluating the effectiveness of interventions; c. Modifying or replacing interventions as needed; and d. Evaluating the effectiveness of new or revised interventions. During a review of the facility's P&P titled, Personal Alarm, revised 2/20/2026, the P&P indicated This facility will use, as indicated a sensor pad that conveniently sounds an audible alarm when the sensor detects a patient rising out of the bed/wheelchair reminding the resident to return to a safe position while alerting staff to a potential fall. Apply sensor pad on the residents bed or chair. Nursing will monitor proper functioning and positioning of personal alarm.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) received their physician-ordered regular diet. Resident 2 was served a soft and bite size (soft, tender, and moist) diet instead of the prescribed regular texture diet. This failure had the potential to result in unnecessary diet restrictions, decreased meal satisfaction, and reduced nutritional intake. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including altered mental status, dysphagia (difficulty swallowing), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2026, the MDS indicated Resident 2 had severely impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making and was dependent (helper does all of the efforts) for eating, toileting hygiene, showers, upper body dressing, and personal hygiene. During a review of Resident 2's Order summary Report (OSR), for the active orders as of 6/23/2026, the OSR indicated NAS (No Added Salt) diet, regular texture, thin consistency, with an order date of 4/22/2026.During an observation on 6/22/2026 at 12:19 p.m. in the dining room, a staff member (name unknown) placed Resident 2's meal tray in front of Resident 2 and Family Member (FM 1). FM 1 removed the lid from Resident 2's tray and stated, This is not the correct tray. He (Resident 2) receives regular texture. Speech Therapist (ST) 1 immediately removed the lunch tray, returned it to the kitchen, and brought Resident 2 a meal tray with the correct regular texture diet. During an interview on 6/23/2026 at 12:16 p.m. with ST 1, ST 1 stated that Resident 2 received an incorrect texture meal tray during lunch on 6/22/2026. ST 1 stated that he (ST 1) immediately returned the tray to the kitchen and replaced it with the correct regular texture tray. ST 1 further stated that providing a diet texture below the resident's prescribed level could cause the resident to refuse the meal or consume less than 100 percent of the meal potentially affecting resident's nutritional intake. During an interview on 6/23/2026 at 12:48 p.m. with Dietary Services Manager (DSM), the DSM stated that Resident 2 received a soft and bite sized diet instead of the prescribed regular texture diet. The DSM stated that staff should verify the diet (food) texture on the tray against the diet order ticket before serving the meal to ensure resident receives the correct diet.During a review of the facility's Policy and Procedure (P&P) titled, Menu, revised on 2/20/2026, the P&P indicated:Twenty-eight-day cycle menus are prepared by the dietitian and modifications of individual resident menus are made as necessary to comply with physician orders and/or resident preferences.

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed when Certified Nurse Assistant (CNA) 1 placed soiled linen and soiled brief directly on the floor while providing care for one of three sampled residents (Resident 3). This failure had the potential to contaminate the care environment, increase risk of cross contamination, and place residents at risk for infection.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including chronic obstruction pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and difficult in walking. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 6/22/2026, the MDS indicated Resident 3 had moderate cognitive skills (ability to think, understand, learn, and remember) for daily decision making and needed maximum assistance (helper does more than half of the efforts) for toileting hygiene, showers, upper body dressing, and personal hygiene. During an observation on 6/22/2026 at 10:18 a.m., outside Resident 3's room, CNA 1 was providing incontinence care to Resident 3. CNA 1 placed Resident 3's soiled brief on the floor with the soiled linen. During an interview on 6/22/2026 at 10:21 a.m., outside of Resident 3's room with the Director of Staff Development (DSD), the DSD stated that staff should not place soiled briefs or soiled linen on the floor. DSD stated that the staff should place the soiled linen in a linen bag and the soiled diaper in a separate waste bag. The DSD stated that placing soiled items on the floor contaminated the floor and could contribute to the spread of infection. During an interview on 6/23/2026 at 3:10 p.m., with the Director of Nursing (DON), the DON stated that nursing staff must place soiled linen in a bag before placing it in the soiled linen cart. The DON stated that staff must also place soiled briefs in a separate waste bag. The DON stated that placing soiled linen or soiled briefs on the floor could contribute to the spread of infection, and was not consistent with proper infection control practices. During a review of the facility's Policy and Procedure (P&P) titled, Laundry and Bedding, Soiled dated 2/20/2026, the P&P indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Staff handle soiled linen with minimal agitation to avoid the contamination of air, surfaces, and persons.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) received care in a manner that maintained the resident's dignity and respect when Certified Nurse Assistant (CNA) 1 did not fully close the privacy curtains while providing personal care. This failure had potential to negatively affect the Resident 3 sense of dignity and respect during the care.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including chronic obstruction pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and difficult in walking.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 6/22/2026, the MDS indicated Resident 3 had moderate cognitive skills (ability to think, understand, learn, and remember) for daily decision making and needed maximum assistance (helper does more than half of the efforts) for toileting hygiene, showers, upper body dressing, and personal hygiene.During an observation on 6/22/2026 at 10:18 a.m., outside Resident 3's room, CNA 1 was providing incontinence care and changing the bed linen for Resident 3 without closing the privacy curtain. The privacy curtain was not completely closed and did not provide complete privacy to Resident 3.During an interview on 6/22/2026 at 10:21 a.m., outside Resident 3's room with the Director of Staff development (DSD), the DSD stated that the privacy curtain in Resident 3 room was not closed all the way and did not provide complete privacy to Resident 3. The DSD stated that it is important to have privacy curtains closed completely to protect Resident 3's dignity.During an interview on 6/23/2026 at 3:10 p.m., with the Director of Nursing (DON), the DON stated that nursing staff must always close the privacy curtain when providing care to residents to prevent exposure and to protect their dignity. The DON stated the importance of maintaining privacy for every resident, as it is part of resident's right.During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, revised on 2/20/2026, the P&P indicated:Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be treated with respect, kindness, and dignity.

Based on interview and record review, the facility failed to ensure a resident who received hemodialysis (a medical treatment that acts as an artificial kidney, filtering waste products and extra fluid from the blood when kidneys are not working well) received treatment in accordance with professional standards of practice for one of three sampled residents (Resident 2) by failing to ensure clear communication between the facility, dialysis center, and the physician for timely administration of Resident 2's medications. This deficient practice had the potential to delay care and negatively affect Resident 2's well-being. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 5/12/2026 with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), dependence on renal dialysis, unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness). During a review of Resident 2's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 5/12/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 5/17/2026, the MDS indicated Resident 2 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 2 required moderate assistance (helper does less than half the effort) from facility staff with oral hygiene and personal hygiene. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) from facility staff with toileting hygiene, showers, and lower body dressing.During a review of Resident 2's Order Summary Report, the Order Summary Report indicated the following physician's order:-5/12/2026: Dialysis days: Monday, Wednesday, and Friday. Chair time: 8 a.m. -5/12/2026: Apixaban (medication used to prevent blood clots from forming) oral tablet 2.5 milligrams (mg.-unit of measurement). Give one tablet by mouth two times a day for deep venous thrombosis prophylaxes (prevention of DVT - a serious medical condition that occurs when a blood clot forms in a deep vein, usually in the legs or pelvis). -5/12/2026: Bumex (medication used to treat swelling and fluid retention) tablet 0.5 mg. Give one tablet by mouth one time a day for ESRD. -5/12/2026: Topiramate (medication used to control certain types of seizures) oral tablet 200 mg. Give one tablet by mouth one time a day for seizures. -5/12/2026: Risperidone (medication used to treat mental health conditions such as psychosis) oral tablet four (4) mg. Give one tablet by mouth two times a day for psychosis manifested by extreme paranoid hallucinations (seeing, hearing, or feeling things that others do not, specifically tied to themes of being watched, threatened, or persecuted) interfering with activities of daily living and causing social isolation. During a review of Resident 2's Medication Administration Record (MAR), dated 5/2026, the MAR indicated that on 5/22/2026, 5/27/2026, and 5/29/2026, for 9 a.m. administration time, there were no licensed staff initials in the box for Resident 2's Apixaban Bumex, Topiramate, and Risperidone to indicate that the medications were administered. The MAR indicated that on 5/22/2026, 5/27/2026, and 5/29/2026, for 9 a.m. administration time, charting code 9 (other/see progress notes) was marked in the box for Resident 2's Apixaban Bumex, Topiramate, and Risperidone indicating to see Resident 2's progress notes for more details. During a concurrent interview and record review on 6/10/2026 at 3:11 p.m. with the Director of Nursing (DON), Resident 2's Order Summary Report, dated 5/2026, and Administration Notes, dated 5/22/2026 at 13:08 p.m., 5/27/2026 at 14:46 p.m., and 5/29/2026 at 14:01 p.m. were reviewed. The Administration Notes indicated that on 5/22/2026, 5/27/2026, and 5/29/2026, Resident 2 was out of the facility for dialysis. The DON stated Resident 2's Apixaban Bumex, Topiramate, and Risperidone were not administered on 5/22/2026, 5/27/2026, and 5/29/2026 for 9 a.m. administration time because Resident 2 was out of the facility for dialysis. The DON stated Resident 2's Order Summary Report did not indicate an order from the physician to hold medications prior to dialysis. The DON stated the facility staff should have contacted the physician to clarify which medications should be administered and which medications should be held prior to Resident 2 leaving the facility for dialysis. The DON stated there was a potential for Resident 2 to experience adverse side effects from missing medications. The DON stated Resident 2 was placed at risk to for experiencing seizures, blood clothes, fluid overload, and uncontrolled behaviors. During a review of the facility-provided policy and procedure (P&P) titled, End-Stage Renal Disease, Care of a Resident with, last reviewed on 2/20/2026, the P&P indicated, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. 2. Education and training of staff includes, specifically. E. timing and administration of medications, particularly those before and after dialysis.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Residents 1) by failing to: 1. Ensure the dosage for Resident 1's Ivermectin (an antiparasitic medication [medications used to treat infections caused by parasites, such as worms, mites] used to treat infections and skin conditions like scabies [a highly contagious skin condition caused by mites]. Ivermectin dosing for adults is based on weight: 0.2 milligram [mg-unit of measurement] per kilogram (kg-unit of measurement] of body weight) order was accurate based on Resident 1's weight. 2. Ensure timely reordering of Resident 1's levocarnitine (medication used to treat or prevent carnitine deficiency [a condition where cells cannot properly utilize fats for energy, often resulting in muscle weakness, heart problems, or liver issues]). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 5/13/2024, and readmitted on [DATE] with diagnoses including unspecified (unconfirmed) multiple sclerosis (MS - a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), acute panmyelosis (aggressive form of acute myeloid leukemia [blood cancer] severe bone marrow scarring [a serious condition in which fibrous scar tissue replaces the spongy marrow), dermatitis (skin inflammation with no determined or officially diagnosed cause), and scabies.During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 3/26/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 1 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 was dependent (helper does all the effort) on facility staff for oral hygiene, toileting hygiene, showers, personal hygiene, upper and lower body dressing. a. During a review of Resident 1's Weights and Vitals Summary, dated 4/12/2026, the Weights and Vitals Summary indicated that on 4/12/2026, Resident 1's weight was 153 pounds (lbs.- unit of measurement). During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order:-4/22/2026: Ivermectin oral tablet six (6) mg. Give one tablet by mouth one time a day every Thursday for scabies for four weeks. During an interview on 6/11/2026 at 9:42 a.m. with the Dispensing Pharmacist (DP -pharmacist who interprets prescriptions, prepares, packages, labels, and provides medications to the facility for administration), the DP stated Resident 1's order for Ivermectin, dated 4/22/2026, was a weight-based dosage (dosage by weight that uses a person's body mass to determine the precise medication amount) administered once a week. The DP stated the dispensing pharmacy does not have access to resident's weight unless provided by the facility staff. The DP stated that since Resident 1's weight was not provided to the dispensing pharmacy, the dispensing pharmacy would not be able to identify that the Ivermectin dosage was low for Resident 1. During an interview on 6/11/2026 at 9:54 a.m. with the Pharmacy Consultant (PC), the PC stated that Ivermectin dosing was based on residents' body weight (0.2 mg per kg of body weight). The PC stated there was no renal adjustment (the process of modifying a medication dosage or timing to account for reduced kidney function) recommendation for Ivermectin. The PC stated that based on Resident 1's weight, the Ivermectin dosage would be 15 mg. During an interview on 6/11/2026 at 10:22 a.m. with the DP, the DP stated 6 mg. of Ivermectin was a subtherapeutic dose for Resident 1. The DP stated administering low dose of Ivermectin had the potential for the medical indication (medical reason for using a specific therapy) not be successfully treated, required an extension of the treatment. During a concurrent interview and record review on 6/11/2026 at 10:36 a.m. with the Director of Nursing (DON), Resident 1's Progress Notes and Order Summary dated 4/2026 were reviewed. The DON stated that once residents returned from an outpatient appointments with new orders, the facility staff should notify the primary physician and place an order with the dispensing pharmacy. The DON stated that on 4/22/2026, Resident 1 returned from an outpatient appointment with Hematologist (a medical doctor who specializes in diagnosing, treating, and managing conditions affecting the blood, bone marrow, and lymphatic system) with an order of 6 mg. Ivermectin once a week for four weeks. The DON stated there was no documented evidence to indicate that facility attempted to clarify Ivermectin dosage with the prescribing physician or Resident 1's Primary Physician. The DON stated the facility staff should have had clear communication with the dispensing pharmacy and the physician for Resident 1's Ivermectin dosage clarification. The DON stated the facility staff should have provided Resident 1's weight to the dispensing pharmacy to ensure the right dosage of Ivermectin was dispensed for Resident 1. The DON stated that administering lower than recommended dose of Ivermectin to Resident 1 had the potential to cause Resident 1's skin condition not to improve. During a review of the facility-provided policy and procedure (P&P) titled, Adverse Consequences, Medication Errors, and Unnecessary Medication, last reviewed on 2/20/2026, the P&P indicated, The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ARDs) and side effects. 5. The staff and practitioner shall strive to avoid the use of unnecessary drug and minimize adverse consequences by: a. following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication.b. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order:-3/14/2026: Levocarnitine tablet 300 mg. Give two tablets by mouth every 12 hours for carnitine deficiency. During a concurrent interview and record review on 6/10/2026 at 9:36 a.m. with Registered Nurse (RN) 1, Resident 1's Progress Notes dated 6/8/2026 timed at 9:45 a.m. and 9:56 p.m. were reviewed. The Progress Note dated 6/8/2026, timed at 9:45 a.m., indicated that on 6/8/2026 for 9 a.m. administration time, Resident 1 received one tablet of levocarnitine. The Progress Note indicated levocarnitine was on the way from the pharmacy. The Progress Note dated 6/8/2026, timed at 9:56 p.m., indicated that on 6/8/2026 for 9 p.m. administration time, levocarnitine was ordered from the pharmacy. RN 1 stated there was no documented evidence to indicated that the facility reordered Resident 1's levocarnitine prior to 6/8/2026. RN 1 stated the facility staff should have reordered the medication at least 5 days prior to completion of the current supply to make sure Resident 1 did not miss a dose. RN 1 stated failure to reorder levocarnitine on time had the potential to place Resident 1 at risk of experiencing adverse reaction (a harmful, unintended, and undesirable response to a medication or treatment) due to a missed dose. During an interview on 6/10/2026 at 2:56 p.m. with the DON, the DON stated facility staff should have reordered Resident 1's levocarnitine five days prior to finishing the current supply to give enough time for order processing and delivery. The DON stated levocarnitine was reordered on 6/8/2026 and on 6/8/2026 for 9 a.m. administration time Resident 1 did not receive full dose and for 9 p.m. administration time missed the dose. The DON stated Resident 1 was placed at risk of experiencing adverse side effects due to missed medication. During a review of the facility-provided P&P titled, Medication Ordering and Receiving from Pharmacy, last reviewed on 2/20/2026, the P&P indicated, Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. A. Ordering Medications from the Dispensing Pharmacy. 2) If not automatically refilled by the pharmacy, repeat medications (refills) are written on medication order form/ordered by peeling the bottom part of the pharmacy label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and ordered as follows: a. Reorder medications five days in advance of need to assure an adequate supply on hand.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities), had a safe discharge by failing to: 1. Ensure Resident 1 received a 30-day-written notice of discharge.2. Create a discharge care plan upon Resident 1's admission.3. Ensure the Social Services Director (SSD) informed Family Member (FM) 1 during a telephone call about Resident 1's Notice of Medicare Non-Coverage regarding appeal rights and the process to appeal the discharge. 4. Identify Resident 1's discharge needs before the discharge on [DATE].5. Include FM 1 in Resident 1's discharge planning process.6. Conduct an interdisciplinary team (IDT) meeting prior to Resident 1's discharge on [DATE].7. Determine a caregiver's availability and evaluate the caregiver's ability to assist with Resident 1's care.These deficient practices resulted to the facility inappropriately discharging Resident 1 on 5/1/2026 and had the potential to place Resident 1 at risk for health complications. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the Resident 1 on 4/17/2026 with diagnoses including metabolic encephalopathy (brain dysfunction caused by an underlying systemic or chemical imbalance in the body, rather than a direct physical injury to the brain), cerebral ischemia (occurs when there is insufficient blood flow to the brain to meet its metabolic demands), paroxysmal atrial fibrillation (a type of irregular heartbeat characterized by intermittent episodes of chaotic electrical activity in the heart's upper chambers), myocardial infarction (occurs when blood flow to a part of the heart is blocked, causing heart muscle tissue to die from oxygen deprivation), difficulty in walking, and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/24/2026, the MDS indicated the resident's cognitive skills for daily decision making were impaired. The MDS indicated Resident 1 needed partial/moderate assistance (helper does less than half the effort and helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene, shower/bathe self, upper body dressing, and lower body dressing.During a review Resident 1's Baseline care plan form, dated 4/22/2026 at 12 p.m., the form indicated the form was not filled and was empty indicating the baseline care plan for discharge was not completed.During a review of Resident 1's Transfer/Discharge summary form, the form indicated Resident 1 was discharged with generalized body dermatitis with excoriation.During a review of Resident 1's Self-Administration of Medication form, the form indicated Resident 1 cannot administer medication to self. During review of Interdisciplinary Team (IDT - a collaborative group of healthcare professionals from various specialties who work together to manage, coordinate, and evaluate a patient's care), the IDT indicated there was no IDT meeting done regarding Resident 1's discharge.During a review of Transfer /Discharge report, the report indicated that Resident 1 was discharged with the following medications:Metropol Tartrate oral Tablet 25 milligrams (mg - unit of measurement). Directions: give one tablet by mouth two times a dayIvermectin oral tablets 3 mg. Directions: give 6 tablets by mouth one time a day every Thursday for unspecified dermatitis for 4 weeks take 6 tablets =18 MGAmiodarone HCL Oral Tablet 200 mg. Directions: Give 1 tablet by mouth one time a dayApixaban Oral Tablet 5 mg. Directions: Give 1 Tablet by mouth tow times a day.Hydroxyzine HCL Tablet 10 mg. Directions: give 1 tablet by mouth one time a day for itching.During an interview with FM 1 on 5/6/2026, at 8:30 a.m., FM 1 stated that the Social Services Director (SSD) called him on 4/28/2026 to come pick Resident 1 from the facility because Resident 1's insurance would not continue paying for her stay at the facility. FM 1 stated the facility did not explain to him the discharge process and was not given an option to appeal the decision to discharging Resident 1 from the facility as he felt Resident 1 was not strong enough to go home. FM 1 stated that when Resident 1 was discharged he was given some of Resident 1's medications from the facility and has not given them to the Resident 1 as he does not know how to give them. FM 1 stated he works 12 hours a day and Resident 1 is left at home all day until he comes back from work. FM 1 stated that Resident 1 spends most of the day in bed until he comes back from work at 6 p.m. FM 1 stated when he comes back home in the evening, that is when he changes the incontinent briefs and feeds Resident 1.During an interview with the Social Services Director (SSD) on 5/7/2026 at 4 p.m., the SSD stated Resident 1 was admitted in the facility on a short-term basis. The SSD stated he received Resident 1's last coverage date notice from the business office on 4/28/2026 and called FM 1 on the same day and informed FM 1 of the Notice of Medicare Non-coverage Notice received from the business office. The SSD stated he informed FM 1 to organize and come to the facility to take Resident 1 home. The SSD stated he did not explain to FM 1 the appeal rights process as FM 1 did not object to the discharge and was willing to come and take Resident 1 home. The SSD stated that by not providing the information regarding the appeal process on discharge FM 1 was denied the opportunity to file for an appeal before Resident 1 was discharged from the facility.During a concurrent interview and record review on 5/8/2026 at 8 a.m. with the Director of Nursing (DON), the policy titled, Transfer of Discharge Documentation, was reviewed. The policy indicated that when a resident is transferred or discharged , details of the discharge will be documented in the medical records, and appropriate information will be communicated to the receiving healthcare facility or provider. The DON stated there was no documentation of the dermatitis (is a broad term for inflammation of the skin) and improvements on discharge. The DON stated there was no documentation that there was discharge planning done for Resident 1 prior to Resident 1's discharge on [DATE]. The DON stated there was no IDT done for Resident 1 and there was no evidence that the care giver (FM 1) was assessed and was able to take care of Resident 1 at home. The DON stated there was no documented evidence that Resident 1's discharge back to the community was feasible. The DON stated the Notice of Medicare Non coverage document is to inform the resident or family member on the non-coverage date. The DON stated the SSD is to provide the family with the appeal process. The DON stated the SSD failed to provide the appeals process to FM 1 and this was against the facility's policy and procedure because it denied FM 1 a chance to appeal the decision of the discharge.During an Interview with Medical Doctor (MD) 1 on 5/8/2026 at 9 a.m., MD 1 stated that if Resident 1 was discharged home on Apixaban and has not taken it since discharge, it is a real risk that can lead to stroke and even death. MD 1 stated if Resident 1 was discharged on Amiodarone Medication interactions: Amiodarone can prolong Apixaban so it can remain anticoagulated (having your blood treated to prevent it from clotting) longer which can lead to the development of blood clots and even death.During an interview with the DON on 5/8/2026 at 9:20 a.m., the DON stated the discharge process starts from admission and to conduct IDT meeting when they meet with the family member and determine the discharge goal and work with the rehabilitation department to be able to get to their prior level of condition before admission. The DON stated the facility's discharge process was not followed for Resident 1 and it placed Resident 1 at risk for unsafe discharge as the facility was not aware of Resident 1's discharge goals prior to discharge. The DON stated FM 1 was not involved in the discharge planning for Resident 1.During a review of the facility-provided policy and procedures (P&P) titled, Discharge Summary and Plan, last reviewed on 1/15/2026, the P&P indicated that when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. 4. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. 5. The post-discharge plan will be developed by the care planning /interdisciplinary team with assistance of the resident and his or her family and will include (c). a description of the residents stated discharge goals. 6. Discharge plan will be r-evaluated based on changes in the resident's condition or needs prior to discharge. 7. The resident representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. 12. A member of the IDT will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 13. A copy of the following will be provided to the resident, and a copy will be filed in the resident medical records. (a). An evaluation of the residents' needs (b). post discharge plan and (c). The discharge summary.

Based on interview and record review, the facility failed to ensure the personal items of clothing of one of three sampled residents (Resident 1), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities), were not lost.This deficiency practice resulted in Resident 1 being discharged to home in a hospital gown with no shoes. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the Resident 1 on 4/17/2026 with diagnoses including metabolic encephalopathy (brain dysfunction caused by an underlying systemic or chemical imbalance in the body, rather than a direct physical injury to the brain), cerebral ischemia (occurs when there is insufficient blood flow to the brain to meet its metabolic demands), paroxysmal atrial fibrillation (a type of irregular heartbeat characterized by intermittent episodes of chaotic electrical activity in the heart's upper chambers), myocardial infarction (occurs when blood flow to a part of the heart is blocked, causing heart muscle tissue to die from oxygen deprivation), difficulty in walking, and muscle weakness. During a review of Resident 1's Inventory List: Resident's Clothing and Possessions, dated 4/17/2026, the Inventory List indicated that upon admission Resident 1 had one jacket, two socks, one sweatpants, and one pair of shoesDuring a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/24/2026, the MDS indicated the resident's cognitive skills for daily decision making were impaired. The MDS indicated Resident 1 needed partial/moderate assistance (helper does less than half the effort and helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene, shower/bathe self, upper body dressing, and lower body dressing. During a review of Resident 1's Progress Notes, dated 5/1/2026 timed at 4 p.m., the Progress Notes indicated that Resident 1 was discharged to home with FM 1 and that staff could not find Resident 1's clothes and FM 1 took her (Resident 1) home wearing a hospital gown. During an interview with Family member 1 (FM 1) on 5/6/2026, at 8:30 a.m., FM 1 stated that Social Services Director (SSD) called him on 4/28/2026 to come pick Resident 1 from the facility because insurance would not continue to pay for Resident 1's stay at the facility. FM 1 stated that on 5/1/2026 when he went to pick Resident 1, Resident 1 was missing all her personal items of clothing that she had upon admission on [DATE]. FM 1 stated the SSD stated he could not find them and Resident 1 was discharged to home wearing a hospital gown with no shoes.During an interview with the Social Services Director (SSD) on 5/7/2026 at 4 p.m., the SSD stated Resident 1 was admitted in the facility on a short-term basis. The SSD stated on 5/1/2026 when Resident 1 was being discharged FM 1 informed him that Resident 1's clothing's were missing. The SSD stated he searched for the missing items of clothing in the facility but did not find them. The SSD stated Resident 1 went home wearing a hospital gown. The SSD stated it was inappropriate to discharge Resident 1 home in a hospital gown.During a concurrent interview and record review on 5/8/2026 at 9:20 a.m. with the Director of Nursing (DON), Resident 1's Inventory List was reviewed. The DON stated Resident 1's Inventory List dated 4/17/26 had personal belongings listed. The DON stated that upon discharge Resident 1 did not have her belongings and Resident 1 went home wearing a hospital gown. The DON stated that was a failure on the facility's part that Resident 1 went home without dignity.During a review of the facility-provided policy and procedure (P&P) titled, Identifying Exploitation, Theft and Misappropriation of Resident Property, last reviewed on 2/20/2026, the P&P indicated 1. Exploitation, theft and Misappropriation 6. Staff and providers are expected to report suspected exploitation, theft or misappropriation of Residents property.During a review of the facility-provided policy and procedures (P&P) titled, Personal property,' last reviewed 2/20/26 indicated 1. Residents are permitted to retain and use personal possessions including clothes. 2. Residents' belongings are treated with respect by the facility staff regardless of perceived value.

Based on interview and record review, the facility failed to conduct a baseline initial comprehensive assessment for functional capacity for one of three sampled residents (Resident 1), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities). This deficiency practice resulted in Resident 1 being discharged to home without proper assessment to determine Resident 1's needs at home.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the Resident 1 on 4/17/2026 with diagnoses including metabolic encephalopathy (brain dysfunction caused by an underlying systemic or chemical imbalance in the body, rather than a direct physical injury to the brain), cerebral ischemia (occurs when there is insufficient blood flow to the brain to meet its metabolic demands), paroxysmal atrial fibrillation (a type of irregular heartbeat characterized by intermittent episodes of chaotic electrical activity in the heart's upper chambers), myocardial infarction (occurs when blood flow to a part of the heart is blocked, causing heart muscle tissue to die from oxygen deprivation), difficulty in walking, and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/24/2026, the MDS indicated the resident's cognitive skills for daily decision making were impaired. The MDS indicated Resident 1 needed partial/moderate assistance (helper does less than half the effort and helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene, shower/bathe self, upper body dressing, and lower body dressing.During an interview with the Social Services Director (SSD) on 5/7/2026 at 4 p.m., the SSD stated Resident 1 was admitted in the facility on a short-term basis. The SSD stated that upon Resident 1's admission on [DATE] he did not do an initial comprehensive assessment of Resident 1. The SSD stated that it was only on 5/1/2026 when Resident 1 was being discharged , that the SSD completed the comprehensive assessment of Resident 1. The SSD stated it is important to do initial baseline comprehensive assessment upon admission to know Resident 1's discharge goals upon discharge. The SSD stated that by not having appropriate care plans and discharge goals it can lead to Resident 1 not receiving services that they need upon discharge. The SSD stated there was no documentation that the care giver (FM 1) was available to take care of Resident 1 at home when discharged . The SSD stated that there was no assessment done on Resident 1 to see if Resident 1 was safe to return home.During a concurrent interview and record review on 5/8/2026 at 9:20 a.m. with the Director of Nursing (DON), Resident 1's assessments were reviewed. The DON stated there was no initial comprehensive assessment done on Resident 1. The DON stated it was important to do an initial comprehensive assessment of residents upon admission to know their discharge goals. The DON stated that the discharge process starts upon admission and for Resident 1 it was not done. The DON stated this failure placed Resident 1 at risk for unsafe discharge as the facility was not aware of Resident 1's discharge goals prior to discharge.During a review of the facility-provided policy and procedures (P&P) titled, Care Plans-Baseline, last reviewed on 2/20/2026, the P&P indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. 2. The baseline care plan includes instructions needed to provide effective, person-centered care of the residents that meet must include. a. initial goals based on admission orders discussion with Residents/representative.

Based on observation, interview, and record review, the facility failed to implement its infection control measures for seven of eight sampled residents (Residents 3, 4, 2, 7, 8, 6, and 5) while the facility had scabies (a contagious skin infestation caused by tiny, eight-legged mites called Sarcoptes scabiei) outbreak (a sudden, unexpected increase in the number of cases of a disease in a specific area or population). The facility: 1. Failed to ensure Restorative Nursing Assistant 1 (RNA) 1 change gowns before providing care between Resident 3 and Resident 4 who were on contact isolation (infection control procedure used in healthcare to prevent the spread of germs transmitted by direct or indirect contact).2. Failed to ensure Certified Nursing Assistant 2 (CNA 2) wear PPE before delivering breakfast tray to Resident 2 who was on contact isolation.3. Failed to ensure CNA 2 and Licensed Vocational Nurse 1 (LVN 1) was aware of Resident 2's contact isolation precaution.4. Failed to ensure facility's Resident Line Listing was complete, to indicate Resident 7 and Resident 8 who were exposed to Resident 3 who was suspected of scabies infection.5. Failed to ensure Housekeeping Staff 1 (HSK 1) wore gloves when tying a clear plastic bag containing soiled (dirty) isolation linens and isolation trash from Resident 6 who was confirmed positive for scabies and Resident 5 who was suspected of scabies.6. Ensure HSK 1 kept isolation carts with isolation linens and trash inside Residents 6 and 5's room.7. Ensure HSK 1 separated soiled isolation linens from confirmed positive and suspected scabies residents from non-isolation residents.These failures had the potential to spread and expose other residents, staff, and visitors to scabies.Findings:a. During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 12/4/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), dermatitis (skin irritation and inflammation, characterized by itchy, dry, or rash-covered skin), and malignant melanoma (aggressive form of cancer arising from melanocytes).During record review of Resident 3's Minimum Data set [MDS- resident assessment tool), dated 4/2/2026, the MDS indicated that Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated that Resident 3 required maximal assistance from staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a record review of Resident 3's Care Plan initiated 4/22/2026, titled, Contact Isolation: Unspecified Dermatitis. The care plan goal indicated to reduce risk of complications, and infections daily until the next assessment. The care plan intervention indicated will observe contact isolation precautions.During a record review of Resident 4's admission Record, the admission Record indicated that the facility admitted Resident 4 on 11/26/2025, with diagnoses that included dementia and history of falling.During record review of Resident 4's MDS, dated [DATE], the MDS indicated that Resident 4's cognitive skills for daily decisions were severely impaired. The MDS indicated that Resident 4 required supervision assistance from staff for ADLs. During an observation on 4/23/2026, at 12:55 p.m. outside of Resident 3 and Resident 4's room, RNA 1 entered the residents' room wearing personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substance and/or environments) and helped Resident 4 in going to the restroom. Resident 3, who was lying in bed, called for assistance. RNA 1 changed her (RNA 1) gloves and assisted Resident 3, still wearing the same gown used with Resident 4. RNA 1 then helped Resident 3 open food items from the bedside table. RNA 1 returned to assist Resident 4 without removing his gloves or gown.During an interview on 4/23/2026, at 12:58 p.m. with RNA 1, RNA 1 stated that staff must use a gown and gloves when providing care for Resident 3 and Resident 4, as both were on contact isolation. RNA 1 stated that he (RNA 1) only changed his (RNA 1) gloves and not his (RNA 1) gown when providing care to Resident 4 and then continued helping Resident 3 while still wearing the same gown. RNA 1 stated that he (RNA 1) should have changed both gown and gloves to prevent the spread of scabies (a contagious skin infestation caused by the microscopic mite) infection.During an interview on 4/24/2026, at 12:15 p.m. with the Director of Nursing (DON), the DON stated that nursing staff should put on gowns and gloves before entering a contact isolation room to prevent the spread of scabies. The DON stated that staff should change gloves and gowns between caring for different residents to avoid cross contamination. The DON further stated that staff must use PPE for all residents in contact isolation.b. During a record review of Resident 2's admission Record, the admission Record indicated that the facility admitted Resident 2 on 2/27/2026, with diagnoses including dermatitis and dementia.During a record review of Resident 2's MDS, dated [DATE], the MDS indicated that Resident 2's cognitive skills for daily decisions were severely impaired. The MDS indicated that Resident 2 is dependent on staff for ADLs.During a record review of Resident 2's Order Summary Report, dated 4/22/2026, the Order Summary Report indicated that Resident 2 was on Contact Isolation Precaution due to unspecified (unconfirmed) dermatitis for four until 5/20/2026.During an observation on 4/24/2026, at 8:34 a.m., CNA 2 entered Resident 2's room with breakfast tray placed it in Resident 2's bedside table without wearing proper PPE, left to collect another tray, and returned to set it up for the roommate (Resident 9).c. During an interview on 4/24/2026, at 8:35 a.m. with LVN 1, LVN 1 stated that Resident 2 was not in contact isolation and was on Enhanced Barrier Precaution (EBP- infection control measures for high-risk residents, to reduce the spread of multidrug-resistant organism [MDRO- Bacteria that resist treatment with more than one antibiotic]) due to a wound. LVN 1 stated that she (LVN 1) was not sure who was on EBP or who was on contact isolation. LVN 1 stated that staff must wear a gown and gloves when taking care of residents on contact isolation.During an interview on 4/24/2026, at 2:30 p.m. with CNA 2, CNA 2 stated that staff must wear a gown and gloves before entering the room of any resident on contact isolation. CNA 2 stated that she (CNA 2) was not sure if she (CNA 2) should wear a gown and gloves when delivering food trays and setting them on resident bedside table to resident on contact isolation. CNA 2 stated that she (CNA 2) was not sure if Resident 2 was on contact isolation or on EBP. CNA 2 stated that she (CNA 2) had only worked at the facility for two months and did not know why residents are placed on contact isolation or EBP.During an interview on 4/24/2026, at 12:15 p.m. with DON, the DON stated that nursing staff should put on gowns and gloves before entering a contact isolation room to prevent the spread of scabies. The DON stated that staff should know who the residents on contact isolation are and who is on EBP. The DON stated that staff should wear proper PPE for residents on contact isolation when delivering food tray and proving care.d. During a record review of Resident 7's admission Record, the admission Record indicated that the facility admitted Resident 7 on 4/7/2026, with diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of right ankle and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review of Resident 7's MDS, dated [DATE], the MDS indicated that Resident 7's cognitive skills for daily decision was intact.During a record review of Resident 8's admission Record, the admission Record indicated that the facility initially admitted Resident 8 on 2/1/2026, and readmitted on [DATE], with diagnoses including sepsis (a life-threatening blood infection) and dementia.During a record review of Resident 8's MDS, dated [DATE], the MDS indicated that Resident 8's cognitive skills for daily decisions were moderately impaired.During a concurrent interview and record review on 4/24/2026, at 9:45 a.m. with the Infection Preventionist (IP) Nurse, Resident Line Listing was reviewed. The IP nurse stated that she (IP) missed adding Resident 7 and Resident 8 names on the resident line list but Residents 7 and 8 were treated for scabies since they were Resident 3's roommates. The IP nurse stated that Resident 7 and Resident 8 were exposed to scabies and should have been on the resident line list to continue to monitor them.During an interview on 4/24/2026, at 12:22 p.m., with the DON, the DON stated that Resident 7 and Resident 8 should have been included in the resident line list because they were roommates of suspected scabies resident. The DON stated that it was important to include all residents who were affected because the facility can monitor them for signs and symptoms and immediately notify the physician. The DON stated that if affective residents were not added to the resident line list the facility would not be able to monitor and provide the care that is needed.During a review of the Acute Communicable Disease Control (ACDC) Program -Scabies Prevention and Control Guidelines for Healthcare Settings (the Guideline) dated 2/2026, the Guideline indicated that a line listing of symptomatic patients/residents and Healthcare Workers (HCW) with a separate line list of their contacts. Identify and prepare a line listing of all patients/residents who were contacts to a patient/resident with scabies or HCW with scabies during the exposure period.During a review of facility's Policy and Procedure (P&P) titled Isolation-Categories of Transmission-Based Precautions revised 2/2026, the P&P indicated that Staff and visitors wear gloves and disposable gowns upon entering the room and remove before leaving the room to avoid touching potentially contaminated surfaces with clothing after gown is removed.During a review of facilities P&P titled Infection Preventionist revised on 9/2022, the P&P indicated that the Infection Preventionist provides education and training on evidence-based infection prevention and control practices.e. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 5/23/2014, with diagnoses that included acute panmyelosis (an abnormal increase in all types of blood-forming cells within the bone marrow [the inside hollow centers of bones, serves as the body's blood cell factory]), multiple sclerosis (MS-a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord) and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs).During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decisions were intact. The MDS indicated Resident 6 was dependent on staff for all ADL.During a review of Resident 6's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 3/26/2026, the H&P indicated Resident 6 had the capacity to understand and make decisions.During a review of Resident 6's Physician Order, dated 4/22/2026, the Physician Order indicated contact isolation precaution due to scabies for four weeks until 5/20/2026.During an observation on the facility's front entrance, on 4/24/2026, at 8 a.m., a notification letter, dated 4/23/2026, was posted by the main sliding entrance door. The notification letter addressed to residents, visitors and staff indicated the facility had scabies infection.During an observation on 4/24/2026, at 8:11 a.m., outside of Resident 6's room, observed contact isolation signage posted outside of Resident 6's room, isolation cart with gloves, gown and mask were at Resident 6's doorway. Observed trash and soiled linen cart inside Resident 6's room.During a concurrent observation and interview on 4/24/2026, at 8:15 a.m., with HSK 1, outside of Resident 6's room, observed HSK 1 without gloves took the trash and isolation soiled cart outside of the room, pushed it along the hallway and tied the clear plastic bag with trash and the clear plastic bag with soiled isolation linen and dropped it off onto the parachute door. Observed HSK 1 returned the empty isolation trash and soiled linen cart back to Resident 6's room. HSK 1 stated the parachute drop off, leading to the laundry room.f. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 4/17/2026, with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by chemical imbalances in the body), unspecified pruritus (an uncomfortable, irritating sensation that makes you want to scratch your skin) and history of fall.During a review of Resident 5's H&P, dated 4/20/2026, the H&P indicated Resident 5 had the capacity to understand and make decisions.During a review of Resident 5's Order Summary Report, dated 4/22/2026, the Order Summary Report indicated contact isolation precaution due to unspecified dermatitis for four weeks until 5/20/2026.During a review of Resident 1's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 4/22/2026, the COC indicated resident 5 was placed on contact isolation to rule out scabies.During a review of Resident 5's Order Summary Report, dated 4/23/2026, the Order Summary Report indicated skin scraping (a quick, minor medical procedure where a doctor uses a dull blade to gently rub or scrape the top layer of skin to collect a small sample).During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 5 required moderate assistance from staff for ADL.During an observation on 4/24/2026, at 8:10 a.m., outside of Resident 5's room, observed contact isolation signage posted outside of Resident 5's room, isolation cart with gloves, gown and mask were at Resident 5's doorway. Observed trash and soiled linen cart inside Resident 5's room.During an observation on 4/24/2026, at 8:18 a.m., outside of Resident 5's room, HSK 1 observed without gloves took the trash and isolation soiled cart outside of the room, pushed it along the hallway and tied the clear plastic bag with trash and the clear plastic bag with soiled isolation linens and drop it off onto the parachute door. Observed HSK 1 returned the empty isolation trash and soiled linen cart back to Resident 5's room.g During a concurrent observation and interview on 4/24/2026, at 8:24 a.m., with HSK 1, in the soiled laundry room, observed tied clear bags of soiled linens on top of a large yellow container. HSK 1 stated he (HSK 1) was not sure which is the isolation linens.During a concurrent observation and interview on 4/24/2026, at 8:26 a.m., with Laundry Staff 1 (LS 1), translated by the Maintenance Supervisor (MS), inside the soiled laundry room, LS 1 stated all the linens currently in the soiled laundry room were from non-isolation rooms. LS 1 stated isolation linens were collected at the same time and placed in a separate location outside and washed separately on the assigned washer and dryer only for isolation linens.During an interview on 4/24/2026, at 8:37 a.m., with the Laundry Staff Supervisor (LSS), the LSS stated the facility's process when collecting isolation linens and trash was to bring the cart only for isolation in front of the isolation room, the LS will don (put on) gloves and gown, go inside isolation room, tie the trash bag and the soiled linen bag inside the room, double bag both trash and soiled linen bag inside the room, place in the cart in the hallway and transport outside of the facility. The LSS stated because HSK 1 dropped off the isolation linens in the parachute drop off, it mixed up with the regular non isolation linens. The LSS stated it could contaminate other linens and could cause spread of infection.During an interview on 4/24/2026, at 9:23 a.m., with CNA 1, CNA 1 stated Resident 5 was on isolation for scabies. CNA 1 stated LS collects soiled trash and linens from the isolation rooms.During an interview on 4/24/2026, at 9:46 a.m. with the IP, the IP stated the facility had scabies outbreak. The IP stated Residents 6 went to his (Resident 6) Oncologist (medical specialists trained to diagnose, treat, and manage care for people with cancer [a group of diseases characterized by uncontrolled, abnormal cell growth that can invade nearby tissues and spread to other parts of the body]) appointment and came back the same day on 4/22/2026, with diagnosis of scabies. The IP stated Resident 5 had symptomatic rashes and was suspected of scabies. The IP stated contact isolation rooms had red hampers for trash and soiled linens. The IP stated the parachute laundry door was for regular soiled linens not from isolation rooms. The IP stated mixing laundry with isolation linens could potentially spread scabies to other residents, staff and visitors.During an interview on 4/24/2026, at 12:25 p.m., with the DON, the DON stated the isolation hampers should stay in the isolation rooms and HSK 1 should have used gloves and gown before collecting the isolation trash and contaminated soiled linens from the isolation rooms. The DON stated HSK 1 should have taken the isolation trash and linens separately and not mix with other non-isolation soiled linens to prevent the spread of scabies.During a review of facility's P&P titled, Scabies Identification, Treatment and Environmental Cleaning, dated 4/2026, was reviewed. The P&P indicated, The purpose of this procedure is to treat residents infected with and sensitized to Sarcoptes scabiei and to prevent the spread of scabies to other residents and staff.12. Individuals who come into contact with the infected resident or with potentially contaminated bedding or clothing should wear a gown and gloves or other protective clothing as established by the facility's infection and exposure control programs.Environmental Control: Typical Scabies (classic scabies-causes intense, night itching and a pimple-like rash, typically affecting few mites): .4. Place bed linens, towels and clothing used by an affected person during the four days prior to initiation of treatment in plastic bags inside the resident's room, handled by gloved and gowned staff without sorting, and washed in hot water for at 10-20 minutes.5. Use the hot cycle of the dryer for at least 10-20 minutes.Environmental Control: Atypical Scabies (crusted/Norwegian-presents with thick, widespread crusts, often lacking itching due to weakened immunity, and harbors thousands of mites): .1. Maintain contact precautions until treatment is complete and/or resident is determined (by Dermatologist [a medical doctor who specializes in treating the health of your skin, hair, and nails] or primary care provider) to be scabies free.5. Bed linens, towels and clothing used by the affected persons during the four days prior to initiation of treatment should be placed in a plastic bag inside the resident's room, handled by gloved and gowned laundry staff without sorting, and laundered in hot water for at least 10 minutes.During a review of ACDC- Scabies Prevention and Control Guidelines for Healthcare Settings, dated 2/2026, the ACDC indicated, Place bed linens, towels and clothing used by an affected person during the three days prior to initiation of treatment in plastic bags inside the patient's/resident's room, handled by gloved and gowned HCW without sorting, and washed in hot water. The hot cycle of the dryer should be used. Non-washable blankets and articles can be placed in a plastic bag for three to seven days, dry cleaned or tumbled in a hot dryer.

Based on interview and record review, the facility failed to notify the Resident's Representative (RR- is a person chosen by a resident-or legally authorized-to act on their behalf to manage care, access personal information, or make decisions, particularly if the resident is incapacitated) for one of three sampled residents (Resident 6) who had a Power of Attorney (POA- a legal document that allows someone else to act on your behalf) of Resident 6's changes in conditions on 3/16/2026, and 3/18/2026.This failure had violated Resident 1's and RR's right to be informed and had the potential to increase Resident 1's and RR level of anxiety (an intense, persistent, and often overwhelming feeling of worry, dread, or unease).Findings:During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 5/23/2014, with diagnoses that included acute panmyelosis (an abnormal increase in all types of blood-forming cells within the bone marrow [the inside hollow centers of bones, serves as the body's blood cell factory]), multiple sclerosis (MS-a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord) and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs).During a review of Resident 6's Advance Health Care Directive Acknowledgement Form, dated 5/14/2024, the Advance Health Care Directive Acknowledgement Form indicated RR was Resident 6's representative.During a review of Resident 6's Durable Power of Attorney (DPOA), dated 7/23/2014, the DPOA indicated the DPOA effective date was 7/23/2014, and Resident 6 appointed RR as the attorney-in-fact. The DPOA was signed and notarized on 7/23/2014.During a review of Resident 6's Minimum Data Set (MDS-a resident assessment tool) dated 3/19/2026, the MDS indicated Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 6 was dependent on staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 6's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 3/26/2026, the H&P indicated Resident 6 had the capacity to understand and make decisions.During a review of Resident 6's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 3/16/2026, the COC indicated Resident 6 had new medication for dermatitis (a common condition that causes swelling and irritation of the skin). The COC indicated Resident 6 was notified.During a review of Resident 6's COC, dated 3/18/2026, the COC indicated Resident 6 had elevated white blood cell count (WBC- (a blood cell that helps attack infection or injury in the body) and platelet (tiny, colorless cell fragments in your blood that act as your body's natural bandage). The COC indicated Resident 6 was notified.During a concurrent interview and record review on 4/24/2026, at 12:25 p.m., with the Director of Nursing (DON), Resident 6's COCs, dated 3/16/2026, and 3/18/2026, were reviewed. The DON stated the COCs on 3/16/2026, and 3/18/2026, indicated RR was not notified. The DON stated the facility was not aware that Resident 6 appointed RR had POA. The DON stated the importance of notifying the RR was to ensure RR was aware of Resident 6's COCs. The DON stated because RR was not informed, the facility may have violated Resident 6 and RR's right to be informed.During an interview on 4/24/2026, at 12:44 p.m., with Resident 6 and RR, Resident 6 stated he (Resident 6) had an Advance Health Care Directive, and it was RR.During a review of facility's policy and procedure (P&P), titled, Resident Rights, dated 2/2021, the P&P indicated, Employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: . k. Appoint a legal representative of his or her choice, in accordance with state law.During a review of facility's P&P, titled, Change in a Residents Condition or Status, dated 3/2023, the P&P indicated Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status ( e.g., changes in level of care, billing/payments, resident rights, etc.).4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source;b. there is a significant change in the resident's physical, mental, or psychosocial status;c. there is a need to change the resident's room assignment;d. a decision has been made to discharge the resident from the facility; and/ore. it is necessary to transfer the resident to a hospital/treatment center.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of five sampled residents (Resident 5) regarding skin scraping (a quick, minor medical procedure where a doctor uses a dull blade to gently rub or scrape the top layer of skin to collect a small sample).This failure had the potential for delays in the delivery of necessary care and services and could place Resident 5 at risk for scabies (a contagious skin infestation caused by tiny, eight-legged mites called Sarcoptes scabiei).Findings:During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 4/17/2026, with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by chemical imbalances in the body), unspecified (unconfirmed) pruritus (an uncomfortable, irritating sensation that makes you want to scratch your skin) and history of fall.During a review of Resident 5's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/20/2026, the H&P indicated Resident 5 had the capacity to understand and make decisions.During a review of Resident 5's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 4/22/2026, the COC indicated Resident 5 was placed on contact isolation (a safety measure used in hospitals to prevent the spread of germs that are transferred by touching a patient or items in their room) to rule out scabies.During a review of Resident 5's Order Summary Report, dated 4/23/2026, the Order Summary Report indicated skin scraping.During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool), dated 4/24/2026, the MDS indicated Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 5 required moderate assistance from staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a concurrent interview and record review on 4/24/2026, at 9:46 a.m., with the Infection Preventionist (IP), Resident 5's Care Plans, were reviewed. The IP stated there was no care plan developed for Resident 5's skin scraping to test for the presence of scabies. The IP stated care plan serves as a guide for nurses on what to do when the skin scraping for scabies resulted. The IP stated without care plan it could potentially spread scabies to other residents.During an interview on 4/24/2026, at 12:25 p.m. with the Director of Nursing (DON), the DON stated care plan for skin scraping for scabies should have been developed. The DON stated without a care plan, the nurses will not have a guide on what to do for a suspected scabies resident. The DON stated there is a potential spread of scabies to other residents, staff and visitors.During a review of facility's policy and procedure (P&P), titled, Comprehensive Person-Centered Care Plans, dated 3/2023, and last reviewed on 2/20/2026, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial (it describes how your mind and emotions affect your social life, and how your social situation affects your mental health) and functional needs is developed and implemented for each resident.7. The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes;b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, .c. includes the resident's stated goals upon admission and desired outcomes;d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem areas and conditions.10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of five sampled residents (Residents 5) by failing to administer clobetasol (medication used to treat severe skin conditions by reducing itching, redness, and swelling) on 4/23/2026, as per physician order.This failure had the potential to result in medication errors and could worsen Resident 5's dermatitis (common condition that causes swelling and irritation of the skin).Findings:During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 4/17/2026, with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by chemical imbalances in the body), unspecified (unconfirmed) pruritus (an uncomfortable, irritating sensation that makes you want to scratch your skin) and history of fall.During a review of Resident 5's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/20/2026, the H&P indicated Resident 5 had the capacity to understand and make decisions.During a review of Resident 5's Order Summary Report, dated 4/22/2026, the Order Summary Report indicated clobetasol propionate external cream 0.05 percent (%-amount in every hundred), apply to general body, topically (directly to a specific surface area of the body, such as the skin) every day and evening for unspecified dermatitis for four weeks.During a review of Resident 5's Treatment Administration Record (TAR- flowsheet that indicates treatment given to a resident), dated 4/2026, the TAR indicated on 4/23/2026, at evening shift, clobetasol was left blank.During a review of Resident 5's Minimum Data Set (MDS-a resident assessment tool), dated 4/24/2026, the MDS indicated Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 5 required moderate assistance from staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a concurrent interview and record review on 4/24/2026, at 9:46 a.m., with the Infection Preventionist (IP), Resident 5's Physician Order, dated 4/22/2026, and TAR, dated 4/23/2026, were reviewed. The IP stated the physician ordered application of clobetasol twice a day for Resident 5's unspecified dermatitis. The IP stated the TAR, dated 4/23/2026, evening was left blank. The IP stated if TAR was blank, it means clobetasol was not given. The IP stated the nurse did not follow the order. The IP stated Resident 5's rashes can worsen because clobetasol was not administered.During an interview on 4/24/2026, at 12:25 p.m., with the Director of Nursing (DON), the DON stated Resident 5's rashes can worsen because clobetasol was not administered. The DON stated Treatment Nurses (TXN) should apply the clobetasol according to the physician order.During a review of facility's policy and procedure (P&P) titled, Administering Medications, dated 3/2023, and last reviewed on 2/20/2026, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to implement contact isolation precautions (infection control measures used in the healthcare settings to prevent the spread of infections transmitted by direct or indirect contact with a resident or their environment) for one of three sampled residents (Resident 1) when Resident 1 was suspected and exhibited signs and symptoms (indicators of an illness, injury, or condition) consistent with Clostridiodes (known before as Clostridium) Difficile infection (CDI or C. difficile - bacteria that causes severe, diarrhea [loose, watery stools], and inflammation [swelling] of the colon) on 1/18/2026 and subsequently tested positive for CDI on 1/20/2026, by failing to:1. Ensure Resident 1, who showed signs and symptoms of CDI on 1/18/2026, was not sharing the same room with Resident 2 and Resident 3. Resident 2 was immunocompromised (having a weakened immune system that cannot fight infections and diseases as effectively as a healthy one) due to a diagnosis of diffuse large B-cell lymphoma (a fast-growing, aggressive type of non-Hodgkin lymphoma [blood cancer] that develops when abnormal B-cell lymphocytes [a type of white blood cell] multiply uncontrollably and frequently, causes swollen lymph nodes [small, bean-shaped immune system organs that act as filters throughout the body, trapping bacteria, viruses, and cancer cells to help fight infection], fever [abnormally high body temperature], and weight loss, and can spread rapidly to other organs) and actively undergoing antineoplastic chemotherapy (the use of medication designed to treat cancer by inhibiting or killing rapidly dividing malignant [abnormal] cells).2. Ensure the facility conducted infection risk assessments (assessments of risk factors that place residents at higher risk for infections) for Resident 2 and Resident 3 before cohorting (an infection control strategy that involves grouping residents together based on their infection status to prevent the spread of illness to healthy residents) them with Resident 1 who was suspected with CDI on 1/18/2026 and tested positive for CDI on 1/20/2026.3. Ensure the facility informed and educated Resident 1's roommates, Residents 2 and 3, when the Medical Director suspected Resident 1 of having CDI on 1/18/2026, that they were at risk of acquiring CDI and what proper infection control guidelines Residents 2 and 3 should follow to reduce the risk of transmission. 4. Ensure the facility performed monitoring of Residents 2 and 3 for signs and symptoms of CDI after their roommate, Resident 1, was suspected with CDI on 1/18/2026 and tested positive for CDI on 1/20/2026.5. Follow the facility's policy and procedure (P&P) titled, Clostridium Difficile, with revised date of 10/2018 and last review date of 8/15/2025, indicating, Residents with diarrhea associated with C. difficile (i.e. [an abbreviation for the Latin phrase id est, which translates to namely], residents who are colonized [when someone has germs on or in their body but does not have symptoms of an infection] and symptomatic [exhibiting symptoms]) are placed on contact precautions. Residents with diarrhea and suspected CDI are placed on contact precautions while awaiting laboratory results.6. Follow facility's P&P titled, Isolation (separating residents with contagious or infectious diseases from others to prevent spreading) - Categories of Transmission-Based Precautions (measures implemented in addition to standard precautions [basic level of infection control] for residents known or suspected to be infected with highly transmissible pathogens [tiny organisms that can make you sick if they get inside your body]), revised date of 9/2022 and last review date of 8/15/2025, indicating, The individual on contact precaution is placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options (e.g. [an abbreviation for the Latin phrase exempli gratia, which means for example], cohorting, placing with a low risk roommate). Staff and visitors wear gloves (clean, non-sterile) when entering the room. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room.This deficient practice had the potential for Resident 1, who was infected with CDI, to transmit the infection (CDI) to Resident 2 (who was immunocompromised) and Resident 3, who were placed in the same room with Resident 1. Transmission of CDI to Resident 2 and Resident 3 could result in serious complications, including severe infection, dehydration (a condition in which the body loses more fluids [like water] than it takes in, and cannot function properly), sepsis (a life-threatening medical emergency caused by the body's extreme response to infection), hospitalization, or death. On 1/30/2026 at 4:58 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Director of Nursing (DON) and the Administrator, due to the facility's failure to implement contact precautions for Resident 1 who continued to share the same room with Resident 2 (who was immunocompromised) and Resident 3, when Resident 1 had signs and symptoms consistent with CDI on 1/18/2026 and subsequently tested positive for CDI on 1/20/2026 which had the potential for Resident 1 to transmit CDI to Residents 2 and 3, placing Resident 2 and Resident 3 at risk for severe infection, dehydration, sepsis, hospitalization, or death.On 1/31/2026 at 4:45 p.m., the Administrator provided an acceptable IJ Removal Plan (a detailed plan that identifies all actions the facility will take to immediately address the non-compliance that has resulted to the IJ situation) for the facility's failure to implement contact precautions for Resident 1.On 1/31/2026 at 5:54 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to implement contact precautions for Resident 1 was no longer present. The SSA removed the IJ situation, while onsite, on 1/31/2026 at 5:54 p.m., in the presence of the Administrator and the Director of Nursing (DON).The acceptable IJ Removal Plan included the following summarized actions:1. On 1/29/2026 at 7:20 p.m., the Social Services Director (SSD) moved Resident 2 to Room B with no roommates due to her immunocompromised condition. Effective 1/31/2026, the Registered Nurse (RN) Supervisors on duty will monitor Resident 2 every shift for 40 days for signs and symptoms of CDI infection such as fever, abdominal pain, abdominal spasms (a sudden involuntary muscular contraction), diarrhea, and vomiting.2. On 1/30/2026 at 2:40 p.m., Room A was designated as a single isolation room, and Resident 1 was assigned no roommates.3. On 1/30/2026 at 6 p.m., the DON reviewed and revised Resident 2's care plan to reflect her (Resident 2) immunocompromised condition and that Resident 2 should not share a room with a resident who has an active infection (Resident 1).4. On 1/30/2026 at 6 p.m. and on 1/31/2026 at 6:30 a.m. and 9 a.m., the DON and/or Infection Preventionist Nurse conducted in-services (short teaching sessions designed to update staff on best practices, safety protocols, and regulatory requirements) training for all nursing staff regarding the facility's Infection Control policy. The DON and/or Infection Preventionist Nurse provided a written quiz following each in-service to validate staff understanding of the topic discussed. The topics included in the in-service were the following:a. Policy on Isolation - Categories of transmission-based precautions (second level of infection control in healthcare, implemented in addition to Standard Precautions [the basic level of infection control that should be used in the care of all residents all of the time] to prevent the spread of infections).b. Precautions specific to CDI.c. Procedures for implementing transmission-based precautions.d. Proper hand washing and disinfection (process of using chemical or physical agents to kill or inactivate most disease-causing microorganisms [an organism that is so small it can only be viewed under a microscope and not with the naked eye] on inanimate [having none of the characteristics of life] objects) of environment.e. Enhanced Barrier Precaution (infection control measure that require healthcare workers to wear gowns and gloves during high-contact activities [refers to specific routine care tasks with a high risk of transferring multi-drug resistant organisms {bacteria that have developed resistance to multiple, commonly used antibiotics - medication that fight bacterial infections, to a staff member's clothing or hands] for residents)f. Personal Protective Equipment (PPE - refers to protective clothing, helmets, goggles, or other garments and equipment designed to shield the wearer's body from injury, infection, or occupational hazards [a risk accepted as a consequence of a particular occupation]).g. Cohorting strategies, including placement in a private room when feasible, or cohorting with a low-risk residents, which includes but is not limited to residents who are:Not immunocompromisedHave no open woundsDo not have significant comorbidities (the simultaneous presence of two or more diseases or medical conditions in a resident), such as uncontrolled diabetes mellitus (DM - chronic disorder characterized by high blood sugar caused by the body's inability to produce or effectively use insulin [hormone that regulates blood sugar]), severe Chronic Obstructive Pulmonary Disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing), or similar high-risk conditions.Any facility staff unable to attend the in-service in person will be contacted by phone and provided follow-up training prior to start of their next scheduled shift. Staff who fail to complete the in-service will be temporarily removed from the schedule until the in-service training is completed.5. On 1/30/2026 at 7 p.m. and 8 p.m., the Quality Assurance Nurse Consultant provided one-on-one (1:1) in-service (1:1 in-service - refers to individualized, one-on-one education a staff member or professional provides to a single individual) to the Administrator and the DON regarding the admission process for residents requiring isolation precautions and appropriate cohorting of residents.6. On 1/30/2026 at 7:30 p.m., the Quality Assurance Nurse Consultant provided 1:1 in-service training to the Infection Preventionist Nurse on infection control practices, including proper use of PPE and appropriate cohorting of residents with infection.7. On 1/30/2026, the Medical Records Designee and the DON conducted a record review of all residents with changes in condition, including physician orders and laboratory results, to identify any residents manifesting signs or symptoms consistent with CDI such as fever, abdominal pain/spasm, diarrhea, nausea/vomiting. No other residents were affected.8. On 1/30/2026 at 9 p.m., RN 1 assessed all residents for signs and symptoms of CDI, including fever, abdominal pain or spasms, diarrhea, nausea, and vomiting, No additional residents were affected by the deficient practice.9. Effective 1/30/2026, the DON and Infection Preventionist Nurse will review all incoming admissions to determine the need for isolation or precaution and arrange the appropriate room placement, and if necessary, newly admitted resident will be cohorted with residents who have the same infection or with residents who are not immunocompromised.10. Effective 1/30/2026, the Infection Preventionist Nurse will maintain a tracking log for all residents with active infections, including residents with CDI to prevent spread of infection.11. The Administrator and the Interdisciplinary Team (IDT - a collaborative group of healthcare professionals who work together to create, implement, and evaluate a personalized, comprehensive care plan for residents) consisting of the DON, Infection Preventionist Nurse, Dietary Supervisor, Housekeeping Supervisor, and Medical Director, will conduct monthly infection control meetings to ensure:a. The facility follows the infection control policy in handling residents with transmission-based precautions and follows the PPE policy.b. Any issues related to room placement and cohorting are promptly identified and addressed. 12. The Administrator, DON, and Infection Preventionist Nurse developed a Quality Assurance and Performance Improvement (QAPI - is a data-driven, systematic program to proactively improve resident care and quality of life, combining ensuring standards [QA] with continuous process enhancement [PI] involving all staff, data, and resident/family feedback to prevent issues and achieve optimal outcomes) for Infection Control practices and root cause analysis (RCA - a structured, team-based investigation process used to identify the underlying system-level causes of adverse events) of the problem. This plan will be reviewed and updated during monthly QAPI meetings for three months to ensure the corrective actions are effective and sustained.Non-compliance of F880 remained at the scope and severity of D no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings:During a review of Resident 1's Face Sheet (admission Record), undated, the Face Sheet indicated the facility admitted Resident 1 on 1/17/2026 with diagnoses including other pulmonary embolism without acute cor pulmonale (indicates a blockage in the pulmonary arteries by a blood clot reducing blood flow but not severe enough to cause right heart failure) and sepsis. The Face Sheet indicated Resident 1 had a diagnosis of enterocolitis (is the inflammation of both the small intestines and colon, causing symptoms like severe diarrhea, abdominal pain, fever, vomiting, and dehydration) due to CDI with onset date of 1/20/2026. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/24/2026, the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was intact. The MDS indicated Resident 1 was dependent (helper does all of the effort and resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) on staff for eating, oral hygiene, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, and putting on/taking off footwear. During a review of Resident 1's Change in Condition (COC - major decline or improvement in a resident's status that will not resolve without intervention) Evaluation form, dated 1/20/2026 timed at 11:30 a.m., the COC indicated Resident 1 had CDI with onset of symptoms on 1/18/2026. The COC form indicated Resident 1 met the following criteria for CDI: Diarrhea: three or more liquid or watery stools above what is normal for the resident within a 24-hour period and a stool sample yields a positive laboratory test result for CDI. The COC indicated the facility placed Resident 1 on contact isolation on 1/20/2026.During a review of Resident 1's Order Summary Report, dated 1/18/2026, the Order Summary Report indicated that the physician ordered a stool sample to be collected from Resident 1 for testing of CDI as soon as possible (ASAP).During a review of Resident 1's Order Summary Report, dated 1/20/2026, The Order Summary Report indicated that the physician ordered Resident 1 to be placed on contact isolation for CDI infection (positive result) for a duration of 21 days.During a review of Resident 1's care plan titled Clostridium Difficile, with date initiated on 1/20/2026, the care plan indicated Resident 1 had CDI infection, and included interventions specifying that facility staff will place Resident 1 on contact isolation precaution.During a review of Resident 1's Laboratory Results Report, dated 1/21/2026, the Laboratory Results Report indicated that a stool sample was collected from Resident 1 on 1/20/2026 at 3:41 a.m., received by the laboratory on 1/20/2026 at 11:56 p.m., and reported on 1/21/2026 at 3:38 a.m. The results indicated that Resident 1 tested positive for CDI.During a review of Resident 2's Face Sheet, undated, the Face Sheet indicated the facility originally admitted Resident 2 on 6/20/2019 and readmitted on [DATE], with diagnoses including diffuse large B-cell lymphoma, encounter for antineoplastic chemotherapy, and acquired absence of kidney (two bean-shaped organs responsible for filtering waste, toxins and excess water from the blood).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive functioning was intact. The MDS indicated Resident 2 needed substantial/maximal assistance (helper does more than half the effort with helper lifting or holding trunk or limbs and providing more than half the effort) from staff with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. During a review of Resident 2's COC, dated 1/27/2026, timed at 6 p.m., the COC indicated Resident 2 was at risk for nosocomial infection (infections acquired in hospitals or healthcare facilities that were not present at the time of admission).During a review of Resident 2's care plan titled Risk for Infection, with date initiated on 1/27/2026, the care plan indicated that Resident 2 is at high risk for infection secondary to immunocompromised status and Resident 2 is at risk for nosocomial infection. The care plan indicated that facility staff will perform hand hygiene (process of cleaning one's hands with soap and water or using alcohol-based hand sanitizers to prevent the spread of infectious diseases), wear gowns and gloves while performing high contact activities.During a review of Resident 3's Face Sheet, undated, the Face Sheet indicated the facility originally admitted Resident 3 on 11/27/2024 and readmitted on [DATE] with diagnoses including other hypertrophic cardiomyopathy (a genetic condition where the heart muscle thickens but does not physically block blood flow out of the heart), chronic kidney disease (long-term, progressive loss of kidney function), type 2 DM, depression (is a serious, common medical illness characterized by a persistent low mood, sadness, or loss of interest in activities), and anxiety disorders (a group of common mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life, work, or relationships).During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderate cognitive impairment (involves noticeable memory, language, or thinking problems that exceed normal aging but do not yet severely disrupt daily independence). The MDS indicated Resident 3 needed substantial/maximal assistance from staff with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear.During an observation on 1/26/2026 at 9:30 a.m., in Resident 1's room, observed Resident 1 sharing the same room with Resident 2 and Resident 3, with an isolation cart positioned outside the room and a contact precaution sign posted.During an interview on 1/26/2026 at 10:15 a.m., with Resident 3, Resident 3 stated she (Resident 3) did not understand why her room was on isolation. Resident 3 stated that when she (Resident 3) asked the nursing staff (did not specify) for an explanation, she (Resident 3) was not provided with any information regarding the reason for the isolation. During a concurrent observation and interview on 1/26/2026 at 11:30 a.m., with Resident 2, in Resident 1's (shared) room, observed Resident 1 still sharing the room with Resident 2 and Resident 3. Resident 2 stated that she (Resident 2) was unaware why an isolation sign was posted on the door and was concerned because she (Resident 2) has a tumor (a swelling of a part of the body caused by an abnormal growth of tissue) and is receiving chemotherapy. Resident 2 stated that she asked the nurses and nurse assistants (did not specify) why they were wearing gowns while caring for Resident 1 but was told it had nothing to do with her and not to worry. Resident 2 stated that she continued to express her (Resident 2) concern because she Resident 2) is aware that her immune system (the organs and processes of the body that provide resistance to infection and toxins) is compromised. During an interview on 1/26/2026 at 2 p.m. with the Infection Preventionist Nurse, the Infection Preventionist Nurse stated that the physician (MD 1) ordered a laboratory test for Resident 1 on 1/18/2026 because he (MD 1) had a suspicion that Resident 1 might be positive for CDI infection. The Infection Preventionist Nurse stated Resident 1 was not placed on isolation precautions when the CDI test was ordered on 1/18/2026. The Infection Preventionist Nurse stated that because Resident 1 was not on contact precautions, there was an increased risk of transmitting the infection to other residents and staff. The Infection Preventionist Nurse further stated that Resident 2 should not have been sharing a room with Resident 1, as Resident 2 is immunocompromised and therefore at higher risk for infection. The Infection Preventionist Nurse stated that an infection in Resident 2 could result in severe complications, including hospitalization or death, due to an inability of Resident 2's immune system to effectively respond to infection.During a telephone interview on 1/28/2026 at 12 p.m., with the Medical Director, the Medical Director was asked about Resident 1, who had CDI, sharing a room with Resident 2 and Resident 3. The Medical Director stated that facility staff were aware of the appropriate infection control measures but failed to implement them. The Medical Director further stated that staff should have followed facility policy and Centers for Disease Control and Prevention (CDC - is the nation's leading science-based, data driven, service organization that protects the public's health) guidelines and should not have cohorted Resident 1 with residents who had high-risk conditions and diagnoses, including Resident 2, who was immunocompromised. The Medical Director stated Resident 1 should not have been placed in the same room (cohorted) as Resident 2, who was highly vulnerable, and stated that there was no excuse for this failure. During an interview on 1/30/2026 at 12:45 p.m., with the Infection Preventionist Nurse, the Infection Preventionist Nurse stated that the facility did not follow its policy on CDI because Resident 1, who was positive for CDI, was cohorted with Resident 2, who was immunocompromised.During a concurrent interview and record review on 1/30/2026 at 2:04 p.m., with the DON, Resident 2 and Resident 3's Infection Risk Assessment records from 1/17/2026 to 1/30/2026 were reviewed. The DON stated that there was no documented evidence that infection risk assessments were completed for Residents 2 and 3. The DON stated that the facility should have cohorted residents correctly based on infection risk assessments and the suitability of potential roommates. The DON further stated that the infection risk assessments should have been completed by the Infection Preventionist Nurse or in their absence, by a licensed nurse to determine whether Residents 2 and 3 were appropriate roommates for Resident 1, who had CDI infection, prior to cohorting the residents. The DON stated that the failure to complete these Infection Risk Assessments placed Residents 2 and 3 at increased risk for transmission of CDI. During a concurrent interview and record review on 1/30/2026 at 3:44 p.m., with the DON, Resident 2's care plan titled Risk for Infection, with date initiated on 1/27/2026 was reviewed. The DON stated the facility failed to follow its policy for CDI because Resident 1, who had active CDI, was cohorted with Resident 2, who was immunocompromised and at high risk for infection. The DON stated that facility should not have cohorted Resident 2 with Resident 1. The DON further stated that Resident 2 was at risk for acquiring CDI, which could further compromise her (Resident 2) immune system and result in serious complications such as sepsis, dehydration, and inability to fight the infection, potentially leading to death. The DON stated she (DON) agreed with the deficient practice and stated that it created a risk of CDI transmission to other residents.During an interview on 1/30/2026 at 4:13 p.m., with the DON, the DON stated there was a failure in the facility's system process because an immunocompromised resident (Resident 2) should not be placed in the same room as Resident 1, who had CDI infection. The DON stated that they (the facility) failed to conduct Infection Risk Assessments for Resident 2 and Resident 3. The DON further stated that RNs should have performed the risk assessments whenever there was a COC or new laboratory results, in order to determine whether residents required isolation or room changes based on the needs of the resident identified with an infection. The DON stated there was a lack of staff training regarding isolation precautions and infection risk assessments.During a concurrent interview and record review on 1/31/2026 at 2:01 p.m. with the Infection Preventionist Nurse, Resident 2 and Resident 3's care plans, COCs, IDT, physician orders, and progress notes from 1/17/2026 to 1/30/2026. The Infection Preventionist Nurse stated there was no documented evidence that facility staff notified Residents 2 and 3 of their potential risk for CDI and that Residents 2 and 3 should have received education on proper infection control guidelines. The Infection Preventionist Nurse further stated that no monitoring was conducted for Residents 2 and 3 for signs and symptoms of CDI.During a review of the facility's P&P titled, Clostridium Difficile, with revised date of 10/2018 and last review date of 8/15/2025, the P&P indicated, Measures are taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are taken while caring for residents with C. difficile to prevent transmissions to other residents. Residents considered at high risk of developing symptoms associated with C. difficile include those with: . antibiotic or anti-neoplastic therapy. The primary reservoir (any person, animal, plant, or substance where an infectious agent [germ] normally lives, grows and multiplies) for C. difficile are infected people and surfaces. Spores (are the dormant, highly resistant, and inactive form of the bacteria that survive for months on surfaces, resisting heat, alcohol-based hand sanitizers, and antibiotics) can persist on resident-care items and surfaces for several months and are resistant to some common cleaning and disinfection methods. C. difficile is transmitted via the fecal-oral route (transfer of bacteria from the feces of an infected person to the mouth of another person). Therefore, any resident-care activity that involves contact with the resident's mouth when hands or instruments are contaminated may provide an opportunity for transmission, for example: a. oral care . c. administration of oral medications . Residents with diarrhea associated with C. difficile (i.e., residents who are colonized and symptomatic) are placed on contact precautions. Residents with diarrhea and suspected CDI are placed on contact precautions while awaiting laboratory results.During a review of the facility's P&P titled, Isolation - Categories of Transmission-Based Precautions, with revised date of 9/2022 and last review date of 8/15/2025, the P&P indicated, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; . has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The Centers for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission and recommended precautions. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Contact precautions are also used in situations when a resident is experiencing . diarrhea, . even before a specific organism has been identified. The individual on contact precaution is placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options (e.g., cohorting, placing with a low risk roommate). Staff and visitors wear gloves (clean, non-sterile) when entering the room. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room.

Based on observation, interview, and record review, the facility failed to have a system-wide (something that extends or exists throughout a system) method of accountability for controlled medications (drugs that are regulated by the government because it may be abused or cause addiction) and ensure safeguarding of controlled medications for two of nine sampled residents (Resident 1 and Resident 2) by: 1. Failing to ensure licensed nurses document the administration of controlled substances in Resident 1's electronic Medication Administration Record (eMAR- an electronic report detailing the drugs administered to a resident) 2. Failing to maintain records on the transfer of controlled medications from licensed nurses to the Director of Nursing (DON) after Resident 1 was discharged , and after the controlled medications were no longer in use and were cleared for disposition (process of returning and/or destroying unused medications). 3. Failing to ensure the DON investigate all discrepancies related to Resident 1's and Resident 2's controlled medication reconciliation (process of comparing a resident's medication orders to all of the medications that the resident has been taking) to determine the cause of the missing controlled medications. 4. Failing to ensure the DON reported Resident 1 and Resident 2's missing controlled medications to the Administrator (ADM). These deficient practices resulted to the facility not able to account for 43 doses of Norco (a controlled medication used to treat moderate to severe pain) 5-325 milligrams (mg - unit of measure) belonging to Resident 1 and was not able to account for the exact amount of Oxycodone-Acetaminophen (generic name for Percocet, a controlled medication used to treat moderate to severe pain) 5-325 mg belonging to Resident 2. The failure to maintain a system to ensure accountability of controlled medications increased the risks of diversion (when a medication is taken for use by someone other than whom it is prescribed or for an indication other than what is prescribed) of medications, staff working in an impaired state (weakened or imperfect condition that results in a loss of function or ability), or accidental exposure of controlled medications to 163 of 188 total residents (facility census [a complete count of residents in the facility] on 1/29/2025) possibly resulting in respiratory depression (inability to breathe) leading to hospitalization and death. On 1/29/2025 at 5:01 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, and/or death to a resident) ) under 42 CFR S483.45 Pharmacy Services in the presence of the Regional Administrator (RAdm), Infection Prevention Nurse (IP), and the Director of Staff Development (DSD), due to the facility's failure to have a system in place to ensure safeguarding of controlled medications for Resident 1 and Resident 2. On 1/31/2025 at 5:29 p.m., the RAdm provided the SSA with an acceptable IJ Removal Plan (a detailed plan that identifies all actions the facility will take to immediately address the non-compliance that has resulted to IJ situation) which included the following summarized actions: 1. Resident 1 was discharged from the facility on 1/21/2025. Resident 1 left against medical advice (AMA - a situation where a resident leaves a healthcare facility or discontinues treatment against the advice of their physician). 2. On 1/30/2025, a complete search of all six medication carts (Medication Cart 1, Medication Cart 2, Medication Cart 3, Medication Cart 4, Medication Cart 5, Medication Cart 6), all two medication rooms (Medication room [ROOM NUMBER], Medication room [ROOM NUMBER]), and the controlled medications for disposal (discarding or destroying unused medications that remain after the end of medical treatment) inside the controlled medications drawer located in the DON's office for Resident 1's hydrocodone-acetaminophen 5-325 mg was conducted and confirmed a total of ten remaining hydrocodone-acetaminophen 5-325 mg tablets with the corresponding Controlled Medication Count Sheet (a form used to account for all controlled medications, and to transfer accountability from the out-going nurse to the on-coming nurse). A total of 43 tablets of Hydrocodone Acetaminophen 5-325 mg were confirmed missing and unaccounted for. 3. The DON was suspended pending completion of investigation, effective 1/27/2025. 4. The Assistant Director of Nursing (ADON), who also had access to the DON's office where the controlled medications for disposal were stored, will be placed on suspension upon her return from her medical leave (projected on 2/4/2025). 5. On 1/29/2025, 1/30/2025, and 1/31/2025, in-services (staff trainings) were provided to licensed nurses regarding the controlled medication policy, covering the following: All licensed nurses are responsible for maintaining accurate records of controlled medication receipts, medication administrations, disposal, loss of medications or possible drug (medication) diversion. 6. Documentation of controlled medication disposal will be maintained accurately in a log, including the following endorsement information: a. Date of endorsement b. Medication information, including name, strength and quantity c. Releasing nurse signature d. Receiving party (Acting DON) signature e. Disposal information including the medication information, medication name, strength and quantity. 7. Proper procedures for controlled medications when discharging a resident to a lower level of care (a healthcare setting or situation where a resident requires minimal assistance and has less complex medical needs), including residents who discharged AMA will be implemented. a. The discharging licensed nurse will be responsible for controlled medication(s) when discharging a resident to a lower level of care, including AMA. b. Obtain a physician's order specifying the controlled medications, including the name and quantity of medications to be provided to the resident or responsible party (the person who is responsible in the resident's health and well-being and may also be financially responsible for paying a resident's medical bill), if indicated. c. The discharging licensed nurse must document the released quantity of the controlled medication in the Controlled Medication Count Sheet with signatures from the licensed nurse and receiving party. d. For resident(s) who are discharging on weekends, the licensed nurse will continue to keep and account for the discharged controlled medications stored in the controlled medication drawer inside the medication cart until the Acting DON is back on duty to receive the controlled medications. 8. On 1/29/2025, 1/30/2025, 1/31/2025, during the in-services, the licensed nurses were observed for possible signs of being under the influence of using controlled medications. No staff were identified to be under the influence of using controlled medications. 9. On 1/30/2025, the local Police Narcotic Unit (consists of officers responsible in investigating and apprehending individuals suspected of illegal sale or use of narcotics [a medication or substance that in moderate doses dulls the senses, affects mood or behavior, relieves pain and induces sleep]) was notified and went onsite to obtain information regarding the missing controlled substances. 10. On 1/31/2025, the Maintenance Supervisor (MS) replaced the locks to the DON's office, the storage room inside the DON's office, and the controlled medications drawer inside the storage room of the DON's office. 11. On 1/31/2025, the universal key (a key that works with many locks that is less secure than other options) that accesses all medication carts, including controlled medications drawer, was discontinued and removed from the facility. On 1/31/2025 at 6:10 p.m., while onsite at the facility and after verifying the facility's full implementation of the IJ removal plan, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the RAdm, Quality Assurance Nurse 1 (QA 1), and Quality Assurance Nurse 2 (QA 2). Findings: a. During a review of Resident 1's Admission Record, the Admission Record indicated the facility originally admitted Resident 1 to the facility on [DATE] and readmitted on [DATE] with diagnoses including malignant neoplasm (a cancerous tumor [mass of abnormal cells that form in the body]) of unspecified part of the left lung, asthma (a chronic lung disease that causes inflammation and narrowing of the airways, making breathing difficult), and anxiety disorder (a mental health condition that involves excessive fear and worry that interferes with daily life). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/2/2024, indicated Resident 1 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 1 required maximum assistance from staff with lower body dressing and moderate assistance with toileting hygiene, shower or bathing, upper body dressing and personal hygiene. During a review of Resident 1's Physician's Orders, dated 9/20/2024, timed at 7:22 a.m., the Physician Orders indicated an order for Norco 5-325, give one tablet by mouth every six hours as needed for severe pain (pain rated seven to ten, using the pain scale as a tool to measure and describe the intensity of pain, using numbers from zero [no pain] to ten [worst possible pain]). During a review of the document titled, Leaving Facility Against Medical Advice, the document indicated Resident 1 left the facility AMA on 1/21/2025 at 9:30 a.m. During an interview on 1/27/2025 at 12:34 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated a physician's order is required in order for the resident to be discharged with the controlled medication. LVN 1 stated that the Controlled Medication Count Sheet will be signed by two licensed nurses and would then release the remaining controlled medication doses to the resident or resident's responsible party. LVN 1 further stated that if a resident is to be discharged and the controlled medications are not to be released with the resident, the Controlled Medication Count Sheet will be signed by two licensed nurses and will then be handed off to the DON, who would also sign the Controlled Medication Count Sheet and will conduct a count of the remaining controlled medication confirming the medication, the dose, and the total amount removed from the medication cart given to the DON for disposal or destruction. LVN 1 stated that the DON had informed her that in this facility, we do not have to do that. LVN 1 stated that the DON just asks for it (referring to discontinued controlled medications or controlled medications for discharged residents). LVN 1 was asked how licensed nurses can prove the controlled medications are no longer in the medication carts if there is no signature proof it was provided to the DON, LVN 1 replied, There would be no evidence we turned in the controlled medications to the DON. During an interview on 1/28/2025 at 1:17 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated, The DON would come around asking if there are controlled medications to be removed from our medication carts. I have only worked here in this facility, but the previous DON never went around asking for our discontinued or discharged controlled medications. LVN 2 stated, If a resident is discharged , we normally give the discharged controlled medications to the DON. We (licensed nurses) don't sign anything. The DON has never asked us to sign a form that indicated we are handing off the discharged controlled medications to her. LVN 2 further stated that Controlled medications can impair the person, like being under the influence, be drowsy (sleepy) or lethargic (having little energy), affecting judgment and decision making. Controlled medications can slow or stop breathing and ultimately cause someone to pass away. It is very dangerous if handled incorrectly. That is why we have the two locked system. The DON has access to a master key. For us (licensed medication nurses), we have two separate keys to access the medication cart. One key is to open the main medication cart, the second key is to open the controlled medication drawer (part of the medication cart located on the side). The DON has access to a key that can open both medication cart and controlled medication drawer with just one key. I don't feel safe that someone has that key in the facility. During a phone interview on 1/28/2025 at 2:20 p.m. with Pharmacist 1 (PD 1), from the facility's contracted pharmacy, PD 1 stated that there were 30 tablets of Norco 5-325 mg delivered to the facility for Resident 1 on 9/20/2024, 26 tablets of Norco 5-325 mg delivered to the facility for Resident 1 on 10/6/2024, 30 tablets of Norco 5-325 mg delivered to the facility for Resident 1 on 10/16/2024, and, lastly, 26 tablets of Norco 5-325 mg were delivered to the facility for Resident 1 on 11/18/2024, for a total of 112 tablets of Norco 5-325 mg delivered to the facility for Resident 1's pain management needs as ordered. During a concurrent observation and record review on 1/28/2025 at 2:47 p.m., observed Resident 1's bubble pack (a form of tamper-evident packaging where an individual pushes individually sealed tablets through the foil in order to take the medication) for Norco 5-325 mg, located in Medication Cart 1, where Resident 1's medications were stored, and the Controlled Medication Count Sheet for Resident 1 was reviewed. The observed bubble pack for Resident 1's Norco 5-325 mg and Controlled Medication Count Sheets indicated there were only ten tablets of Norco 5-325 mg under the name of Resident 1 that were found in the medication cart. During an observation on 1/29/2025 at 11:10 a.m., a facility-wide search for Resident 1's missing Norco 5-325 mg tablets was initiated on all nursing medication carts (total of 6 medication carts) and nursing medication rooms (total of 2 medication rooms) at both facility's nursing stations. Resident 1's Norco 5-325 mg were not found. There were 43 doses of Norco 5-325 mg belonging to Resident 1 that are missing and unaccounted for. During a concurrent interview and record review on 1/29/2025 at 12:09 p.m., with the DON, Resident 1's eMARs, from 9/20/2024 to 1/21/2025 were reviewed. The DON stated Resident 1 had an order on 9/20/2024 for Norco 5-325 to be given every six hours as needed for management of severe pain. The DON stated Resident 1 received a total of five doses of Norco 5-325 mg for 9/2024. The DON stated Resident 1 received a total of 54 tablets of Norco 5-325 mg during 10/2024, with the last dose administered to Resident 1 on 10/22/2024 at 12:17 p.m. The DON stated a total of 112 tablets were delivered by the pharmacy to the facility, with a total of 59 tablets recorded as administered to Resident 1 and ten tablets remaining in the medication cart. The DON stated a total of 43 tablets of Norco 5-325 remained missing. The DON stated the last disposal or destruction of controlled medications with Consulting Pharmacist 1 (CP 1) was on 1/8/2025. The DON stated Resident 1 was discharged from facility on 1/21/2025, and confirmed Resident 1's controlled medications were not inside the DON's office even with Resident 1's discharge date happening after the controlled medication destruction date of 1/8/2025. When the DON was asked if the ADM was informed of the missing controlled medications, the DON stated the ADM was not made aware and that there was no investigation started regarding the missing controlled medications. During a concurrent interview and record review on 1/30/2025 at 7:44 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 1's eMARs, from 9/20/2024 to 1/21/2025 and Controlled Drug Records (Controlled Medication Count Sheet) were reviewed. LVN 3 stated, Most residents know what medications they have, such as Norco. So, I check when the controlled medication was last administered, then I prepare the controlled medication, sign the controlled medication count sheet, then administer the medication to the resident. I then document on the eMAR that it was administered. A review of Resident 1's eMARs and Controlled Drug Records indicated a total of 10 doses of Norco 5-325 mg that was dispensed by LVN 3, but not recorded as administered to Resident 1 on the eMAR. LVN 3 stated, I was failing to document the administration of the controlled medication. During an interview on 1/30/2025 at 7:52 a.m., with RN 1, RN 1 stated, I think there is a lack of training in the facility. The LVNs (licensed vocational nurses in general) think that by signing the Controlled Medication Count Sheet, it is equal to administering the controlled medication itself. They (LVNs) don't realize that the count sheet only counts the remaining controlled medications, but they (LVNs) would still need to sign the eMAR to prove the controlled substance was administered to the resident. b. During a review of Resident 2's Admission Record, the Admission Record indicated the facility originally admitted Resident 2 to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertensive urgency (a medical condition in which a person's blood pressure is very high), osteoarthritis of hip (a degenerative disease that causes cartilage in the hip joint to wear away, causing pain and stiffness), and depression (a mental health condition that involves persistent feelings of sadness, hopelessness, and loss of interest in activities). During a review of Resident 2's Physician's Order, dated 2/8/2022, timed at 9:12 p.m., the Physician's Order indicated an order for Oxycodone-Acetaminophen 5-325 mg, give one tablet by mouth twice a day as needed for moderate to severe pain. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment. During an interview on 1/29/2025 at 3:20 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated that on 1/2/2025, while counting the controlled medications with Licensed Vocational Nurse 5 (LVN 5), the controlled medications (Oxycodone-Acetaminophen 5-325 mg) of Resident 2 were missing. LVN 4 stated she (LVN 4) was informed by LVN 5 that in the morning (7 a.m. to 3 p.m.) shift, the DON had asked for the keys to the medication cart from LVN 5. LVN 4 stated in the afternoon of that same day (1/2/2025) that she (LVN 4) was in a meeting when the DON had called her (LVN 4) to step out and was handed Resident 2's missing Oxycodone-Acetaminophen 5-325 mg. LVN 4 stated that Resident 2's bubble packet for Oxycodone-Acetaminophen 5-325 mg only contained 16 tablets when LVN 4 recalled there were over 20 tablets of Resident 2's Oxycodone-Acetaminophen 5-325 mg just the day before (1/1/2025). LVN 4 stated she (LVN 4) witnessed the DON returned the Controlled Medication Count Sheet and noticed it was in handwritten form with the DON's handwriting. LVN 4 stated she took pictures of the incident. LVN 4 stated, No, there is no form that she (DON) has us sign when we give her the discharged residents' controlled medications, so there is no proof that the staff (LVNs) even gave the controlled medications to the DON. LVN 4 stated she (LVN 4) called the facility's pharmacy on 1/2/2025 at around 3:30 p.m. and confirmed the DON ordered more Oxycodone-Acetaminophen 5-325 mg for Resident 2. LVN 4 stated having days off in between, then she (LVN 4) returned to work on 1/5/2025, only to notice Resident 2's delivered Oxycodone-Acetaminophen 5-325 mg controlled medications were now missing (total amount of missing tablets unknown). During an interview on 1/30/2025 at 11:24 a.m., with LVN 5, LVN 5 stated on 1/2/2025 in the morning shift (7 a.m. to 3 p.m.), the DON had borrowed the keys to the Medication Cart 5 (containing Resident 2's medications). LVN 5 stated during the change of shift with the 3 p.m. to 11 p.m. shift nurse (LVN 4), LVN 5 was asked by LVN 4 on where Resident 2's Oxycodone-Acetaminophen 5-325 mg medications were. LVN 5 stated feeling panicked, but that was when another LVN (Licensed Vocational Nurse 6 [LVN 6]) working in the same unit stated witnessing the DON borrow the keys from LVN 5 in the morning shift on 1/2/2025 and removing a Controlled Medication Count Sheet and controlled medication bubble packet from LVN 5's assigned medication cart. LVN 5 stated the DON had taken controlled medications in the past from LVN 5's assigned medication cart. LVN 5 stated the facility has a universal key that can open the main medication cart and controlled medications drawer with just one key. LVN 5 stated that was why LVN 4 was skeptical, because the DON was ordering Oxycodone-Acetaminophen 5-325 mg when Resident 2 does not always need to take the controlled medication (Oxycodone-Acetaminophen 5-325 mg). LVN 5 stated LVN 4 found out when she (LVN 4) called the pharmacy, and confirmed that the DON ordered Resident 2's Oxycodone-Acetaminophen 5-325 mg to be refilled on 1/2/2025 at 3:30 p.m. During an interview on 1/30/2025 at 12:04 p.m., with LVN 6, LVN 6 stated seeing the DON grabbed medications from LVN 5's medication cart during the morning shift on 1/2/2025. LVN 6 stated hearing LVN 4 and LVN 5 discussing missing controlled medications during their controlled medication counts, that was when LVN 6 told LVN 4 and LVN 5 that she (LVN 6) saw the DON took the medications (narcotic controlled medications) and Controlled Medication Count Sheet from Medication Cart 5. LVN 6 stated LVN 4 was able to get the controlled medications from the DON during her (LVN 4) shift (3 p.m. to 11 p.m.). During an interview on 1/30/2025 at 12:35 p.m. with the RAdm, the RAdm stated being aware of the missing controlled medications a week prior to the SSA's investigation. RAdm stated, We were missing the controlled medications. It was identified that we had issues. The system we have works, but we were not following the procedures such as tracking the controlled medications once received or safeguarding the controlled medications when the residents are discharged . This was a system-wide failure. During an observation on 1/30/2025 at 1:45 p.m. to 1:49 p.m., with Registered Nurse 2 (RN 2), RN 2 was able to access all facility medication carts (Medication Cart 1, Medication Cart 2, Medication Cart 3, Medication Cart 4, Medication Cart 5, Medication Cart 6), and the controlled medication drawers using just one universal key. The universal key was used on the following times: - 1/30/2025 at 1:45 p.m., opened nursing station 1 medication cart 1 and narcotic drawer. - 1/30/2025 at 1:46 p.m., opened nursing station 1 medication cart 2 and narcotic drawer. - 1/30/2025 at 1:47 p.m., opened nursing station 1 medication cart 3 and narcotic drawer. - 1/30/2025 at 1:48 p.m., opened nursing station 2 medication cart 4 and narcotic drawer. - 1/30/2025 at 1:48 p.m., opened nursing station 2 medication cart 5 and narcotic drawer. - 1/30/2025 at 1:49 p.m., opened nursing station 2 medication cart 6 and narcotic drawer. During an interview on 1/30/2025 at 3:03 p.m. with the facility's CP 1, CP 1 stated the difference from controlled medications depends on the category, how potent the medication is, how it affects a person, and dependence to the medication. Class II controlled substances (are drugs or medications with high potential for abuse, with use potentially leading to severe psychological [a mental reliance on a substance to feel good, cope with problems, or avoid feeling bad] or physical dependence [when the body adjusts to a substance and needs it to prevent withdrawal symptoms]) are highly abused and we need to have it controlled. The lower the class number, such as Class II, would be stricter than a Class V (drugs with lower potential for abuse and consist of preparations containing limited quantities of certain narcotics). CP 1 stated that drug diversion would consist of doing something with the controlled substance medication outside of what the medication was ordered for, such as not administering to the correct resident, not being stored properly, or not being destroyed properly. CP 1 confirmed Norco would be a Class II controlled medication. CP 1 stated the medication carts should have two keys, one to open the main medication cart, and the second (separate) key is for the double lock for the controlled medication drawer. CP 1 stated not knowing the facility has a universal key that can open all medication carts and all controlled medication drawers with just one key. CP 1 stated, This key means it is not double locked. This goes against management of controlled medications. CP 1 stated the use of the controlled medication Norco can lead to decreased breathing rate, lead to high risk for overdose or the dose of the medication is too high for a resident, it could lead to fainting (to pass out due to low blood flow to the brain), have difficulty breathing, possible need for hospitalization , and the possibility of death. During a review of the current facility-provided policy and procedure (P&P) titled, Controlled Substances, with last revised date of 3/2023, the P&P indicated, The facility complies with all laws, regulations, and other requirements related to administration, handling, storage, disposal, and documentation of controlled substances. The policy indicated controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. The policy indicated, Upon Admission: a. The nurse administering the medication is responsible for recording: (1) Name of the resident receiving the medication, (9) name, strength and dose of the medication, (10) time of administration, (11) method of administration, (12) quantity of medication remaining; and (13) signature of nurse administering medication. During a review of the current facility-provided P&P titled, Controlled Medication Storage, dated 8/2014, the P&P indicated, Medications included in the Drug Enforcement Administration (DEA - is a United Stated federal law enforcement agency under the U.S. Department of Justice tasked with combating illicit drug trafficking and distribution within the U.S.) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. The policy stated, Schedule II-V (Class 2 to 5) medications and other medications subject to abuse are stored in separate area under double lock. The policy indicated: 1) If a major discrepancy or pattern of discrepancies occurs or if there is apparent criminal activity, the director of nursing notifies the administrator and consultant pharmacist immediately. 2) The administrator, the consultant pharmacist, and/or the director of nursing determine whether other action(s) are needed, e.g. (abbreviation for the Latin phrase exempli gratia which means for example), notification of police or other enforcement personnel. During a review of the current facility-provided P&P titled, Controlled Medication Disposal, with last revised date of 1/2025, the P&P indicated, The facility will document the disposal of controlled substances in a log that includes the following details: - Endorsement information: Date of endorsement Medication information, including name, strength and quantity Releasing nurse signature Receiving party (DON or designated RN) signature During a review of the current facility-provided P&P titled, Drug Diversion, with last revision date of 1/2025, the P&P indicated, Drug diversion refers to illegal or unauthorized use, distribution, or theft of prescription medications intended for patients under the care of the facility. This policy is designed to prevent and address possible drug diversion and ensure patient safety and regulatory compliance. All Facility staff who have access to controlled substances are required to comply with the state and federal laws regarding handling, and security, as well as the facility policies. The policy indicated the following: B. Recordkeeping 1) All records of controlled substances, including receipts, administration, waste, disposal, loss, or possible diversion must be accurate and maintained. D. Investigation and Reporting 1) Any suspected drug diversion must be reported to the facilities designated authority immediately. The incident must be investigated immediately and thoroughly.

Based on interview and record review, the facility failed to have a discharge planning process (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) for five of 11 sampled residents (Residents 1, 8, 9, 10, and 11). The facility failed to: 1. Develop a Discharge Care Plan for Residents 1, 8, 9, 10, and 11 since admission to the facility. 2. Ensure regular re-evaluation of Residents 1, 8, 9, 10, and 11 to identify changes that require modification of the discharge plans. 3. Discuss, make referrals, and document in the clinical record when Resident 1 manifested interest in returning to the community. 4. Complete on a timely basis an evaluation of Resident 1 ' s discharge needs and discharge plan and discussed with the resident and document all relevant information in Resident 1 ' s clinical record. 5. Ensure the facility, which was more than 120 beds, had a qualified social worker to evaluate and address social services-related needs of Residents 1, 8, 9, 10, and 11. These deficient practices resulted in: 1. Resident 1 eloping (a patient who is incapable of adequately protecting himself/herself, and who departs the health care facility unsupervised and undetected) from the facility after a second attempt, which resulted in Resident 1 encountering a fracture (break of a bone) on 12/23/2023. Two days later, on 12/25/2023, Resident 1 was admitted at General Acute Care Hospital 1 (GACH 1) where she was identified with a displaced comminuted fracture (the bone is broken in two or more pieces and moves so that the two ends are not lined up straight) of the left distal femur (lower part of the thigh bone near the knee). 2. Residents 8, 9, 10, and 11 being placed at increased risk of unsafe discharge, unnecessary delays in the residents ' discharge, and preventable readmissions to health care facilities. Cross reference F850. Findings: 1. A review of Resident 1 ' s Admission Record indicated the facility originally admitted the resident, a [AGE] year-old female on 1/21/2021, with diagnoses including schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion [a false belief or judgment against what is real]), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and arthritis (pain and swelling causing decreased function on the joints). The Admission Record also indicated Resident 1 was admitted for short-term, was self-responsible, and was a transient (homeless). A review of Resident 1 ' s Care Plan developed on 10/21/2021, for Resident 1 ' s risk for fracture, indicated as a goal to minimize Resident 1 ' s risks for fracture and injury. The interventions included providing Resident 1 with a safe and hazard-free environment, assisting Resident 1 with all transfers and ambulation (walking) as needed, and implementing useful interventions per assessment. A review of Resident 1 ' s Care Plan developed on 2/21/2022, for Resident 1 ' s elopement risk, had a goal for Resident 1 not leaving the premises/safe area unauthorized, with target date of 4/11/2024. The interventions included monitoring at frequent intervals and providing one-to-one (one staff supervising the resident always) if indicated to redirect behavior. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/13/2023, indicated the resident had moderate impaired cognition ability (to comprehend, think, solve problem, process information, and make decisions). A review of Resident 1 ' s Social Services (SS) interdisciplinary team (IDT, group of health professionals from different disciplines that participate in the care of a resident) Discharge Planning form, with an effective date of 10/13/2023, and signed by Social Services Assistant 2 (SSA 2) on 11/10/2023, indicated Resident 1 needed long term care without discharge potential, had family support, level of care was adequate, and Resident 1 preferred not to talk about returning to the community. A review on the Monthly Record of Vital Signs and Weights forms, from 1/2022 through 11/2023, indicated Resident 1 refused to be weighed each month. A review of Resident 1 ' s Fall Risk Assessment, with effective dates of 4/14/2023, 7/26/2024, and 10/25/2023, indicated Resident 1 had no history of falls and was a low fall risk. A review of Resident 1 ' s Elopement Risk Evaluation, with effective dates of 4/14/2023, 7/26/2023, and 10/25/2023, indicated Resident 1 had no history of elopement and was a low elopement risk. A review of Resident 1 ' s Podiatric (branch of medicine that deals with the diagnosis, treatment, and prevention of foot and leg disorders) Evaluation and Treatment, dated 6/1/2023, indicated Resident 1 refused podiatry evaluation. A review of Resident 1 ' s Annual Dental Assessment, dated 10/25/2023, indicate Resident 1 refused dental evaluation and became upset for being asked to be evaluated. A review of Resident 1 ' s History and Physical exam, completed by the attending physician and dated 11/24/2023, indicated Resident 1 had mild impaired cognition. A review of Resident 1 ' s Change of Condition (COC)/Interact Assessment Form, dated 11/29/2023, indicated that at 9 a.m. and at 11 a.m., Resident 1 was in bed talking to herself and refused medications and nursing care. At 1 p.m., Resident 1 had increased confabulation (a type of memory error in which gaps in a person's memory are filled with fabricated, misinterpreted, or distorted information; imagined and real memories are confused), aggression toward staff, and was trying to leave the facility. A staff had to chase after Resident 1 and returned her to the facility. At 1:30 p.m., Resident 1 was still trying to leave the facility. The attending physician was informed and ordered to transfer Resident 1 to a hospital for evaluation due to increased agitations and delusions and aggression (having violent behavior towards others). A review of Resident 1 ' s unsigned Description of a Concern/Grievance/Theft Loss form, dated 11/29/2023, indicated Resident 1 stated, I want to leave this facility and you guys don ' t let me leave. The form indicated Resident 1 said she would not tell where she was going and just let her leave. Resident 1 also told the social services staff (unable to determine who wrote the note) that I am well capable of taking care of myself, and I just don ' t want to be here anymore. A review of Resident 1 ' s Licensed Nursing Note, dated 11/30/2023, indicated Resident 1 returned from the hospital and was readmitted to the facility. A review of Resident 1 ' s Physical Therapy (PT) Evaluation, dated 11/30/2023, indicated the reason for referral was the recent hospitalization . The evaluation indicated Resident 1 appeared functioning at baseline and was very active/mobile within the facility using the wheelchair. Resident 1 was independent with transfers, standing, bed mobility, and was moving in the hallways in her wheelchair. PT intervention was not necessary. A review of Resident 1 ' s COC/Interact Assessment Form, dated 12/23/2023, indicated that at 4:19 p.m., Licensed Vocational Nurse 3 (LVN 3) was informed that Resident 1 was missing. Police was called at 4:41 p.m. and arrived at the facility at 4:45 p.m. The facility did not have a picture of Resident 1 ' s refusal to allow staff to take her picture. A description of Resident 1 was provided to the police. The COC form indicated Resident 1 did not have money, was non-compliant (not willing to cooperate with treatment or refusing of care offered) with care, was confused, and was verbally aggressive at times. A review of the Concern Report form, dated 12/23/2023, indicated Resident 1 was seen by Resident 2 and visitors leaving the facility in her wheelchair. The form indicated Resident 1 was able to make decisions, did not tell staff she was leaving, did not have family, was self-responsible, was able to make decisions, and was non-compliant with care. The police were called to help finding Resident 1 because she had limited mobility, did not have money, and it was cold. A review of Resident 1 ' s Leaving Against Medical Advice form (AMA, patient's decision to leave the facility having been informed of and appreciating the risks of leaving without completing treatment), dated 12/23/2023, indicated Resident 1 left the facility AMA and did not sign the AMA form. The AMA form also indicated the police was notified. A review of an untitled document, dated 12/27/2023 and signed by the Director of Nursing (DON), indicated police found Resident 1 at GACH 1 on 12/26/2023. The note indicated Resident 1 did not wish to return to the facility. A review of Resident 1 ' s GACH 1 Emergency Documentation, dated 12/25/2023, indicated the resident was admitted on [DATE]. Resident 1 ' s X-ray (a type of radiation exam used to produce images of internal body parts) results showed Resident 1 had a displaced comminuted fracture of the left distal femur. On 3/15/2024 at 12:55 p.m., during an interview, Resident 2 stated she witnessed Resident 1 leaving the facility. Resident 2 stated she observed Resident 1 in the wheelchair using the feet to push and propel the wheelchair backwards up the driveway incline. Resident 2 stated Resident 1 was wearing only a shirt with no sweater or jacket. Resident 2 stated telling a staff member (unable to remember the name of the staff member) that Resident 1 went out of the facility. On 3/15/2024 at 3:23 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated during the time Resident 1 left the facility, the outside temperatures have been between 40 degrees Fahrenheit ( F - unit of measuring temperature) to 55 degrees F during the night. LVN 1 indicated Resident 1 would be exposed to extreme cold, rain, or frost. LVN 1 indicated that Resident 1 would not have access to food or water, or ultimately will be harmed from assault by another person, or even death. LVN 1 stated Resident 1 did not want to be in the facility. On 3/15/2024 at 5:04 p.m., during an interview, Registered Nurse 1 (RN 1) stated Resident 1 was always angry and non-compliant with care. On 3/20/2024 at 12:50 p.m., during an interview and concurrent review of Resident 1 ' s clinical record, SSA 1 stated that the role of Social Services is to be in-charge of discharge planning, to be able to answer any questions or concerns that residents may have, to advocate (to provide support or recommendations) for the residents if they need anything, to assist in finding placement, or to help with home health or home care if needed. SSA 1 stated that discharge planning starts upon a resident ' s admission to the facility, and this would include discussing the prior living situation and any goal to return home after being cleared by the attending physician. SSA 1 stated there was no documentation that the physician addressed Resident 1 ' s discharge from the facility and the type of living arrangement Resident 1 needed post-discharge. SSA 1 stated Resident 1 did not want to stay at the facility but did not have family or a place to go to. SSA 1 stated there was no documented discharge plan discussed with Resident 1 and there should have been a meeting to ensure Resident 1 had a safe discharge. SSA 1 stated there was no Social Worker in the facility. SSA 1 stated that on 11/29/2023, Resident 1 had increased delusions and was trying to leave the facility. SSA 1 stated that Resident 1 would have benefited from discharge planning to discuss what Resident 1 ' s goals or future goals were and if Resident 1 refused to have discharge planning, then there should be documentation. On 3/20/2024 at 2:33 p.m., during an interview with SSA 2 and a concurrent review of Resident 1 ' s clinical record, SSA 2 stated Resident 1 did not have documented discharge planning since Resident 1 ' s admission on 1/21/2021 and there was no discharge planning discussed with Resident 1 after Resident 1 ' s initial attempt to leave the facility on 11/29/2023. SSA 2 stated that Resident 1 ' s discharge from the facility was not a planned discharge and was not a safe discharge. SSA 2 indicated that Resident 1 is exposed to the risks of falling, having no food available, or having nowhere to sleep. SSA 2 stated it is scary to be out in the streets. On 3/20/2024 at 4 p.m., during an interview and review of Resident 1 ' s clinical records, the Director of Nurses (DON) stated that on Resident 1 ' s first attempt to elope from facility on 11/29/2023, a Psychiatry (branch of medicine who study mental illness) or Psychology (study of mind and behavior) evaluation should have been provided, but nothing was offered. The DON indicated that Resident 1 was readmitted to the facility on [DATE] and eloped for the second time on 12/23/2023, but there were no attempts to speak with Resident 1 about discharge planning between those dates. On 4/16/2024 at 1:18 p.m., during an interview and record review, the DON stated that Resident 1 did not have a discharge care plan created since originally being admitted to the facility on [DATE]. On 4/17/2024 at 12:25 p.m., during an interview with LVN 6 and concurrent review of Resident 1 ' s progress notes dated 7/24/2023 and timed at 3:03 p.m., LVN 6 stated a police officer came to visit Resident 1 to conduct a welfare visit and recommended Resident 1 to cooperate with the staff to achieve safe discharge goals. The progress notes indicated the Director of Social Services (DSS) would continue to provide support. LVN 6 indicated that Resident 1 was readmitted to the facility on [DATE] after an elopement attempt but there was no documentation that discharge planning was discussed with Resident 1, and 23 days later, Resident 1 successfully eloped. On 4/17/2024 at 4:17 p.m., during an interview, the DON indicated she worked at the facility on 7/5/2023 as an Interim (temporary) DON and knew that not having a Social Worker was a problem. The DON stated Resident 1 should have been assisted to find placement and a Social Worker may have had a better or more effective way of communicating with Resident 1. A review of the facility-provided Policy and Procedure (P&P) titled, Social Services, last revised date in 9/2021 indicated, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The policy also indicated that the director of social services is a qualified social worker and is responsible for: a. program planning, policy development, and priority setting of social services; b. providing for the social and emotional needs of the resident and family; c. supervising social services personnel; d. maintaining records related to social services; e. conducting or coordinating in-service training classes; and f. meeting or assisting with the medically related social services needs of residents. The social worker/social services staff are responsible for: Resident Assessments and Comprehensive Person-Centered Care Planning. A review of the facility-provided P&P titled, Care Plans, Comprehensive Person-Centered, with last revision date of 2/2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P also indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change. A review of the facility-provided P&P titled, Discharging a Resident without a Physician ' s Approval, with last revised date of 10/2022 indicated, An order for an approved discharge must be signed and dated by a physician and recorded in the resident ' s medical record no later than seventy-two (72) hours after the discharge. The P&P also indicated, If the resident or representative (sponsor) requests discharge without the approval of the attending physician, the resident and/or representative (sponsor) will be asked to sign a release of responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident ' s medical record and witnessed by two staff members. A review of the facility-provided P&P titled, Transfer or Discharge, Resident-initiated, with last revised date of 10/2022 indicated, for resident-initiated discharges, the medical record contains: a) Documentation or evidence of the resident ' s or resident representative ' s verbal or written notice of intent to leave the facility; b) A discharge care plan; and c) Documented discussions with the resident or, if appropriate, his/her representative, containing details of discharge planning and arrangements for post-discharge care. 2. A review of Resident 8 ' s Admission Record indicated the facility admitted the resident on 8/21/2020 with diagnoses including muscle weakness, Alzheimer ' s disease (brain disorder causing problems with memory, thinking, or behavior), and major depressive disorder (persistent feeling of sadness and loss of interest). A review of Resident 8 ' s MDS, dated [DATE], indicated the resident had severe impaired cognition (mental action or process of acquiring knowledge and understanding). On 4/16/2024 at 3:08 p.m., during an interview with RN 2 and concurrent review of Resident 8 ' s clinical records, RN 2 stated discharge planning is discussed upon admission, quarterly, and annually but Resident 8 ' s clinical records did not have a discharge care plan since admission on 8/21/2020. On 3/20/2024 at 12:50 p.m., during an interview, SSA 1 stated that the role of Social Services is to be in charge of discharge planning, to be able to answer any questions or concerns that residents may have, to advocate for the residents if they need anything, to assist in finding placement, or to help with home health or home care if needed. SSA 1 stated that discharge planning starts upon a resident ' s admission to the facility, and this would include discussing the prior living situation and any goal to return home after being cleared by the attending physician. On 4/17/2024 at 4:17 p.m., during an interview, the DON indicated she worked at the facility on 7/5/2023 as an Interim (temporary) DON and knew that not having a Social Worker was a problem. The DON stated Resident 1 should have been assisted to find placement and a Social Worker may have had a better or more effective way of communicating with Resident 8. A review of the facility-provided Policy and Procedure (P&P) titled, Social Services, last revised date in 9/2021 indicated, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The policy also indicated that the director of social services is a qualified social worker and is responsible for: a. program planning, policy development, and priority setting of social services; b. providing for the social and emotional needs of the resident and family; c. supervising social services personnel; d. maintaining records related to social services; e. conducting or coordinating in-service training classes; and f. meeting or assisting with the medically-related social services needs of residents. The social worker/social services staff are responsible for: Resident Assessments and Comprehensive Person-Centered Care Planning. A review of the facility-provided P&P titled, Care Plans, Comprehensive Person-Centered, with last revision date of 2/2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P also indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change. 3. A review of Resident 9 ' s Admission Record indicated the facility admitted the resident on 9/11/2022 with diagnoses including degenerative disease of the nervous system (a condition that gradually damages or destroys the brain, spinal cord, and a complex network of nerves) and dementia (a range of conditions that affect memory, thought process, and function). A review of Resident 9 ' s MDS, dated [DATE], indicated that Resident 9 was able to communicate and had intact cognition. On 4/17/2024 at 12:30 p.m., during an interview with RN 2 and concurrent review of Resident 9 ' s clinical records, RN 2 stated there was no discharge plan since Resident 9 ' s admission to the facility on [DATE]. On 3/20/2024 at 12:50 p.m., during an interview, SSA 1 stated that the role of Social Services is to be in charge of discharge planning, to be able to answer any questions or concerns that residents may have, to advocate for the residents if they need anything, to assist in finding placement, or to help with home health or home care if needed. SSA 1 stated that discharge planning starts upon a resident ' s admission to the facility, and this would include discussing the prior living situation and any goal to return home after being cleared by the attending physician. On 4/17/2024 at 4:17 p.m., during an interview, the DON indicated she worked at the facility on 7/5/2023 as an Interim DON and knew that not having a Social Worker was a problem. The DON stated Resident 1 should have been assisted to find placement and a Social Worker may have had a better or more effective way of communicating with Resident 9. A review of the facility-provided Policy and Procedure (P&P) titled, Social Services, last revised date in 9/2021 indicated, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The policy also indicated that the director of social services is a qualified social worker and is responsible for: a. program planning, policy development, and priority setting of social services; b. providing for the social and emotional needs of the resident and family; c. supervising social services personnel; d. maintaining records related to social services; e. conducting or coordinating in-service training classes; and f. meeting or assisting with the medically-related social services needs of residents. The social worker/social services staff are responsible for: Resident Assessments and Comprehensive Person-Centered Care Planning. A review of the facility-provided P&P titled, Care Plans, Comprehensive Person-Centered, with last revision date of 2/2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P also indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change. 4. A review of Resident 10 ' s Admission Record indicated the facility admitted the resident 10 on 1/25/2021 with diagnoses that included sepsis (a life-threatening condition when the body ' s response to infection causes injuries to tissues and organs of the body), muscle weakness, and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 10 ' s MDS, dated [DATE], indicated the resident had severely impaired cognition. On 4/17/2024 at 1:28 p.m., during an interview with RN 2 and concurrent review of Resident 10 ' s clinical records, RN 2 indicated Resident 10 did not have a discharge plan since admission on 1/25/2021. On 3/20/2024 at 12:50 p.m., during an interview, SSA 1 stated that the role of Social Services is to be in charge of discharge planning, to be able to answer any questions or concerns that residents may have, to advocate for the residents if they need anything, to assist in finding placement, or to help with home health or home care if needed. SSA 1 stated that discharge planning starts upon a resident ' s admission to the facility, and this would include discussing the prior living situation and any goal to return home after being cleared by the attending physician. On 4/17/2024 at 4:17 p.m., during an interview, the DON indicated she worked at the facility on 7/5/2023 as an Interim DON and knew that not having a Social Worker was a problem. The DON stated Resident 1 should have been assisted to find placement and a Social Worker may have had a better or more effective way of communicating with Resident 10. A review of the facility-provided Policy and Procedure (P&P) titled, Social Services, last revised date in 9/2021 indicated, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The policy also indicated that the director of social services is a qualified social worker and is responsible for: a. program planning, policy development, and priority setting of social services; b. providing for the social and emotional needs of the resident and family; c. supervising social services personnel; d. maintaining records related to social services; e. conducting or coordinating in-service training classes; and f. meeting or assisting with the medically-related social services needs of residents. The social worker/social services staff are responsible for: Resident Assessments and Comprehensive Person-Centered Care Planning. A review of the facility-provided P&P titled, Care Plans, Comprehensive Person-Centered, with last revision date of 2/2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P also indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change. e. A review of Resident 11 ' s Admission Record indicated the facility admitted the resident on 2/24/2020 with diagnoses including muscle weakness and schizophrenia. A review of Resident 11 ' s MDS, dated [DATE], indicated the resident had moderately impaired cognition. On 4/17/2024 at 2:02 p.m., during an interview with LVN 6 and concurrent review of Resident 11 ' s clinical records, LVN 6 stated Resident 11 did not have documented discharge plan since admission on 2/24/2020. On 3/20/2024 at 12:50 p.m., during an interview, SSA 1 stated that the role of Social Services is to be in charge of discharge planning, to be able to answer any questions or concerns that residents may have, to advocate for the residents if they need anything, to assist in finding placement, or to help with home health or home care if needed. SSA 1 stated that discharge planning starts upon a resident ' s admission to the facility, and this would include discussing the prior living situation and any goal to return home after being cleared by the attending physician. On 4/17/2024 at 4:17 p.m., during an interview, the DON indicated she worked at the facility on 7/5/2023 as an Interim DON and knew that not having a Social Worker was a problem. The DON stated Resident 1 should have been assisted to find placement and a Social Worker may have had a better or more effective way of communicating with Resident 11. A review of the facility-provided Policy and Procedure (P&P) titled, Social Services, last revised date in 9/2021 indicated, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The policy also indicated that the director of social services is a qualified social worker and is responsible for: a. program planning, policy development, and priority setting of social services; b. providing for the social and emotional needs of the resident and family; c. supervising social services personnel; d. maintaining records related to social services; e. conducting or coordinating in-service training classes; and f. meeting or assisting with the medically-related social services needs of residents. The social worker/social services staff are responsible for: Resident Assessments and Comprehensive Person-Centered Care Planning. A review of the facility-provided P&P titled, Care Plans, Comprehensive Person-Centered, with last revision date of 2/2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P also indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change.

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse inflicted by Resident 2. On 9/12/2023 at 5:35 p.m., while in the activity/dining room, Resident 2, who had episodes of aggressive and agitated behaviors, without provocation hit, grabbed, and pulled Resident 1 ' s right arm. In response to the attack from Resident 2, Resident 1 in defense hit, grabbed, and pulled Resident 2 ' s left arm. As a result, Resident 1 sustained a skin tear (a wound caused by shear [cut], friction, and / or blunt force resulting in separation of skin layers) on the back of the right hand measuring 4 centimeters (cm - a unit of measurement) in length by 4 cm in width. Resident 2 sustained a skin tear on the left arm measuring 4 cm by 4 cm. Also, based on the reasonable person concept (refers to a tool to assist the survey team ' s assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Resident 1 ' s severely impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and medical condition, an individual subjected to physical abuse, may have psychological (mental or emotional) effects. These psychological effects include feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself). Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 2/3/2023 with diagnoses including atrial fibrillation (an abnormal heartbeat caused by extremely fast and irregular beats from the upper chambers of the heart), depression (a constant feeling of sadness and loss of interest which stops a person from doing normal activities), and essential hypertension (abnormal blood pressure that was not a result of a medical condition). A review of Resident 1 ' s undated History and Physical indicated the resident had agitation and did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/10/2023, indicated the resident ' s cognition was severely impaired. Resident 1 required extensive assistance (resident involved in activity and staff provided guided maneuvering) with one-person physical assist in bed mobility, transfer, locomotion on and off unit (how resident moves between locations in the room, adjacent corridor, and returns from off-unit locations), dressing, eating, toilet use, and personal hygiene. The functional limitation in range of motion section of the MDS indicated that Resident 1 had impairment on one side of the upper extremity (shoulder, elbow, wrist, hand). A review of Resident 1 ' s Care Plan on skin breakdown related to aging process and fragile skin, initiated on 2/12/2023, indicated the goal of minimizing the risk of skin breakdown. The interventions indicated to handle Resident 1 gently and carefully during care. A review of Resident 1 ' s Care Plan on abuse, initiated on 8/14/2023, indicated the goal that the resident would be free from abuse daily. The care plan indicated the definition of abuse as the willful infliction of injury, unreasonable confinement, or punishment with resulting physical harm or pain, mental anguish, or deprecation by an individual. A review of Resident 1 ' s Care Plan on self-care deficits and extensive assistance, initiated on 8/14/2023, indicated an intervention to provide a safe environment, maintain resident ' s privacy, and respect resident rights. A review of Resident 1 ' s Change of Condition / Interact Assessment Form, dated 9/12/2023, indicated that at 5:45 p.m., Certified Nursing Assistant (CNA) informed the licensed nurse that Resident 1 had an altercation with another resident. Resident 1 sustained a four centimeter by four cm skin tear on the right hand with scant (little) bleeding. A review of Resident 1 ' s Physician Orders, dated 9/13/2023, indicated a right back hand skin tear to cleanse with normal saline (a mixture of water and salt solution), pat dry, and apply steri-strips (an adhesive strip used to secure, close, and support cuts, wounds, and surgical incisions), and keep steri-strips for 7 days. A review of Resident 2 ' s Admission Record indicated the facility admitted the resident on 1/3/2022 and readmitted on [DATE] with diagnoses including unspecified psychosis (a collection of symptoms that affect the mind and loss contact with reality), dementia (loss of cognitive functioning such as thinking, remembering, and reasoning to such extent that it interferes with a person ' s daily life and activities), and essential hypertension. A review of Resident 2 ' s MDS, dated [DATE], indicated the resident ' s cognition was severely impaired. Resident 2 required extensive assistance with one-person physical assist in bed mobility, locomotion on and off unit (how resident moves between locations in the room, adjacent corridor, and returns from off-unit locations), dressing, eating, toilet use, and personal hygiene. A review of Resident 2 ' s Care Plan on abuse, revised on 2/8/2023, indicated the goal that the resident would be free from abuse daily. The care plan indicated the definition of abuse as the willful infliction of injury, unreasonable confinement, or punishment with resulting physical harm or pain, mental anguish, or deprecation by an individual. A review of Resident 2 ' s Change of Condition / Interact Assessment Form, dated 4/13/2023, indicated the resident had an increased agitation as evidenced by hitting staff and non-compliance with safety measures or precautions. A review of Resident 2 ' s Change of Condition / Interact Assessment Form, dated 5/26/2023, indicated the resident had an episode of aggression by grabbing the face of another resident. A review of Resident 2 ' s Care Plan on acute aggression, initiated on 5/26/2023, indicated an intervention to assess the cause and trigger of the behavior and attempt to reduce and eliminate the triggers. The care plan indicated the intervention to provide redirection as needed. A review of Resident 2 ' s Change of Condition / Interact Assessment Form, dated 5/31/2023 and 8/5/2023, indicated the resident had increased agitation. A review of Resident 2 ' s History and Physical, dated 6/26/2023, indicated the resident had aggressive behavior and did not have the capacity to understand and make decisions. A review of Resident 2 ' s Care Plan on self-care deficits and extensive assistance, initiated on 7/7/2023, indicated an intervention to provide a safe environment, maintain resident ' s privacy, and respect resident rights. A review of Resident 2 ' s Care Plan on skin breakdown related to aging process and fragile skin, dated 7/7/2023, indicated the goal of minimizing the risk of skin breakdown. The interventions indicated to handle Resident 2 gently and carefully during care. A review of Resident 2 ' s Care Plan on increased agitation, revised on 8/5/2023, indicated an intervention to assess the cause and trigger of the behavior and attempt to reduce and eliminate the triggers. The care plan indicated the intervention to provide redirection as needed. A review of Resident 2 ' s Change of Condition / Interact Assessment Form, dated 9/12/2023, indicated that at 5:45 p.m., CNA informed the licensed nurse that Resident 1 and Resident 2 had an altercation that resulted in Resident 2 ' s four cm by four cm skin tear on the left forearm with scant bleeding. A review of Resident 2 ' s Physician Orders, dated 9/13/2023, indicated a left arm skin avulsion (a tearing away of a body part), to cleanse with normal saline, pat dry, then apply steri-strips, and keep steri-strips for 7 days. On 9/21/2023 at 10:55 a.m., during an interview, Activity Assistant (AA) stated that Resident 1 and Resident 2 were in the TV room seated at less than an arm ' s length distance from each other. AA stated that she did not witness Resident 1 and Resident 2 ' s physical altercation. AA stated that CNA 1 informed her that Resident 1 and Resident 2 were bleeding from the arm and both residents were assisted to the nurse station for wound treatment. On 9/21/2023 at 2 p.m., during an interview, CNA 1 stated that she saw Resident 2 ' s left arm with blood and the skin was almost removed. CNA 1 stated she checked on Resident 1 and saw that the resident had blood and the skin on the right arm was also almost removed. CNA 1 stated she reported the findings to the Licensed Vocational Nurses (LVN) in charge of Resident 1 and Resident 2. On 9/22/023 at 8:49 a.m. with the Interim Director of Nursing (IDON), an observation of the surveillance video recording for 9/12/2023 was conducted: - Camera #16 at 5:35:46 p.m. showed Resident 2 had the left arm raised and was facing Resident 1. Resident 2 started hitting Resident 1 on the right arm and Resident 1 hit Resident 2 ' s left arm. - At 5:36:08 p.m. Resident 2 grabbed and pulled Resident 1 ' s right arm while Resident 1 grabbed and pulled Resident 2 ' s left arm. The IDON stated that the surveillance video recording indicated there were five facility staff present in the TV room during the incident and none responded to Resident 1 and Resident 2. - At 5:36:55 p.m., Resident 2 hit Resident 1 again on the right arm. - At 5:42:28 p.m., CNA 1 was observing Resident 2 ' s left arm and Resident 1 ' s right arm. CNA 1 and AA assisted Resident 1 and Resident 2 to Nursing Station 1. On 9/22/2023 at 12:22 p.m., during a follow up interview, the IDON stated that she was not aware of Resident 2 ' s aggressive behavior and Resident 1 ' s agitation. The IDON further stated that residents should not be seated within each other ' s reach. A review of the facility provided policy and procedure titled, Resident Rights, last revised on 9/15/2023, indicated that federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident ' s right to be free from abuse, neglect, misappropriation of property, and exploitation. A review of the facility provided policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised on 9/15/2023, indicated a facility-wide commitment and resource allocation to support the objective to protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including but not necessarily limited to facility staff and other residents.

Based on interview and record review, the facility failed to ensure the safe operation of a Low Air Loss mattress (LAL - is an air mattress covered with tiny holes so that the user floats on a soft cushion of air) and the use of full side rail up when bathing and repositioning one of three sampled residents (Resident 1) in bed to prevent accident with injury. Resident 1 had functional [CONDITION(S)] (loss of muscle function and strength on four extremities), was overweight, and had upper bed rails up (towards the head of the bed). On 12/11/2021 at 10:30 a.m., Certified Nursing Assistant 1 (CNA 1), who was not trained on the safe operation of the LAL mattress and while standing on the opposite side of the bed, turned Resident 1 to the right side, resulting on the resident to slide off the bed down to the floor and sustained a right femoral neck (hip) fracture (broken bone) requiring transfer to General Acute Care Hospital 1 (GACH 1) on 12/12/2021. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility initially admitted the resident, a [AGE] year-old female, on 08/22/2018 and was discharged home on 09/05/2018. The facility readmitted Resident 1 on 12/04/2021 after a two-day hospitalization . Resident 1's diagnoses included spinal stenosis (narrowing of spinal canal commonly occurs in the neck and lower back), [CONDITION(S)] (loss of muscle function in the lower half of the body including both legs), morbid (severe) obesity (overweight) due to excess calories, and muscle weakness. Resident 1 was self-responsible (made own decisions about her care). A review of Resident 1's nursing Admission Assessment, with an effective date of 12/04/2021, indicated the resident was in bedrest, required total assistance with transfers, was non-weight bearing (no weight can be placed on the legs), needed assistance with eating, was dependent for bed bath, dressing, shampooing, and grooming. Resident 1 was able to communicate clearly, quick to comprehend, alert (awake) and oriented (aware of person, place, time/date). A review of Resident 1's undated History and Physical exam, completed by the attending physician, indicated Resident 1 was able to understand and make decisions and the diagnoses included functional [CONDITION(S)] (is the complete inability to move due to severe disability or frailty caused by another medical condition, without physical injury or damage to the brain or spinal cord. The patient with functional [CONDITION(S)] requires assistance with all activities of daily living). A review of Resident 1's Initial Fall Risk Assessment, with an effective date of 12/04/2021 (readmission), indicated the resident scored 12. A total score of 18 or more represented high risk. A review of the Physician's Orders for Resident 1 dated 12/06/2021 to have a LAL mattress (which helps keep the skin dry and [NAME] away any moisture. Low air loss mattresses are designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) for pressure redistribution. A review of the Physician's Order for Resident 1's, dated 12/06/2021, indicated bilateral upper (part of the bed) side rails up and locked when in bed for mobility and positioning, as enabler. A review of Resident 1's Care Plan on Self-Care Deficit requiring extensive assistance with two-person assist for bed mobility and total dependence with two-person assist for bathing, developed on 12/06/2021, had a goal to minimize risk of decline. The interventions included assist as needed, provide a safe environment, and bathing per schedule. A review of Resident 1's weight on 12/07/2021 indicated the resident weighed 249 pounds. A review of Resident 1's Care Plan, developed on 12/02/2021, for the resident's Fall Risk from using a LAL mattress included in the interventions having two-person assist with transfers, repositioning, and daily care as indicated. The interventions did not include the manufacturer's recommendations for the mattress setting during care or the use of full side rails to prevent falls when repositioning and turning Resident 1 in bed as resident was unable to firmly grasp the rails and was overweight. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/12/2021, indicated the resident had no memory problems and could make decisions. Resident 1 needed extensive assistance with two-person assist with bed mobility, personal hygiene, dressing, bathing, and toilet use. Resident 1 was frequently incontinent (unable to control) of bowel and bladder functions. A review of Resident 1's Change of Condition nursing note, dated 12/11/2021, indicated the resident slid off the bed at 10:30 a.m., body assessment was done with no injury but Resident 1 had mild discomfort. Resident 1's physician was notified and did not give new orders. A review of the Physician's Order for Resident 1, dated 12/12/2021, timed at 3:01 p.m. indicated to take stat (immediately) right hip X-rays (types of electromagnetic [CONDITION(S)] with to see through a person's skin and reveal images of the bones beneath it) due to pain. A review of Resident 1's Radiology Results Report, dated 12/12/2021, indicated acute (sudden) right femoral neck (hip) fracture (broken bone) with modest displacement (the bone snaps into two or more parts and moves so that the two ends are not lined up straight). A review of the Physician's Order for Resident 1, dated 12/12/2021, timed at 7:24 p.m. indicated to transfer the resident to GACH 1 emergency room (ER) for evaluation of the right [CONDITION(S)]. A review of GACH 1's Radiology Results for Resident 1, dated 12/12/2021 timed at 11:58 p.m., indicated comminuted (bone breaks into several pieces) and mildly displaced right femoral neck fracture. A review of GACH's Orthopedic Progress Note, dated 12/15/2021, indicated no orthopedic surgical intervention required as resident bed bound since 2018, was non-ambulatory and has severe cervical spine stenosis with [CONDITION(S)]. A review of the facility's Admission Record indicated Resident 1 returned to the facility on [DATE]. On 01/24/2022 at 01:13 p.m., during an interview, Resident 1 stated on 12/11/2021, CNA 1 was giving her a bed bath, the bed was slippery, her legs slid down to the floor, and her body followed, and Resident 1 fell off the bed and landed on the floor. Resident 1 stated only one person (CNA 1) was bathing and repositioning the resident. Resident 1 stated she could not hold the upper rail. On 01/24/2022 at 01:56 p.m., during an interview, CNA 1 stated, on 12/11/2021, between 9:30 a.m. to 10:30 a.m., she gave a bed bath to Resident 1, when she turned her to her right side, CNA 1 stood behind her (at the left side of the bed), the resident's legs slid off the floor causing her to fall on her right side. CNA 1 stated she did not raise the full rail of the bed before turning the resident. On 01/24/2022 at 02:09 p.m., during an interview with Registered Nurse 1 (RN 1) and concurrent review of Resident 1's nursing Admission Assessment, RN 1 confirmed Resident 1 was totally dependent on staff for daily care. RN 1 stated totally dependent meant the resident needed at least two-person assistance with daily care. RN 1 stated the fall was preventable if there were two staff bathing Resident 1. On 01/25/2022 at 08:35 a.m., during an interview, Director of Staff Development (DSD) stated Resident 1 should have two-person assistance for bed mobility and bathing. DSD did not provide documentation CNAs were trained on safe use of the LAL mattress, the importance of changing the setting for care, preventive measures such us two-person assist and side rail up while turning and repositioning residents. On 01/25/2022 at 09:02 a.m., during an interviewing, Director of Nursing (DON) stated Resident 1 should had two-person always assist. DON stated fall could have been prevented if there were two staff with Resident 1 at the time of the bed bath and bed repositioning. On 02/02/2022 at 10:04 a.m., during an interview, Treatment Nurse 1 (TN 1) stated LAL mattress setting is changed when providing care. CNA 1 should have called for any nurse to change the setting to AutoFirm (provides maximum air inflation designed to assists both resident and caregivers during resident transfer and treatment) for resident comfort and safety. CNAs were not allowed to change the mattress setting. On 02/04/2022 at 01:51 p.m., during an interview, CNA 1 stated she did not change the setting of the LAL mattress and did not call for anybody to change the setting prior to Resident 1's bed bath on 12/12/2021. CNA 1 stated she was not informed that she needed to ask licensed nurses to change the LAL mattress setting for bed bath, incontinent care, and repositioning. A review of LAL Manufacturer's Manual, revised date 2002, indicated, The safe use of equipment is maximized when used in conjunction with bed rails; there may be an increased risk of falls when such bed rails are not present. Local policies regarding the use of side rails should be taken into account. Whether and how to use the side rails is a decision that should be based on each resident's individual needs and should be made by the physician, caregivers and responsible parties. A review of facility's policy and procedure titled Pressure Reducing Mattress reviewed on 10/15/2021, indicated special considerations for LAL may require side rails to be in place and up when resident is in bed with LAL mattress. A review of facility's In-services for Patient Care, LAL Mattress and Certified Nursing Assistant's (CNA) job description dated 09/23/2021 indicated CNA 1 attended the in-service. The lesson plan indicated CNA's essential duties and responsibilities that includes: When making residents beds, provides the necessary measures to ensure safety, comfort, bed position and skin management needs of the resident A review of facility's policy and procedure titled, Positioning and Moving Residents reviewed on 10/15/2021 indicated, Obtain assistance from other professionals as needed. When multiple professionals are working together, always establish a method to synchronize efforts. Use hydraulic lift or mechanical lift as necessary and always with two persons assisting A review of facility's policy and procedure titled, Abuse and Mistreatment of Residents, reviewed on 10/15/2021 indicated, Department Supervisors shall ensure that adequate supervision is being given and appropriate assistance extended to residents in need when performing their daily monitoring and rounds.

Based on interview and record review, the facility failed to provide supervision, assistance, and a safe environment for one of three sampled residents (Resident 1) to prevent accident and injuries. Resident 1, who had poor judgement due to confusion and was at risk for falls due to poor balance and unsteady gait, was not provided one-person assist when observed walking. As a result, on [DATE], at 8:35 p.m. Resident 1 fell sustaining a laceration (skin cut) above the left eyebrow with bleeding and bruising to the right eye. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where he was diagnosed with a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and head trauma. Resident 1 was discharged home from GACH 1 on [DATE] for comfort measures. Resident 1 subsequently expired on [DATE] at 5:10 a.m., eight days after his fall at the facility. Findings: A review of Resident 1's Admission Record indicated Resident 1, a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including transient cerebral ischemic attack (TIA - a temporary blockage of blood flow to the brain), chronic [CONDITION(S)] (an irregular rapid heart rate resulting to poor blood flow), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), chronic heart failure, [CONDITION(S)] (DVT - occurs when a blood clot forms in a deep vein. These clots usually develop in the lower leg, thigh, or pelvis, but they can also occur in the arm), other abnormalities of gait (manner of walking) and mobility, generalized muscle weakness, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and [CONDITION(S)] (a spinning sensation or that the world around is spinning). A review of Resident 1's Fall Risk Assessment form dated on admission [DATE], indicated Resident 1's score was 16 and a total score of 18 or more represented high risk. The form indicated the resident did not have history of falls. The physical therapy (PT) evaluation dated [DATE] indicated Resident 1 had fallen at home three weeks prior. Including the fall, the fall risk assessment total score would have been a score of 24, representing high fall risk A review of Resident 1's Baseline Care Plan developed on admission, [DATE], for the resident's Safety and Fall Risk related to weakness, TIA, [CONDITION(S)], and depression, had goals for the resident to have reduced risk of fall and injuries and reduced risk for complications from safety devices. The interventions included encourage to ask for assistance and call light within reach. The interventions did not include supervision and assistance with walking. A review of Resident 1's History and Physical (H&P) exam, completed by the attending physician on [DATE], indicated the resident did not have the capacity to understand and make decisions due to diagnosis of dementia (a chronic disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes and impaired reasoning). A review of Resident 1's Physical Therapy (PT) evaluation and treatment, dated [DATE], indicated the reasons for the referral included decline in strength, decreased functional mobility and reduced ability to safely ambulate. Resident 1 prior living arrangement was at home in a two-story house, used a single point cane indoors and a front-wheeled walker (FWW) outdoor. Resident 1 had a fall three weeks prior and was at high fall risk. Fall predictors included poor negotiation of obstacles, reduced proactive balance, reduced quad strength, and reduced reactive balance. Resident 1 was able to ambulate up to 50 feet with minimum assist with FWW with complaints of fatigue at the end of ambulation. A review of Resident 1's PT service dated [DATE], indicated the resident was able to walk with the FWW but liked to look around while walking. Moderate cues for safety required. A review of Resident 1's Physician's Order dated [DATE], indicated to administer: - [MEDICATION(S)] (anti-anxiety medication) 0.5 milligrams (mg) tablet every 12 hours as needed for anxiety manifested by panicky feeling causing stress, a [CONDITION(S)] medication. - [MEDICATION(S)] 10 mg (antidepressant) once a day for depression manifested by extreme sadness causing social withdrawal. - [MEDICATION(S)] (anticoagulant [blood thinner] medication to prevent blood clots) 5 mg daily for DVT. A review of Resident 1's Situation, Background, Assessment, Recommendation SBAR (SBAR, Situation, Background, Assessment, Recommendation - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident), dated [DATE], indicated that at 8:35 p.m., Certified Nurse Assistant 1 (CNA 1) saw Resident 1 was going back and forth out of his room, when suddenly Resident 1 lost his balance and fell to the floor. The SBAR further indicated that Resident 1 stated that he landed on the floor on his left forehead sustaining a wound on the forehead. The SBAR indicated that Resident 1 was noted with a wound of about 1.5 inches long and was bleeding continuously that a pressure dressing was applied. The SBAR indicated that Resident 1 was trying to get up so many times and kept saying he was okay. 911 (telephone number to request emergency help) was called and Resident 1 was transported to GACH 1 emergency room (ER, or emergency department [ED]) for medical evaluation. A review of Resident 1's Discharge Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated the resident had severe impaired cognition (when a person has very hard time remembering things, making decisions, concentrating, or learning). Resident 1's gait was not steady; he was only able to stabilize with staff assistance. Resident 1 could walk with walker and wheelchair. Resident 1 needed extensive assistance from staff with bed mobility, transfers, walking in room, dressing, toilet use, and personal hygiene. A review of Resident 1's Interdisciplinary Team (IDT - a group of healthcare professionals from different disciplines caring for the resident) meeting report, dated [DATE], indicated when Resident 1 was noted to be non-compliant on safety as he didn't call for assistance, resident stood up, lost balance, and landed on the floor. Resident 1 was still trying to get up from the floor as the nurse was trying to control the bleeding from his head after the fall. A review of GACH 1's ED Provider Notes for Resident 1, dated [DATE], timed at 10:25 p.m., indicated the resident did not remember the fall, had a laceration on the forehead and traumatic head injury. A review of GACH 1's H&P Notes for Resident 1, dated [DATE], indicated in the history of present illness, the resident had been recently admitted to GACH 1 due to acute confusion was diagnosed with TIA and discharged to the facility. Per family, the resident has become more agitated and confused over the past few days. A review of GACH 1's computerized tomography scan (CT scan - is a medical imaging technique used in radiology to obtain detailed internal images of the body for diagnostic purposes) of Resident 1's brain dated [DATE] indicated a thick subarachnoid hemorrhage after head trauma. Intraventricular hemorrhage (IVH - is a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space) with [CONDITION(S)] (is a severe complication of IVH that can serve as an independent predictor of increased mortality) with bifrontal diameter measuring 5.7 centimeters (cm). A review of GACH 1's Discharge record for Resident 1 indicated the resident was discharged with family to home on [DATE]. According to the complainant, Resident 1 was placed on Hospice care (care for people who are nearing the end-of-life prioritizing comfort and quality of life by reducing pain and suffering). Resident 1 expired at home on [DATE] at 5:10 a.m. During a telephone interview on [DATE] at 8:59 p.m., Certified Nurse Assistant 1 (CNA 1) stated he was from a registry (a staffing agency which provide nursing personnel per shift or temporarily) and was assigned, for the first time, to care for the resident on [DATE] during the 3 p.m. to 11 p.m. shift. CNA 1 confirmed he was not familiar with Resident 1. CNA 1 stated he asked for Resident 1's information from the previous CNA and the charge nurse, but nobody had any idea because Resident 1 was new to the facility. CNA 1 stated he assisted the resident to the restroom and when he called out or used the call light for assistance. CNA 1 confirmed he did not know Resident 1 was at risk for falling. CNA 1 stated Resident 1 was confused and kept calling his daughter's name during the shift. CNA 1 stated he was not around at the time Resident 1 fell because he was charting (documenting in the clinical records). During a telephone interview on [DATE] at 12:51 p.m., Registered Nurse 1 (RN 1) stated she worked the 3 p.m. to 11 p.m. shift on the evening of Resident 1's fall. RN 1 stated two CNAs saw him walking in the hallway and when the resident lost balance, but they could not reach him before the fall. During a telephone interview on [DATE] at 1:33 p.m., RN 2 stated that at the beginning of shift on [DATE], she reminded CNA 1 that Resident 1 was very confused and needed frequent monitoring. RN 2 she was the staff that assisting Resident 1 to stop the bleeding from the forehead. Resident 2's forehead after the fall. RN 2 stated Resident 1 needed close monitoring because he was confused, forgetful, and non-compliant with using the call light and when he was walking on the hallway unassisted, he said I am sorry I forgot to press the call light. RN 2 stated Resident 1 needed someone to hold him when he got up. During a record review of Resident 1's care plan for Resident is at risk for falls/injury dated [DATE] indicated the following interventions: 1. Visibly observe resident frequently. 2. Proper fitting shoes. 3. Assess meds for possible adverse side effects. 4. Safe and clutter free environment. 5. Keep personal items within easy reach. 6. Provide safety instructions. During a telephone interview on [DATE] at 2 p.m., CNA 2 stated she worked the 3 p.m. to 11 p.m. shift on [DATE] and was assigned to care for other residents. CNA 2 stated she was with two residents when she saw Resident 1 in the hallway, by his room, falling and hitting his head on the floor. During a telephone interview on [DATE] at 1:25 p.m., Director of Nursing (DON) confirmed she was not familiar with Resident 1 because he was new to facility. DON confirmed Resident 1 was a high risk for fall. A review of facility's policy and procedures undated, titled, Promoting Safety, Reducing Falls, Major Risk Factors: if caregivers are to prevent falls, they must firs have a working knowledge of the key factors that determine which residents are most at risk. 1. History of Falls . 5. Gait and Balance Disturbance . What caregivers can do: caregivers who understand the risk and causes of falls can best assist in falls or accident prevention by keeping the following in mind, be alert to residents who have a history of falls and make conscious efforts to eyeball them more frequently . Preventing falls is the responsibility of everyone in the facility.

Based on interview and record review, the facility failed to provide the necessary care and services in accordance with its policy and procedure, and professional standards of care for one of seven sampled residents (Resident 1), by: 1.) Failing to ensure Licensed Vocational Nurse 1 (LVN 1) verified each medication order with Admitting Physician (AP) upon the resident's admission to the facility. 2.) Failing to ensure Licensed Vocational Nurse 1 (LVN 1) properly transcribed the Physician's admission medication orders correctly. 3.) Failing to ensure that AP, validated each MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident receiving nine (9) doses of [MEDICATION(S)] ([CONDITION(S)] [sudden, uncontrolled electrical disturbance in the brain] medication) that were 150 milligrams (mg-unit of measure) less than the intended prescribed dose between the dates of 5/15/2021 to 5/19/2021. Subsequently, Resident 1 was transferred to a General Acute Care Hospital (GACH) for further evaluation due to uncontrolled body movement, potentially compromising his health and safety, and placing Resident 1 at risk for death. On 6/16/2021 at 4:13 p.m., in the presence of the Director of Nursing (DON), Administrator In Training (AIT), and Director of Staff Development (DSD), the State Survey Agency (The Department) called an Immediate Jeopardy (a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, and/or death to a resident [Resident 1]). The admitting physician failed to review the transcribed order to ensure accuracy prior to signing for validation. On 6/18/2021 at 3:54 p.m., the AIT provided a Plan of Action (POA) for the health and safety of Resident 1, which included the following summarized actions: 1.) Resident 1 was transferred to GACH on 5/20/2021 for uncontrolled body movements. DON and DSD provided an in-service education to licensed nurses on 6/16/2021 addressing the admission process, verification of orders with attending physician, procedure in handling medication error(s) including resident assessment and notification of the physician and family. 2.) On 6/16/21, the DON gave an in-service to the Attending Physician (AP) of Resident 1 to follow facility policy concerning verifying and reviewing medication orders prior to physician signing. 3.) On 6/18/21, the licensed nurses completed a triple check of all medication carts to ensure that appropriate medications are available and provided as ordered. 4.) On 6/17/21 and 6/18/21, the Pharmacy Consultant completed a medication regimen review of newly admitted residents and residents on [CONDITION(S)] medications. 5.) On 6/17/21, the Pharmacy Consultant provided an in-service education to licensed staff on medication administration concerning proper transcribing of transfer/discharge medication orders from the General Acute Care Hospital. On 6/18/2021 at 4:48 p.m., while onsite and after confirming the facility's implementation of the immediate actions, the Department accepted the POA and removed the Immediate Jeopardy in the presence of the DON, AIT, and DSD. Cross Reference to F760 and F711 Findings: A record review of Resident 1's Admission Record indicated an admitted [DATE]. List of Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 5/20/2021 indicated that Resident 1 was severely impaired with thought process and decision-making tasks. Further review of the MDS indicated that Resident 1 required total dependence from staff for bed mobility (turning side to side), transfers (moving from bed to chair), dressing, eating, toilet use (how resident uses toilet room, cleansing after elimination), and personal hygiene. A review of the GACH record titled Skilled Nursing Facility Transfer Orders dated 5/13/2021, indicated that Resident 1 was to continue on the medication [MEDICATION(S)] 25 mg tablet, to take seven (7) tablets via gastrostomy tube (G-tube, a surgical opening on the abdomen used to deliver nutrients or medication directly into the stomach) two (2) times daily, for a total of 175 mg per dose. A record review of the Physician's Orders for Resident 1 dated 5/14/2021 at 7:26 p.m. obtained via telephone indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/2021 at 4:55 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that they spoke to Resident 1's Responsible Party (RP) on 5/19/2021 to go over medications. LVN 1 indicated that RP noted that the dosage for the medication [MEDICATION(S)] was incorrect and informed her that it should have been seven (7) tablets equaling a total of 175 mg per administered dose versus one (1) tablet equaling only 25 mg. On 6/16/2021 at 2:06 p.m., during an interview and concurrent record review with LVN 1, Resident 1's physicians orders and skilled nursing facility medical records were reviewed. LVN 1 stated that upon admission, AP changed Resident 1's [CONDITION(S)] medication order for [MEDICATION(S)] 25 mg, give seven (7) tablets two (2) times to [MEDICATION(S)] 25 mg give one (1) tablet two (2) times daily. LVN 1 indicated not having any further documentation to prove as to why AP would decrease the [CONDITION(S)] medication order. On 6/16/2021 at 3:25 p.m., during a phone interview with AP, AP stated giving the facility staff orders to continue all discharge medication orders from the GACH for Resident 1. AP stated that this was done until AP can familiarize more with Resident 1's needs. AP stated that it has been the standard of practice to approve all medications from the hospital first before adjusting the medications. AP denied giving an order to decrease Resident 1's dose of [MEDICATION(S)] from 175 mg to 25 mg per dose. On 6/16/2021 at 12:53 p.m., during a phone interview with the facility's Pharmacy Consultant (PC), PC stated that the medication [MEDICATION(S)] should be gradually decreased in dosage if possible. PC indicated that if a resident received a decreased dose of a [CONDITION(S)] medication, it would increase the risks of encountering a [CONDITION(S)] for that resident and that would be a preventable incident. On 6/17/2021 at 2:34 p.m., during an interview and concurrent record review with Registered Nurse 1 (RN 1), Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 confirmed that Resident 1 was given [MEDICATION(S)] tablet 25 mg; one (1) tablet for seizures on the following dates: 1. 5/15/2021, Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. and 5:00 p.m. 2. 5/16/2021, Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. and 5:00 p.m. 3. 5/17/2021, Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. and 5:00 p.m. 4. 5/18/2021, Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. and 5:00 p.m. 5. 5/19/2021 Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. RN 1 stated between the dates of 5/15/2021 to 5/19/2021, Resident 1 received a total of nine (9) doses of [MEDICATION(S)] 25 mg, one (1) tablet rather than the intended dose of [MEDICATION(S)] 25 mg, seven (7) tablets totaling 175 mg per dose. On 6/17/2021 at 2:34 p.m., during an interview with RN 1, RN 1 indicated that for admissions, the transferring hospital sends a list of discharge medications, and then the facility's licensed staff are to verify each medication individually with the admitting physician. RN 1 stated that any instructions by the doctor should be documented on the admission notes or the nursing progress notes. Concurrent review of Resident 1's record titled Progress Notes dated 5/20/2021 at 7:43 p.m. with RN 1, indicated Resident 1 experienced on and off uncontrolled body movement and was transferred to the GACH. RN 1 stated that uncontrolled body movements is a [CONDITION(S)]. RN 1 stated that if the intended dose of [MEDICATION(S)] been administered, then the medication would be effective, and Resident 1 would not have needed to go to the GACH. On 6/18/2021 at 1:40 p.m., during an interview and concurrent record review with AP, Resident 1's physician orders were reviewed. A physician's order was noted for Resident 1 dated 5/14/2021 at 7:26 p.m. obtained via telephone indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was noted to be signed by AP indicating that AP had reviewed and validated the order. When asked why the order for [MEDICATION(S)] 25 mg was signed when the intended order was [MEDICATION(S)] 175 mg, AP admitted to not reviewing the orders prior to signing. AP stated due to the long list of medications that Resident 1 was admitted with, AP did not go through each medication and dosages with the admitting nurse individually upon Resident 1's admission to facility. AP stated that they told the admitting nurse to continue all medications and expected that the medication list for Resident 1 to be written correctly based on the Skilled Nursing Facility Transfer Orders form. On 6/18/2021 at 3:59 p.m., during interview with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that the importance of verifying each medication with the physician is to avoid medication errors such as wrong dosage, and mainly to protect the residents. LVN 2 indicated that documentation needs to exist on the progress notes if the physician's orders are changed. On 6/18/2021 at 4:07 p.m., during an interview with Registered Nurse 2 (RN 2), RN 2 indicated that within 24 hours of an admission, it is the responsibility of the RN Supervisor to review the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 2 further stated, the RN Supervisors are to countersign medication orders collected by the admitting nurse. RN 2 indicated that Licensed Vocational Nurses (LVNs) are the admitting nurses and are within the scope of practice to be able to obtain orders from physicians. During a concurrent record review of Resident 1's Admission assessment dated [DATE] at 7:03 p.m. with RN 2, indicated that there was no documented evidence that a registered nurse reviewed Resident 1's admission assessment and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the record titled Job Description with approved date 8/23/2011 for the job title Registered Nurse stated The Registered Nurse is responsible for assuring physician's orders are followed and quality of care is provided on each shift in a skilled nursing facility. Essential duties and responsibilities for a registered nurse includes Assessment of new admissions. A record review of the facility policy titled Licensed Nurses Notes dated 1/04 states, Meaningful and informative notes shall be written by a licensed nurse to reflect the care and treatment, observations and assessments and other appropriate entries. The policy includes entries as necessary such as during an admission, and All resident notification and calls to the resident's personal representative, or family member (when appropriate), about care and treatment and of any changes in that care or treatment that may affect the resident's well-being are to be recorded, including the name of that party. A record review of an undated facility policy titled Medication Reconciliation and Verification indicates, It is the policy of the facility that the licensed staff will do verification of orders prior to transcribing to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of an undated facility policy titled Quality of Care states, It is the policy of the facility to ensure that each resident receive and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, in accordance with State and Federal Regulations. The policy also indicated, The facility will ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident's right to refuse treatment and within the limits of recognized pathology and the normal aging process.

Based on interview and record review, the facility failed to administer [MEDICATION(S)] ([CONDITION(S)] [burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements] medication) as ordered by the physician for one of seven sampled residents (Resident 1). Resident 1 was given [MEDICATION(S)] 25 milligram (mg, a unit of measure) rather than the intended dose of [MEDICATION(S)] 175 mg. This deficient practice resulted in Resident 1 receiving nine (9) doses of [MEDICATION(S)] that was seven (7) times less than the intended prescribed dose between the dates of 5/15/2021 to 5/19/2021. Subsequently, Resident 1 was transferred to a General Acute Care Hospital (GACH) for further evaluation due to uncontrolled body movement, potentially compromising the health and safety, and placing Resident 1 at risk for death. On 6/16/2021 at 4:13 p.m., in the presence of the Director of Nursing (DON), Administrator In Training (AIT), and Director of Staff Development (DSD), the State Survey Agency (The Department) called an Immediate Jeopardy (a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, and/or death to a resident [Resident 1]). The facility staff failed to administer the correct dose of [MEDICATION(S)] a total of nine (9) doses. On 6/18/2021 at 3:54 p.m., the AIT provided a Plan of Action (POA) for the health and safety of Resident 1, which included the following summarized actions: 1.) Resident 1 was transferred to GACH on 5/20/2021 for uncontrolled body movements. DON and DSD provided an in-service education to licensed nurses on 6/16/2021 addressing the admission process, verification of orders with attending physician, procedure in handling medication error(s) including resident assessment and notification of the physician and family. 2.) On 6/16/21, the DON gave an in-service to the Attending Physician (AP) of Resident 1 to follow facility policy concerning verifying and reviewing medication orders prior to physician signing. 3.) On 6/18/21, the licensed nurses completed a triple check of all medication carts to ensure that appropriate medications were available and provided as ordered. 4.) On 6/17/21 and 6/18/21, the Pharmacy Consultant completed a medication regimen review of newly admitted residents and residents on [CONDITION(S)] medications. 5.) On 6/17/21, the Pharmacy Consultant provided an in-service education to licensed staff on medication administration concerning proper transcribing of transfer/discharge medication orders from the General Acute Care Hospital. On 6/18/2021 at 4:48 p.m., while onsite and after confirming the facility's implementation of the immediate actions, the Department accepted the POA and removed the Immediate Jeopardy in the presence of the DON, AIT, and DSD. Cross Reference to F684 and F711 Findings: A record review of Resident 1's Admission Record indicated an admitted [DATE]. List of Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 5/20/2021 indicated that Resident 1 was severely impaired with thought process and decision-making tasks. Further review of the MDS indicated that Resident 1 required total dependence from staff for bed mobility (turning side to side), transfers (moving from bed to chair), dressing, eating, toilet use (how resident uses toilet room, cleansing after elimination), and personal hygiene. A review of the GACH record titled Skilled Nursing Facility Transfer Orders dated 5/13/2021, indicated that Resident 1 was to continue on the medication [MEDICATION(S)] 25 mg tablet, to take seven (7) tablets via gastrostomy tube (G-tube, a surgical opening on the abdomen used to deliver nutrients or medication directly into the stomach) two (2) times daily, for a total of 175 mg per dose. A record review of the Physician's Orders for Resident 1 dated 5/14/2021 at 7:26 p.m. obtained via telephone indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/2021 at 4:55 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that they spoke to Resident 1's Responsible Party (RP) on 5/19/2021 to go over medications. LVN 1 stated that RP noted that the dosage for the medication [MEDICATION(S)] was incorrect and informed her that it should have been seven (7) tablets equaling a total of 175 mg per administered dose versus one (1) tablet equaling only 25 mg. On 6/16/2021 at 2:06 p.m., during an interview and concurrent record review with LVN 1, Resident 1's physician's orders for 5/2021 and skilled nursing facility medical records were reviewed. LVN 1 alleged that upon admission, Resident 1's [CONDITION(S)] medication order for [MEDICATION(S)] 25 mg, give seven (7) tablets two (2) times daily was changed by AP to [MEDICATION(S)] 25 mg, give one (1) tablet two (2) times daily. LVN 1 indicated not having any further documentation to prove as to why AP would decrease the [CONDITION(S)] medication order. On 6/16/2021 at 3:25 p.m., during a phone interview with AP, AP stated giving the facility staff orders to continue all discharge medication orders from the GACH for Resident 1 on 5/14/2021. AP stated that this was done until AP can familiarize more with Resident 1's needs. AP stated that it has been the standard of practice to approve all medications from the hospital first before adjusting the medications. AP denied giving an order to decrease Resident 1's dose of [MEDICATION(S)] from 175 mg to 25 mg per dose. On 6/16/2021 at 12:53 p.m., during a phone interview with the facility's Pharmacy Consultant (PC), PC stated that the medication [MEDICATION(S)] should be gradually decreased in dosage if possible. PC indicated that if a resident received a decreased dose of a [CONDITION(S)] medication, it would increase the risks of encountering a [CONDITION(S)] for that resident and that would be a preventable incident. On 6/17/2021 at 2:34 p.m., during an interview and concurrent record review with Registered Nurse 1 (RN 1), Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 confirmed that Resident 1 was given [MEDICATION(S)] tablet 25 mg; one (1) tablet for seizures on the following dates: 1. 5/15/2021, Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. and 5:00 p.m. 2. 5/16/2021, Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. and 5:00 p.m. 3. 5/17/2021, Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. and 5:00 p.m. 4. 5/18/2021, Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. and 5:00 p.m. 5. 5/19/2021 Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. RN 1 stated between the dates of 5/15/2021 to 5/19/2021, Resident 1 received a total of nine (9) doses of [MEDICATION(S)] 25 mg, one (1) tablet rather than the intended dose of [MEDICATION(S)] 25 mg, seven (7) tablets totaling 175 mg per dose. On 6/17/2021 at 2:34 p.m., during an interview with RN 1, RN 1 indicated that for admissions, the transferring hospital sends a list of discharge medications, and then the facility's licensed staff are to verify each medication individually with the admitting physician. RN 1 stated that any instructions by the doctor should be documented on the admission notes or the nursing progress notes. Concurrent review of Resident 1's record titled Progress Notes dated 5/20/2021 at 7:43 p.m. with RN 1, indicated Resident 1 experienced on and off uncontrolled body movement and was transferred to the GACH. RN 1 stated that uncontrolled body movements is a [CONDITION(S)]. RN 1 stated that if the intended dose of [MEDICATION(S)] had been administered, then the medication would be effective, and Resident 1 would not have needed to go to the GACH. On 6/18/2021 at 1:40 p.m., during an interview and concurrent record review with AP, Resident 1's physician orders were reviewed. A physician's order was noted for Resident 1 dated 5/14/2021 at 7:26 p.m. obtained via telephone indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was noted to be signed by AP indicating that AP had reviewed and validated the order. When asked why the order for [MEDICATION(S)] 25 mg was signed when the intended order was [MEDICATION(S)] 175 mg, AP admitted to not reviewing the orders prior to signing. AP stated due to the long list of medications that Resident 1 was admitted with, AP did not go through each medication and dosages with the admitting nurse individually upon Resident 1's admission to facility. AP stated that he told the admitting nurse to continue all medications and expected that the medication list for Resident 1 to be written correctly based on the Skilled Nursing Facility Transfer Orders form. On 6/18/2021 at 3:59 p.m., during interview with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that the importance of verifying each medication with the physician is to avoid medication errors such as wrong dosage, and mainly to protect the residents. LVN 2 indicated that documentation needs to exist on the progress notes if the physician's orders are changed. On 6/18/2021 at 4:07 p.m., during an interview with Registered Nurse 2 (RN 2), RN 2 indicated that within 24 hours of an admission, it is the responsibility of the RN Supervisor to review the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 2 further stated, the RN Supervisors are to countersign medication orders collected by the admitting nurse. RN 2 indicated that Licensed Vocational Nurses (LVNs) are the admitting nurses and are within the scope of practice to be able to obtain orders from physicians. During a concurrent record review of Resident 1's Admission assessment dated [DATE] at 7:03 p.m. with RN 2, indicated that there was no documented evidence that a registered nurse reviewed Resident 1's admission assessment and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility's record titled Job Description with approved date 8/23/2011 for the job title Registered Nurse indicated, The Registered Nurse is responsible for assuring physician's orders are followed and quality of care is provided on each shift in a skilled nursing facility. Essential duties and responsibilities for a registered nurse includes Assessment of new admissions. A record review of the facility policy titled Licensed Nurses Notes dated 1/2004 states, Meaningful and informative notes shall be written by a licensed nurse to reflect the care and treatment, observations and assessments and other appropriate entries. The policy includes entries as necessary such as during an admission, and All resident notification and calls to the resident's personal representative, or family member (when appropriate), about care and treatment and of any changes in that care or treatment that may affect the resident's well-being are to be recorded, including the name of that party. A record review of an undated facility policy titled Medication Reconciliation and Verification indicates, It is the policy of the facility that the licensed staff will do verification of orders prior to transcribing to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to ensure the admitting physician for one of seven sampled residents (Resident 1) reviewed the transcribed order for [MEDICATION(S)] ([CONDITION(S)] [sudden, uncontrolled electrical disturbance in the brain] medication) to ensure accuracy prior to signing for validation. This deficient practice resulted in Resident 1 receiving nine (9) doses of [MEDICATION(S)] that was seven (7) times less than the intended prescribed dose between the dates of 5/15/2021 to 5/19/2021. Subsequently, Resident 1 was transferred to a General Acute Care Hospital (GACH) for further evaluation due to uncontrolled body movement, potentially compromising the health and safety, and placing Resident 1 at risk for death. On 6/16/2021 at 4:13 p.m., in the presence of the Director of Nursing (DON), Administrator In Training (AIT), and Director of Staff Development (DSD), the State Survey Agency (The Department) called an Immediate Jeopardy (a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, and/or death to a resident [Resident 1]). The admitting physician failed to review the transcribed order to ensure accuracy prior to signing for validation. On 6/18/2021 at 3:54 p.m., the AIT provided a Plan of Action (POA) for the health and safety of Resident 1, which included the following summarized actions: 1.) Resident 1 was transferred to GACH on 5/20/2021 for uncontrolled body movements. DON and DSD provided an in-service education to licensed nurses on 6/16/2021 addressing the admission process, verification of orders with attending physician, procedure in handling medication error(s) including resident assessment and notification of the physician and family. 2.) On 6/16/21, the DON gave an in-service to the Attending Physician (AP) of Resident 1 to follow facility policy concerning verifying and reviewing medication orders prior to physician signing. 3.) On 6/18/21, the licensed nurses completed a triple check of all medication carts to ensure that appropriate medications are available and provided as ordered. 4.) On 6/17/21 and 6/18/21, the Pharmacy Consultant completed a medication regimen review of newly admitted residents and residents on [CONDITION(S)] medications. 5.) On 6/17/21, the Pharmacy Consultant provided an in-service education to licensed staff on medication administration concerning proper transcribing of transfer/discharge medication orders from the General Acute Care Hospital. On 6/18/2021 at 4:48 p.m., while onsite and after confirming the facility's implementation of the immediate actions, the Department accepted the POA and removed the Immediate Jeopardy in the presence of the DON, AIT, and DSD. Cross Reference with F760 and F684 Findings: A record review of Resident 1's Admission Record indicated an admitted [DATE]. List of Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 5/20/2021 indicated that Resident 1 was severely impaired with thought process and decision-making tasks. Further review of the MDS indicated that Resident 1 required total dependence from staff for bed mobility (turning side to side), transfers (moving from bed to chair), dressing, eating, toilet use (how resident uses toilet room, cleansing after elimination), and personal hygiene. A review of the GACH record titled Skilled Nursing Facility Transfer Orders dated 5/13/2021, indicated that Resident 1 was to continue on the medication [MEDICATION(S)] 25 milligram (mg, unit of measure) tablet, to take seven (7) tablets via gastrostomy tube (G-tube, a surgical opening on the abdomen used to deliver nutrients or medication directly into the stomach) two (2) times daily, for a total of 175 mg per dose. A record review of the Physician's Orders for Resident 1 dated 5/14/2021 at 7:26 p.m. obtained via telephone indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/2021 at 4:55 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that they spoke to Resident 1's Responsible Party (RP) on 5/19/2021 to go over medications. LVN 1 indicated that RP noted that the dosage for the medication [MEDICATION(S)] was incorrect and informed her that it should have been seven (7) tablets equaling a total of 175 mg per administered dose versus one (1) tablet equaling only 25 mg. On 6/16/2021 at 2:06 p.m., during an interview and concurrent record review with LVN 1, Resident 1's physicians orders and skilled nursing facility medical records were reviewed. LVN 1 alleged that upon admission, Resident 1's [CONDITION(S)] medication order for [MEDICATION(S)] 25mg, give seven (7) tablets two (2) times daily was changed by AP to [MEDICATION(S)] 25mg, give one (1) tablet two (2) times daily. On 6/16/2021 at 3:25 p.m., during a phone interview with AP, AP stated giving the facility staff orders to continue all discharge medication orders from the GACH for Resident 1. AP stated that this was done until AP can familiarize more with Resident 1's needs. AP stated that it has been the standard of practice to approve all medications from the hospital first before adjusting the medications. AP denied giving an order to decrease Resident 1's dose of [MEDICATION(S)] from 175 mg to 25 mg per dose. On 6/16/2021 at 12:53 p.m., during a phone interview with the facility's Pharmacy Consultant (PC), PC stated that the medication [MEDICATION(S)] should be gradually decreased in dosage if possible. PC indicated that if a resident received a decreased dose of a [CONDITION(S)] medication, it would increase the risks of encountering a [CONDITION(S)] for that resident and that would be a preventable incident. On 6/17/2021 at 2:34 p.m., during an interview and concurrent record review with Registered Nurse 1 (RN 1), Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 confirmed that Resident 1 was given [MEDICATION(S)] tablet 25mg; give one (1) tablet two (2) times a day for seizures on the following dates: 1. 5/15/2021, Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. and 5:00 p.m. 2. 5/16/2021, Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. and 5:00 p.m. 3. 5/17/2021, Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. and 5:00 p.m. 4. 5/18/2021, Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. and 5:00 p.m. 5. 5/19/2021 Resident 1 received [MEDICATION(S)] 25 mg one (1) tablet at 9:00 a.m. RN 1 stated between the dates of 5/15/2021 to 5/19/2021, Resident 1 received a total of nine (9) doses of [MEDICATION(S)] 25mg, one (1) tablet rather than the intended dose of [MEDICATION(S)] 25 mg, seven (7) tablets totaling 175 mg per dose. On 6/17/2021 at 2:40 p.m. during an interview and concurrent review of Resident 1's record titled Progress Notes dated 5/20/2021 at 7:43 p.m. with RN 1, the note indicated that Resident 1 experienced on and off uncontrolled body movement and was transferred to the GACH. RN 1 stated that uncontrolled body movements is a [CONDITION(S)]. RN 1 stated that had the intended dose of [MEDICATION(S)] been administered, then the medication would be effective, and Resident 1 would not have needed to go to the GACH. On 6/18/2021 at 1:40 p.m., during an interview and concurrent record review with AP, Resident 1's physician orders were reviewed. A physician's order was noted for Resident 1 dated 5/14/2021 at 7:26 p.m. obtained via telephone indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was noted to be signed by AP indicating that AP had reviewed and validated the order. When asked why the order for [MEDICATION(S)] 25mg was signed when the intended order was for [MEDICATION(S)] 175 mg, AP admitted to not reviewing the orders prior to signing. AP stated due to the long list of medications that Resident 1 was admitted with, AP did not go through each medication and dosages with the admitting nurse individually upon Resident 1's admission to facility. AP indicated stating to the admitting nurse to continue all medications and expected that the medication list for Resident 1 to be written correctly based on the Skilled Nursing Facility Transfer Orders form. A record review of the facility policy titled Physician Documentation dated 1/04 indicated, The physician is to provide admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility staff failed to protect one of 3 residents (Resident 1) from financial abuse. Resident 1 felt manipulated in giving Certified Nursing Assistant (CNA) 1 money in a span of a four (4) month period. This deficient practice caused the resident to be tearful, feel guilty, and manipulated. As a result, Resident 1, who was diagnosed with [REDACTED]. Findings: Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's History and Physical dated 9/26/14 indicated the resident had the capacity to understand and make decisions. A review of the resident's Minimum Data Set (MDS, an assessment tool) dated 6/21/15, indicated the resident was assessed with [REDACTED]. A review of Resident 1's Psychiatric Progress Note dated 6/24/15 indicated the resident had persistent depression, pain, [MEDICAL CONDITION] (trouble sleeping), and anxiety. The recommendations indicated to continue [MEDICATION NAME] DR 30 milligrams (mg) one tablet for depression manifested by sciatic pain (pain that radiates along the path of the sciatic nerve, which branches from your lower back through your hips and buttocks and down each leg). Further review of the resident's clinical record indicated a doctor's order dated 8/14/15, to administer [MEDICATION NAME] every morning for depression and crying episodes. On 9/11/15, at 10:08 a.m., an interview was conducted with Resident 1, who stated that at the end of April or early May 2015, CNA 1 visited often in the resident's room, to talk. CNA 1 confided in the resident and shared stories about CNA 1's personal life. The resident stated CNA 1 told the resident she was having financial problems and did not have enough money to feed her family or food at home in the cupboards. Resident 1 felt bad and gave CNA 1 twenty dollars ($20.00). Resident 1 thought CNA 1 would pay the resident. CNA 1 did not pay the resident back. The resident stated they exchanged cellular phone numbers. CNA 1 made a call to the resident's cellular phone to tell the resident that CNA 1 was being evicted from her home. CNA 1 also told the resident she wanted to buy a gift for her boyfriend, but did not have any money to buy a gift. The resident felt badly and gave CNA 1 another twenty dollars ($20.00). Throughout the month of June, Resident 1 stated that CNA 1 (who was not assigned to care for Resident 1) visited the resident almost every night, and used the resident ' s personal facial moisturizer, body lotion, and body mist; products delivered from the resident's family. The resident stated CNA 1 started asking for more money that ended up being a total of about $100. In August 2015, CNA 1 asked for money from the resident to buy school uniform for CNA 1's son. Resident 1 stated it was making the resident feel more and more uncomfortable, having CNA 1 in the resident's room, and the resident wanted to sleep, but could not sleep when CNA 1 was in the room. The resident then stated sometime early September 2015, CNA 1 asked for the resident's coin jar. The resident's coin jar contained quarters, dimes and nickels. CNA 1 then opened the resident's bedside drawer and took the resident's dollar coin. Throughout the interview, from 10:08 a.m. - 11:50 a.m., Resident 1 was observed to be teary-eyed. The resident felt guilty for giving CNA 1 money that was never returned by the CNA. The resident felt manipulated and taken advantage of. A review of Resident 1's [MEDICAL CONDITION] assessment dated [DATE] indicated the resident exhibited crying spells. On 10/9/15, at 9:50 a.m., an interview was conducted with Registered Nurse 1 (RN 1) who stated in the last six (6) months, she witnessed Resident 1 and CNA 1 talking to each other during CNA 1's break. RN 1 then stated she witnessed CNA 1 sleeping past her break time, and would not call or show up to work. RN 1 further stated CNA 1 would be sitting and talking to Resident 1 and neglected other residents. RN 1 stated she informed the DSD (Director of Staff Developer) and Administration in writing regarding CNA 1's actions, but was unsure if anything was done to correct the issue. RN 1 stated Resident 1 approached her at the end of her shift, sometime early September 2015, regarding CNA 1 taking money from the resident and informed the DSD right away. On 9/11/15, at 1:50 p.m., an interview was conducted with the DSD, who stated she was given a notice in writing regarding CNA 1 taking money from Resident 1, but denied any other disciplinary actions against CNA 1, prior to this incident. The DSD stated CNA 1 was terminated on 9/10/15. The DSD informed the Director of Nursing (DON) regarding the incident. A review of CNA 1's personnel file indicated no disciplinary actions against her, until the CNA was terminated from her position on 9/10/15. Attempts were made to contact CNA 1 via telephone regarding the above incident, but there was no response made by the CNA. A review of the facility's policy and procedure for Abuse and Mistreatment of [REDACTED]. Department Supervisors shall ensure that adequate supervision is being given and appropriate assistance extended to residents in need when performing their daily monitoring and rounds.

Based on observation, interview, and record review, the facility failed to implement written policy and procedure, to protect one of 3 residents (Resident 1) from financial abuse by Certified Nursing Assistant (CNA) 1. Resident 1 felt manipulated in giving CNA 1 money in a span of a four (4) month period. This deficient practice caused the resident to be tearful, feel guilty, and manipulated. As a result, Resident 1, who was diagnosed with [REDACTED]. Findings: Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's History and Physical dated 9/26/14 indicated the resident had the capacity to understand and make decisions. A review of the resident's Minimum Data Set Assessment (an assessment tool) dated 6/21/15 indicated the resident was assessed with [REDACTED]. A review of Resident 1's Psychiatric Progress Note dated 6/24/15 indicated the resident had persistent depression, pain, [MEDICAL CONDITION] (trouble sleeping), and anxiety. The recommendations indicated to continue [MEDICATION NAME] DR 30 milligrams (mg) one tablet for depression manifested by sciatic pain (pain that radiates along the path of the sciatic nerve, which branches from your lower back through your hips and buttocks and down each leg). Further review of the resident's clinical record indicated a doctor's order dated 8/14/15 to administer [MEDICATION NAME] every morning for depression and crying episodes. On 9/11/15, at 10:08 a.m., an interview was conducted with Resident 1 who stated at the end of April or early May 2015, CNA 1 visited often in the resident's room, to talk. CNA 1 confided in the resident and shared stories about CNA 1's personal life. The resident stated CNA 1 told the resident she was having financial problems and did not have enough money to feed her family or food at home in the cupboards. Resident 1 felt bad and gave CNA 1 twenty dollars ($20.00). Resident 1 thought CNA 1 would pay the resident. CNA 1 did not pay the resident back. The resident stated they exchanged cellular phone numbers. CNA 1 made a call to the resident's cellular phone to tell the resident that CNA 1 was being evicted from her home. CNA 1 also told the resident she wanted to buy a gift for her boyfriend, but did not have any money to buy a gift. The resident felt badly and gave CNA 1 another twenty dollars ($20.00). Throughout the month of June, Resident 1 stated, CNA 1 (who was not assigned to care for Resident 1) visited the resident almost every night, and used the resident ' s personal facial moisturizer, body lotion, and body mist; products delivered from the resident's family. The resident stated CNA 1 started asking for more money that ended up being a total of about $100. In August 2015, CNA 1 asked for money from the resident to buy school uniform for CNA 1's son. Resident 1 stated it was making the resident feel more and more uncomfortable having CNA 1 in the resident's room, and the resident wanted to sleep, but could not sleep when CNA 1 was in the room. The resident then stated sometime early September 2015, CNA 1 asked for the resident's coin jar. The resident's coin jar contained quarters, dimes and nickels. CNA 1 then opened the resident's bedside drawer and took the resident's dollar coin. Throughout the interview, from 10:08 a.m. - 11:50 a.m., Resident 1 was observed to be teary-eyed. The resident felt guilty for giving CNA 1 money that was never returned by the CNA. The resident felt manipulated and taken advantage of. A review of Resident 1's [MEDICAL CONDITION] assessment dated [DATE] indicated the resident exhibited crying spells. On 10/9/15, at 9:50 a.m., an interview was conducted with Registered Nurse 1 (RN 1) who stated in the last six (6) months, she witnessed Resident 1 and CNA 1 talking to each other during CNA 1's break. RN 1 then stated she witnessed CNA 1 sleeping past her break time, and would not call or show up to work. RN 1 further stated CNA 1 would be sitting and talking to Resident 1 and neglected other residents. RN 1 stated she informed the DSD (Director of Staff Developer) and Administration in writing regarding CNA 1's actions, but was unsure if anything was done to correct the issue. RN 1 stated Resident 1 approached her at the end of her shift, sometime early September 2015, regarding CNA 1 taking money from the resident and informed the DSD right away. On 9/11/15, at 1:50 p.m., an interview was conducted with the DSD, who stated she was given a notice in writing regarding CNA 1 taking money from Resident 1, but denied any other disciplinary actions against CNA 1, prior to this incident. The DSD stated CNA 1 was terminated on 9/10/15. The DSD informed the Director of Nursing (DON) regarding the incident. A review of CNA 1's personnel file indicated no disciplinary actions against her until the CNA was terminated from her position on 9/1015. Attempts were made to contact CNA 1 via telephone regarding the above incident, but there was no response made by the CNA. A review of the facility's policy and procedure for Abuse and Mistreatment of [REDACTED]. Department Supervisors shall ensure that adequate supervision is being given and appropriate assistance extended to residents in need when performing their daily monitoring and rounds.

Based on observation, interview, and record review, the facility failed to ensure one of three sample residents, Resident 1, who was assessed as high risk for fall and injury due to poor balance and safety awareness/judgment, physical limitations, in need of one-person assistance for transfer and walking with the use of a front wheel walker (FWW), and in need of extensive assistance from staff for toilet use, was provided with supervision and assistance to prevent fall and injury by: 1. Failure to ensure Resident 1 was supervised and assisted while sitting on the toilet. 2. Failure to implement the plan of care interventions to provide assistance with toilet use and provide a safe environment On 7/29/15, Resident 1 fell in the restroom when she got up from the toilet, after being left unattended and nobody responded to her calls for assistance, sustaining a fractured thoracic vertebra (T-12 - the mid-back spine). Findings: On 8/11/15, at 9 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 sustaining a fall at the facility which resulted in a back fracture. A review of the clinical record indicated the Resident 1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS - standardized assessment and care planning tool) dated 6/22/15, indicated Resident 1 usually had the ability to understand others with some difficulty communicating some words; required extensive assistance with one-person assist transferring from bed to chair and using the toilet; was not steady with moving from seated to standing position and moving on and off the toilet; and was only able to stabilize with staff assistance. A review of Resident 1's Fall Risk Assessment form, dated 6/12/15, indicated the resident was assessed at a high risk for falls. A review of Resident 1's Rehabilitation Fall Risk Assessment form completed by a physical therapist (PT) on 6/13/15 and 7/9/15, indicated the resident required extensive assistance with transfers, did not use the call bell properly, was unable to demonstrate proper safety while using assistive devices, and was unable to show proper sitting or standing balance or sufficient strength and correct posture in sitting and standing. A care plan revised on 6/22/15, developed for Resident 1's risk for falls/injury related to poor balance, poor safety awareness/judgment, and history of falls, included in the interventions to observe the resident frequently, keep call light within easy reach, provide safety instruction regarding ambulation, transfers and activities of daily living (ADLs). A care plan revised on 6/22/15, developed for Resident 1's self-care deficits, and need of extensive assistance with transfers, toilet use, and personal hygiene, included in the approaches to provide a safe environment, and assist with ADLs as needed. According to the Change of Condition form dated 7/29/15, timed at 10:10 a.m., Resident 1 was up in a shower chair with a seat belt with the assigned Certified Nursing Assistant (CNA 1), who wheeled the resident to the bathroom. The resident was instructed by CNA 1 to call while CNA 1 went to get linen. CNA 1 walked away to answer a call light in another room. At 10:24 a.m., a visiting hospice nurse found Resident 1 lying on the floor in the bathroom. A Registered Nurse supervisor (RN 1) assessed the resident and the resident denied pain. At 10:32 a.m., the resident was given a shower and taken back to room at 10:47 a.m. and Tylenol 325 milligrams (mg) two tablets were given to the resident for comfort. The physician was notified and ordered an X-ray of the back. A nursing note, dated 7/29/15, timed at 5 p.m., indicated the X-ray reported an acute moderate compression fracture of T-12. Resident 1 was complaining of pain rated 7/10 (scale of zero to 10, zero indicating no pain and 10 indicating the worst possible pain) and was given two tablets of Tylenol 325 mg. The director of nursing (DON) called the physician's office about the x-ray result and the secretary took the message for the on call physician. At 7:30 p.m., the on call physician called back and ordered to transfer the resident to a general acute care hospital (GACH) for evaluation; but the family decided to have the resident transferred the following day. On 7/30/15, at 10:45 a.m., Resident 1 was transferred to the GACH. The resident returned to the facility the same day at 6:45 p.m. A review of the x-ray report from the GACH dated 7/30/15 indicated T-12 compression fracture. On 8/11/15, at 11:04 a.m., during an interview, PT 1 stated Resident showed no signs of improvement from the therapy. On 8/11/15, at 11:39 a.m., during an interview, CNA 1 stated on the day of Resident 1's fall incident (7/29/15), she took the resident to the bathroom on a shower chair (a wheeled chair with a toilet shaped seat that can fit over a toilet) and stayed with the resident for about two minutes, she then heard a call light (from another room) and walked out of Resident 1's room, leaving the resident alone. CNA 1 went to a room across the hall to attend to another resident. While CNA 1 was in the other resident's room, she heard another CNA (CNA 2) call out to her telling her Resident 1 was found on the floor. CNA 1 stated she was not supposed to leave Resident 1 in the restroom alone, but was concerned the other resident across the hall needed help also. On 8/11/15, at 12:05 p.m., during an interview, CNA 2 stated she was making a resident's bed when someone down the hall called out that Resident 1 was on the floor. CNA 2 then told CNA 1 Resident 1 fell . CNA 2 stated residents were not to be left alone while sitting in the shower chair and there should always be one person with the resident, even if another call light is ringing. On 8/11/15, at 12:11 p.m., during an interview, LVN 1 stated she was told Resident 1 was on the floor and found the resident lying between the doorways of the bathroom. RN 1 was already in the room. The resident was responsive and had no visible injuries. LVN 1 gave the resident Tylenol 650 milligrams for possible pain. LVN 1 further stated a nurse should always be with the resident while the resident is sitting in a shower chair. On 9/10/15, at 1 p.m., an interview and observation with Resident 1 was conducted with the assistance of a translator. Resident 1, who was alert and was able to recall the details of the fall incident, stated the nurse (CNA 1) left her alone and left the restroom door open, When she was done in the restroom, she yelled out for help several times, but no one came. After yelling out for help, she stood up, grabbed the grab bar along the wall, felt dizzy and fell back on the floor, hitting her back and buttocks on the floor. The resident further indicated she grabbed a pink pitcher and started banging it on the floor to get someone's attention. The resident denied having a seat belt while in the shower chair. The resident was asked to demonstrate to release a seat belt but did not know how to remove it. Resident 1 stated this was the first time she was left alone in the restroom.