Every finding on record at California Nursing & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure wound treatments ordered by a wound consultant were implemented in a timely manner for five of six residents reviewed for pressure injuries (PI - bed sore), Residents 1, 2, 3, 4, and 5.This failure resulted in the delay of the appropriate treatment as ordered by the wound consultant and contributed to the worsening of Residents 1 and 2's PI. In addition, this failure had the potential to contribute to the worsening of Residents 3, 4 and 5's PI.Findings:1.A review of Resident 1's admission Record indicated that the resident was admitted to the facility on [DATE], with diagnoses which included fracture (break in the bone) of the right tibia. Resident 1 was transferred to the general acute hospital (GACH) due to hyperglycemia (high blood sugar) on May 24, 2026, and returned to the facility on May 25, 2026. A review of Resident 1's Progress Notes Type: N-Adv Skin Issues, on May 25, 2026, indicated the resident had a sacrococcyx (the area where a large triangular bone at the base of the spine [sacrum] connects to the tail bone [coccyx]) unstageable (UTD - a deep bedsore where the true depth of the damage is blocked by dead, hardened, or decaying tissue) pressure injury (PI - bedsore) measuring 7 centimeters (cm - a unit of measurement) in length (L - a unit of measurement) x 9 cm in width (W - a unit of measurement) with 100% epithelial cells (new layer of skin cells, white or light pink in color). On July 6, 2026, at 12:14 p.m., during a telephone interview with Resident 1's family member (FM 1), FM 1 stated she brought Resident 1 home on June 19, 2026, and the next day (June 20, 2026), the resident was taken to the GACH because her wound was bad. FM 1 stated Resident 1 was now back home under hospice care (specialized medical care for people with serious illness who are nearing the end of life). On July 6, 2026, at 12:42 p.m., during a concurrent interview and record review of Resident 1's medical record with Treatment Nurse (TN) 1, TN 1 stated the following: -On May 25, 2026, Resident 1 returned to the facility from the GACH with a sacrococcyx deep tissue pressure injury (DTPI - intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration), the treatment order was medical grade honey (MGH); -On May 26, 2026, the Wound Consultant (WMD) gave a verbal order of MGH for Resident 1's sacrococcyx DTPI; -On June 2, 2026, Resident 1's sacrococcyx DTPI declined to a stage 3 PI (a serious, full-thickness bedsore extending into the subcutaneous fatty layer) and measured 7 cm (L) x 9 cm (W) x 0.4 cm (D) with 50% granulation (pink to beefy-red tissue) and 50% eschar (a thick, dry, leathery layer of dead tissue) and the treatment ordered was Santyl (prescription medicine that removes dead tissue from wounds); -On June 9, 2026, Resident 1's stage 3 sacrococcyx PI was restaged to UTD that measured 7 cm (L) x 9 cm (L) x undetermined (D) with 25% granulation, with 75% eschar and the treatment ordered was Santyl; and -On June 16, 2026, Resident 1's UTD PI measured 6 cm (L) x 7 cm (W) x undetermined (D) with 25% granulation, 25% slough (a soft, moist, yellow, or white substance that forms in a wound) and 50% eschar, the treatment ordered was Santyl. A review of the facility document titled Wound Assessment and Plan, documented by the WMD indicated the following: May 26, 2026, .Wound Location: Sacro-coccyx .DTPI .Treatment Order .Medical Honey Gel .; and June 2, 2026, Wound Location: Sacro-coccyx .3 (Full thickness .) Healing status: Declined .Treatment Order. Santyl .A review of Resident 1's, Order Details, indicated the MGH was not transcribed (entered in the medical record) until May 31, 2026 (five days after it was ordered) and the Santyl order was not transcribed until June 16, 2026 (14 days after it was ordered).On July 7, 2026, at 10:35 a.m., during a concurrent interview and record review of Resident 1's medical records, TN 1 stated she transcribed the MGH order on May 31, 2026, and the Santyl order on June 16, 2026, because she waited to receive the WMD's written notes. TN 1 stated that the WMD typically provides verbal treatment orders during wound rounds (a scheduled bedside evaluation where a team of nurses and/or physicians examines, measures, and discusses a resident's wounds). TN 1 stated that she normally carry out (transcribe) those verbal orders on the same day the orders were given. TN 1 further stated that the WMD's written notes were sometimes different from his verbal orders. On July 7, 2026, at 11:11 a.m., during an interview, the Director of Nursing (DON) stated physician verbal orders are implemented the same day, to avoid delays in treatment; and are clarified with the physician if there were questions. The DON stated she expected TN 1 to transcribe wound treatment orders for Resident 1 on the same day the orders were given.On July 7, 2026, at 4:23 p.m., during a telephone interview, the WMD stated he verbally would communicate treatment changes during weekly rounds and would expect those changes to be implemented the same day. The WMD stated he ordered MGH on May 26, 2026, and Santyl on June 2, 2026, and expected both treatments to be implemented the same day they were ordered for Resident 1.On July 9, 2026, at 3:42 p.m., during a telephone interview, the WMD stated he was unaware that the treatment orders for Resident 1 were not implemented on the same day they were ordered and the delays in initiating the treatments ordered could contribute to the worsening of Resident 1's PI.2. On July 6, 2026, at 11:35 a.m., during a concurrent observation and interview, Resident 2 was in her room, lying on an air mattress, with the head of bed elevated at 45 degrees, alert, awake, and there were two family members (FM) at the bedside. Resident 2 did not respond during the interview. Resident 2's FM (FM 2) stated Resident 2 only speaks Spanish. FM 2 stated Resident 2 has a big bed sore (PI - pressure injury) on her buttocks which developed in the facility.A review of Resident 2's admission Record indicated she was admitted to the facility on [DATE], with diagnoses which included stroke with right side weakness.A review of Resident 2's Progress Notes Type: N ADV Clinical Admission dated June 11, 2026, indicated there were no skin issues identified.A review of Resident 2's Progress Note Type: N Adv - Skin Check dated June 13, 2026, indicated the resident had a stage 2 (a damaged area of the skin that forms an open wound) coccyx PI and a left buttock open lesion that were present on admission.On July 6, 2026, at 12:42 p.m., during a concurrent interview and record review of Resident 2's medical record with Treatment Nurse (TN) 1, TN 1 stated the following:-On June 13, 2026, Resident 2 had a stage 2 coccyx PI that measured 5 cm (L) x 0.8 cm (W) and the treatment ordered was zinc barrier cream (helps rebuild damaged skin barrier);-On June 16, 2026, Resident 2 had a stage 2 right buttock PI that measured 2 cm (L) x 2 cm x (W) x 0.2 cm (D); Resident 2's stage 2 coccyx PI became a sacrococcyx DTPI that was dark red to maroon in color and measured 4 centimeters (cm- a unit of measurement) in length (L - a unit of measurement) x 3 cm in width (W - a unit of measurement) with 100% epithelial (thin tissues covering all the exposed surfaces of the body); the treatment ordered for both PIs was zinc barrier cream; -On June 23, 2026, Resident 2's stage 2 right buttock deteriorated to stage 3 PI that measured 7 cm (L) x 3.5 cm (W) x 0.3 cm (D) with 50% epithelial cells and 50% granulation tissue; Resident 2's sacrococcyx DTPI deteriorated to a stage 3 PI that measured 9 cm (L) x 4 cm (W) x 0.5 cm (D) with 50% epithelial and 50% granulation (pink to beefy-red tissue). Both PIs were merging as one wound and the Wound Consultant (WMD) ordered Santyl (prescription medicine that removes dead tissue from wounds); and-On June 30, 2026, Resident 2's stage 3 right lower buttock PI measured 7 cm (L) x 4 cm (W) x 0.3 cm (D) with 50% epithelial and 50% granulation; Resident 2's sacrococcyx DTPI was restaged to UTD that measured 8.5 cm (L) x 10 cm (W) x undetermined (D) with 50% granulation, 10 % slough (dead tissue usually light yellow/cream colored) and 40% eschar (a thick, dry, leathery layer of dead tissue); according to the WMD, the treatment ordered was Santyl. A review of Resident 2's Wound Assessment and Plan, documented by the WMD, dated June 23, 2026, indicated, .Wound location: Right lower buttock .Pressure Injury Stage Upon completion of Visit: 3 (full thickness) Healing Status: Declined .Treatment Order. Santyl .; A review of Resident 2's Order Details indicated Santyl order was not transcribed until June 28, 2026 (five days after it was ordered on June 23, 2026). On July 7, 2026, at 10:35 a.m., during a concurrent interview and record review of Resident 2's medical record, TN 1 stated she transcribed the Santyl order on June 28, 2026, after receiving the written notes of the WMD. On July 7, 2026, at 11:11 a.m., during an interview, the Director of Nursing (DON) stated TN 1 should have transcribed the verbal orders from the WMD for Resident 2 on the same day they were given and to clarify the order with the WMD if there were any questions. On July 7, 2026, at 4:35 p.m., during a telephone interview, the WMD stated he expected the treatment order changes to be implemented the same day it was verbally given. On July 9, 2026, at 3:42 p.m., during a telephone interview, the WMD stated he was not aware that the treatment orders for Resident 2 were not implemented on the same day they were ordered and the delays in initiating the ordered treatments could contribute to worsening of Resident 2's PIs. 3. A review of Resident 3's medical record indicated the resident was re-admitted to the facility on [DATE], with diagnoses which included stroke with left-sided weakness.A review of Resident 3's History & Physical dated November 16, 2025, indicated the resident cannot participate in the plan of care.A review of Resident 3's Braden Scale for Predicting Pressure Ulcer Risk Evaluation (Braden Scale), dated February 2, 2026, indicated a score of 11 (high risk for developing pressure injury [PI]).On July 7, 2026, at 2:03 p.m., during a concurrent interview and record review of Resident 3's medical record with Treatment Nurse (TN) 1, TN 1 stated the following:-Resident 3 has a stage 3 (a serious, full-thickness bedsore extending into the subcutaneous fatty layer) left heel and right calf PIs; -On April 13, 2026, Resident 3 was identified to have a left heel deep tissue pressure injury (DTPI - intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration) that measured 3 centimeters (cm - a unit of measurement) in length (L - a unit of measurement) x 3 cm in width ( a unit of measurement) x undetermined depth (D - a unit of measurement) with the skin 100% dry and intact, red to maroon in color, the treatment ordered was betadine; Resident 3's stage 3 right calf PI measured 3 cm (L) x 1 cm (W) and the treatment ordered was Xeroform (a non-adherent, petrolatum-based gauze dressing);-On May 12, 2026, Resident 3's left heel DTPI measured 4 cm (L) x 3 cm (W) with 100% epithelial cells, there were no changes in treatment; Resident 3's stage 3 right calf PI measured 4.2 cm(L) x 1 cm (L) x 0.3 cm (D) with 90% granulation (pink to beefy-red tissue) and 10% slough (a soft, moist, yellow, or white substance that forms in a wound), the treatment order was changed to Santyl (prescription medicine that removes dead tissue from wounds); -On May 19, 26, June 2, 9 and 16, 2026, both PIs (left heel and right calf) remained at the same stage, size and treatment;-On June 23, 2026, Resident 3's left heel DTPI got bigger and became a Stage 3 PI and measured 4.5 cm (L) x 3.5 cm (W) x 0.3 cm (D) with 60% epithelial cells (thin tissues covering all the exposed surfaces of the body) and 40% granulation and treatment was changed to medical grade honey (MGH); there were no changes in treatment for the stage 3 right calf PI;-On June 30, 2026, Resident 3's stage 3 left heel PI measured 4 cm (L) x 2 cm (W) x 0.3 cm (D), with no changes in treatment; Resident 3's stage 3 right calf PI measured 1 cm (L) x 1 cm (W) x 0.2 cm (D) and the treatment order was changed to wound gel;-She (TN 1) transcribed the Santyl order on May 28, 2026 (16 days after it was ordered). She did not know why TN 2, who was with the wound consultant (WMD) during the wound rounds, did not transcribe the order on May 12, 2026;-She (TN 1) transcribed the MGH order for the left heel on June 28, 2026 (5 days after it was ordered on June 23, 2026) because she was waiting to receive the WMD's written notes; and-The wound gel ordered on June 30, 2026, was not transcribed because she (TN 1) only noticed it today.A review of Resident 3's Wound Assessment and Plan, documented by the WMD, indicated the following:May 12, 2026, .right posterior calf .Pressure Injury Stage Upon Completion of Visit: 3 (Full thickness) .Treatment Order .Santyl .; June 23, 2026, .Left heel .Pressure Injury Stage Upon Completion of Visit: 3 (Full thickness) .Treatment Order .Medical Honey Gel .; June 30, 2026, .right posterior calf .Pressure Injury Stage Upon Completion of Visit: 3 (Full thickness) .Treatment order .Wound gel . On July 7, 2026, at 3:40 p.m., during a concurrent observation and interview, Resident 3 was lying on an air mattress, eyes were closed, with steady breathing, with bilateral heel protectors. Resident 3 did not respond when her name was called. On July 7, 2026, at 4:24 p.m., during a telephone interview, the WMD stated he ordered Santyl on May 12, 2026, MGH on June 23, 2026, and wound gel on June 30, 2026, for Resident 3 and he expected the treatments to be implemented the same day they were ordered. On July 9, 2026, at 3:42 p.m., during a telephone interview, the WMD stated he was unaware the treatment orders for Resident 3 were not implemented on the same day it was ordered and the delay in initiating out the treatment orders could worsen Resident 3's PIs. 4. A review of Resident 4's medical record indicated the resident was re-admitted to the facility on [DATE], with diagnoses which included sacrococcyx (the area where a large triangular bone at the base of the spine [sacrum] connects to the tail bone [coccyx]) stage 4 (full thickness skin and tissue loss with exposed or palpable fascia (connective tissue), muscle .bone in the ulcer) PI.A review of Resident 4's H & P dated April 24, 2026, indicated the resident can make needs known but cannot make medical decisions.A review of Resident 4's Braden Scale dated May 14, 2026, indicated the resident has a moderate risk of developing PIs.A review of Resident 4's Treatment Administration Record for the month of July 2026, indicated the resident has a sacral stage 4 PI and the treatment was a wound vacuum (wound vac - an advanced wound treatment that promotes healing through controlled suction) to be changed every Tuesday, Thursday and Friday.On July 7, 2026, at 2:03 p.m., during a concurrent interview and record review of Resident 4's medical record with Treatment Nurse (TN) 1, TN 1 stated the following:-Resident 4 was transferred out to the GACH due to a deteriorating stage 3 sacrococcyx PI on April 16, 2026;-Resident 4 was re-admitted to the facility on [DATE], with a stage 4 coccyx PI;-On April 24, 2026, Resident 4's stage 4 coccyx PI measured 3.4 centimeters (cm - a unit of measurement) in length (L - a unit in measurement) x 3 cm (W) x 2.5 cm (D) and the treatment was Santyl (prescription medicine that removes dead tissue from wounds);-On May 5, 2026, Resident 4's stage 4 coccyx PI measured 4.4 cm (L) x 2 cm x 2.5 cm with 90% granulation (pink to beefy-red tissue) and 20% slough (a soft, moist, yellow, or white substance that forms in a wound) with no changes in treatment;-On May 12, 2026, Resident 4's stage 4 coccyx PI declined and measured 4 cm (L) x 2 cm (W) x 2.5 cm (D) and the treatment order was changed to wound vac;-The wound vac was started on May 19, 2026 (seven days after it was ordered) because that was when she received the wound vac. TN 1 stated while they were waiting for the wound vac, they continued to apply Santyl to Resident 4's PI; and-She documented on May 20, 2026, that on May 12, 2026, the WMD gave orders for a moist to dry dressing until the wound vac arrives.A review of Resident 4's Wound Assessment and Plan, documented by WMD, dated May 12, 2026, indicated, .Wound location: sacrum .Pressure Injury Stage upon completion of visit: 4 (Full thickness: Exposed underlying structure) .Treatment Order .Negative Pressure Wound Therapy .A review of Resident 4's Treatment Administration Record for the month of May 2026, indicated the resident continued to receive Santyl on May 12 to 19, 2026 and orders for MGH moist to dry dressing was implemented on May 20 to 22, 2026. Further review of the TAR did not indicate an order to continue Santyl while awaiting the wound vac.On June 7, 2026, at 3:50 p.m., during a concurrent observation and interview, Resident 4 was in her room, lying on an air mattress, alert and awake, with wound vac at bedside. Resident 4 stated she has a bed sore on her bottom and when asked about the wound vacuum, Resident 4 responded it's getting better and do not worry about it.On June 7, 2026, at 4:23 p.m., during an interview, the wound consultant (WMD) stated he ordered the wound vac for Resident 4 on May 12, 2026, and it usually takes a day for the facility to have a wound vac. The WMD stated he was not notified that the facility did not have a wound vac for several days and that facility usually notifies him if they do not have it. The WMD stated the delay in starting the wound vac could potentially contribute to worsening of Resident 4's PI.On June 7, 2026, at 6:09 p.m., during an interview, the Director of Nursing (DON) stated they usually have a wound vac available in house and if it was available, it should be placed right away. The DON stated for Resident 4, TN 1 should have called and followed up with the vendor providing the wound vac, if they still have not received the wound vac, they should have an alternative treatment of wet to dry dressing in place.5. On July 9, 2026, at 9:29 a.m., during a concurrent observation and interview, Resident 5 was in her room, lying on an air mattress, alert and awake, with a wound vacuum (wound vac - an advanced wound treatment that promotes healing through controlled suction) next to her. Resident 5 stated she is quadriplegic (a person affected by paralysis that impacts both arms and both legs, as well as the torso) and when she was transferred to the facility, she already had a wound on her bottom which worsened due to lack of care from the staff.A review of Resident 5's medical record indicated Resident 5 was initially admitted to the facility on [DATE], with diagnoses which included fracture of the neck and stage 4 (full thickness skin and tissue loss with exposed dermis, adipose, and various underlying structures) sacral PI.A review of Resident 5's Braden Scale dated April 23, 2026, indicated the resident is at moderate risk for developing PI.On June 9, 2026, at 11:32 a.m., during a concurrent interview and record review of Resident 5's medical record with TN 1, TN 1 stated the following:-Resident 5 was sent out to the general acute hospital (GACH) on April 13, 2026, because the resident's stage 4 coccyx PI developed a foul odor and increased in size. The treatment at the time was a wound vac with changes every Monday, Wednesday and Friday;-Resident 5 returned to the facility on April 23, 2026, with multiple PIs including stage 4 sacral PI which was being treated with wound vac and UTD right lateral malleolus (the bony prominence located on the outer side of the ankle) PI which was being treated with Santyl (prescription medicine that removes dead tissue from wounds);-On May 26, 2026, Resident 5's UTD right lateral malleolus PI was restaged to stage 3 PI and there were no changes in treatment order;-On June 9, 2026, the treatment order for the stage 3 right lateral malleolus was changed to medical grade honey (MGH); however, it was not applied due to delayed written notes from the WMD and lack of verbal communication; and-Resident 5 continued to receive Santyl on his stage 3 right lateral malleolus from May 12 to June 15, 2026.On July 9, 2026, at 5:10 p.m., during an interview, the Director of Nursing (DON) stated, for Resident 5, the orders given by the WMD should be implemented on the same day it was ordered; if the nurses are unsure of the orders, they can clarify the orders with the WMD.A review of the facility's policy and procedure titled Physician Orders dated November 16, 2022, indicated .The licensed nurse receiving the telephone/verbal order will transcribe the order in the resident medical record at the time the order is taken .A review of the facility's policy and procedure titled Skin Integrity Management dated July 31, 2024, indicated .Treatments to pressure injuries or other skin integrity conditions will be ordered by the physician .

Based on interview and record review, the facility failed to conduct and review planned quality improvement monitoring activities and audits to determine whether corrective actions were effective for the problems identified for pressure injuries (PI).This failure resulted in wound treatment orders recommended by the wound consultant (WMD) not being implemented in a timely manner, for five of six residents reviewed for PIs. (Cross refer F-686)Findings: A review of the facility document titled, QAPI (Quality Assurance and Performance Improvement) Plan dated [DATE], indicated the improvement plan required weekly wound reports, monitoring of implementation of wound treatment orders, and presentation of audit findings to the QAPI Committee for review and recommendations monthly for three months.A review of the facility's QAPI Meeting Minutes from January to May 2026 did not include any documentation of wound treatment audits, monitoring tools or evidence that audit findings were reviewed by the QAPI Committee to evaluate the effectiveness of corrective actions.On July 9, 2026, at 1:55 p.m., during an interview with the Director of Nursing and Administrator (ADM), the ADM stated the facility conducts QAPI meetings monthly and quarterly to discuss areas needing improvement and to assess if the facility is improving. The ADM stated wounds and skin integrity had been a focus since December 2025.On July 9, 2026, at 4:37 p.m. during an interview with the Regional Quality Management Consultant (RQMC), the RQMC stated the Treatment Nurse should review the audit tool, report her findings to the DON so that it can be present to the QAPI Committee for review and recommendations.A review of the facility's policy and procedure titled, Quality Assurance and Performance Improvement (QAPI) Program dated June 4, 2024, indicated the facility implements and maintains an ongoing, facility wide Quality Assurance and Performance Improvement (QAPI) Program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality of care and resolve identified issues .

Based on observation, interview, and record review, the facility failed to immediately respond to a Wander Guard alarm (A bracelet that triggers an alarm when the resident attempts to exit the facility - elopement) for one of three residents reviewed (Resident 1).This failure resulted in Resident 1's elopement from the facility. Resident 1 experienced a fall outside of the facility and was transported to the General Acute Care Hospital (GACH) for evaluation and treatment.Findings:On May 28, 2026, at 11:00 a.m., a concurrent observation and interview was conducted with Resident 1 who stated on May 22, 2026, he walked out of the facility. He stated Nobody was around .so I left . Resident 1 did not know what time he left the facility. Resident 1 stated after leaving the facility he fell and was taken to the hospital. Resident 1 was observed to have two scabs on his left knee, one scab on his right knee, and a small laceration (cut) on the left side of his forehead just above his eye, with three intact sutures. Resident 1 stated he was fine and was not in pain. Further observation indicated Resident 1 was wearing a Wander Guard on his left wrist.A review of Resident 1's Progress Notes, dated May 23, 2026, at 12:15 a.m., indicated, . After change of shift, during rounds CNA noticed patient (Resident 1) was not in bed. CNA reported to nurse. All staff in the building immediately went from room to room and outside looking for patient. PM (3-11 shift) nurse was called to see if patient was OOP (out on pass) or sent to the hospital. DON (Director of Nursing) was called and nurse was instructed to call 911 (emergency services) and report elopement. Nurse called 911, gave dispatcher patient name and was informed patient was found on the street at 2230 (10:30 pm) and taken to (name of GACH). Family was notified by DON.A review of Resident 1's, Resident Information, indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of Hemiplegia (partial or total paralysis) of his right side, with muscle weakness and unsteadiness on his feet.A review of Resident 1's, Brief Interview for Mental Status (A cognitive assessment), dated, March 19, 2026, indicated a score of four out of fifteen, severely cognitively impaired.A review of Resident 1's, Elopement Evaluation, dated, March 19, 2026, indicated resident had a history of wandering the facility, and elopement attempts prior to admission to the facility.A review of Resident 1's, Doctor's orders, dated May 5, 2026, at 9:56 a.m., indicated . Wander guard . to right wrist for safety/elopement risk .On May 28, 2026, at 1:55 p.m., an interview was conducted with CNA 1 who stated when the facility exit door alarms, the process is to immediately go to the door alarming and assess the situation; check inside and outside of the facility for the resident who may have triggered the alarm or exited the facility; alert all staff on the radio the exit alarm was going off; and check the facility to ensure all residents are present. CNA 1 stated on the night of May 22, 2026, at approximately 10:15 p.m., she was doing rounds on the residents when she heard the front door alarm. CNA 1 stated the alarm was on for approximately four to five minutes. CNA 1 stated she walked over to the front door and she didn't see any residents within the immediate area. She turned off the alarm, looked out the window, cracked open the front door, and she did not see any residents. CNA 1 verified she did not walk outside to make sure a resident didn't exit the facility unsupervised. CNA 1 further stated she did not see any staff around the area to ask about the alarm, she did not speak to other staff regarding the alarm, and she did not report the incident to any staff members or the charge nurse. CNA 1 further stated she should have walked outside and looked around the facility to check if a resident was present, and she should have reported the alarm to other staff members including the charge nurse. On May 28, 2026, at 2:50 p.m., an interview was conducted with the DON who stated when the exit door alarms go off staff are to check right away, and if they do not initially see a resident present in the area, staff should look outside of the facility to ensure a resident did not exit unattended. She expected staff to do a head count, of residents when the alarm is going off and there are no residents around.The DON stated on May 23, 2026, after she was notified Resident 1 was missing, she called the GACH and was informed Resident 1 had fallen and sustained a laceration to his left forehead, and skin scrapes to both knees. The DON stated she was informed Resident 1 was found and picked up by the police at 10:30 p.m., and arrived at the GACH at 10:50 p.m. (May 22, 2026).A review of Resident 1's Progress Notes, dated, March 23, 2026, at 8:56 a.m., indicated Resident 1 returned to the facility unable to give details of why he was out of the facility or at the hospital.

Based on interview and record review, the facility failed to provide copies of medical records within two business days after receiving the written request from the resident representative, for one of two residents reviewed, Resident 1.This failure is a violation of Resident 1 and the resident's representative's rights.Findings:A review of Resident 1's medical record indicated he was admitted to the facility on [DATE], with diagnoses which included cancer (growth of abnormal cells) of the intrahepatic bile duct (a part of the liver) and his family member (FM) was listed as the responsible party.On June 9, 2026, at 2:52 p.m., during an interview with the FM, she stated she has been requesting Resident 1's medical record from the facility. The FM stated she mailed a completed and signed release form to the facility on May 28, 2026, via certified mail. The FM stated the certified mail card receipt indicated that the facility received the mail on June 1, 2026.A review of the certified mail card receipt provided by the FM indicated that the facility received the mail on June 1, 2026.On June 11, 2026, at 12:46 p.m., during a concurrent interview, and record review of her e-mails and release form, the Medical Records Director (MRD) stated the residents, or their responsible parties need to complete a Resident Request for Access to Protected Health Information (release form) form when requesting for medical records. The MRD stated it typically takes two to three business days to produce and release medical records after receiving the completed release form. The MRD stated Resident 1's FM had been requesting medical records, but she had not received a release form. The MRD stated she emailed the FM the release form on May 26, 2026. The MRD stated she found the completed release form signed by the FM on May 28, 2026, on June 4, 2026, after the Administrator (ADM) told her he left something on her desk. The MRD stated she emailed the requested medical records to the FM on June 9, 2026 (six business days after June 1, 2026).On June 11, 2026, at 1:17 p.m., during an interview, the Receptionist stated they receive the mail and they put it on the mail slots. The Activity or Business Office Department would bring them to the addressee.On June 11, 2026, at 2:01 p.m., during an interview, the ADM stated, the facility mail sorting goes to the receptionists and activities department would give it to the patients; some mails are for him. The facility's policy for fulfilling medical records request is five days, after receiving the release forms from the residents or their power of attorney (POA). The ADM stated he does not recall receiving any mail from the FM. The ADM stated he assumed the mail from Resident 1's FM has been lost during the sorting process.On June 11, 2026, at 2:15 p.m., during a concurrent interview and record review of the facility's policy and procedure titled, Resident Access to PHI (Protected Health Information), with the ADM, the ADM stated that according to their policy, medical records request are provided within two working days.A review of the facility's policy and procedure titled, Resident Access to PHI (Protected Health Information), dated November 1, 2015, indicated .Time and Manner of Access .If the resident and/or their personal representatives requests a copy of the resident's medical record, the HIPAA Privacy Officer will provide the resident or their personal representative with a copy of the medical record within two (2) working days after receiving the written request .

Based on observation, interview, and record review, the facility failed to maintain the kitchen environment in a clean and sanitary condition when:1. The kitchen sink and underneath the preparation counter were found to have black residue, dark build up, and areas of flaking and rusty-brown discoloration.2. The underside and bottom portion of the kitchen sink were coated with stains and spots of scattered yellow and brown food debris. 3. The kitchen sink's white funnel-shaped drainpipe contained debris, rust, and old food residue. These failures had the potential to expose residents to contaminants and increased the risk of food-borne illnesses.Findings:1. During an initial observation tour of the kitchen and interview on 5/4/26 at 7:52 AM with the Dietary Manager (DM), the area underneath the kitchen sink and preparation counter were found covered with dark residue and rust. The DM confirmed the presence of the black residue, dark build up, and areas of flaking and rusty-brown discoloration under the kitchen sink area.2. During a concurrent observation and interview on 5/4/26 at 7:52 AM with the DM, the underside and bottom portion of the kitchen sink were observed coated with stains and spots of scattered yellow and brown food debris and the kitchen sink's white funnel-shaped drainpipe contained debris, rust and old food residue. The DM confirmed that the bottom part and drainpipe of the kitchen sink were coated with stains and spots of scattered food debris and residue and acknowledged that the sink required cleaning.The following facility kitchen logs were reviewed: CNRC Weekly Deep Cleaning Chart for April Week 4 Food and Nutrition: Cleaning Log AM Cook, dated 4/6/26-4/12/26 Food and Nutrition: Cleaning Log PM Cook, dated 4/27/26-5/3/26 Cook's Cleaning Log, dated 4/20/26-4/25/26 Dishwasher/Dietary Aide Cleaning Log, 4/27/26 - 5/3/26The above logs did not include the area underneath the kitchen sink and preparation counter was cleaned daily.During a concurrent interview and record review on 5/5/26 at 4:28 PM with Registered Dietitian (RD), the facility's Policy & Procedure (P&P) titled, Cleaning Schedule with date of revision October 1, 2014, was reviewed. The P&P indicated, The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the Dietary Manager . The RD acknowledged that kitchen sink area required cleaning and replacement.During an interview on 5/6/26 at 7:19 AM with the DM, the findings underneath the kitchen sink and preparation area were verified. The DM acknowledged that the area required cleaning and replacement and affirmed responsibility for addressing these findings.

Based on interview and record review, the facility failed to ensure its Payroll Based Journal (a mandated reporting system used by the Centers for Medicare & Medicaid Services (CMS) to collect auditable, employee-level staffing data from long-term care facilities) was submitted for the first fiscal year quarter.This deficient practice resulted in the facility's failure to provide required information regarding staffing levels necessary to ensure the provision of safe and comprehensive care for all residents in accordance with federal regulations.Findings:During a review of the facility's PBJ Staffing Data Report for Fiscal Year Quarter 1, dated 4/26/26, the PBJ report indicated the facility failed to submit data for the fiscal year (FY) quarter 1 2026 (October 1-December 31). During an concurrent interview and record review, on 5/6/26 at 10:29 AM, with the Clinical Project Director (CPD), the CPD stated the PBJ staffing data submitted reflected a submission for quarter 2. The CPD stated the facility's CMS Submission Report dated 2/13/26 indicated, Fiscal Quarter 2 was reflected.During a record review of the State Operations Manual (SOM), dated 7/23/2025, the SOM indicates the facility is responsible for submitting staffing data through the CMS Payroll-Based Journal (PBJ) system. The facility's failure to submit PBJ data, as required, will be reflected on their CASPER report and result in a deficiency citation.

Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for three of five sampled residents (Resident 17, 1, and 39) when:Resident 17's respiratory bag was mislabeled, and respiratory supplies were not labeled changed as ordered.Resident 1's nasal cannula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not changed as ordered.Resident 39's respiratory supplies were unlabeled and kept in Resident 39's bedside for several days after the treatment was completed.Findings:1. A review of Resident 17's Face Sheet, (front page of the chart that contains a summary of basic information about the resident) dated 5/7/26, indicated Resident 17 was readmitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary ([COPD] - a progressive lung disease which blocks air flow making breathing difficult), and shortness of breath.A review of Resident 17's Order Summary Report, dated 5/7/26, indicated, Resident 17 had the following physician's orders dated:5/15/25 to Change nebulizer mask/tubing every Sunday Noc (night) shift or AS NEEDED every night shift every Sun (Sunday)10/31/25 for Albuterol Sulfate Inhalation Solution (a liquid medication turned into fine mist for inhalation used to open the airways) (2.5 MG [milligram] - metric unit of measurement, used for medication dosage and/or amount)/3 ML ([milliliter] - metric unit of measurement for volume of a liquid) 3 milliliter inhale orally via nebulizer every 6 hours as needed for SOB (Shortness of Breath)During a concurrent observation and interview on 5/4/26 at 10:24 AM, with the Licensed Vocational Nurse (LVN) 2, by Resident 17's doorway, LVN 2 removed the respiratory bag from Resident 17's bedside and stated he was asked to replace it. An inspection of the respiratory bag and label was conducted with LVN 2. The respiratory bag found at Resident 17's bedside indicated Name: [Name of Resident 1].Room: [Resident 1's room and bed number].Time: 6 AM.Date Issued: 3/30. LVN 2 confirmed that the respiratory bag contained a nebulizer tubing (flexible, hollow plastic tube that connects air compressor machine to the medication cup) that was not labeled with a date and the nebulizer mouthpiece (accessory part that delivers medication directly into the lungs through the mouth) had a date of 3/30. LVN 2 stated that the facility's expectation and practice was to change it every week and as needed. LVN 2 also stated that these should have been changed as bacteria can grow on it.During a concurrent observation and interview on 5/4/26 at 10:33 AM, in Resident 17's room, Resident 17 was alert, verbally responsive, and lying on his bed. Resident 17 was receiving oxygen via NC attached to an oxygen concentrator at a rate of 2 LPM (Liters Per Minute- unit of measure or dose). Resident 17 also stated that he received breathing treatments when needed.During a subsequent observation on 5/4/26 at 10:36 AM, LVN 2 placed a new respiratory bag with respiratory supplies at Resident 17's bedside.During a concurrent observation and interview on 5/4/26 at 12:20 PM with LVN 2, at Resident 17's bedside, the newly replaced respiratory bag containing respiratory supplies was inspected. The respiratory bag found at Resident 17's bedside had a new label which indicated, Name: [Name of Resident 1] .Date Issued: 5/4/26. LVN 2 acknowledged that the newly replaced respiratory bag containing respiratory supplies had the incorrect information and was labeled for Resident 1, instead of Resident 17. LVN 2 also stated he should have asked and verified Resident 17's name before replacing the respiratory bag to ensure the new respiratory bag and supplies would be labeled to the correct resident for use. 2. A review of Resident 1's Face Sheet, dated 5/7/26, indicated Resident 1 was readmitted to the facility on [DATE], with diagnoses that included COPD and pneumonia ([PNA]- an infection/inflammation in the lungs).A review of Resident 1's Order Summary Report, dated 5/7/26, indicated, Resident 1 had the following physician's orders dated:12/7/25 to Change O2 (oxygen) Tubing every night shift every Sun (Sunday)2/6/26 for Oxygen at 2 L (Liters)/min Via NC to keep O2 Sat (O2 Saturation - a measurement of how much oxygen the blood is carrying as a percentage) at/above 92% every shift for COPD.During a concurrent observation and interview on 5/4/26 at 10:38 AM, with Resident 1, Resident 1 wheeled himself out of his room and stated he was late for activities. A NC dated 4/24/26 was observed on top of Resident 1's bed.During a concurrent observation and interview on 5/4/26 at 10:40 AM, with LVN 2, LVN 2 acknowledged that the label on the NC on top of Resident 1's bed was dated 4/24/26.3. A review of Resident 39's Face Sheet, dated 5/5/26, indicated Resident 39 was admitted to the facility on [DATE].A review of Resident 39's Physician's Order, dated 5/5/26, indicated, Resident 39 had the following telephone order dated for: 4/24/2026 for Ipratropium-Albuterol Solution (a liquid medication turned into fine mist for inhalation used to open the airways) 0.5-2.5 (3) MG/3 ML 1 vial inhale orally every 6 hours for PNA for 5 days.A review of Resident 39's Medication Administration Record, ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated from April 1, 2026 -April 30, 2026, indicated, Resident 39 received the last dose of Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML 1 vial inhale orally every 6 hours for PNA on 4/29/26 at 6:00 AM.During an observation on 5/4/26 at 9:35 AM, inside Resident 39's room, Resident 39 was alert, verbally responsive, and wore a neck brace while lying on his bed. The nebulizer tubing and mouthpiece did not have a dated label and was left on top of the nebulizer machine at the bedside. The respiratory bag was dated 4/26/26.During a concurrent observation and interview on 5/4/26 at 9:53 AM, with LVN 8, LVN 8 acknowledged these findings and stated that Resident 39 had completed the ordered respiratory treatments. LVN 8 also stated that the nebulizer tubing and mouthpiece should have been labeled with a date and the respiratory supplies should have been removed from the resident's bedside after the last treatment was given on 4/29/26.During an interview on 5/5/26 at 1:01 PM, with the Registered Nurse Supervisor (RNS) 1, RNS 1 stated that staff were expected to keep respiratory supplies inside the respiratory bag when not in use. RNS 1 stated that these respiratory supplies such as NC, nebulizer tubing, and nebulizer mouthpiece should be labeled with a date and changed every week. RNS 1 verified that it was not acceptable for these supplies to be unlabeled and not changed as ordered by the physician. RNS 1 also stated that staff were expected to check and verify the resident's identity before labeling and placing the respiratory supplies at the resident's bedside. RNS 1 stated these actions were nursing standard of practice and for infection control purposes.During an interview on 5/6/26 at 1:01 PM, with the Infection Preventionist (IP), the IP stated staff were expected to remove these respiratory supplies and equipment from resident's bedside after the treatment had been completed. The IP also stated when these supplies were left and not changed as ordered by the physician, these had the potential for transmission of infections.A review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, with an effective date of 10/31/2025, indicated, POLICY: 1. Oxygen is administered under safe and sanitary conditions to meet resident needs. 2. Oxygen will be initiated with a provider order.II. Oxygen- Maintenance, and Safety A. Oxygen equipment shall be maintained as follows: 1. The tubing and mask should be changed at least every 7 days and labeled with the date of change.A review of the facility's policy and procedure (P&P) titled, Nebulizer (small volume), revised10/15/20, indicated, Procedure: I. Equipment A. Nebulizer machine.C. Physician ordered medication. D. Aerosol mask/mouthpiece.III. Assemble the necessary equipment needed for therapy. If new, label the set-up bag with Resident's name and date.XV. Place the nebulizer back into the Resident's set-up bag and leave the equipment at the bedside for further treatments. The small volume nebulizer set up, and filter will be changed every seven days and as needed.

Based on observation, interview, and record review, the facility failed to ensure medications were stored properly and securely when a medication cart (Medication Cart 3) was left unlocked and not under direct observation by authorized staff.This had the potential to allow unauthorized access to medications and supplies which could cause undetected misuse, diversion (distribution, abuse, or use of drugs for purposes not intended by the prescriber), and unsafe use of medications. Findings:During an initial tour observation on 5/4/26, at 12:28 PM, in the facility hallway in front of room [ROOM NUMBER], Medication Cart 3's lock was not pushed in and was left unlocked and unattended. Staff and residents passed by the unlocked medication cart.During a concurrent observation and interview with the Licensed Vocational Nurse 4 (LVN 4), on 5/4/26, at 12:32 PM, LVN 4 acknowledged she was assigned to Medication Cart 3 and the medication cart was left unlocked and unattended. LVN 4 also stated that medication carts should be kept locked when unattended to prevent residents and other people from having access to medications.During an interview with LVN 5, on 5/5/26, at 12:02 PM, LVN 5 stated that Medication Cart 3 contained medications including narcotic drugs (a type of medication, specifically painkillers that is heavily regulated by the Federal Government and considered a controlled substance due to high addiction potential) and medical supplies for the residents of Rooms 24-35.During an interview with Registered Nurse Supervisor (RNS) 1 on 5/5/26, at 12:09 PM, RNS 1 stated the medication carts were to be kept organized and locked when not supervised. RNS 1 added that the importance of locking the medication cart when unattended was to prevent unauthorized access of medications from residents, staff, and visitors.During a concurrent interview and record review on 5/5/26 at 12:45 PM, with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY, revised February 2020, the DON stated that it was her expectations from the staff to keep the medication cart locked at all times when staff were away from the cart. The DON also stated that this was important to prevent unauthorized access to residents' medications. The DON stated the facility's policy and procedure was not followed.A review of the facility's policy and procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY, revised February 2020, indicated, STORAGE OF MEDICATIONS Policy: Medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel, pharmacist, or Pharmacy Nursing personnel. Procedures: . B. Only licensed nurses, pharmacist, medications are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access .

Based on observation, interview, and record review, the facility failed to ensure care was provided in a dignified manner for one of 17 sampled residents (Resident 12) when a Certified Nursing Assistant (CNA) 1 fed Resident 12 while standing and not at eye level.This failure had the potential to have a negative impact on Resident 12's psychosocial well-being during dining. Findings: A review of Resident 12's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 5/7/26, indicated the resident was admitted to the facility on [DATE]. A review of Resident 12's Minimum Data Set ([MDS] a federally mandated standardized assessment tool) dated 2/19/26 indicated Resident 12 required, partial/moderate assistance for eating. During an observation on 5/4/26 at 1:10 PM, in Resident 12's room, Resident 12 was seated in a wheelchair, while CNA 1 stood over Resident 12 and fed Resident 12 lunch. CNA 1 fed Resident 12 with a spoon and remained standing, above Resident 12's eye level throughout the interactionDuring an interview with CNA 1 on 5/4/26 at 1:10 PM, CNA 1 stated she preferred to stand while feeding and assisting Resident 12's with meals.During an interview with CNA 2 on 5/7/26 at 9:50 AM, CNA 2 stated staff should establish eye contact and sit at the residents' eye level while feeding to convey respect and ensure residents feel valued. CNA 2 further stated that these practices were covered during orientation and in-service training.During an interview with the Director of Staff Development (DSD) on 5/7/26 at 10:30 AM, the DSD stated staff received in- services regarding feeding residents at eye level and in a sitting position. Feeding residents while standing was discouraged to demonstrate respect and promote resident comfort. DSD further stated that CNA 1 should have fed the resident while seated.A review of the facility's policy and procedure (P&P) titled, Resident Rights - Quality of Life, revised March 2017 indicated, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person centered manner as well as those that support the resident in attaining or maintaining his or her highest practicable well-being.

Based on interview and record review, the facility failed to ensure an informed consent (a process providing the resident and/or resident representative information regarding risks, benefits, and potential side effects [unintended or adverse reactions caused by a medication] of treatment before agreement for treatment) was obtained prior to the administration of an increased dose of a psychotropic (medications affecting brain activities associated with mental processes and behaviors) medication for one of five sampled residents (Resident 16) reviewed for unnecessary medications.This failure had the potential for residents and/or resident representatives not fully informed regarding medication risks, benefits, and potential side effects before the resident received an increased dose of a psychotropic medication. Findings:A review of Resident 16's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 5/7/26, indicated Resident 17 was readmitted to the facility on [DATE], with diagnoses including depression.A review of Resident 16's physician orders indicated the resident had been receiving sertraline (medication used to treat depression), in various doses, for depression manifested by verbalization of sadness and hopelessness.A review of Resident 16's physician orders indicated the following physician's orders dated:- On 9/5/25, Sertraline (a prescription medication used to treat depression, anxiety, and other mood disorders by increasing serotonin [a chemical in the brain that controls mood]) 25 mg (milligram - unit of measurement), with a direction to give one tablet by mouth one time a day for depression 'm/b (manifested by) verbalization of fe (feeling) hopeless,' discontinued.- On 9/5/25, Sertraline dose increased to 100 mg with a direction to give one tablet by mouth one time a day for depression m/b verbalization, 'I feel depressed.'- On 3/23/26, Sertraline 100 mg with a direction to give one tablet by mouth one time a day for 'depression manifested by verbalization being depressed,' discontinued.- On 3/23/26, Sertraline dose decreased to 50 mg with a direction to give one tablet by mouth one time for depression manifested by verbalization of feeling depressed.A review of Resident 16's Medication Administration Record, ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated from 9/25 through 3/26, indicated Resident 16 received sertraline 100 mg daily from 9/6/25 to 3/23/26.A review of Resident 16's Care Plan Report, (an individualized outline of specific care, interventions, and goals for a resident/patient) dated 1/8/25, indicated an Intervention for the use of an antidepressant medication was to .Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of Sertraline.During a concurrent interview and record review on 5/6/26 at 3:01 PM, with the Medical Record Director (MRD), the MRD reviewed Resident 16's medical record and stated the informed consent for Sertraline 100mg initiated on 9/5/25 could not be found.During a follow-up interview on 5/7/26 at 7:56 AM, with MRD, the MRD confirmed there was no informed consent for increased dose of Sertraline 100 mg initiated on 9/5/25 for Resident 16.During a concurrent interview and record review on 5/7/26 8:17 AM, with the Director of Nursing (DON), the DON stated the informed consent should have been obtained before the administration of the increased dose of Sertraline 100 mg, after the information regarding medication risks, benefits, and potential side effects to the resident and/or resident representative was provided.A review of the facility's policy and procedures (P&P) titled, NP67 Informed Consent, revised 12/21/2023, indicated: .Except in emergencies, informed consent must be obtained prior to the proposed treatment or procedure. Where possible, consent should be obtained sufficiently in advance to allow the resident or their surrogate decision-maker time to consider and make an informed decision.A review of the facility's P&P titled, P-NP67 Informed Consent, dated 1/30/2026, indicated, .D. The informed consent will be placed in the resident's medical record.A review of the facility's P&P titled, P-NP106 Behavior/Psychoactive Medication Management, dated 1/30/2026, indicated: .Facility must obtain a resident's written informed consent for treatment using psychoactive drugs.

Based on interview and record review, the facility failed to ensure timely completion of the comprehensive admission Minimum Data Set ([MDS] - a federally mandated resident assessment tool) assessments for one of 17 sampled residents (Resident 76).This deficient practice had the potential to delay the care planning process to meet Resident 76's comprehensive and individualized care needs.Findings:A review of Resident 76's Face Sheet, (front page of the chart that contains a summary of basic information about the resident) dated 5/6/26, indicated Resident 76 was readmitted to the facility on [DATE], with diagnoses that included encounter for palliative care (specialized medical care focused on providing relief from pain, and stress from serious illness), chronic obstructive pulmonary ([COPD] - a progressive lung disease which blocks air flow making breathing difficult) , and immunodeficiency (a state in which a person's ability to fight infections is compromised or entirely absent).A review of Resident 76's Comprehensive admission MDS Assessment, with an Assessment Reference Date ([ARD] - a specific date that serves as the end point of the look back or observation period for capturing a resident's clinical condition) of 4/11/26, indicated, Section (Sec.) A1600 [Entry Date]: 3/30/36. Sec. B (Hearing, Speech and Vision), Sec. GG (Functional Abilities), Sec. H (Bladder and Bowel), Sec. J (Health Conditions), Sec. K (Swallowing/Nutrition Status), Sec. L- (Oral/Dental Status), Sec. M (Skin Conditions), Sec. N (Medications), Sec. O ( Special Treatments, Procedures, and Programs), Sec. V. (Care Area Assessment Summary, Sec. Z0500 A (Signature of [Registered Nurse] RN Assessment Coordinator Verifying Assessment Completion and Sec. Z0500B (Date RN Assessment Coordinator signed assessment as complete) were all left blank.During a concurrent interview and record review on 5/6/26 at 1:33 PM with the MDS Coordinator (MDS-C), the MDS-C reviewed Resident 76's Comprehensive admission MDS Assessment, with an ARD of 4/11/26 via PCC (PointClickCare- cloud-based electronic health record). The MDS-C stated that the assessment was not completed yet. The MDS-C also stated Resident 76's Comprehensive admission MDS Assessment should have been completed within 14 days of admission and should have been completed on 4/12/26 (24 days overdue). The MDS-C stated this was not acceptable because there will be no baseline assessment of the resident that was needed to develop comprehensive and individualized care plan for the resident.During an interview on 5/6/26 at 2:01 PM with the Director of Nursing (DON), the DON stated the MDS must be completed in a timely manner to avoid delays in the development of the residents' care plans.The Centers for Medicare & Medicaid Services (CMS)'s Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, indicated Chapter 5: Submission and Correction of the MDS Assessments.5.2 Timeliness Criteria. Completion Timing: .For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days, after the Entry Date (A1600).

Based on observation, interview, and record review, the facility failed to provide the necessary nail care services and personal hygiene for one of two sampled residents (Resident 97) by failing to ensure Resident 97's fingernails were cleaned and trimmed.This failure resulted in Resident 97 having overgrown and untrimmed fingernails, which placed Resident 97 at risk for discomfort, impaired hygiene, skin breakdown and infection.Findings:During an initial tour observation and interview on 5/4/26 at 9:12 AM, inside Resident 97's room, Resident 97 was awake, verbally responsive, and lying in bed. Resident 97's fingernails on both hands were extending beyond the fingertip. There was a build-up of yellow substance at the base of the fingernails, and the fingernail tips had black residue underneath. Resident 97 stated he wanted his fingernails cleaned and trimmed but no one had done it since he was admitted .A review of Resident 97's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 5/6/26, indicated the resident was admitted to the facility on [DATE].During a concurrent observation and interview on 5/5/26 at 4:35 PM, inside Resident 97's room with Licensed Vocational Nurse 3 (LVN 3), LVN 3 acknowledged Resident 97's fingernails on both hands were long and had dirt underneath. LVN 3 also stated it needed to be cleaned and trimmed for it may cause skin tears and infections.During a subsequent observation and interview on 5/5/26 at 4:46 PM, inside Resident 97's room with Director of Staff Development (DSD), the DSD acknowledged that Resident 97's fingernails on both hands were long and had black residues underneath. DSD stated it had to be cleaned and trimmed. The DSD also stated that the Certified Nursing Assistants (CNA) were primarily responsible for cleaning and trimming the fingernails and the licensed nurses were responsible for the oversight to ensure residents were well groomed.A review of Resident 97's Care Plan Report, initiated on 4/28/26, indicated, Focus: The resident has potential impairment to skin integrity related to (r/t) fragile skin and immobility.Goal: The resident will maintain or develop clean and intact skin.Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short .A review of the facility's CNA's Job Description, undated indicated, .GENERAL DUTIES AND RESPONSIBILITIES.Provide assigned personal hygiene care in accordance with facility procedures, including.nail care.to maintain resident cleanliness, dignity, and comfort.A review of the facility's LVN's Staff Nurse Job Description, undated indicated, .General Duties and Responsibilities.CLINICAL.Conducts daily resident rounds to observe the resident's physical and emotional status. Supervise CNAs. SUPERVISION.Make resident rounds to ensure appropriate care is being rendered, identifying, and making corrections as necessary.A review of the facility's policy and procedure (P&P) titled, Grooming, revised on 1/1/12, indicated, .Policy: The facility will work with residents to improve their ability to groom him/herself to promote independence, hygiene, comfort, self-esteem, and dignity.Procedure: IV. F. Nail Care.ii. Many residents find soaking to be soothing but the main advantage of soaking is softening and loosening of dirt particles lodged under the nails. Iii. A nailbrush can be used to gently remove any remaining dirty particles under the nails.

Based on observation, interview, and record review, the facility failed to ensure needed treatment and services were provided to maintain range of motion (ROM- full movement potential of a joint) for one of three sampled residents (Resident 4) when Resident 4's Restorative Nursing Program (a nursing-driven service in long-term care settings that helps residents maintain or improve their functional abilities to their highest possible level) orders were not followed and in accordance with Resident 4's plan of care.These failures had the potential to cause further decline in functional mobility, ROM, and quality of life for Resident 4.Findings:During an initial tour observation on 5/4/26 at 3:47 PM, inside Resident 4's room, Resident 4 was awake, verbally responsive, and lying in bed. Resident 4 had a left arm sling and was observed with limited movement in the arms and legs.A review of Resident 4's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 5/7/26, indicated the resident was readmitted to the facility on [DATE] with diagnosis that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke- loss of blood flow to a part of the brain) affecting left non-dominant side, muscle weakness, and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion).A review of Resident 4's Minimum Data Set, ([MDS] a federally mandated resident assessment tool) with an Assessment Reference Date ([ARD] a specific date that serves as the end point of the look back or observation period for capturing a resident's clinical condition) of 2/16/26, indicated, R4's Brief Interview for Mental Status (BIMS) score was 7 (severely impaired). The MDS assessment also indicated that Resident 4 was dependent on eating, toileting hygiene, and personal hygiene.A review of Resident 4's Order Summary Report, dated 5/7/26, indicated, Resident 4 had the following order: RNA (Restorative Nursing Assistant) services for RUE AAROM (Right Upper Extremity [limb] Assisted Active Range of Motion) exercises, frequency QD (Daily) 3x/wk (three times per week), or as tolerated and as needed order date: 3/30/2026 .A review of Resident 4's Documentation Survey Report, (legal document used to track RNA services provided) dated 4/1/26 to 5/7/26, indicated RNA services for RUE AAROM exercises, frequency QD 3x/wk or as tolerated and as needed. However, there were no documented evidence indicating these services were provided on 4/2/26, 4/7/26, 4/9/26, 4/14/26, and 4/18/26, as the boxes in the Documentation Survey Report were left blank.During an interview on 5/7/26 at 9:58 AM, with the RNA, the RNA stated that Resident 4 is on an RNA program. The RNA also stated that RNAs were expected to document the services provided to Resident 4 via PCC (PointClickCare- cloud-based electronic health record) right after the treatment was given.During a concurrent interview and record review on 5/7/26 at 10:18 AM, with the RNA, the RNA reviewed Resident 4's Documentation Survey Report dated 4/1/26 to 5/7/26. The RNA stated that RNA services were usually done on Tuesdays, Thursdays, and Saturdays. RNA also stated that the blank boxes in Resident 4's Documentation Survey Report, on 4/2/26, 4/7/26, 4/9/26, 4/14/26, and 4/18/26 indicated that the treatment was not provided.During a concurrent interview and record review on 5/7/26 at 10:27 AM, with the Registered Nurse Supervisor (RNS) 1, RNS 1 reviewed Resident 4's Documentation Survey Report dated 4/1/26 to 5/7/26. RNS 1stated that it was her expectations for staff to follow doctor's orders and document after the services were provided because if it was not documented, it meant it was not done.A review of Resident 4's Care Plan Report, undated, indicated Resident has self-care performance deficit r/t (related to) LEFT SHOULDER, HAND AND ELBOW CONTRACTURES AND BILATERAL ANKLES.Goal: The resident will maintain current level of function.Interventions. RUE AAROM exercises, frequency QD 3x/wk or as tolerated and as needed.During a concurrent interview and record review on 5/7/26 at 2:55 PM, with the Director of Nursing (DON), the DON reviewed Resident 4's Documentation Survey Report dated 4/1/26 to 5/7/26. The DON acknowledged that RNA services for RUE AAROM exercises, frequency QD 3x/wk or as tolerated and as needed on 4/2/26, 4/7/26, 4/9/26, 4/14/26, and 4/18/26, were left blank. The DON stated that there was no documented evidence that these services were rendered to Resident 4 on those dates. The DON also stated that it was her expectations for staff to follow the doctor's order. The DON stated Resident 4's plan of care and the facility's policy and procedure were not followed.A review of the facility's P&P titled RESTORATIVE NURSING PROGRAM GUIDELINES, effective January 30, 2026, indicated I. Implementation of a restorative nursing program.B. Frequency of the RNA program will be determined by the medical necessity and Provider order.V. The RNA carries out the restorative program according to the Care Plan. VI. The RNA documents the amount of time the Resident spent in the activity and their tolerance to the program.

Based on interview and record review, the facility failed to ensure accurate accountability of controlled substances (CS - medications with high potential for abuse and addiction) for two of six randomly selected residents (Residents 45 and 51) who were reviewed for controlled substance accountability when:Resident 45's Tramadol (an opioid medication used to treat moderate to moderately severe pain) Individual Narcotic Record (inventory records used to document receipt, use, and count of controlled substances [medications with potential for abuse and dependence]) did not match the Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).Resident 51's Percocet (an opioid medication used to treat severe pain) Individual Narcotic Record did not match the MAR.These failures resulted in an inaccurate accountability of controlled substances and had the potential for diversion (controlled substances used by someone other than the resident for whom the medication was prescribed), or misuse of controlled substances and compromised residents' medication therapy and safety.Findings:1. During a concurrent interview, record review, and inspection of Medication Cart 2A on 5/5/26 at 10:13 AM, with Licensed Vocational Nurse (LVN), the following facility items and records were reviewed:Resident 45's Blister Card (a type of medicine packaging where individual doses of medication are sealed in small, clear plastic bubbles (blisters) and attached to a rigid card or foil backing) for Tramadol 50 mg (milligram - unit of measurement) was inspected with LVN 7. Resident 45's physician's telephone order, dated 3/21/26, indicated an order for Tramadol 50 mg, give 1 tablet by mouth every 6 hours as needed for severe excruciating pain (scale: 8-10 [pain scale]).Resident 45's Individual Narcotic Record dated from 3/16/26 - 5/4/26 indicated, Tramadol 50 mg one tablet was removed from the blister card and signed out by a licensed staff on 4/6/26 at 0500 (5:00 AM) and 5/2/26 at 0900 (9:00 AM).Review of Resident 45's MAR, for April 2026 through May 2026, indicated there was no corresponding documentation of administration and pain assessments on the Resident 45's MAR. LVN 7 confirmed the above findings and stated there were discrepancies between Resident 45's Individual Narcotic Record dated 3/16/26-5/4/26 and Resident 45's MAR dated April 2026 through May 2026. LVN 7 confirmed and verified Resident 45's records did not match.2. During a concurrent interview, record review, and inspection of Medication Cart 3 on 5/5/26 at 11:13 AM, with LVN 5, the following facility items and records were reviewed:Resident 51's Blister Card, for Percocet 10/325 mg (brand name medication containing oxycodone [narcotic medication] and acetaminophen used for pain) was inspected with LVN 5.Resident 51's Physician's Telephone Order, dated 3/16/26, indicated an order for, Percocet 10-325mg (oxycodone with acetaminophen), 'give 1 tablet by mouth every 4 hours as needed for severe-excruciating pain' (scale: 8-10).Resident 51's Individual Narcotic Record dated from 4/26/26 - 5/5/26 indicated, Percocet 10/325 mg one tablet was removed from Resident 51's Blister Card and signed out by a licensed staff on 4/26/26 at 1330 (1:30 PM), 4/29/26 at 0700 (7:00 AM), 1400 (2:00 PM) and at 2050 (8:50 PM).Review of Resident 51's MAR, for April 2026 indicated there was no documentation of Resident 51 received Percocet 10/325 mg on the following dates and times:4/26/26 at 1:30 PM4/29/26 at 7:00 AM and 8:50 PM LVN 5 confirmed the above findings and stated staff should have documented the administration of Resident 51's Percocet 10/325 mg one tablet in Resident 51's MAR at the time the medication was signed out of Resident 51's Individual Narcotic Record.During a concurrent interview and record review on 5/5/26 at 11:50 AM, with the Director of Nursing (DON), the DON confirmed discrepancies between the Individual Narcotic Records and the MARs for Resident 45 and 51. The DON stated the nursing staff were expected to document in the resident's Individual Narcotic Record and MAR when the controlled medication is removed and administered to the resident.A review of the facility's policy and procedures (P&P) titled, Medication - Administration, dated 8/19/25, indicated: .The Licensed Nurse will .Right documentation: Immediately document after administration .Documentation: The time and dose of the medication or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the medication or treatment .A review of the facility's P&P titled, Medication Storage in the Facility - ID2: Controlled Substance Storage, dated June 2016, indicated: .Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and Form 12: INDIVIDUAL RESIDENT'S CONTROLLED SUBSTANCE RECORD .

Based on observation, interview, and record review, the facility failed to adequately monitor one of 17 sampled residents (Resident 34) for side effects (secondary, often predictable, unintended effects of a medication that can be beneficial, neutral, or harmful) and adverse drug reactions (strictly unintended, harmful, and unexpected reaction of a medication, usually requiring intervention) for the use an anticoagulant (medication that thins the blood to prevent blood clots) medication per facility's policy.This failure had the potential to result in adverse outcomes, including bleeding complications, bruising, hemorrhage, hospitalization, or other medication related complications associated with anticoagulant use.Findings:During an initial tour observation on 5/4/26, at 3:45 PM, inside resident's room, Resident 34 was lying in bed, awake, and watching TV.A review of Resident 34's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 5/7/26, indicated Resident 34 was admitted to the facility on [DATE].A review of Resident 34's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated April 2026, indicated Resident 34 was on Heparin Sodium (Porcine) Solution 5000 unit/ml. Inject 1 ml subcutaneously (SQ- between the skin and muscle) two times a day for Deep Vein Thrombosis (DVT is a serious medical condition where a blood clot (thrombus) forms in a deep vein, most commonly in the legs or pelvis) prophylaxis (a medical term for preventive care) with a start date of 4/18/26.Further review of Resident 34's MAR dated May 2026 indicated Resident 34 was administered Heparin from 5/1/26-5/7/26.During a concurrent interview and record review with the Registered Nurse Supervisor (RNS) 1 on 5/7/26, at 9:14 AM, RNS 1 reviewed Resident 34's MAR for the months of April and May 2026. RNS 1 stated that there was no documented evidence in the MAR monitoring for adverse reactions that was completed for Resident 34 for the use of Heparin. RNS 1 also stated when a resident is on Heparin, the resident should be monitored for bruising, bleeding and side and adverse effects of the medication.A review of the facility's policy and procedure (P&P) titled, Adverse Drug Reactions, dated 8/19/25 indicated, The facility will monitor, promptly identify, document, report, and appropriately address adverse drug reactions in accordance with federal and state laws and facility policy and procedures.Adverse Drug Reaction (ADR): An unintended and harmful reaction resulting from the use of medication at normal doses for prophylaxis.1. Identification of Adverse Drug Reaction (ADR).a. Nursing staff shall observe for any changes in condition that may be associated with medications, including but not limited to: .v. Bleeding. 2. Evaluation a. The licensed nurse must evaluate the resident, document findings in the medical record and notify the physician. 3. Documentation a. Document the following in the medical record: i. Description of the reaction.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders when a medication error rate of 8% was identified, with two medication errors out of 25 medication administration opportunities, during medication administration observations for one of four residents observed (Resident 39).These failures included the administration of an incorrect dose and an incorrect dosage form of medications, which had the potential to compromise the resident's medication therapy and safety.Findings:During a medication administration observation for Resident 39 on 5/4/26 at 8:58 AM, Licensed Vocational Nurse (LVN) 4 prepared and administered 17 medications, including two tablets of Senna (medication used to treat constipation) 8.6 mg (milligram - unit of measurement) and one tablet of OxyContin CR (controlled-release narcotic pain medication designed to release slowly over time) 10 mg.A review of Resident 39's Physician's Orders indicated the following physician's orders dated: 4/6/26, Senna Oral Tablet (Sennosides [active ingredient in senna used to treat constipation]), give 8.6 mg by mouth one time a day for constipation. 4/15/26, Oxycodone (a medication used to manage severe pain that requires round-the-clock, long-term treatment) HCl (hydrochloride - chemical salt form of medication) Tablet 10 mg (oxycodone HCl), give 1 tablet by mouth two times a day for pain management.During a concurrent interview and record review on 5/4/26 at 11:49 AM, with LVN 4, LVN 4 confirmed the Resident 39's Physician's Order, for Senna indicated one tablet, but LVN 4 administered two tablets. LVN 4 stated she should have administered one tablet of Senna per the physician's order. LVN 4 also confirmed the Resident 39's Blister Card, (a type of medicine packaging where individual doses of medication are sealed in small, clear plastic bubbles (blisters) and attached to a rigid card or foil backing) label and Individual Narcotic Record (inventory records used to document receipt, use, and count of controlled substances [medications with potential for abuse and dependence]) dated 4/15/26-4/20/26, indicated OxyContin CR 10 mg ER 12hrs, while the Physician's Order, indicated, Oxycodone 10mg tablet. LVN 4 stated ER meant extended release but stated she did not know the meaning of CR and needed to look up the meaning.During a record review on 5/5/26 at 9:38 AM, Resident 39's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 4/1/26-4/30/26 and 5/1/26-5/31/26, indicated staff documented the administration of oxycodone 10 mg twice daily from 4/15/26 through 5/4/26. Concurrent review of the Individual Narcotic Records dated 4/15/26-4/20/26 and pharmacy Packing Slips (delivery receipts) dated 4/16/26, indicated the facility received and administered OxyContin ER/CR 10 mg during that period.During an interview on 5/5/26 at 10:22 AM, with the Primary Physician (MD 1), MD 1 stated the intended order was oxycodone immediate-release (IR - medication designed to release immediately after administration) 10 mg twice daily, not controlled-release (CR) formulation.During a concurrent interview and record review on 5/5/26 at 11:50 AM, with the Director of Nursing (DON), the DON stated nursing staff were expected to verify correct medication, correct dose, and correct dosage form before administration. The DON stated discrepancies between immediate-release (IR) and controlled-release (CR) dosage forms should have been clarified with the physician or pharmacy prior to medication administration.A review of the facility's policy and procedures (P&P) titled, Medication - Administration, dated 8/19/25, indicated: .All medications shall be administered by licensed using staff according to physician orders .The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner .The Licensed Nurse will verify.before administering the medication using the 6 rights of medication administration .Right Medication: Verify against the MAR and pharmacy label .Right Dose: Ensure accuracy based on provider order .A review of the facility's P&P titled, Medication Orders - IB2: Controlled Substance Prescriptions, dated October 2012, indicated: .Elements of a controlled substance prescription .dosage form .The prescriber is contacted to verify or clarify a prescription when needed .If changes to a controlled substance prescription are necessary, the prescriber (or prescriber's employee) must communicate the new order to the facility nursing staff for documentation in the chart and communicate or transmit the new prescription to the pharmacy prior to dispensing .

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 81) reviewed for unnecessary medications was free from a significant medication error when, Resident 81 did not receive phenobarbital (a controlled substance used to control seizures [a sudden, uncontrolled electrical disturbance in the brain that may cause involuntary jerking movements, staring spells, and/or loss of consciousness] by stabilizing electrical activity in the brain) as ordered by the physician for five consecutive days. The facility failed to ensure the physician was notified of the missed doses and failed to follow-up on the status of the medication with the facility's contracted pharmacy.This failure resulted in missed doses of anticonvulsant (seizure-control) medication and had the potential for decreased medication levels in the body and increased risk for seizure activity.Findings:A review of Resident 81's Face Sheet, (front page of the chart that contains a summary of basic information about the resident) dated 5/7/26 indicated Resident 81 was admitted to the facility on [DATE], with diagnoses including epilepsy (a disorder characterized by recurrent seizures caused by abnormal electrical activity in the brain).A review of Resident 81's Physician's Orders, dated 4/14/26, indicated an order for Phenobarbital oral tablet 30 mg (milligram - unit of measurement), give 3 tablets by mouth one time a day for seizures.A review of Resident 81's Care Plan Report, dated 4/15/26, indicated, a Focus area for Resident 81 the resident has a seizure disorder r/t (related to) disease process. and had Interventions for an action to, Give medications as ordered.A review of the pharmacy delivery receipt titled Packing Slip, dated 4/14/26, indicated the facility received 45 tablets of phenobarbital 30 mg on 4/14/26.A review of Resident 81's Individual Narcotic Record, (inventory records used to document receipt, use, and count of controlled substances [medications with potential for abuse and dependence]) and Medication Administration Record, ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments administered given to a resident) dated April 2026 - May 2026, indicated phenobarbital administration began on 4/15/26 with removal of 3 tablets daily through 4/29/26. The last documented removal of phenobarbital on the Individual Narcotic Record, occurred on 4/29/26, which indicated Resident 81 received all 45 tablets during this period, with no remaining supply available after 4/29/26. Further review of Resident 81's Individual Narcotic Record indicated there was no documentation the phenobarbital medication was available and administered to Resident 81 from 4/30/26 through 5/4/26.A review of Resident 81's MAR, dated April 2026 - May 2026, indicated the nursing staff documented phenobarbital with chart code 9 - see progress notes on 4/30/26, 5/1/26, and 5/2/26. A review of Resident 81's Progress Notes (a formal, often daily, record documenting a resident's clinical status, medical necessity, and response to treatment) dated 4/30/26-5/2/26, indicated an Administration Note dated 4/30/26 for Phenobarbital Oral Tablet 30 mg.medication pending refill delivery from pharmacy. Further review of Resident 81's Progress Notes dated 5/1/26-5/2/26, indicated there was no documentation of the medication status, no follow-up with the pharmacy on the availability of the medication, and no notification to the physician regarding the unavailable medication and missed doses for Resident 81. A review of the pharmacy delivery receipt titled Packing Slip, dated 5/5/26, indicated the facility received 45 tablets of phenobarbital 30 mg on 5/5/26.During an interview on 5/7/26 at 8:38 AM with Pharmacy Technician (PT), the PT stated the pharmacy did not receive a refill request from the facility for phenobarbital between 4/30/26 and 5/4/26, and no communication occurred between the facility and the pharmacy regarding the medication during this timeframe.Further review of Resident 81's MAR, dated for May 2026, indicated Resident 81 received and was administered phenobarbital on 5/3/26 and 5/4/26, despite the unavailability of the medication.During a concurrent interview and record review on 5/7/26 at 8:56 AM, with the Director of Nursing (DON), the DON confirmed no documented evidence showed nursing staff notified the physician or followed up with the pharmacy regarding the unavailability of phenobarbital from 4/30/26 through 5/4/26. The DON reviewed Resident 81's MAR, dated May 2026 and confirmed licensed nursing staff documented the phenobarbital was administered to Resident 81 in Resident 81's MAR on 5/3/26 and 5/4/26, when Resident 81's Individual Narcotic Record, indicated no remaining supply was available after 4/29/26. The DON stated the licensed nursing staff should have requested a refill from the pharmacy prior to depletion of medication supply and should have notified the physician regarding the unavailable medication for further instruction or guidance.A review of the facility's Policy and Procedures (P&P) titled, Miscellaneous Special Situations - IF11: Unavailable Medications, dated October 2012, indicated: .The facility must make every effort to ensure that medications are available to meet the needs of each resident.B. Nursing staff shall 1). Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy that are available. a. If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for order and/or direction.A review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy - IC4: Receiving Controlled Substances, dated October 2012, indicated: .Controlled substances are reordered when a five day supply remains to allow for transmittal of the required written prescription to the pharmacist.

Based on observation, interview, and record review, the facility failed to implement infection control and prevention measures when:1. The sharps container (a puncture-resistant, leak-proof receptacle designed for the safe disposal of medical sharps to prevent injury and infection) on one of three medication carts (Medication Cart 2) was filled beyond the fill line indicator.2. The Certified Nurse Assistant (CNA) 1 failed to follow the facility's policy for Enhanced Barrier Precautions ([EBP] - an infection control prevention designed to reduce the transmission of multi-drug-resistant organisms (MDROs) in healthcare settings, particularly nursing homes) when CNA 1 did not wear a gown while providing incontinent care to Resident 60.These failures had the potential for increased risk of infection which can compromise the health and wellbeing of residents, staff, and visitors.Findings:1. During a concurrent observation and interview on 5/4/26 at 11:16 AM, with License Vocational Nurse (LVN) 1, LVN 1 was observed pushing Medication Cart 2. The sharps container attached to the side of the medication cart was filled past the fill line indicator. LVN 1 confirmed the finding and stated that the sharps container should have been replaced.During an interview on 5/7/26 at 9:34 AM, with Registered Nurse Supervisor (RNS) 1, RNS 1 stated that a full sharps container had an indicator line, and the disposal and replacement of the container was needed once the line was reached. RNS 1 stated the importance of changing the sharps container was to prevent accidental needle stick injuries. RNS 1 confirmed Medication Cart 2's sharps container was over the fill line and needed to be replaced.During an interview on 5/7/26 at 10:05 AM, with Infection Preventionist (IP), the IP stated the staff member assigned to the medication cart was responsible for ensuring the sharps container was replaced when the indicator line was reached. The IP confirmed that the container exceeded the fill line and required replacement.During a review of the facility's policy and procedure (P&P) titled, Sharps Disposal, revised January 1, 2012, indicated, .Nursing staff discard contaminated sharps into designated containers .Procedure .III .C. The infection control coordinator or designee is responsible for sealing and replacing containers when they are 75% to 80% full to protect Nursing Staff from punctures and/or needlesticks when attempting to push sharps into the container.2. A review of Resident 60's Face Sheet, (front page of the chart that contains a summary of basic information about the resident) dated 5/7/26, indicated Resident 60 was admitted to the facility on [DATE] and included a diagnosis of Gastrostomy (a medical procedure used to create an opening through the skin directly into the stomach, usually to insert a feeding tube. This allows for nutrition, fluids, and medication to be delivered directly to the stomach).A review of Resident 60's History and Physical, (H&P) dated 2/5/26, indicated under Physical Findings.Abdominal.+ (positive) PEG ([percutaneous endoscopic gastrostomy] a feeding tube placed directly into the stomach through a small incision in the skin of the belly) and Resident 60's .Current diagnosis, status post (s/p - a medical term meaning after, following, or condition after a specific event, procedure, or treatment) PEG.During an observation on 5/4/26 at 9:45 AM, a sign at the entrance to Resident 60's room indicated EBP - Enhanced Barrier Precaution. CNA 1 was observed changing Resident 60's incontinence brief without wearing a gown.During an interview on 5/4/26 at 10:00 AM, with CNA 1, CNA 1 stated Resident 60 was on EBP. CNA 1 stated that as per EBP sign and the facility's policy gloves and a gown must be worn when changing a resident's incontinence brief and providing direct care for a resident on EBP. CNA 1 confirmed she did not wear a gown when providing direct care and when changing Resident 60's incontinence brief.During an interview on 5/7/26 at 9:40 AM, with LVN 2, LVN 2 confirmed Resident 60 was on EBP because Resident 60 had a feeding tube. LVN 2 further stated that CNA 1 should have worn a gown while providing direct care to Resident 60.During an interview on 5/7/26 at 9:55 AM, with RNS 1 verified Resident 60 was on EBP and stated CNAs, LVNs, and RNs were required to wear gloves and gown during high contact care activities (applies to activities that involve high-touch contact with a resident's body or environment including direct care services).A review of the facility's policy and procedure titled Enhanced Barrier Precautions, revised 10/15/24, indicated .Process.2. For residents for whom EBP are indicated, EBP is employed when performing the following high contact resident care activities for those at risk of transmission or acquisition of MDROs: .f. changing briefs or assisting with toileting g. device care or use.feeding tube. h. Wound care: any skin opening requiring a dressing.9.a.i. Gown and gloves are to be donned before each high contact task.10.Table: Summary of Personal Protective Equipment (PPE) use an .Applies to .EBP, all residents with any of the following: wounds and or indwelling medical devices (e.g., feeding tube).

Based on interview and record review, the facility failed to ensure two of five sampled residents (Residents 17 and 52) reviewed for immunizations, were offered the COVID-19 (contagious respiratory illness caused by the SARS-CoV-2 virus) vaccine and failed to maintain documentation of vaccine education, refusals, or acceptance.These failures had the potential for Residents 17 and 52 to be unprotected against COVID-19, increased the risk of serious illness, delayed identification of vaccine status, and missed opportunities to prevent the spread of infection within the facility.Findings:A review of Resident 17's admission Record, (a document showing a summary of the resident's information) dated 5/24/23, indicated Resident 17 was readmitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary ([COPD] - a progressive lung disease which blocks air flow making breathing difficult), shortness of breath, and muscle weakness.A review of Resident 52's Face Sheet, (front page of the chart that contains a summary of basic information about the resident) dated 5/24/23, indicated Resident 52 was readmitted to the facility on [DATE], with diagnoses that included pulmonary fibrosis (a chronic, and progressive lung disease which makes it difficult for oxygen to enter the bloodstream), essential hypertension ([HTN] -high blood pressure), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).During a concurrent interview and record review on 5/6/26 at 10:08 AM, with the Infection Preventionist (IP), the IP stated that COVID-19 vaccine was offered to residents annually. The IP reviewed Resident 17 and 52's medical records via PCC (PointClickCare- cloud-based electronic health record) and immunization log. The IP stated there were no documented evidence that COVID-19 vaccine was offered and informed consent was obtained by staff from Residents 17 and 52 or their representative for over a year.During an interview on 5/7/26 at 8:37 AM, with Medical Records Director (MRD), the MRD stated that after review of Resident 17 and Resident 52's medical records, the MRD confirmed that there were no recent documented evidence of COVID-19 informed consent and vaccination were kept for these residents.During a subsequent interview on 5/7/26 at 8:40 AM, with the IP, the IP stated that after further review of Resident 17 and Resident 52's records and the facility's infection and control program records, the IP acknowledged that there were no documented evidence of the COVID-19 vaccination and no documentation of vaccine education, refusals, or acceptance for these two residents. The IP also stated that the expectation at the facility was for informed consent be obtained and the COVID-19 vaccine to be offered annually to all residents.During an interview on 5/7/26 at 10:15 AM, with the Director of Nursing (DON), the DON stated that it was the facility's policy to annually offer the COVID-19 vaccine to residents and informed consents be obtained so that the vaccine benefits and risks can be explained.A review of the facility's P&P titled IPC406 Management of COVID-19, effective 10/28/2022, indicated .Purpose: To prevent the development and transmission of COVID-19.Education: 31. Provide COVID-19 education as indicated to employees, patients, and visitors.Vaccination.37. Residents are encouraged to receive COVID-19 vaccination and boosters. 38. The facility will maintain documentation of resident and staff vaccination status.

Based on interview and record review the facility failed to administer the resident's morning medications and notify the doctor (Dr) on February 20, 2026, for one of three residents reviewed (Resident 1).This failure had the potential for Resident 1 to experience adverse effects from not receiving their morning medications as ordered.Findings:On March 9, 2026, an unannounced visit was made to the facility for a Quality-of-Care issue.A review of Resident 1's, Resident Information, indicated, the resident was admitted to the facility on [DATE], with a diagnosis of Pulmonary Embolism (A blood clot in the lungs).Further record review indicated Resident 1 had a Brief Interview of Mental Status (BIMS-a cognitive assessment) score of 15, no cognitive impairment.On March 9, 2026, at 11:15 a.m., an interview was conducted with Resident 1 who stated she did not receive her morning (9:00 a.m.) medications on February 20, 2026. Resident 1 stated she did not experience any adverse side effects from missing her morning medications on February 20, 2026.A review of Resident 1's Doctor's (Drs) Orders, indicated Resident 1 had the following medications ordered for the morning of February 20, 2026: Eliquis (Blood thinner) 5 mg (Milligrams-a unit of measure); andHydrochlorothiazide (Anti-diuretic-helps to eliminate excess fluid and swelling of legs) 25 mg.A review of Resident 1's Medication Administration Record (MAR), dated February 20, 2026, indicated Resident 1's morning medications were not administered by Licensed Vocational Nurse (LVN) 1.A review of Resident 1's Progress Notes, dated February 20, 2026, indicated no documentation explaining why Resident 1 did not receive her morning medications. A review of Resident 1's Care Plan titled, Resident (1) has edema (fluid retention), initiated January 24, 2024, indicated the intervention of . Administer Hydrochlorothiazide as ordered . Further review of Resident 1's Care Plan titled, Resident (1) is on (an) anticoagulant (blood thinner) therapy Eliquis, indicated the intervention of, . Administer ANTICOAGULANT medications as ordered by (the Dr) .On March 5, 2026, at 2:17 p.m., a concurrent interview with the Director of Nursing (DON) and review of Resident 1's February 2026 MAR and documentation was conducted. The DON stated it's the facility's policy medications can be administered one hour before to one hour after, the ordered/scheduled times. The DON further stated that when medications are not administered as ordered, she expects the medication nurse to notify the Dr, follow the Drs orders if any, and document. The DON verified LVN 1 was Resident 1's medication nurse on February 20, 2026, and the resident's MAR indicated Resident 1 did not receive their morning medications as ordered. The DON further verified there was no documentation on February 20, 2026, provided by LVN 1 explaining why Resident 1 did not receive her medications or notification to the Dr.On March 9, 2025, at 3:35 p.m., an interview was conducted with LVN 1, who stated it is the facility policy that medications can be administered between one hour before and one hour after the ordered medication times. LVN 1 stated when she does not administer a resident's scheduled medications, she will notify the Dr and document a progress note.On March 12, 2026, at 2:10 p.m., a concurrent interview with LVN 1 and record review of Resident 1's February 2026 MAR and documentation was conducted. The LVN stated when a resident is scheduled to go out on a pass, the nurse should administer their scheduled medications prior to the resident leaving the facility. LVN 1 verified she was Resident 1's medication nurse the morning of February 20, 2026, and she did not administer Resident 1's morning medications that day. LVN stated she could not remember why she did not administer Resident 1's medications, but she may have thought resident was out of the facility on a day pass. LVN 1 further verified she did not notify the Dr or document a progress note explaining why Resident 1 did not receive her medications the morning of February 20, 2026, stating she should have. LVN 1 stated Resident 1 did not report any signs or symptoms of side effects from not receiving her morning medications February 20, 2026.A facility policy titled, Medication Administration, with an effective date of August 19, 2025, indicated, .Policy . All medications shall be administered . according to physician's (Drs) orders.The facility shall ensure residents receive the correct medication in a timely, safe and documented manner.Process .Administration of Medications.Medications must be administered within one hour before or one hour after the scheduled time.Holding Medications .Whenever a medication is held of any reason, it must be documented along with reason and the prescribing (Dr) will be notified.

Based on observation, interview, and record review, the facility failed to implement a comprehensive systematic approach to ensure effective monitoring to maintain acceptable parameters of nutritional status for 5 of 5 sampled Residents (23, 43, 51, 58, and 673) when: 1. Resident 23 experienced a severe unplanned weight loss of 16 lbs. (pounds- a measurement of weight), 8.04% from the weights obtained on 11/5/24 to 2/26/25. Weights were obtained but a weight loss change of condition was not completed, the resident was not placed on weekly weights, the Registered Dietitian (RD) did not reassess the resident to determine appropriate interventions, weight loss was not communicated to the Physician, the IDT (IDT- an interdisciplinary team comprised of professionals from various disciplines who work in collaboration to address a Resident with multiple physical and psychological needs) did not address the severe unplanned weight loss, and the care plan did not reflect the severe unplanned weight loss for the interventions to be implemented. Resident 23 was diagnosed with uncontrolled diabetes mellitus (condition in which the body has trouble controlling blood sugar). 2. Resident 43 experienced a severe unplanned weight loss of 14 lbs. or 11.67% from the weights obtained on 11/5/24 to 2/7/25. Weights were obtained but a weight loss change of condition was not completed, the resident was not placed on weekly weights, the RD did not reassess the resident to determine appropriate weight loss interventions, weight loss was not communicated to the Physician, the IDT did not address the severe unplanned weight loss, and the care plan did not reflect the severe unplanned weight loss for the interventions to be implemented. Resident 43 was diagnosed with hyperlipidemia (elevated blood fat levels) and a body mass index (BMI) of 16.5 (less than 18 is underweight). 3. Resident 51 experienced a severe unplanned weight gain of 16 lbs., 10.26% from the weights obtained on 11/5/24 to 2/7/25. Weights were obtained but the resident was not placed on weekly weights, the weight loss was not addressed by the Physician, the IDT did not address the severe unplanned weight loss, and the care plan did not reflect the severe unplanned weight loss for the interventions to be implemented. Resident 51 was diagnosed with chronic kidney disease (CKD) (when the kidneys cannot filter waste). 4. Resident 58 experienced a severe unplanned weight loss of 23 lbs., 12.3% from the weights obtained on 12/24/24 to 2/20/25. Weights were obtained but the resident was not reassessed by the RD to determine appropriate interventions, and the IDT did not follow up with the Physician to address the severe unplanned weight loss to ensure appropriate interventions were implemented. Resident 58 was diagnosed with hypothyroidism (condition which the thyroid gland does not produce enough thyroid hormone). 5. Resident 673 experienced a severe unplanned weight loss of 8.6 lbs., 5.78% from the weights obtained on 11/5/24 to 2/6/25. Weights were obtained but a change of condition for severe unplanned weight loss was not completed, the Physician or the RD did not address the severe weight loss with the IDT to determine effective interventions to prevent further weight loss, and the care plan did not reflect goals to address the severe unplanned weight loss. Resident 673 was diagnosed with dysphagia (difficulty swallowing) and hemiplegia (paralysis of one side of the body). As a result of these failures, these five (5) residents compromised nutritional status was not addressed which could have resulted in further medical complications including but not limited to dehydration, loss of muscle mass with decreased mobility and negatively affect the diagnoses for each resident, which could include death. Because of the severe unplanned weight losses for Residents 23, 43, 51, 58, and 673 and the facility lacking a comprehensive systematic approach to ensure effective monitoring to maintain acceptable parameters of nutritional status, an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) situation was called on 2/27/25 at 7:45 PM, under Code of Federal Regulations (CFR) S483.25 Nutrition/Hydration Status Maintenance (F692) with the Administrator (ADM), Director of Nursing (DON), and Dietary Services Manager/Registered Dietitian (DSM-RD) in attendance. The IJ template was provided to the ADM. The facility submitted an acceptable IJ Removal Plan (Version 3) on 2/28/25, at 4:53 PM. The IJ Removal Plan included but was not limited to the following: 1) Notify the Physicians for Residents 23, 43, 51, 58, and 673 of significant and severe weight change. 2) Re-weigh all five residents and place on weekly weights for four weeks. 3) Review labs (clinical blood tests), weights, physician visits, PO (eating by mouth) intake, and therapy orders for the five identified weight loss residents 23, 43, 51, 58, and 673. 4) The RD will re-assess and re-evaluate Residents 23, 43, 51, 58, and 673 nutrition status. 5) Immediate training for Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) on monitoring and recording meal intake percentages and supplement orders. 6) The RD will monitor the weekly weights and residents with significant weight loss of 5% /5# (pounds) x 30 days, 7.5% x 90 days, 10% x 180 days, and 3# or more for residents who are under 100# x 30 days were reevaluated by the Senior (Sr.) Regional Registered Dietitian and followed up by the Facility RD, as well as the Weight Variance and Nutrition Condition Interdisciplinary team (IDT) weekly for 4 weeks, then, bi-monthly for 2 months. 7) IDT will monitor for sustainable compliance to determine weight variances/significant weight losses and accuracy of assessments to meet weight loss resident's nutritional needs and goals of care such as improved PO intake or weight goals are met. Identified concerns will be addressed immediately and reported to the DON and Administrator for follow-up as warranted. 8) Senior Regional Registered Dietitian provided one to one (1:1) re-education to the Registered Dietitian on Evaluation of Weight & Nutritional Status Policy and Procedures and an RD competency with current facility's RD. 9) Regional Quality Management Compliance (RQMC) and Senior RD completed education on Evaluation of Weight and Nutritional Status policy with IDT members. 10) the Medical Director was notified by the Administrator and Director of Nursing (DON) of the concerns related to Weight Loss and Nutritional Assessments and presented and discussed the immediate action plan for implementation. 11) Pharmacy medication regimen review completed for the five (5) identified weight loss residents 23, 43, 51, 58, and 673 for review of weight change related medications. The components of the IJ Plan of Removal were validated through observations, interviews, and record review and the IJ was removed on 3/3/25 at 12:50 PM with the ADM and DON in attendance. Findings: According to a 2002 American Academy of Family Physicians Journal article, Involuntary weight loss can lead to muscle wasting, decreased immunocompetence, (the ability for the body to develop an immune response) depression and an increased rate of disease complications. Research has shown institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. (www.aafp.org/afp) According to a literature review of the Academy of Nutrition & Dietetics, Nutrition Care Manual, dated 2022, .Unintended weight loss is linked to increased mortality (death) among older adults . residents in long-term-care facilities who continue losing weight have a higher mortality rate compared with those who stop losing weight. Weight loss of 5% or more within 30 days is associated with a tenfold increase in the likelihood of death . https://www.nutritioncaremanual.org/ 1. A record review of Resident 23's Facility Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), diabetes mellitus, hypertension (elevated blood pressure levels), gastro-esophageal reflux disease-GERD (a condition where stomach contents flow back up into the esophagus, causing irritation) and hyperlipidemia (abnormally high levels of fat in the blood). Record review of Resident 23's minimum data set (MDS- a standardized comprehensive assessment of residents' health conditions, functional abilities, and care needs) report dated 1/8/25 indicated the resident's brief interview of mental status-BIMS (a short cognitive screening test) score was 6, whereby a score of 0-7 refers to severe impairment. Review of Resident 23's Weights and Vitals Summary report on 2/28/25 indicated: 8/06/24 - 198 lbs. 9/03/24 - 200 lbs. 10/2/24 - 198 lbs. 11/5/24 - 199 lbs. 12/5/24 - 197 lbs. 01/6/25 - 203 lbs. 02/7/25 - 185 lbs. 2/26/25 - 183 lbs. Resident 23 experienced a 16-pound, 8.04% severe weight loss in ninety days or 3 months, from 11/5/24 to 2/26/25. Review of Resident 23's eInteract Change in Condition (COC) Evaluation dated 1/30/25 completed by Licensed Vocational Nurse (LVN) 7 indicated the .Signs and symptoms . Food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts) and Functional decline (worsening mobility). Weight loss was not checked. Review of Resident 23's physician's diet order dated 2/10/25 indicated NAS (no added salt) CCHO (consistent carbohydrate) diet, Mechanical Soft texture, Regular/Thin consistency and supplement order dated 2/8/25 indicated 4 ounce (oz.) House Supplement/Milk Shake three times a day for Malnutrition risk with meals. On 2/28/25 at 12:40 PM, a joint observation and interview of resident 23's lunch meal intake was conducted in the resident's room. Resident 23's lunch meal tray was on his bedside table. Certified Nursing Assistant (CNA) 2 and CNA 5 were feeding the resident his lunch meal which was beef goulash with spaghetti noodles, bite-sized coin carrots, and a parsley garnish on the plate. The resident drank thickened milk in 8-ounce cup with his meal. The CNA 5 stated the resident generally eats 50%-100% of his meals, depending on the meal. Review of Resident 23's January 2025 - February 2025 Meal Intake percentage (%) report indicated the resident consumed an average of 25% to 100% of meals, 25% of his house supplements. The facility's Diet Manual indicated the CCHO diet provided 2200 calories and 70-90 grams of protein per day, which led to Resident 23 consuming up to 550 fewer calories and 20 fewer grams of protein per day required to meet his estimated daily nutrition needs. Review of Resident 23's Nutrition Risk assessment dated [DATE] completed by the DSM-RD, indicated the resident's usual body weight was 206 lbs., estimated daily nutrition needs were 1800-2250 kcal (calories) and 90-108 grams of protein. Nutrition Goal: 1) stable wt. (weight) (fluct.- fluctuation) < 5%/month) within goal weight range: 195-205 lbs. through review date. 2) Maintain adequate nutrition & hydration status as evidenced by no new signs and symptoms of malnutrition, skin breakdown or dehydration. 3) Tolerate diet; average PO meets 75%-100% est. (estimated) needs. During a concurrent interview and record review with the Dietary Services Manager- Registered Dietitian (DSM-RD) on 2/27/25 at 3:06 PM, the DSM-RD stated resident 23's weight loss interventions should have been reassessed to address his continual weight loss. The DSM-RD further stated the resident should have remained on weekly weights and the change of condition form should have indicated weight loss as a sign and symptom so the IDT could have evaluated the resident's weight changes with the physician to avoid further loss. 2. A review of Resident 43's Facility Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease-COPD (a condition involving restricted airflow in the lungs and difficulty breathing), hypertension (elevated blood pressure levels) and hyperlipidemia (abnormally high levels of fat in the blood). Record review of Resident 43's MDS report dated 12/28/24 indicated the BIMS score was 11, whereby a score of 8-12 refers to moderate impairment. Review of Resident 43's Weights and Vitals Summary report on 2/28/25 indicated: 11/05/24- 120 lbs. 12/05/24 -117 lbs. 01/07/25 -105 lbs. 02/07/25 -106 lbs. Resident 43 experienced a 14-pound, 11.67% severe weight loss in ninety days or 3 months, from 11/5/24 to 2/7/25. Review of Resident 43's eInteract Change in Condition (COC) Evaluation dated 11/26/24 completed by LVN 1 indicated the signs and symptoms was 31. Other Change in Conditions . Low Hemoglobin 3.2 g/dL (normal range 12.1 g/dL to 15.1 g/dL). Weight loss was not checked. Review of Resident 43's physician's diet order dated 11/29/23 indicated Fortified (addition of calories to meals to reduce weight loss) Diet, Regular texture diet, Regular thin consistency; supplement order: 4 oz House Supplement/Milk Shake two times a day for Malnutrition risk w/ Lunch and dinner dated 1/8/25, 8 oz High Protein Nourishment two times a day dated 11/30/24, and Prostat (protein rich item) one time a day for Supplement for Wound Healing 30 ml PO, started 11/27/23. On 3/3/25 at 7:49 AM, an observation of resident 43's breakfast meal intake was conducted. Resident 43 received a Banana, Toast, Cereal, Bacon, and chocolate health shake. The resident did not have assistance and fed herself. Resident 43's January 2025 - February 2025 Meal Intake percentage (%) reports were requested by Surveyors on 2/28/25 and 3/3/25 but were not provided by the facility. Review of Resident 43's Nutrition Risk assessment dated [DATE] completed by the DSM-RD, indicated the resident's weight was 103 lbs., height 5 feet 7.5 inches tall, BMI (body mass index) 16.5 (below 18 is underweight), No labs indicated, PI (Pressure Injury) sacrum (large bone at bottom of spine) stage 2 pressure wound, estimated daily nutrition needs 1410-1645 kcal and 47-57 grams of protein.Nutrition Risk Related To: The resident has risk for unplanned/unexpected weight loss and risk for malnutrition r/t chronic conditions: COPD (chronic obstructive pulmonary disease), HTN (hypertension), HLD (hyperlipidemia), Muscle weakness; increased protein/calorie needs for wound healing; variable food intake with low BMI =16.5. Nutrition Goal: The resident will consume 75% two of three meals/day to maintain weight within goal range: 103-113# (pounds). The resident will consume >75% of nutrition supplements ordered. The resident will maintain adequate hydration status. Nutritional Intervention: Continue all supplements for wound healing and monitor prn (as needed) . Review of Resident 43's Lab's Results Report dated 11/26/24 indicated the resident's Albumin (a protein in blood that transport nutrients and maintains fluid balance) = 3.2 g/dL (grams/deciliter) was low, where 3.5 g/dL to 5.7 g/dL is the normal range. During a concurrent interview and record review on 2/27/25 at 3:06 PM about resident 43's lab results on 11/26/24 with the DSM-RD, the DSM-RD stated the resident's albumin was borderline low and recent weight loss was unintentional. The DSM-RD further acknowledged the resident's nutritional needs should have been addressed by completing a reassessment of the resident's nutrition interventions and change of condition for the weight loss when it was identified. The DSM-RD also stated modifying the resident's nutrition interventions may have prevented further weight loss. 3. A review of Resident 51's Facility Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), hypertension (elevated blood pressure levels), hyperlipidemia (abnormally high levels of fat in the blood), rhabdomyolysis (breakdown of muscle tissue), and chronic kidney failure (the kidneys cannot filter waste). Review of Resident 51's minimum data set (MDS) report dated 11/22/24 indicated the resident's brief interview of mental status-BIMS (a short cognitive screening test) score was 14, where a score of 11-15 refers to intact cognition. Review of Resident 51's Weights and Vitals Summary report on 2/28/2025 indicated: 8/19/24 - 177 lbs. 9/03/24 - 167 lbs. 10/1/24 - 160 lbs. 11/5/24 - 156 lbs. 12/5/24 - 149 lbs. 01/7/25 - 148 lbs. 02/7/25 - 140 lbs. Resident 51 experienced a 16-pound, 10.26% severe weight loss in ninety days or 3 months, from 11/5/24 to 2/7/25, and a 20.9% severe loss in 180 days or 6 months from 8/19/24 to 2/7/25. Review of Resident 51's eInteract Change in Condition (COC) Evaluation dated 12/6/24 completed by LN 4 indicated the .Signs and symptoms .30. Weight loss . was checked. The COC also stated Resident noted with 7 lbs. weight loss x 30 days & 18 lbs. weight loss x 90 days .no s/s (signs and symptoms) of dehydration noted. Communicated with RD & MD (medical doctor), no new orders/ recommendations at this time. Review of Resident 51's physician's diet order dated 9/5/24 indicated CCHO - Standard Portion diet Regular texture, Regular Thin liquid consistency, fortify meals; Supplement order: 4 oz House Supplement/Milk Shake three times a day for Malnutrition risk with meals. Review of Resident 51's December 2024 - February 2025 Meal Intake percentage (%) report indicated the resident consumed 51% to 100% of meals. Resident 51's Nutrition Assessment completed in 2024 by the Registered Dietitian was requested by Surveyors but not provided by the facility. Review of Resident 51's IDT Progress Notes dated 11/8/24 completed by the DSM-RD indicated .Note Text: IDT Reviewed d/t: significant wt loss WT/BMI: 156#/23.7 kg/m2 WT TREND: -21#/-11.9% x 90 days; DIET: CCHO - Standard Portion diet, Regular texture, Regular/Thin consistency SNACK/SUPPLEMENT: Pro-stat, Vit C, Zinc, Vit D3 MEAL PO: Mostly 76-100%, 51-75% at times. EVAL: At risk for malnutrition d/t: spinal stenosis, sepsis, enterocolitis d.t c diff, AKF, BPH, HLD Weight loss likely r/t poor PO intake at times and compromised skin integrity. Resident currently has a L- posterior knee . Supplements for wound healing in place. Goal weight 155-165#. No new recommendations at this time. RECS: 1) Continue POC (plan of care) . During a concurrent interview and record review on 2/27/25 at 3:06 PM with the DSM-RD about resident 51's weight loss, the DSM-RD acknowledged a nutrition assessment was not completed for resident 51 when weight loss was identified at thirty and sixty days in 2024. The DSM-RD further stated the IDT progress notes were completed in September and November 2024 that mentioned resident 51's weight loss but the recommendations should have been modified with weekly weights and other interventions to avoid further weight loss. 4. A record review of Resident 58's Facility Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included GERD (gastro-esophageal reflux disease), hypertension, and hyperlipidemia, type 2 diabetes with hyperglycemia, and hypothyroidism (condition which the thyroid gland does not produce enough thyroid hormone). Review of Resident 58's minimum data set (MDS) report dated 12/27/24 indicated the resident's brief interview of mental status- BIMS (a short cognitive screening test) score was 11, whereby a score of 8-12 refers to moderate impairment. Review of Resident 58's Weights and Vitals Summary report on 2/28/25 indicated: 12/24/24 -187 lbs. 01/22/25- 176 lbs. 02/07/25 -163 lbs. 02/20/25 -164 lbs. Resident 58 experienced a 23 pound, 12.3%, severe weight loss in ninety days or 3 months from 12/24/24 to 2/20/25. Review of Resident 58's eInteract Change in Condition (COC) Evaluation dated 2/7/25 completed by LN 4 indicated .Signs and symptoms .30. Weight loss .Resident noted with 25 lbs. weight loss within 30 days. no s/s of dehydration noted. Offered fluids & snacks as tolerated. Notified MD, no new orders at this time, RD aware . Continue to monitor .resident Review of Resident 58's physician's diet order dated 12/23/24 indicated CCHO - Standard Portion diet, Regular texture, Regular/Thin consistency; Supplement order dated 2/9/25, 4 oz House Supplement/Milkshake one time a day for Malnutrition risk w/ Dinner . Review of Resident 58's December 2024 - February 2025 Meal Intake percentage (%) report indicated the resident consumed 51% to 100% of meals and 75% to 100% of liquids, not including supplements. The daily supplement percentage intake was requested by Surveyors but not provided by the facility. Resident 58's initial Nutrition Risk Assessment completed by the RD was requested but not provided. During a review of Resident 58's IDT Weight and Nutrition Condition progress notes dated 1/22/25 and signed by the DSM-RD, indicated Note Text: IDT Reviewed d/t:significant wt loss WT/BMI: 176#/27.6 kg/m2, WT TREND: -9#/-4.9% x 1 week. DIET: CCHO - Standard Portion diet, Regular texture, Regular/Thin consistency SNACK/SUPPLEMENT: Snack HS, MEAL PO: 76-100% poor PO x 2 days likely r/t high k+ (potassium) abnormal labs. EVAL:73 yo (year old) male at risk for malnutrition r/t (related to) a-fib (atrial fibrilation), DM2 (diabetes mellitus), ASHD (atherosclerotic heart disease- abnormal heart functioning), CKD (chronic kidney disease) .hypothyroidism, HLD (hyperlipidemia). Weight loss likely r/t COC for hyperkalemia sent out for immediate care returned same day 1/21/2024. RECS: 1) 4oz Health Shake QD w/ Dinner. IDT will continue to monitor. MD and Family made aware . During a joint interview and record review on 2/27/25 at 3:06 PM with the DSM-RD about Resident 58's weight loss, the DSM-RD stated resident 58's nutrition interventions should have been modified and follow up with the physician should have occurred to prevent further weight loss. 5. A record review of Resident 673's Facility Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension, and hyperlipidemia, dysphagia, depression, and hemiplegia and hemiparesis (paralysis or weakness on one side of the body). Review of Resident 673's minimum data set (MDS) report dated 11/30/24 indicated the resident's brief interview of mental status- BIMS (a short cognitive screening test) score was 7, whereby a score 0-7, severe cognitive impairment. Review of Resident 673's Weights and Vitals Summary report on 2/27/25 indicated: 8/26/24 - 150 lbs. 9/24/24 - 142 lbs. 10/5/24 - 138 lbs. 11/5/24 - 135 lbs. 12/05/24-121 lbs. 01/3/25 - 121 lbs. 02/6/25 - 123 lbs. Resident 673 experienced a 12-pound, 8.89% severe weight loss in ninety days or 3 months, from 11/5/24 through 2/6/25, and an 18% severe weight loss in 6 months from 8/26/24 to 2/6/25. Resident 673's eInteract Change in Condition (COC) Evaluation was requested by Surveyors but not provided by the facility. Review of Resident 673's physician's diet order dated 2/10/25 indicated NAS (no added salt) diet, Pureed texture, Thin liquids, Nectar thick consistency; Supplement order dated 12/07/24, 4 oz. House supplement/Milk shake three times a day for Malnutrition risk with all meals . Resident 673's December 2024 - February 2025 Meal Intake percentage (%) report was requested from Surveyors but not provided by the facility. On 2/28/25 at 12:30 PM, an observation and interview of resident 673' lunch meal was conducted in the resident's room. Resident 673 stated she did not like mashed potatoes, and they serve them 3 to 4 times a week, or almost every other day. The meal tray was placed on the resident's bedside table, and it had pureed beef goulash, pureed mashed potatoes, and pureed carrots. The tray also had a chilled 8 ounce thickened 2 % milkshake drink carton. Resident 673 ate 25% to 50% of her lunch meal and drank 0% of the milkshake drink. On 3/3/25 at 7:47 AM, an observation and interview of resident 673's breakfast meal intake was conducted in the resident's room. CNA 5 stated the resident consumed 50% of her meal and needed minimal assistance. CNA 5 further stated the resident did not like her meals and the food choices. CNA 5 stated the resident was offered alternate meals for lunch and dinner, and the charge nurse was notified each time. Review of Resident 673's Nutrition Risk Assessment completed by the DSM-RD dated 9/4/24, indicated the resident's usual weight was 145-150 lbs., goal weight: 140-150 pounds, labs: Albumin 2.5 g/dL (Low) dated 8/30/24, estimated daily calorie and protein intake to meet needs: 1600-1920 kcal and 80-96 grams of protein; Nutrition Intervention: hydration status a/e/b (as evidenced by) no new s/s of malnx (malnutrition), skin b/d (breakdown), or dehydration. 3) Tolerate diet; avg (average) PO meets 75-100% of est. needs through next review date. Nutrition Goal: 1) 4 oz Health Shake QD (once a day) with Dinner 2) Weekly weights x 4 then monthly when stable 3) Update food preference as needed. During a concurrent interview and record review on 2/27/25 at 3:06 PM with the DSM-RD about resident 673's weight loss, the DSM-RD acknowledged she completed a nutrition assessment on 9/6/24 and identified weight loss, and stated a change of condition for weight loss should have been completed to notify the physician and IDT. The DSM-RD stated she did not reevaluate or assess resident 673 to determine if the nutrition interventions were successful to prevent further weight loss. During an interview on 2/27/25 at 4:05 PM with the RD-C (Corporate Registered Dietitian), the RD-C stated her expectation is for the facility's Dietitian to reassess the resident's weight history, clinical conditions, person-centered care plans, a calculated goal weight, and lab values to make nutrition recommendations and set goals to prevent further weight loss. The RD-C stated this information should be documented in the resident's medical chart for members of the IDT to view what the resident's nutrition goals are to prevent weight loss. During an interview on 2/27/25 at 5:19 PM with the Director of Nursing (DON) about residents' weight loss, the DON stated residents with significant or severe weight loss should be addressed with appropriate interventions with the RD, physician, nursing and IDT according to the facility's policy. During an interview on 3/3/25 at 11:41 AM with the facility's medical physician (FMP), the FMP stated it was important for residents to maintain a certain weight because they're an aging population who could lose lean body mass if the weight loss was not addressed. The FMP stated she was recently notified in February of Resident 43 and Resident 51's weight loss but had not spoken to the IDT about the reason for the weight loss. The FMP stated she knows Resident 43 had a low BMI (body mass index), does not like the facility's food and recently declined an appetite stimulant but did not know there was severe weight loss. The FMP also stated she expected to be notified when a significant or severe weight loss occurred for a resident so she could follow-up with a nutrition consult, request lab tests, and address the weight loss to prevent further problems. During an interview on 3/3/25 at 12:18 PM with the medical director (MDR), the MDR stated there should be a process for how weight losses of 2% to 3% are reported to the physician depending on the resident's underlying condition. The MDR stated they need to make sure there are no 15-pound weight losses experienced in one month and the policies and procedures be followed to prevent or avoid further weight loss. He stated physicians should be documenting how they address the resident's weight loss in the chart and to make sure the interventions are appropriate and the RDs need to be involved to address the weight loss. The MDR further stated weight is a very important component of a resident's medical and nutrition status because it helps them gain strength to fight off diseases. During an interview on 3/03/25 at 3:29 PM with the DSM-RD, the DSM-RD stated it was important for resident weight loss issues to be appropriately addressed to ensure the care of the resident. The DSM-RD further stated all tools should be used including fortified diets, supplements and shakes, additional portions and possible appetite medications to help improve a resident's food intake and nutrition status, and prevent more weight loss. Review of the facility's policy titled Change of Condition dated April 1, 2015, indicated .Procedure . III. A Licensed Nurse will notify the resident's Attending Physician and legal representative or an appropriate family member when there is an: .D. A change in weight of five pounds or more within a 30 day period unless a different stipulation has been stated in writing by the patient's physician . Review of the facility's policy titled Evaluation of Weight and Nutritional Status dated 2022 revised 1/30/25, indicated .1. The facility will maintain an acceptable nutritional status for residents per professional standards by a) Assessing the residents nutrition status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status. b) Analyzing the assessment information to identify the medical conditions, causes and/or problems related to the resident's condition and needs. c) Implementing interventions for maintaining or improving nutrition status that are consistent with the resident's needs, preferences, goals, and professional standards of practice. d) Developing interventions involving the resident and/or resident representative to ensure the resident's needs .are accommodated. e) Monitoring and evaluating the resident's response .to interventions. PROCESS 1 .b. Weight Loss- Unplanned weight loss in a resident. Significant weight loss (5% &/or 5 lb. in one month, 7.5%in three months, or 10% in six months), .c. Insidious weight loss refers to gradual, unintended, progressive weight loss over a three (3) or twelve (12) month period. 2 .b. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days or 10% in 180 days, or is considered insidious weight loss, with be evaluated by the IDT to determine the cause of the weight loss .and the intervention(s) required. c. The resident's Attending Physician will be notified when there is a weight variance of 5 pounds in 1 month .d.Residents at risk who should be weighed weekly include (but are not limited to) the following: .2. Significant weight loss or gain identified .3. Residents demonstrating insidious weight loss; .5. Residents on dialysis .ii. Weekly weights will be discontinued when the resident's weight has been within stable range for a period of four (4) weeks . Review of the facility's policy titled Nutritional Status Evaluation dated May 19, 2022, indicated .I. A registered dietitian will complete a nutritional evaluation upon admission .readmission, annually, and upon a significant change of condition.The Dietitian will use information from the Resident's medical record to complete the nutritional evaluation .including but not limited to: .A. diagnosis, B. diet order .E. skin condition, F. Ability to chew and swallow . H. Meal intake percentage .K. pertinent medications, L. laboratory data, M. usual body weight, N. BMI, O. estimated nutrition needs range .IV. The registered dietitian will provide recommendations in narrative and identify any risk factors for weight loss or dehydration and complete a clinical recommendation . Review of the facility's policy titled Nutritional Status Evaluation Committee dated June 2018, indicated .Purpose: [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the facility's policy and procedures were followed, for two of three sampled residents, Residents 1 and 2, who were identified as at risk for elopement (when a resident leaves a healthcare facility without permission or when they are unable to make safe decisions on their own), when: 1. The facility did not provide supervision for Resident 1 who had multiple prior attempts to elope; and 2. The facility did not ensure there was a system in place to monitor placement and functionality of the WanderGuard (bracelet worn by the resident that triggers alarms on doors to alert staff if a resident leaves a safe area) when Resident 2 was observed not wearing a WanderGuard bracelet as ordered by the physician. On November 18, 2024, at 7:20 p.m., The Administrator (ADM) and Director of Nursing (DON) were verbally notified of an Immediate Jeopardy (IJ- situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death to a resident), due to the facility ' s failure to implement a system for monitoring residents identified at risk for elopement. The facility failed to provide supervision to Resident 1, who was identified to be at risk for elopement and had multiple prior attempts to elope. This failure resulted in Resident 1 eloping from the facility on November 18, 2024, at approximately 2:00 a.m., placing Resident 1 at risk for serious injury while out in the cold environment with no access to needed healthcare. The facility failed to monitor the placement and functionality of the WanderGuard for Resident 2, who was observed not wearing a WanderGuard bracelet as ordered by the physician. This failure resulted in the potential for Resident 2 to elope from the facility placing her at serious risk for injury and no access to needed healthcare. On November 19, 2024, at 3:30 p.m., the ADM presented an acceptable plan of action which included the following: On November 18, and 19, 2024: a. Resident 1 was located by law enforcement and taken to the hospital for evaluation. b. The DON/Designee reviewed and audited residents with multiple attempts to leave the facility. Resident 2 was identified and placed under one-on-one supervision for safety. c. The Maintenance Supervisor inspected all exit doors and the WanderGuard system to ensure the alarms were working. All alarms and systems were functioning properly. d. New orders to monitor WanderGuard placement and function were added to the medication administration records for the five residents who were at risk. All wander guards were in place as ordered. IDT ((interdisciplinary team - a group of healthcare professionals from different disciplines who work together to provide care for a resident), and care plans were updated based on elopement risk assessments. e. The Administrator and DON provided in-service training to facility staff on the facility's wandering and elopement, policies, focusing on interventions for residents attempting to leave the facility and monitoring the WanderGuard system. The Administrator initiated an in-service with facility staff regarding Adequate Supervision and providing the appropriate level of oversight for all residents based on their needs. f. The Administrator conducted an in-service to licensed nurses on using the transmitter tester for WanderGuard, including proper usage, storage, extra supplies, and battery changes. g. The elopement binder (book with information on the residents identified as an elopement risk) was updated, and residents are being monitored and supervised according to their care plans. h. Starting on 11/19/24, the licensed nurses will conduct room rounds every 2 hours during their assigned shifts to ensure all residents are accounted for and safe. i. DON/Designee checked that all resident identified as risk for elopement had orange arm bands. On November 19, 2024, at 7:43 p.m., the Immediate Jeopardy was removed in the presence of the ADM, DON, Regional Quality Management Consultant and ADM Consultant, upon onsite verification of implementation of the plan of action. Noncompliance for F689 remained at the lower scope and severity of D no actual harm with potential for more than minimal harm. Findings: On November 15, 18, and 19, 2024, unannounced visits were conducted at the facility to investigate complaint allegations. 1. On November 18, 2024, at 12:00 p.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he received notice that Resident 1 eloped from the facility on November 18, 2024, during the night (11:00 p.m. to 7:00 a.m.) shift and had not returned yet. LVN 1 stated according to the information he received Resident 1 opened the front door of the facility at 2:00 a.m. A certified nursing assistant (CNA) tried to stop him, but he started running. LVN 1 stated the CNA tried to follow Resident 1 for 30 minutes outside the facility, but it got too dark, and the CNA returned to the facility. LVN 1 stated Resident 1 had an ankle monitor due to being on probation, and a WanderGuard as well. LVN 1 stated Resident 1 had a history of leaving the facility and staff had been able to bring him back to the facility. LVN 1 stated the facility placed an extra lock to the front door and there are alarms on all the doors of the facility. LVN 1 stated residents are assessed for risk for elopement upon admission, after each incident of elopement and quarterly. LVN 1 stated when a resident is identified as at risk for elopement, they get an order for WanderGuard from the physician, place the resident ' s information in the elopement binder, initiate a care plan and notify the staff as well. LVN 1 stated a resident at risk for eloping may also be placed on close monitoring like a 1:1 (a medical intervention where a resident is constantly observed by a staff member). LVN 1 stated a 1:1 is initiated after a resident tries to elope from the facility and if the resident is at high risk for elopement. LVN 1 stated the 1:1 ends depending on how the resident is doing. A concurrent review of Resident 1 ' s medical record was conducted with LVN 1. The record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (loss of cognitive functioning, such as thinking, remembering, and reasoning, that interferes with daily life). A review of Resident 1 ' s Elopement assessment dated [DATE], indicated Resident 1 was identified as at risk for elopement. A review of Resident 1 ' s care plan indicated Resident 1 had multiple attempts to leave the facility on August 19 and 23, September 4 and 19, October 27, and November 2 and 15, 2024. LVN 1 stated Resident 1 should have been placed on a 1:1 and frequent visual checks. On November 18, 2024, at 2:10 p.m., during an interview with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated Resident 1 was independent to most activities of daily living (ADL) and had a WanderGuard on. She stated on November 15, 2024, as they were passing out breakfast trays, she heard that Code Pink was announced and that meant that a resident eloped. CNA 1 stated she knew that it was Resident 1. CNA 1 stated LVN 3 followed Resident 1 up to the gasoline station and Resident 1 was brought back to the facility. CNA 1 stated Resident 1 was not placed on a 1:1. They just kept a closer eye on Resident 1, and all staff checked the doors. CNA 1 stated Resident 1 did not have any further attempts to elope during that shift. On November 18, 2024, at 3:29 p.m., during an interview with LVN 2, LVN 2 stated residents identified as at risk for elopement were frequently checked visually, the facility has alarms installed on all exit doors and provides WanderGuard to these residents. LVN 2 stated she was the charge nurse for the night shift (11:00 p.m. to 7:00 a.m.) when Resident 1 eloped on November 18, 2024, at around 2:00 a.m. LVN 2 stated Resident 1 had frequently eloped from the facility, and they conducted visual checks on him every 30 minutes. LVN 2 stated Resident 1 was pacing throughout the hallways, she gave him Ativan (a medication that treats anxiety-a mental illness) and approximately 15 minutes after giving Resident 1 Ativan, a CNA saw Resident 1 leave through the emergency exit door. The CNA followed Resident 1 but was not able to bring him back to the facility. The CNA returned to the facility and took her car to continue searching for the resident but Resident 1 could not be located. LVN 2 stated Resident 1 was not on a 1:1 at the beginning of the shift, and he continued to pace around the facility. LVN 2 stated there were no other interventions initiated for Resident 1. LVN 2 stated when Resident 1 was pacing around the facility a 1:1 was indicated, and she would have placed Resident 1 on 1:1 if there was enough staff. A review of Resident 1 ' s medical record was conducted on November 18, 2024. Resident 1's History and Physical dated May 6, 2024, indicated Resident 1 can make needs known but cannot make medical decisions. A review of Resident 1's Elopement Evaluation dated August 23, 2024, on PointClickCare (PCC - an electronic health record) indicated he was at risk for elopement. A review of the care plan titled, The resident has a behavior problem attempted to leave the facility, initiated on July 9, 2024, and revised on November 18, 2024, indicated Resident 1 had an actual attempt to leave the facility on August 19, 2024, and he eloped on November 18, 2024. The care plan had interventions initiated on July 9, 2024, which included .Administer medications as ordered. Monitor/document for side effects and effectiveness .Anticipate and meet The (sic) resident ' s needs .Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately . The care plan also had interventions inititated on August 20, 2024, which included .Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes .Provide a program of activities that is of interest and accommodates residents (sic) status . A review of the care plan titled, Risk for Wandering / Elopement Identified with an initiated date of August 19, 2024, indicated Resident 1 had an episode of elopement on September 4, 2024, and three episodes of elopement on August 19, 2024. The care plan had interventions initiated on September 4, 2024, which included, .Clearly identify Resident ' s room & bathroom .Engage Resident in purposeful activity .Identify if there is a certain time of day wandering / elopement attempts occur .Implement scheduled hydration, if not contraindicated .schedule time for regular walks / appropriate activity . A review of the care plan titled, Resident had an episode of non-compliance and attempted to leave the facility on 10/27/2024 .11/2/2024 . initiated on October 27, 2024 and revised on November 18, 2024, had interventions initiated on October 27, 2024, which included .Anticipate and meet needs .Apply wanderguard (sic) for increase safety, resident refused wanderguard (sic) .For monitoring of behavior per protocol .IDT with parole officer for safe discharge .Psychiatric evaluation . The care plan had interventions initiated on October 28, 2024, which included .Redirect resident as necessary . The care plan also had interventions initiated on November 2, 2024, which included .Lorazepam (Ativan) Tablet 0.5 mg Give 1 tablet by mouth every 8 hours as needed for restlessness for 14 Days and re-assess .Notify family per protocol .Notify MD (medical doctor) for recommendations . A review of Resident 1 ' s Physician Note titled Psychiatry dated October 29, 2024, indicated Resident 1 .presents significant risk to self due to impaired judgment and attempts to leave facility without safety awareness. Requires close supervision . A review of Resident 1's Behavior Note dated November 15, 2024, indicated .Resident 1 eloped this morning using emergency side door and staff were able to walk the resident back to the facility . A review of Resident 1 ' s Progress Notes indicated the following: a. On November 15, 2024, Resident 1 eloped from the facility in the morning using emergency side door. Resident 1 was brought back to the facility by staff. The ADM, Resident 1 ' s doctor and family were made aware. b. On November 18, 2024, at 2:13 a.m., staff heard a door alarm and ran to the doors. CNA 1 chased Resident 1 but was unable to redirect back to the facility. Staff drove around the perimeter of the facility but was unable to locate the resident. The ADM and Police Department were notified. Resident 1 ' s doctor and family were notified. There was no documented revision on Resident 1 ' s care plans or post elopement IDT meetings from November 15 to November 18, 2024, to address why Resident 1 continued to make elopement attempts or interventions implemented to reduce his risk for elopement. On November 19, 2024, at 11:59 a.m., during an interview with Registered Nurse (RN) 1, RN 1 stated residents who are at risk for elopement and exhibit exit seeking behaviors are provided with a WanderGuard and a 1:1. RN 1 further stated a 1:1 is also recommended for a patient who had eloped. RN 1 stated incidents of elopement were discussed during their stand-up meeting, and sometimes they do not document that. RN 1 further stated it was usually the Social Service Director who documents IDT meetings. A review of Resident 1 ' s care plan was conducted with RN 1. RN 1 stated there were no updates on Resident 1 ' s elopement care plans after November 2, 2024. RN 1 stated the care plans were ineffective because Resident 1 successfully eloped on November 18, 2024. On November 19, 2024, at 2:27 p.m., during an interview with the DON, the DON stated Resident 1 had multiple attempts to elope, was always redirected back to the facility by staff, was provided with frequent visual checks, every 30-minute monitoring, had a psychiatry evaluation with (name of psychiatrist), and the family, doctors and parole officers were notified. The DON further stated the facility was not the proper place for Resident 1 and he needed a locked unit. The DON stated it was not appropriate for Resident 1 to stay at the facility. The DON stated every time Resident 1 eloped, they contacted the police; on August 19, 2024 after he attempted to elope, he was transferred to the hospital for evaluation and returned to the facility the same day, they contacted the crisis team interventions multiple times and sought a 5150 hold (a legal procedure that allows involuntary detention of an adult for up to 72 hours for psychiatric evaluation and treatment), but none were able to assist. A record review of the Social Services Progress Note dated November 5, 2024, indicated .Crisis team in this afternoon, no changes per team the resident is safe, and in safe environment . On November 19, 2024, at 6:30 p.m., during a concurrent interview and record review with the DON, Resident 1 ' s care plans and progress notes for the period of November 15 to 18, 2024 were reviewed. The DON stated there were no revisions on the care plans titled The resident has a behavior problem attempted to leave the facility, initiated on July 9, 2024, and revised on November 18, 2024, Risk for Wandering / Elopement Identified with an initiated date of August 19, 2024, and Resident had an episode of non-compliance and attempted to leave the facility on 10/27/2024 .11/2/2024 . initiated on October 27, 2024 and revised on November 18, 2024, and there was no IDT meeting conducted on November 15 to 18, 2024. On November 19, 2024, at 7:08 p.m., during an interview with the ADM, The ADM stated the expectation for staff and the IDT was to find other interventions to prevent Resident 1 from eloping from the facility, but it was challenging. The ADM stated the facility tried to manage Resident 1 the best they could. On November 20, 2024, at 11:30 a.m., during an interview with Resident 1 at the general acute hospital (GACH), Resident 1 stated he left the facility because his wife and cousins were waiting for him. A review of Resident 1 ' s GACH records titled, ED (Emergency Department) Note - Physician dated November 19, 2024, indicated Resident 1 was admitted to the GACH on November 18, 2024, at approximately 8:50 p.m., and was placed on a 5150 hold (a legal process for the involuntary detainment of an adult in a psychiatric hospital up to 72 hours). The police found Resident 1 wandering in a stranger ' s backyard covered in feces (poo) and was disoriented. On November 29, 2024, at 2:09 p.m., during a telephone interview with the DON, the DON stated prior to Resident 1 eloping on November 18th, he was being monitored for elopement every shift. The DON stated he was not placed on every 30-minute monitoring because his elopement attempts was considered as his behavior. A review of the facility ' s policy and procedure titled, ' Wandering and Elopement dated February 10, 2023 indicated .The resident ' s risk for elopement and preventative interventions will be documented in the resident ' s medical records and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly and upon change in condition .The IDT will develop a plan of care considering the individual risk factors of the resident .upon return the Licensed Nurse will implement immediate interventions to prevent further elopement of the resident and update the plan of care .The Interdisciplinary Team as part of the investigation will conduct a post elopement meeting to determine if alternative prevention measures can be put in place (activities, rehab, etc.) . A review of the facility ' s policy and procedure titled, Resident Safety dated April 15, 2021, indicated .During the comprehensive assessment period the interdisciplinary team (IDT) members will assess the Resident ' s safety risk (e.g.wandering, elopement .) as well as any other Resident specific safety risks . After a risk evaluation is completed, a Resident-centered care plan will be developed to mitigate safety risk factors . 2. On November 18, 2024, a review of Resident 2 ' s electronic health information on PointClickCare (PCC) indicated the following: -Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia and was identified at risk for elopement. -The Minimum Data Set (MDS - an assessment tool) dated August 17, 2024, indicated Resident 2 had moderate cognitive (ability to think and reason) impairment. -The physician ' s order indicated Resident 2 had an order for .Wander Guard to left wrist for safety/elopement . dated August 15, 2024. -The care plan titled Risk for Wandering /Elopement Identified dated August 13, 2024, and was revised on September 6, 2024, indicated Resident 2 left the faciity on [DATE], and Resident 2 attempted to elopement on September 6, 2024. On November 18, 2024, at 3:29 p.m., during an interview with LVN 2, LVN 2 stated she was not sure who monitors if the WanderGuards were functioning. On November 18, 2024, at 4:20 p.m., during an interview with LVN 3, LVN 3 stated Resident 2 had an order for a WanderGuard. On November 18, 2024, at 4:28 p.m., a concurrent interview and observation with Resident 2 was conducted with LVN 3. Resident 2 was in bed, alert, awake, and watching television. A suitcase was observed on top of a chair opposite her bed. Resident 2 stated she did not have any type of bracelet monitors on her. LVN 3 stated he did not know what happened to Resident 2 ' s WanderGuard. LVN 3 stated he did not know how to check if WanderGuards were working or how to connect it to the WanderGuard alarm system. LVN 3 stated that when a resident with a WanderGuard goes near the doors, the alarm will go off. On November 18, 2024, at 6:19 p.m., during a follow up observation of Resident 2 in her room, Resident 2 was not wearing a WanderGuard bracelet. On November 18, 2024, at 6:20 p.m., CNA 2 was asked to check if Resident 1 was wearing a WanderGuard. CNA 2 stated Resident 2 did not have a WanderGuard, CNA 2 further stated Resident 2 should have a WanderGuard on because she packed her things and has said she wanted to leave the facility in the past. On November 19, 2024, at 2:27 p.m., during an interview with the Director of Nursing (DON), the DON stated Resident 2 should have the WanderGuard on because there was a physician ' s order. On November 25, 2024, at 11:29 a.m., during a telephone interview with the DON, the DON stated it was the licensed nurses ' responsibility to check for the placement and functionality of the WanderGuard. A review of the facility ' s policy and procedure titled .Signaling Device dated October 26, 2023, indicated .A Signaling device is an intervention that can be utilized as part of a Resident ' s plan of care when they have been identified as being at risk for elopement .The need for the use of a signaling device will be based on the Resident ' s Elopement Assessment . A Physician ' s order must be obtained for the use of signaling device .The placement will be verified every shift .Functionality of the signaling device should be verified daily .The licensed nurse will document the placement and functionality in the Resident ' s medical record .

Based on interview and record review, the facility failed to ensure a resident (Resident A), was free from financial abuse by Certified Nursing Assistant (CNA) 1, when CNA 1 misappropriated checks/resident finds to a total of $1,300.00. This placed other residents at risk of financial abuse by CNA 1. Findings: The facility failed to ensure Resident A was protected from the misappropriation of the resident's property when checks were deliberately taken from Resident A's purse and cashed without Resident A's consent by CNA 1 (Certified Nursing Assistant). On July 24, 2013, the facility reported that CNA 1 had been accused of stealing and cashing three checks taken from Resident A's purse. Copies of the checks were provided to Administrator 1 by Resident A on July 22, 2013. A follow-up telephone interview with Administrator 1 on July 24, 2013, indicated the checks totaled $1300.00. Check #505 for $500.00 and dated July 11, 2013, check #506 for $400.00 and dated July 15, 2013 and check #507 for $400.00 and dated July 18, 2013. The checks were written out to CNA 1's mother. The resident was provided with the Potential Identity Theft Notification Letter. The (name of city) Police Department (PD) was notified. On August 6, 2013, an unannounced visit was made to the facility to investigate the entity-reported event regarding the alleged misappropriation of Resident A's funds by CNA 1. Administrator 1 was interviewed at 10:55 a.m., and indicated a call was received on July 18, 2013, from an officer of the PD. It was reported that the PD was investigating the financial abuse of another resident by CNA 1. An investigation of the incident was then initiated by the facility and it was discovered that three other residents (including Resident A) had reported thefts. CNA 1 had been arrested by the PD on July 19, 2013, for fiduciary elder abuse and forgery against another resident. The record for Resident A was reviewed on August 6, 2013. Resident A, age 65, was admitted to the facility on [DATE]. Resident A was discharged from the facility on July 30, 2013.

Based on interview and record review, the facility failed to protect the rights of Resident A from the misappropriation of the resident ' s property by CNA 1 (Certified Nursing Assistant) when money was deliberately used without the resident's consent. Findings: On July 19, 2013, the facility reported that CNA 1 had been accused of stealing money from Resident A. CNA 1 was arrested by the (name of city) Police Department (PD) on July 19, 2013. On August 6, 2013, an unannounced visit was made to the facility to investigate the entity-reported event regarding the alleged misappropriation of Resident A's funds by CNA 1. Administrator 1 was interviewed at 10:55 a.m., and indicated a call was received on July 18, 2013, from an officer of the PD. It was reported that the PD was investigating the financial abuse of Resident A by CNA 1. The PD officer scheduled an interview with the resident for July 19, 2013, at 7:30 a.m. An investigation of the incident was then initiated by the facility. On July 24, 2013, the police report regarding the above allegation was faxed to the Department. The following was documented under Summary: "Suspect (CNA 1) ...used (Resident A ' s) ATM debit card and wrote out several checks without (Resident A's) permission. All the transactions totaled $14,919.58. " The Narrative Report indicated CNA 1 had written nine checks to himself, made four electronic debits and one pre-authorized debit. The report further indicated that Resident A's friend, who had Power-of-Attorney over the resident's finances, had gone to the bank and was told "the account had been frozen" due to "suspected possible fraud" . Discrepancies were noticed within the account statements from April 26, 2012, to July 12, 2013 - "ATM transactions and several checks written out for large amounts" . This was then reported to the police department on July 15, 2013. The report further indicated the PD officer interviewed Resident 1's roommate, Resident B who provided a witness statement. Resident B reported that he had never seen Resident A write a check to CNA 1 and that Resident A had a bad habit of leaving his checkbook on top of his nightstand. The PD officer then waited in the facility's parking lot for the arrival of CNA 1. Upon arrival, CNA 1 was approached and asked whether Resident A had given him money or checks. Per the report, CNA 1 stated, ...he had been "suffering from financial hardship ... (Resident A) had offered to help him and gave him the checks ...all the checks and had signed them all on the same day." The report indicated CNA 1 was then arrested for fiduciary elder abuse and forgery. The record for Resident A was reviewed on August 6, 2013. Resident A, age 83, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The facility failed to protect Resident A from the misappropriation of the resident ' s funds by CNA 1 when money, totaling $14, 919.58, was deliberately used without the resident ' s consent. This failed practice placed Resident A and other residents at risk for abuse by CNA 1.