Every finding on record at College Oak Nursing and Rehabilitation Center

Based on interview and record review the facility failed to provide accurate information to a receiving facility (Assisted Living Facility-ALF) for one of three sampled residents (Resident 1) when the facility sent inaccurate assessment information (contained in form LIC 602A; a mandated Physician's Report used for assisted living facility admissions to determine if the facility can care for the resident) that did not reflect Resident 1's overall level of function, skin status and other care needs prior to Resident 1's acceptance and transfer to the ALF on 7/24/26.This failure had the potential for the ALF to be unable to care for Resident 1 based on inaccurate overall care needs documented on assessment form LIC 602A the facility provided.A review of Resident 1's facesheet (a single-page summary document used in healthcare to display a patient's core administrative and clinical data quickly) indicated Resident 1 was admitted to Facility A on 7/4/26, with diagnoses of Cognitive communication deficit (trouble with communication caused by disrupted thinking skills-such as memory, focus, or planning), history of falling, muscle weakness, mild cognitive impairment (a condition causing more memory and thinking trouble than normal aging), and bilateral ( on both sides) hearing loss.A review of Resident 1's progress note dated 7/4/26, indicated, He [Resident 1] needs redirection as he has been observed wandering in and out of the room.A review of Resident 1's Discharge Instruction Form dated 7/23/26 indicated, Perineal area [area between the scrotum and the anus] onto coccyx [tailbone area] MASD [(Moisture-Associated Skin Damage) is a specific type of skin breakdown when prolonged exposure to bodily fluids or moisture breaks down and erodes the skin's outer protective barrier]/redness. Form indicated Resident 1 had areas of skin breakdown.A review of Resident 1's Change in Condition Evaluation dated 7/20/26 indicated, Resident 1 had an episode of elopement (occurs when a patient/resident who lacks the mental capacity or legal authorization to leave, leaves the facility).A review of Resident 1's Minimum Data Set (MDS- federally mandated, standardized clinical evaluation tool that measures a resident's functional capabilities, cognitive status, and health needs) Section GG dated 7/10/26 indicated Resident 1 requires partial to moderate assistance for dressing upper and lower body.A review of Resident 1's MDS Section GG dated 7/24/26 indicated Resident 1 needs partial to moderate assistance to bathe self.A review of Resident 1's LIC602A form undated, with exam date of 7/21/26 indicated transferring facility name, address, phone number were blank. Form indicated for Auditory Impairment NO was marked. For History of Skin Condition or Breakdown NO was marked. For Wandering Behavior NO was marked. For able to bathe self YES was marked. For able to dress/groom self YES was marked. For able to manage own cash resources YES was marked.During an interview on 8/12/26, at 11:20 a.m., with Case Manager (CM), CM stated she is responsible for filling out the LIC602A form and having the physician sign. CM stated the purpose of the form is provide a brief summary of the residents' cognition, mobility and care requirements to the outside facility to determine if they meet criteria to be accepted at the facility and they are able to care for them.During an interview on 8/12/26, at 10:56 a.m., with Director of Nursing (DON) DON stated Resident 1 had a diagnosis of cognitive communication deficit, and bilateral hearing loss.During an interview on 8/12/26, at 1:17 p.m., with DON, DON stated Resident 1's LIC602A form had some inaccurate answers. DON stated Resident 1 has hearing loss, so the form should be marked YES in that section instead of NO. DON stated if Resident 1 was assessed in the MDS as partial to moderate assistance with bathing and dressing, those sections that ask able to bathe self and able to dress self, should be marked as NO, and they were marked as YES. DON stated, Resident 1 is not capable of managing his own cash, so that section should be marked as NO, and it was marked as YES. DON further stated for section about wandering behavior, it should be marked YES, instead of NO, because Resident 1 had an elopement from the facility and exhibited that behavior. DON stated it was her expectation that assessments accurately reflect the resident care needs.During an interview on 8/12/26, at 2:25 p.m., with CM, CM stated, she would mark yes on the LIC602A form for A wandering behavior if the resident had an elopement attempt or wandering without supervision. CM stated she was aware of Resident 1's elopement from the facility on 7/20/26. CM stated in order to answer the question if the resident could bathe or dress themselves, she will review the resident's MDS. CM stated she should have marked NO when asked if the Resident is able to manage own cash.A review of Facility A's Policy and Procedure (P&P) titled, Transfer or Discharge dated 2025 indicated, Transfer and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record.Transfer or Discharge Documentation in the Medical Record 1. When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: .A summary of the resident's overall medical, physical, and mental condition.

Based on interview and record review the facility failed to provide written notice of bed hold policy upon transfer to one of three sampled residents (Resident 1). When Resident 1 was transferred to an acute care hospital and Resident 1's responsible party (RP) was not given a written notice of the facility's bed hold policy.This failure had the potential for Resident 1 and their RP to not be informed of their rights to return to the facility.A review of Resident 1's progress note dated 5/11/26 indicated, resident was sent to an acute care hospital for treatment via 911 as an emergency transfer.A review of Resident 1's Notice of Transfer/discharge date d 5/11/26 indicated, Resident 1's RP was notified via phone of the transfer. Notice indicated, [RP name] did not give concent [sic] for bed hold via phone. Notice indicated, no signature from RP or indication it was sent to RP.During an interview on 5/29/26, at 12:01 p.m., with the Director of Nursing (DON), DON stated, We did not send a written notification of bed hold for Resident 1's transfer on 5/11/26. DON stated, the facility notified the RP of the bed hold via phone only.During an interview with Assistant Business Office Manager (ABOM) on 5/29/26, at 12:18 p.m., ABOM stated, the business office is responsible for sending bed hold policy notifications to the residents or the resident's family. ABOM stated, the facility did not send a written notice of the facility's bed hold policy to Resident 1's RP for the transfer on 5/11/26.During a review of the facility's Policy & Procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, dated 2022, the P&P indicated, 5. Notice of Facility Bed-Hold and return policies are provided to the resident and representative within 24 hours of emergency transfer.During a review of the facility's Policy & Procedure (P&P) titled, Bed-Holds and Returns dated 2022, the P&P indicated, Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. 1. All residents/representatives are provided in written information regarding the facility an state bed-hold polices, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents regardless of payer source, are provided written notice about these policies at least twice: a. Notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours).

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and served in a sanitary manner for a census of 112 when:1.Three bags of food were found unsealed in the freezer, and 2.There was a large buildup of black residue on the inside door jam of the walk-in refrigerator .These failures present a potential risk of foodborne illnesses for residents eating facility prepared meals.Findings:1.During a concurrent observation and interview on 4/6/26 at 8:12 a.m. with the Dietary Supervisor (DS) in the facility kitchen, a plastic bag of 216 biscuits, about 1/3/full, a large bag of 144 enchiladas in an open box and a partial bag of 107 sausage patties were found in unsealed plastic bags, open and exposed to the air and contamination in the facility freezer. DS verified the bags were unsealed and available for use.2. During an observation on 4/6/26 at 8:28 a.m. of the walk-in refrigerator in the facility kitchen, a heavy black residue was observed around the door frame inside the walk-in fridge. There was heavier residue toward the bottom and blackish residue on the putty around a pipe containing electrical wiring in the left corner of the refrigerator window.During an interview on 4/6/26 at 8:30 a.m. with Dietary Aid (DA)1 in the facility kitchen, DA 1 stated, I have not noticed black [residue on the door frame] in the walk-in fridge. Two other anonymous kitchen staff were asked and indicated they had not noticed any black residue in the walk in fridge.During an interview on 4/6/26 at 8:32 a.m. with the DS in the facility kitchen, DS said, I was not aware of the black [residue] around the door casing in the walk-in refrigerator.Food should be tightly closed and the [enchilada] box closed as well.During a concurrent observation and interview on 4/6/26 at 8:34 a.m. with the Maintenance Supervisor (MS), MS verified the black colored residue around the door jam and pipes carrying electrical wiring and indicated he had never noticed the black [residue] on the inner door jam or on the putty at the top of the window.During an interview on 4/9/26 at 8:55 a.m. with the Registered Dietician (RD) in her office, the RD said, I do an inspection of the walk-in refrigerator monthly and have never seen black discoloration around the door jam. The RD was asked her expectation for cleaning of the walk-in refrigerator and the sealing of plastic bags of food in the freezer and said, My expectation is to monitor and keep the refrigerator clean. Bags of food should be kept sealed to protect from freezer burn. If not sealed, it could cause freezer burn, change in appearance and flavor.During a review of the facility policy and procedure (P&P) titled PROCEDURE FOR FREEZER STORAGE, dated 2023, the P&P indicated, Store frozen foods in an airtight moisture resistant wrapper such as a plastic bag.to prevent freezer burn.During a review of the facility P&P titled, PROCEDURE FOR REFRIGERATED STORAGE, dated 2023, the P&P indicated, Refrigeration equipment should be routinely cleaned.

Based on interview and record review, the facility failed to notify a room change and to provide room transfer assessment for two of 112 sampled residents (Resident 32 and Resident 127) when Resident 127 was moved into Resident 32's room.These failures resulted in both Resident 32 and Resident 127 to be inadequately informed regarding the transfer and did not receive complete assessments following the room change.Findings:Resident 127 was admitted to the facility in December of 2025 with diagnoses which included Diabetes Type II with neuropathy (nerve damage) and Asthma (a condition in which your airways narrow and swell and may produce extra mucus)Resident 32 was admitted to the facility in August of 2023 with diagnoses which included Epilepsy (a type of seizure) and Diabetes Type II.A review of Resident 127's Order Summary Report (ORS) indicated, Resident has capacity to understand choices and make health care decisions.A review of Resident 127's Minimum Data Set (a standardized assessment tool used in nursing homes), dated 3/17/26, indicated Resident 127 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition.During an interview with Resident 127 on 4/6/26 at 8:43 a.m. in her room, Resident 127 stated being relocated from her previous room without a clear explanation, other than being informed that the room required cleaning and she would return afterwards. Resident 127 expressed concern that the information provided for the transfer was inaccurate and stated she did not wish to move rooms. She further stated that neither the nursing staff nor the Certified Nurse Assistants (CNA) provided additional information regarding the transfer. Resident 127 stated a staff informed her that the room had been reassigned to provide accommodation for short-term residents.During an interview with the Assistant Director of Nursing (ADON) on 4/6/26 at 10:51 a.m., the ADON explained that facility policy requires obtaining resident consent prior to moving them to a different room. She emphasized that the facility could not relocate a patient solely to accommodate another individual, regardless of whether they were receiving long-term or short-term care. Furthermore, she stated that residents must be informed of the reason for any transfer. The ADON stated that she was unaware of the reason for Resident 127's room change.During a concurrent interview and records review with the Social Services Director (SSD) on 4/6/26 at 11:11 a.m., the SSD explained that residents must be notified of any room changes and must provide consent. The SSD stated that requiring a short-term room was not an appropriate justification for initiating room changes. Additionally, the SSD stated that once a room change was initiated, a room change assessment must be completed. It was confirmed that Resident 127 was relocated on 4/4/26; however, the room change assessment section was not completed. Furthermore, there was no documentation regarding the reason for the transfer or evidence of Resident 127's consent to the move. The SSD acknowledged that all transfers should be documented in resident records, The SSD was unable to identify who initiated the transfer of Resident 127.During an interview with Resident 32 on 4/9/26 at 9:15 a.m., outside the dining hall, Resident 32 stated that she remembered her roommate, Resident 127, moving into her room. She further stated that she was not informed by staff regarding the move.During a concurrent interview and records review with SSD on 4/9/26 at 9:55 a.m., SSD verified that documentation was not available to indicate that Resident 32's responsible party (RP) was notified of the transfer. Additionally, the SSD stated there was no record indicating that Resident 32 was informed of the transfer. Furthermore, she confirmed that the transfer form had not been initiated. The SSD stated that there should have been documentation in Resident 32's records.During an interview conducted with the Administrator (ADM) on 4/9/26 at 10:06 a.m., the ADM verified that Resident 127 had been transferred to another room on 4/4/26. However, the ADM was unable to provide information regarding who authorized the transfer or the reason for its occurrence.A review of the facility policy and procedure (P&P) titled, Room Change/Roommate Assignment revised 03/21 indicated, .Resident preferences are taken into account when such changes are considered.Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives are given written notice of such change.Resident have the right to refuse to move to another room in the facility if the purpose of the move is:.from skilled nursing within the facility to one that is not a skilled nursing unit.from a nursing unit within the facility to one that is skilled nursing unit.solely for the convenience of staff.Documentation of a room change is recorded in the resident's medical record.

Based on interviews, observations, and record review the facility failed to manage pain for two of 24 sampled residents (Resident 3 and Resident 136), when Resident 3 and Resident 136 reported significant pain to staff and did not receive their ordered pain medication when requested. This failure led to prolonged pain for Resident 3 and Resident136.Findings:Resident 3 was admitted to the facility in March of 2026 with diagnoses that included epididymitis (inflammation in the sperm-carrying tube at the back of the testicle causing pain and swelling).A review of Resident 3's Minimum Data Set (MDS, an assessment tool used in skilled nursing facilities), dated 3/25/26, indicated Resident 3's Brief Interview for Mental Status (BIMS, an assessment to test cognitive function) was 15, indicating that Resident 3 had no cognitive deficits.A review of Resident 3's, Order Details, dated 3/30/26, indicated, oxyCODONE [medication used to treat moderate to severe pain] HCL [hydrochloride] Oral tablet 10 MG [milligrams, a unit of measurement] Give 1 tablet by mouth every 6 hours as needed for pain.A review of Resident 3's, Medication Administration Record, dated 4/2026, indicated that Resident 3 had received his last dose of oxycodone on 4/6/26 at 5:22 a.m. and was due for another dose by 11:22 a.m.During an interview on 4/6/26 at 2:57 p.m. with Resident 3, Resident 3 indicated that he had requested his oxycodone pain medication before lunch but did not receive it until two to three hours later at 1:59 p.m. Resident 3 had described his pain as, It feels like someone is hitting me with a hammer on my testicle. He further indicated that the pain had made it very difficult for him to move around limiting his mobility and independence.During an interview on 4/7/26 at 9:14 a.m. with Licensed Nurse 3 (LN 3), LN 3 indicated that he had been running behind during his shift on 4/6/26 and it had caused him to administer Resident 3's pain medication late.Resident 136 was admitted to the facility in March of 2026 with diagnoses that included breast cancer.A review of Resident 136's, Order Details, dated 3/31/26, indicated, Hydrocodone-Acetaminophen [medication used to treat significant pain] Tablet 5-325 MG *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for pain management Hold if RR [respiration rate] is less than 12.A review of Resident 136's, Medication Administration Record, dated 4/2026, indicated that Resident 136 had received her last dose of hydrocodone-acetaminophen on 4/5/26 at 1:44 a.m.During an interview on 4/6/26 at 12:13 p.m. with Resident 136, Resident 136 indicated that she had requested her pain medication last night but was not given the pain medication because staff told her, It is not available. Resident 136 further indicated that she had not slept well and was in pain during the night due to the missed dose of pain medication.During an interview on 4/6/26 at 12:57 p.m. with LN 2, LN 2 confirmed that Resident 136 had not received a dose of her pain medication last night even though the pain medication was due and was available to obtain from an e-kit [emergency kit, a container with medications that are used during emergencies or shortages]. LN 2 indicated that nursing staff should have ensured pain medications did not run out and that nursing staff should have called pharmacy prior to running out of medications to ensure there was adequate pain management for residents.During an interview on 4/8/26 at 1:56 p.m. with the Director of Nursing (DON), the DON explained that if a resident had reported pain, staff should have assessed the resident and administered pain medications as ordered by the physician. The DON indicated that a resident should not wait hours to receive pain medication if it was due. The DON further indicated that if pain medication was not available in the medication cart, staff should have obtained it from the e-kit and requested a refill from the pharmacy.During a review of the facility's policy and procedures (P&P) titled, Pain Assessment and Management, revised 10/22, the PNP indicated, The medication regimen is implemented as ordered.

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the accepted professional principles and current standard of practice for a census of 112 when an over the counter medication was found stored out of its original package. These failures had the potential for residents to receive medications that were expired and with unsafe or reduced potency.Findings: During a concurrent observation and interview on [DATE] at 1:52 p.m., with Licensed Nurse (LN) 5 on south medication cart, seven cough drops were found in a clear plastic cup and not in their original packaging. LN 5 confirmed the observation. LN 5 stated there were no expiration dates on the cough drops and they should have been in their original packaging. During an interview on [DATE] at 2:04 p.m., with LN 4, LN 4 stated over the counter cough drops needed to be stored in their original package. LN 4 further stated if not stored in the original package, the cough drops could potentially be expired and not safe for residents. During an interview on [DATE] at 8:39 a.m., with the Director of Nursing (DON), the DON stated the expectation was for nursing staff to store all medications, including over the counter medications, in their original packaging. DON further stated medications not stored in their original packaging and without expiration dates, could potentially be expired and have reduced potency. During a review of the facility's Policy and Procedure (P&P) titled, Medication Labeling and Storage, revised 2/23, the P&P indicated, Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.For over the counter (OTC) medications in bulk containers (if permitted by state law) the label contains: a. medication name; b. strength; c. quantity; d. accessary instructions; e. lot number; and f. expiration date (if applicable).

Based on interview and record review the facility failed to maintain accurate medical records for one out of 13 sampled residents when Resident 12's Medication Administration Record (MAR, a legal document that list administered drugs) was inaccurate and inconsistent with the Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident).This failure placed Resident 12 at risk for medication errors, adverse drug reactions and ineffective drug therapy. Findings: A review of Resident 12's clinical record indicated Resident 12 was admitted March of 2026 with multiple diagnoses which included anxiety disorder and bipolar disorder (mental illness that causes extreme mood swings). A review of Resident 12's active physician's order, dated 4/7/26, indicated, Valium [medication to treat anxiety] Oral Tablet 5 MG [milligrams- unit of measurement] (Diazepam) Give 1 tablet by mouth every 6 hours as needed for Anxiety.A random audit of Resident 12's MAR and the CDR for valium (Diazepam), for March and April 2026, indicated nursing staff did not document valium administration on the MAR when signed out from CDR on 4/1/26 at 1730 [5:30 p.m.]. During a concurrent interview and record review on 4/7/26 at 3:25 p.m. with the Director of Nursing (DON), Resident 12's CDR and MAR were reviewed. The DON confirmed Resident 12's valium use was not accurately documented on the MAR. During an interview on 4/7/26 at 3:56 p.m. with the Nursing Supervisor (NS), the NS confirmed the expectation was for nursing staff to document in both the CDR and MAR when a controlled drug medication was administered. The NS stated inaccurate documenting could potentially result in residents not getting accurate dosage of medication per physician's order. A review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised 7/2017, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .complete, and accurate.A review of the facility's P&P titled, Controlled Medications, dated 3/2018, indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration 2) Amount administered 3) Signature of the nurse administering the dose, completed after the medication is actually administered.

Based on interview and record review, the facility failed to ensure a safe and appropriate discharge was provided to one of three sampled residents (Resident 1), when Resident 1 was not permitted admission to the facility upon return from a day leave and was discharged to her car.This failure resulted in Resident 1's unanticipated discharge and homelessness with no resources, medical care, or information on how to file an appeal.On 10/23/25 at 1:52 p.m. an Immediate Jeopardy (IJ, a situation in which the facility'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) was identified in the presence of the facility's Administrator (Admin). The IJ began on 9/24/25 when the facility failed to reassess or allow readmission to Resident 1 which resulted in Resident 1's homelessness. The Admin was informed of the facility's failure to follow discharge protocols to ensure resident safety and rights were protected.On 10/29/25 at 11:37 a.m. during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action (POA, interventions to correct the deficient practice) which included:An offer to Resident 1 to be readmitted to the facility;Placement options to Resident 1 in several locations and different levels of care;Hotel accommodations while working with the Resident on options;Immediate in-service training to facility staff regarding the discharge process and education surrounding F627, proper documentation, and what constitutes a resident leaving against medical advice (AMA);Resident leave of absence (LOA) process and policy review and training to all staff;Audits to the LOA binder and orders to ensure facility policy is followed; and,Facility interdisciplinary team (IDT, a team consisting of healthcare professionals across several fields of care) reviewed all AMA discharges to ensure proper and consistent process is followed and documented.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included a right femur (thigh bone) fracture, history of venous thrombosis (blood clot in the veins of the legs), embolism (when the blood clot breaks off and travels to another part of the body, commonly the lungs), localized edema (swelling from trauma, surgery or thrombosis), and chronic kidney disease (damage and dysfunction to the kidneys). During a review of Resident 1's Nurse Practitioner Progress Notes (NPPN) dated 7/31/25 at 10:36 p.m., the NPPN indicated Resident 1 was a high risk for re-hospitalization.During a review of Resident 1's Minimum Data Set (MDS, federally mandated resident assessment tool), dated 9/5/25, the MDS indicated Resident 1 was cognitively intact and capable of making her own decisions. During a review of Resident 1's Order Review History Report (ORHR, physician orders), the ORHR indicated an order, dated 9/5/25, for skilled physical therapy (PT) for five times a week for four weeks which included gait training, wheelchair mobility and neuromuscular re-education (a therapy that improves muscle strength, coordination, and timing after an injury by retraining the body's communication between nerves and muscles). The PT order indicated Resident 1's long term goal would be the ability to demonstrate transfers and ambulation with moderate independence (the ability to perform a significant portion of a task but still need help with other parts, typically involving about 50% assistance from a caregiver or the use of an assistive device).During a review of the Discharge Summary, dated 9/11/25 at 10:27 a.m., the physician documented, Discharge disposition to: Transfer pt [patient] to custodial [personal care or long-term support and is focused on meeting a person's basic needs to ensure their comfort and dignity] until placement is secured. Pt needs placement because she is homeless. [Resident 1] will be transferred back to custodial care until a placement is secured.During a review of Resident 1's Care Plan Conference Notes, dated 9/18/25 at 10:42 a.m., the notes indicated Resident 1's discharge plan was to transfer from skilled to custodial care until placement was secured.During a review of the Social Services Notes, dated 9/24/25 at 2:33 p.m., the Social Services Assistant (SSA) documented, [Due to] patient being out more than 4 [hours], it will be an AMA discharge. During a review of the Social Services Note, dated 9/24/25 at 2:45 p.m. the Social Services Director (SSD) documented, The Nurse Practitioner (NP) has been notified and is in agreement with proceeding with discharge. The resident's belongings and medications will be prepared and made available for pick-up.During a review of Resident 1's Nursing Progress Notes (NPN), dated 9/24/25 at 5:18 p.m., the Director of Nursing (DON) documented, The resident came back to the facility at [4 p.m.] and it was discussed with the resident that the MD [Medical Director] has DC'd [discharged ] the resident AMA.During a review of a physician's order dated 9/24/25 at 6:23 p.m. the order indicated, Resident discharge against medical advice .During a review of Resident 1's NPPN, dated 9/26/25 at 2:24 p.m. the NPPN indicated, Per the nursing notes, Resident 1 left AMA from the facility. The NP indicated she was not in the facility at the time of discharge.During a review of Resident 1's NPN, dated 9/24/25 through 9/26/25, there was no documentation which indicated Resident 1 had the desire to leave the facility AMA. The NPN did not include documentation that the risks and benefits of leaving the facility were discussed with the resident, options or locations that would meet Resident 1's needs having been presented to the resident, or if Resident 1 understood the reason for being discharged and her response to the discharge.During a telephone interview on 10/7/25 at 4:38 p.m. with Resident 1, Resident 1 stated the discharge occurred on 9/24/25, while she was out on private business for a LOA from the facility. Resident 1 indicated that when she returned to the facility that same day, staff notified her she could not return as a resident, failed to assess her after her LOA, packed up her belongings, discharged her to her car, and the facility stated the resident's discharge was considered as Against Medical Advice. Resident 1 indicated the facility wanted her to sign the AMA form, which she refused to sign, because it was not her decision. Resident 1 stated, I'm homeless, I wasn't trying to leave against medical advice, that wasn't my decision, I didn't want to leave. Resident 1 further stated, I was pretty traumatized that day, what do I do now? They made my life hell; their intention was to get rid of me and they did. Resident 1 indicated her discharge plan was to find placement in transitional housing and confirmed she is still unhoused.During a concurrent interview and record review on 10/8/25 at 3:51 p.m. with the Assistant Director of Nursing (ADON), Resident 1's medical record and the facility's Policy and Procedure (P&P) for LOA was reviewed. The ADON confirmed there was no documented evidence in Resident 1's medical record that indicated staff attempted to contact the MD for an LOA order. The ADON stated staff should have contacted Resident 1's MD to request an LOA order, and documented the date and time of the request, the MD's decision and that education was provided to the resident in the resident's medical record. The ADON stated, [Resident 1] was going on LOAs, the last day [9/24/25] she overstayed her LOA. The ADON confirmed the LOA P&P did not indicate a time limit for an LOA or that a resident will be discharged if the LOA P&P was not followed.During a concurrent interview and record review on 10/8/25 at 4:01 p.m. with the Social Services Director (SSD), Resident 1's medical record was reviewed from June 2025 through September 2025. The SSD acknowledged Resident 1 did not have a physician's order for an LOA. The SSD confirmed there was no documentation prior to 9/24/25 in Resident 1's medical record that discussed the facility's LOA process or procedure, the allotted hours Resident 1's insurance authorized for an LOA or that Resident 1 had been non-compliant with her plan of care. The SSD stated Resident 1 had been homeless when she was admitted to the facility and was on a transitional housing waitlist. The SSD stated, Every day [Resident 1] would take off from the facility and would stay over five or six hours. I provided [Resident 1] with housing resources, but at that point it's on the resident to follow through with the discharge placement. The SSD stated, On that day [9/24/25] [Resident 1] left the facility around 10:30 a.m. and the decision to discharge her was because the resident chose to drive her own car instead of having a ride. The SSD indicated for a resident's transfer or discharge the facility needed to provide the resident with a Notice of Transfer or Discharge form which included information on how to file an appeal if the resident did not agree with the transfer or discharge. The SSD confirmed there was no documentation provided to Resident 1 upon her discharge due to the physician's order to discharge her as AMA. The SSD stated, We have to follow the doctor's orders. [Resident 1] did have a discharge plan, but she could not return to living in her car, [Resident 1] is homeless. The SSD admitted , I wouldn't discharge a [resident] to their car. That's not a safe discharge. The SSD acknowledged Resident 1 did not initiate the AMA discharge. During an interview on 10/23/25 at 11:37 a.m. with the DON, the DON acknowledged AMA discharges were resident initiated, not facility initiated, and confirmed the facility was not allowed to discharge a resident while on a LOA. The DON acknowledged that when a resident expressed a desire to leave AMA the facility should educate the resident, explain the risks and benefits of an AMA discharge, and provide follow-up information on where to get additional care and document the discussion in the resident's medical record. The DON stated, Since [Resident 1] was gone for more than four hours, the MD decided to DC the resident AMA.During an interview on 10/23/25 at 12:32 p.m. with the Admin, the Admin acknowledged if a resident verbalized a desire to leave the facility AMA then staff should attempt to provide the resident with education, the risks and benefits between leaving the facility versus staying at the facility, supplies, and additional resources. The Admin indicated if a resident returned to the facility after an identified LOA timeframe, the facility should have ensured the resident was safe and provided the resident with education on following MD orders and the facility's LOA P&P.During a telephone interview on 10/23/25 at 1:18 p.m. with MD 1, MD 1 confirmed an AMA discharge, by definition, was initiated by the resident. MD 1 stated if a resident indicated they wanted to leave the facility AMA and he [MD 1] was not at the facility at the time, he expected the facility staff to document the conversations between the resident and staff which discussed the resident's options, encouragement for the resident to remain in the facility, what the negative outcomes might be if the resident left the facility and what specific medical advice was provided to the resident. MD 1 stated, No, I would not discharge a resident to 'on the street'.During a telephone interview on 10/28/25 at 11:27 a.m. with Resident 1, Resident 1 confirmed she has been living in her car, in a parking lot, since her discharge from the facility on 9/24/25. Resident 1 stated, Emotionally and mentally, I'm gutted.this is very traumatic.and I'm very depressed. Resident 1 stated the healing to her right leg has deteriorated significantly and has continued to swell. Resident 1 stated her right leg is very weak and indicated the need for continued rehabilitation to regain strength and endurance. Resident 1 reported severe pain in her legs and hips, after sleeping in her car. Resident 1 has some blankets and a pillow but continues to worry about the colder weather and rain. Resident 1 stated she will need to relocate to a different parking lot, since her current location was prone to flooding. Resident 1 confirmed her last entry in the LOA binder was 9/24/25 at 10:30 a.m. and when she had returned to the facility at 4 p.m. she expressed that she wanted to be permitted to return.During a review of the facility's policy and procedure (P&P) titled, Resident Leave of Absence, dated 8/2006, the P&P indicated, Each resident leaving the premises (excluding transfers/discharged /appointments) must obtain an MD order for approved leave of absence (LOA).During a review of the facility's P&P titled, Discharging a Resident Without a Physician Approval revised October 2022, the P&P indicated, A physician's order is obtained for discharges, unless a resident or representative is discharging himself or herself against medical advice. 1. Should a resident. request an immediate discharge, the resident's attending physician is promptly notified. 4. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility will. a) discuss with the resident.and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; b) document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed; c) document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings; and d) determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge.During a review of the facility's P&P titled, Transfer or Discharge, Resident Initiated, dated 10/2022, the P&P indicated, 3. a. Therapeutic leave is a type of resident-initiated transfer. However, if the facility makes a determination to not allow the resident to return, the transfer becomes a facility-initiated discharge.For resident-initiated discharges, the medical record contains: e. documentation or evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility; f. a discharge care plan; and g. documented discussions with the resident, or if appropriate, his/her representative, containing details of discharge planning and arrangements for post-discharge care. 2. The comprehensive care plan contains the resident's goals for admission and desired outcomes, which will be in alignment with the discharge if it is resident-initiated.During a review of the facility's P&P titled, Transfer or Discharge Notices, dated 3/2025, the P&P indicated, Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing.A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman. Notice of Transfer or Discharge (Anticipated): 1. The resident and his or her representative are provided with a written notice of impending transfer or discharge at least 30 days prior to the transfer or discharge. 3. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge, including the basis under S483.15(c)(1)(i)(A)-(F); b. The effective date of the transfer or discharge; c. The specific location (such as the name of the new provider, description, and/or address if the location is a residence) to which the resident is being transferred or discharged ; d. An explanation of the resident's rights to appeal the transfer or discharge to the state, including: (1) the name, address, email, and telephone number of the entity which receives such appeal hearing requests; (2) information about how to obtain an appeal form; and (3) how to get assistance in completing and submitting the appeal hearing request; e. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; f. The Notice of Facility Bed-Hold and policies.

Based on interview and record review, the facility failed to ensure one resident out of three sampled residents (Resident 1) was provided with the required discharge notices, when Resident 1 was discharged from the facility.This failure resulted in Resident 1's denied access for advocacy and information for appeal options before being discharged unexpectedly to her car. Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in [DATE] with diagnoses which included a right femur (thigh bone) fracture, history of venous thrombosis (blood clot in the veins of the legs), embolism (when the blood clot breaks off and travels to another part of the body, commonly the lungs), localized edema (swelling from trauma, surgery or thrombosis), and chronic kidney disease (damage and dysfunction to the kidneys).During a review of Resident 1's Minimum Data Set (MDS, federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 1 was cognitively intact and capable of making her own decisions.During a review of Resident 1's Care Plan Report (CPR), dated [DATE] and revised [DATE], Resident 1's CPR indicated Resident 1 would receive verbal and written discharge instructions. During a review of Resident 1's Care Plan Conference Notes, dated [DATE] at 10:42 a.m., the notes indicated Resident 1's discharge plan was to transfer from skilled to custodial care until placement was secured.During a review of a voicemail Resident 1 received from the SSD on [DATE] at 2:36 p.m. the SSD left Resident 1 a voicemail to formally inform her of the facility's decision to discharge her since she has been out of the facility for more than four hours. The SSD continued to reiterate the voicemail was a formal reminder to update and notify Resident 1 of the facility's decision to discharge her as AMA. The SSD indicated Resident 1 may return to the facility to sign paperwork, but she will not be able to stay at the facility. The SSD suggested if Resident 1 has a place to go, then Resident 1 should go there or Resident 1 should return to the emergency room for proper placement. The voicemail indicated a licensed nurse will give Resident 1 her paperwork and the facility will have her belongings available for pickup.During a review of the Social Services Note, dated [DATE] at 2:45 p.m. the SSD documented, The Nurse Practitioner (NP) has been notified and is in agreement with proceeding with discharge. The resident's belongings and medications will be prepared and made available for pick-up.During a review of Resident 1's Nurse Progress Notes (NPN) dated [DATE] at 5:18 p.m., the Director of Nursing (DON) documented, The resident came back to the facility at [4 p.m.] and it was discussed with the resident that the MD [Medical Director] has DC'd [discharged ] the resident AMA.During a review of a physician's order dated [DATE] at 6:23 p.m. the order indicated, Resident discharge against medical advice .During a review of Resident 1's NPN, dated [DATE] through [DATE], there was no documentation which indicated Resident 1 had expressed the desire to leave the facility or if Resident 1 understood the reason for the unexpected discharged or her response to the discharge.During a telephone interview on [DATE] at 4:20 p.m. with the Ombudsman (an advocate for residents in nursing homes addressing issues related to care, safety, and residents' rights), the Ombudsman stated he had not received any recent reports or notifications for Resident 1's discharge from the facility. During a telephone interview on [DATE] at 4:38 p.m. with Resident 1, Resident 1 stated the discharge occurred on [DATE], while she was out on private business for a LOA (leave of absence) from the facility. Resident 1 indicated that when she returned to the facility that same day, staff notified her she could not return as a resident, failed to assess her after her LOA, packed up her belongings, and unexpectedly discharged her to her car. Resident 1 stated, I'm homeless, I wasn't trying to leave., that wasn't my decision, I didn't want to leave. Resident 1 further stated, I was pretty traumatized that day, what do I do now? They made my life hell; their intention was to get rid of me and they did. Resident 1 indicated her discharge plan was to find placement in transitional housing and confirmed she is still unhoused. Resident 1 confirmed the facility did not give her written notification or discharge instructions at the time of her discharge and stated she was unaware of her right to appeal the decision or who to contact for support or guidance. During a concurrent interview and record review on [DATE] at 4:01 p.m. with the Social Services Director (SSD), Resident 1's medical record was reviewed from [DATE] through [DATE]. The SSD indicated a Notice of Transfer or Discharge form, which included information on how to file an appeal if the resident did not agree with the transfer or discharge, was provided to the resident at least 30 days prior to the transfer or discharge, and a copy of the notice was sent to the local Ombudsman office. The SSD confirmed there was no documentation in Resident 1's medical record that indicated Resident 1 had been provided with the Notice of Transfer or Discharge form, prior to or on the day of her discharge. The SSD confirmed Resident 1 was not given the required notices. During an interview on [DATE] at 11:37 a.m. with the Director of Nursing (DON) the DON acknowledged the Notice of Transfer or Discharge form was provided to residents prior to their transfer or discharge from the facility and a copy of the notice was sent to the Ombudsman office. The DON confirmed the Notice of Transfer or Discharge was required under federal and state guidelines. During a follow-up telephone interview on [DATE] at 3:19 p.m. with the Ombudsman, the Ombudsman indicated he has not received any recent notifications regarding discharges from the facility and further stated, I have not received any [transfer or discharge] notifications from [the facility]. During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notices, revised 3/2025, the P&P indicated, Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman. 1.the resident and his or her representative are provided with a written notice of an impending transfer or discharge at least 30 days prior to the transfer or discharge. 3. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge, including the basis under S483.15(c)(1)(i)(A)-(F); b. The effective date of the transfer or discharge; c. The specific location (such as the name of the new provider, description, and/or address if the location is a residence) to which the resident is being transferred or discharged ; d. An explanation of the resident's rights to appeal the transfer or discharge to the state, including: (1) the name, address, email, and telephone number of the entity which receives such appeal hearing requests; (2) information about how to obtain an appeal form; and (3) how to get assistance in completing and submitting the appeal hearing request; e. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; f. The Notice of Facility Bed-Hold and policies. 4. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. During a review of the facility's P&P titled, Transfer of Discharge, Resident-Initiated, dated [DATE] the P&P indicated, . 3. Resident-initiated transfer or discharge means the resident.has provided verbal or written notice of intent to leave the facility. a. Therapeutic leave is a type of resident-initiate transfer. However, if the facility makes a determination to not allow the resident to return, the transfer becomes a facility-initiated discharge.

Based on observation, interview and record review the facility failed to ensure accurate accountability of controlled medication when: 1. There was a discrepancy between the Controlled Drug Record (CDR-inventory sheet that keeps record of the usage of controlled medications) and medication blister card (medcard-a type of medication packaging) for Resident 76, Resident 151 and Resident 17. 2. A bottle of morphine sulfate solution (controlled medication [medication with high potential for abuse or addiction] to relieve pain) was not reconciled properly. These failures resulted in the facility not having an accurate accountability of controlled medications, and the potential for abuse or misuse of these medications. Findings: 1. During a medication cart check of the south B medication cart on 2/5/25 starting at 12:20 p.m. with LN 5, controlled medications were reconciled. The following discrepancies were found between the CDR and the medcard: a. Resident 76's CDR for clonazepam (used to treat anxiety-feeling of worry) 0.5 mg (milligram-a unit of measure) indicated there were 28 doses left, however, the medcard contained 27 doses. b. Resident 76's CDR for hydrocodone-apap (a combination of acetaminophen and hydrocodone, used to treat pain) 5-325 mg indicated there were 25 doses left, however the medcard contained 24 doses. c. Resident 151's CDR for methadone hydrochloride (used to treat pain) 5 mg indicated there were 22 doses left, however, the medcard contained 21 doses. d. Resident 17's CDR for lacosamide (used to treat seizures) 200 mg indicated there were 29 doses left, however, the medcard contained 28 doses. During an interview on 2/5/25 at 1:06 p.m. with Licensed Nurse (LN) 5, LN 5 stated that once a controlled medication was taken out of the medcard, it should also be signed out in the CDR. During an interview on 2/5/25 at 1:09 p.m. with Director of Nursing (DON) 2, DON 2 stated that controlled medication should be signed out and reconciled with the CDR before the nurses left the cart to administer medication to resident. During a review of the facility's policy and procedure (P&P) titled, Controlled Medications undated, the P&P indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enter the following information on the accountability record .date and time of administration, amount administered and signature of the nurse administering the dose . 2. During a concurrent observation and interview on 2/5/25 at 1:06 p.m. with LN 5, Resident 63's bottle of morphine sulfate 20mg/ml solution was checked, and LN 5 stated that the liquid in the bottle was at 24 ml. During a review of Resident 63's CDR for morphine sulfate 20mg/ml solution, the CDR showed that 17 ml remained in the bottle. During a telephone interview on 2/7/25 at 12:07 p.m. with Pharmacist/Pharmacy Manager (PM), PM stated that morphine was provided by the manufacturer in 15 ml or 30 ml containers. Manufacturers do not overfill the containers; at most, there might have been an extra 1 ml of residue left in the medication or plastic container, but overfilling a liquid medication was not standard practice. During a review of the facility's P&P titled, Controlled Medication Storage, undated, the P&P indicated, Any discrepancy in controlled substance medication counts is reported to the director of nursing immediately .separate records of use shall be maintained on all Schedule II drugs, such records shall be maintained accurately .

Based on observation, interview and record review, the facility failed to ensure medication error rate was not less than 5% when the error rate was 17.86% based on five medication errors out of 28 opportunities observed during a medication pass observation for three out of six residents (Resident 7, Resident 204 and Resident 351). This failure resulted in medications not given in accordance with the prescriber's orders or manufacturer's specifications and had the potential to affect the resident's clinical conditions. Findings: 1. During a concurrent medication observation and interview on 2/5/25 at 7:29 a.m. with Licensed Nurse (LN) 3, LN 3 was observed preparing 11 medications for Resident 7, including ArgiMent AT packet (medical food specifically formulated to provide essential nutrients for the dietary management of pressure injuries and wounds). LN 3 emptied the contents of the packet into a Styrofoam cup and mixed it with water without measuring it. At 7:48 a.m., LN 3 went inside the room to give the medication to Resident 7, Styrofoam cup was placed on the overbed table. LN 3 was intervened and was asked to take the cup out to measure the liquid in it. At 7:49 a.m., LN 3 measured the mixture by pouring it into a graduated cup (a cup that has visible markings on its side indicating specific volume measurements), which measured 230 mL (milliliter, a unit of measurement) plus an additional 150 mL, for a total of 380 ml. LN 3 confirmed that this was more than the recommended amount. During a review of the ArgiMent AT packaging, the dosing and administration recommendation for oral intake was to mix one packet with 180-240 mL of water or juice twice a day. During a review of Resident 7's OSR, dated 2/6/25, the OSR indicated, Resident 7 had an order for an ArgiMent oral packet, to be given one packet by mouth twice a day as a supplement. During a review of the facility's policy and procedures (P&P) titled Administering Oral Medications, dated October 2010, the P&P indicated, Prepare the correct dose of medication .for powdered medications, mix with liquids as indicated. 2. During a medication observation on 2/6/25 at 8:03 a.m. with LN 4, LN 4 went inside Resident 204's room and checked the blood pressure but was not observed to have taken the pulse rate at that time. At 8:06 a.m., LN 4 was observed preparing three medications for Resident 204, including Glycolax 3350 (medication to treat occasional constipation) 17 gm (grams-unit of measurement) mixed with 130 mL of water, Irbesartan (medication used to lower blood pressure) 150 mg (milligram-unit of measurement), and Isosorbide Dinitrate 30 mg (medication used to treat chest pain). During an observation on 2/6/25 at 8:09 a.m. LN 4 asked Resident 204 if he still wanted the water with Glycolax mixed in it. Resident 204 did not respond, and LN 4 took the water cup out with about 1/4 of the water remaining in it and tossed it in the garbage. During a review of Resident 204's OSR, dated 2/6/25, the OSR indicated that Resident 204 had the following orders: Glycolax powder, 17 gm by mouth once a day, mixed with 4-8 oz (ounces-unit of measurement) of fluids; Irbesartan 150 mg tablet (tab), one tab by mouth once a day for hypertension (HTN- high blood pressure), to be held if SBP (systolic blood pressure- top number in blood pressure reading) less than (<) 110 or pulse <60; and Isosorbide Dinitrate 30 mg tab, 1 tab by mouth once a day for HTN, to be held if SBP was <110 or pulse <60. During an interview on 2/6/25 at 10:08 a.m. with Director of Nursing (DON) 1, DON 1 stated that the pulse rate should have been checked for one whole minute before medication administration. During an interview on 2/7/25 at 10:25 a.m. with DON 2, DON 2 stated that for Glycolax medication administration, the entire mixture should have been consumed by the resident to ensure the proper dose was administered. During a review of the facility's P&P titled Administering Medications, dated April 2019, the P&P indicated, The following information is checked/verified for each resident prior to administering medications .vital signs, if necessary. During a review of the facility's P&P titled Administering Oral Medications, dated October 2010, the P&P indicated, Remain with the resident until all medications have been taken. 3. During a medication administration observation on 2/6/25 at 8:27 a.m. with LN 8, LN 8 was observed preparing 5 medications for Resident 351, including aspirin (medication for pain that can be used as prevention for heart disease) 81 mg chew tablet. During a review of Resident 351's OSR, dated 2/6/25, the OSR indicated, Resident 351 had an order for aspirin EC (enteric coated-a special coating that prevents it from dissolving in the stomach) tablet by mouth once a day for prophylaxis. LN 8 did not administer the right form of aspirin as indicated in the OSR. LN administered the chewable form instead of the EC form. During a review of the facility's P&P titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in accordance with prescriber orders .the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage .

Based on observation, interview and facility policy and procedure (P&P) review, the facility failed to ensure the residents' medications were stored and labeled properly when: 1. An insulin pen did not have an open date on it. 2. Methadone (controlled medication to relieve pain) pills were not stored in their original packaging. 3. A bottle of morphine sulfate solution was not in the correct box and did not have the correct administration instruction on the label. These failures had the potential for medication diversion, medication errors and resident exposure to the expired medication. Findings: 1. During a medication cart check of the south B medication cart on [DATE] starting at 12:20 p.m. with Licensed Nurse (LN) 5, an opened (Brand name)(an insulin pen used to lower blood sugar level) 100 u/ml (unit per milliliter, unit of measurement) was found in the cart. LN 5 confirmed that the (Brand name) pen had been opened and used. During an interview on [DATE] at 10:08 a.m. with Director of Nursing (DON) 1, DON 1 stated that it was important to put open dates on insulin pens because they expired within 28 or 30 days after opening and should be replaced by then. During a review of the facility's P&P titled, Proper Storage of Insulin, undated, the P&P indicated, .the pharmacy will send pens maintaining the cold chain and place an 'Opened Date' label on each pen . Facility nursing staff will need to indicate the date opened on that label when removing from the refrigerator and placing on the medication cart. 2. During a medication cart check of the south B medication cart on [DATE] at 12:42 p.m. with LN 5, a Ziploc bag contained a bottle of methadone with four tablets inside it and a pill crusher pouch that had been stapled, which contained ten tablets of unlabeled medication. LN 5 confirmed that the proper storage of the medication should be inside the bottle. During an interview on [DATE] at 10:08 a.m. with DON 1, DON 1 stated that medications should be kept in their original packaging because the information on the label, such as the resident's name and the expiration date, is essential. 3. During a medication cart check of the south B medication cart on [DATE] at 12:50 p.m. with LN 5, a 30 ml bottle of morphine sulfate solution without label was in a box for morphine sulfate that indicated 15 mL on the outside for Resident 63. LN 5 confirmed that the medication bottle did not match the box it was in. During a record review of Resident 63's CDR for morphine sulfate solution, the CDR indicated a different prescription number than the one on the medication box. During a concurrent interview and record review on [DATE] at 12:57 p.m. with DON 1, Resident 63's OSR and CDR for morphine sulfate 20mg/ml solution was reviewed, DON 1 confirmed that the medication administration instruction on the label on the box and the label on the CDR did not match the Medical Doctor's order. The label on the CDR indicated morphine sulfate 20mg/ml soln, take 0.25ml by mouth every 4 hours as needed for pain or SOB [shortness of breath]. Resident 63's OSR indicated the following orders for morphine sulfate: a. Morphine sulfate (concentrate) solution 20mg/ml, give 0.25 ml by mouth every 1 hour as needed for pain or respiration >,d+[DATE]/min b. Morphine sulfate (concentrate) solution 20mg/ml, give 0.5 ml by mouth every 1 hour as needed for moderate pain or respiration ,d+[DATE]/min c. Morphine sulfate (concentrate) solution 20mg/ml, give 1 ml by mouth every 8 hours as needed for severe pain or respiration above 32. During a review of the facility's P&P titled, Medication Storage in the Facility, undated, the P&P indicated, The provider pharmacy dispenses medications in containers that meet legal requirements . Medications are kept in these containers . The drugs of each patient shall be kept and stored in their originally received containers. No drug shall be transferred between containers.

Based on observation, interview and record review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety for a census of 103 residents out of a census of 104 who ate facility prepared food when: 1. Thick, black, charcoal-like debris was found between all spokes of the two front gas burners of the facility stove, 2. [NAME] 2 handled parsley with her bare hands then placed it directly on the resident plate, and when 3. [NAME] 2 scratched her back and continued plating food without washing her hands. These failures increased the risk for the spread of infection and reduced the facility's potential to prepare residents' food in a sanitary manner. Findings: 1. During a concurrent observation and interview on initial tour of the kitchen with the Dietary Manager (DM) on 2/4/25 at 8:25 a.m., the DM verified there was a heavy accumulation of black, charcoal-like debris between all spokes of the two front gas burners on the industrial stove. 2. During a subsequent lunch tray line observation and interview with the DM on 2/5/25 at 11:17 a.m., [NAME] 2 used her bare fingers to break parsley into small pieces for garnish and placed them on the resident plates. When the DM was asked her expectations, she said, Technically, she should be using tongs for the parsley. 3. During a further observation on 2/5/25 at 11:21 a.m., [NAME] 2 scratched her back and continued to plate food with utensils. The DM verified the observation and said, She should not touch the back of her shirt and continue plating the food. During an interview with the Registered Dietician (RD) on 2/6/25 at 10:32 a.m., the RD was asked her expectations regarding dietary staff using bare hands to break up parsley and scratching their back without re-washing their hands and said, They should be wearing gloves whenever touching ready to eat food. Any time you make contact with clothing, hands should be washed before continuing to serve food. During a review of the facility policy and procedure (P&P) titled SANITATION, dated 2023, the P&P indicated All equipment shall be maintained as necessary .All .equipment shall be kept clean .Hands must not contact the food surface .Separate chopping boards are to be used for .vegetables . During a review of the facility P&P, untitled, dated 2023, the P&P indicated, Pay close attention to prevent cross-contamination of workers going from handling dirty .and then clean, touching .body .etc. Wash hands and change gloves whenever cross-contamination occurs. During a review of the facility P&P titled FOOD HANDLING, dated 2023, the P&P indicated Food and Nutrition Services personnel should never use bare hand contact with any foods, ready to eat or otherwise. This includes .food item preparation .personnel shall use suitable utensils such as deli tissue, spatulas, tongs, or single use gloves.

Based on observation, interview and record review, the facility failed to ensure garbage and refuse was disposed of properly when a large amount of cardboard and miscellaneous items was strewn around and under the garbage dumpsters at the back of the facility. This failure increased the risk of attracting of pests and spread of infection. Findings: During a concurrent observation and interview with Dietary Assistant Supervisor (DAS), on 2/4/25 at 1:30 p.m., two dumpsters were at the back of facility. A large amount of empty cardboard boxes was in front of one dumpster on the left and miscellaneous garbage strewn about the area including milk cartons, straws, sugar packets, plastic gloves, a coffee pot top, soft drink cans, a Christmas tree decoration, Styrofoam pieces, a metal tube about 1/3 wide by 18 inches long was protruding out from under the dumpster, and zip lock bags. The DAS was helping throw cardboard into the empty dumpster and was asked how long the large quantity of cardboard and trash had been there and said, Maybe it's been out here for a day or so, I don't know. Dumpsters are emptied once or twice a week. I think Maintenance is responsible, During an interview with the Maintenance Supervisor (MS) on 2/4/25 at 1:33 p.m., MS was asked about a pest control servicing and garbage pickup and said, Pest control comes to spray one time a month. The dumpsters are emptied by [name of garbage collection company] once a day, cardboard three times a week . maintenance is supposed to keep the area clean around the dumpsters . During an observation on 2/5/25 around 6:30 a.m., cardboard was seen still protruding out from under right dumpster. During an interview with the Maintenance Assistant (MA) on 2/5/25 at 8:37 a.m., the MA said, If nothing else is urgent, I will clean up around the dumpsters around 8:45 a.m. every day .Normally the cardboard pieces should be thrown in the dumpster and the lid closed. They come from the kitchen, central supply, janitorial. It makes no sense to leave the cardboard out if the dumpster is empty .The Maintenance Supervisor, [name of MS] should be checking and cleaning up the area . During a review of the facility document titled, Daily Maintenance Trash Area/Outside Cleaning log 2025, dated 2023, the log indicated To ensure the outside of the building and the trash area is clean and clear of trash and debris to maintain a cleanliness look for the exterior of the facility .I have performed the above maintenance - Initial date was not initialed as done on 12/26/24, 12/17/24,1/20/25, 1/21/25, had a handwritten note with an arrow pointing to 2/4/25 which indicated New Trash cans Delivered - Cleaned Late . During a review of the facility policy and procedure titled, Grounds, revised 5/08, the P&P indicated Maintenance shall be responsible for keeping the grounds free of litter .Areas around the buildings shall be maintained in a safe and orderly manner at all times.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for a census of 104 when: 1.TB (tuberculosis, a contagious lung infection) screening and testing was not done for three sampled residents (Resident 3, Resident 8 and Resident 79), 2. No Enhanced Barrier Precautions (EBP, wearing a gown and gloves during high-contact care activities with patients who are at risk of spreading multidrug-resistant organisms (MDROs), like those with open wounds or indwelling medical devices, to prevent the spread of these infections, even when full contact precautions aren't needed) were used for three sampled residents (Resident 9 and Resident 151 ) who had wounds, 3. Resident 201's nebulizer mask (a face mask that fits over the nose and mouth to deliver medication into the lungs), Resident 84's oxygen tubing was on the floor and Resident 202's oxygen tubing was on the floor and nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not stored properly. 4. Restorative Nursing Assistant (RNA) 2 did not perform hand hygiene when feeding multiple residents during lunch. 5. Certified Nursing Assistant (CNA) 3 provided care without wearing all the required personal protective equipment (PPE) for Resident 351 who was on Droplet Precautions (isolation precautions for an individual that is infected with microorganisms transmitted by droplets) These failures increased the risk for the spread of infection. Findings: 1. Resident 3 was admitted to the facility in September of 2021 with diagnoses which included asthma (a chronic lung condition where the airways in the lungs become inflamed and narrow, making it difficult to breathe, often causing symptoms like wheezing, coughing, chest tightness, and shortness of breath). During a review of Resident 3's physician order (PO), dated 9/10/21, the PO indicated Aplisol Solution .Inject .intradermally [into the skin] one time only for TB . During a review of Resident 3's immunization record (IR), dated 9/10/21, the IR indicated Resident 3 had a two-step TB test (a method for screening for tuberculosis where a person receives the initial TB skin test, and if the result is negative, they get a second identical test a few weeks later to minimize the chance of missing a past infection due to a weak initial reaction) on 9/10/21 and 9/27/21. During a review of Resident 3's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/11/24, the MDS indicated Resident 3 had a mildly impaired memory. During an interview on 2/7/25 around 7:15 a.m., Resident 3 was asked if she had a TB test and said she only remembered having one when she was admitted in 2021. During a concurrent interview and record review on 2/7/25 at 10:18 a.m. with the MDS Coordinator (MDSC), the MDSC verified Resident 3 was not screened and had not received another TB test since the initial test on 9/10/21. MDSC verified there was no documented evidence of other PO for TB testing in 9/22, 9/23, or 9/24. MDSC verified there was no documented evidence on the Medication Administration Record (MAR) for 9/22, 9/23, or 9/24. MDSC also verified there was no documented evidence of nurses note (NN) for a TB test in 9/22, 9/23, or 9/24. Resident 8 was admitted to the facility in September of 2023 with diagnoses which included bronchiectasis (a condition that occurs when the tubes that carry air in and out of your lungs get damaged, causing them to widen and become loose and scarred). During a review of Resident 8's MDS, dated [DATE], indicated Resident 8 had severe memory impairment. During a review of Resident 8's physician order (PO), dated 9/28/23, the PO indicated Aplisol solution .inject .intradermally one time only .[to rule out] TB . During a review of Resident 8's MAR, dated 9/27/23, the MAR did not indicate whether the TB test was given to or refused by Resident 8. During a review of the Progress Notes (PN), dated 9/27/23, the PN had no documented evidence which indicated Resident 8 received or refused the TB test. Resident 8's immunization record was requested multiple times but not provided. During a concurrent record review and interview on 2/7/25 at 7:24 a.m. with the MDSC, the MDSC reviewed the physician orders, progress notes, the nurses notes, and MAR since admission to the facility and said, [Residents] should have a two step TB test the day of admit or the following day .[Staff] should have notified the doctor if the patient refused. There's no note from admit until today regarding doctor notification of her refusal or a chest X-ray order .There [was] no order or X ray done to rule out TB . During an interview on 2/7/25 at 8:24 a.m. with the Infection Preventionist (IP), the IP was asked his expectations for TB screening and testing and said, For all residents the TB test should be done on admission. It should be documented if refused by the resident or RP [responsible party]. The physician should be notified so a chest X-ray can be done to rule out TB. We have to have some result to ensure they are free of TB . Resident 79 was admitted to the facility in March 2023 with diagnoses which included acute respiratory failure. During a review of Resident 79's IR, dated 2/7/23, the IR indicated Resident 79 had a two-step TB test on 3/13/23 and 5/8/23. During a concurrent interview and record review on 2/7/25 at 11:00 a.m.with the IP , the IP verified Resident 79 was not annually screened for TB. The IP confirmed there was no documented evidence that a TB annual assessment was done. During a review of the facility policy and procedure (P&P), titled, Tuberculosis, Screening Residents for, dated 8/19, the P&P indicated The facility will conduct an annual risk assessment to determine risk of exposure . 2. Resident 9 was admitted to the facility in October of 2021 with multiple diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 9's MDS, dated [DATE] the MDS indicated Resident 9 had a severe memory problem and had the treatment of Application of non-surgical dressings .ointments/medications . During a review of the PO, dated 1/10/25, the PO indicated Right Temporal [area to the right of eyebrow] Ca [cancer] lesion: Cleanse with normal saline [salt water], pat dry, apply Calcium alginate [a water-insoluble salt derived from brown seaweed that's used in wound care], cover with clear dressing, change daily until healed . During a review of Resident 9's CP titled .Right temporal face lesion- carcinoma suspected ., dated 11/26/24, the CP indicated Follow facility protocols for treatment . During a wound care observation and interview on 2/5/25 at 9:40 a.m. with Licensed Nurse (LN) 7, LN 7 walked into the room of Resident 9 without wearing a gown. There was no EBP sign posted outside the door to indicate the personal protective equipment (PPE) to wear when in close contact with Resident 9. LN 7 placed barrier between skin and cancerous area, touching the Resident 9. LN 7 soaked gauze with saline, wiped inside to out, opened the dressing, patted the wound and said, .Calcium Alginate helps absorb drainage .We clean it every day. There was no EBP sign observed outside Resident 9's door, LN 7 did not wear a gown during wound care, and LN 7 was observed not washing hands between two residents dressing changes. During a review of Resident 9's skin assessment (SA), dated 2/6/25, the SA indicated, .biopsy results is positive for squamous cell acarcinoma (sic) of the right temporal area . Resident 151 was admitted to the facility in January of 2025 with multiple diagnoses which included carcinoma [cancer] of the right breast. During a review of Resident 151's CP titled Resident has alteration in skin status r/t [related to] .RIGHT BREAST - CANCER ., dated 1/22/25, the CP indicated Monitor scab/abrasions for s/s/ [signs/symptoms] of infection or worsening of condition . During a review of Resident 151's PO, dated 1/23/25, the PO indicated RIGHT BREAST CANCER - CLEANSE WITH NORMAL SALINE, PAT DRY, APPLY XEROFORM [a non-adherent gauze dressing that contains medication used to treat wounds.] DRESSING DAILY TILL HEALED . During a concurrent observation of Resident 151 and interview with LN 7 on 2/5/25 at 9:52 a.m., LN 7 placed a barrier pad on bedside table with supplies, assisted Resident 151 to remove her T-shirt which exposed the Xeroform dressing on the right breast. Plain gauze was resting on top to catch drainage. Resident 151 stated the wound had a little smell. LN 7 patted the wound and stated it drained quite a bit. Drainage was observed on the front of Resident 151's shirt. LN 7 wiped it well and stated It usually has an ABD [abdominal, a medical dressing used to treat wounds that are draining a lot of fluid] pad but it fell off. LN 7 put Xeroform and dry gauze on wound then placed an ABD with large piece of tape to hold it in place. LN 7 stated he changed the dressing every day. There was no EBP sign observed outside Resident 151's door and LN 7 did not wear a gown during wound care. During an interview with LN 7 on 2/5/25 at 10 a.m., LN 7 said, I don't wash my hands with every resident . During a concurrent observation and interview on 2/6/25 at 10 a.m. with the IP, the IP confirmed Resident 9 and Resident 151 did not have EBP precautions signage outside their rooms. The IP stated that all residents with wounds needed to be on EBP precautions. IP also confirmed that Resident 9 and Resident 151 had chronic wounds and should be with Enhanced Barrier Precautions. During a review of the facility P&P titled Enhanced Barrier Precautions, dated 6/24, the P&P indicated Enhanced Barrier Precautions [EBPs] are used as an infection prevention and control intervention .Gloves and gown are applied prior to performing high contact resident care activity .Examples .wound care .any skin opening requiring a dressing that is considered a longer lasting wound . Standard precautions apply to the care of residents regardless of suspected or confirmed infection . 44946 3. During a review of Resident 201's Admission Record (AR), the AR indicated, Resident 201 was admitted on [DATE] with diagnoses which included morbid obesity (severe form of having too much body fat) with alveolar hypoventilation (condition where the lungs don't get enough oxygen or remove enough carbon dioxide), obstructive sleep apnea (sleep disorder that occurs when the airway becomes blocked while sleeping), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing.) During a review of Resident 201's Order Summary Report (OSR), dated 2/6/25, the OSR indicated Resident 201 had an order for ipratropium-albuterol solution (used to treat air flow blockage and prevent worsening of COPD) 0.5-2.5 (3) milligram/milliliter (mg/ml), 1 vial inhale orally four times a day for COPD. During a review of Resident 84's AR, the AR indicated, Resident 84 was admitted on [DATE] with diagnoses which included COPD with exacerbation, chronic respiratory failure with hypoxia (long-term condition that occurs when the lung can't get enough oxygen into the blood), chronic respiratory failure with hypercapnia (condition that occurs when the lungs can't get rid of enough carbon dioxide from the blood), malignant neoplasm of unspecified part of bronchus or lung (cancerous tumor that develops in the lungs), dependence on supplemental oxygen, shortness of breath. During a review of Resident 84's OSR, dated 2/6/25, the OSR indicated Resident 84 had an order to start oxygen at 2 liters per minute (L/min) for shortness of breath (SOB), chest pain, oxygen saturation less than 90% and to notify the MD. During a review of Resident 202's AR, the AR indicated, Resident 202 was admitted on [DATE] with diagnoses which included influenza due to other identified influenza virus with other respiratory manifestations (viral infection of the nose, throat and lungs), acute respiratory failure with hypoxia (condition where the lungs are unable to get enough oxygen into the blood), COPD, During a review of Resident 202's OSR, dated 2/6/25, the OSR indicated Resident 202 had an order to administer oxygen via nasal cannula at 2L/min as needed for SOB. During a concurrent observation and interview on 2/4/25 at 10:59 a.m. with IP in Resident 84's room, Resident 84's oxygen tubing was touching the floor. IP stated that the tubing was too long but should not be touching the floor. During a concurrent observation and interview on 2/4/25 at 10:46 a.m. with LN 6 in Resident 201's room, Resident 201's nebulizer mask was seen on the floor behind the oxygen concentrator. LN 6 stated that this was not the proper way to store the nebulizer mask and that it could be a source of infection. During an observation on 2/4/25 at 11:34 a.m. in Resident 202's room, Resident 202 had the oxygen concentrator on, but the nasal cannula was on top of the overbed table, and the tubing was touching the floor. During an interview on 2/4/25 at 11:45 a.m. with IP, IP stated that oxygen tubing should not be touching the floor due to infection control concerns, as someone should not be breathing it in since it is dirty. IP stated that when oxygen tubing touched the floor, the Certified Nursing Assistant (CNA) or other staff should inform the nurses so it could be changed right away. During an interview on 2/6/25 at 11:35 a.m. with Director of Nursing (DON) 2, DON 2 stated that oxygen tubing should not be touching the floor as it is part of their infection control practices. If not in use, it should be stored in a bag to prevent infection. During a review of the facility's P&P titled, Departmental (Respiratory Therapy)-Prevention of Infection, dated November 2011, the P&P indicated, Infection Control Considerations Related to Oxygen Administration: Change the oxygen cannula and tubing every seven (7) days, or as needed .keep the oxygen cannula and tubing used PRN (given as needed or requested) in a plastic bag when not in use .Infection Control Considerations Related to Medication Nebulizers: store the circuit in plastic bag, marked with resident's name, between uses . 49933 4. During an observation on 2/4/25 at 11:40 a.m. in RNA dining room, five residents were sitting around the dining table. There were four hand sanitizer bottles that were on the table within reach of staff and residents. At 11:45 a.m., RNA 2 was holding a juice cup next to Resident 8's mouth to help the resident sip from the straw. RNA 2 then went to Resident 36 and picked up the utensils and prompted Resident 36 to hold it. RNA 2 further assisted Resident 36 to hold the chocolate milk carton. RNA 2 then went to the coffee station to get coffee for Resident 56. At 11:48 a.m., RNA 2 assisted and held Resident 24's hands to hold the milk carton up to Resident 24's mouth. At 11:49 a.m., RNA 2 wiped Resident's 24's mouth and nose after resident 24 sneezed. RNA 2 continued to help assist and prompt resident. At 11:51 a.m., RNA 2 touched Resident 60's shirt, tapped resident on the shoulder and returned to Resident 24 to assist with feeding. At 11:56 a.m., RNA 2 returned to Resident 8 and touched Resident 8's utensil and cup. RNA 2 did not perform proper hand hygiene between residents and between the tasks observed. During an interview on 2/4/25 at 12:25 p.m. with RNA 2, RNA 2 confirmed that she did not perform hand hygiene in between residents when assisting them with their lunch. During an interview on 2/6/25 at 9:00 a.m. with the IP, the IP stated that hand hygiene should be performed in between residents due to the risk of spreading infection. During a review of the facility's P&P titled, Hand washing/Hand Hygiene, revised 8/19, the P&P indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water .Before and after assisting a resident with meals .after contact with resident's intact skin . after contact with objects .before and after .handling food . 5. A review of Resident 351 Admission Record indicated Resident 351 was admitted [DATE] with multiple diagnoses that included influenza (flu). During an observation on 2/4/25 at 11:19 a.m. outside of Resident 351's room, a sign was posted above resident name card which indicated, Droplet Precaution. A plastic bin was observed in the hallway outside of resident 351's room. The bin contained disposable masks and face shields available for staff to use. During an observation on 2/5/25 at 9:50 a.m., CNA 3 entered Resident 351's room wearing only a mask. CNA 3 came out and put on a face shield after having gone into the room already to assist Resident 351. During a concurrent observation and interview on 2/5/25 at 10:00 a.m., CNA 3 disposed face shield before leaving Resident 351's room but did not discard disposable mask. CNA 3 confirmed she did not use proper PPE before entering Resident 351's room. CNA 3 further confirmed that she did not dispose of the mask before exiting resident room. During an interview on 2/6/25 at 9:19 a.m. with the IP, the IP confirmed that proper PPE should be worn for residents in droplet precautions. IP confirmed that staff must wear the correct PPE and dispose of PPE due to the risk of spreading infection. During a review of the facility's P&P titled, Isolation-Categories of Transmission-Based Precautions, dated 10/18, the P&P indicated Droplet precautions .gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. During a review of Centers for Disease Control (CDC) guidelines titled, HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) undated, indicated, 4. MASK OR RESPIRATOR .Front of mask/respirator is contaminated .Discard in a waste container .

Based on observation, interview and record review the facility failed to ensure resident needs were accommodated for two of 23 sampled Residents (Residents 6 and 307), when the call light was not within reach. This failure had the potential to result in the residents not attaining their highest practicable physical, psychosocial and emotional well-being. Findings: Review of an Admission Record indicated Resident 6 was admitted in January of 2025 with multiple diagnoses of aftercare following joint replacement surgery, other abnormalities of gait and mobility, and muscle weakness. Review of Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 1/13/24, indicated Resident 6 was cognitively intact. The MDS also indicated Resident 6 was dependent to required partial/moderate assistance (helper does less than half of the effort) for activities of daily living (ADL's-routine tasks such as bathing, dressing and toileting a person performs daily care themselves). During a concurrent observation and interview on 2/4/25 at 9:56 a.m. Resident 6 was in her bed and her call light was on the floor and out of reach. Licensed Nurse 3 (LN3) confirmed the call light was on the floor and is not within reach and stated the call lights should be clipped to the linens or by their side where they can reach it. Review of Resident 6's Care Plan, dated 1/8/25, indicated Residents 6 was at risk for falls related to impaired mobility .interventions .Ensure call light is within reach when in room. During an interview on 2/6/25 at 9:21 a.m., Resident 6 stated she likes the call light where she can reach it. Resident 6 stated, It is difficult to call for help when I can't reach my call light. Review of an Admission Record indicated Resident 307 was admitted [DATE] with several diagnoses including acute respiratory failure (a condition that can cause trouble breathing), history of falling, and muscle weakness. A review of MDS dated [DATE] indicated that Resident 307 had severely impaired cognition. The MDS also indicated Resident 307 was dependent to required substantial/maximal assistance (Resident requires significance assistance to complete the task) or ADLs. During a concurrent observation and interview on 2/4/25 at 9:25 a.m., Resident 307 was lying in bed and stated, I need to be changed. Observed call light wrapped under Resident 307's bedrail and out of reach. LN 5 was prompted to assist Resident 307. LN 5 stated that the call light should be within reach of the resident so they can call easily when they need help. During an interview with Resident 307 on 2/6/25 at 9:25 a.m., Resident 307 stated that he waited a long time for help and felt really uncomfortable because I needed to be changed. Review of Resident 307's Care Plan, dated 2/4/2025, indicated that Resident 307 was on .Bladder re-training program .interventions .have call light within reach and answer promptly . During an interview with Director of Nursing 1 (DON 1) on 2/5/25 at 10:47 a.m., the DON 1 stated that the call light should be within reach for each resident. The DON 1 stated a resident could become distressed if they could not reach the call light. A review of the facility's policy and procedure (P&P) titled, Call light System, Resident, dated 9/22, the P&P indicated, .Each resident is provided with a means to call a staff member directly .

Based on interview and record review, the facility failed to timely submit a Minimum Data Set (MDS- a federally mandated resident an assessment tool) for one of 23 sampled residents (Resident 85) when a discharge MDS from 10/24 had not yet been submitted. This failure resulted in inaccurate data being transmitted and resulted in Resident 85's discharged MDS data not received by the Centers for Medicare and Medicaid Services (CMS). Findings: A review of Resident 85's admission record indicated Resident 85 was admitted to the facility in 9/24 and discharged on [DATE]. During an interview on 2/6/25 at 3:33 p.m., the Minimum Data Set Coordinator (MDS) confirmed Resident 85's discharge MDS had not yet been submitted to CMS and was overdue and further stated that it needed to be turned into CMS with required timeframes for MDS submission. During a review of the facility's policy and procedure (P&P) titled, MDS Completion and Submission Timeframes, revised 7/17, the policy indicated the facility would conduct and submit resident assessments in accordance with current federal and state submission . timeframes for completion and submission is based on current requirements published in the Resident Assessment Instrument (RAI) Manual. During a review of CMS's RAI Manual, dated 10/24, the manual indicated the discharge MDS was to be submitted within seven days of completion.

Based on observation, interview and record review the facility failed to ensure a comprehensive and person-centered care plan was implemented for one of 23 sampled residents (Resident 26). This failure posed the risk of not providing appropriate, consistent and individualized care plan for Resident 26 to attain their highest practicable physical, mental and psychosocial wellbeing. A review of Resident 26's admission record indicated he was admitted ,d+[DATE] with diagnoses including dementia (a progressive state of decline in mental abilities.) A review of Resident 26's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 6/26/24 indicated Resident 26 was totally dependent for all his care, with dependent assistance for bed mobility, dressing, hygiene, activities including for sit to stand. The MDS indicated bed to chair transfer was not attempted by staff. A review of Resident 26's care plan dated, 5/11/24 indicated, Activities: Up in chair daily, be out of the room daily. During an observation on 2/4/25 at 1:00 p.m. in room [ROOM NUMBER] C, the Resident 26 was in bed. No activities observed. During an observation on 2/5/25 at 11 a.m., 11:30 a.m., 1:45 p.m., in room [ROOM NUMBER] C, Resident 26 was in bed and not in a chair and out of the room, no activities observed. During an interview on 2/5/25 at 12:30 p.m., in room [ROOM NUMBER] C, CNA 1 stated, Resident 26 was still not up and out of bed. During an observation on 2/6/25 at 8:50 a.m., 9:25 a.m., and 1:00 p.m. in room [ROOM NUMBER] C, Resident 26 was in bed and not out of the room, no activities observed. During a concurrent observation and interview on 2/7/25 at 9:26 a.m. with Resident 26 in room [ROOM NUMBER] C, Resident 26 was in bed and had not gotten up into chair. Resident 26 stated, I would love to get up, but they don't let me. During a concurrent interview and record review on 2/6/25 at 9:45 a.m. with Activities Director (AD), the AD confirmed that Resident 26 was not up for activities. The AD confirmed that there was no documented evidence of daily log or daily progress notes written for Activities offered for Resident 26, and no documented evidence of Resident 26 refusal to participate with activities. During a review of the facility's policy and procedure titled, Activity Programs dated August 2006, indicated, .Activities are scheduled seven days a week and residents are given opportunity to contribute .Individualized activities are provided and offered at hours convenient to the residents .

Based on observation, interview and record review the facility failed to meet the professional standards of nursing practice for one of 23 sampled residents (Resident 7), when there was no order for a Foley catheter. This failure placed the resident with a Foley catheter at risk for not getting proper nursing care. Findings: Review of an Admission Record indicated Resident 7 was admitted December of 2024 with several diagnoses including obstructive and reflux uropathy (a blockage in the urinary tract), infection and inflammatory reaction due to indwelling catheter (a tube inserted outside of the body that helps drain urine from the bladder). Review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/24/25 indicated for Urinary Continence (the ability to control urinary function) Resident 7 had a catheter (indwelling-a tube that is left inside the body). Review of a Order Summary Report dated 2/4/25 indicated no active orders for a Foley catheter for Resident 7. Review of Resident 7's Care plan, dated 12/30/24 indicated Resident 7 has an Indwelling Catheter related to Obstructive and Reflexive Uropathy and interventions included, Catheter per MD [Medical Doctor] orders. During a concurrent observation and interview on 2/5/25 at 10:20 a.m. with Licensed Nurse 3 (LN 3), LN 3 reviewed MD orders for Resident 7 and confirmed that Resident 7 did have a Foley catheter but did not have an active order for a Foley catheter. Review of Resident 7's Medication Administration Record (MAR) on 2/7/25 indicated no documented evidence of Foley Catheter Care. During an interview on 2/5/25 at 10:30 a.m. with the Director of Nursing 2 (DON 2), DON 2 stated that a Foley catheter order would include catheter care, changing the catheter as needed, a diagnosis that indicates why the resident has the Foley catheter and further stated her expectation would be that every resident that has a Foley Catheter should have an active order for one. During a review of the facility's policy and procedure (P &P) titled, Indwelling [Foley] Catheter Insertion, Male Resident, dated 8/22, the P&P indicated .Verify there is a physician's order for the procedure .

Based on observation, interview and record review, the facility failed to ensure food preferences were honored for one (Resident 1) of 11 sampled residents when Resident 1's dislike food item was served. This failure had the potential to negatively impact Resident 1's nutritional status. Findings: Resident 1 was admitted to the facility in the August of 2024 with diagnoses that included: Type 2 Diabetes Mellitus (disease that affects blood sugar control) with unspecified complications, dysphagia, oropharyngeal phase (difficulty swallowing), and long-term use of Insulin (medication used to bring down blood sugar levels). During a review of Resident 9's meal tray ticket for lunch on 10/23/24, the tray ticket indicated, Dislikes: Fish, Chillie Beans, Asparagus. During a concurrent observation and interview on 10/23/24 at 12:25 p.m., with Resident 1, Resident 1's lunch tray was observed to contain a filet of breaded fish. When asked how she felt about being served fish, Resident 1 stated, I really don't like fish. During an interview on 10/23/24 at 12:29 p.m., with the Certified Nursing Assistant (CNA 1), CNA 1 confirmed Resident 1 received fish despite Resident 1 having a dislike for fish. During an interview on 10/23/24 at 12:35 p.m., with the Dietary Supervisor (DS), the DS confirmed Resident 1 received fish for lunch and that fish is documented as one of Resident 1's dislikes. The DS stated, Not respecting food preferences could lead to potential turn off from wanting to eat anything. During an interview on 10/23/24 at 2:12 p.m., with the Director of Nursing (DON), the DON stated the facility, absolutely should honor food preferences and confirmed not honoring food preferences could affect residents' nutrition. During a review of the facility's policy and procedure (P&P) titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, dated 2001, the P&P indicated, The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. a. Treatment decisions should consider all pertinent evidence and relevant issues (e.g., food intake, resident/patient wishes, overall condition and prognosis, etc.) .

Based on interviews, record review, facility document review, and facility policy review, the facility failed to ensure 1 (Resident #72) of 2 residents reviewed for vision services received treatment to maintain vision abilities. Specifically, the facility failed to obtain an ophthalmology appointment for the treatment of cataracts for Resident #72, who requested multiple times to be seen by a specialist for treatment. This failure resulted in Resident #72's vision worsening. Findings included: A review of a facility policy titled Referrals, Social Services, revised in December 2008, revealed, Social services personnel shall coordinate most resident referrals with outside agencies. The policy revealed, 3. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. A review of Resident #72's Admission Record revealed the facility admitted the resident on 04/15/2022 with diagnoses that included major depressive disorder, atrial fibrillation, paraplegia, and essential hypertension. A review of Resident #72's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/20/2022, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Per the MDS, Resident #72 also had impaired vision (sees large print, but not regular print in newspapers/books) and did not wear corrective lenses. A review of Resident #72's care plan revealed a Focus area initiated on 04/22/2022 that indicated the resident had impaired visual function. The facility developed interventions that directed staff to arrange consultation with an eye care practitioner as required, to identify and record factors affecting visual function such as cataracts, and to tell the resident where staff placed their items. A review of Resident #72's Activities - Initial Review assessment dated [DATE] indicated the resident enjoyed painting, jigsaw puzzles, and watching television. A review of Resident #72's Order Summary Report, with active orders as of 02/07/2024, revealed an order dated 04/15/2022 for an eye health and vision consultation with follow-up treatment as indicated. Further review revealed no documented evidence that a consultation was obtained for the resident. A review of Resident #72's Progress Notes dated 04/13/2023 revealed the resident wanted to be seen by the eye doctor for cataracts because they could not see well. The note indicated the nursing staff would follow up. A review of Resident #72's Progress Notes dated 04/14/2023 revealed the resident would like to see a specialist for their cataracts. The note revealed the resident's physician was notified. The note indicated an ophthalmologist referral would be obtained. A review of Resident #72's Order Summary Report, with active orders as of 02/07/2024, revealed an order dated 04/14/2023 for an ophthalmologist referral when available. A review of Resident #72's Referral for Follow-up Ophthalmology Care for HMO [Health Maintenance Organization] Patients, dated 06/23/2023, two months after the most recent physician order for an ophthalmology referral, revealed the resident was referred to an ophthalmology group for non-emergent cataracts; however, the note revealed the group was not on any HMO plans and could not complete Resident #72's eye examination. Further review indicated the facility had to refer the resident to a local ophthalmologist covered by the resident's HMO plan. Further review revealed no documented evidence that another ophthalmology referral was obtained for Resident #72. During an interview on 02/08/2024 at 2:45 PM, the Regional Director of Ophthalmology stated Resident #72 had not been seen by any of their providers because the medical group was not credentialed with HMOs, which was Resident #72's primary insurance coverage. The Regional Director of Ophthalmology further stated Resident #72 had a cataract diagnosis and probably needed surgery, but due to their payor source, the resident needed to go through a provider that was in their HMO network. A review of Resident #72's Progress Notes indicated the following: - 06/24/2023: A physician's visit note indicated the resident wanted to see ophthalmology for cataracts. - 07/01/2023: A psychiatrist's visit note indicated the resident had anxiety related to their cataracts. - 07/20/2023: A case management note revealed the resident had concerns with their cataracts, and social services were to follow up. - 10/09/2023: New orders from the Nurse Practitioner (NP) indicated a referral for ophthalmology was needed. A review of Resident #72's Order Summary Report, with active orders as of 02/07/2024, indicated a referral to ophthalmology was ordered on 10/09/2023. However, there was no documented evidence a referral was obtained; subsequently, there was no documented evidence Resident #72 received an eye examination. Further review of Resident #72's Progress Notes indicated the following: - 10/11/2023: An NP note revealed the resident stated they had a history of cataracts and requested to be seen by ophthalmology. - 10/12/2023: A physician's visit note indicated the resident's chief complaint was related to their cataracts. Resident #72 stated they could barely see and was waiting for an ophthalmology appointment for cataract extraction. The plan for treatment included an ophthalmology referral. There was no documented evidence the facility had acted on the provider's order for a referral on 10/09/2023, and no documented evidence an appointment for an eye examination was obtained for Resident #72. - 10/19/2023: A case management note revealed the resident wanted surgery for cataracts. The note revealed the nurse would notify the NP for an order, even though the NP had already given an order dated 10/09/2023. - 12/21/2023: A physician's visit note indicated the resident's chief complaint was related to their cataracts. Resident #72 stated they could barely see and was waiting for an ophthalmology appointment for cataract extraction. A review of Resident #72's Order Summary Report, with active orders as of 02/07/2024, revealed a referral to ophthalmology for cataract due to decreased vision was ordered on 12/21/2023. Further review revealed there was no documented evidence a referral was obtained; subsequently, there was no documented evidence Resident #72 received an eye examination. A review of Resident #72's Progress Notes revealed a case management note dated 01/23/2024 that indicated during the quarterly care conference that Resident #72 wanted an appointment for cataract surgery. The note indicated that the nursing staff would follow up and get an appointment. A review of Resident #72's Order Summary Report, with active orders as of 02/07/2024, revealed a referral to ophthalmology for cataract due to decreased vision was ordered on 01/25/2024. However, as of 02/06/2024, when the survey began, there was no documented evidence the facility had obtained an eye examination for Resident #72, who had been requesting an eye examination for at least approximately 10 months. A review of Resident #72's quarterly MDS, with an ARD of 01/09/2024, revealed the resident continued to have a BIMS score of 15, which indicated the resident was cognitively intact. Per the MDS, Resident #72's vision had worsened since the resident's admission MDS was completed. The MDS revealed the resident had moderately impaired vision (limited vision, not able to see newspaper headlines but can identify objects). A review of Resident #72's Activities - Quarterly/Annual Participation Review quarterly assessment dated [DATE] indicated the resident enjoyed listening to the news, music, and audiobooks. There were no longer visual activities listed. During an interview on 02/06/2024 at 12:34 PM, Resident #72 stated they needed to see an ophthalmologist for cataracts, but the Social Services Director (SSD) would not make the appointment. Resident #72 further stated they were losing their vision and could now barely see a plate of food. During an interview on 02/08/2024 at 1:15 PM, Resident #72 stated their vision had declined considerably since their initial admission. Per Resident #72, they could see the television about a year ago and the food they were eating. Resident #72 stated that now, they could only see flashes from the television and staff must explain what was on their meal tray. Resident #72 further stated they had requested multiple times to see an ophthalmologist because they were miserable and wanted something done to improve their vision. An interview with Certified Nursing Assistant (CNA) #16 on 02/08/2024 at 9:08 AM revealed Resident #72 reported their vision was blurry and cloudy, and the resident only saw shadows. CNA #16 stated he made sure to explain where things were when he delivered the resident's meal because the resident did not see well. During an interview on 02/08/2024 at 9:31 AM, Licensed Vocational Nurse (LVN) #17 stated Resident #72 was legally blind and was not sure whether the resident was receiving treatment. LVN #17 stated she was not sure what the process was for obtaining referrals but thought social services was involved. During an interview on 02/08/2024 at 3:06 PM, Registered Nurse (RN) #5 stated she was the nurse who addressed Resident #72's ophthalmology referral on 10/09/2023 but did not follow up to ensure the resident was seen. RN #5 further stated she should have followed up. RN #5 stated she was not sure who was responsible for making resident appointments. RN #5 stated that management expected the floor nurses to do it, but referrals became hard when she was overloaded with work on the floor. RN #5 stated she thought she gave a referral packet for Resident #72 to the Assistant Director of Nursing (ADON) but did not follow up to ensure the resident was seen. During an interview on 02/08/2024 at 3:21 PM, the ADON stated that when there was a referral for a resident to see an outside service, the nurses should notify the SSD, who then contacted the outside service to set up the appointment. The ADON further stated Resident #72 had a few referrals to see an ophthalmologist, and the only one she was aware of was a referral she faxed to a provider on 01/25/2024 to set up an appointment. During an interview on 02/08/2024 at 12:25 PM, the SSD stated that when there was an order for an outside referral, she sent an email to the provider that the resident needed to be seen. She stated it usually took 60 to 90 days following the referral for the resident to be seen. The SSD further stated it was not typical for a resident to have as many referrals as Resident #72 had to see an ophthalmologist and for them not to be seen. The SSD confirmed there was no documentation in the medical record that Resident #72 had seen an ophthalmologist. During an interview on 02/08/2024 at 10:57 AM, the NP stated Resident #72 requested to see an ophthalmologist, and she put in an order to be seen in October 2023. While looking through Resident #72's medical record, the NP stated there were multiple referrals for Resident #72 to see an ophthalmologist, so there should at least be a scheduled appointment, but she did not see anything in the record. The NP further stated she did not know who at the facility was responsible for outside referrals. She stated that the staff took no real ownership of who was responsible for carrying out referral orders. During an interview on 02/09/2024 at 10:16 AM, the Director of Nursing (DON) stated that when a resident had a referral to see an outside provider, the SSD was responsible for following up. The DON further stated she expected the SSD to set up appointments and to follow up to ensure a resident was seen as needed. The DON then stated it was important to follow up on referrals because if a resident had a problem with their eyes, they needed to see a provider for treatment. During an interview on 02/09/2024 at 10:58 AM, the Administrator stated if a resident requested to be seen by an ophthalmologist, that referral went through the SSD, who should have worked with the clinical team to set up an appointment. The Administrator further stated that if the SSD reached out to a provider who was not covered by a resident's HMO plan, the SSD needed to follow up to ensure the resident was seen by a practitioner who was covered within their insurance network.

Based on staff interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent accidents for 1 of 2 sampled residents (1) when, on 11/26/14 at 9:20 a.m., Resident 1 slipped out of the shower chair and sustained a traumatic brain injury with traumatic bleeding in the brain. According to the U.S. National Library of Medicine, (www.nlm.nih.gov), a "Subarachnoid hemorrhage is bleeding in the area between the brain and the thin tissues that cover the brain. This area is called the subarachnoid space. Changes in consciousness and alertness due to a subarachnoid hemorrhage may become worse and lead to seizures, stroke, coma or even death." This failure resulted in Resident 1's fall causing a laceration and subarachnoid hemorrhage requiring acute hospitalization . Findings: Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The Occupational Therapy Initial Plan of Treatment, dated 9/2/10-9/21/10, indicated Resident 1's functional mobility status at the beginning and end of treatment were the same, "Static sitting balance-poor. Dynamic sitting balance-unable." (According to the resource Physical rehabilitation: assessment and treatment, 2007, 5th ed., "A functional balance grade of 'Poor' Static sitting balance means : Patient requires handheld support and moderate to maximal assistance to maintain position and Dynamic sitting balance: Patient unable to accept challenge or move without loss of balance"). A review of the admission Minimum Data Set, (an assessment tool), dated 11/24/14, indicated Resident 1 was unable to make himself understood, nor did he have the capabilities to understand others. The resident was noted to have memory problems and his decision-making skills were severely impaired. He had bilateral impairment of both his upper and lower extremities. When the resident was assessed for transfer mobility, the Licensed Nurse (LN) determined the resident to be "totally dependent, 2 person physical assist while transferring between surfaces." A review of the clinical record titled, At Risk for Fall Care Plan, dated 4/8/12, indicated, "Requires assistance with bed mobility, locomotion and transfer - poor safety awareness - Functional limitations in Range of Motion secondary to CVA (stroke), dependent with transfers and mobility - Not able to consistently follow instructions...mechanical lift for transfers." The Self Care Deficit Care Plan, dated 4/8/12, indicated Resident 1, "Requires assistance with ADL (activities of daily living) and mobility. Dependent for ADL care and transfers. Unable to communicate needs to staff secondary to aphasia - attempts to use hand gestures, facial expressions and eye contact to communicate. Episodes of grabbing/reaching towards staff during care." A review of the clinical record titled Care Plan Conference/Interdisciplinary Review, dated 11/25/14, indicated, "Dependent with ADL care and transfers. Resident continues to make attempts to communicate some needs via gestures (i.e., facial expressions and hand movements). However, unable to make needs known consistently. Has episodes of reaching towards staff and grabbing at staff and has to be redirected, but behaviors not easily deterred." A nurse's note written by LN 1, dated 11/26/14 at 9:20 a.m., indicated Resident 1 was found lying on his back on the floor in between the shower chair and the mechanical lift. The note indicated, "Moderate amount of blood on his head and floor. Induration (Hardened, usually used with reference to soft tissues becoming extremely firm) noted on the back of patient's head but unable to fully assess patient's injury due to patient does not follow instructions and non verbal." The nurse's note indicated Resident 1 was transported to the acute hospital at 9:55 a.m. A review of the acute hospital emergency report, dated 11/26/14, and written by the emergency room physician, indicated a "CT (special X-ray tests that produce cross-sectional images of the body using X-rays and a computer) of the head shows subarachnoid hemorrhage and contusions (bruises) over the right anterior temporal and parietal lobes (lower side and back of the head). Small contusions are seen in the left parietal convexity (curved outward) and frontal lobe...small subdural hematoma (collection of blood on the surface of the brain) overlying the left parietal lobe is seen...the patient has a high probability of imminent life-threatening deterioration due to acute brain injury and cerebral edema (swelling of the brain)." During an interview on 12/8/14 and again on 12/23/14, Certified Nurse Assistant (CNA) 1 stated on 11/26/14 at approximately 9 a.m., she was transporting Resident 1 back to his room after his shower. The resident was still seated in the shower chair as she began to prepare his transfer back onto the mechanical lift and back into his bed. CNA 1 stated, "I lifted the shower safety bar on the shower chair. I was going to fix the sling (the mesh sling used to transfer the residents from the mechanical lifts are left in place during the shower), pull it up, and then call another CNA in to help me, but that's when he (Resident 1) reached out. He grabbed out for my chest. I tried to calm him down. He reached out again and that's when he slid off the chair, and then fell on his bum, and then his head hit the leg of the mechanical lift. It happened so quick...to be honest, in retrospect I probably should have had someone there with me. Because you know, he was known to move around a lot." In an interview with CNA 2 on 12/8/14 at 1:30 p.m., she stated, "He's (Resident 1) quick. He'll just reach out and grab you." In an interview with LN 2 on 12/8/14 at 1:40 p.m., she stated, "He (Resident 1) would reach out when I would check his GT (feeding tube). Yes, he has been doing this for a while." In an interview with CNA 3 on 12/23/14 at 2:26 p.m., she stated, "I'm very organized. I like to have everything ready. I would've asked for someone to come help me as I was going down the hallway (back to the resident's room)...the mesh sling is all wet and slippery. I would not lift the bar up. I'd keep it down till I was ready to transfer him. But everyone in here does it different, you know." In an interview with the Director of Staff Development (DSD) on 12/8/14 at 2 p.m., the Department asked if the facility trained the CNA's specifically on transfers to and from the shower chairs, from the mechanical lifts. The DSD stated, "There is no training on that." A two person transfer policy and procedure was requested from the facility on 1/20/15 at 12:10 p.m. The Administrator stated, "We do not do two person transfers in our facility." The Administrator referred to the facility undated policy titled, Clarification of Facility NO-LIFT policy, that directed, "ALL patients who require the assistance of more than one CNA for a transfer will be transferred using a mechanical lift ONLY." The facility's document titled, "Hospital Safety/Accident Prevention", revised 1/6/03, stipulated, "Know how to prevent accidents from happening...When operating equipment, make sure that required guards and safety devices are in place and functioning." The facility document titled, "Operation Instructions" (for the facility shower chairs), dated 9/1/10, stipulated, "Precautions, exaggerated movement in any direction or sitting on the edge of the seat may cause the chair to tip." The Mosby's Nursing Assistant video skills 4.0, Transferring the Person Using a Mechanical Lift, (<http://prairiestate.edu/academics/academic-programs/nursingcertified-nursing-assistant/Nursingassistantvideoskills>), directs, "Use mechanical lifts to transfer persons who cannot help themselves or who are too heavy for the staff to transfer. Use the lift for transfers to and from beds, wheelchairs, chairs, stretchers, tubs, shower chairs, toilets, commodes, whirlpools, or other vehicles. Before using a lift...you must be trained in its use. At least two staff members are needed." In an interview with LN 1 on 1/26/14 at 11:09 a.m., she stated, "Everybody knows about (Resident 1's) behaviors. Sometimes you are unaware. We cannot tell when (he's going to reach out). It's documented in the chart. We tell (CNA's) to just be careful. Protect the patient."