Every finding on record at Country Oaks Care Center

Based on interview and record review, the facility failed to provide care and services to prevent falls for three of four sampled residents (Residents 3, 7, and 9) when:a. The facility replaced wheels on a shower chair (a movable or rolling waterproof seat used by residents who cannot safely stand during showering) with wheels that were larger than the original set. As a result, Resident 3 fell from the shower chair when the shower chair tipped while Certified Nursing Assistant (CNA) 1 was showering Resident 3.b. CNA 2 failed to ensure Resident 7's shower chair was locked in place according to the facility's Policy and Procedure (P&P) titled, Resident Showers, dated [DATE], when providing a shower to Resident 7. The shower chair slipped out from Resident 7 and Resident 7 fell to the ground.c. The facility failed to provide one-to-one (1:1) supervision (a dedicated staff member is assigned to continuously watch and protect a single resident) to Resident 9 on [DATE].These failures had the potential to result in Residents 3, 7, and 9 sustaining injury and/or harm due to falling while in the care of the facility.(Cross reference F580, F656, and F725)a. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on [DATE] with diagnoses including type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD, irreversible kidney failure), and history of falling.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 3 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort to complete the activity) from staff for lower body dressing and putting on/off footwear. The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort to complete the activity) from staff for bathing and toileting hygiene.During review of Resident 3's Change in Condition Evaluation (CICE), dated [DATE], the CICE indicated that on [DATE] at 3:23 PM, Resident (Resident 3) was in the shower room with CNA (CNA 1), upon exiting the shower stall, resident (Resident 3) slid from shower chair and was assisted to the floor by CNA (CNA 1). On the way down, the back of the shower chair hit resident (Resident 3) across (Resident 3's) back.Resident (Resident 3) c/o (complained of) of pain to (Resident 3's) back.During an interview on [DATE] at 9:46 AM with CNA 1, CNA 1 stated that on [DATE] at around 2:15 PM, CNA 1 was showering Resident 3 in the shower room closest to the Administrator's (ADM) office. CNA 1 stated CNA 1 had finished the shower and was moving the shower chair out of the shower stall. CNA 1 stated that while CNA 1 was pulling the chair toward CNA 1, the wheels on the chair got stuck, and the chair tipped toward CNA 1. CNA stated the Director of Staff Development (DSD) later removed the chair from being used to give residents (in general) showers because the chair's wheels were too high. CNA 1 stated someone had replaced the wheels of the shower chair about 4 months ago with larger wheels.During an interview on [DATE] at 10:41 AM with the Director of Staff Development (DSD), the DSD stated the DSD disposed of the shower chair CNA 1 had used during the fall incident of Resident 3. The DSD stated the shower chair was taller than usual because the wheels had been changed about 2 months before the fall of Resident 3. The DSD stated the DSD noticed the wheels had been replaced with larger wheels. The DSD stated the DSD removed the chair because the DSD tipped over because it was modified from the original design.During a concurrent observation and interview on [DATE] at 12:00 PM with the Maintenance Supervisor (MS), the MS showed the surveyor the 2 different kinds of wheels that had been on the shower chair that was being used when Resident 3 fell. The MS measured the wheel which the MS stated was the original wheel on the shower chair. The measurement was 3 inches. The MS measured the wheel which the MS stated was the replacement wheel on the shower chair. The measurement was 4 1/2 inches. The MS stated the MS should have replaced the wheels with the same size as originally designed.b. During a review of Resident 7's AR, the AR indicated the facility readmitted Resident 7 on [DATE] with diagnoses which included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and displaced fracture of lateral malleolus of right fibula (a broken outer ankle bone where the separated bone ends are out of alignment). The AR indicated RR 2, who was Resident 7's daughter, was Resident 7's emergency contact and care conference person.During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 was moderately impaired in cognitive skills. The MDS indicated Resident 7 was dependent (helper does all the effort to complete the activity) on staff for bathing, lower body dressing, and toileting hygiene. The MDS indicated Resident 7 required substantial/maximal assistance from staff for upper body dressing. The MDS indicated Resident 3 had fallen multiple times while at the facility.During a review of Resident 7's H&P, dated [DATE], the H&P indicated Resident 7 had fluctuating capacity to understand and make decisions.During a review of Resident 7's Progress Notes (PN), dated [DATE], the PN indicated that on [DATE], Resident 7 had a fall in the facility shower and hit Resident 7's head on the wall.During a concurrent observation and interview on [DATE] at 10:32 PM with CNA 2, a shower chair was observed in the shower room next to station 2. The shower chair had a wheel on each leg of the shower chair. Each wheel had a locking mechanism that could be activated by staff using their feet to activate the lock. CNA 2 stated that CNA 2 used the chair to shower Resident 7. CNA 2 stated CNA 2 did not lock the wheels once CNA 2 moved Resident 7 into the shower stall on the right side of the shower room. CNA 2 stated CNA 2 was standing behind the chair cleaning Resident 3 when the chair tipped forward, and Resident 3 fell to Resident 7's knees on the ground.During an interview on [DATE] at 10:41 AM with the DSD, the DSD stated the DSD was not aware that CNA 2 had not activated the brakes on Resident 7's shower chair prior to CNA 7 showering Resident 7. The DSD stated staff (in general) should put the shower chair brakes on before showering the residents (in general).During an interview on [DATE] at 12:26 PM with Resident 7, Resident 7 stated that the shower chair slipped out from under Resident 7 when Resident 7 was assisted in taking a shower.c. During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted Resident 9 on [DATE] with diagnoses including end stage renal disease (ESRD, irreversible kidney failure), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 9 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 9 required substantial/maximal assistance (helper does more than half the effort to complete the activity) from staff for upper body dressing, oral hygiene, and personal hygiene. The MDS indicated Resident 9 was dependent on staff for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 9 had a history of falling prior to being admitted to the facility. The MDS also indicated Resident 9 had fallen once while in the care of the facility.During a review of Resident 9's CPR, initiated on [DATE], the CPR indicated, Resident had an unwitnessed fall during shift change. The CPR indicated one of the interventions to be Have 1:1 sitter at all times; sitter to wait for replacement before leaving.During an interview on [DATE] at 2:16 PM with the DSD, the DSD stated the facility was no longer providing 1:1 sitter supervision for Resident 9. The DSD stated the facility had stopped providing 1:1 sitter to Resident 9 as of a few days ago.During an observation on [DATE] at 2:46 PM in Resident 9's room, Resident 9 was lying in bed. There were no staff present in the room with Resident 9.During an interview on [DATE] at 2:50 PM with the DON, the DON stated Resident 9 still required 1:1 supervision and that staff should always be with Resident 9.During a concurrent observation and interview on [DATE] at 2:54 PM with Certified Nursing Assistant (CNA) 3 in the hallway next to Resident 9's room, the Surveyor asked CNA 3 if CNA 3 was assigned as Resident 9's 1:1 supervision. CNA 3 stated CNA 3 was not assigned to Resident 9 and that the facility had stopped providing 1:1 supervision for Resident 9. CNA 3 went into Resident 9's room with the Surveyor and stated Resident 9 was alone, lying in bed, without 1:1 supervision.During a concurrent interview and record review on [DATE] at 9:50 AM with the Director of Nursing (DON), Resident 9's CPR, initiated on [DATE], was reviewed. The DON stated Resident 9 needed 1:1 supervision from staff because Resident 9 was impulsive and would forget Resident 9 was missing one of Resident 9's lower limbs. The DON stated the 1:1 sitter intervention was based on the recommendation of the interdisciplinary team (IDT, a team of professionals from various disciplines who work in collaboration to address the resident's care). The DON stated the purpose of Resident 9's care plan was to direct nursing care for Resident 9. The DON stated the DON was not aware Resident 9 was left unattended by 1:1 supervision on [DATE]. The DON stated a staff person needed to always be with Resident 1.During a review of the facility's policy and procedure (P&P) titled, Fall Prevention Program, dated [DATE], the P&P indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.The nurse and/or interdisciplinary team will initiate interventions on the resident's care plan, in accordance with the resident's level of risk.Fall interventions include, but not limited to: a. Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to.v. Wheelchairs and assistive devices are in good repair. Provide additional interventions as directed by the resident's assessment, including but not limited to.iii. Sitter, if indicated.

Based on interview and record review, the facility failed to promptly notify two of three sampled residents' (Resident 3's and Resident 7's) representatives (RR), according to the facility's Policy and Procedure (P&P) titled, Notification of Changes, dated 12/19/2022, when:a. On 8/4/2026, the facility failed to notify RR 1 of Resident 3's fall that occurred in the shower.b. On 8/15/2026, the facility failed to notify RR 2 of Resident 7's fall that occurred in the shower.These failures had the potential for Resident 3's and Resident 7's representatives not being able to advocate for or assist Residents 3 and 7 in participating in decision making of treatment following their falls.(Cross reference F689 and F725)a. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 7/31/2026 with diagnoses including type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD, irreversible kidney failure), and history of falling. The AR indicated RR 1, who was Resident 3's daughter, was Resident 3's emergency contact and care conference (a planned meeting between a resident, their family, and their health care team to review health status, discuss goals, and update the plan for care) person.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 8/7/2026, the MDS indicated Resident 3 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort to complete the activity) from staff for lower body dressing and putting on/off footwear. The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort to complete the activity) from staff for bathing and toileting hygiene.During a review of Resident 3's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 8/1/2026, the H&P indicated, Resident 1 had the capacity to understand and make decisions.During a concurrent interview and record review on 8/19/2026 at 12:20 PM with the Social Services Director (SSD), Resident 3's Social Services Assessment (SSA), dated 8/5/2026, was reviewed. The SSA indicated Resident 3 participated in care decisions together with Resident 3's Resident Representative (RR 1). The SSD stated Resident 3 lived with RR 1 before being admitted to the facility and that the plan was for Resident 3 to return home with RR 1. The SSD stated Resident 3 wanted RR 1 to be involved with decisions regarding Resident 3's care.During a concurrent interview and record review on 8/20/2026 at 9:10 AM with Licensed Vocational Nurse (LVN) 1, Resident 3's Change in Condition Evaluation (CICE), dated 8/4/2026, was reviewed. The CICE indicated LVN 1 signed the CICE. The CICE indicated that on 8/4/2026 at 3:23 PM, Resident (Resident 3) was in the shower room with CNA (CNA 1), upon exiting the shower stall, resident (Resident 3) slid from shower chair and was assisted to the floor by CNA (CNA 1). On the way down, the back of the shower chair hit resident (Resident 3) across (Resident 3's) back.Resident (Resident 3) c/o (complained of) of pain to (Resident 3's) back. The CICE indicated RR 1 was not notified of Resident 3's fall. LVN 1 stated LVN 1 did not notify Resident 3's family regarding Resident 3's fall. LVN 1 stated LVN 1 was responsible to notify Resident 3's family of Resident 3's fall even though Resident 3 was self-responsible.b. During a review of Resident 7's AR, the AR indicated the facility readmitted Resident 7 on 8/16/2026 with diagnoses which included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and displaced fracture of lateral malleolus of right fibula (a broken outer ankle bone where the separated bone ends are out of alignment). The AR indicated RR 2, who was Resident 7's daughter, was Resident 7's emergency contact and care conference person.During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 was moderately impaired in cognitive skills. The MDS indicated Resident 7 was dependent (helper does all the effort to complete the activity) on staff for bathing, lower body dressing, and toileting hygiene. The MDS indicated Resident 7 required substantial/maximal assistance from staff for upper body dressing. The MDS indicated Resident 3 had fallen multiple times while at the facility.During a review of Resident 7's H&P, dated 8/14/2026, the H&P indicated Resident 7 had fluctuating capacity to understand and make decisions.During a review of Resident 7's Progress Notes (PN), dated 8/24/2026, the PN indicated that on 8/15/2026, Resident 7 had a fall in the facility shower and hit Resident 7's head on the wall.During a telephone interview on 8/20/2026 at 12:56 PM with RR 2, RR 2 stated no one from the facility called and notified RR 2 that Resident 7 had fallen at the facility on 8/15/2026. RR 2 stated RR 2 was the one who made medical decisions for Resident 7 because Resident 7 had cognitive decline due to MS.During a concurrent interview and record review on 8/24/2026 at 9:50 AM with the Director of Nursing (DON), Resident 7's CICE, dated 8/15/2026, was reviewed. The CICE indicated Resident 7 experienced a fall at the facility on 8/15/2026. The CICE indicated RR 2 was not notified of Resident 7's fall. The DON stated Resident 7's nurse on 8/15/2026 should have notified Resident 7's family of Resident 7's fall even if Resident 7 was self-responsible.During a review of the facility's P&P titled, Notification of Changes, dated 12/19/2022, the P&P indicated, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The P&P indicated, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents a. Resulting in injury. b. Potential to require physician intervention.

Based on observation, interview, and record review, the facility failed to post actual nursing hours worked at the start of each shift according to the facility's policy and procedure (P&P) titled, Nurse Staffing Posting Information, revised 3/10/2025.This failure had the potential to result inaccurately reflecting the actual nurses providing direct care to the residents.During a concurrent interview and record review on 8/24/2026 at 1:37 PM with the Director of Staff Development (DSD), the facility's Nurse Staff Projection (NSP), dated 8/20/2026, was reviewed. The NSP indicated the projected number of nursing staff (in general) who would provide care to residents (in general) on 8/20/2026 but failed to indicate the actual number of staff who worked and provided care to residents on 8/20/2026. The DSD stated the facility did not have any other copies of NSPs from previous shifts. The DSD stated the facility did not keep the copies of the previous shift's NSPs.During a concurrent observation and interview on 8/24/2026 at 1:42 PM with the DSD in the hallway next to the nurses' station at the entry of the facility, the facility's NSP, dated 8/24/2026, was posted on the wall across from the nurses' station. The NSP indicated the projected number of nursing staff (in general) who would provide care to residents (in general) on 8/24/2026 but failed to indicate the actual number of staff who worked and provided care to residents on the morning shift of 8/24/2026. The DSD stated the NSP should be updated at the beginning of each shift to indicate how many nursing staff (in general) were providing care to the residents (in general). The DSD stated the NSP needed to be posted so family and visitors knew how many staff (in general) the facility had.During a review of the facility's P&P titled, Nurse Staffing Posting Information, revised 3/10/2025, the P&P indicated, 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name. b. The current date. c. Facility's current resident census. d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides.2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. Nursing schedules and posting information will be maintained in the Human Resources Department for review for a minimum of 18 months or as required by State law, whichever is greater.

Based on interview and record review, the facility failed to provide sufficient number of certified nursing assistants (CNAs) on [DATE] and [DATE] according to the facility's Facility Assessment Tool (FAT - facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies), updated [DATE]. The facility also failed to save CNA staffing assignments from [DATE] and [DATE].This failure had the potential to result in residents receiving inadequate care and supervision which can lead to falls, elopement, and delayed recognition of residents' significant changes in condition. (Cross Reference F656 and F689)During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted Resident 9 on [DATE] with diagnoses including end stage renal disease (ESRD, irreversible kidney failure), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 9 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 9 required substantial/maximal assistance (helper does more than half the effort to complete the activity) from staff for upper body dressing, oral hygiene, and personal hygiene. The MDS indicated Resident 9 was dependent on staff for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 9 had a history of falling prior to being admitted to the facility. The MDS also indicated Resident 9 had fallen once while in the care of the facility.During a review of Resident 9's CPR, initiated on [DATE], the CPR indicated, Resident had an unwitnessed fall during shift change. The CPR indicated one of the interventions to be Have 1:1 (one-to-one supervision - a dedicated staff member is assigned to continuously watch and protect a single resident) sitter at all times; sitter to wait for replacement before leaving.During a concurrent interview and record review on [DATE] at 10:52 AM with the Director of Staff Development (DSD), the facility's CNA Assignment Sheet (CNAAS) for the Night shift (NOC, 11 PM - 7 AM), dated [DATE], was reviewed. The CNAAS indicated four (4) CNAs were assigned to provide care for 72 residents. The CNAAS indicated one (1) CNA was assigned to provide care to 7 residents, two (2) CNAs were assigned to provide care to 22 residents, and one (1) CNA was assigned to provide care to 21 residents. The DSD stated the facility was short-staffed that night because a CNA called off. The DSD stated Resident 9 also required 1:1 supervision and that the staff took turns sitting with Resident 9.During a concurrent interview and record review on [DATE] at 10:57 AM with the DSD, the facility's CNAAS for the Afternoon shift (PM, 3 PM - 11 PM) dated [DATE] was reviewed. The CNAAS indicated six (6) CNAs were assigned to provide care for 71 patients. The CNAAS also indicated that the CNA's were assigned to take turns providing 1:1 supervision to Resident 9, 1 hour at a time. The CNAAS indicated the CNA to resident staffing ratio was 1:14. The DSD stated the ratio for CNAs should have been 1:9 or 1:10 during the PM shift. The DSD stated the facility should have assigned 7 or 8 CNAs on the shift, but a CNA called off for that shift. The DSD stated the facility was missing CNAASs for the NOC shifts on [DATE] and [DATE]. The DSD stated the facility should retain the CNAAS to provide accurate data when determining the Direct Care Service Hours Per Patient Day (DHPPD, a mandatory minimum staffing standard for skilled nursing facilities [SNFs] in California).During a review of the facility's FAT, updated [DATE], the FAT indicated that the facility had 78 licensed beds and that the average daily census was 70-78. The FAT indicated, The facility will adjust staffing levels as needed to meet the needs of the current patient population while both meeting and, if required, exceeding the required staffing PPD. The FAT indicated the facility offered services and care based on residents' (in general) needs, including, .fall/fall with injury prevention. The FAT indicated that Nursing Services was a resource which the facility needed to provide care for the residents (in general) every day and during emergencies. The FAT described Nursing Services consisting of DON, RN, LVN, CNA and MDS nurse. The FAT indicated the facility's staffing plan to be, Nursing staffing is reviewed by leadership daily. Calendars are prepared monthly. Changes in acuity are addressed as they occur to meet residents' needs at any given time. Other categories are reviewed and revised by Administrator as needed based on acuity to meet residents' needs at any given time. The FAT indicated CNA staffing levels to be 8 CNAs for the morning shift, 7 CNAs for the afternoon shift, and 5 CNAs for the night shift, when the census was full at 75 residents.

Based on interview and record review, the facility failed to implement the comprehensive person-centered care plan for one of four sampled residents (Residents 9) when the facility failed to provide one-to-one (1:1) supervision (a dedicated staff member is assigned to continuously watch and protect a single resident) to Resident 9, on [DATE], in accordance with Resident 9's Care Plan Report (CPR), initiated on [DATE].This failure had the potential for Resident 9 to fall and/or injure himself while in the care of the facility.(Cross Reference F689 and F725)During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted Resident 9 on [DATE] with diagnoses including end stage renal disease (ESRD, irreversible kidney failure), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 9 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 9 required substantial/maximal assistance (helper does more than half the effort to complete the activity) from staff for upper body dressing, oral hygiene, and personal hygiene. The MDS indicated Resident 9 was dependent on staff for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 9 had a history of falling prior to being admitted to the facility. The MDS also indicated Resident 9 had fallen once while in the care of the facility.During a review of Resident 9's CPR, initiated on [DATE], the CPR indicated, Resident had an unwitnessed fall during shift change. The CPR indicated one of the interventions to be Have 1:1 sitter at all times; sitter to wait for replacement before leaving.During an observation on [DATE] at 2:46 PM in Resident 9's room, Resident 9 was lying in bed. There were no staff present in the room with Resident 9.During a concurrent observation and interview on [DATE] at 2:54 PM with Certified Nursing Assistant (CNA) 3 in the hallway next to Resident 9's room, the Surveyor asked CNA 3 if CNA 3 was assigned as Resident 9's 1:1 supervision. CNA 3 stated CNA 3 was not assigned to Resident 9 and that the facility had stopped providing 1:1 supervision for Resident 9. CNA 3 went into Resident 9's room with the Surveyor and stated Resident 9 was alone, lying in bed, without 1:1 supervision.During a concurrent interview and record review on [DATE] at 9:50 AM with the Director of Nursing (DON), Resident 9's CPR, initiated on [DATE], was reviewed. The DON stated Resident 9 needed 1:1 supervision from staff because Resident 9 was impulsive and would forget Resident 9 was missing one of Resident 9's lower limbs. The DON stated the 1:1 sitter intervention was based on the recommendation of the interdisciplinary team (IDT, a team of professionals from various disciplines who work in collaboration to address the resident's care). The DON stated the purpose of Resident 9's care plan was to direct nursing care for Resident 9. The DON stated the DON was not aware Resident 9 was left unattended by 1:1 supervision on [DATE]. The DON stated a staff person needed to always be with Resident 1.During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plans, revised [DATE], the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The P&P indicated, The comprehensive care plan will describe.services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Resident specific interventions that reflect the resident's needs.

Based on observation, interview, and record review, the facility failed to maintain safe and proper storage of food practices in accordance with the facility's policy and procedures (P&P) by failing to:1. Ensure one of one kitchen staff's (Cook [CK]) personal food item was not stored inside one of three freezers (Freezer 1) located in the facility's kitchen.2. Discard two-week old personal food items, brought to the facility from outside for one of one sampled resident (Resident 17), stored at Resident 17's bedside.These deficient practices could result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) of food items stored in Freezer 1 and cause foodborne illness (illness caused by the ingestion of contaminated food or beverage) and serious health complications to the residents (in general) consuming food from Freezer 1 and to Resident 17.Findings:1. During a concurrent observation and interview on 5/5/2026 at 9:08 AM with the CK, in the presence of the Dietary Supervisor (DS), during the initial walkthrough of the kitchen, there was an unlabeled bottle with a green colored cover lid with half (1/2) contents of a light chocolate colored drink stored at the bottom shelf of Freezer 1. The CK stated the unlabeled bottle belonged to the CK and the content was a protein shake. The CK stated the CK stored the bottle of protein shake inside Freezer 1 because the CK's protein shake, got a little warm. The CK stated staff (in general) had a refrigerator in the employee lounge where staff stored personal food items. The CK stated not storing staff personal food items in the facility's kitchen freezers was important for infection control.During a review of the facility's policy and procedure (P&P) titled, Food Safety and Food Storage, date revised 11/4/2024, the P&P indicated food would be stored, prepared, distributed and served in accordance with professional standards for food service safety. The P&P indicated additional strategies to prevent foodborne illness included but not limited to preventing cross-contamination of foods.During a review of the facility's P&P titled, Designated Area for Employee Personal Belongings, date reviewed 6/23/2025, the P&P indicated guidelines for promoting an area for the safe retention of personal belongings. The P&P indicated personal belongings, beverages, and/or food may be stored in the designated area such as the DS office, dry storage area, or any designated separate employee personal belongings area with signage.2. During a review of Resident 17's admission Record (AR), the AR indicated Resident 17 was admitted to the facility on [DATE] with multiple diagnoses including Huntington's disease (an inherited, progressive brain disorder that causes nerve cells in the brain to break down), and immunodeficiency (any condition, illness or sickness that deteriorates the usual functioning parts of the body) due to conditions classified elsewhere.During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool), dated 2/26/2026, the MDS indicated Resident 17's cognitive skills (ability to think and process information) for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 17 was independent (resident completes the activity by themselves with no assistance) to requiring setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 17's History and Physical Examination (H&P), dated 3/3/2026 the H&P indicated Resident 17 had the capacity to understand and make decisions.During a concurrent observation and interview on 5/5/2026 at 9:56 AM with Resident 17, inside Resident 17's room, Resident 17's bedside had multiple personal food items, including a container of Sweet P's (brand name) chocolate cupcakes with a manufacturer's sticker indicating 4/21/26 Bakery $5.99 with two (2) cupcakes left inside and a container of Sweet P's unicorn cupcakes with a manufacturer's sticker indicating 4/20/26 Bakery $5.99 with six (6) cupcakes left inside the container. Resident 17 stated, Resident 17's daughter (unnamed) brought the cupcakes to the facility.During a concurrent observation and interview on 5/6/2026 at 3:46 PM, with the Restorative Nurse Assistant (RNA, nurse assistants with extra training to help residents regain or maintain mobility, strength, and independence with activities of daily living), in Resident 17's room, there were Sweet P's unicorn cupcakes with a manufacturer's sticker indicating 4/20/2026 Bakery $5.99 with six (6) cupcakes left inside. The RNA stated the RNA discarded the other container that had chocolate cupcakes dated 4/21/2026 because Resident 17 no longer wanted the cupcakes. The RNA stated the unicorn cupcakes with a manufacturer's sticker indicating 4/20/2026 located at Resident 17's bedside were more than 2 weeks old and were older than the chocolate cupcakes discarded by the RNA. The RNA stated checking and monitoring resident rooms for food brought from outside was important because residents could be poisoned from food getting rotten, and food could attract bugs, like flies.During an interview on 5/7/2026 at 10:18 AM with the Registered Nurse Supervisor (RN), the RN stated food brought from outside should be dated and timed to indicate when the food was delivered (received) since food brought from outside was usually thrown away after three days. The RN stated the RN had seen Resident 17's bedside with food brought from outside and had seen Resident 17 share the food with other residents (unidentified). The RN stated the RN did not know who brought food from outside to Resident 17. The RN stated Resident 17's cupcakes dated 4/20/2026 and 4/21/2026 were over 2 weeks old. The RN stated discarding food brought from outside that became old was important to prevent mold, that could cause diarrhea, stomach upset, or foodborne illness, from growing.During an interview on 5/8/2026 at 10:27 AM with the Registered Dietician (RD), the RD stated the facility had designated areas for staff to store personal food items located in the DS's office and in the facility's staff breakroom. The RD stated staff storing food items in the designated areas [was important] to reduce the potential risk of contamination to the residents. The RD stated staff were supposed to discard resident's food brought from outside after 3 days of receipt and staff should be monitoring and checking the beside for foods brought from outside to prevent food-borne illness to the residents. The RD stated Resident 17 should not have been allowed to share Resident 17's food brought from outside with other residents.During a review of the facility's P&P titled, Use and Storage of Food Brought in by Family or Visitors, date reviewed 9/14/2023, the P&P's policy indicated it was the right of the residents of the facility to have food brought in by family or other visitors; however, the food must be handled in a way to ensure the safety of the resident. The P&P indicated all food items brought in that were manufactured and did not require refrigeration, may be kept in the resident room inside a lock tight container that was provided by the resident. The P&P indicated all food items brought in must be approved per Nursing.labeled with [food] content and dated. The P&P indicated if not consumed within 3 days, the food will be thrown away by facility staff.

Based on observation, interview, and record review, the facility failed to ensure to prevent accident for three of three sampled residents' (Resident 28, Resident 1, and Resident 9) by failing to maintain Resident 28, Resident 1 and Resident 9's beds at a low position at all times. Resident 28, Resident 1, and Resident 9 were assessed at risk for falls on admission. This failure could have potentially caused Resident 28 to fall on 5/1/2026 resulting in Resident 28's laceration (a cut, tear or rip somewhere on or in your body) above Resident 28's left eyebrow and could potentially result in Resident 28, Resident 1 and Resident 9 who had history of multiple falls to sustain another fall.a. During review of Resident 1's admission Record (AR), the AR indicated the resident was admitted on [DATE], with diagnoses that include metabolic encephalopathy (sudden change in brain function like confusion, severe drowsiness, or memory loss), abnormal posture, muscle weakness and bilateral osteoarthritis (cartilage cushioning the ends of bones wears down) of hip. During review of Resident 1's Fall Risk Assessment, dated 2/6/2026, the Fall Risk Assessment indicated resident's level of conscious as intermittent confusion, decreased muscle coordination, with 3 or more present predisposing diseases. The resident is at risk for falls. During review of Resident 1's Minimum Data Set (MDS- standardized, comprehensive assessment form used to record a resident's physical, mental, and social health status) dated 2/12/2026, the MDS indicated Resident 1 has moderate cognitive impairment. During review of Resident 1's Care Plan (CP) dated 4/12/2026, the CP indicated Resident 1's bed is to be in lowest position in order to provide safety. During review of Resident 9's admission Record (AR), the AR indicated the resident was admitted on [DATE], with the diagnosis the include metabolic encephalopathy (sudden change in brain function like confusion, severe drowsiness, or memory loss), contracture of left knee, amputation of right lower extremity, rhabdomyolysis (rapid breakdown of damaged skeletal muscle tissue) and other seizures. During review of Resident 9's Care Plan (CP) dated 11/23/2025, the CP indicated Residents 9's bed is to be in lowest position. During review of Resident 9 's MDS dated [DATE], the MDS indicated Resident 1 has severe cognitive impairment. During review of Resident 9's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated residents' level of conscious as confused and cannot correctly identify three key aspects of their reality: who they are, where they are, and what time it is at all times, with 1-2 falls in the past 3 month. During review of Resident 9's nursing progress notes dated 4/23/2026, 4/27/2026 and 5/4/2026, the progress notes indicated Resident 9 has fallen a total of three times. During a concurrent observation and interview on 5/5/2026 at 11:15 AM with License Vocational Nurse (LVN) 2 in Resident 1's room, Resident 1 was lying in bed with the head of the bed elevated at a 45 degree angle, with their head slumped toward the right side, and the bed positioned above waist level. LVN 2 stated Resident 1's bed should have been maintained in a lower position to reduce the risk of injury. Keeping the bed at a lower height would help prevent more serious harm in the event of a fall, as falling from an elevated height increases the likelihood of neurological injury. During a concurrent observation and interview on 5/7/2026 at 9:08 AM with LVN 3 in Resident 9's room, Resident 9 was lying in bed with the head of the bed elevated at a 45 degree, with their bed positioned above waist level. LVN 3 stated, the resident is at high risk for falls and that the bed should be kept at a lower level. Failure to do so could result in sprains, fractures, or potential head injuries. During an interview on 5/7/2026 at 9:59 AM with the DON, the DON stated that the bed should be kept in a lower position because the resident attempts to get out of bed and maintaining the bed at a higher height could result in more severe injuries. During an interview on 5/7/2026 at 11:40 AM with Director of Nursing (DON), DON stated, resident's beds should be maintained in a low position to reduce the potential risk of injury in the event of a fall During a review of the facility's policy and procedures (P&P) title, Fall Prevention Program, dated 12/19/2022, the P&P indicated residents beds are to be locked and lowered to a level that allows the residents feet to be flat on the floor when resident is sitting on the edge of the bed. b. During a review of Resident 28's AR, the AR indicated Resident 28 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including hemiplegia (paralysis on one side of the body), unspecified affecting left nondominant side, other seizures (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and history of falling. During a review of Resident 28's History and Physical Examination (H&P), dated 8/1/2025, the H&P indicated, Resident 28 did not have the capacity to understand and make decisions. During a review of Resident 28's Fall Risk (FR) (assessments), dated 12/4/2025, 3/19/2026 and 5/1/2026, the FR indicated Resident 28 was at risk for falls. During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28's cognitive skills (ability to think and process information) for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 28 required substantial/maximal assistance (helper does more than half the effort) for setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for activities of daily living (ADL – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 28 had two (2) or more falls without injury since admission/reentry. During a review of Resident 28's CP, titled, initiated 2/19/2026, the CP's focus indicated Resident 28 was at risk for falls. The CP's interventions indicated to keep Resident 28's bed at the lowest position at all times when Resident 28 was in bed. During a review of Resident 28's Change in Condition Evaluation (COC), dated 5/1/2026, timed at 11:07 PM, the COC indicated Resident 28 had an unwitnessed fall (found on the floor) and a laceration (cut) on the left eyebrow. The COC indicated Resident 28 was sent to the General Acute Care Hospital (GACH). During a review of the facility's untitled list of fall incidents, the list indicated Resident 28 had ten (10) fall incidents since 11/11/2024 with the latest incident dated 5/1/2026. During an observation on 5/5/2026 at 10:29 AM, Resident 28 was lying in bed, awake and confused (talking to self in Spanish). Resident 28's bed was in a high position, about three (3) feet off the floor. There was brown colored long floor mats placed on both sides of Resident 28's bed. Resident 28 had an old bruise below the left eye and a dry laceration with 2 steri-strips (thin adhesive bandages that help seal minor wounds) above the left eyebrow. During a concurrent observation and interview on 5/5/2026 at 10:45 AM with Certified Nursing Assistant (CNA) 2, Resident 28 was in bed, awake, confused, and Resident 28's bed was about three (3) feet off the floor. CNA 2 stated Resident 28's bed was not in a low position and staff (unnamed) might have forgotten to lower Resident 28's bed after Resident 28 had breakfast. CNA 2 stated Resident 28 had a bruise on the left eye and steri-strips above the left eyebrow from a [previous] fall, I heard he fell. CNA 2 stated keeping Resident's 28 bed in a low position always was important because Resident 28 was a fall risk, confused at times, and had tried to get up [from bed]. During an interview on 5/5/2026 at 12:55 PM with Resident 28's Responsible Party (RP), the RP stated Resident 28 fell on 5/1/2026 and [this incident] was not the first time Resident 28 had fallen at the facility. The RP stated the RP had noticed Resident 28's bed was not always in a low position. During a concurrent interview and record review on 5/8/2026 at 11:44 AM with the DON, Resident 28's CP, date initiated 5/1/2026, the CP's focus indicated Resident 28 had an unwitnessed fall with minor injury. The CP's interventions indicated to consider moving Resident 28 to a room closer to nurse's station. The DON stated Resident 28 was in a spot where Resident 28 was not near the nursing station. The DON stated, the DON had given Resident 28's RP some room options and the RP would consider the options. The DON stated Resident 28 was a fall risk and had the tendency to get out of bed. The DON stated always keeping Resident 28's bed in a low position was important because a low bed helped minimize falls for Resident 28. During a review of the facility's P&P titled, Fall Prevention Program, date revised 4/20/2026, the P&P indicated each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The P&P indicated providing additional fall prevention interventions as directed by the resident's assessment included but not limited to a low bed. During a review of the facility's P&P titled, Incidents and Accidents, date reviewed/revised 12/19/2022, the P&P indicated, incidents/accidents included falls.

Based on observation and interview the facility failed to ensure three of 24 sampled residents (Resident 8, 23, and 84) had their call light within reach.This failure had the potential to affect the residents' ability to request assistance when needed.During a review of Resident 8's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE], with the diagnosis that include sequelae of cerebral infarction (when a blood clot blocks blood flow to the brain), abnormalities of gait (natural pattern or style of walking), lack of coordination, retention of urine, contracture (permanent tightening or shortening of muscles, tendons, skin, or joint capsules ) of right elbow and right hand.During a review of Resident 8's Minimum Data Set (MDS- standardized, comprehensive assessment form used to record a resident's physical, mental, and social health status) dated 3/10/2026, the MDS indicated the resident has severe cognitive impairment.During a review of Resident 23's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE], with the diagnosis that include dementia (decline in memory, thinking, and reasoning), dysphagia (difficult swallowing) and psychosis.During a review of Resident 23's MDS dated [DATE], the MDS indicated the resident has severe cognitive impairment. During a review of Resident 84's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE], with the diagnosis that include abnormal posture, psychosis (difficulty distinguishing what is real from what is not) and signs and symptoms involving cognitive awareness.During a review of Resident 84's MDS dated [DATE], the MDS indicated the resident has severe cognitive impairment. During a concurrent observation and interview on 5/5/2026 at 10:06 AM with Director of Staff Development (DSD) in Resident 8,23, and 84's (shared) room, Residents were positioned on their in their beds. The residents' call lights were on the floor and out of their reach. The DSD stated, not having the call light within reach could prevent residents from requesting assistance, potentially worsening their existing condition.During an interview on 5/7/2026 at 10:03 AM with the Director of Nursing (DON), DON stated, that having the call light on the floor could create an infection control concern due to the floor being dirty, and it could also place the resident at risk of injury if they attempt to retrieve the call light from the floor.During a review of the facility's policy and procedure (P&P) titled Call Lights: Accessibility and Timely Response, dated 12/19/2022, the P&P indicated Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices by failing to label and properly store personal care items found in two of five sampled [NAME] & [NAME] restrooms ([a shared restroom situated between two bedrooms with direct access from both rooms], Restroom [ROOM NUMBER] and Restroom [ROOM NUMBER]). Restroom [ROOM NUMBER] was situated between Resident 50 and Resident 20's double-occupancy (two people sharing a single room) room and Resident 65 and Resident 6's double-occupancy room. Restroom [ROOM NUMBER] was situated between Resident 48 and Resident 45's double-occupancy room and Resident 40 and Resident 67's double-occupancy room. This deficient practice had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development and transmission of disease (an illness or sickness) and infections to Residents 50, 20, 65, 6, 48, 45, 40 and 67.Findings:During an observation on 5/5/2026 at 11:51 AM, Resident 50 and Resident 20's double-occupancy room had Enhanced Barrier Precaution (EBP - an infection-control practice to prevent the spread of bacteria in nursing homes) signage posted outside of the room. During a concurrent observation and interview on 5/5/2026 at 12:11 PM with Certified Nurse Assistant (CNA) 3, inside Restroom [ROOM NUMBER], an unlabeled hair comb and an unlabeled eight (8) fluid ounce (fl oz - a measurement of volume) of Remedy (brand name) Essential Cleanse Shampoo & Body Wash were stored on the sink. CNA 3 stated CNA 3 did not know what resident the hair comb and shampoo body wash belonged to and [the personal items] should have been labeled with the resident's name (in general) for staff to know and not to use on another resident and to prevent cross contamination.During a concurrent observation and interview on 5/5/2026 at 1:23 PM with CNA 4, Resident 40 and Resident 67's double-occupancy room had EBP signage posted outside of the room. Restroom [ROOM NUMBER] had an unlabeled 10 fl oz Vaseline (brand name) Advanced Repair Body Lotion tucked away horizontally behind the sink faucet. CNA 4 stated CNA 4 thought the body lotion may belong to Resident 40. CNA 4 stated the body lotion should have been labeled with Resident 40's name so other residents would not use the body lotion and for infection control.During an interview on 5/7/2026 at 7:52 AM with the Infection Preventionist Nurse (IP), the IP stated the comb, body wash, and lotion were considered personal care items. The IP stated labeling personal care items with resident names and room numbers and storing the personal care items at the resident's bedside or closet was important for residents and staff to know who the resident care items belonged to and for infection control.During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, date reviewed 12/19/2022, the P&P indicated the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.During a review of the facility's P&P titled, Resident Personal Belongings, date reviewed 12/19/2022, the P&P indicated the facility would ensure resident belongings were kept in a neat and orderly fashion and maintained in each resident's room.

Based on observations, interview and record review, the facility failed to ensure that the Bed Rail Assessment (a safety check to determine if side rails are needed, if they are safe, and if they pose more risks than benefits) was completed for one of eight sampled residents (Resident 1) with bedrails in use.This failure had the potential to result in entrapment and/or injuries to the resident.During review of Resident 1's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE], with the diagnoses that included metabolic encephalopathy (sudden change in brain function like confusion, severe drowsiness, or memory loss), abnormal posture, muscle weakness and bilateral osteoarthritis (cartilage cushioning the ends of bones wears down) of hip.During review of Resident 1's Minimum Data Set (MDS- standardized, comprehensive assessment form used to record a resident's physical, mental, and social health status) dated 6/29/2025, the MDS indicated Resident is cognitively intact.During review of Resident 1's care plan, dated 1/21/2026, the care plan indicated Resident 1 is to have bilateral 1/4 side rails up while in bed as enabler for transferring, repositioning and during ADL care.During review of Resident 1's Standard Assessments, the Standard Assessments indicated the Bed Rail Assessment was past due as of 2/6/2026.During an on observation on 5/7/2026 at 8:22 AM in Resident 1's room, Resident 1 was lying in bed on her back with the head of the bed elevated at a 45 degrees angle, with bilateral 1/4 Side Rails up.During an interview on 5/7/2026 at 3:25 AM with Registered Nurse (RN), RN stated Bed Rail Assessments are to be completed by the Minimum Data Set Coordinator (MDSC), Licensed Vocational Nurse (LVN) or a Registered Nurse (RN) prior to implementing bedrails on a resident's bed.During an interview on 5/7/2026 at 3:41 PM with MDSC, MDSC stated, that Bed Rail Assessments are completed upon admission and annually for residents who use bed rails and stated that a Bed Rail Assessment had not been completed for Resident 1. Failing to complete required bed rail assessments could result in resident entrapment and injuries.During a review of the facility's policy and procedure (P&P) titled, Proper Use of Bed Rails, dated 12/19/2022, the P&P indicated the resident assessment should assess the residents' risks of entrapment between the mattress and bed rail or in the bed rail itself. The facility will assess to determine if the bed rail meets the definition of a restraint.

Based on observations, interview and record review, the facility failed to ensure that two of eight sampled residents (Resident 1 and 72) with active skin breakdown were repositioned frequently in accordance with their individualized care plans.This failure had the potential to cause the residents' existing pressure injuries to worsen.During review of Resident 1's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE], with the diagnoses that included metabolic encephalopathy (sudden change in brain function like confusion, severe drowsiness, or memory loss), abnormal posture, muscle weakness and bilateral osteoarthritis (cartilage cushioning the ends of bones wears down) of hip.During review of Resident 1's care plan, dated 1/14/2026, the care plan indicated Resident 1 is to be reposition every 2 hours and as needed.During review of Resident 1's Minimum Data Set (MDS- standardized, comprehensive assessment form used to record a resident's physical, mental, and social health status) dated 2/12/2026, the MDS indicated Resident 1 has moderate cognitive impairment.During review of Resident 1s's skin assessment, dated 3/4/2026, the skin assessment indicated that Resident 1 has active skin breakdown on her front left leg, perineum (small patch of sensitive skin and flesh located between the sex organs (vagina or scrotum) and the anus), sacrococcygeal (the area at the very base of the spine), front right leg and her left heel.During review of Resident 72's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE], with the diagnoses that included metabolic encephalopathy, type 2 diabetes (chronic condition where the body cannot properly use or make enough insulin, leading to high levels of sugar (glucose) in the blood, difficulty walking and lack of coordination.During review of Resident 72's MDS, dated [DATE], the MDS indicated Resident 72 has severe cognitive impairment.During review of Resident 72's care plan, dated 3/16/2026, the care plan indicated resident is to be repositioned frequently due to active skin breakdown and immobility.During review of Resident 72's Skin Assessment, dated 4/1/2026, the skin assessment indicated that Resident 72 has active skin breakdown on the left outer arm, right outer forearm, coccyx (small, triangle-shaped bone located at the very bottom of the spine), and perineum.During multiple observations on 5/5/2026 at 10:46 AM, 12:05 PM, 3:14 PM and on 5/7/2026 at 8:17 AM, 11:00 AM and 1:50 PM, in Resident 72's room, Resident 72 was lying in bed on her back with the head of the bed elevated at a 45 degrees angle. During multiple observations on 5/5/2026 at 11:05 AM, 5/7/2026 8:22 AM, 9:33 AM, 3:20 PM, 5/8/2026 1:37 PM and 1:54 PM, in Resident 1's room, Resident 1 was lying in bed on her back with the head of the bed elevated at a 45 degrees angle.During a concurrent observation and interview on 5/5/2026 at 3:10 PM with Resident 72 in Resident 72's room, Resident 72 was lying in bed on her back with the head of the bed elevated at a 45 degrees angle. Resident 72 stated, they are often left lying on their back and must request to be repositioned.During an observation on 5/5/2026 at 3:14 PM. in Resident 72's room, Resident 72 was lying in bed on her back with the head of the bed elevated at a 45 degrees angle. Resident 72 informed the Treatment Nurse (TN) that they wished to be repositioned. The TN stated the resident was scheduled to get out of bed soon and did not reposition the resident. During a concurrent observation and interview on 5/7/2026 at 9:33 AM, with Certified Nurse Assistant (CNA) 1 in Resident 1's room, Resident 1 was lying in bed on her back with the head of the bed elevated at a 45degree angle. Resident 1 stated she would like to be repositioned. CNA 1 repositioned Resident 1. CNA 1 stated, that residents are to be repositioned in accordance with the facility's Turning and Repositioning Schedule, and that failure to follow the schedule could result in existing wounds worsening.During an interview on 5/7/2026 at 10:01 AM, with Director of Nursing (DON), the DON stated there is no formal log used to track residents' repositioning times, and that failure to reposition residents could result in worsening wounds.During a concurrent interview and record review on 5/7/2026 at 11:50 AM with DSD, the Turning & Repositioning Schedule (job aid), was reviewed. The Turning & Repositioning Schedule indicated, the residents are to be positioned on their back from 12:00-2:00, facing the door from 2:00-4:00, facing the window from 4:00-6:00, on their back 6:00-8:00, facing the door 8:00-10:00 and facing the window 10:00-12:00. The DSD stated that residents who are at risk for, or who have existing skin breakdown, should be repositioned every two hours and as needed, and that staff follow the turning schedule displayed on their badges. The DSD added that failure to reposition residents as required could cause active skin breakdown to worsen.During an interview on 5/8/2026 at 2:00 PM with the DON, the DON stated, it is important to reposition residents because skin breakdown can develop or worsen over bony areas of the body.During review of the facility's policy and procedure (P&P) titled, Pressure Injury Prevention and Management, dated 12/19/2022, indicated, the facility shall establish and utilize a systemic approach for pressure injury prevention and management.

Based on interview and record review, the facility failed to develop or implement individualized person-centered care plans (CP) for two of two sampled residents (Resident 4 and Resident 26) when:a. For Resident 4, the facility failed to implement a CP addressing bipolar disorder (mental health condition that causes extreme mood swings).b. For Resident 26, the facility failed to create a CP addressing impaired hearing and the use of hearing aids.These deficient failures had the potential to result in unmet individualized needs for Resident 4 and Resident 26 and the potential to affect the resident's physical and psychosocial well-being.a. During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, depression (sadness, loss of interest, and decreased energy) and morbid obesity (excess body fat). During a review of Resident 4's History and Physical (H&P), dated 3/10/2926, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 3/14/2026, the MDS indicated Resident 4 was cognitively (the ability to think and process information) intact, had clear speech, and had the ability to understand and be understood by others. The MDS indicated Resident 4 was dependent (helper does all the work), with oral and toilet hygiene, upper and lower body dressing, and from sit-to-lay positions and bed to chair transfers. During an interview and concurrent record review on 5/8/2026 at 9:45 AM, Resident 4's paper and electronic medical record was reviewed with the Medical Records Director (MRS), the MRS stated Resident 4 did not have a CP for bipolar disorder. During an interview and concurrent record review on 5/8/2026 at 9:49 AM Resident 4's paper and electronic medical record was reviewed with the Director of Nursing (DON), the DON stated Resident 4 had a diagnosis of bipolar disorder. The DON stated Resident 4 did not have a CP for bipolar disorder. The DON stated [creating a CP was important] to be aware and address Resident 4's needs and complications that could arise from this disorder. b. During a review of Resident 26's AR, the AR indicated Resident 26 was admitted to the facility on [DATE] with diagnoses that included a urinary tract infection (UTI- an infection in the bladder/urinary tract) and Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve damage caused by diabetes). During a review of Resident 26's Progress Notes, dated 4/22/2026, the progress note indicated Resident 26 received a pair of hearing aids. During a review of Resident 26's MDS, dated [DATE], the MDS indicated Resident 26 had had intact cognition and indicated Resident 26 used a hearing aid or other hearing appliance. During a concurrent interview and record review on 5/7/2026 at 2:45 PM with Licensed Vocational Nurse (LVN) 1, Resident 26's current CPs were reviewed, the CPs did not indicate a CP that addressed Resident 26's hearing impairment. LVN 1 stated, Resident 26 had hearing issues and used hearing aids. LVN 1 stated CPs provided a focus, goals, and interventions to achieve resident improvement. LVN 1 stated Resident 26 needed a CP for impaired hearing to make nursing staff aware of his hearing aids and of their proper use. During an observation on 5/7/2026 at 4:10 PM in Resident 26's room, Resident 26 was sitting up in bed and had hearing aids in both ears. During an interview on 5/8/2026 at 9:07 AM with the DON, the DON stated CPs needed to be comprehensive and encompass all the residents' needs and were used to ensure all staff followed the same interventions for the resident's best outcome. The DON stated residents with hearing impairments needed a CP to recognize those needs and provide them with the best interventions. During a review of the facility's policy and procedure (P&P) titled Comprehensive Care Plans, dated revised 12/19/2022, the P&P indicated it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure their process for over the counter (OTC) product self-administration (the process where patients manage and take their own medications) was followed, for one of one sampled resident (Resident 45) when on 5/5/2026 Resident 45 had a non-legend (drug that can be purchased OTC without a prescription) product at Resident 45's bedside without a self-administration assessment or a physician's order.This deficient practice had the potential to result in misuse and side effects (SE - an unwanted, unintended, or secondary effect that occurs in addition to the desired therapeutic effect of a drug) of the OTC product to Resident 45 and the potential for OTC product sharing with other residents (in general) by Resident 45.Findings:During a review of Resident 45's admission Record (AR), the AR indicated Resident 45 was admitted to the facility on [DATE] with multiple diagnoses including unspecified atrial fibrillation (an irregular and often very rapid heartbeat), and type 2 diabetes mellitus (DM II - adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing) with unspecified complications.During a review of Resident 45's History and Physical Examination (H&P), dated 2/27/2026, the H&P indicated, Resident 45 had the capacity to understand and make decisions.During a review of Resident 45's Care Plan (CP), titled, date initiated 3/1/2026, the CP's focus indicated Resident 45 was at risk for re-hospitalization. The CP's interventions indicated medications as ordered.During a review of Resident 45's Minimum Data Set (MDS - a resident assessment tool), dated 3/3/2026, the MDS indicated Resident 45's cognitive skills (ability to think and process information) for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 45 was dependent (helper does all of the effort) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 45's Order Summary Report (OSR), dated active as of 5/5/2026, the OSR did not indicate an order for Australian Dream (brand name) Arthritis (a condition that causes inflammation, pain, stiffness, and swelling in one or more joints) Pain Relief Cream.During a concurrent observation and interview on 5/5/2026 at 1:10 PM with Resident 45 in Resident 45's room, Resident 45 had a four (4) oz (ounce - a unit of weight) of Australian Dream Arthritis Pain Relief Cream at Resident 45's bedside. Resident 45 stated, Resident 45 brought the cream from Resident 45's home and the cream worked for Resident 45's arthritis. During an interview on 5/7/2026 at 10:18 AM with the Registered Nurse Supervisor (RN), the RN stated Resident 45's arthritis pain relief cream was an OTC medication. The RN stated residents (in general) were allowed to keep OTC medications at their bedside with a physician's order and [after] the risks [were] explained to the resident. The RN stated not keeping an OTC medication at the bedside was important to avoid residents from overdosing (overusing), reactions and allergies, and to prevent residents from sharing the OTC medication with other residents. The RN stated staff should be checking resident's bedside for OTC medications and, whatever family brings.During an interview on 5/8/2026 at 11:44 AM with the Director of Nursing (DON), the DON stated Resident 45's OTC arthritis pain relief cream was a medication and should have been ordered by Resident 45's physician [after] a self-administration assessment was conducted. The DON stated following the facility's self-administration process was important to prevent the risk of Resident 45 applying the cream incorrectly or in the wrong areas causing injury and to prevent Resident 45 from sharing OTC products with other residents.During a review of the facility's policy and procedure (P&P) titled, Resident Self-Administration of Medication, date reviewed/revised 12/19/2022, the P&P indicated a resident may only self-administer medications after the facility's interdisciplinary team (IDT - a group of healthcare professionals from various disciplines who collaborate, assess, coordinate, and manage each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) had determined which medications may be self-administered safely. The P&P indicated, all nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. The P&P indicated, medications stored at the bedside were reordered in the same manner as other medications.

Based on interview and record review, the facility failed to ensure complete and accurate medical records for one of three sampled residents (Resident 2) when:Resident 2's admission Record (AR) did not indicate the responsible party (RP-an individual chosen by the resident to act on behalf of the resident to support the resident in decision-making) or the RP's contact information.Resident 2's Consent for Treatment did not indicate the RP's last name or the date the consent was signed.These failures had the potential to result in the RP not being informed of the need for treatment or of a medical emergency involving Resident 2, leading to unmet medical needs or interrupted continuity of care to Resident 2.Findings:a&b. During a review of Resident 2's AR, the AR indicated the facility originally admitted Resident 2 on 4/4/2026 with diagnoses including acute cystitis (a sudden infection in the bladder) without hematuria (blood in the urine) and difficulty in walking. The AR did not indicate who Resident 2's RP was or the RP's contact information.During a review of Resident 2's History and Physical (H&P), dated 4/5/2026, the H&P indicated Resident 2 could make needs known but could not make medical decisions. The H&P indicated Resident 2's surrogate decision maker was the RP.During a review of Resident 2's undated Consent for Treatment, the consent form did not indicate the RP's last name or the date the consent was signed.During an interview on 4/16/2026 at 3:45 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated it was the policy of the facility to fill out Resident 2's Consent for Treatment completely by including the RP's full name and the date the form was signed. LVN 2 stated the AR should have been completed by indicating Resident 2's RP contact information right away after Resident 2 was admitted on [DATE]. Additionally, LVN 2 stated it was important to have the RP's contact information included on the AR in case of emergencies where the RP needed to be notified.During an interview on 4/16/2026 at 3:54 PM with the Registered Nurse (RN), the RN stated it was important to indicate on Resident 2's Consent for Treatment the full name of the RP as well as the date because it let the facility know Resident 2 was approved [consented] to be treated.During a review of the facility's Policy and Procedure (P&P) titled, Documentation in Medical Record, dated 12/19/2022, the P&P's policy indicated, Each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. The P&P's policy explanation and compliance guidelines indicated, Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. Documentation shall be timely and in chronological order. Record date and time of entry.

Based on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1's) medical record was complete and accurately documented when:1. Resident 1's Change in Condition Evaluation form (CICE- a standardized documentation form, used in healthcare to detect, document, and communicate changes in a resident's baseline condition), dated 3/5/2026 and timed at 9:35 PM, was completed and contained the most recent vital signs (measurements of the body's basic functions, such as heart rate, breathing rate, blood pressure, and temperature) of Resident 1.2. Registered Nurse (RN) 1's assessment on 3/5/2026 of Resident 1's condition, the care and treatment RN 1 provided to Resident 1 in response to Resident 1's change in condition, and the notification of Resident 1's primary physician regarding Resident 1's change in condition were not documented in Resident 1's medical record.3. Licensed Vocational Nurse (LVN) 1 documented the correct time when 911 was called on Resident 1's Progress Note, dated 3/5/2026 and timed at 11 PM.These deficient practices resulted in incomplete and inaccurate documentation in Resident 1's medical record and had the potential for delaying interventions and services for Resident 1.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/19/2026 with diagnoses which included acute pulmonary edema (a life-threatening, sudden buildup of fluid in the lungs, causing severe breathing difficulty) and end stage renal disease (ESRD- irreversible kidney failure), and severe sepsis with septic shock (a life-threatening blood infection).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 2/21/2026, the H&P indicated Resident 1 could make needs known but could not make medical decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 1was dependent on staff (helper does all the effort to complete the activity) for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Change in Condition Evaluation form (CICE), dated 3/5/2026 and timed at 9:35 PM, the CICE indicated Resident 1 had altered mental status on 3/5/2026. The CICE indicated that Resident 1's most recent temperature was 97.9 and Resident 1's most recent O2 sat was 91% with oxygen via NC on 3/5/2026 at 3:05 PM. The CICE indicated Resident 1's most recent heart rate was 90 and breathing rate was 20 on 3/5/2026 at 2:20 PM and Resident 1's most recent blood pressure was 133/61 on 3/5/2026 at 4:06 PM. The CICE indicated the evaluation of Resident 1's behavioral, respiratory (relating to lungs and breathing), cardiovascular (relating to heart and blood vessels), abdominal/gastrointestinal (relating to stomach and intestines), genitourinary (relating to the genital and urinary organs), and neurological (relating to the brain, spinal cord, or nerves) status were not completed. The CICE also indicated Resident 1's primary physician notification was not completed.During a review of Resident 1's Progress Notes (PN) created by Licensed Vocational Nurse (LVN) 1, dated 3/5/2026 and timed at 11 PM, the PN indicated on 3/5/2026 at 9:30 PM Resident 1 was found pale with shallow breathing with oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage, with a normal reading for most healthy individuals between 95% and 100%) of 88% while receiving oxygen at 2 liters per minute (L/min- flow rate unit measuring the volume of liquid or gas in liters that passes through in one minute) via nasal cannula (NC- a lightweight, flexible tube used to deliver supplemental oxygen or increased airflow, featuring two prongs inserted into the nostrils). The PN indicated the registered nurse (RN) supervisor reassessed Resident 1 and called 911 (emergency number to request the services of the police, fire department, paramedics, ambulance) at 7:37 PM and the paramedics (healthcare professional who responds to emergencies and provide medical care to patients both on the scene and on their way to a nearby hospital or medical facility) arrived within 5 minutes.During an interview on 3/20/2026 at 1:46 PM with RN 1, RN 1 stated on 3/5/2026 at approximately 9 PM, LVN 1 told RN 1 that Resident 1 was breathing fast with an O2 sat of 86%, so RN 1 placed Resident 1 on a non-rebreather mask (NRM - a medical device used in emergencies to deliver high concentrations of oxygen) and Resident 1's O2 sate went up to 90%. RN 1 stated 911 was called after 9 PM and the paramedics came within 7 minutes. RN 1 stated Resident 1 was connected to continuous O2 sat and heart rate monitoring and RN 1 stayed at the bedside with Resident 1 until the paramedics came.During a review of Resident 1's medical record, RN 1's assessment of Resident 1's condition, RN 1 placing Resident 1 on a NRM and on continuous O2 sat and heart rate monitoring were not found in Resident 1's medical record.During a concurrent interview and record review on 3/24/2026 at 3:24 PM with the Director of Nursing (DON), Resident 1's CICE, dated 3/5/2026 at 9:35 PM, was reviewed. The DON stated Resident 1's CICE form was incomplete. The DON stated it was important to complete the documentation accurately to reflect the care provided.During a review of the facility's policy and procedure (P&P) titled, Documentation in Medical Record, dated 12/19/2022, the P&P indicated, Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. The P&P indicated, Sign each entry with name and credentials of the person making the entry.During a review of the facility's P&P titled, Notification of Changes, dated 12/19/2022, the P&P indicated, The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include:a. Life-threatening conditions, orb. Clinical complications.

Based on interview and record review, the facility failed to ensure six of six licensed nurses (Treatment Nurses [TN], 1, 2, 3, 4, 5 and 6) had assessments to demonstrate competency for the handling and management of Pleurx catheters (a small, soft tube that doctors put into the chest to help drain extra fluid that builds up around the lungs).This failure had the potential to result in compromised safety for the residents with Pleurx catheters and the potential to result in TNs 1, 2, 3, 4, 5, and 6 not to deliver high quality of care when handling Pleurx catheters due to lack of competency validation. Cross Reference: F656 and F684Findings:During an interview on 7/17/2025 at 10:55 AM, Treatment Nurse (TN) 3 stated TN 3 received in-service training on Pleural effusion (a condition where excess fluid builds up in the space between the lungs and the chest wall) and Pleurx catheters a few months ago (no date recall). TN 3 stated TN 3 did not remember completing an assessment to demonstrate TN 3's competency to properly care for resident with or manage Pleurx catheters.During an interview on 7/17/2025 at 1:41 PM with the Director of Staff Development (DSD), the DSD was unable to provide documentation that indicated completed assessments to demonstrate competency for Pleurx catheter handling by TNs (responsible for draining Pleurx catheters). The DSD stated in-service training courses were important for providing information [to staff] and competency assessments were critical to ensure staff could safely and effectively apply the knowledge and put the knowledge into practice. The DSD stated without documented competency assessments, there was no verification to show staff could properly manage Pleurx catheters. The DSD stated this, [lack of assessments] placed residents at risk for complications such as infections, improper drainage, or delayed care.During a review of the facility's Policy and Procedure (P&P) titled, Provision of Quality Care, revised 12/19/2022, the P&P indicated based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered CPs, and the residents' choices. The policy explanation and compliance guidelines indicated:1. Each resident will be provided with care and services to attain and maintain his/her highest practicable physical, mental, and psychosocial well-being.During a review of the facility's assessment (FA) titled, Facility Assessment Tool, updated 1/23/2025, the FA indicated if any staff require certification the facility validate that it's happened upon hire and routinely thereafter. The FA indicated in addition to the regulatory-required training, the facility takes into account the diagnoses, characteristics, and any new conditions of its resident population. The FA indicated the facility develops additional training and skills competencies as needed to provide the level and types of support and care needed by the resident population. The FA indicated the facility also looks at any new regulations and P&Ps when assuring staff competency. The FA indicated the facility may consider the following training and education topics.1. Specialized care - catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op and post-op care, trach care/suctioning, ventilator care, tube feedings, wound care/dressings, dialysis care.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and services in accordance with professional standards of practice. The facility failed to obtain a physician's order prior to draining Resident 1's Pleurx catheter (a small, soft tube that doctors put into the chest to help drain extra fluid that builds up around the lungs) on 7/5/2025. This failure placed Resident 1 at risk for complications like hypotension (low blood pressure, complication from Pleurx drainage due to rapid fluid shifts), infection, respiratory complications, and fluid imbalance. Additionally, the failure had the potential to result in a physical decline to Resident 1.Cross Reference: F656 and F726Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/3/2025, and re-admitted the resident on 7/11/2025, with diagnoses including malignant neoplasm of the prostate (a cancerous lump or growth on the small gland in men that helps make fluid for semen), pleural effusion (when extra fluid builds up between the lungs and the chest wall, making it harder to breathe), and neutropenia (when you have too few neutrophils [a type of white blood cell that helps the body fight off infections, especially bacteria]). During a review of Resident 1's Section GG Data Collection Tool, dated 7/3/2025, the data collection tool indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent (helper does all of the effort) and mobility.During a review of Resident 1's History and Physical (H&P), dated 7/5/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's General Acute Care Hospital (GAHC) Progress Notes, dated 7/2/2025, the GAHC progress notes indicated that Resident 1 had recurrent right pleural effusion with multiple hospital admissions and the ultrasound-guided Pleurx catheter was placed on 6/7/2025. During a concurrent interview and record review on 7/16/2025 at 1:34 PM, Resident 1's Progress Notes, dated 7/5/2025, timed at 5:37 PM, were reviewed with Treatment Nurse (TN) 1. TN 1 confirmed Registered Nurse Supervisor (RNS) 1 and TN 2 drained approximately 1,100 milliliters (mL- a unit of volume) from Resident 1's Pleurx catheter on 7/5/2025, as documented in the progress notes by RNS 1. TN 1 stated there was a physician's order to drain Resident 1's catheter every Monday, Wednesday, and Friday during the day shift and the start date for that order was 7/7/2025. TN 1 stated there was no active order on 7/5/2025 indicating drainage of Resident 1's catheter. TN 1 confirmed drainage of Resident 1's catheter should not have occurred without a valid physician order. TN 1 stated performing a medical procedure like Pleurx catheter drainage without a physician's order [was not in agreement with] professional standards of practice and could place Resident 1 at risk for harm, including hypotension, infection, respiratory complications, or fluid imbalance.During an interview on 7/17/2025 at 12:45 PM, The Director of Staff Development (DSD) stated staff were expected to always ensure a valid physician order was in place prior to performing Pleurx catheter drainage. The DSD emphasized this [obtaining a physician's order prior to performing the drainage] was critical for Resident 1's safety. The DSD stated draining a Pleurx catheter without an active physician order placed the resident at serious risk, such as stress on internal organs, hypotension, or fluid imbalance, particularly if the drainage volume or frequency was not clinically appropriate.During a review of the facility's policy and procedure (P&P) titled, Ambulatory Drainage Catheter (Pleurx), revision dated 12/19/2022 the P&P indicated it is the policy of the facility to establish procedures for care of residents who have an ambulatory drainage catheter such as a Pleurx tube in place. Compliance guidelines indicated:1. The bottle should be drained as per the practitioner's orders and per the manufacturer's instructions. During a review of the facility's P&P titled, Provision of Quality Care, revised 12/19/2022, the P&P indicated based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered CPs, and the residents' choices. The policy explanation and compliance guidelines indicated:1. Each resident will be provided with care and services to attain and maintain his/her highest practicable physical, mental, and psychosocial well-being.During a review of the facility's job description titled, Licensed Vocational Nurse [LVN], dated 2023 indicated LVNs: Provide direct care skills such as colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) changes, tube feedings, wound care, suctioning, intravenous (IV, a soft flexible tube placed inside a vein, usually in the hand or arm and used to give a person medicine or fluids) administration, etc. in accordance with current policies and procedures. Transcribe physician orders to medical record and carries out orders as written. Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines.During a review of the facility's job description titled, Registered Nurse [RN], dated 2023, the P&P indicated the RNs: Provide direct care skills such as colostomy changes, tube feedings, wound care, suctioning, IV administration, etc. in accordance with current policies and procedures. Transcribe physician orders to medical record and carries out orders as written. Establishe a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines.

Based on interview and record review, the facility failed to develop a care plan (CP) upon admission for one of three sampled residents (Resident 1) who had a Pleurx catheter (a small, soft tube that doctors put into the chest to help drain extra fluid that builds up around the lungs). that addressed the presence of the device.This failure had the potential to result in unmet individualized needs for Resident 1 and the potential to affect Resident 1's physical well-being. Cross Reference: F684 and F726Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/3/2025, and re-admitted the resident on 7/11/2025, with diagnoses including malignant neoplasm of the prostate (a cancerous lump or growth on the small gland in men that helps make fluid for semen), pleural effusion (when extra fluid builds up between the lungs and the chest wall, making it harder to breathe), and neutropenia (when you have too few neutrophils [a type of white blood cell that helps the body fight off infections, especially bacteria]). During a review of Resident 1's Section GG Data Collection Tool, dated 7/3/2025, the data collection tool indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent (helper does all of the effort) and mobility.During a review of Resident 1's History and Physical (H&P), dated 7/5/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's General Acute Care Hospital (GAHC) Progress Notes, dated 7/2/2025, the GAHC progress notes indicated Resident 1 had recurrent right pleural effusion with multiple hospital admissions and the ultrasound-guided Pleurx catheter was placed on 6/7/2025. During a concurrent interview and record review on 7/16/2025 at 2:45 PM, Resident 1's CPs were reviewed with Licensed Vocational Nurse (LVN) 1. LVN 1 stated LVN 1 admitted Resident 1 to the facility 7/3/2025, and completed the admission assessment. LVN 1 stated Resident 1 had a Pleurx catheter upon admission. LVN 1 stated a CP specific for Resident 1's Pleurx catheter was not created (develop) at the time of Resident 1's admission. LVN 1 stated that creating a CP for the Pleurx catheter in a timely manner was important to ensure proper catheter monitoring, timely drainage, infection prevention, and clear guidance for staff. LVN 1 stated timely care planning was essential for continuity of care and allowed the care team to provide consistent, safe, and individualized treatment based on the resident's (in general) clinical needs.During an interview on 7/16/2025 at 3:15 PM with the Registered Nurse Supervisor (RNS) 2. RNS 2 stated RNS 2 assisted [LVN 1] with Resident 1's admission on [DATE]. RNS 2 stated Resident 1 had a Pleurx catheter in place at the time of admission and stated staff were responsible for creating CP timely, one specific to the Pleurx catheter. RNS 2 stated CPs were essential for devices like a Pleurx catheter because they provided clear, individualized guidance for [staff] regarding monitoring, catheter drainage, and infection prevention. RNS 2 stated CPs ensured safe, consistent, and proactive care from the moment of admission.During an interview on 7/17/2025 at 1:41 PM, The Director of Staff Development (DSD) stated a CP must be created upon admission, especially for residents who have medical devices such as a Pleurx catheters. The DSD stated [creating CPs] ensured appropriate interventions, monitoring, and staff guidance were in place from [admission].The DSD stated if a CP was not created timely, the team lacked clear direction on how to safely manage the catheter. The DSD stated staff were expected to create CPs for medical devices promptly and upon admission to ensure continuity and quality of care.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, revised 12/19/2022, the P&P indicated it is the policy of the facility to develop and implement a comprehensive person-centered CP for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. During a review of the facility's P&P titled, Provision of Quality Care, revised 12/19/2022, the P&P indicated based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered CPs, and the residents' choices. The policy explanation and compliance guidelines indicated:1. A comprehensive CP will be developed for each resident in accordance with procedures for development of the CP.2. Responsibility for interventions on the CP will be clearly identified.

Based on interview and record review, the facility failed to maintain accurate medical records for one of four sampled residents (Resident 3), according to the facility's policy and procedure (P&P) titled, Documentation in Medical Record, by failing to: Ensure licensed nurses (LNs) documented the redness on and leaking from Resident 3's gastrostomy tube (G-tube- tube inserted through the belly that brings nutrition directly to the stomach) stoma (surgically created opening in the abdomen) in Resident 3's Progress Notes (PN) under Advanced Skilled Evaluation (PN ASE) between 2/17/2025 and 2/20/2025. This failure had the potential for Resident 3 to not receive the care and services needed to appropriately treat the redness and leaking from Resident 3's G-tube stoma, and for Resident 3 to develop further infection. Findings: During a review of Resident 3's Admission Record (AR), the AR indicated the facility initially admitted Resident 3 on 12/20/2022, and readmitted Resident 3 on 3/10/2025, with diagnoses that included encounter for attention to G-tube, encounter for attention to tracheostomy (incision made in the windpipe to relieve an obstruction to breathing), and chronic respiratory failure (serious condition that makes it difficult to breathe on your own) with hypoxia (low level of oxygen in the body that causes confusion, restlessness, and difficulty breathing). During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 1/27/2025, the MDS indicated Resident 3 had severely impaired cognition (ability to think, remember, and function). the MDS indicated was dependent (helper does all the effort, or the assistance of 2 or more helpers is required) on the staff for oral, toileting, and personal hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, rolling left and right (in bed), sitting to lying, lying to sitting on the side of the bed, sitting to standing, chair/bed-to-chair transfers, and tub/showers transfers. During a review of Resident 3's eINTERACT/Change in Condition (CIC- a change in the resident's health or functioning that requires further assessment and intervention) Evaluation (CICE) dated 2/17/2025, timed at 6:23 pm, the CICE indicated Resident 2's G-tube was noted with leaking and redness around the G-tube stoma. During a review of Resident 3's six PN ASE dated 2/17/2025 timed at 10:29 pm, 2/18/2025, timed at 2:37 pm, 2/18/2025, timed at 11:23 pm, 2/19/2025, timed at 9:12 am, 2/20/2025, timed at 9:37 am, and 2/20/2025, timed at 10:44 pm, the six PN ASE indicated no documentation about the redness on Resident 3's G-tube stoma and the leaking coming from Resident 3's G-tube stoma. During an interview on 4/16/2025 at 2:29 pm with Licensed Vocational Nurse (LVN) 3, LVN 3 stated (in general) LNs documented the head-to-toe assessment of their assigned residents in the PN ASE. LVN 3 stated skin assessments were documented in the PN ASE. LVN 3 stated redness and leaking from a G-tube stoma should be documented in the skin assessment of the PN ASE. LVN 3 stated if LNs were not documenting skin assessment in the PN ASE, the LNs may not know if the condition was healing or getting worse. LVN 3 stated if skin issues were not appropriately documented, the LNs may not know if treatments were needed and this could lead to a worsening condition for the resident and, could lead to infection or sepsis. During an interview on 4/16/2025 at 3:17 pm with LVN 1, LVN 1 stated (in general) any resident's skin issues documentation in the (nursing) progress notes needed to match the resident's PN ASE documentation for accuracy. LVN 1 stated if skin issues were not documented in the PN ASE, other staff may not know to check on the resident's skin issue and the skin issue may not get better. LVN 1 stated on 2/19/2025 at 9:12 am, LVN 1 should have documented the redness on and leaking from Resident 3's G-tube stoma, under the skin assessment of Resident 3's PN ASE. During a concurrent interview and record review on 4/16/2025 at 3:53 pm with LVN 5, Resident 3's six PN ASE dated 2/17/2025 timed at 10:29 pm, 2/18/2025, timed at 2:37 pm, 2/18/2025, timed at 11:23 pm, 2/19/2025, timed at 9:12 am, 2/20/2025, timed at 9:37 am, and 2/20/2025, timed at 10:44 pm were reviewed. LVN 5 stated (in general) if a resident had a G-tube, the LNs were supposed to be assessing and documenting the skin around the G-tube, even if the resident did not have any skin issue. LVN 5 stated the LNs did not document that Resident 3 had redness on and leaking from Resident 3's G-tube stoma in Resident 3's PN ASE under the skin assessment dated [DATE], timed at 10:29 pm, 2/18/2025, timed at 2:37 pm, 2/18/2025, timed at 11:23 pm, 2/19/2025, timed at 9:12 am, 2/20/2025, timed at 9:37 am, and 2/20/2025, timed at 10:44 pm. LVN 5 stated between 2/17/2025 and 2/20/2025, the LNs were supposed to assess and document Resident 3's skin status once a shift in the PN ASE. LVN 5 stated Resident 3's PN ASEs should have indicated the leaking and the redness to Resident 3's G-tube stoma under the skin assessment section. During an interview on 4/16/2025 at 4:10 pm with the Director of Nursing (DON), the DON stated it was all LNs' responsibility to complete and document residents' (in general) skin issues every shift in residents' PN ASE. The DON stated accurate documentation was important to ensure appropriate patient care and to capture any new issues in a timely manner so the resident's physician could be notified. The DON stated if a skin issue was not being documented in the PN ASE, then it was possible a resident may not receive the appropriate care, that could lead to skin infection and hospitalization . During a review of the facility's P&P titled, Documentation in Medical Record, revised 12/19/2022, the P&P indicated each resident's medical record would contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. The P&P indicated licensed staff and interdisciplinary team (IDT- group of health care professionals with various areas of expertise who work together toward goals of their residents) member shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. The P&P indicated documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on observation, interview, and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Safe Resident Handling/Transfers, by failing to ensure one of three sampled residents (Resident 1) had two staff members with Resident 1 when staff used a mechanical lift (a device used to assist in lifting and transferring individuals who have difficulty moving independently). This deficient practice had the potential to place Resident 1 ' s safety at risk. Findings: During an observation on 4/15/2025 at 10:43 am, Resident 1 was observed being lifted above the bed on a sling (a soft fabric or mesh material used with a mechanical lift to support and cradle a patient during transfer or movement) attached to a mechanical lift. Restorative Nursing Assistant (RNA) 1 was observed using the mechanical lift to put Resident 1 on the bed and was observed to be the only staff member in the room with Resident 1. During a review of Resident 1 ' s Admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/28/2025 with diagnoses that included acute (sudden onset) and chronic (long-term) respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body) with hypoxia (low levels of oxygen in the body tissues), type 2 diabetes mellitus with hyperglycemia (a chronic condition that happens when having persistently high blood sugar levels), and acute pulmonary edema (abnormal buildup of fluid in the lungs). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/29/2025, the MDS indicated Resident 1 was understood by others and had the ability to understand others. The MDS indicated Resident 1 was dependent (the assistance of two or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, and putting on/taking off footwear. During a review of Resident 1 ' s Care Plan Report (CP), dated 4/6/2025, the CP indicated Resident 1 had an ADL (activities of daily living) self-care performance deficit (the inability to complete activities due to the lack of skills) related to confusion and impaired (weakened) balance. The CP indicated Resident 1 required the use of a mechanical lift with two staff total assistance for transfers. During an interview on 4/15/2025 at 11:14 am, with RNA 1, RNA 1 stated there should have been two staff members present when using a mechanical lift. RNA 1 stated RNA 1 was supposed to put safety first, make sure there were no accidents, and have the mechanical lift in the right place before lifting a resident. During an interview on 4/15/2025 at 11:22 am, with the Director of Staff Development (DSD), the DSD stated staff were aware that there should be two persons assisting at all times when using a mechanical lift. The DSD stated the mechanical lift could tilt down and cause an accident. The DSD stated one staff member was supposed to be maneuvering the mechanical lift, and the other staff member was supposed to be supporting the resident while on a sling. During a review of the facility ' s P&P titled, Safe Resident Handling/Transfer, revised on 12/19/2022, the P&P indicated it was the policy of the facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident ' s condition and mobility, the use of mechanical lifts are a safer alternative and should be used Two staff members must be utilized when transferring residents with a mechanical lift.

Based on observation, interview, and record review, the facility failed to provide one of four sampled residents (Resident 1) with behavioral health care and services for the treatment of Resident 1's emotional, mental, and drug abuse (a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medication) by failing to: 1. Identify goals and nursing interventions when Resident 1 had cannabis (marijuana, a mind-altering drug), sedative (a category of drugs that slow brain activity) abuse, anxiety (nervousness), and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) would leave the facility on out on pass (OOP, temporary permission of a resident to leave the facility in a specified time) unsupervised, without OOP orders from Resident 1's Physician (MD 1) and would return to the facility with aggressive behaviors toward staff (in general). These deficient practices resulted in Resident 1 being involved in a motor vehicle accident (MVA) on 4/10/2023, and the Police Officer (PO 1) identified Resident 1 as a drunk homeless and picked Resident 1 up at the City Hall on 4/13/2023 while Resident 1 was OOP. Resident 1 continued to go OOP unsupervised and without MD 1's orders had the potential to result in serious injury, harm, impairment, or death of Resident 1. 2. Ensure Resident 1 did not go to unauthorized areas in the facility and video record Residents 2 and 4 without Resident 2 and 4's consent. These deficient practices violated Residents 2 and 4's rights and created an uncomfortable environment for Residents 2 and 4. 3. Ensure Resident 3 (Resident 1's roommate) did not experience Resident 1's aggressive behaviors towards staff (in general). This deficient practice violated Resident 3's rights and created an uncomfortable environment for Resident 3. On 4/25/23, at 1:30 pm, during a complaint investigation, the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ-a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents), in the presence of the facility's Administrator (ADM), for the facility's failure to provide Resident 1 with behavioral health care and services for the treatment of Resident 1's emotional, mental, and drug abuse which placed Resident 1, 2, and 3 and 4's at risk for injury . On 4/26/2023, at 10:20 pm, the facility submitted an acceptable IJ Removal Plan/Plan of Action (POA- the facility's plan of action to correct the deficient practices) included the following: 1. On 4/26/2023, at 10 pm, the facility sent Resident 1 to an General Acute Care Hospital (GACH 3) on a 5150 hold (involuntarily detained for a 72- hours) for a psychiatric (medical specialty devoted to the diagnosis, prevention, and treatment of mental conditions) evaluation. 2. On 4/26/2023, Residents 2, 3, and 4 had psychological evaluations and were placed on monitoring for psychosocial well-being. 3. On 4/26/2023, the Director of Nurses (DON) conducted in-services on substance abuse, OOP orders, and assessment of residents before and after returning from OOP. On 4/27/2023, at 11:55 am, the CDPH verified the IJ removal plan while onsite and removed the IJ in the presence of the ADM. Cross Reference F689 Findings: a. A review of Resident 1's GACH 1 Care Coordination Transition forms dated 10/11/2022, indicated Resident 1 was not safe at home. The form indicated Resident 1 needed a mental evaluation and a Skilled Nursing Facility (SNF) placement. The form indicated Resident 1 had threatened Resident 1's Care Giver (CG) at home and the CG could no longer care for Resident 1. A review of Resident 1's GACH 1 History and Physical (H&P) dated 10/11/2022, indicated Resident 1 was diagnosed with acute encephalopathy (mental status change due to medications, illegal drugs, or toxic [poisonous] chemicals), due to benzodiazepine (medication used to sedate) and Tetrahydrocannabinol (THC, substance responsible for the effects of marijuana) use. The H&P indicated Resident 1's drug screen (a drug test looks for signs of one or more illegal or prescription drugs in a sample of the urine, blood, or saliva) was positive for benzodiazepine and cannabis. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 10/15/2022 with diagnoses including toxic encephalopathy, cannabis abuse, sedative, hypnotic (tending to produce sleep) or anxiolytic (a medication or other intervention that reduces nervousness) abuse, anxiety, and depression. A review of Resident 1's Initial History and Physical dated 10/19/2022, indicated Resident 1 could understand and make decisions. A review of Resident 1's Psychiatric Progress Note dated 2/10/2023, indicated Resident 1's psychiatric (mental) condition was fluctuating (changing) The note indicated Resident 1 had a mood disorder (a group of mental conditions characterized by a persistent disturbance of mood), anxiety disorder, major depressive disorder, generalized anxiety, and sleep disorders (being unable to fall asleep and stay asleep). The note indicated the plan was to monitor and continue the current regimen. A review of Resident 1's untitled care plan dated 2/14/2023, indicated Resident 1 had a behavior of yelling at staff (unidentified), getting close to staff's faces, and recording staff without staff's consent. The care plan did not have interventions to address Resident 1's behavior. A review of Resident 1's untitled care plan dated 3/22/2023, indicated Resident 1 would set up her (Resident 1's) own doctor appointments and transportation. The nursing interventions indicated follow-up with Resident 1 to ensure Resident 1's needs were met. A review of Resident 1's Social Services Progress Notes dated 4/10/2023 at 4:30 pm, indicated on 4/10/2023 at 1:20 pm, Resident 1 called the facility (SNF) to report she (Resident 1) was in a car accident. The notes indicated Resident 1 refused to disclose her location and hung up the phone. The notes indicated the Social Services Director (SSD) called the transportation company (unidentified) who reported dropping Resident 1 off at the facility on 4/10/2023 at 11:50 am. The notes indicated Resident 1 called the facility back on 4/10/2023 at 2:36 pm requesting a list of Resident 1's current medications to provide to GACH 2. The notes indicated the facility staff (unidentified) informed Resident 1 that medical information could not be given over the phone and Resident 1 hung up the phone. The notes indicated the facility called local hospitals and located Resident 1 at GACH 2's emergency room (ER). The notes indicated the facility's staff (unidentified) notified MD 1 and MD 1 ordered an absent without official leave (AWOL, absent often without notice or permission) since Resident 1 did not check back in with the facility at 11:50 am when the transportation company drops Resident 1 off at the facility. A review of Resident 1's GACH 2's Emergency Documentation, dated 4/10/2023, timed 2:10 pm, indicated Resident 1 was involved in an MVA, rear-ended, and complained of head pain. A review of Resident 1's Social Services Progress Notes dated 4/12/2023, timed at 9 am, indicated the SSD called the local police department to file a report against Resident 1 using her rollator device (walker, a type of mobility aid that offers stability and support while walking) to ram against the SSD twice. A review of Resident 1's Nurses Progress Notes dated 4/13/2023 at 7:22 am, indicated Resident 1 left the facility for an appointment at 7 am. A review of Resident 1's Nurses Progress Notes dated 4/13/2023 at 4:40 pm, indicated the local police officer (PO 1) dropped Resident 1 at the facility on 4/13/2023, at 4:30 pm. The notes indicated PO 1 stated Resident 1 was at the City Hall, from a neighboring city, yelling and screaming. PO 1 stated the City Hall's staff member (unidentified) called the police department stating a drunk homeless, person (Resident 1) was causing a scene. The notes indicated PO 1 picked Resident 1 from the City Hall. The notes indicated Resident 1 told PO 1 that she (Resident 1) needed a ride to pick up her car at a mobile home located in a neighboring city. The notes indicated PO 1 identified the car was registered to Resident 1's CG who had an active restraining order (a court order that can protect someone from being physically abused or threatened) against Resident 1. A review of Resident 1's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status) dated 4/14/2023, indicated Resident 1 could think and process information. A review of Resident 1's untitled care plan dated 4/19/2023, indicated Resident 1 went to unauthorized areas in the facility and the nursing interventions were to address Resident 1's behavior, educate and provide redirection. A review of Resident 1's Social Services Progress Note dated 4/24/2023 at 9:37 am, indicated Resident 1 informed a staff (unidentified) that she (Resident 1) had a doctor's appointment on 4/24/2023. The note indicated the SSD called the medical provider's office to confirm Resident 1's appointment and the medical provider's office told the SSD that Resident 1 did not have an appointment for a wellness check. The note indicated Resident 1 left the facility at 9 am. During a telephone interview on 4/24/2023 at 12 noon, Resident 1 stated she walked out of the facility earlier on 4/24/2023 and walked up a main road to a mental health wellness center (2 miles from the facility). Resident 1 stated she fell to the floor while passing a freeway off-ramp after she left the facility. Resident 1 stated she had cannabis in my purse, alcohol, almond extract, tinctures (a medicine made by dissolving a drug in alcohol) with alcohol in them, some herbs, liver cleanser supplements. Resident 1 stated she bought Benadryl (medication to treat the symptoms of allergies and allergic reactions) on the way to the mental health wellness center. Resident 1 stated the cannabis was given to her for free at a farmer's market but would also buy cannabis at a local dispensary. Resident 1 stated she consumed alcohol periodically for years. A review of Resident 1's Nurses Progress Note dated 4/24/2023 at 12:13 pm, indicated a police officer (PO 2) arrived at the facility due to Resident 1 going to a local Mental Health Wellness Center and reported feeling unsafe at the facility. During an interview on 4/24/2023 at 2 pm, the ADM stated Resident 1 was OOP at the time of the interview. The SSD joined the interview visibly upset and crying. The SSD stated two weeks prior (did not state the date) Resident 1 rammed, the SSD twice with the resident's walker. The SSD stated the last time a psychiatrist assessed Resident 1 was in February 2023. The SSD stated Resident 1 scheduled her own appointments and transportation and would often not tell the facility's staff when or where she (Resident 1) was going. The SSD stated, We can't stop her from going. During an interview on 4/24/2023 at 2:45 pm the SSD stated the facility's procedure for OOP included getting a doctor's order for each OOP. The SSD stated there had been times when Resident 1 would call the SSD while out on pass and Resident 1 sounded as if the resident was under the influence (drunk). The SSD stated Resident 1's doctor's office's staff (unidentified) would call the SSD to report Resident 1 being intoxicated (drunk or under the influence). The SSD stated on 4/13/2023, PO 1 returned Resident 1 to the facility because the police department received a call from a City Hall staff reporting a homeless drunk disturbing the City Hall. The SSD stated facility's staff (in general) would not check Resident 1 for contraband (items that are illegal to trade, carry, produce, or otherwise have in one's possession) when Resident 1 would return to the facility because she won't allow us. It's scary, I'm afraid. The SSD reported another incident on 4/10/2023 in which Resident 1 left the facility for an 8 am medical appointment and at 1 pm the SSD noticed Resident 1 had not returned to the facility. The SSD called the doctor's office and was informed the resident left the appointment around 11:10 am. The SSD stated she called the transport company who informed the SSD the resident had been dropped off at the facility at 11:50 am. The SSD stated at that point she (the SSD) called Resident 1's listed emergency contacts and local hospitals until the Resident was located at a neighboring city's ER. The SSD stated Resident 1 called the SSD at 3:00 pm to inform the SSD she (Resident) had been in a car accident. A review of Resident 1's Nurses Progress Notes dated 4/24/2023 at 2:50 pm, indicated at 12:40 pm, Resident 1 was behind the local Mental Health Wellness Center building. The note indicated PO 2 spoke with Resident 1 and Resident 1 agreed to go back to the facility. During a concurrent interview and a review of the facility's OOP form on 4/24/2023 at 3:13 pm, Licensed Vocational Nurse 1 (LVN 1) stated every time a resident (in general) left the facility, the resident needed to sign out in a logbook and sign back in upon returning to the facility. LVN 1 reviewed the facility's OOP form and stated Resident 1 left the facility almost daily and stated not all dates on which Resident 1 left had the facility staff's signature or a sign-out or return time listed. LVN 1 stated there had been times in which Resident 1 would return to the facility appearing to be intoxicated with slurred speech (when a person has trouble speaking, the words are slow or garbled, or run together) and more aggressive than normal. A review of Resident 1's Nurses Progress Note dated 4/24/2023 at 5:45 pm, indicated Resident 1 returned to the facility and was verbally aggressive with staff using vulgar (rule or offensive) language. A review of Resident 1's Nurses Progress Note dated 4/25/2023 at 2:28 am, indicated Resident 1 entered the Nurse's Station attempting to open another resident's chart. The note indicated Resident 1 noted to have multiple attempts to open locked medication cart and was also opening drawers at the receptionist's desk. The note indicated Staff reported seeing resident in staff breakroom and supply closet and touching items. The note indicated Staff escorted resident out of the unauthorized area. The resident returned to the SNF station and began swearing at CN (charge nurse), backing CN against the wall before pushing CN. CN politely asked the resident to back away and return to the resident's room. The resident refused and began laughing, invading CN'S personal space by putting her (Resident 1's) face in front of CN's face. CN walked away from the situation and the resident continued to follow CN for the remainder of the med pass. During an observation on 4/25/2023, at 7:28 am, Resident 1 was awake and walked inside the facility's conference room. Resident 1 said loudly You all are [derogatory word] crazy. Resident 1 had a cell phone in her hand and was recording the surveyors. During an interview on 4/25/2023, at 7:44 am, the facility's Cook 1 (Cook 1) stated Resident 1 would go inside the kitchen daily in the morning and would cross the yellow line, toward the clean area, and would yell derogatory words to staff and would record using Resident 1's cell phone. Cook 1 reported witnessing Resident 1 attacking Activities Assistant 1 (AA 1) and Cook 1 stood in front of AA 1 to prevent Resident 1 from hitting AA 1. Cook 1 stated she (Cook 1) then escorted Resident 1 back to Resident 1's room. During a follow-up interview and review of Resident 1's Physician orders for OOP, on 4/25/2023 at 9:24 am, the DON stated per facility policy an order needed to be obtained for each OOP day. The DON reviewed Resident 1's physician orders and stated on 4/13/2023, 4/17/2023, and 4/24/2023 Resident 1 left the facility without OOP orders. The DON stated orders were necessary to ensure Resident 1 was safe to leave the facility. The DON stated she was aware Resident 1 would go into the kitchen and stated the interventions in place to prevent Resident 1 from going into unauthorized areas were not working and the facility's staff were not able to manage Resident 1's behaviors. The DON stated the last psychiatrist visit for Resident 1 was in February 2023 and was not sure why Resident 1 had not been assessed by a psychiatrist since then. The DON stated Resident 1 could potentially consume drugs or alcohol while out on pass unsupervised and could harm herself due to overdose on drugs or alcohol. During a telephone interview on 4/25/2023 at 11:31 am, Psychiatrist 1 (Psych 1) stated the last time he saw Resident 1 was in February 2023. Psych 1 denied being aware of the behaviors Resident 1 had been displaying such as entering restricted areas in the facility, other residents' rooms, going out on pass unsupervised, being involved in a car accident, or being picked up at the courthouse by the police. Psych 1 stated he had not been a part of any interdisciplinary team meetings or care planning meetings for Resident 1. A review of Resident 1's Psychiatric Evaluation Team Assessment Form, dated 4/26/2023, timed at 4:07 pm, indicated Resident 1's behavior was aggressive towards others, uncooperative, and was placed on a 5150 hold for danger to others. b. A review of Resident 2's Admission Record indicated the facility admitted the resident on 12/21/2022 with diagnoses that included depression and anxiety disorder. A review of Resident 2's MDS dated [DATE], indicated the resident had severely impaired cognition. The MDS indicated the resident was dependent on staff for all care. A review of Resident 4's Admission Record indicated the facility admitted the resident to the facility on [DATE] with diagnoses that included malignant neoplasm of the larynx (cancer of the throat) and respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 4's MDS dated [DATE], indicated the resident was cognitively intact. During an interview on 4/25/2023, at 7:20 am, Certified Nursing Assistant 1 (CNA 1), stated Resident 1 recorded Resident 2 inside of Resident 2's room. CNA 1 stated she could not remember the date and time. During an interview on 4/25/2023 at 8:09 am, the ADM stated he asked Resident 1 to stop going inside other residents' (unidentified) rooms. The ADM stated he had noticed Resident 1 either recording or on Facetime with someone and had asked Resident 1 to stop. The ADM stated Resident 1's behaviors were a safety concern. During an interview on 4/26/2023 at 11:59 am, AA1 stated Resident 1 would enter restricted areas in the facility and if asked Resident 1 to stop Resident 1 would attack staff. AA 1 stated Resident 1 would constantly video record other residents (unidentified) and put the residents on Facetime. AA 1 stated Resident 1 was recording Resident 4 who became upset and told Resident 1 to stop recording him (Resident 4). AA 1 stated she reported Resident 1 going into other residents' rooms (in general) and violating other residents' rights. AA 1 stated facility's administrative staff (unidentified) would let Resident 1 have Resident 1's way. AA 1 stated facility's administrative staff did not know how to deal with Resident 1. AA 1 stated Resident 1 was dangerous to staff and other residents (in general). During an interview on 4/26/2023 at 12:47 pm, LVN 2 stated facility staff (in general) were not trained to deal with Resident 1's level of behavior. LVN 2 stated Resident 1 would go into other residents' rooms, especially Resident 2's room. LVN2 stated all interventions in place for Resident 1 were not working and Resident 1 did whatever she wanted. During an interview on 4/26/2023 at 1:10 pm, Resident 4 stated Resident 1 would walk around the facility all day recording other residents (in general). Resident 4 stated he reported to staff (unidentified) that Resident 1 recorded him. Resident 4 stated he would tell Resident 1 to stop but Resident 1 would not listen. Resident 4 stated Resident 1 recorded him between 90-100 times in March 2023, and stated Resident 1 would either be recording or on Facetime showing Resident 4 and other residents in the facility to an unidentified person. Resident 4 stated being recorded by Resident 1 makes me feel not cared about, and violates my privacy. Resident 4 stated Resident 1 was mean to all staff and would yell and hit staff creating an uncomfortable environment in the facility. Resident 4 stated, They cannot control her. c. A review of Resident 3's Admission Record indicated the facility admitted Resident 3 on 8/5/2022 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life). A review of Resident 3's MDS dated [DATE], indicated the resident was cognitively intact. During an interview on 4/25/203 at 11:02 am, Resident 3 stated it was very difficult being Resident 1's roommate. Resident 3 stated Resident 1 was very rough, with staff. Resident 3 stated Resident 1 was difficult and abusive towards the staff. Resident 3 stated she did not like seeing Resident 1 abuse staff. A review of a facility policy titled, Behavioral Health services, dated 9/22/2022, indicated It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. The policy indicated The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. A review of a facility policy titled, Therapeutic Leave, dated 9/02/2022, indicated The nurse will obtain an order from the practitioner specifying approval of a therapeutic leave.

Based on interview and record review, the facility failed to provide the necessary care and services for one of four sampled residents (Resident 1) by failing to: 1. Obtain a physician's order for insulin (a medication used to control high blood sugar). 2. Implement interventions in the plan of care, dated 6/15/17, to treat Resident 1's diabetes mellitus (DM, a disorder that causes high blood sugar) type two (the body needs insulin to keep the blood sugar at normal levels). 3. Identify the irregularities in list of discharged medications from the general acute care hospital (GACH 1) at readmission during the medication reconciliation (the process of comparing a patient's medication orders to all of the medications that the patient has been taking to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions) at the facility and by the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident). Resident 1 had been receiving insulin at the facility for four months prior to the transfer to GACH 1. After readmission to GACH 1 on 10/13/17, the resident did not receive insulin up to 10/31/17 (for 18 days). The IDT met on 10/19/17 and concluded to continue the (MONTH) (YEAR) care plan, which contained interventions to administer insulin and conduct blood sugar monitoring, but the IDT failed to identify the irregularities in the resident's medication regimen. This deficient practice resulted in Resident 1 being transferred to a general acute care hospital 1 (GACH 1) and developing diabetic ketoacidosis (DKA, a life threatening condition that develops when the body does not have enough insulin to process the blood sugars). Findings: A review of Resident 1's Record of Admission indicated the resident was originally admitted to the facility, on 6/15/17. Resident 1 was admitted with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 6/22/17, indicated Resident 1's cognitive (understanding) skills of daily decision making was severely impaired. A review of Resident 1's Physician admission orders [REDACTED]. The physician also ordered blood sugar monitoring every twelve hours and a sliding scale (additional insulin dose given based on the blood sugar level in milligrams per deciliter or mg/dL, the higher the blood sugar the more insulin was administered) with Humalog Regular. The sliding scale order indicated to administer Humalog Regular (in units) as follows: Blood sugar range Units of Humalog Regular - 60 to 150 0 - 151 to 200 2 - 201 to 250 4 - 251 to 300 6 - 301 to 350 8 - 351 to 400 10 - greater than 400 12 The physician's order indicated for the staff to notify the physician for a blood sugar less than 60 mg/dL (milligram per deciliter) or greater than 400 mg/dL. A review of Resident 1's care plan, dated 6/15/17 and titled, Insulin Dependent Diabetes Mellitus, indicated the goal for the resident was for her blood sugar within acceptable range daily to prevent complications. The interventions included monitoring blood sugars by finger stick per orders and notifying the physician of significant changes; administering oral medication and insulin per orders; and administering Insulin Detemir and insulin sliding scale, and finger stick blood sugar (FSBS) check every 12 hours A review of Resident 1's Medication Administration Records (MAR) indicated that from 6/17/17 to 10/4/17, Resident 1 received 30 units of Insulin Detemir every night and one (1) unit to 10 units of Humalog Regular Insulin following the ordered sliding scale. A review of Resident 1's Interact Resident Transfer, dated 10/5/18, indicated resident was transferred to GACH 1 for further evaluation and transfusion (receive blood intravenously). A review of GACH 1's Medication Discharge Summary Report indicated the hospital followed an insulin sliding scale for Resident 1. Resident 1 received regular insulin sliding scale on 10/9/17, 10/11/17, 10/12/17, and 10/13/17. A review of Resident 1's list of medications from Discharge Care Plan from GACH 1, which had an instruction to continue the medications on the list, did not include insulin. A review of Resident 1's Record of Admission indicated resident was readmitted to the facility on [DATE]. A review of Resident 1's Physician admission orders [REDACTED] A review of Resident 1's MAR, from 10/13/17 to 10/31/17, indicated no Insulin treatment for [REDACTED]. A review of the facility's additional comments in the Resident 1's Admission Assessment, dated 10/13/17 indicated that Resident 1 was under the care of Physician 1 but that Physician 2, who was on call for Physician 1, verified and approved the hospital's list (medication reconciliation that includes discontinued and continued medications) of medications. Physician 2 gave orders to continue the medications. On 11/01/17 at 9:55 a.m., an interview was conducted with the responsible party (RP). The RP stated that Resident 1 was diabetic and received Insulin for more than [AGE] years. The RP stated that when Resident 1 was originally admitted on [DATE] to the facility, an IDT meeting was held and the RP and the IDT discussed all of Resident 1's medications (including Insulin). During the interview, the RP stated that when Resident 1 was readmitted to the facility, she was responsive and alert but as days went by, Resident 1's level of alertness decreased and no longer opened her eyes, attempted to sing along, or assisted by holding the bed's side bar. The RP stated that on 10/31/17, Resident 1 was unresponsive, lethargic, and wouldn't open her eyes and the facility did not administer Insulin to help control/lower Resident 1's blood sugar since the 10/13/17 readmission. On 11/01/17 at 10:55 a.m., during an interview, the Licensed Vocational Nurse 1 (LVN 1) stated that the facility did not monitor Resident 1's blood sugar, on 10/13/17, readmission, because the Doctor did not order it, and the facility administered medications and monitored blood sugars when the physician wrote the order. On 11/25/17 at 8:12 a.m., during an interview, the Registered Nurse (RN) 1 stated readmission documents for resident included all medications (continued and discontinued) from the hospital, and the nurse then called the physician to share the list of medications. RN 1 stated when the physician approved the continued medications, the nurse transcribed the continued medications to the resident's admission orders [REDACTED]. On 11/25/17 at 10:32 a.m., during an interview, the Assistant Director of Nursing (ADON) stated when a resident was readmitted to the facility, it was not the facility's practice for the nurses to obtain the old chart to compare old with newly ordered medications. The nurses would get the hospital report that included the medication reconciliation, call the primary physician and verify the reconciliation. The ADON stated that Resident 1 did not receive insulin because it was not included in the GACH 1's medication reconciliation. A review of the readmission Resident Care Conference Review (IDT) dated 10/19/17 indicated that one Licensed Vocational Nurse (LVN), the dietary supervisor, a social service staff, and the case manager attended the meeting. The areas that were reviewed included: physician's orders, diagnosis, and care planning. Resident 1 was not able to attend the meeting because she was unable to verbalize needs (due to cognitive) impairment. The responsible party did not attend the meeting (the notification portion was left blank). The IDT indicated that there were no significant changes for Resident 1 and the (MONTH) (YEAR) plan of care was to be continued. A review of Resident 1's Diagnostic Laboratories results indicated that Resident 1's glucose (blood sugar) were 230 mg/dL on 10/20/17, 316 mg/dL on 10/26/18, and 295 mg/dL on 10/27/18. There were no documented evidence that the physician was made aware of the glucose results. A review of Resident 1's Nursing Progress Notes, dated 10/31/17 at 9:30 a.m., indicated that the facility made the RP aware that Resident 1 was not being administered insulin or getting blood sugar checked because there was no physician's order. The RP notified the facility that Resident 1 had been diabetic for [AGE] years. The RP made a request to the charge nurse to check Resident 1's blood sugar. Resident 1's blood sugar was greater than 400 mg/dL. The physician was notified and a new order for [MEDICATION NAME] Regular (insulin medication) 10 units to be given STAT (urgent) for the high blood sugar, [MEDICATION NAME] 5% Normal Saline (intravenous sugar solution) at 50 milliliters per hour for hydration, and transfer to the hospital's emergency room for evaluation of uncontrolled blood sugar. At 12 p.m., Resident 1's blood sugar was 393 and at 1:25 p.m., the ambulance picked up the resident. A review of the hospital's Emergency Department (ED) Course notes and report of physical exam, dated 10/31/17, indicated Resident 1 was admitted with [DIAGNOSES REDACTED]. According to the American Diabetes Association, edited 3/18/15, indicated that DKA is a serious condition that can lead to diabetic coma (passing out for a long time) or even death. http://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.html A review of the facility's policy and procedure with revised date of 4/07, titled, Admission Assessment and Follow Up: Role of the Nurse, indicated the facility was to gather information about the resident's physical condition upon admission and initiate a care plan. The nurse was to conduct an admission assessment (history and physical), including: A summary of the resident's medical history that included: hospitalization s, acute illnesses, relevant medical, social, and family history. This policy and procedure was also used for resident readmissions.

Based on observation, interview, and record review, the facility failed to provide adequate intervention and care for one of 16 sampled residents (Resident 5), who had a medication ([MEDICATION NAME] acid or [MEDICATION NAME]-medication for [MEDICAL CONDITION]) titration (continual adjustment of a dose based on patient response. Dosages are adjusted until the desired clinical effect is achieved), due to history of multiple episodes of [MEDICAL CONDITION] (medical condition where body muscles contract and relax rapidly and repeatedly, resulting in an uncontrolled shaking of the body) by failing to: 1. Ensure Resident 5's physician transfer orders from the general acute care hospital (GACH) to the skilled nursing facility are verified and accurate. GACH's order indicated to continue [MEDICATION NAME] acid ([MEDICATION NAME]) 250 milligrams (mg)/5 milliliters (mL) to give a total of 1500 milligrams (mg) or 30 mL three times a day (a total dose per day of 4500 mg). Resident 5 was receiving 250 mg/5 mL three times a day (a total dose per day of 750 mg) instead of receiving [MEDICATION NAME] acid 4500 mg/day since September 6, 2016. The medication error resulted in Resident 5 receiving 1/6th or 16.6% of the total required dose. 2. Monitor Resident 5's [MEDICAL CONDITION] activity every shift while on [MEDICAL CONDITION] medication since re-admission to skilled nursing the facility on 9/6/16. On October 27, 2016 at 12:45 p.m., an immediate jeopardy (IJ) was called due to facility's failure to protect Resident 5 from harmful side effects of the resident not receiving the prescribed the medication, lack of monitoring and identification of potential serious adverse reactions, and repeated medication error without intervention. The Administrator and Director of Nursing were verbally notified of the findings. On October 31, 2016 at 1:45 p.m., the facility submitted an acceptable plan of correction as follows: · Resident 5's attending physician was called by the licensed nurse to verify medication orders. · Licensed nurse reviewed the medication orders in the past 72 hours for transcription accuracy on 10/28/16. · Licensed nurses will conduct a 24 hour chart check for medication orders with focus on transcription accuracy. Findings will be reported to the DON for follow-up. · The DON will provide a summary trend analysis of the findings to the monthly QAA committee for further review and recommendations. · Monitoring of Resident 5's [MEDICAL CONDITION] activity every shift was added to the MAR on 10/26/16. · The DON reviewed all in house residents with [DIAGNOSES REDACTED]. · The Nurse Resource Consultant, DON, and/ or Director of Staff Development (DSD) will reeducate licensed nurses, CNAs, and respiratory therapists on the facility's [MEDICAL CONDITION] precautions monitoring protocols, emphasizing on the licensed nurses continuing care planning [MEDICAL CONDITION] monitoring on the MAR and the licensed nurse weekly summaries. · The medical records designee (MRD) will conduct QA audits of the residents with [MEDICAL CONDITION] disorder [DIAGNOSES REDACTED]. Any findings will be reported to the administrator and DNS for appropriate corrective actions. · The DON will conduct random review of 5 sample residents for compliance and will provide a summary trend analysis of the findings to the monthly QAA committee for further review and recommendations. · A list of in-house residents with [DIAGNOSES REDACTED]. This list will be reviewed and updated daily, or as needed, at stand up meeting and will be used to alert staff to the residents who are on [MEDICAL CONDITION] precautions. · The director of nursing (DON) educated the licensed nurses, CNAs, respiratory therapists, and rehab staff on 10/27/16 regarding the list of residents with [DIAGNOSES REDACTED]. · On an ongoing basis, this training will be included in their orientation and reviewed annually. · Department managers will randomly ask licensed nurses, CNAs, respiratory therapists, and rehab staff to identify at least 3 residents with [DIAGNOSES REDACTED]. Findings will be reported to the DON for follow-up. · The DON will provide a summary trend analysis of the findings to the monthly QAA committee for further review and recommendations. On October 31, 2016 at 1:45 p.m., the IJ was abated. The administrator and the DON were notified of the findings. Findings: A review of Resident 5's clinical record indicated [MEDICATION NAME] acid levels (therapeutic level was 50-100 microgram/ milliliter (mcg/ml)) were obtained periodically and a titration of [MEDICATION NAME] acid doses were done as follows: -On 10/3/13, clinical record review indicated Resident 5 had episodes of seven [MEDICAL CONDITION] activities. The resident was transferred to the GACH. Resident 5 was re-admitted to the facility on [DATE]. [MEDICATION NAME] acid 250 mg/5ml to give 10 ml via gastrostomy tube (GT-surgical opening into the stomach) twice daily (500 mg/dose-total 1000 mg/day). On 10/23/13, [MEDICATION NAME] acid level was 21.9 mcg/ml. The [MEDICATION NAME] acid order was changed from 500 mg (10 ml) to 750 mg (15 ml) via GT twice a day. On 10/29/13, [MEDICATION NAME] acid level was 33.3 mcg/ml. [MEDICATION NAME] acid order was changed to 750 (15 ml) via GT three times a day. On 1/22/14, [MEDICATION NAME] acid level was 14 mcg/ml. [MEDICATION NAME] acid order was changed to 1,000 mg (20 ml) via GT three times a day. On 12/24/14, [MEDICATION NAME] acid level was less than 10 mcg/ml. On 12/26/14, [MEDICATION NAME] acid order was changed to 1,250 mg (25 ml) via GT three times a day. On 1/2/15, [MEDICATION NAME] acid level was 33 mcg/ml. [MEDICATION NAME] acid order was changed to 1,500 mg (30 ml) via GT three times a day. On 2/2/16, [MEDICATION NAME] acid level was less than 10 mcg/ml. [MEDICATION NAME] acid 250 mg/5 ml (30 ml) order was changed to [MEDICATION NAME] acid 500 mg (10 ml) via GT three times a day. On 2/4/16, [MEDICATION NAME] acid order was clarified and was back to 1,500 mg (30 ml) via GT three times a day. <http://www.dovemed.com/[MEDICATION NAME]-acid-blood-test/> . If the levels are too low, the drug may not successfully ward-off a [MEDICAL CONDITION] attack. Low [MEDICATION NAME] acid levels may indicate that more [MEDICATION NAME] acid is necessary to achieve a therapeutic dose. On 2/23/16, [MEDICATION NAME] acid level was 32 mcg/ml. [MEDICATION NAME] acid dose continued at 1,500 mg (30 ml) via GT three times a day. On 8/9/16, [MEDICATION NAME] acid level was 38 mcg/ml. [MEDICATION NAME] acid dose continued at 1,500 mg (30 ml) via GT three times a day. A review of the facility's pharmacy consultant's report, dated 8/1/16 indicated a recommendation to consider monitoring a [MEDICATION NAME] acid serum concentration on the next convenient laboratory day, two weeks after any dosage changes and every six months thereafter to monitor efficacy and toxicity of this therapy. A review of Resident 5's Face Sheet indicated the resident was initially admitted to the facility on [DATE], and was readmitted from GACH on 9/6/16, with [DIAGNOSES REDACTED]. A review of Resident 5's admission order dated 9/6/16 included [MEDICATION NAME] acid 250 mg/5ml-total of 750 mg/day) every 8 hours via gastrostomy tube (GT- surgical opening into the stomach) for [DIAGNOSES REDACTED]. A review of Resident 5's care plan initiated on 9/6/16 titled, At Risk for Injury secondary to Involuntary Muscle Movements related to [MEDICAL CONDITION] Disorder- on [MEDICATION NAME], identified an intervention to monitor [MEDICAL CONDITION] activity and notify physician as indicated. Staff's approaches included to identify precipitating factors, determine safety needs of the resident, provide padded side rails if indicated, administer medication as ordered, monitor for potential side effects of the medication and notify physician, monitor therapeutic drug levels as ordered, and to obtain baseline level. A review of the significant change in status Minimum Data Set, ((SCSA MDS) a resident assessment and care screening tool), dated 9/19/16, indicated Resident 5 was severely impaired with cognitive skills for daily decision making, unable to understand others or make needs known. Resident 5 was totally dependent on the staff for all activities of daily living (ADL) such as bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. Resident 5 had limitations in range of motion of the upper and lower extremities. On 10/26/16, at 8:55 a.m., a concurrent interview and record review of Resident 5's GACH 's Medication Reconciliation Patient Discharge Summary Report, with registered nurse (RN 1) indicated to continue [MEDICATION NAME] acid 250 mg/5cc- total=1,500 mg via GT every 8 hours. RN 1 stated Resident 5's admission order on 9/6/16 for [MEDICATION NAME] acid was transcribed to the MAR as [MEDICATION NAME] acid 250 mg every 8 hours, instead of [MEDICATION NAME] acid 250 mg/5cc-1500 mg per GT every 8 hours (total of 4500 mg/day). On 10/26/16, at 11:02 a.m., during an interview, licensed vocational nurse LVN 4 stated Resident 5 was getting [MEDICATION NAME] Acid 250 mg/5 milliliters (ml) via GT for [MEDICAL CONDITION] disorder. LVN 4 stated [MEDICAL CONDITION] activity should be monitored and documented every shift on the MAR. LVN 4, after reviewing Resident 5's MAR, stated it was not done. A review of the MAR indicated that Resident 5 received [MEDICATION NAME] Acid 250 mg every 8 hours via GT since 9/6/16 to 10/26/16. There was no documented evidence any [MEDICAL CONDITION] episode was being monitored every shift on the MAR from 9/6/16 to 10/26/16. On 10/26/16, at 2:45 p.m., during an interview, RN 2 called the physician for clarification of the order. RN 2 stated the physician gave an order to continue what was on the admission order ([MEDICATION NAME] acid 250 mg every 8 hours) and to obtain [MEDICATION NAME] acid level immediately (STAT). On 10/26/16, at 4:02 p.m., during an interview, medical director (MD) stated a dose reduction of [MEDICATION NAME] acid from 1,500 mg every 8 hours to 250 mg every 8 hours will need further investigation. MD stated that a [MEDICATION NAME] acid at a low dose such as 250 mg is usually indicated for mood disorder. MD stated a [MEDICATION NAME] acid level (measures the amount of [MEDICATION NAME] acid in the blood which is used as a basis for gradual [MEDICATION NAME] dose change) will be indicated. On 10/27/16, at 10:35 a.m., during an interview, RN 3 stated that the admission process begins with the verification of transfer orders with the attending physician. RN 3 stated that she admitted Resident 5 on 9/6/16. RN 3 also stated that she was aware of Resident 5's change of [MEDICATION NAME] acid dose from 1,500 mg (4500/day) to 250 mg (750 mg/day) every 8 hours which RN 3 considered to be a red flag. On 10/27/16, at 1:50 p.m., Resident 5 was transferred to the GACH due [MEDICAL CONDITION] (potentially life-threatening complication of an infection) and lethargy (state of being drowsy and dull). On 10/27/16, at 2:25 p.m., during an interview, director of nursing (DON) stated that residents with active [MEDICAL CONDITION] disorder [DIAGNOSES REDACTED]. A review of the facility form titled, Licensed Nurse Progress Notes, dated 10/1/16- 10/4/16, 10/6/16, 10/8/16, 10/9/16-10/26/16, indicated that Resident 5 was not on [MEDICAL CONDITION] precaution and was not monitored for any [MEDICAL CONDITION] activity. On 10/29/16, at 12:46 p.m., during an interview, LVN 8 stated had received an in-service from the DON regarding the new process of transcribing physician orders. LVN 8 stated all medications on the acute hospital discharge medication list indicated to be continued will be written as an admission order. Any changes to the physician order [REDACTED]. According to the facility's policy titled, [MEDICAL CONDITION] and [MEDICAL CONDITION], dated 4/2007, stipulated as part of the initial assessment, the physician and staff will help identify individuals who have had a [MEDICAL CONDITION] or [MEDICAL CONDITION], and individuals who are receiving antiepileptic medications. Policy also stipulated that the staff and physician will monitor the progress of individuals with a new [MEDICAL CONDITION] or a [MEDICAL CONDITION] disorder, and will modify interventions accordingly. It also indicated that they should document periodically the absence of [MEDICAL CONDITION], as well as any recurrences. The physician will order antiepileptic medication blood levels periodically, where applicable. <http://www.mayoclinic.org/diseases-conditions/[MEDICAL CONDITION]/home/ is a central nervous system disorder (neurological disorder) in which nerve cell activity in the brain becomes disrupted, causing [MEDICAL CONDITION] or periods of unusual behavior, sensations and sometimes loss of consciousness. [MEDICAL CONDITION] symptoms can vary widely. Some people with [MEDICAL CONDITION] simply stare blankly for a few seconds during a [MEDICAL CONDITION], while others repeatedly twitch their arms or legs. <http://www.medicinenet.com/[MEDICAL CONDITION]/. Generalized convulsion, also called the grand-mal [MEDICAL CONDITION], the patient loses consciousness and usually collapses. The loss of consciousness is followed by generalized body stiffening for 30 to 60 seconds, then by violent jerking for 30 to 60 seconds, after which the patient goes into a deep sleep. During grand-mal [MEDICAL CONDITION], injuries and accidents may occur, such as tongue biting and urinary incontinence. Absence [MEDICAL CONDITION] cause a short loss of consciousness (just a few seconds) with few or no symptoms. The patient typically interrupts an activity and stares blankly. These [MEDICAL CONDITION] begin and end abruptly and may occur several times a day. Myoclonic [MEDICAL CONDITION] consist of sporadic jerks, usually on both sides of the body. Clonic [MEDICAL CONDITION] are repetitive, rhythmic jerks that involve both sides of the body at the same time. Tonic [MEDICAL CONDITION] are characterized by stiffening of the muscles. Atonic [MEDICAL CONDITION] consist of a sudden and general loss of muscle tone, particularly in the arms and legs, which often results in a fall. Autonomic symptoms affect the autonomic nervous system, which is the group of nerves that control the functions of our organs, like the heart, stomach, bladder, and intestine. Therefore autonomic symptoms are things like racing heartbeat, stomach upset, diarrhea, loss of bladder control.