Every finding on record at Cypress Ridge Care Center

Based on observation, interview, and record review, the facility failed to ensure services to accommodate resident's needs were provided for one of three residents (Resident 1) when there was a delayed response to his call light. This failure prevented Resident 1 from receiving timely assistance in meeting his needs for a toilet transfer. Findings: During a review of Resident 1's admission record, it indicated he was originally admitted to the facility on [DATE] and had diagnoses including hemiplegia (is severe or complete paralysis (inability to move) on one side. Both are caused by brain or spinal cord damage) and hemiparesis (is mild-to-moderate muscle weakness on one side of the body, allowing some movement) following cerebral infarction (is a type of ischemic stroke where a blockage in a blood vessel disrupts blood flow to the brain, causing brain tissue to die from lack of oxygen) affecting left non-dominant side, morbid severe obesity (is a person who has severe obesity has a BMI (Body mass index, is a measure of body fat based on height and weight) of 40 or higher ), difficulty in walking muscle weakness. During a review of Resident 1's minimum data set (MDS, an assessment), dated 3/3/26, it indicated that his brief interview for mental status (BIMS) was 10 and his toilet transfer was coded three for partial/ moderate assistance (helper does less than half the effort). Review of Resident 1's clinical record indicated three falls in 2025 and one fall on 2/14/26. During an interview on 4/20/26, at around 11:35 a.m. to 11:55 a.m., with Resident 1 in his room, Resident 1 stated no one was responding to his call lights and he waited too long for getting help, so he had falls in the bathroom several times. While during the interview, he pressed the call light and waited for 15 minutes with no one responding to his call lights. During an interview on 4/22/26, at around 11:20 a.m., with Resident 2, Resident 2 was lying in bed with oxygen in use through a nasal cannula. Resident 1 was asked about the call light taking how long to respond and he stated, They do not come after pressing a call light. During an observation and interview 4/22/26 1:40 p.m., Resident 1 was assessed by the nurse practitioner (NP) after an incident fall from using the toilet without assistance by the CNA at around 1:25 p.m. Resident 1 stated no one come to assist him after pressing the call light, so he transferred himself to use the shared restroom, then he fell down with no injury. During an interview on 4/24/26, at 1:20 p.m., with Resident 3, Resident 3 stated the call light response would depend on how many staff working on the floor and usually took 20 minutes to 45 minutes to respond to her call lights. During an interview on 4/24/26, at around 12:40 p.m., with the director of Nursing (DON) and assistant director of nursing (ADON) regarding call light responses. DON was validated above findings that the call lights were not responded to timely for Resident 1. A review of the facility's policy and procedure (P&P) titled, Answering the call light, dated 2001, the P&P indicated, The purpose of this procedure is to ensure timely response to the resident's requests and needs.

Based on interview and record review, the facility failed to develop a care plan to address treatment of a rash for one of five residents (Resident 1). This failure had the potential to place the resident at risk for not receiving necessary care and services.Findings: Review of Resident 1's clinical record indicated he was admitted to the facility with diagnoses including neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet) and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). Review of Resident 1's Change of Condition Note, dated 9/4/25 indicated his skin was fragile and had an erythematous maculopapular rash (reddened discolored area of skin and elevated lesions) scattered over trunk, back and all extremities. Review of Resident 1's care plans indicated there was no care plan that addressed Resident 1's rash. During an interview on 12/23/25 at 3 p.m., the director of nursing (DON) confirmed there was no care plan regarding Resident 1's rash. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, dated 12/2016 indicated the comprehensive, person-centered care plan will include measureable objectives and timeframes and incorporate identified problem areas.

Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three sampled residents (Residents 1) when there was no documentation that staff informed a clinician (ex. doctor of medicine, MD or nurse practitioner, NP) timely regarding Resident 1's fractured hip. This failure had the potential to delay care compromising the residents' health, safety, and overall well-being.Findings: Review of Resident 1's clinical record indicated he was admitted to the facility with diagnoses including neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet) and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). Review of Resident 1's Nurse's Notes, dated 10/4/25 indicated at approximately 3:50 p.m. on 10/4/25, Resident 1 was found on the floor and complained of 10/10 (on a scale from 1 to 10, worst pain). Review of Resident 1's Xray, dated 10/5/25 indicated, .deformity of the right femoral neck area [thigh bone] consistent with subcapital fracture [break in thigh bone/hip below the head of the femur]. Confirmation with CT or MRI exam is recommended. Review of Resident 1's progress notes, dated 10/5/25 at 7:14 p.m., indicated, Results sent to MD and placed in box for review. There was no documentation of the MD's reply on 10/5/25. During an interview on 10/20/25 at 2:45 p.m. with certified nursing assistant (CNA A) stated CNA A took care of Resident 1 on a Monday (10/6/25) and was informed that he fell on Saturday and was in a lot of pain. During interview and concurrent record review on 12/24/25 at 11:08 a.m., the director of nursing (DON) stated Resident 1 had a fall on 10/4/25 at 3:50 p.m., the results of Resident 1's X-ray were received on 10/5/25, and Resident 1 was sent to the hospital on [DATE] at 12:44 p.m. The DON confirmed Resident 1 was sent to the hospital two days after his fall. The DON stated the time it took to send Resident 1 to the hospital after his fall was not ok. Review of the facility's undated policy, Change of Resident's Condition or Status, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . The policy also indicated the nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident and the need to transfer the resident to a hospital/treatment center;

Based on interview and record review, the facility failed to properly reconcile medications and wound care treatment orders upon admission from the hospital for one of three sampled residents (Resident 1). when:1.The wound care treatment order was not transcribed from the hospital discharge instructions from 9/5/2025 to 9/11/2025, which resulted in two missed wound care treatments.2. There was no documented evidence that wound care treatment was provided on 9/15/2025.3. Two insulin aspart orders were not transcribed from the hospital discharge instructions onto the facility's medication list from 9/5/2025 to 9/16/2025. As a result, blood sugar levels were not checked, and insulin was not administered per sliding scale orders during this period.These failures resulted in missed wound care treatments and unmonitored blood sugar levels, which had the potential to compromise Resident 1's health and well-being. 1. A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a chronic condition characterized by hyperglycemia due to the body's inability to use insulin effectively or produce enough insulin), skin ulcers, and a non-pressure chronic ulcer of the right ankle. A review of the hospital discharge instructions dated 9/5/2025 indicated wound care orders for the right lower extremity, with dressings to be changed on Monday, Wednesday, and Friday using the following materials:1) Prisma activated by saline2) Gauze3) Two ABD pads4) Kerlix5) ACE bandageA review of the facility's Treatment Administration Record (TAR) for September 2025 indicated a wound care treatment order for the right lower extremity that included Prisma (activated with saline), gauze, ABD pads, kerlix, and ACE wrap from below the knee. The order, scheduled for every Monday, Wednesday, and Friday on the day shift, was not entered until 9/12/2025.2. A review of the TAR of September 2025 and nursing progress notes from 9/5 to 9/17/2025 indicated no evidence that wound care treatments were provided on 9/8 (Monday), 9/10 (Wednesday), and 9/15 (Monday). During an interview and concurrent record review on 9/23/2025 at 2:20 p.m., Licensed Vocational Nurse (LVN) A reviewed the September 2025 TAR and nursing progress notes from 9/5 to 9/16. LVN A confirmed that the wound care order was not transcribed on admission [DATE]). The order was instead entered on 9/12/2025. LVN A acknowledged there was no documented evidence of wound care treatments on 9/8, 9/10, and 9/15. LVN A stated the wound care nurse should have transcribed the wound care treatment order on 9/5/2025 per the hospital discharge instructions and that the treatments should have been provided as ordered.3. A review of the hospital discharge instructions dated 9/5/2025 also indicated updated medication orders to carry over to the skilled nursing facility (SNF), including:1)Insulin aspart correctional scale, subcutaneously before meals (three times daily)2)Insulin aspart correctional scale, subcutaneously at bedtimeA review of the facility's medication list indicated insulin aspart (Novolog 100 units/mL) was not started until 9/17/2025. The order included a sliding scale:150-189 = 1 unit190-249 = 2 units250-309 = 3 units310-369 = 4 units370-429 = 5 units430-479 = 6 units480-500 = 7 unitsAbove 500 = call MDThe order also required blood sugar checks and insulin administration before meals and at bedtime.A review of Resident 1's blood sugar results on 9/17/2025 showed elevated values, including:12:52 p.m. - 174 mg/dL5:37 p.m. - 214 mg/dL9:40 p.m. - 228 mg/dL10:10 p.m. - 282 mg/dLDuring an interview on 9/23/2025 at 2:29 p.m., LVN A reviewed the above documents and confirmed that the insulin aspart orders should have been initiated on 9/5/2025. LVN A acknowledged that he reconciled medications using the hospital inpatient medication list instead of the discharge to SNF medication list, which resulted in a delay in entering the orders. He further confirmed that blood sugar checks and insulin administration were not completed from 9/5 to 9/16/2025. LVN A stated that if the orders had been entered on 9/5/2025, Resident 1's blood sugar levels could have been maintained within the normal range.A review of the facility's policy titled Reconciliation of Medication on admission (Revised July 2017) indicated:.use an approved medication reconciliation form or other record; list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders ('sources'). List the dose, route, and frequency for all medications.

Based on observation, interview and record review, the facility failed to ensure palatability and nutritive value of cooked foods were maintained when: 1. Three of forty-nine facility residents, (Residents 33, 61 and 51), received food from the kitchen and complained that the food tasted bland (lacking taste or flavor); and, 2. Minced/moist (dietary modification where food is prepared to be soft, moist and easily swallowed with minimal chewing required) country fried steak, soft/bite-sized (foods that are soft, tender, moist and easily broken down by chewing) country fried steak, vegetable or veggie patties and mashed potatoes (made by mashing boiled or steam potatoes) were held in the heated oven for an extended period. These failures resulted in decreased food palatability that could lead to decrease in food consumed by residents, and the food held in the heated oven for extended period could lose nutritive value, that could lead to decreased nutrient intake for the ninety-five facility residents receiving food from the kitchen. Findings: 1. During a concurrent observation and interview of Resident 33 on 5/12/25 at 9:53 a.m., Resident 33 was in his bed, alert, oriented, calm and verbally responsive. Resident 33 stated that his food did not taste good and that it tasted bland. Review of the admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) of Resident 33 indicated, Resident 33 was readmitted to the facility on [DATE] with the primary diagnosis of hemiplegia (complete paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following unspecified cerebrovascular disease (group of conditions that impact the brain's blood vessels and blood flow) affecting left non-dominant side. Review of the order summary report of Resident 33 dated 5/14/25 indicated, Resident 33 had an order of regular diet (normal diet without restrictions), regular texture (no modifications), with thin liquids consistency (liquid that is easy to pour and no additives), ordered and started on 12/16/24. During a concurrent observation and interview of Resident 61 on 5/12/25 at 9:56 a.m., Resident 61 was in his bed, alert, oriented, comfortable and verbally responsive. Resident 61 stated that the food tasted bland. Review of the admission record of Resident 61 indicated, Resident 61 was admitted to the facility on [DATE] with the primary diagnosis of unspecified fracture (break or crack in a bone) of right femur (thigh bone), subsequent encounter for closed fracture (type of bone fracture where the broken bone does not penetrate the skin) with routine healing. Review of the order summary report of Resident 61 dated 5/14/25 indicated, Resident 61 had an order of controlled carbohydrate diet (CCHO, type of diet in which the individual consumes a consistent daily amount of carbohydrates), regular texture, with thin liquids consistency, no melon with any meal, side salad with lunch and dinner and extra cold cereal with breakfast, ordered and started on 9/17/24. During a concurrent observation and interview of Resident 51 during the resident council meeting (gathering where residents of a facility come together to discuss issues) on 5/13/25 at 11:00 a.m., Resident 51 was in her wheelchair in the activity room, alert, oriented, verbally responsive and participating in the resident council meeting. Resident 51 stated that the meat was dry, overcooked and tasted bland. Review of the admission record of Resident 51 indicated, Resident 51 was readmitted to the facility on [DATE] with the primary diagnosis of other idiopathic peripheral autonomic neuropathy (peripheral nerve damage where the cause is unknown or cannot be determined). Review of the order summary report of Resident 51 dated 5/14/25 indicated, Resident 51 had an order of controlled carbohydrate diet, regular texture, with thin liquids consistency, ordered and started on 7/16/24. During the test tray observation and tasting with dietary supervisor (DS) and director of dietary services (DODS) on 5/14/25 at 1:41 p.m., they brought 2 trays with 4 test plates containing: a. puree (smooth, typically creamy, mixture made by blending or mashing food until it reaches a uniform, soft texture) country fried steak and peas and mashed potatoes; b. minced/moist country fried steak and peas and mashed potatoes; c. soft/bite-sized country fried steak and peas and mashed potatoes and d. regular country fried steak and peas and mashed potatoes. During the food tasting on 5/14/25, from 1:43 p.m. to 1:46 p.m., tasted all the foods of the 4 test plates in the 2 trays. The puree country fried steak, minced/moist country fried steak, soft/bite-sized country fried steak and regular country fried steak, they all tasted bland. During the concurrent interviews with the DS and DODS after they both tasted all the foods of the 4 test plates in the 2 trays on 5/14/25 at 1:48 p.m., they both verified that the puree, minced/moist, soft/bite-sized and regular country fried steaks, they all tasted bland. During an interview with the registered dietitian (RD) on 5/14/25 at 3:00 p.m., RD acknowledged that all foods should be palatable. RD then stated that she would do an in-service training with the staffs about it. Review of the facility's policy titled, Food and Nutrition Services, revised October 2017, indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. 2. During the food preparation observation in the kitchen with cook B (CK B) on 5/14/25 at 9:57 a.m., CK B stored the already cooked minced/moist country fried steak, soft/bite-sized country fried steak, veggie patties and mashed potatoes in the oven, heated at 200 degrees Fahrenheit (F, temperature scale). During the continued observation in the kitchen on 5/14/25 at 12:20 p.m., CK B started preparing the tray line, putting foods in the meal trays of the residents after checking the food temperatures, then placing them in the tray carts until they were ready for distribution. During a concurrent interviews with the DS and DODS on 5/14/25 at 1:50 p.m., both the DS and DODS verified that foods should be prepared near or within 1 hour from the tray line preparation to keep the taste and nutritive value of the prepared foods. They further verified that the already cooked minced/moist country fried steak, soft/bite-sized country fried steak, veggie patties and mashed potatoes were placed in the oven, heated at 200 degrees F at 9:57 a.m., and the tray line preparation started at 12:20 p.m. for lunch. They then stated that they would change the time, they would start preparing the foods. During an interview with the RD on 5/14/25 at 3:00 p.m., the RD verified that foods should be prepared near or within 1 hour of the tray line preparation and serving to keep or preserve the taste and nutritive value of the foods. Review of the facility's undated policy titled, Section E: Dining Service: Mealtimes Overview, indicated, The Food and Nutrition Services Department will provide accurate, efficient and consistent meal service with nutritious and attractive food served at the appropriate temperature and in a pleasant atmosphere . Food is to be on the tray line no longer than 20 minutes before meal service starts or put out at time to ensure proper food temperatures and quality . Review of the State Operations Manual (SOM, a federal document from the Centers for Medicare and Medicaid Services that provides rules and guidance for state surveys of healthcare institutions), Appendix PP: Guidance to Surveyors for Long Term Care Facilities, dated 2/3/23, indicated, . Foods are . not held at hot temperatures for hours prior to meal service because prolonged hot temperatures can result in a loss of vitamins .

Based on observation, interview and record review, the facility failed to implement infection control and prevention practices when: 1. The Licensed Vocational Nurse A (LVN) did not perform hand hygiene between every task; 2. Resident 15's nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen [a colorless and odorless gas that people need to breathe] ) was undated and the nebulizer (a small machine that turns liquid medicine into a mist, allowing you to breath it in directly into your lungs through a mouthpiece or mask) mask was not properly stored after use; 3. Resident 308's nasal cannula was undated; the humidifier was outdated, and the oxygen filter was dusty with whitish grayish colored substance in the filter; 4. Dark brownish substances were observed in the medication storage room cabinet. 5. The licensed nurse did not change gloves between tasks. These failures had the potential for development and transmission of communicable disease and infection in the facility. Findings: 1. During an observation on 5/12/25 at 12:18 p.m., the LVN A observed came out in one of the resident's rooms without sanitizing her hands, then went to another resident room to answer the call light. Then the LVN took the empty cup used by another resident on top of the medication carts and threw the remaining fluid in the sink at the nurse station, then went to another residents room. During an interview with LVN A on 5/12/25 at 1:54 p.m., LVN A confirmed the above observation of not performing hand hygiene after every task. The LVN further stated they should do hand hygiene between every task, because of infection control. During a review of the facility's policy and procedure (P&P) titled, Handwashing/ Hand hygiene, revised date 2019, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. 2. During a concurrent observation and interview on 5/12/25 at 8:58 a.m., Resident 15's nasal cannula tubing was undated. Another nasal cannula hanging on Resident 15's wheelchair was undated and not properly stored. Resident 15's nebulizer mask was observed undated and was not properly stored. Resident 15 stated the nebulizer was last used on Sunday. During a concurrent observation and interview with Director of Nursing (DON) on 5/12/25 at 12:27 p.m., the DON confirmed the nasal cannula, and the nebulizer mask was undated and not properly stored. DON further stated it should be placed inside the black bag for prevention of infection. During a review of the facility's policy and procedure (P&P) titled, Respiratory Therapy- Prevention of Infection, undated, the P&P indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .7. Change the oxygen cannula and tubing every seven days , or as needed. 8. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use . Infection Control Consideration Related to Medication Nebulizer / Continuous Aerosol . 7. Store the circuit in plastic bag, marked with date and resident's name between uses. 3. Review of Resident 308's clinical record indicated Resident 308 was admitted to the facility on [DATE] with diagnoses including Respiratory disorders ( any disorders or illness that affects the lungs and the respiratory system), Emphysema ( a lung disease and a type of chronic obstructive pulmonary disease, any air filled enlargement in the body's tissue, Chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung) with exacerbation. Review of Resident 308's order summary report, dated 5/12/25 indicated Resident 308 had orders for change humidifier bottle and tubing every Friday every day shift every Fri. During an observation on 5/12/25 at 12:39 p.m., Resident 308's nasal cannula tubing was undated, the humidifier was dated 4/18/25. The oxygen concentrator filter (a medical device that concentrates oxygen from environmental air and delivers it to a resident in need of supplemental oxygen. The filter is at the back of the oxygen concentrator.) was dusty, with an accumulation of whitish grayish colored substances on the filter. During a concurrent observation and interview with DON on 5/12/25 at 1:01 p.m., the DON confirmed the nasal cannula was undated, the humidifier was outdated, and the oxygen concentrator filter was dusty, with an accumulation of whitish grayish colored substances on the filter. During a review of the facility's policy and procedure (P&P) titled, Respiratory Therapy- Prevention of Infection, undated, the P&P indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . Infection Control Consideration Related to Medication Nebulizer / Continuous Aerosol: 3.Mark bottle with date and initials upon opening and discard . 8. Wash filters from oxygen concentrators every seven days . 46001 4. During an observation and interview with the DON on 5/12/2025 at 11:00 a.m., dark brownish substances were observed all over the top of the medication storage cabinets in the south medication storage room. The DON confirmed the above observation and stated the staff should keep the medication storage cabinet clean. During an interview with the housekeeping manager (HM) on 5/15/2025 at 10:28 a.m., the HM stated that staff should have kept the medication storage cabinet clean. A review of the facility policy and procedures titled Storage of Medications, revised November 2020, indicated . the nursing staff is responsible for maintaining medication storage and preparation area in a clean, safe and sanitary manner . 5. A review of Resident 345's clinical record indicated Resident 345 was admitted to the facility on [DATE] with diagnoses including aftercare following joint replacement surgery, and infection and inflammatory reaction due to unspecified internal joint prosthesis (an artificial device that replaces a missing body part), subsequent encounter. A review of Resident 345's physician's order dated 5/10/2025 indicated Cefepime HCI (Cefepime Hydrochloride, a fourth-generation cephalosporin antibiotic) intravenous solution Reconstituted 2 gm (gram, a unit of mass in the metric system) intravenously every 8 hours for intraprosthetic infection (an infection occurs within a prosthetic device) for 6 weeks. Started on 5/11/2025. During a concurrent medication administration observation and interview on 5/14/2025 at 2:07 p.m., the Minimum Data Set Coordinator (MDSC) was observed preparing and administering intravenous (IV) Cefepime 2 gm for Resident 345. The MDSC used the same pair of gloves throughout the process-preparing the medication, hanging the IV bag on the pole, reaching into his pant pocket to retrieve an alcohol wipe, opening the wipe, scrubbing the IV hub, flushing with 10 mL of normal saline (NS), and connecting the IV line to the resident's midline catheter (a type of intravenous catheter). The MDSC acknowledged that he performed multiple tasks without changing gloves. During an interview with the Director of Nursing (DON) on 5/16/2025 at 3:00 p.m., the DON stated that nurses should change gloves between tasks to prevent cross-contamination and reduce the risk of infection. A review of the facility undated policy and procedures titled glove use indicated, . to prevent the spread of infection . when gloves are indicated, use disposable single-use gloves .

Based on observation, interview, and record review, the facility failed to ensure cooking and kitchen equipment were maintained and kept in accordance with professional standards for food safety when: 1. There were unsanitary cooking equipment stored in the kitchen; and, 2. Ice scoop for the ice machine was placed on top of a dusty and uncleaned tray. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the ninety-five residents who received food from the facility kitchen. Findings: 1. During the initial kitchen tour observation with the dietary supervisor (DS), on 5/12/25 at 8:08 a.m., observed 8 large pans with brownish to blackish discolorations and rusty spots in them that were still stored there. During an interview with DS on 5/12/25 at 8:09 a.m., the DS acknowledged that the 8 large pans had brownish to blackish discolorations and rusty spots. The DS then stated that it should not be kept there and would have them replaced. During an interview with the registered dietitian (RD), on 5/14/25 at 3:00 p.m., the RD verified that the 8 large pans with brownish to blackish discolorations and rusty spots should not be kept there and should have been replaced. The RD then stated that she would follow-up on that concern. Review of the facility's policy and procedure titled, Sanitization, revised on November 2022 indicated, The food service area is maintained in a clean and sanitary manner . All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . 2. During the initial kitchen tour observation on 5/12/25 at 8:15 a.m., surveyor checked the ice machine and observed that the ice scoop was placed on top of a dusty and unsanitary tray. During an interview with DS on 5/12/25 at 8:16 a.m., the DS acknowledged that the ice scoop was placed over a dusty and unsanitary tray and should not be put there. The DS then removed the ice scoop with the unsanitary tray from the ice machine and said it will be cleaned. During an interview with RD on 5/14/25 at 3:00 p.m., the RD verified that the ice scoop should not be placed over a dirty tray and would talk to the staff about it. Review of the undated facility's policy titled, Recommended Food Storage Practices: Ice, indicated, . Scoops shall be stored separately from the ice machine in a sanitary container that allows for water drainage away from the scoop .

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice for two of 25 sampled residents (Residents 59 and 301) when: 1. The facility failed to follow the physician's order for Resident 59 by not applying the prescribed wound care dressing and offloading boots while the resident was in bed. 2. For Resident 301, the licensed nurse incorrectly transcribed the physician's order for Chlorhexidine Gluconate mouth rinse. These failures had the potential to compromise the residents' health and well-being. Findings: 1. A review of Resident 59's clinical record indicated Resident 59 was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, presence of a left artificial knee joint, and bilateral primary osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) of the knee. A review of Resident 59's physician's order dated 3/26/2025 indicated that the left heel cover was with foam dressing every day shift every Tuesday, Thursday, and Saturday. A further review of 59's physician order dated 3/22/2025 indicated that blue booties should be on at all times while in bed every shift to prevent further skin breakdown. During a concurrent observation and interview with the Licensed Vocational Nurse (LVN ) A on 5/14/2025 at 10:59 a.m., Resident 59 was lying in bed, the foam dressing was not on his left heel, and the booties were not applied on both feet. LVN A confirmed the above observation. During a concurrent observation and interview with the Treatment Nurse (TN) on 5/14/2025 at 11:15 a.m., Resident 59 was observed lying in bed with dark purple discoloration on his left heel. The TN stated that the area was consistent with a deep tissue injury. The TN also confirmed that the foam dressing and booties, which were intended to prevent further skin breakdown, had not been applied. 2. A review of Resident 301's clinical record indicated Resident 301 was admitted to the facility on [DATE] with diagnoses including diabetes (a disease that causes high blood sugar), infection and inflammatory reaction due to other cardiac and vascular devices, and methicillin-susceptible staphylococcus aureus infection (MSSA, a type of bacterial infection caused by Staphylococcus aureus bacteria that are susceptible to treatment with methicillin and other beta-lactam antibiotics) as the cause of diseases classified elsewhere. A review of Resident 1's acute hospital discharge summary dated 5/7/2025 indicated Resident 301 had a recent dental extraction. The discharge medication, including Chlorhexidine Gluconate (Peridex, Chlorhexidine Gluconate 0.12% Oral Rinse, provides antimicrobial activity during oral rinsing. ) 15 ml (milliliters, a measuring unit) as directed twice daily. A review of Resident 1's physician's order dated 5/8/2025 indicated Chlorhexidine Gluconate Liquid 4%: give 15ml by mouth two times a day for post dental extraction mouth rinse. During a concurrent record review and interview with the Director of Nursing (DON) on 05/12/2025 at 3:26 p.m., the DON reviewed Resident 301's physician's order and stated that the nurse had incorrectly transcribed the hospital discharge medication Chlorhexidine Gluconate mouth rinse. The mouth rinse should have been Chlorhexidine Gluconate 0.12%, and Chlorhexidine Gluconate 4% should have been used for wound care. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 5/15/2025 at 2:46 p.m., the MDSC stated that he had transcribed Resident 301's hospital discharge order for Chlorhexidine Gluconate (Peridex) incorrectly as 4%, when it should have been 0.12%. During a phone interview with the Consultant Pharmacist (CP) on 05/16/2025 at 9:23 a.m., the CP stated that Chlorhexidine Gluconate 4% is intended for external use in wound care, while the appropriate concentration for a mouth rinse is 0.12%. The CP further stated that using the 4% solution as a mouth rinse may cause a bitter taste, dry mouth, and oral irritation. A review of drug resource, DailyMed (https://dailymed.nlm.nih.gov), indicated, indicating that Peridex, (Chlorhexidine Gluconate 0.12%) Oral Rinse provides antimicrobial activity during oral rinsing . chlorhexidine gluconate solution 4% Purposes of use: Surgical hand scrub - Healthcare personnel handwash - Skin wound and general skin cleanser. For external use only, when using this product - keep out of eyes, ears, and mouth .

Based on observation, interview, and record review, the facility failed to ensure the adequate provision of pharmaceutical services when: 1. Chlorhexidine Gluconate mouth rinse was unavailable for administration for five consecutive days for one of 25 sampled residents (Resident 301). 2. The pharmacy linked the different medications and incorrect administration instructions for one of the 25 sampled residents (Resident 36). This link resulted in the licensed nurse administering the wrong medication to Resident 36. These failure had the potential to worsen the resident's condition or lead to complications. Findings: 1. During a medication administration observation on 5/12/2025 at 10:00 a.m. in Resident 301's room, Licensed Vocational Nurse (LVN) A was observed administering the resident's morning medications. The Chlorhexidine Gluconate Oral Rinse was not administered. During an interview with LVN A on 5/12/2025 at 10:20 a.m., LVN A confirmed that she did not administer the Chlorhexidine Gluconate Oral Rinse to Resident 301, and she stated the Chlorhexidine Gluconate Oral Rinse was not available since the order date 5/8/2025. A review of Resident 301's acute hospital discharge summary dated 5/7/2025 indicated that the resident had a recent dental extraction. A review of Resident 301's physician's order dated 5/8/2025 indicated Chlorhexidine Gluconate Liquid 4%, to be given as a 15 ml (milliliters, a measuring unit) oral rinse twice daily for post-dental extraction care. A review of Resident 301's medication administration record (MAR) for May 2025 showed that Chlorhexidine was not administered during the morning and evening shifts from 5/8/2025 through 5/12/2025. During an interview with the facility Medical Director (MD) on 5/12/2025 at 3:28 p.m., the MD stated that the facility had sent the order for Chlorhexidine Gluconate Oral Rinse to the pharmacy on 5/8/2025 and the pharmacy should have communicated with the facility regarding the non-delivery of the medication. During an interview with the Assistant Director of Nursing (ADON) on 5/15/2025 at 2:00 p.m., the ADON confirmed that the Chlorhexidine Gluconate Oral Rinse was delivered to the facility on [DATE]. 2. During a medication administration observation on 5/13/2025 at 11:25 a.m. in Resident 36's room, Licensed Vocational Nurse (LVN) B was observed administering insulin before lunch. Resident 36's blood glucose level was 241 mg/dL(milligrams per decilitre ), and LVN B administered 4 units of Novolog Solution 100 units/mL (insulin aspart, a rapid-acting human insulin analog indicated for glycemic control in individuals with diabetes mellitus), per the sliding scale. However, the Electronic Medication Administration Record (eMAR) indicated that 4 units of insulin lispro were administered before lunch. During an interview with LVN B on 5/13/2025 at 11:30 a.m., she reviewed Resident 36's physician's order and confirmed that the active order was injecting insulin lispro per the sliding scale. She explained that she administered insulin aspart instead because insulin lispro was not available. She stated that two additional orders had been linked under the original lispro sliding scale order-one for insulin aspart with a sliding scale and one for insulin lispro at a fixed dose of 12 units. LVN B stated that nurses had the option to choose between these linked orders, and due to the unavailability of lispro, she chose to administer aspart. During a phone interview with the Consultant Pharmacist (CP) on 5/16/2025 at 9:39 a.m., the CP stated that although both insulin lispro and insulin aspart are rapid-acting insulins, they are different medications. Lispro acts more quickly than aspart. The CP further stated that insulin aspart should not be administered under an order for insulin lispro. If insulin aspart is to be used as a substitute, a new physician order needs to be obtained. During an interview with the Assistant Director of Nursing (ADON) on 5/15/2025 at 2:06 p.m., the ADON stated that he entered the original order for insulin lispro with a sliding scale before meals on 8/24/2024, and it had not been revised since. On 5/12/2025, when insulin lispro became unavailable, the pharmacy linked an insulin aspart sliding scale order under the existing lispro order. Additionally, the pharmacy also linked an inappropriate fixed-dose lispro order of 12 units, which Resident 36 did not have. The ADON confirmed that the pharmacy's action to auto-link these orders was inappropriate because insulin lispro and insulin aspart are different medications, and Resident 36 did not have an order for a fixed dose of 12 units of lispro. A review of the facility's Order Audit Report dated 5/15/2025 indicated the following two medication orders were auto-linked by the pharmacy under the original insulin lispro sliding scale order: a. Insulin Aspart 100 units/mL Solution, inject up to 12 units per sliding scale subcutaneously before meals (auto-linked on 5/12/2025). b. Insulin Lispro 100 units/mL Solution, inject 12 units subcutaneously before meals for diabetes mellitus (auto-linked on 4/5/2025). During a phone interview with the Pharmacy Manager (PM) on 5/16/2025 at 3:23 p.m., the PM declined to answer questions related to the medication errors involving Residents 301 and 36. A review of the facility's P&P titled Organization Aspects Provider Pharmacy Requirements , revised August 2014, indicated, The provider pharmacy agrees to perform the following pharmaceutical service, including but not limited to . Accurately dispensing prescriptions based on authorized prescriber orders, .provide routine and timely pharmacy service as contracted . all other new medication orders are received and available for administration on the next routine delivery . screen each new medication order for an appropriate indication or diagnosis . if diagnosis or indication is not available, notifying the nursing staff of the need to obtain the information from the prescriber prior to administering the drug .

Based on observation, interview, and record review, the facility had a medication error rate of 7.14 % when two medication errors were observed out of 28 opportunities during medication administration for two out of six residents (Residents 301 and 36). 1. Chlorhexidine mouth rinse was not administered as ordered for Resident 301, 2. Insulin was not administered as ordered for Resident 36 before lunch. These failures resulted in residents not receiving medications as prescribed, which had the potential to result in residents not receiving the full therapeutic benefit of their medications and/or experiencing negative health outcomes. Findings: 1. During a medication administration observation on 5/12/2025 at 10:00 a.m. in Resident 301's room, Licensed Vocational Nurse (LVN) A was observed administering Resident 301's morning medications. The Chlorhexidine Gluconate Oral Rinse was not administered. During an interview with LVN A on 5/12/2025 at 10:20 a.m., she confirmed that the Chlorhexidine Gluconate Oral Rinse was not administered because it had not been available since the order was placed on 5/8/2025. 2. During a medication administration observation on 5/13/2025 at 11:25 a.m. in Resident 36's room, LVN B was observed administering insulin before lunch. Resident 36's blood sugar was 241 mg/dL, and LVN B administered 4 units of Novolog Solution 100 units/ml (insulin aspart, a rapid-acting human insulin analog indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus) according to the sliding scale. However, the medication administration record indicated that 4 units of insulin lispro were administered before lunch. A review of Resident 36's physician's order dated 8/24/2024 indicated Humalog Solution 100 uint/ml (insulin lispro, a rapid-acting human insulin analog indicated to improve glycemic control in adult and pediatric patients with diabetes mellitus) injected as per sliding scale subcutaneously before meals for diabetes, give 15 minutes before meals. During a concurrent interview and record review with LVN B on 5/13/2025 at 11:30 a.m., LVN B reviewed Resident 36's physician order and confirmed that the order was to administer insulin lispro per sliding scale before meals. LVN B stated she administered insulin aspart instead because insulin lispro was unavailable, believing the two insulins were equivalent. During a phone interview with the Consultant Pharmacist (CP) on 5/16/2025 at 9:39 a.m., the CP stated that although both insulin lispro and insulin aspart are rapid-acting insulins, but they are different medications. the nurse should not administer insulin aspart under an order for insulin lispro. If insulin aspart is to be used as a substitute, a new physician order needs to be obtained. A review of the facility's policy titled, Medication Administration, revised April 2019, indicated, Medications are administered in accordance with prescriber orders .

Based on interview and record review, the facility failed to accurately complete the discharge Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 92). Failure to accurately assess Resident 92's discharge status resulted in an inaccurate record. Findings: Review of Resident 92's discharge summary report indicated he was discharged home with home health services on 2/20/25. Review of Resident 92's discharge MDS, dated [DATE], indicated he was discharged to the acute hospital. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 5/14/25 at 10:18 a.m., the MDSC confirmed Resident 92 was discharged to his home on 2/20/25. The MDSC verified that Resident 92's discharge MDS was incorrectly coded and stated that Resident 92 was discharged home, not to the acute hospital as was coded on Resident 92's 2/20/25 discharge MDS. Review of the Centers for Medicare and Medicaid Services (CMS) 10/2019 Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions) indicated for section A2100, Discharge Status, Code 01, community, if discharge location is a private home.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan for one out of five residents investigated for their activities, (Resident 51), when Resident 51 did not have a care plan for her activities. This failure had the potential for the resident to not receive the appropriate interventions necessary to maintain her highest level of well-being. Findings: During a concurrent observation and interview of Resident 51 during the resident council meeting (gathering where residents of a facility come together to discuss issues) on 5/13/25 at 11:00 a.m., Resident 51 was in her wheelchair in the activity room, alert, oriented, verbally responsive and participating actively in the resident council meeting discussion. Resident 51 stated that she's the current resident council president and she attends the meetings regularly. Review of the admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) of Resident 51 indicated, Resident 51 was readmitted to the facility on [DATE] with the primary diagnosis of other idiopathic peripheral autonomic neuropathy (peripheral nerve damage where the cause is unknown or cannot be determined). Review of the order summary report of Resident 51 dated 5/14/25 indicated, Resident 51 may participate in activities, not in conflict with treatment plan, ordered on 7/16/24. Review of Resident 51's care plans indicated, Resident 51 did not have an activity care plan. Resident 51 did not have the necessary interventions for her activities and did not have any updates whether her current activities were effective. During a concurrent review of Resident 51's care plan's and interview with the director of activities (DOA) on 5/15/25 at 10:29 a.m., the DOA verified that Resident 51 did not have an activity care plan. The DOA further verified that she would update the care plan of Resident 51, to include her activity care plan and the interventions for her activities. During an interview with the director of nursing (DON) on 5/15/25 at 1:47 p.m., the DON verified that Resident 51 should have an activity care plan and would follow up on it. Review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised on December 2016 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan will: include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change .

Based on observation, interview, and record review, the facility failed to implement their policy on self-administration of medication (resident takes medication without staff assistance) for one of 25 sampled residents (Resident 27) when the facility did not determine that the resident was clinically appropriate and safe to self-administer medications; did not obtain a physician's order to self-administer medications; and did not develop a care plan to address self-administration of medications. These failures had the potential for unsafe and improper administration of medications. Findings: Review of Resident 27's medical record indicated he was admitted on [DATE] with diagnoses including diabetes mellitus (abnormally high blood glucose [sugar] levels), peripheral vascular disease (narrow blood vessels reduce blood flow to the limbs), obesity, hypothyroidism (thyroid gland does not produce enough thyroid hormone), hyperlipidemia (abnormally high levels of fats [lipids] in the blood). Resident 27's Minimum Data Set (MDS, an assessment tool), dated 4/18/25, indicated he had a brief interview for mental status (BIMS) score of 9 (a score of 8 to 12 indicates moderate impairment). During an observation in Resident 27's room on 5/12/25 at 8:23 a.m., there were five medication bottles on Resident 27 ' s bedside dresser. Two of the bottles outer labels indicated Simethicone Tablets 80 mg (mg - a unit of measure). One bottle was labeled PB8 Probiotic, another bottle was labeled Maximum Strength Ultra-Zyme, and a third bottle was labeled Say Yes to Beans. During a concurrent interview with Resident 27, he stated Yes I have stomach issues and these help me. During an observation and concurrent interview with the director of nursing (DON) on 5/12/25 at 3:08 p.m., the DON went to Resident 27 ' s room and confirmed he had the above-mentioned medications at his bedside. The DON stated a physician ' s order, and a medication self-administration assessment should be done prior to resident ' s self-administration of medications. The DON further stated a care plan should be developed indicating Resident 27 is safe to self- administer medications. The DON reviewed Resident 27's medical record and confirmed there was no assessment to self-administer medications, and no care plan developed. The DON further confirmed there was no physician's order for Resident 27 to self-administer medications or to keep medications at the bedside. A review of the facility 's policy titled Administering Medications, revised April 2019, indicated Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on observation, interview and record review, the facility failed to ensure that the residents would know and be reminded of the results of the previous state recertification surveys when 4 out of 4 residents who attended the resident council meeting, (Residents 18, 51, 65 and 244), did not know about the results of the previous state recertification surveys or where the survey results binder was located. These failures jeopardized the right of the residents to know and examine the results of the previous state recertification surveys and the plan of corrections that the facility did for those failures. Findings: During the resident council meeting (gathering where residents of a facility come together to discuss issues) on 5/13/25 at 11:00 a.m., 4 residents, (Residents 18, 51, 65 and 244), attended the meeting. During a concurrent observation and interview with Resident 18 during the resident council meeting on 5/13/25 at 11:30 a.m., Resident 18 was in his elctric wheelchair, alert, oriented and verbally responsive. He verbalized that he was not aware about the results of the previous state recertification surveys or where the survey results binder was located. Review of Resident 18's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 18 was readmitted to the facility on [DATE] with the primary diagnosis of incomplete paraplegia (a form of paralysis that affects the lower body, specifically the legs and trunk, but not the upper body or arms). During a concurrent observation and interview of Resident 51 on 5/13/25 at 11:30 a.m., Resident 51 was in her wheelchair in the activity room, alert, oriented, verbally responsive and participating in the resident council meeting. Resident 51 stated that she was not aware about the results of the previous state recertification surveys or where the survey results binder was located. Review of the admission record of Resident 51 indicated, Resident 51 was readmitted to the facility on [DATE] with the primary diagnosis of other idiopathic peripheral autonomic neuropathy (peripheral nerve damage where the cause is unknown or cannot be determined). During a concurrent observation and interview of Resident 65 on 5/13/25 at 11:30 a.m., Resident 65 was alert, oriented, calm, comfortable and verbally responsive and participating actively in the resident council meeting. Resident 65 also stated that he was not aware about the results of the previous state recertification surveys or where the survey results binder was located. Review of the admission record of Resident 65 indicated, Resident 65 was readmitted to the facility on [DATE] with the primary diagnosis of unspecified cord compression (a condition where the spinal cord is squeezed by external pressure). During a concurrent observation and interview of Resident 244 on 5/13/25 at 11:30 a.m., Resident 244 was alert, oriented, comfortable and verbally responsive and participating actively in the resident council meeting. Resident 244 stated that he was not aware about the results of the previous state recertification surveys or where the survey results binder was located. Review of the admission record of Resident 244 indicated, Resident 244 was readmitted to the facility on [DATE] with the primary diagnosis of other idiopathic peripheral autonomic neuropathy. During an interview with the director of activities (DOA) on 5/16/25 at 1:38 p.m., the DOA acknowledged that she did not know about the results of the previous state recertification surveys or where the survey binder for the results of the previous surveys was located. The DOA then stated that she would go and ask, where it could be located. During an interview with the administrator (ADM) on 5/16/25 at 1:41 p.m., the ADM verified that the DOA should know where the survey binder for the results of the previous surveys was located so she could inform and remind the residents about that. The ADM then stated that he would in-service the DOA about it. During an interview with the director of nursing (DON) on 5/16/25 at 1:47 p.m., the DON also verified that the DOA should know where the survey binder for the results of the previous surveys was located and would check on it. Review of the facility's policy and procedure titled, Survey Results, revised on April 2017 indicated, Survey reports and plans of correction are readily accessible to the resident, family members, resident representatives and to the public. Residents may examine the results of the most recent survey of the facility conducted by Federal or State surveyors, as well as any plans of correction in effect. A copy of the most recent survey report and any plans of correction are kept in a binder and placed in easily accessible location .

Based on interview and record review, the facility failed to provide an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, document that specifies the medical treatments the resident wants to receive during serious illness) was completed for one of two sampled residents (Residents 75). These failures could lead to the delivery of unnecessary or inappropriate medical services, which are against the residents' goals and wishes. Findings: Review of Resident 75's clinical record indicated Resident was admitted on [DATE]. Further review of Resident 75's clinical record indicated there was no POLST form completed for Resident 75. During an interview and concurrent record review with the director of nursing (DON) on 5/15/25 at 1:10 p.m., the DON confirmed there was no copy of POLST form in Resident 75's clinical records. The DON stated it should be there, maybe it was misplaced. Review of the facility's policy titled Advanced Directives, revised 12/2016, indicated Advance Directives will be respected in accordance with state law and facility policy. 7. Information about whether or not the resident has executed an advanced directive an advance directive shall be displayed prominently in the medical record. A review of the title Physician Order for Life Sustaining Treatment (POLST) dated 4/1/2017, indicated, Directions for Health Care Provider, completing POLST. Use of original form is strongly encouraged . A copy should be retained in patient's medical record .

Based on interview and record review, the facility failed to ensure resident's right to be treated with dignity was rendered for one of two residents (Resident 1) when Resident 1's request not to move to another room was not followed. This failure had the potential to cause emotional distress and a feeling of less self-worth for Resident 1. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included encephalopathy (disorder or damage that affect the brain's structure or function), and psychotic disorder (a mental disorder that affects a person's ability to think and perceive reality) with delusions (having false and unrealistic beliefs). Review of Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 11/2/24 indicated her cognition (the mental process of thinking, learning, remembering, being aware of surroundings, and using judgement) was severely impaired but had a clear speech, made herself to be understood, and understood by others. During an interview with the Social Worker Staff (SWS) on 1/9/25 at 10:50 a.m., she stated that Resident 1 requested to be moved to another room in the morning of 1/3/25 due to previous roommate who passed away, but the notice of room change was not signed yet by Resident 1 at that time. SWS further stated that when she came back in the afternoon on same day to have the Resident 1 sign the notice of room change, Resident 1 was already transferred to another room, and Resident 1 refused to sign. During an interview with the Housekeeping Staff (HS) on 1/9/25 at 10:20 a.m., he stated that on 1/3/25 at around between 5:00 to 5:30 p.m., while helping the Assistant Director of Nursing (ADON) and Transportation Staff (TS) to move Resident 1 to another room, Resident 1 become upset, screaming, and crying and telling them she did not want to be moved to another room. The HS told ADON that it was not a good idea to move Resident 1 to another room at that time, but the ADON continued to instruct them to move Resident 1 to another room. Resident 1 was moved by the above three staff while lying in her bed to another room that time. During an interview with the TS on 1/9/25 at 10:44 a.m., he stated that on 1/3/25 at around between 400 p.m. to 5:00 p.m., while helping the ADON and HS to move Resident 1 to another room, Resident 1 become upset and was screaming and stated she did not want to move to another room. TS told ADON that Resident 1 was upset and screaming and did not want to move to another room, but the ADON told TS We have to. Resident 1 was moved by the above three staff while lying in her bed to another room that time. During an interview with the Director of Nursing (DON) on 1/10/25 at 2:13 p.m., he stated that the ADON should have not executed the room change on 1/3/25 at around between 5:00-5:30 p.m. when Resident 1 became upset, crying, and screaming and did not want to be moved to another room. DON further stated ADON should have waited for about 10-15 minutes for Resident 1 to calm down, then explained and tried the room change procedure again. The DON also stated ADON should have seek the assistance of other staff that are familiar and with good rapport with Resident 1 in order to move Resident 1 to another room smoothly. DON acknowledged ADON should have respected Resident 1's right request not to move to another room at that time because the facility is considered Resident 1's home. Review of revised facility's policy and procedures dated 12/2016 titled Resident Rights indicated Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; be treated with respect, kindness, and dignity .g. exercise his or her rights as a resident of the facility and be supported the facility in exercising his or her rights . Review of revised facility's policy and procedures dated 8/2009 titled Quality of Life-Dignity indicated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. 1. Resident shall be always treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or herself esteem and self-worth .12. Staff shall treat cognitively impaired residents with dignity and sensitivity; for example: a. Addressing the underlying motives or root causes for behavior; and b. Not challenging the resident's beliefs or statements.

Based on interview and record review, the facility failed to ensure the residents' pressure ulcers (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) had weekly assessment for four of seven residents (1, 2, 3, and 4). This failure resulted in undetermined wound status and had the potential to negatively affect the healing of the wounds and/or to cause the deterioration of the wounds. Findings: Review of Resident 1's Admission Record indicated she was admitted to the facility on [DATE] with diagnoses including severe obesity, muscle weakness, and cognitive communication deficit. Review of Resident 1's clinical record indicated she had a pressure ulcer stage 2 (a partial-thickness skin loss that appears as a shallow, open wound with a red or pink wound bed) on her sacrum (a large, triangular bone at the base of the spine), but her sacral pressure ulcer was not assessed from 11/8/24 to 12/2/24. Review of Resident 2's Admission Record indicated he was admitted to the facility on [DATE] with diagnoses including muscle weakness, difficulty in walking, iron deficiency, vitamin deficiency, and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Review of Resident 2's clinical record indicated he had an unstageable pressure ulcer (a full-thickness pressure injury in which the base is obscured by soft, yellow, white and/or thick, dry, black, brown dead tissue) on his sacrum, but his sacral pressure ulcer was not assessed from 11/13/24 to 12/2/24. Review of Resident 3's Admission Record indicated she was admitted to the facility on [DATE] with diagnoses including severe obesity, muscle weakness, and peripheral vascular disease (the reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel). Review of Resident 3's clinical record indicated she had a deep tissue pressure injury (DTPI, a serious form of pressure injuries; the condition remains invisible for up to 48 hours and then progresses rapidly to full-thickness skin and soft tissue loss) on her right lateral foot, but her right lateral foot DTPI was not assessed from 11/13/24 to 12/2/24. Review of Resident 4's Admission Record indicated he was admitted to the facility on [DATE] with diagnoses including muscle weakness, difficulty in walking, and sepsis (a serious condition in which the body responds improperly to an infection; the infection-fighting processes turn on the body, causing the organs to work poorly). Review of Resident 4's clinical record indicated he had a pressure ulcer stage 3 (pressure injury extends through the skin into deeper tissue and fat) on his sacrum, but his sacral pressure ulcer was not assessed from 8/13/24 to 8/29/24, from 8/31/24 to 9/12/24, and from 9/14/24 to 10/21/24. During an interview with the director of nursing (DON) on 12/10/24, at 3:30p.m., he reviewed Resident 1's, Resident 2's, Resident 3's, and Resident 4's clinical records and confirmed that Resident 1's sacral pressure ulcer was not assessed from 11/8/24 to 12/2/24; Resident 2's sacral pressure ulcer was not assessed from 11/13/24 to 12/2/24; Resident 3's right lateral foot DTPI was not assessed from 11/13/24 to 12/2/24; and Resident 4's sacral pressure ulcer was not assessed from 8/13/24 to 8/29/24, from 8/31/24 to 9/12/24, and from 9/14/24 to 10/21/24. The DON stated the residents' pressure ulcers should be assessed every week. Review of the progress notes of the physician assistant-certified (PA-C) from Professional Wound Specialists organization where the facility sent its residents for pressure ulcer treatments indicated that the residents' pressure ulcers needed to be followed up, assessed, and evaluated in seven days.

Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Certified nursing assistant A (CNA A) did not sanitize/wash her hands after removing the gloves which she wore during working with Resident 5; 2. CNA B walked out of Resident 6's room with gloves on and did not sanitize/wash her hands; and 3. CNA C walked out of Resident 7's room with gloves on. These failures had the potential to spread infection in the facility. Findings: During an observation on 12/2/24, at 4:05 p.m., CNA A was working with Resident 5 in his room. She removed and discarded her gloves and walked out of Resident 5's room and in the hallway without sanitizing/washing her hands. During an interview with CNA A on 12/2/24, at 4:10 p.m., she stated she was preparing Resident 5 and transferring him for shower in his room. CNA A stated she should sanitize/wash her hands when she walked out of Resident 5's room and in the hallway. During an observation on 12/2/24, at 4:20 p.m., CNA B was working with Resident 6 in his room. She walked out of Resident 6's room and in the hallway with gloves on, removed the gloves and threw them in the hamper, which was parked in the hallway, then walked in the hallway without sanitizing/washing her hands. During an interview with CNA B on 12/2/24, at 4:25 p.m., she stated she was transferring Resident 6 from chair to bed in his room. CNA B stated she should remove and discard her gloves in Resident 6's room and should sanitize/wash her hands when she walked out of Resident 6's room and in the hallway. During an observation on 12/9/24, at 1:50 p.m., CNA C was working with Resident 7 in his room. She walked out of Resident 7's room and in the hallway with gloves on, removed the gloves and threw them in the hamper, which was parked in the hallway. During an interview with CNA C on 12/9/24, at 1:55 p.m., she stated she was transferring Resident 7 from chair to bed, changed his brief, removed his pants, and put him to bed in his room. CNA C stated she should remove and discard her gloves in Resident 7's room. During an interview with the backup infection preventionist (BUIP) on 12/9/24, at 3:40 p.m., she stated staff should remove and discard their gloves in the residents' rooms and should sanitize or wash their hands when exiting the residents' rooms. Review of the facility's policy, Personal Protective Equipment - Using Gloves, dated 9/2010, indicated . 2. Discard used gloves into the waste receptacle inside the examination or treatment room . 5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.)

Based on observation, interview, and policy review, the facility failed to ensure proper medication storage when an unlocked medication cart was left unattended. This failure had the potential for residents, unauthorized staff, and visitors to access the medications. Findings: During an observation and interview with registered nurse A (RN A) on 7/9/24, at 1:45 p.m., RN A was in Resident 1's room and her medication cart was facing out in the hallway and not locked. RN A stated she was checking on Resident 1's knee in his room. RN A acknowledged that she should lock her medication cart before going to Resident 1's room to check his knee. During an interview with the director of nursing (DON) on 7/9/24, at 4:05 p.m., he stated the unattended medication cart should be locked. Review of the facility's policy, Storage of Medication, dated 8/2014, indicated Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.

Based on interview and record review, the facility failed to ensure one of three Certified Nursing Assistants (CNA) A had a current CNA certificate during the time of employment working as a CNA while providing resident care from August 2023 to April 2024. This deficient practice had the potential for an unqualified CNA to provide care to the residents. Findings: A review of CNA A's employee file indicated that she applied for the CNA position on 7/19/23 and signed the Team Member Handbook Acknowledgement and at-will Agreement as a CNA on 7/26/23. A further review of CNA A's employee file revealed that there was no documentation that indicated she had obtained her CNA certificate. During an interview with CNA A on 3/29/24 at 1:03 p.m., CNA A confirmed she started working as a CNA and worked with several residents after passing the CNA knowledge portion on 8/13/23 and the skill examinations on 8/5/23 even though she did not received her CNA certificate. A review of the facility's work schedule on 3/29/24 indicated that CNA A worked from 7:00 a.m. to 3:30 p.m. and provided care to multiple residents. A review of CNA A's California Certified Nurse Aide Exam Results Report dated 8/5/23 indicated you have passed the skill portion of the Certified Nurse Aide exam .A passing score does not imply certification.You must verify on the registry. A review of CNA A's California Certified Nurse Aide Exam Results Report dated 8/13/23 indicated you have passed the knowledge portion of the Certified Nurse Aide exam .A passing score does not imply certification. You must verify on the registry. During an interview with the Director of Nursing (DON) on 6/4/24 at 10:50 a.m., The DON stated that all CNAs who worked here should have obtained their CNA certificate. During an interview with the Director of Staff Development (DSD) on 6/4/24 at 3:26 p.m., the DSD confirmed that CNA A had not obtained her CNA certificate while providing care to multiple residents.The DSD further stated that CNA A should not have provided direct care until she obtained her CAN certificate and CNA A was removed from the work schedule at the beginning of May 2024. A review of the facility's job description for a CNA indicated .must be a licensed Certified Nursing Assistant.

Based on observation, interview, and record review, the facility failed to ensure to notify four of six residents (Resident 1, 2, 3 and 4) regarding the transfer reasons when these four residents transferred from the long-term care Skilled Nursing Facility (LTC-SNF, refers as transferring SNF, LTC-SF: a nursing facility which provides 24-hours skilled nursing care for the residents who reside in the facility for a long term) to another long-term care SNF (refers as receiving SNF) even though these residents' needs, and services could be met at this transferring SNF. These residents did not endanger themselves or the other residents' safety in the transferring SNF. In addition, the facility failed to notify six of six residents (Resident 1,2,3,4,5, and 6) in writing at least 30 days prior to the transfer/discharge. All these six residents had resided in the transferring SNF for more than 30 days. The facility also failed to advise all six residents of their rights to appeal regarding the transfer/discharge timely. When: 1.Resident 1 verbalized she was sad and cried when she left the transferring SNF to the receiving SNF. Resident 1 stated she kept on telling the staff from transferring SNF that she did not want to go (to the receiving SNF). Resident 1's representative (RP- resident's legal guardian, an individual acting on behalf of the resident) did not receive the transfer notice 30 days prior to the transfer. 2.Resident 2 verbalized staff from the transferring SNF told her to get into the van and dropped her at the receiving SNF without explaining the reason for her transfer. Resident 2 stated she was sad and mad about the way the transferring SNF handled her transfer. Resident 2 did not receive the transfer notice 30 days prior to the transfer. 3. Resident 3 verbalized he was angry at the transferring SNF and emotionally felt sad when he left the transferring SNF. Resident 3 did not receive the transfer notice 30 days prior to the transfer. 4. Resident 4's RP stated she did not ask for Resident 4's transfer from the transferring SNF. Resident 4's RP did not receive transfer notice 30 days prior to Resident 4's transfer. 5.Resident 5's RP did not receive transfer notice 30 days prior to the Resident 5's transfer. 6.Resident 6 did not receive discharge notice 30 days prior to his discharged home. These transfers and discharge had caused significant emotional distress to three of six residents (Resident 1, 2, and 3). Resident 1 verbalized she was sad and cried when she left the transferring SNF to the receiving SNF. Resident 2 stated she was sad and mad about the way the transferring SNF handled her transfer. Resident 3 verbalized he was angry at the transferring SNF and emotionally felt sad when he left the transferring SNF. These transfers and discharge had potential to violate the six of six residents' (Resident 1, 2, 3, 4, ,5, and 6) rights to appeal for their transfers and discharge. Findings: 1.Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated, Resident 1 admitted to the transferring SNF on 1/18/2023 with diagnoses including parkinson's disease (a disorder of brain and spinal cord [begins at the bottom of the brain and ends in the lower back] that affects movement, often including tremors), tourette's disorder (a nervous system disorder involving repetitive movements or unwanted sounds), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and obsessive-compulsive disorder (unreasonable thoughts and fears that lead to repetitive behaviors). She had an assigned RP. Resident 1 transferred to the receiving SNF on 3/14/2023 and readmitted from the receiving SNF to transferring SNF on 4/11/2023. Review Resident 1's minimum data set (MDS, an assessment tool), dated 1/20/2023, indicated, Resident 1's BIMS (brief interview for mental status) score was 11 of 15 (score of 8-12: moderately impaired cognition). Review of Resident 1's physician order, dated 3/13/2023, indicated, to discharge Resident 1 to the receiving SNF. Review of Resident 1's physician order, dated 4/11/2023, indicated, to admit Resident 1 to the transferring SNF. Review of Resident 1's Notice Of Proposed Transfer Discharge, dated 3/13/2023, indicated, to transfer Resident 1 to the receiving SNF on 3/14/23. Resident 1's RP signed the transfer notice on 3/14/23, the same day when Resident 1 was transferred to the receiving SNF. The transfer notice indicated the reason for Resident 1's transfer/discharge was RP and resident choice to transfer to another facility. During an observation and interview with Resident 1 in the resident's room at the transferring SNF on 5/19/2023 at 12:30 p.m., Resident 1 was lying in the bed. Resident 1 stated she was sad and cried when she left the transferring SNF to the receiving SNF. Resident 1 also stated she kept on telling the transferring SNF case manager (CM) who was also a licensed vocational nurse (LVN) that she (Resident 1) did not want to go (to the receiving SNF), but CM did not listen to Resident 1's request and her cry. Resident 1 stated she was told by the CM that there was no permanent bed for her to stay in the transferring SNF and she had to go (to the receiving SNF). Resident 1 further stated the social service director (SSD) did not give her any choice other than going to the receiving SNF. Resident 1 stated she had difficult time adjusting and staying away from her family when she was in the receiving SNF. She stated she requested for an Ombudsman (advocate for residents and their families in skilled nursing facility) to help her to go back to the transferring SNF. Resident 1 stated she was happy when she went back to the transferring SNF, and she was able to see her family every day. During an interview with Resident 1's RP over the telephone on 5/19/2023 at 12:45 p.m., RP confirmed she did not request the transferring SNF to transfer Resident 1. The RP (RP is one of Resident 1's family members) stated Resident 1 called the RP and told the RP that she (Resident 1) did not want to go to the receiving SNF. RP stated Resident 1 cried over the phone before she left from the transferring SNF to the receiving SNF. RP also stated staff from the transferring SNF informed her the day before Resident 1's transfer that the reason to transfer Resident 1 was because there was no permanent bed for Resident 1 to stay in the transferring SNF. RP stated she signed the transfer notice on the same day on 3/14/23 when Resident 1 was transferred to the receiving SNF. RP further stated Resident 1 missed seeing her family, sad and cried every time when the RP visited Resident 1 in the receiving SNF or whenever Resident 1 called RP. During an interview with certified nursing assistant A (CNA A) at the transferring SNF on 5/19/2023 at 2:17 p.m., CNA A stated Resident 1 cried before Resident 1 left the transferring SNF and Resident 1 told CNA A that she (Resident 1) did not want to go to the receiving SNF and wanted to stay in transferring SNF. CNA A further stated upon Resident 1's return to the transferring SNF, Resident 1 told CNA A that she (Resident 1) was happy to come back to the transferring SNF. During an interview with CNA B at the transferring SNF on 5/19/2023 at 2:32 p.m., CNA B stated Resident 1 gave her a hug and cried when Resident 1 left the transferring SNF. Resident 1 told CNA B that she (Resident 1) did not want to go to the receiving SNF. CNA B also stated Resident 1 told CNA B the transferring SNF sending Resident 1 away from the resident's family. CNA B further stated Resident 1 was happy when she (Resident 1) came back to the transferring SNF. CNA B stated Resident 1 told her that Resident 1 was sad, cried, and missed seeing her family while Resident 1 was in the receiving SNF. During an interview with Ombudsman over the telephone on 5/23/2023 at 10:46 a.m., Ombudsman stated Resident 1 requested Ombudsman to help her to go back to the transferring SNF when she (Ombudsman) visited Resident 1 in the receiving SNF. During an interview with CNA C at the transferring SNF on 6/19/2023 at 10:30 a.m., CNA C stated Resident 1 was alert to the name, place, and time. CNA C further stated Resident 1 was able to participate in the conversation with staff and Resident 1 was able to tell staff of her needs. During an interview with licensed vocational nurse D (LVN D) at the transferring SNF on 6/19/2023 at 10:40 a.m., LVN D stated Resident 1 was alert to the name, place, time, and situation. LVN D further stated Resident 1was able to communicate her needs, express her feelings, and emotions with staff. During an interview with Resident 1's assigned nurse practitioner (NP- clinician with clinical expertise in diagnosing and treating health conditions) at the transferring SNF on 6/19/2023 at 11:45 p.m., NP stated she was not involved with discharge/transfer planning for Residents, and she was the last one to know why and where residents were transferred. She also stated Resident 1 was alert to the name, place, and time. NP further stated Resident 1 was able to communicate her needs and express her feelings with staff. Review of Resident 1's NP's progress notes dated 4/13/23 indicated Patient (Resident 1) was discharged to another SNF (receiving SNF) in the area and continued PT(physical therapy) OT(occupational therapy) there (receiving SNF) but patient (Resident 1) reports she really did not like that facility (receiving SNF). She (Resident 1) is happy to have been transitioned back here (transferring SNF). Review of Resident 1's NP's progress notes dated 4/27/23 indicated, Resident 1 was initially admitted to the transferring SNF . to complete treatment. Her (Resident 1's) knee is well-healed and there is been no further events. She (Resident 1) continued PT OT at another facility (receiving SNF) but apparently there were some issues and she has been transition back to (the name of the transferring SNF). NP's progress notes also indicated .she (Resident 1) is much happier to be here (transferring SNF) than anywhere else. Review of Resident 1's medical record, there were no documents indicated Resident 1 endangered herself and other residents in the transferring SNF. There were no documents indicated Resident 1's needs and services could not be met at the transferring SNF. 2. Review of Resident 2's face sheet indicated, Resident 2 admitted to the transferring SNF on 9/30/2021 with diagnoses including cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in brain), depression, diabetes type 2 (a chronic condition the body either does not produce enough insulin [a hormone which regulates the amount of glucose in the blood], or it resists insulin), and cirrhosis of the liver (a chronic liver damage from variety of causes leading to scarring and liver failure). Resident 2 was her own RP. Resident 2 was transferred to the receiving SNF on 3/17/2023. Review of Resident 2's MDS assessment, dated 6/21/23, indicated, Resident 2's BIMS score was 15 of 15 (score of 13-15: intact cognition). Review of Resident 2's physician orders, dated 3/17/2023, indicated, to discharge Resident 2 to the receiving SNF on 3/17/2023. Review of Resident 2's Notice Of Proposed Transfer Discharge, dated 3/17/2023, indicated, Resident 2 signed the transfer notice on 3/17/2023, the same day when Resident 2 was transferred to the receiving SNF. The transfer notice indicated the reason for the transfer/discharge was Resident choice to transfer. During an observation and interview with Resident 2 in the resident's room at the receiving SNF on 6/20/2023 at 10:35 a.m., Resident 2 was observed lying in the bed. Resident 2 stated staff from the transferring SNF told her to get into the van and then dropped Resident 2 at the receiving SNF without explaining to her (Resident 2) the transfer reason. Resident 2 stated she was sad and mad about the way the transferring SNF handled her transfer. Resident 2 stated that she had difficult time to adjust to the receiving SNF. Resident 2 further stated she did not request or give consent to the transferring SNF for her transfer any time during her stay in the transferring facility. During an interview with CNA E at the receiving SNF on 6/20/2023 at 11:06 a.m., CNA E stated Resident 2 told her that Resident 2 was sad because the transferring SNF moved her (Resident 2) to the receiving SNF without talking to her (Resident 2) regarding her transfer. CNA E also stated Resident 2 was in the room most of the time and had difficulty adjusting to the receiving SNF when she (Resident 2) was new to the receiving SNF. During an interview with LVN F at the receiving SNF on 6/20/2023 at 1:03 p.m., LVN F stated Resident 2 was crying when Resident 2 was new to the receiving SNF. LVN F stated Resident 2 had difficult time adjusting in the beginning to the receiving SNF. Review of Resident 2's medical record, there were no documents indicated Resident 2 endangered herself and other residents in the transferring SNF. There were no documents indicated Resident 2's needs and services could not be met at the transferring SNF. 3.Review of Resident 3's face sheet indicated, Resident 3 admitted to facility on 10/06/2022 with diagnoses including parkinson's disease, diabetes type 2, cerebrovascular disease, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and asthma (a condition in which a person's airways becomes inflamed, narrow, and swell, produce extra mucus which makes it difficult to breathe). He was his own RP. Resident 3 was transferred to the receiving SNF on 2/24/2023. Review of Resident 3's MDS assessment, dated 3/25/2023, indicated, Resident 3's BIMS score was 13 of 15 (score of 13-15: intact cognition). Review of Resident 3's physician orders, dated 2/24/2023, indicated, to discharge Resident 3 to the receiving SNF on 2/24/23. Review of Resident 3's Notice Of Proposed Transfer Discharge, dated 2/24/2023, indicated, Resident 3 signed on 2/24/2023, the same day when Resident 3 was transferred to the receiving SNF. The notice indicated the reason for the transfer/discharge was resident and family request to transfer to facility. During an observation and interview with Resident 3 at the receiving SNF on 6/20/2023 at 10:40 a.m., Resident 3 was observed sitting in the wheelchair in the hallway. Interviewed Resident 3 at his room, Resident 3 stated he did not request for the transfer from the transferring SNF. He stated he did not know why he was transferred to the receiving SNF. Resident 3 stated he was told about the transfer on the same day a few hours prior to his transfer from the transferring SNF. Resident 3 stated he was angry at the transferring SNF and emotionally felt sad when he left the transferring SNF. During an interview with Resident's 3 significant family member (SFM) over the telephone on 6/20/2023 at 12:45 p.m., SFM stated she was not aware of Resident 3's transfer until the receiving SNF called her to inform her about Resident 3's arrival in the receiving SNF. SFM also stated either Resident 3 or her absolutely not requested the transfer to the receiving SNF or the other SNF in the area. SFM further stated the transferring SNF used out Resident 3's Medicare days (a benefit period for expenses coverage by federal health insurance program for resident's stay in a LTC-SNF including medically necessary skilled nursing and rehabilitation care needs) and dumped Resident 3 at the receiving SNF. Review of Resident 3's medical record, there were no documents indicated Resident 3 endangered himself and other residents in the transferring SNF. There were no documents indicated Resident 1's needs and services could not be met at the transferring SNF. 4. Review of Resident 4's face sheet indicated, Resident 4 admitted to the transferring SNF on 2/1/2023 with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), syncope (a sudden temporary loss of consciousness), cardiomegaly (an enlarged heart describes a heart that's bigger than what is typical), and white matter disease (damage to white matter in the brain). She had an assigned RP. Resident 4 was transferred from the transferring SNF to the receiving SNF on 3/14/2023. Review of Resident 4's MDS assessment, dated 3/20/2023, indicated, Resident 4's BIMS score was 12 of 15 (score of 8-12: moderately impaired cognition). Review of Resident 4's physician orders, dated 3/14/23, indicated, to discharge Resident 4 to the receiving SNF on 3/13/2023. Review of Resident 4's Notice Of Proposed Transfer Discharge, dated 3/13/2023, indicated, Resident 4's RP signed the notice on 3/14/2023 on the same day that Resident 4 was transferred to the receiving SNF. The notice also indicated the reason for the transfer/discharge was RP and resident requested transfer. Review Resident 4's care planning meeting notes, dated 3/6/2023, indicated, D/C (discharge) date 3/14/2023 to receiving SNF temporarily and then transfer to LTC ALF (LTC ALF- long-term care assisted living facility) 151 miles away from transferring SNF per RP request. During an observation and interview with Resident 4 in her room at the receiving SNF on 6/20/23 at 10:45 a.m., Resident 4 was observed lying in the bed. Resident 4 stated her RP knew about the transfer and asked the surveyor to talk to her RP. During an interview with Resident 4's RP over the telephone on 6/23/2023 at 3:10 p.m., Resident 4's RP stated she attended Resident 4's care plan meeting over the telephone with transferring SNF staff and she (RP) did not ask for Resident 4's transfer. RP stated she was told by the staff at the transferring SNF that the transferring SNF was not a long-term care facility and there was no long-term bed (the bed for long term stay in the facility) available at the transferring SNF for Resident 4, and Resident 4 had to go to a long-term care facility in another city, which was about 151 miles away from the transferring SNF. RP also stated she was worried for Resident 4 to be away from her if Resident 4 had to go to the facility 151miles away from her. RP stated the transferring SNF gave her no option other than let Resident 4 to be transferred to the receiving SNF. Review of Resident 4's medical record, there were no documents indicated Resident 4 endangered herself and other residents in the transferring SNF. There were no documents indicated Resident 4's needs and services could not be met at the transferring SNF. 5. Review of Resident 5's face sheet indicated Resident 5 admitted to facility on 5/5/2022 with diagnoses including cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), diabetes type 2, atrial fibrillation, malignant neoplasm of kidney and renal pelvis (a kidney cancer tumor near the renal pelvis), neoplasm of bone (bone cancer), and gout (a form of arthritis, joint pain or joint disease, characterized by severe pain, redness, and tenderness in joints). Resident 5 had an assigned RP. Resident 5 was transferred from the transferring SNF to the receiving SNF on 2/24/2023. Review of Resident 5's MDS assessment, dated 2/28/2023, indicated, his BIMS score was 10 of 15 (score 8-12: moderately impaired cognition). Review of Resident 5's physician orders, dated 2/24/2023, indicated, to discharge Resident 5 to the receiving SNF on 2/24/23. Review of Resident 5's Notice Of Proposed Transfer Discharge, dated 2/24/2023, indicated, Resident 5 signed the notice with his initial on 2/24/2023, the same day when Resident 5 was transferred to the receiving SNF. Resident 5's RP did not sign the transfer notice. Review of Resident 5's medical record, there were no documents indicated Resident 5 endangered himself and other residents in the transferring SNF. There were no documents indicated Resident 5's needs and services could not be met at the transferring SNF. During a concurrent records review and interview with SSD on 4/7/2023 at 2:16 p.m., SSD confirmed there were no IDT (interdisciplinary team of professional's plan, coordinate and deliver care to residents) discharge meeting notes for Resident 1, 2, 3, 4 and 5). SSD stated she conducted discharge meeting for all these five Residents, but she did not document the meeting notes for all these five residents. When asked for the transfer reasons for these five residents, SSD stated the transfer reason for Resident 1 was Resident 1 was the RP and it was Resident 1's choice to transfer to another facility. SSD stated transfer reason for Resident 2 was it was the Resident 2's choice to transfer. For Resident 3, SSD stated Resident 3 and his family requested to transfer to another facility. SSD stated Resident 4's RP requested for the transfer. SSD stated Resident 5's family requested to transfer Resident 5 to be close to his family. When asked the documentation for the above requests from the residents and their families, SSD stated she did not document such transfer requests for Resident 1, 2,3, and 4. SSD also stated she documented her conversations depending on her workload for that day or later when she got chance. During a concurrent interview and records review on 5/19/2023 at 2:20 p.m., Director Of Nursing (DON) stated the transfer reason for Resident 1 was not documented. DON stated for Resident 2, plateaued with therapy (resident reached a state of little or no change after a time of physical therapy or progress) was not a reason for the transfer. DON stated Resident 3 could continue to stay in this facility (transferring SNF) for his long-term care needs. DON stated Resident 4 could have avoided transferring to the receiving SNF as a temporary stay and Resident 4 could continue to stay in this facility (transferring SNF) while waiting for the bed availability in another facility. DON stated SSD should have explained the transfer reasons and documented the transfer reasons for Resident 1's RP, and provided transfer reasons for Resident 2, 3, and Resident 4's RP. 6.Review of Resident 6's face sheet indicated, Resident 6 admitted to facility on 1/23/2023 with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), gout and atrial fibrillation. Resident 6 was his own RP. He was discharged home on 5/6/2023. Review of Resident 6's MDS assessment, dated 4/27/23, indicated, his BIMS score was 15 of 15 (score 13-15: intact cognition). Review of Resident 6's physician orders, dated 5/4/2023, indicated, to discharge Resident 6 home on 5/6/23. Review of Resident 6's Notice Of Proposed Transfer Discharge, dated 5/4/2023, indicated, Resident 6 signed the discharge notice on 5/6/2023, which was the same day when Resident 6 was discharged home. During a concurrent interview and record review with the transferring SNF SSD on 5/19/2023 at 2:45 p.m., SSD confirmed the facility provided the transfer/discharge notices for Resident 1,2,3,4,5, and 6 on the same day when these residents were transferred or discharged . During an interview with the transferring SNF DON on 6/19/2023 at 1:15 p.m., DON stated staff did not follow the facility's policy for the notice of proposed transfer/discharge. DON stated staff should have followed their transfer/discharge policy to give the transfer/discharge notice 30 days prior to the transfer/ discharge or as soon as possible, but not on the day of transfer or discharge. Review of facility's P&P titled, Discharge, dated 12/2015, the P&P indicated, A transfer or discharge will be in accordance with federal and state law or upon the request of resident/family. a. Federal Regulations specify the following: i. A thirty (30) day notification of discharge before the discharge occurs in the following cases: 1.The resident's welfare and needs cannot be met in the facility. 2.The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid (Medicare: federal health insurance program for people 65 or older, people with certain disabilities, and people with permanent kidney failure requiring dialysis [process of removing excess water, and toxins from blood in people with kidneys can no longer perform these functions naturally], Medicaid: state government program that provides health insurance for adults and children with limited income and resources) a stay at the facility. 3.The facility ceases to operate. ii. Notification as soon as practicable in the following cases: 1. The safety of individuals in the facility would be endangered. 2. The health of individuals in the facility would be endangered. 3. The resident's health has improved sufficiently to allow a more immediate transfer or discharge. 4. An immediate transfer or discharge is required by the resident's urgent medical needs, or 5. A resident has not resided in the facility for thirty (30) days.

Based on interview and record review, the facility failed to ensure residents were free from abuse when two of two residents (Residents 1 and 2) were allegedly sexually battered by certified nursing assistant A (CNA A). This failure resulted in emotional trauma for Resident 1 and Resident 2. Findings: Review of Resident 1's admission sheet indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's Progress Notes dated [DATE] at 12:10 a.m., written by licensed vocational nurse A (LVN A) indicated at 10:25 p.m. writer was notified by CNA that another CNA allegedly behaved inappropriately with a resident. Review of Resident 2's admission sheet indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 2's Progress Notes dated [DATE] at 12:17 a.m., written by LVN A indicated at 10:25 p.m. writer was notified by CNA that another CNA allegedly behaved inappropriately with a resident. In an interview on 3/3/2020 at 2:09 p.m., LVN A stated in the night of 2/29/2020 after 10:00 p.m. he was approached by CNA B who stated CNA A spanked Resident 2 on the bare buttocks and CNA A pinched the breast and twisted the nipple of Resident 1. LVN A stated he went to Resident 1 who nodded her head to the question of pain and nodded yes for the question if something happened to her. LVN A stated he went to Resident 2 who stated she was not in pain, but the slapping happened. In an interview on 3/3/2020 at 2:51 p.m., CNA B stated in the night of 2/29/2020 she wanted to change Resident 2 and she needed CNA A for assistance. Resident 2 was positioned on her side and CNA A held her. She stated she needed a pad and left the room. When she returned she could hear a slapping sound and Resident 2 told CNA A stop hitting my butt. Since the curtain was pulled she was not able to see what she heard. CNA B asked CNA A what he had done and his response was only that he chuckled. When they left the room Resident 1 called for help and they both entered her room. Resident 1 needed her top to be changed. We both pulled her top off and CNA A had one hand on her shoulder and with the other hand he pinched the nipple and said titty twist. Resident 1 giggled in nervousness, which she would do when she felt uncomfortable. CNA B stated she asked CNA A why he did this and he responded, don't tell anybody. During an interview with Resident 1 on 3/3/2020 at 3:50 p.m., when approached if she would like to talk regarding the incident she stated no and became emotional and had teary eyes. Concurrently, the director of nursing (DON) approached Resident 1 again regarding the incident and Resident 1 did not say anything, only shook her head from side to side. During an interview on 3/3/2020 at 3:30 p.m., Resident 2 stated CNA A leaned over her but did not physically touch her. Review of a Police Department's Primary Narrative dated [DATE], indicated (CNA A) was arrested for sexual battery and elder abuse after he was observed inappropriately touching a resident's breast at the facility. During review of the facility's policy and procedure, Abuse Prevention Program, dated August 2011, indicated under Policy Statement: Our residents have the right to be free from abuse.

Based on interview and record review, the facility failed to ensure nursing staff verified a physician's order prior to administering excessive insulin (a medication used to lower blood sugar) for one of four residents (Resident 1) and monitored Resident 1's blood sugar every 30 minutes as ordered after administering the excessive dose of insulin. This failure resulted in Resident 1 developing [DIAGNOSES REDACTED] (a condition caused by a very low level of blood sugar) and unnecessary hospitalization . Findings: Review of Resident 1's Progress Notes, dated 3/26/18, indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's Discharge Summary from an acute care hospital, dated 3/26/18, indicated insulin [MEDICATION NAME] ([MEDICATION NAME]) (a type of insulin, used for blood sugar control) 100 units/mL (units per milliliter (mL, a unit of volume)) (3 mL). The order included a concentration (the strength of a solution, the amount of dissolved substance in a given volume) of the insulin and did not include the specific dosage to administer. Review of Resident 1's Medication Administration Record [REDACTED]. It indicated licensed vocational nurse A (LVN A) administered 3 mL (300 units) of [MEDICATION NAME] to Resident 1. Review of Resident 1's Progress Notes, dated 3/27/18 at 6:50 a.m., indicated registered nurse C (RN C) received a report from LVN A and notified an on-call doctor regarding administration of 300 units of insulin. The doctor ordered to monitor the resident's blood sugar (BS) every 30 minutes to maintain the BS level at 90 mg/dL (milligrams per deciliter, a unit of measurement of blood sugar, the normal BS ranges from 72 to 99 when fasting) and administer a glucose gel tube (an over-the-counter medication used to raise blood sugar) when the BS went below 90 mg/dL. Review of Resident 1's physician's order indicated no orders for blood sugar monitoring every 30 minutes and glucose gel administration when the blood sugar went below 90 mg/dL. Review of Resident 1's blood sugar monitoring indicated Resident 1's BS was checked four times on 3/27/18. The results were 172 mg/dL at 6:44 a.m., 82 mg/dL at 10:56 a.m., 97 mg/dL at 5:30 p.m., and 111 mg/dL at 7:30 p.m. There was no documented evidence the resident's BS was monitored every 30 minutes as ordered or staff contacted the physician to adjust the BS monitoring orders. A review of Resident 1's Progress Notes, dated 3/27/18 at 2:45 p.m., indicated LVN A documented Resident 1's BS was above 90 mg/dL during her shift even though it was 82 mg/dL at 10:56 a.m. There was no documented evidence a glucose gel tube was administered as ordered. Review of Resident 1's Progress Notes, dated 3/28/18, indicated at 3:40 a.m., Resident 1's BS was 65 mg/dL and LVN D gave Resident 1 some snack and juice per Resident 1's request, instead of a glucose gel tube as ordered. It indicated at 5:20 a.m. during the rounding, Resident 1 was diaphoretic and hard to arouse, verbalized she felt nauseated and terrible and scared, and the BS was 55 mg/dL. At 5:49 a.m., Resident 1's BS was 58 mg/dL and the nurse called 911 at 5:55 a.m. Review of Resident 1's Discharge & Transfer-Hospital Transfer Form, dated 3/28/18, indicated Resident 1 was lethargic (sleepy), unresponsive (not responding), diaphoretic (sweating), nauseated (queasy), and shaking. It indicated Resident 1 was experiencing fluctuating blood sugars, the nurse was unable to raise Resident 1's blood sugar, and Resident 1 was transferred to the emergency department (ED) in an acute care hospital. Review of Resident 1's ED Evaluation from the acute care hospital, dated 3/28/18, indicated Resident 1's laboratory glucose (sugar) level was 25 mg/dL when she arrived in the ED. It indicated Resident 1 received 300 units of insulin as opposed to the normal 20 units and there was 3 mL noted but what that basically said was 3 ml in the pen, not 3 mL to be given. The impression was persistent [DIAGNOSES REDACTED] secondary to accidental insulin overdose. Review of Resident 1's Transfer Summary from the acute care hospital, dated 3/31/18, indicated Resident 1 was discharged from an acute care hospital to a skilled nusing facility with a [DIAGNOSES REDACTED]. During an interview on 4/9/18 at 3:18 p.m., LVN A acknowledged she administered 300 units of [MEDICATION NAME] to Resident 1 on 3/26/18 at bedtime and she stated that was a lot of insulin. LVN A stated on 3/26/18 she went to her supervisor, RN B, for clarification of the order before administering the insulin. LVN A stated RN B was busy and she brushed her away. She stated she drew 3 mL insulin into three insulin syringes containing 1 mL (100 unit) each and administered them to Resident 1. LVN A stated she should have clarified the insulin order with Resident 1's attending physician before she administered the insulin. During an interview with RN B, the nursing supervisor, on 4/9/19 at 3:45 p.m., she stated she told LVN A she was not comfortable with that amount of insulin and to clarify the order with Resident 1's attending physician. RN B stated 300 units were not an order to administer. During an interview with the ward clerk, on 4/9/18 at 4:13 p.m., she stated she transcribed Resident 1's [MEDICATION NAME] order from a discharge summary to the MAR. She stated licensed nurses had to verify the orders. During an interview with RN C on 4/18/18 at 8:40 a.m., he stated during a change-of-shift report, LVN A told him she administered 300 units of [MEDICATION NAME] to Resident 1. RN C stated he reported the insulin administration to an on-call doctor and the doctor ordered to monitor Resident 1's BS every 30 minutes to keep her BS above 90 mg/dL, and to give a glucose gel tube if her BS went below 90 mg/dL. RN C stated he checked Resident 1's BS every 30 minutes during his shift but did not document it in Resident 1's clinical record. RN C stated he was unsure if he wrote a verbal order. During an interview on 4/9/18 at 2:45 p.m. with LVN D, who transferred Resident 1 to the hospital on [DATE], she stated she did not perform the 30-minute BS monitoring during her shift and did not administer a glucose gel tube when Resident 1's BS went below 90 mg/dL because there were no orders. During an interview on 4/18/18 at 2:20 p.m., the director of nurses (DON) reviewed Resident 1's clinical record and stated there were no orders written to monitor Resident 1's BS every 30 minutes and administer a glucose gel tube when the resident's BS went below 90 mg/dL. She stated RN C should have written a doctor's order. She stated there was no documented evidence Resident 1's BS monitoring was done as ordered. During an interview on 4/18/18 at 2:40 p.m., LVN A stated she checked Resident 1's BS twice during her shift on 3/27/18. She stated she did not monitor Resident 1's BS every 30 minutes because there was no order. Review of the facility's 6/2015 policy, NON-CONTROLLED MEDICATION ORDER D[NAME]UMENTATION, indicated medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders for non-controlled medications are received only by licensed nurses or pharmacists and confirmed in writing by the prescriber. To facilitate effective communication, documentation, and aid in preventing of medication errors, medication orders should be clear and concise. Medication orders specify strength of medication and dose. Any dose or order that appears inappropriate is verified by nursing with the attending physician and unsigned written transfer orders sent with a resident by a hospital should be verified with the current attending physician before medications are administered. Review of the facility's 9/2014 policy, Insulin Administration, indicated the type of insulin, dosage requirements, strength, and method of administration must be verified before administration. Review of the facility's 2/2014 policy, Verbal Orders, indicated the individual receiving the verbal order must write it on the physician's order sheet as v.o. (verbal order) or t.o. (telephone order). Review of the facility's 12/2012 policy, Administering Medications, indicated if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns.

Based on observation, interview, and record review, the facility failed to ensure a safe discharge for one of three sampled residents (Resident 1) when the facility did not assess the resident's house, determine the level of home care the resident required, and ensure the resident received the necessary care. These failures resulted in the resident being admitted to the hospital by ambulance the day following her discharge after the in-home health services found her alone, soiled in a recliner, unable to get up, and in an altered state. She was treated for [REDACTED]. Findings: Resident 1's clinical record was reviewed and indicated she was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. In addition, she had [DIAGNOSES REDACTED]. She was admitted for rehabilitation (the physical restoration of a sick or disabled person by therapeutic measures and reeducation to participation in the activities of a normal life within the limitations of the person's physical disability). Resident 1 was self-responsible and her Minimum Data Set (MDS, an assessment tool), dated 9/3/17, indicated she was cognitively intact. Resident 1's physician ordered physical therapy five days a week on 5/29/17. On 5/30/17, he ordered occupational therapy six days a week and speech therapy five days a week. On 10/4/17, Resident 1 was discharged from physical therapy. The physical therapist (PT) noted Resident 1 was discharged from physical therapy to remain in the facility and to continue to receive rehabilitation in the restorative nurse assistant program (nurse assistant with specialized training who helps residents gain an improved quality of life by increasing their level of strength and mobility). Resident 1 was noted to be impulsive, to misjudge her ability, and to not be safe at home alone. On 10/6/17, Resident 1 was discharged from occupational therapy. The occupational therapist (OT) noted Resident 1 was discharged from occupational therapy to remain in the facility and then to eventually go home. She was noted to have mild cognitive deficits and to need significant support and assistance. On 10/9/17, Resident 1 was discharged home with a three day supply of medication. Her discharge social services note indicated the resident wanted to go home. She was advised in-home health services had not been fully established and her permanent wheelchair and walker had not yet arrived but would be delivered to her home the next day. She claimed she had a caregiver who would be at her house when she arrived. Resident 1's nurse's note at the time of her discharge on 10/9/17 indicated she was discharged by car to her home. Resident 1's hospital admission note, dated 10/10/17, indicated she was admitted to the hospital after the in-home health services found her soiled in a recliner and called an ambulance. No caregiver was present and Resident 1 was unable to move her wheelchair into the bathroom and bedroom and was unable to get into her bed. She was noted to be exhausted and to have a urinary tract infection. She was evaluated and treated with antibiotics. The PT determined she needed additional physical therapy for strength training to get up from a sitting to a standing position. On 10/12/17, Resident 1 was transferred to another long term care facility for further rehabilitation. On 10/20/17, the second facility's OT B performed a home evaluation and determined Resident 1 lived in senior community housing. She was able to enter her front door in her wheelchair but she was unable to enter her bedroom or bathroom because the wheelchair was too wide. She was unable to get her wheelchair over the thresholds between each room and out onto the patio. She required assistance to get through the doorways, over the thresholds, and over the carpets in the living room and bedroom. She also required assistance to use the bathroom, including the toilet, sink, and shower. She required assistance to transfer in and out of bed, on and off of chairs and a sofa, and to use the kitchen. She was unable to manage laundry, shopping, cooking, and cleaning. In-home health care was recommended. On 11/27/17, she was discharged home with a caregiver and in-home services. During an interview on 1/24/18, at 10:27 a.m., the social services director (SSD) stated Resident 1 insisted on going home before her rehabilitation was completed. She stated Resident 1 had her own caregiver and home health care services would be provided. She also stated medical equipment, including a special walker and a bariatric wheelchair, had been ordered but had not yet been delivered at the time of Resident 1's discharge. The SSD stated she thought the rehabilitation department and the home health agency had performed a home evaluation prior to the resident's discharge. During an interview on 1/24/18, at 12:15 p.m., OT A reviewed Resident 1's clinical record and stated she was unable to find any documentation of a home evaluation. She stated she thought a home evaluation should have been performed before Resident 1's discharge because she was leaving prematurely and was not ready or safe to go home. During an interview on 1/24/18, at 12:45 p.m., the director of nurses (DON), reviewed Resident 1's clinical record and stated she was unable to find any documentation of a home evaluation. She stated the facility does not perform home evaluations on all discharged residents but she thought one should have been performed on Resident 1. During an interview on 1/25/18, at 1 p.m., OT B from the long term care facility where Resident 1 was transferred on 10/12/17 stated she provided care for the resident after she was admitted . She stated Resident 1 was unable to care for herself and could not get up from a standing position. She stated Resident 1 stayed another month and a half for further rehabilitation and gained strength. OT B also stated she performed a home evaluation prior to Resident 1's discharge from the second long term care facility. She stated Resident 1 lived in a senior apartment on the first floor. She stated although Resident 1's wheelchair would fit through the front door, it was too wide to fit through the bathroom and bedroom doors and she could not get over any of the thresholds in her home without assistance. She stated Resident 1 needed assistance with all of the activities of daily living and she recommended a caregiver and in-home health services. During an interview on 1/31/18, at 9:45 a.m., the rehabilitation director (RD) reviewed Resident 1's clinical record and stated she was discharged from physical therapy on 10/4/17 and was scheduled to continue rehabilitation in the RNA program until she went home. He stated she was not considered safe to be at home when she was discharged from physical therapy. The RD stated a home evaluation was not done when she was discharged from physical therapy because the physical therapists thought she was staying in the facility for RNA. He stated a home evaluation should have been done before Resident 1 was discharged and he did not know why an evaluation was not performed. During an interview on 1/31/18, at 12:10 p.m., with the assistant director of nurses (ADON), she stated in-home health services were to be provided for Resident 1 after she went home. She stated she spoke to the resident, the caregiver, and the nurse from the in-home services agency shortly after the resident arrived home and was told the caregiver was spending the night. The ADON stated she did not know the caregiver's name. She stated when she spoke to the nurse from the in-home services agency the next day, the nurse advised when she returned, no caregiver was present and the resident was sitting in her recliner covered in urine and feces. The ADON stated the nurse told her Resident 1 said the caregiver left during the night and she was sending the resident to the hospital. During an interview on 1/31/18, at 1:15 p.m., the licensed vocational nurse (LVN) who discharged Resident 1 stated she did not recall how the resident got home but she charted the resident went home in a car so she must have gone home with a caregiver. She stated she did not recall the caregiver's name. The LVN also stated she did not recall speaking to Resident 1's treating physician or advising him physical therapy did not think the resident was safe to go home. She stated she did not know whether a home evaluation was performed. She stated she had an order to discharge the resident so she discharged her. The LVN stated she did not know Resident 1 had a urinary tract infection but she does not recall her exhibiting any symptoms. She stated she knew Resident 1 was [MEDICAL CONDITION], confused, and impulsive. During an interview on 2/2/18, at 9:30 a.m., the home health nurse (HHN) stated she was asked by her agency's account executive (AE) to check on Resident 1 and see if the resident had arrived home safely since she was already visiting another patient in the same apartment complex. She stated she arrived at Resident 1's apartment at about 5:30 p.m. the day the resident was discharged . The HHN stated when she arrived, Resident 1 was in the apartment with the caregiver. She stated she talked to the resident and the caregiver and was advised they had just ordered pizza for dinner and the caregiver was spending the night. The HHN stated she did not know the caregiver's name. She also stated Resident 1 was sitting in a recliner and appeared to be cognitively intact. The HHN stated she did not assess the apartment or the resident at that time because she was scheduled to perform the assessments the next day. She stated she thought the resident was safe because the caregiver was spending the night. The HHN stated she returned to Resident 1's apartment the next day at about noon. She stated the resident's front door was open and the caregiver was not present. The HHN stated Resident 1 was still sitting in her recliner. She stated the resident had soiled herself and was in an altered state. The HHN stated she called an ambulance and had Resident 1 transferred to the hospital because she was obviously unable to care for herself. She stated she did not think this was a safe discharge. During an observation and interview on 2/2/18, at 11 a.m., Resident 1 stated she did not think her discharge from the facility was safe. She stated the facility never assessed her apartment. Resident 1 stated she did not go home in a car with a caregiver. She stated she was transported to her home by the facility's bus without a caregiver and the bus driver wheeled her into her apartment. Resident 1 stated shortly after she arrived at home, one of the certified nurses aides (CNA) from the facility came over and stayed with her for about three hours. She stated there was no other caregiver present and she did not recall the CNA's name. She stated she asked the CNA to order a pizza for their dinner and the CNA went home at about 8 p.m. Resident 1 stated she was sitting in her recliner at the time and she could not get out of it. She stated she could not get to the bathroom and she soiled herself. Resident 1 stated a nurse came the next day, told her she was not safe, and sent her to the hospital. The resident stated she did not think this was a safe discharge because she could not get out of her recliner or into the bathroom or the bedroom because her wheelchair was too wide. Resident 1 stated the hospital sent her to another facility where she received additional rehabilitation for another month. She stated the other facility assessed her home and determined her wheelchair would not fit and she needed care at home. Resident 1 stated her church provided a caregiver. She stated after she went home for the second time with a caregiver, the caregiver thought she needed more help than the caregiver could provide. She stated she was then sent back to the hospital where she remains while she waits for long term placement. During a telephone interview on 2/6/18, at 10:50 a.m., the AE from the home health agency stated he received a request from the facility to provide some nursing services for Resident 1. He stated he does not recall the specifics of the request or who at the facility made the request. He stated he does not recall asking one of the agency's nurses to check on the resident while she was providing care for another patient in the same apartment complex. Review of the facility's 11/2012 policy, Discharging the Resident, indicated when a resident is discharged home, the facility should ensure the resident receives teaching and the necessary supplies and equipment. Review of the facility's 11/2010 policy, Discharge Summary and Plan, indicated the discharge summary will include a description of the resident's physical and mental status including determining the resident's need for staff assistance and assistive devices. The post-discharge summary will identify the specific resident needs and include a description of the necessary services and how the resident will access the services.

Based on observation, interview, and record review, the facility transferred three of three residents (Residents 1, 2, and 3) to another long term care facility even though the residents' needs could be met at the transferring facility, the residents continued to need the services provided by the transferring facility, the safety of the transferred residents and the other residents was not endangered, and the residents had resided in the transferring facility for more than 30 days. In addition, the facility failed to notify the residents in writing at least 30 days prior to the transfer and failed to advise the residents of their rights to appeal. These transfers were improper, violated the residents' rights, and caused significant emotional distress. Findings: 1. Resident 1's clinical record was reviewed and indicated he was admitted to the transferring facility from a hospital in 6/2013 with [DIAGNOSES REDACTED]. His Face Sheet (a document providing a patient's information at a glance) indicated he was his own responsible party (RP, person responsible for making medical decisions). Resident 1's Progress Notes, dated 8/6/13 and 9/5/13, indicated he would need long term care in a nursing facility. His Minimum Data Set (MDS, an assessment tool), dated 3/24/17, indicated he was cognitively intact. Resident 1's physician order, dated 4/25/17, indicated he was to be transferred to another facility located over 200 miles away for continued physical and occupational therapy. There was no documentation in his clinical record indicating the transfer had been discussed with the resident prior to the transfer on 4/25/17. There was no written notice of the transfer and there was no documentation indicating the resident had been advised of his rights to appeal. Resident 1's Progress Note from the receiving facility, dated 4/25/17, indicated he was upset regarding the transfer and refused to be completely assessed at the time of his admission. His Progress Note, dated 4/26/17, indicated he did not know why he was forced to leave the transferring facility. His Progress Note, dated 4/27/17, indicated he did not think he was in the right facility, and he needed to get out of this place. During an observation and interview on 5/22/17, at 11:15 a.m., Resident 1 stated he was told about the transfer a few hours prior to his departure. He stated he did not want to leave the transferring facility, but he was told if he did not accept the transfer, he would be taken to a hotel where he could stay for a few days at the facility's expense and then he would be out on the street. Resident 1 also stated he was told he was being transferred to a different facility than the one where he is currently located. He stated he is very unhappy and he wants to return to the transferring facility. 2. Resident 2's clinical record was reviewed and indicated he was admitted to the transferring facility in 10/2016 with [DIAGNOSES REDACTED]. His Face Sheet indicated he was his own RP. Resident 2's Progress Notes, dated 10/25/16 and 2/1/17, indicated he was considering a transfer to a VA (Veterans Affairs) facility (facility provided by the federal government as part of the provision of benefits for veterans). His MDS, dated [DATE], indicated he was cognitively intact. Resident 2's Physical Therapy Notes indicated he was actively participating in physical therapy and he had just been provided with a custom-made leg brace necessitating additional treatment. Resident 2's physician order, dated 4/25/17, indicated he was to be transferred to another facility located over 200 miles away for continued physical and occupational therapy. There was no documentation in his clinical record indicating the transfer had been discussed with the resident prior to 4/22/17. There was no written notice of the transfer and there was no documentation indicating the resident had been advised of his rights to appeal. Resident 2's Progress Notes from the receiving facility, dated 4/25/17, indicated he was upset about the transfer. His Progress Note, dated 4/26/17, indicated he did not know why he was transferred, he had been dropped off without his permission, he thought he had been tricked into transferring by the social service director (SSD) at the transferring facility, he had only been given two days notice of the transfer, and he had been told he was being transferred to a different facility than the one where he is currently located. He also was uncooperative, kicked the treatment nurse, and refused to participate in anything. Resident 2's Progress Notes, dated 4/27/17, indicated he thought his rights had been violated, he had been lied to, and he was mistreated. His Progress Note, dated 5/5/17, indicated he complained about everything, was unable to relax, did not trust the facility, refused a change in medication, and refused physical and occupational therapy. During an observation and interview on 5/22/17, at 10:30 a.m., Resident 2 stated he was told about the transfer two days before it occurred. He stated the SSD told him he had to leave because there were no long term beds available at the transferring facility and because the transferring facility was going to be a nonsmoking facility and he was a smoker. He stated he was not given anything in writing and was not advised he had any rights to appeal. Resident 2 also stated when he asked to see the pictures of the proposed new facility, he was shown a different facility than the one where he is currently located. He stated he was told the transfer would occur at 6 a.m. However, he stated the van did not leave for another four and a half hours because the facility could not find his medications and Resident 3's wallet. Resident 2 stated he and Resident 3 were crying when they left. Resident 2 also stated he had just gotten a new custom-made leg brace right before he left. The final fittings and adjustments and training regarding the use of the brace had not been completed before his departure. Resident 2 stated when he arrived at the new facility, he noticed the facility was not the facility he had seen in the pictures and he advised the driver. He stated the driver told him the receiving facility had changed its name. He also stated Resident 1 refused to get out of the van and Residents 1, 2, and 3 stated they did not want to be there. Resident 2 stated when he got into the new facility, the staff put a name band on his arm with the incorrect name. He stated the receiving facility said they were not expecting him. He stated the new facility would not give him the medications the transferring facility sent with him because they needed to get new orders and new medications from the receiving facility's pharmacy. He said he finally got them to take some medications out of their emergency kit. Resident 2 stated he called ADM A at the transferring facility the next day and told him the three transferred residents wanted to come back. He stated he was advised there were no beds available. He stated he also called the SSD who told him he was instigating trouble. Resident 2 stated he has been unhappy and depressed since he arrived at the new facility. He stated he feels bad and he feels like he was pushed to the curb. He stated he is so depressed he does not participate in many activities or any rehabilitation. He also stated the weather where the new facility is located is too hot, the food, care, and decor were better at the transferring facility, and there is a lady at the new facility who sits in the hall all day and screams. He stated is very unhappy and he wants to return to the transferring facility. 3. Resident 3's clinical record was reviewed and indicated he was admitted to the transferring facility from a hospital in 1/2017 with [DIAGNOSES REDACTED]. valve to close tightly), a pacemaker (a small device placed in the chest or abdomen to help control abnormal heart rhythms), and [MEDICAL CONDITION]. His Face Sheet indicated he was his own RP. His MDS indicated he had moderately impaired cognition. Resident 3's Physical Therapy Notes indicated he was actively participating in physical therapy. Resident 3's physician order, dated 4/25/17, indicated he was to be transferred to another facility located over 200 miles away for continued physical and occupational therapy. There was no documentation in his clinical record indicating the transfer had been discussed with the resident prior to 4/22/17 when the Progress Notes indicated he was reluctant to transfer. There was no written notice of the transfer and there was no documentation indicating the resident had been advised of his rights to appeal. Resident 3's Progress Note from the receiving facility, dated 4/25/17, indicated he did not want to stay at the receiving facility and he would not participate in rehabilitation. His Progress Note, dated 4/26/17, indicated he was transferred for some unknown reason, he was upset about the transfer and depressed, no one told him why he had to leave the transferring facility, and he will do anything to leave the new facility. His Progress Note, dated 4/27/17 indicated he had only been given two days notice of the transfer, the SSD at the transferring facility had lied to him, he had not been given the option to stay, he had been told if he did not transfer, he would be out on the street, and he felt like he had been dumped. Later the same day, he complained of severe chest pain and was transferred to the emergency room . Resident 3's Progress Note, dated 4/29/17, indicated he was readmitted from the hospital with new medication orders. His Progress Note, dated 5/1/17, indicated he was sent back to the hospital for abdominal pain and diagnosed with [REDACTED]. After he returned later the same day, his Progress Note indicated he and Resident 2 met with the discharge planner and the ombudsman regarding the recent transfers and were advised referrals back to the transferring facility would be made. Resident 3's Progress Note, dated 5/8/17, indicated he was transferred to the hospital again for abdominal pain where a hematoma (solid swelling of clotted blood within the tissues) in his abdominal wall and fluid were found. He returned two days later and was treated with medication and fluid restriction. Resident 3's Progress Notes, dated 5/12/17, indicated he was transferred to the hospital for pain and shortness of breath. An ultrasound (sound or other vibrations having an ultrasonic frequency used in medical imaging) revealed [MEDICAL CONDITION] (chronic liver damage from a variety of causes leading to scarring and liver failure) and bilateral renal cysts ([MEDICAL CONDITION] on both kidneys). Resident 3's Progress Note, dated 5/17/17, indicated he does not like the new facility and he will not comply with medical orders until he is sent back. Later the same day, he signed himself out against medical advice, called emergency services, and went to the hospital. When he returned to the facility the next day, his Progress Note indicated he will continue to call emergency services until he is sent back to the transferring facility. During an observation and interview 5/22/17, at 10:30 a.m., Resident 3 stated shortly after he was admitted to the transferring facility in 1/2017, he was told he could stay as a long term resident. He stated he was told about the transfer two days before it occurred. He stated the SSD told him he had to leave because there were no long term beds available at the transferring facility. He stated he was not given anything in writing and was not advised he had any rights to appeal. He also stated when he asked to see the pictures of the proposed new facility, he was shown a different facility than the one where he is currently located. He stated he was told the transfer would occur at 6 a.m. However, he stated the van did not leave for another four and a half hours because the facility could not find his wallet and Resident 2's medications. Resident 3 stated he and Resident 2 were crying when they left. Resident 3 stated on the trip to the new facility, the van driver stopped at a fast food restaurant for lunch. He stated he and Resident 1 could not eat the food because they were on special diets. He also stated shortly before his arrival at the new facility, the van went over a bump and he wet his pants and was very embarrassed. Resident 3 stated when he arrived at the new facility, he noticed the facility was not the facility he had seen in the pictures. He stated the van driver told him the receiving facility had changed its name. He also stated Resident 1 refused to get out of the van and Residents 1, 2, and 3 stated they did not want to be there. Resident 3 stated he has been unhappy, depressed, and anxious since he arrived at the new facility. He stated the day after he arrived he was so anxious he thought he was having a [MEDICAL CONDITION] so he went to the hospital. He stated he feels bad and he feels like he was pushed to the curb. He also stated he has never been treated so badly in his life. During an interview with the SSD, from the transferring facility, on 5/16/17, at 9:15 a.m., she stated Resident 1 wanted a change of scenery and agreed to go. She stated Resident 2 was a smoker and when the facility became nonsmoking he was told he had to go. She stated the three residents knew each other and were transferred to a sister facility over 200 miles away because none of the other local facilities were accepting long term residents. She also stated the social services assistant (SSA) mistakenly told the three residents they were going to a different smaller facility. During an interview with the SSA, from the transferring facility, on 5/16/17, at 11:40 a.m., she stated Resident 2 asked her to show him pictures of the proposed new facility. She mistakenly showed him pictures of the wrong facility. The pictures she showed him were of a facility with 100 residents. The facility the residents were actually transferred to had 200 residents including psychiatric patients. During an interview on 5/16/17, at 12:30 p.m., administrator A (ADM A), from the transferring facility, and the SSD reviewed the three residents' clinical records and stated they could not find any documentation indicated the residents consented to the transfers other than their signatures on the transferring documents signed at the time of discharge. ADM A also stated the facility has no policies regarding transfers. During an interview on 5/22/17, at 2:40 p.m., licensed vocational nurse E (LVN E) stated he performed the admission assessment at the receiving facility on Resident 3. He stated he was helping another LVN who was performing the admission assessment on Resident 2. He stated both residents were assigned to the same room and were very upset about the transfer. LVN E stated both residents thought they were transferred to the wrong facility and both residents were surprised they were transferred at all. He also stated once a resident was transferred, new orders need to be obtained and medications need to be ordered from the receiving facility's pharmacy. During an interview on 5/23/17, at 8:45 a.m., director of admissions C (DA C), from the receiving facility, stated she first received a request for transfer from the transferring facility on 4/17/17. She stated the transferring facility wanted to transfer four residents but she told them the receiving facility could only accept three residents. She stated the receiving facility thought Residents 1 and 3 and another resident were being transferred. She stated the transferring facility actually transferred Residents 1, 2, and 3. During an interview on 5/23/17, at 9:10 a.m., ADM B, from the receiving facility, stated he talked to the three transferred residents shortly after their arrival. He stated they were very upset they were transferred and they wanted to go back to the transferring facility or go to the other facility they had seen in the pictures. ADM B stated he told them the facility in the pictures knew nothing about them because all of the communication had occurred between the transferring facility and the receiving facility. He stated he told the residents he would speak to the transferring facility about a return transfer. ADM B stated when he last spoke to the transferring facility they were attempting to get enough staff so they could accept the three residents back. During an interview on 5/23/17, at 12:35 p.m., with the activities director (AD)/discharge planner (DP), from the receiving facility, she stated the three transferred residents do not participate in many activities. She stated they primarily keep to themselves. She stated she called the transferring facility's DA D and she agreed to take Residents 2 and 3 back. The AD/DP stated she expects the two residents to be transferred back on 5/29/17 and she will call DA D about the potential transfer of Resident 1. She also stated she told DA D the transfers of the three residents to the receiving facility were not appropriate since the transfers violated the residents' rights. She stated she also called the local ombudsman and told him the transfers were not appropriate. The AD/DP stated DA D asked her to have Resident 2 sign a no smoking agreement but he refused.