Every finding on record at Edgewater Skilled Nursing Center

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a Stage II sacral pressure ulcer (a partial-thickness loss of skin that exposes the dermis over the lower spine/tailbone), received wound treatments as ordered. From 7/6/2026 to 7/11/2026, wound treatments were missed because the treatment order was placed on hold for seven days.This deficient practice had the potential to result in Resident 1's sacral pressure ulcer deteriorating and developing an infection.FindingsDuring a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis that included a Stage II sacral pressure ulcer.During a review of Resident 1's physician order dated 7/4/2026, the physician order indicated to cleanse Resident 1's sacral pressure injury with normal saline, pat dry, apply barrier cream, and cover with a silicone dressing.During a review of Resident 1's pressure ulcer care plan dated 7/13/2026, the care plan included an intervention to administer treatments as ordered and monitor for effectiveness.During a review of Resident 1's Minimum Data set ([MDS] a resident assessment tool) dated 7/29/2026, the MDS indicated Resident 1's cognition was intact and Resident 1 required partial to moderate assistance (helper does less than half the effort) to complete activities of daily living ([ADLs] such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Treatment Administration Record (TAR) for July 2026, the TAR indicated the order sacral pressure injury, cleanse with normal saline, pat dry, apply barrier cream and cover with silicone dressing everyday shift for 14 days was on Hold (treatment plan temporarily paused or delayed ) from 7/6/2026 to 7/11/2026.During an interview on 8/7/2026 at 12:27 p.m., the Treatment Nurse (TN) stated he does not remember providing treatment to Resident 1 from 7/5/2026 to 7/12/2026. TN stated he would not know to provide the treatment order if the order was placed on HOLD.During an interview on 8/7/2026 at 1:20 p.m., the Director of Nursing (DON) stated when there is a physician order indicating to HOLD when the resident transfers out to the hospital for seven days, when the resident comes back the orders should be reinstated after being reconciled with the physician. The DON stated all orders should be reactivated when the resident returns. The DON stated Resident 1's treatment order should have been reinstated when he returned to the facility on 7/5/2026.During a review of the facility's policy and procedure (P/P) titled Skin and wound monitoring and management dated 1/2026, the P/P indicated the facility staff should be monitoring wounds daily via medication administration and treatment records and confirm all orders have been implemented as ordered.

Based on interview, and record review, the facility failed to ensure an allegation of missing/stolen money was reported to the California Department of Public Health (CDPH) for one of five sampled resident's (Resident 1). This deficient practice resulted in the inability of the CDPH to investigate the allegation of stolen money in a timely manner and had the potential for information pertinent to the investigation to be lost and/or forgotten.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis including neuritis (a condition where the nerve or the nerve that surrounds the nerve is inflamed), neuralgia (a sharp, severe and burning pain that results from nerve irritation or damage) and osteomyelitis (infection of the bone) of the right ankle and foot. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/3/2026, the MDS indicated Resident 1 was able to make decisions that were reasonable and consistent and he required a one -person assist to complete his activities of daily living ([ADLs]routine tasks/activities such as bathing, dressing, toileting hygiene, repositioning in bed and transferring from sitting to standing position. During a review of Resident 1's Order Summary (Physician's Order) dated 5/18/2026, the Physician's Order indicated to transfer Resident 1 the GACH for further evaluation because of back pain and per family request. During a telephone interview on 5/20/2026 at 10:32 a.m., Resident 1's Emergency Contact (EC) stated Resident 1 told her he had $300 at the facility but when she picked up Resident 1's belongings from the facility there was only $48.The EC stated Resident 1 told her he reported to a staff person (unknown) at the facility that he was missing money before he was transferred to the General Acute Care Hospital (GACH) because he was worried his money was stolen at the facility. During an interview on 5/20/2026 at 1:37 p.m., Licensed Vocational Nurse (LVN) 1 stated a week before Resident 1 was transferred to the GACH (date unknown) he overheard Resident 1 telling a rehabilitation staff person (unknown) that he (Resident 1) lost $300 at the facility heard the rehabilitation staff person report what Resident 1 said to Registered Nurse Supervisor (RNS) 1. LVN 1 stated he did not report Resident 1's concern to the Administrator (ADM) because the rehabilitation staff person had already reported it to RNS 1. During a telephone interview on 5/20/2026 at 2:24 p.m., RNS 1 stated she was unaware that Resident 1 was missing money and no one reported it to her. During an interview on 5/21/2026 at 11:43 a.m., the ADM stated LVN 1 should have immediately reported Resident 1's allegation of missing and/or stolen money to him so he could file a report with the local government agencies including the CDPH and so he could conduct an investigation The ADM stated reporting to the CDPH was necessary to ensure they were implementing the facility's policies and procedures on abuse prevention and resident rights and they were compliant with the state and federal regulations. During a review of the facility's Policy and Procedure (P/P) titled, Abuse: Prevention and Prohibition Against revised 12/2023, the P/P indicated the facility shall ensure the residents of the facility are free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. The facility staff with knowledge of an actual or potential violation of this policy must report the violation to his/her supervisor and/or the facility administrator immediately and such allegations of abuse, neglect and misappropriation of property be reported to the appropriate State and Federal Agencies in the applicable timeframe.

The facility failed to ensure a care plan was created for one of five sampled residents (Resident 1), who was at risk for constipation (a common condition where bowel movements become difficult, infrequent) due to opioid use (a drug used to reduce moderate to severe pain). This deficient practice resulted in Resident 1's transfer to a General Acute Care Hospital (GACH) for evaluation and treatment due to back pain where he was assessed with constipation. This deficient practice had the potential for Resident 1 to become impacted (a mass of dry, hard stool that cannot be eliminated by a normal bowel movement).Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis including neuritis (a condition where the nerve or the nerve that surrounds the nerve is inflamed), neuralgia (a sharp, severe and burning pain that results from nerve irritation or damage) and osteomyelitis (infection of the bone) of the right ankle and foot. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/3/2026, the MDS indicated Resident 1 was able to make decisions that were reasonable and consistent and he required a one -person assist to complete his activities of daily living ([ADLs]routine tasks/activities such as bathing, dressing, toileting hygiene, repositioning in bed and transferring from sitting to standing position. During a review of Resident 1's Physician's Order dated 4/27/2026, the Physician's Order indicated Resident 1 was prescribed Tramadol (an opioid medicine used to treat moderate to severe pain) 50 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) every six hours as needed for a severe pain level of 7 out of 10 (an 11 eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). During a review of Resident 1's Care Plan on use of opioids dated 4/27/2026, the Care Plan indicated Resident 1 would be free from adverse reactions, pain and discomfort related to opioid use with interventions to monitor Resident 1 for adverse reactions associated with the use of opioids such as drowsiness, dizziness, nausea and vomiting, respiratory depression (a potentially life-threatening condition where breathing becomes abnormally show. shallow, or ineffective) and constipation. During a review of Resident 1's clinical record, there was no indication that a Care Plan was developed to address the potential for Resident 1 to become constipated as a result of his opioid use until Resident 1 was transferred to a GACH (5/18/2026). During a telephone interview on 5/20/2026 and timed at 10:32 a.m., Resident 1's Emergency Contact (EC) stated she decided to take Resident 1 to a General Acute Care Hospital (GACH) to be evaluated due to back pain. The GACH found he had a Urinary Tract Infection ([UTI] an infection in any part of the urinary tract system) and was constipated. During an interview on 5/21/2026 and timed at 1:41 p.m., the Director of Nursing (DON) stated Resident 1's Care Plan should have been created in a timely manner to address Resident 1's risk of constipation. During a review of the facility's Policy and Procedures (P/P) titled, Comprehensive Person-Centered Care Planning revised 12/2023, the P/P indicated the facility shall develop a comprehensive person-centered plan of care for each resident necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

Based on interview and record review, the facility failed to ensure the property for one of four sampled residents (Resident 1) was documented correctly on 3/12/2026 during admission to include the contents of her wallet and on 4/5/2026 during discharge, verify a ring documented on admission as left with the resident was still with the resident, and missing property were reported to law enforcement. This deficient practice resulted in Resident 1's Family Member (FM) claiming Resident 1's cash and ring were missing and the facility's inability to determine if Resident 1 had cash in her wallet and if a ring left with Resident 1, per the Inventory List documentation on 3/12/2026, was accounted for on 4/5/2026 during discharge. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis including cognitive communication deficit (difficulty in using thinking skills for communication, such as problems with attention, memory, understanding information, organizing thoughts, or expressing ideas clearly) and delirium (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking) due to know physiological condition. During a review of Resident 1's History and Physical (H&P) dated 3/12/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/16/2026, the MDS indicated Resident 1's cognition was moderately impaired and was dependent on staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Inventory List dated 3/12/2026, the Inventory List indicated on admission [DATE]) a wallet and jewelry (ring) was documented. During a review of Resident 1's Physician's Orders dated 4/5/2026, the Physician's Orders indicated Resident 1 was to be transferred to a General Acute Care Hospital (GACH) via 911. During a review of Resident 1's Transfer Form dated 4/5/2026, the Transfer Form indicated Resident 1's belongings were not sent with her when she was transferred to the GACH.During a review of Resident 1's Inventory List, dated 4/5/2026 (discharge), the Inventory List indicated one wallet was documented. During an interview on 5/4/2026, at 1 p.m., Certified Nursing Assistant (CNA) 1 stated she documented Resident 1's property when she was admitted to the facility (3/12/2026). Resident 1 had a wallet and a ring; she did not look in the wallet to see the if there was any money or other items. There was a ring that Resident 1 kept with her. CNA 1 did not offer the resident if she can store her ring for her.During an interview on 5/4/2026, at 1:48 p.m., the Social Service Director (SSD) stated. The SSD stated they did not complete a theft/loss report because she assumed Resident 1 had the ring, per the Inventory List documentation on 3/12/2026.During an interview on 5/4/2026, at 2:15 p.m., the Director of Nursing (DON) stated staff should have checked the contents of Resident 1's wallet and they should have checked Resident 1 to see if she had the ring when she was discharged (4/5/2026). During an interview on 5/4/2026, at 2:20 p.m., the Administrator (ADM) stated they had no way of knowing if there was money in Resident 1's wallet because the nurse who documented Resident 1's property on the Inventory List did not look in her wallet. The ADM stated staff should have looked for Resident 1's ring when she was discharged (4/5/2026).During a telephone interview on 5/4/2026, at 2:30 p.m., Resident 1's Family Member (FM) 1 stated Resident 1's ring was given to her by her relative. During a follow up interview on 5/4/2026 at 2:45 p.m., the SSD stated she should have looked for the missing ring and when she was not able to find it and should have notified law enforcement. The SSD stated she failed to notify law enforcement about the missing ring because she assumed it was with Resident 1.During a review of the facility's policy and procedure (P&P) titled, Theft and Loss of Personal Property, dated 7/14/2017, the P&P indicated any reported lost or stolen resident property will be investigated, and reported to local law enforcement under section of valuables and cash, indicated residents are advised to not bring any valuable possession in the facility, resident should not keep more than $5.00 in their room, resident can set up a trust fund with business office.

Based on interview and record review, the facility failed to ensure the Interdisciplinary Team (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) initiated a care conference meeting for one of two sampled residents (Resident 1) after Resident 1 experienced an alleged manhandling from Certified Nursing Assistant (CNA)1.This failure had the potential to delay addressing Resident 1's care needs which could result in a delay in necessary interventions.Findings:During a review of Resident 1's admission Record, the admission record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis( total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (lack of adequate blood supply to the brain) affecting right dominant side, diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), anxiety disorder(mental health condition characterized by excessive and persistent fear or worry), and major depressive disorder(mental health condition characterized by persistent, intense feelings of sadness, worthlessness).During a review of Resident 1's Minimum Data Set ( MDS- a resident assessment tool) dated 3/3/2026, the MDS indicated Resident 1 had a moderate cognitive impairment( a person has significant trouble with remembering, learning new information or making sound decisions) and required partial / moderate assistance (helper does less than half the effort) with rolling left and right on the bed, transferring to and from a bed to a chair or wheelchair, toileting hygiene, dressing and personal hygiene.During a review of Resident 1's Progress Notes titled, SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 3/24/2026 at 6:17 p.m., the SBAR indicated Resident 1 reported to the police CNA 1 mishandled her during patient care. The SBAR indicated Resident 1 stated she was turned from side to side that her hand swung.During a review of Resident 1's Care Plan titled, Risk for Decline in Psychosocial Well Being related to Resident Made Allegation that Staff Mishandled her During Care, initiated 3/24/2026, the Care Plan's goal indicated Resident 1 would be safe and free from harm through review date with a target date of 6/1/2026. The Care Plan's interventions included monitoring for any change in mood or behavior after the allegation, encouraging the resident to express feelings and no male staff to care for the resident.During an interview on 4/8/2026 at 2:19 p.m. with the Social Services Director (SSD), the SSD stated the facility did not conduct an IDT Meeting for the alleged incident of abuse on Resident 1. The SSD stated an IDT Meeting should have been done because it was a change in condition(COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention),so the facility will find ways in preventing occurrence or incidence of the alleged abuse to Resident 1.During a concurrent interview and record review on 4/8/2026 at 2:51 p.m. with the Director of Nursing (DON), Resident 1's electronic chart was reviewed. The DON stated there was no IDT Meeting conducted addressing the manhandling of Resident 1 during personal care by CNA 1. The DON stated an IDT Meeting should have been held so the facility could discuss the incident and plan of care for Resident 1. The DON stated Resident 1's plan of care addressing the incident of the alleged abuse would not be followed if IDT Meeting was not conductedDuring a review of facility's policy and procedure (P&P) titled, Change in Condition, dated 4/2025, the P&P indicated Interdisciplinary Team (IDT) will collaborate with the attending physician, resident, and/or resident representative to review risk indicators and the plan of care.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 32) had a completed informed consent (a document ensuring the resident was educated of the risks and benefits of the treatment and agreed or disagreed to continue with the treatment ) for Trazodone (medication prescribed to treat depressive disorder [a mental health condition marked by a prolonged low mood and a loss of interest or pleasure in everyday activities]) and Lorazepam [medication prescribed to treat anxiety disorders (persistent and excessive worry that interferes with daily activities)].This failure had the potential to result in violating the resident's right to be informed of the benefits and risks of the treatment and the right to refuse the treatment.Findings:During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including depression disorder, anxiety disorder, and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage).During a review of Resident 32's Minimum Data Set (MDS - a resident assessment tool), dated 2/6/2026, the MDS indicated Resident 32 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating, and oral hygiene, required maximal assistance (helper does more than half the effort) for upper body dressing, and was dependent for toileting hygiene, bathing, and lower body dressing. During a review of Resident 32's Physician Order Summary dated 3/19/2026, the Order Summary indicated the following:Trazodone tablet 50 milligrams (MG- a unit of measure). Give 50 MG by mouth at bedtime for Depression manifested by (M/B) inability to sleep with Start date 2/4/2026.Lorazepam tablet 1 MG. Give 1 MG by mouth every 6 hours as needed for Anxiety M/B restlessness for 14 days with start date of 3/13/2026.During a review of Resident 32's Medication Administration Record for February 2026, Resident 32 received: Trazadone tablet 50 MG as ordered from 2/7/2026 - 2/28/2026.During a review of Resident 32's Medication Administration Record for March 2026, Resident 32 received:Trazadone tablet 50 MG as ordered from 3/1/2026 - 3/19/2026.Lorazepam tablet 1 MG on 3/18/2026.During a concurrent interview and record review on 3/18/2026 at 11:03 a.m., with Registered Nurse (RN) 1, Resident 32's Informed Consent for Trazodone, dated 2/3/2026, and Informed Consent for Lorazepam, dated 2/3/2026, were reviewed. RN 1 stated the Informed Consent for Trazodone did not indicate a physician had educated the resident of risks and benefits of the treatment, therefore was incomplete. RN 1 stated the facility did not obtain consent from Resident 32 or Resident 32's representative when the Lorazepam was reordered on 3/13/2026.During an interview on 3/19/2026 at 3:40 p.m., with the Director of Nursing (DON), the DON stated it was important for informed consents to be obtained and complete to ensure the resident or responsible party is giving permission to treat them (resident), before the treatment is initiated. The DON stated if the consent is missing a physician signature, there is a risk that the physician did not explain the indication, risk, and benefits to the resident or responsible party. The DON stated informed consents should be obtained when a medication is renewed or reordered.During a review of the facility's policy and procedure (P&P), titled Informed Consent - CA, revised May 2019, the P&P indicated Physician's orders related to the use of psychotherapeutic drug and physical restrains should not be initiated until an informed consent is obtained.

Based on interview and record review, the facility failed to ensure residents/responsible party had the opportunity to formulate an advance directive (document indicating the Resident's healthcare wishes in emergency cases where they are not able to make a decision) for one of four sampled residents (Resident 11).This deficient practice had the potential to violate the resident's right to be fully informed of the option to formulate their advance directives and cause conflict with the residents' wishes regarding health care.Findings:During a review of Resident 11's admission record, the admission record indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (stroke - loss of blood flow to a part of the brain), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool), dated 1/19/2026, the MDS indicated Resident 11's cognition (ability to learn, reason, remember, understand, and make decisions) was intact and was dependent (helper does all of the effort) for toileting, bathing, oral hygiene, and dressing.During a concurrent interview and record review on 3/18/2026 at 4:12 p.m., with the Social Services Director (SSD), Resident 11's Social Services Assessment/Evaluation - V3, dated 12/19/2025, was reviewed. The SSD stated Resident 11's Social Services Assessment/Evaluation-V3 did not indicate that Resident 11 had an advance directive or was informed about their (Resident 11's) right to formulate an advance directive. The SSD stated Resident 11 should have been screened for an advance directive and informed of the right to formulate an advance directive when Resident 11 was readmitted on [DATE]. The SSD stated it was important to screen resident's for an advance directive to ensure that residents' wishes and preferences are carried out.During an interview on 3//19/2026 at 3:40 p.m., with the Director of Nursing (DON), the DON stated advance directives are assessed upon admission. The DON stated it was important to screen for advance directives on admission because it is the resident's right to formulate an advance directive.During a review of the facility's policy and procedure (P&P), titled Advance Directives, revised May 2017, the P&P indicated Information about advance directives will be given to each resident as part of the admission paperwork. Resident and/or responsible parties will complete the Advance Directive checklist that will be maintained in the resident's chart. The checklist will indicate whether an Advance Directive has been executed and, if so, a copy will be provided to the facility. If an Advance Directive has not been executed, the checklist will indicate such, however if the resident executes one in the future, a copy shall be provided to the facility.

Based on interview, and record review, the facility failed to ensure staff were monitoring behaviors for a medication being administered for one of three sampled residents (Resident 88) when resident was taking quetiapine (a medication used to treat behavioral disorders). This deficient practice had the potential to place Resident 88 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic medication (medications that alter the chemical makeup of the brain and nervous system to treat mental health disorders, affecting mood, cognition, and behavior) for an extended period, which could result in impairment or decline in the resident's mental, physical condition, functional, and psychosocial status.Findings:During a review of Resident 88's admission Record, the admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the hips. During a review of Resident 88's Minimum Data Set ([MDS], a resident assessment tool) dated 3/11/2026, the MDS indicated Resident 88 had intact cognitive (thought process) functioning for daily decision making. The MDS indicated Resident 88 was maximal assistance (helper does more than half the effort to complete the task) with self-care abilities such as eating, hygiene and dressing. The MDS indicated Resident 88 was moderate assistance (helper does less than half the effort to complete the task) for mobility such as rolling, sitting, standing and transfers. During a review of Resident 88's Order Summary Report, the Order Summary Report, dated 3/9/2026, indicated quetiapine oral tablet 25 milligram ([mg], a unit of measurement for medication use) give 25 mg by mouth at bedtime for schizophrenia manifested by restlessness.During a review of Resident 88's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/1/2026 to 3/31/2026, the MAR indicated quetiapine oral tablet 25 mg was documented give 25 mg by mouth at bedtime for schizophrenia manifested by restlessness was administered nine times from 3/1/2026 to 3/31/2026 at 9:00 p.m.During a review of Resident 88's comprehensive care plan, dated 3/13/2026, the comprehensive care plan indicated a focus of anti-psychotic medication use related to quetiapine oral tablet 25 mg, give 25 mg by mouth at bedtime for schizophrenia manifested restlessness with goals that resident will show a decrease in episodes of signs and symptoms of the diagnosis through the review date with interventions to document episodes of behavior and document non-pharmacological interventions: back rub, speak to /approach in a calm manner, reposition, offer snacks/fluids, assess for pain, provide a quiet environment.During a concurrent interview and record review on 3/19/2026 at 9:20 a.m. with the Assistant Director of Nursing (ADON), the Order Summary Report and the MAR for March 2026 were reviewed. The ADON stated the monitoring of behaviors for the quetiapine oral tablet medication should have been done on the same day the medication was ordered. The ADON stated the staff could be giving the residents medication for behaviors that may not exist if the staff are not monitoring for the behaviors the medication was ordered for. The ADON stated the medication given to the residents can make the residents' behaviors worse if the resident was given a medication for a behavior they are not displaying.During a concurrent interview and record review on 3/19/2026 at 10:36 a.m. with Licensed Vocational Nurse (LVN) 2, the Order Summary Report and the MAR for March 2026 were reviewed. LVN 2 stated the quetiapine medication was ordered for Resident 88's restlessness behaviors such as not being able to calm down and having episodes of restless and not being able to sleep. LVN 2 stated there should have been an order for monitoring behaviors that Resident 88 was having because if staff may be giving the medication for no reason. LVN 2 stated the medication can affect Resident 88's mental status and it can be considered a chemical restraint (the use of medication to control behavior or restrict freedom of movement, rather than to treat a specific medical or psychiatric condition) for the residents. During an interview on 3/19/2025 at 4:14 p.m. with the Director of Nursing (DON), the DON stated there should have been monitoring of behaviors for the medication residents are taking for behaviors. The DON stated the staff should be monitoring the behaviors that was related to the medication residents are taking. The DON stated the behavior monitoring of restlessness should be more specific as well as behavior monitoring should not be vague. The DON stated the staff should be monitoring the target behaviors of the medication it was ordered for so the staff can know if the medication was effective at targeting the behaviors residents was manifesting. The DON stated if staff are not monitoring behaviors for the medication it was ordered for, the medication ordered can be considered a chemical restraint and the resident can get unwanted side effects. During a review of the facility's policy and procedures (P&P) titled Psychotropic Medications, revised 12/2023, indicated, it is the policy of this facility to ensure that residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.psychotropic medications shall not be administered for the purpose of discipline or convenience.psychotropic medications shall not be administered for the purpose of discipline or convenience. They are to be administered only when required to treat the resident's medical symptoms and will be considered only after nonpharmacological interventions have been attempted and failed. psychotropic medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record and monitoring for adverse consequences and effectiveness of medications are in place.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was implemented for one of three sampled residents (Resident 88), who received narcotic pain medication (strong prescription medications used to treat moderate-to-severe acute or chronic pain).This deficient practice had the potential to negatively affect the quality of life and wellbeing for Resident 88 to prevent them from achieving their highest practical well-being.Findings:During a review of Resident 88's admission Record, the admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the hips.During a review of Resident 88's Minimum Data Set([MDS], a resident assessment tool) dated 3/11/2026, the MDS indicated Resident 88 had intact cognitive (thought process) functioning for daily decision making. The MDS indicated Resident 88 was maximal assistance (helper does more than half the effort to complete the task) with self-care abilities such as eating, hygiene and dressing. The MDS indicated Resident 88 was moderate assistance (helper does less than half the effort to complete the task) for mobility such as rolling, sitting, standing and transfers.During a review of Resident 88's Order Summary Report, the Order Summary Report indicated tramadol tablet 100 milligram (mg, a unit of measurement) by mouth every 12 hours as needed for pain, for moderate pain 4 - 6 to severe pain 7 - 10 in pain scale (a tool used to measure pain intensity and guide treatment, 1 to 3 being mild pain, 4 to 6 being moderate pain, and 7 to 10 being severe pain).During a review of Resident 88's comprehensive care plan, dated 3/13/2026, the comprehensive care plan did not indicate a focus for tramadol medication as needed for pain with goals and interventions in place for the narcotic pain medication use.During a concurrent observation and interview on 3/16/2026 at 10:33 a.m. in Resident 88's room, Resident 88 was lying in bed. Resident 88 stated he has pain in both of his legs and that he gets Tramadol for the leg pain.During a concurrent interview and record review on 03/19/2026 at 11:00 a.m. with Licensed Vocational Nurse (LVN) 2, the comprehensive care plan dated 3/13/2026 was reviewed. LVN 2 stated there should have been a care plan for the narcotic pain medication tramadol. LVN 2 stated some of the interventions for any type of pain medication would be to try non pharmacologic interventions first and if that does not work, then give the pain medication tramadol as ordered. LVN 2 stated for interventions with pain medication, the staff should be monitoring the adverse effects like respiratory depression, any side effects the resident may experience while on the pain medications and if the pain medication was effective at relieving the pain. LVN 2 stated the care plan was a plan of care for the residents and how the staff will care for the residents. LVN 2 stated the care plan was important, so the staff can meet the goal of the residents.During an interview on 3/19/2026 at 3:57 p.m. with the Director of Nursing (DON), the DON stated a care plan was interventions of what the facility staff will do for the residents and that it was a structure of how the residents will be cared for. The DON stated there should have been a care plan for the narcotic pain medication tramadol. The DON stated the goal of the care plan was to see if the interventions being done for the residents are effective and if not, the care plan would need to be revised and updated. The DON stated if a care plan was not implemented for the pain medication, the staff wouldn't know if the medication was effective, if the pain was relieved, or if the residents needed additional interventions to manage the pain.During a review of the facility's policy and procedure (P&P) titled Comprehensive Person Centered Care Planning, revised 12/2023, indicated, the facility shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 40) who received hemodialysis (a medical procedure to remove fluid and waste products from the body) had a dialysis emergency kit (a prepared, accessible collection of essential medical supplies, medications, and documents designed for dialysis patients to use during emergencies) at the bedside.This failure had the potential for delayed intervention during accidental bleeding including death for Resident 40.Findings:During a record review of Resident 40's admission Record, the admission Record indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis including end stage renal disease ([ESRD], irreversible kidney failure) on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed), diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing) and anemia (a condition where the body does not have enough healthy red blood cells).During a record review of Resident 40's Minimum Data Set ([MDS], a resident assessment tool) dated 3/6/2026, the MDS indicated the Resident 40 has an intact cognitive (thought process) functioning. The MDS indicated Resident 40 needed clean up assistance (helper cleans up while resident completes the task) to moderate assistance (helper does less than half the effort to complete the task) with self-care abilities such as eating, hygiene, and dressing. The MDS indicated Resident 40 was dependent (helper does all of effort to complete the task) for mobility such as rolling and sitting up at edge of bed.During a record review of Resident 40's Order Summary Report dated 3/6/2026, the Order Summary Report indicated an order for hemodialysis on Monday and Friday related to ESRD dependence on renal dialysis. During a record review of Resident 40's Order Summary Report dated 3/6/2026, the Order Summary Report indicated a physician order of dressing on dialysis access site (a surgically created lifeline on the body that allows blood to be removed, cleaned by a machine, and returned to the body during dialysis) to be changed at dialysis center and as needed at facility. The Order Summary Report also indicated monitor dialysis access site for signs or symptoms of infection, swelling, bleeding every shift.During a concurrent observation and interview on 3/19/2026 at 12:09 p.m. in Resident 40's room, there was no emergency dialysis kit visible at bedside or anywhere in the room. Resident 40 stated he has dialysis on Monday and Friday. Resident 40 stated an emergency kit usually hangs up on the board near the side of his bed, but it was not there anymore and stated staff keep moving it so now he does not know where it was.During a concurrent observation and interview on 3/19/2026 at 12:13 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 40's room, CNA 1 checked Resident 40's bedside dresser with Resident 40's permission and around the resident's room but could not find the dialysis emergency kit at the bedside. CNA 1 stated that the dialysis emergency kit was kept at the bedside hanging from the wall, but it was not there. CNA 1 stated Resident 40 was supposed to have dialysis emergency kit at bedside in case of emergencies like bleeding out of the dialysis access site.During a concurrent observation and interview on 3/19/2026 at 12:18 p.m. with the Assistant Director of Nursing (ADON) in Resident 40's room, the ADON stated the dialysis emergency kit should be hanging on the wall. The ADON stated the importance to have the dialysis emergency kit readily available at the bedside was in case the resident bleeds out at the bedside, the dialysis emergency kit was readily available to use right away.During an interview on 3/20/2026 at 4:37 p.m. with the Director of Nursing (DON), the DON stated it was important to have the dialysis emergency kit at the bedside for emergency purposes such as if the residents bleed out, the staff can put a dressing and apply pressure to stop the bleeding. The DON stated if the dialysis emergency kit is not readily available at the bedside, the staff would be scrambling to find supplies to stop the bleeding, and the resident could bleed out.During the facility's policy and procedure (P&P) titled Dialysis (Renal), Pre- and Post-Care, revised on 12/2023, indicated, it is the policy of this facility to assess and maintain patency of renal dialysis access. dialysis access should be assessed upon return to the facility for patency and any unusual redness or swelling.post dialysis access care as ordered.any problems with a resident's access should be addressed immediately.excessive bleeding from graft sites, redness, swelling, pain, or a non-functioning graft requires medical attention.

Based on interview and record review, the facility failed to ensure staff were in-serviced (specialized training or education provided to staff while on the job) to care for residents that was diagnosed for trauma-informed care and post-traumatic stress disorder ([PTSD], a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).This failure had the potential to result in residents being re-traumatized by staff who were not educated on PTSD and could be harmful for resident's psychosocial status.Findings:During a concurrent interview and record review on 03/19/2026 at 12:37 p.m. with the Director of Staff Development (DSD), the Inservice Binder for Staff Training of 2025 was reviewed. The DSD stated there was no in-services or training for staff on residents with PTSD, or trauma informed care. The DSD stated there should be in-service for staff on PTSD and trauma informed care, so staff are aware of residents' potential triggers and changes of behavior. The DSD stated staff should have been educated on understanding the types of behaviors to keep themselves and the residents safe. The DSD stated there should be in-service for staff on residents with PTSD and trauma informed care every year. During an interview on 3/19/2026 at 4:28 p.m. with the Director of Nursing (DON), the DON stated the staff should have been in-service for PTSD and trauma informed care due to some of the residents having the diagnosis of PTSD in the facility. The DON stated the importance of staff being in-serviced for PTSD and trauma informed care so the staff can approach and know how to talk to the residents, have specific interventions for residents and know what to avoid when providing care for the residents. The DON stated if staff are not educated on trauma informed care for PTSD residents, the residents may feel the fear that happened before, which can be very traumatic on the resident and create more trauma for the residents. During a review of the facility's policy and procedures (P&P) titled, Behavioral Health Services, revised 12/2023, indicated it is the policy of this facility to provide residents with necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.trauma survivors will receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.the interdisciplinary team ([IDT], a collaborative group of healthcare professionals who work together to create and implement a comprehensive care plan for a patient) will ensure that residents who display or have a history of trauma, or PTSD receives the appropriate treatment and services to attain the highest practicable mental or psychosocial well-being.

Based on observation, interview and record review, the facility failed to follow manufacturer's storage specifications for one of six sampled resident's (Resident 11) levalbuterol inhalation solution, USP (an inhaled prescription medicine used for the treatment or prevention of breathing difficulties).This failure had the potential to reduce the medication's effectiveness and placing the resident at risk for shortness of breath and difficulty.Findings:During a concurrent interview and record review on [DATE] at 1:38 p.m. with Licensed Vocational Nurse (LVN) 1, at nurses' station 1, medication cart 1 contained an open levalbuterol inhalation solution, USP 0.63 milligram (mg)/3 milliliters (ml) labelled for Resident 11. The medication packaging indicated an open date of [DATE]. LVN 1 stated the label indicated Once the foil pouch is opened, the vials should be used within two weeks. During an interview on [DATE] at 3:40 p.m., with the Director of Nursing (DON), the DON stated, ensuring medications were not expired was important to maintain medication potency and effectiveness. The DON stated, staff should follow the manufacturer's guidelines for discard and expiration dates. The DON stated, residents who receive expired levalbuterol inhalation solution are at risk for shortness of breath and wheezing. During a review of the manufacturer's information insert for levalbuterol inhalation solution, dated 02/2020, the insert indicated when a Levalbuterol Inhalation Solution, USP foil pouch is opened, use the vials within 2 weeks. During a review of the facility's policy and procedure (P&P) titled, Medication Storage and Labeling, undated, the P&P indicated, All drugs will be labeled and stored in a manner consistent with manufacturers' published specifications, federal and state regulations, and to enhance accurate and safe medication administration by the facility staff.

Based on observation, interview, and record review, the facility failed to ensure documented food preferences was followed for one of three sampled residents (Resident 75), when Resident 75 was served food items documented as resident's dislikes. This failure had the potential to contribute to reduced nutritional intake, affecting the resident's overall health and well being.Findings:During a review of Resident 75's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 9/14/2023 and re-admitted on [DATE], with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (HTN- high blood pressure).During a review of Resident 75's Minimum Data Set (MDS- a resident assessment tool), the MDS indicated the resident had intact cognitive function (ability to process information, learn, and reason without impairment).During a review of Resident 75's physician's order dated 3/15/2025, the physician's order indicated a consistent carbohydrate (CCHO- an eating plan designed to keep blood sugar levels stable) diet.During a review of Resident 75's care plan (personalized health care plan) dated 9/26/2023 and revised 6/22/2025, the care plan indicated the resident was at risk for hypoglycemia (low blood sugar). The care plan indicated interventions including monitoring compliance with diet and offering substitutes for foods not eaten.During a review of Resident 75's lunch meal ticket, the lunch meal ticket indicated chicken and turkey only, and no dessert. The lunch meal ticket indicated 1/2 cup ice cream or sherbet and listed green beans as a dislike.During a concurrent observation and interview on 3/16/2026 at 12:43 p.m. with Resident 75 in the resident's room, Resident 75 stated she did not eat lunch because she was served green beans despite disliking them. Resident 75 pointed to the lunch meal ticket on her tray, which listed green beans under the dislikes section. [NAME] beans were observed on the resident's lunch plate.During a concurrent observation and interview on 3/18/2026 at 12:39 p.m. with Resident 75 in the resident's room, a covered food tray was observed on the bedside table. Resident 75 uncovered the tray, and stated she was served a chocolate dessert, and sherbet. The resident stated she was not supposed to receive any dessert other than sherbet as per her meal ticket. The resident stated she felt the staff were not reading her ticket and trays should have been prepared with food preferences and dislikes first, so they could be done correctly.During a review of the facility's CCHO Diets weekly menu, dated 3/16-3/22, the menu indicated green beans were served for lunch on March 16, 2026. The menu indicated 1/2 portion of chocolate peanut butter bar was served for lunch on March 18, 2026. During a concurrent interview and record review on 3/18/2026 at 1:03 p.m. with the kitchen aid (KA), a photograph of Resident 75's 3/16/2026 lunch tray was reviewed. The KA stated green beans were present on the plate and the meal ticket listed green beans as a dislike. The KA stated she verified residents' food preferences and dislikes by comparing the meal tickets with the food items during tray line. The KA stated residents would not want to eat when their food preferences were not honored.During an interview on 3/18/2026 at 1:13 p.m. with Dietary Manager (DM), the DM stated she kept track of residents' food preferences and dislikes by assessing residents upon admission and updating meal tickets weekly and as needed. The DM stated residents become unhappy when preferences were not honored. The DM stated residents could remain hungry and upset if meals were not consumed due to their preferences not being followed.During an interview on 3/19/2026 at 4:03 p.m. with Director of Nursing (DON), the DON stated residents' food preferences and dislikes were reviewed upon admission, quarterly, and as needed through meal tickets. The DON stated honoring food preferences was important to encourage residents to eat. The DON stated residents felt unheard when preferences were not honored, which could lead to poor food intake and weight loss. The DON stated residents should have been offered food alternatives when they did not eat their meal.During a review of the facility's policy and procedure (P&P) titled, Food Preferences, undated, the P&P indicated Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group.Updating of food preferences will be done as the resident's needs change and/or during the quarterly review.

Based on interview and record review, the facility failed to provide documented evidence of COVID-19 (a contagious respiratory disease that spreads from person to person through coughing, sneezing, or talking) vaccine screening, education, administration, and/or declination for two of seven sampled staff members: Medical Doctor (MD) 1 and MD 2.This failure had the potential for an increased risk of COVID-19 exposure for facility residents and staff from delayed identification of vaccine status and missed opportunities to prevent the spread of COVID-19 within the facility.Findings:During a concurrent interview and record review on 3/18/2026 at 3:31 p.m., with the Infection Prevention Nurse (IPN), the facility's Employee Health Tracking Log (record that includes vaccination status of all employees) was reviewed. The IPN stated there was no documentation indicating MD 1 and MD 2 were educated and offered the COVID-19 vaccine. The IPN stated they (IPN) did not offer the COVID-19 vaccine to the physicians.During an interview on 3/19/2026 at 3:40 p.m., with the Director of Nursing (DON), the DON stated that all facility staff, including physicians, should have been screened for having received the COVID-19 vaccine. The DON stated COVID-19 vaccines and record-keeping was important to help prevent the spread of COVID-19 to the residents and staff within the facility.During a review of the facility's policy and procedure (P&P) titled, Immunizations - Staff, revised July 2023, the P&P indicated, Staff includes individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. This includes facility employees, students, trainees, volunteers, licensed practitioners.Employees will be encouraged to remain up to date and current with COVID-19 vaccine guidance, per the CDC.2. Staff receiving a COVID-19 vaccine will provide written consent using the Consents for COVID-19 Vaccination Form. a. If an employee declines the vaccine for reasons other than medical contraindication, this shall be documented on the Consent for COVID-19 Vaccination. b. The consent and record of vaccination record shall be maintained in the employee medical record.

Based on interview and record review, the facility failed to review Infection Prevention and Control Program Policy annually.This finding has the potential to increase the risk of infection for the residents.Findings:During a concurrent interview and record review on 3/18/2026 at 3:31 p.m., with the Infection Prevention Nurse (IPN), the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, revised December 2023 was reviewed. The IPN stated the P&P was last reviewed and updated by the facility on December 2023. The IPN stated the P&P should be reviewed annually. The P&P indicated, The facility will conduct an annual review of the Infection Prevention and Control Program and the program.During an interview on 3/19/2026 at 3:40 p.m. with the Director of Nurses (DON), the DON stated policies should be reviewed every year to ensure the policy reflects updates and changes to the regulations.

Based on observation, interview and record review, the facility failed to ensure 15 of 35 residents rooms met the 80 square feet ([sq. ft.] unit of area equal to a square one foot long on each side) per residents in multiple resident rooms. Rooms 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34 housed two residents per room, and Rooms 18, 20, 21, 35 and 36 housed four residents per room. This deficient practice had the potential to result in inadequate nursing care to the residents.Findings:During an observation on 3/19/2026 at 2:40 p.m., the following rooms were observed room [ROOM NUMBER],20,21,25,26,27, 28,29, 30, 31, 32, 33,34, 35, and room [ROOM NUMBER] did not meet the requirement of 80 square feet per residents.During a review of the Client Accommodations Analysis Form, dated 3/16/2026, provided by the Administrator (ADM) on 3/16/2026, the Client Accommodations Analysis Form indicated Rooms 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34 were occupied by two residents per room and had a total square feet measurement of 153.33 square feet. The Client Accommodations Analysis Form indicated Rooms 18, 20, 21, 35 and 36 were occupied with four residents per room and had a total square feet measurement ranging from 283.5 square feet to 296.66 square feet.During an interview on 3/19/2026 at 3:13 p.m. with Resident 39, Resident 39 stated there was no issues with the room space, Resident 66 stated having adequate space for all the belongings in the multiple resident room.During an observation of rooms 18, 20, 21, 25, 26,27,28,29,30,31,32,33,34,35, and room [ROOM NUMBER] from 3/16/2026 - 3/19/2026 by the survey team, the residents care needs, and health were not affected by room size. The residents or the facility staff, who were providing care to the residents in these resident rooms, did not complain about not having enough space to provide adequate care.During an interview on 3/19/2026 at 3:59 p.m. with the ADM, the ADM stated the facility will request to continue the room waivers as part of their plan of correction.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a history of urinary retention (inability to completely empty the bladder of urine), and was exhibiting signs of urinary retention (groin and abdominal pain), requiring indwelling catheter (flexible soft tube inserted in the body to drain urine) insertion was inserted timely by Licensed Vocational Nurse (LVN) 1 when she could not locate the indwelling catheter supply in the facility. This deficient practice resulted in Resident 1 experiencing further pain and discomfort and placed him at risk for bladder injury and infection. Resident 1 was subsequently transferred to a General Acute Care Hospital (GACH) via 911 for treatment. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including myocardial infarction ([MI] heart attack), type 2 Diabetes Mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle weakness.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 1/10/2026, the MDS indicated Resident 1 had moderate cognitive impairment (ability to think and reason) and was always able to understand and be understood by others.During a review of Resident 1's Order Summary Report (Physician's Orders), dated 2/5/2026, the Order Summary Report indicated discontinue foley catheter (indwelling catheter) and monitor for urinary retention every shift and reinsert indwelling catheter if unable to void (urinate), every shift for three days, ordered on 1/21/2026.During a review of Resident 1's Nursing Notes, dated 1/21/2026 and timed at 9:10 p.m., the Nursing Notes indicated Resident 1's was on monitoring for urinary retention after the indwelling catheter was removed.During a review of Resident 1's Nursing Notes, dated 1/22/2026, the Nursing Notes indicated Resident 1's was unable to urinate and reported feeling pressure and later pain in the groin and abdomen after attempting to urinate several times. The Nursing Note indicated LVN 1 was unable to insert indwelling catheter resulting in Resident 1's transfer to the GACH.During a review of Resident 1's Skilled Nursing Facility (SNF) to Hospital form, dated 1/22/2025, the SNF to Hospital form indicated Resident 1's reported pain in his groin area at level of 9 out of 10 on the numeric pain scale rating of 0 to 10 (where 0 to 3 = mild pain, 4 to 7 = moderate pain, 8 to 10 = severe pain, and 10 = worst pain possible). The SNF to Hospital form indicated Resident 1 was transferred to the GACH on 1/22/2026 at 3:39 a.m. due to abdominal pain.During a telephone interview on 2/5/2026 at 8:17 a.m. with LVN 1, LVN 1 stated she received report that Resident 1's indwelling catheter was removed on 1/21/2026 before 3 p.m. LVN 1 stated that around 12:30 a.m., Resident 1 was attempting to urinate but was unable to and began experiencing increasing groin pain. LVN 1 stated the physician's order required reinsertion of the catheter if Resident 1 could not urinate. LVN 1 stated she was unable to locate catheter supplies to carry out the order, resulting in increased pain for Resident 1. LVN 1 stated she asked her coworker, another staff nurse, for help to locate the catheter but they were unsuccessful in locating them. LVN 1 stated she called the Director of Nursing (DON) for assistance; however, the DON did not provide specific instructions on where to find the supplies. LVN 1 stated she was not oriented on where the facility kept its supplies. LVN 1 stated the delay in inserting the indwelling catheter caused unnecessary pain and placed Resident 1 at risk of bladder injury. LVN 1 stated since she could not find nor insert the indwelling catheter into Resident 1's bladder, she had to call emergency services for transfer to the GACH as she could not provide the necessary care at the facility.During an interview on 1/6/2025 at 8:50 a.m., with the DON, the DON stated on 1/22/2026 at approximately 12:30 a.m., she received a call from LVN 1 regarding Resident 1's severe pain requiring indwelling catheter insertion. The DON stated LVN 1 asked where the catheters were located. The DON stated she could not provide the location because she did not know where the supplies were stored. The DON stated she considered going to the facility to assist her in looking for the supplies but instructed LVN 1 to call 911 due to Resident 1's increased pain and risk of bladder injury. The DON stated the nursing staff is trained to reinsert the indwelling catheters but could not because they did not know where the supplies were. The DON stated she failed to give specific instructions because she was unaware of the supply location and stated she needed to be oriented to the location of facilities supplies. The DON stated it is her responsibility to know supply locations and provide guidance to nurses at all times. The DON stated she later learned that the catheters were stored in a locked nursing supply closet. The DON stated the lack of availability of supplies placed Resident 1 in unnecessary pain and placed Resident 1 at risk for bladder injury and even infection.During a review of the facility's undated 2025-2026 Facility Assessment (detailed evaluation that a skilled nursing facility must perform at least once a year to ensure it has the staff, equipment and resources to meet its residents' care needs), the facility assessment indicated the facility cares for many different residents with various types of care needs. The list below identifies the most common or frequently provided services including.intermittent or indwelling or other urinary catheters.

Based on interview and record review, the facility failed to:1. Re-admit one of three sampled residents (Resident 1) to the facility after Resident 1 was evaluated and cleared by the General Acute Care Hospital (GACH) to return to the facility.2. Ensure the facility followed its policy and procedure (P&P), titled Bed Holds which indicated if the resident's hospitalization or therapeutic leave exceeds the bed-hold period of (7) days, the resident may return to the facility to their previous room, if available, or immediately upon the first availability of a bed, if the resident requires the services provided by the facility.This deficient practice resulted in Resident 1 being unable to return to the skilled nursing facility (SNF) that has been considered their home, for about 12 months after being deemed appropriate for transfer to the SNF. As a result, Resident 1 was transferred to another SNF, and both the Resident 1 and Family Member (FM) 1 experienced unnecessarily psychosocial harm, including emotional distress and dissatisfaction.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on [DATE] with diagnoses including psychotic disorder (severe mental illnesses where people lose touch with reality) with hallucinations ( a sensory experience that feels real but is not based on an external stimulus) and major depressive disorder( a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a lack of energy that significantly impact daily life). During a review of Resident 1's History and Physical Examination (H&P), dated [DATE], the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was intact. The MDS indicated Resident 1 required setup assistance (helper sets up or cleans up) with eating, oral hygiene, moderate assistance (helper does less than half the effort to complete the task) with toileting hygiene, personal hygiene, maximal assistance (helper does more than half the effort to complete task) with showering, and dressing. During a review of Resident 1's Order Summary Report, dated [DATE], the Order Summary Report indicated the facility may transfer Resident 1 to a GACH for psych evaluation and bed-hold for seven days. During a review of Resident 1's Notice of Transfer/Discharge, dated [DATE], the Notice of Transfer indicated the facility transferred Resident 1 to the GACH. During a review of Resident 1's Nursing Life Cyle (NLC) at the GACH, dated [DATE], the NLC indicated the physician at the GACH ordered to discharge Resident 1 back to the facility on [DATE]. During a review of Resident 1's Discharge Planning note at the GACH, dated [DATE], at 3:07 p.m., the Discharge Planning note indicated, Director of Community Liaison (DCL) 1 at the facility informed the Discharge Care Planner (DCP) 1 at GACH that the facility did not have a bed available for the patient but they will refer to a sister facility who can accommodate Resident 1 until a bed becomes available. The Discharge Planning note indicated, DCP1 spoke to Resident 1's family member (FM) 1 and FM 1 did not want Resident 1 moved to a new facility, stating Resident 1 had been there for about a year. DCP 1 informed the facility that the patient needs to be discharged back to the facility. During a review of Resident 1's Discharge Planning note at the GACH, dated [DATE], at 3:28 p.m., the Discharge Planning note indicated FM 1 had not spoken to anyone at the facility regarding placement and stated she was very upset. The Discharge Planning note indicated DCP 1 reached out to the facility and informed Resident 1's medical Power of Attorney (POA) was waiting for someone at the facility to reach out to her. The Discharge Planning note indicated, DCP 1 was awaiting a response. During a review of Resident 1's Nursing Progress Notes, dated [DATE] at 10:46 p.m., the Nursing Progress Notes indicated the Director of Staff Development (DSD) informed FM1 that the facility had no empty beds to accept Resident 1 from the GACH. During a review of Resident 1's Discharge Planning note at the GACH, dated [DATE] at 1:50 p.m., the Discharge Planning indicated FM1 expressed her frustration with the facility to DCP1. During a review of Resident 1's Discharge Summary at the GACH, dated [DATE] at 3:05 p.m., the Discharge Summary indicated the GACH discharged Resident 1 to another facility. During an interview on [DATE] at 1:52 p.m. with Resident 1, Resident 1 stated the facility told FM1 the facility could not accept Resident 1 back to the facility because there was no bed available. Resident 1 stated when FM 1 visited the facility to pick up Resident 1's belongings on [DATE], FM 1 saw empty beds in the facility. Resident 1 stated that made him and FM 1 upset. During a concurrent interview and record review on [DATE] at 3:56 p.m. with the Director of Nursing (DON), the Facility Census, dated [DATE] ,[DATE], [DATE], [DATE], [DATE], and [DATE] were reviewed. The DON stated there were open beds available on [DATE], and the information given by the DSD to FM 1 on [DATE] was not accurate. The DON stated if Resident 1 wished to return to the facility, he could have been readmitted . The DON stated there were empty beds available on the following dates: [DATE], there were total 3 female and 1 male empty beds available. [DATE], there were total 3 female and 1 male empty beds available. [DATE], there were total 3 female and 1 male empty beds available. [DATE], there were total 4 female and 1 male empty beds available. [DATE], there were total 4 female and 1 male empty beds available. [DATE], there were total 4 female beds 2 male empty beds available. During an interview on [DATE] at 1:56 p.m. with the DON, the DON stated residents have the right to return to the facility, even after seven-day bed hold period ends, if the resident wishes to return to the facility. During an interview on [DATE] at 3:41p.m. with the Administrator (ADM), the ADM stated this facility was considered as the residents' home. The ADM stated if a resident's seven-day bed hold had expired the facility should have accepted the resident back to the facility if there was bed available. The ADM stated if the resident was refused reentry, they may have felt unwanted by the facility, which could have caused anxiety and distress. During a review of the facility's policy and procedure (P&P) titled, Bed hold, revised 12/2023, the P&P indicated If the resident's hospitalization or therapeutic leave exceeds the bed-hold period of (7)days, the resident may return to the facility to their previous room, if available, or immediately upon the first availability of a bed, if the resident requires the services provided by the facility.

Based on interview and record review, the facility failed to provide a completed written Bed Hold notification to one of one sampled resident (Resident 1) upon transfer on 7/15/2025 to the General Acute Care Hospital (GACH). This failure had the potential to result in a resident and/or their representative being unaware of their right to return to the facility within the designated bed-hold period, potentially leading to unnecessary displacement.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/24/2024 with diagnoses including psychotic disorder (severe mental illnesses where people lose touch with reality) with hallucinations ( a sensory experience that feels real but is not based on an external stimulus) and major depressive disorder( a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a lack of energy that significantly impact daily life). During a review of Resident 1's History and Physical Examination (H&P), dated 7/26/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/28/2025, indicated Resident 1's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was intact. The MDS indicated Resident 1 required setup assistance (helper sets up or cleans up) with eating, oral hygiene, moderate assistance (helper does less than half the effort to complete the task) with toileting hygiene, personal hygiene, maximal assistance (helper does more than half the effort to complete task) with showering, and dressing. During a review of Resident 1's Order Summary Report, dated 7/15/2025, the Order Summary Report indicated the facility may transfer Resident 1 to a GACH for psychological evaluation and bed-hold for seven days. During a review of Resident 1's Notice of Transfer/Discharge, dated 7/15/2025, the Notice of Transfer indicated the facility transferred Resident 1 to the GACH. During a review of Resident 1's Bed Hold Notification, dated 7/15/2025, the Bed Hold Notification indicated the section for the resident or resident representative's response was left blank, including the resident's desire for bed hold, date and time of notification, and the facility representative's signature. During a concurrent interview and record review on 7/31/2025 at 4:35 p.m. with the Director of Nursing (DON), Resident 1's Bed Hold Notification, dated 7/15/2025, was reviewed. The DON stated facility staff did not notify Resident 1 of the Bed Hold notification upon transfer. The DON stated the Bed Hold Notification lacked documentation of Resident 1's desire for bed hold, the resident or representative's signature, the date and time, and the facility representative's signature. The DON stated there was no documentation indicating Resident 1 refused to sign the form. The DON stated providing bed hold notification upon transfer is essential to ensure the residents are informed of their right to seven-day bed hold. During a review of the facility's policy and procedure (P&P) titled, Bed hold, revised 12/2023, the P&P indicated the resident, or the resident's representative shall be informed in writing of their right to exercise the bed hold provision in the event of a transfer from the facility to a general acute care hospital or at the start of a resident's therapeutic leave.

Based on interview and record review, the facility failed to ensure a refund was issued within 30 days to the Responsible Party (RP 1), upon a resident's discharge for one out of three sampled residents (Resident 1). This deficient practice resulted in Resident 1's RP 1 not receiving a refund of $1,752.00. Findings: During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated, Resident 1 was originally admitted on [DATE] and readmitted on [DATE], with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body), and malignant neoplasm of the prostate (prostate cancer). The Face Sheet further indicated Resident 1 was discharged from the facility on 2/19/2025 at 3:25 p.m. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 12/6/2024, the MDS indicated Resident 1 was usually understood and usually able to understand others. During an interview on 5/23/2025 at 12:20 p.m., with the Business Office Manager (BOM), the BOM stated Resident 1 had a refund because his share of cost which was $3292 was lowered to $2416 as of 1/2025. There was no credit or refund showing in 2/2025. No funds were taken for 3/2025. The 2/2025 payment was posted on 6/2024 to the private account by the Business Office Manager Assistant (BOMA), which was incorrect. On 4/21/2025, the BOMA stated Resident 1 had a drop in share of cost so that alerted her to an audit of Resident 1's entire account so that if Resident 1 had a refund, that money could be refunded back to them. The BOM stated she realized that the 2/2025 payment was deposited in 6/2024 because there were two payments for that month. The funds were deposited into the correct patient liabilities account for 2/2025. The BOM stated in March, the balance didn't flag her because it wasn't a large amount, meaning owing funds for three to four months and the money could be collected from the family. On 4/21/2025, the BOM spoke to FM 1 and notified FM 1 that Resident 1 had a refund and to see if FM 1 wanted to pick up the check once the refund was received from corporate and to verify Resident 1's address. The BOM stated she tried to initiate the refund on 4/21/2025, but it didn't show the credit in the system because the books had to be closed. The books are closed at the end of the month meaning the first week of the following month. The books closed on 5/6/2025. If the process is expedited, the refund should be received by the resident or resident family in five to 10 business days and if not expedited, the process takes 15-30 days. The BOM stated the refund of $1752.00 was overlooked on 5/6/2025, because it got busy, and she forgot to go back and check for the refund and it should have been expedited at that time. During an interview on 5/23/2025 at 2:07 p.m., with the Administrator (ADM 2), ADM 2 stated she spoke to FM 1, and told FM 1 she would find out from the business office if there was a refund for Resident 1. ADM 2 let the facility know to contact FM 1 but does not recall when she contacted the facility. During an interview on 5/23/2025, at 4:18 p.m., with ADM 1 stated, ADM 2 had contacted him to let him know that FM 1 had reached out regarding if Resident 1 had a refund. ADM 1 reached out to FM 1 and let FM 1 know that the system was not showing any refund for Resident 1 at that time. The ADM stated he spoke to the BOM and was told after an audit a refund was shown. ADM 1 stated he let the business office handle the issue. The ADM 1 stated there is no standard time for refunds to be returned to the resident. The business office runs the audits and only notified if it is needed. Weekly and monthly audits to alleviate the turnaround time for refunds. ADM 1 states he oversees the business office but doesn't get into the details unless it's a significant amount of money due to the resident. During an interview on 5/23/2025, at 4:32 p.m., with the Director of Nursing (DON), the DON stated the facility did not have any policies pertaining to the timeframe when a refund should be received by the resident or resident responsible party after discharge.

Based on interview and record review, the facility failed to ensure, the resident who was assessed as a high risk for falls and was totally dependent on staff for activities of daily living (ADL), did not fall out of bed and sustained injuries for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 had more than one staff present to provide incontinence care when the resident was found being soiled while in bed. 2. Ensure Resident 1's bed was maintained in a lowest position as care planned to prevent the resident from fall. 3. To have floor mats (high-impact foam pads which are placed adjacent to the bed on the floor to help reduce the impact from falls and help prevent injuries) at the bed side to lessened possible injury during fall as care planned. These deficient practices resulted in Resident 1 falling from a bed on 4/11/2024, which was in a high position and landing on the floor without a floor mats in place and sustaining a non-displaced (broken bone that remains in the proper alignment) left intertrochanteric fracture (fracture of the thigh bone that connects to the hip bone), bump on her forehead and an abrasion on her left arm. On 4/12/2024 Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses including generalized muscle weakness. During a review of Resident 1's Minimum Data Set ([MDS]) a standardized assessment and care screening tool), dated 12/14/2023, the MDS indicated Resident 1's cognitive skills (thinking process) for daily decision-making were severely impaired. The MDS indicated Resident 1 was totally dependent on staff for activities of daily living (ADL) including toileting, bathing, upper and lower body dressing, and personal hygiene. The MDS indicated a total dependence was when a helper does all of the effort for the resident. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity. The MDS indicated Resident 1 had functional limitations in range of motion ([ROM] the distance and direction a joint can move to its full potential) to both sides of her lower extremities (legs). During a review of Resident 1's Fall Risk Evaluation, dated 3/22/2024, the Fall Risk Evaluation indicated Resident 1's fall risk score was 13. A score of 13 and above indicated a high risk for falls. During a review of Resident 1's Care Plan, dated 12/14/2023, the Care Plan indicated Resident 1 was at risk for falls and fall related injuries due to the use of antidepressant medication (medication used to treat depression), impaired cognition, and impaired ADLs. The Care Plan's goal indicated Resident 1 would be free from falls through the review date of 7/19/2024 and the Care Plan's interventions included to have floor mats at Resident 1's bedside and to keep Resident 1's bed in the lowest position. During a review of Resident 1's Change of Condition (COC) dated 4/11/2024 and timed at 11:15 p.m., the COC indicated a Certified Nurse Assistant (CNA 2) heard a thud and found Resident 1 on the floor in a prone (lying on the stomach) position. Resident 1 was noted with a bump on her forehead and an abrasion on her left arm. During a review of Resident 1's physician's order dated 4/11/2024, the physician's order indicated to transfer Resident 1 to a GACH for further evaluation and treatment as indicated, status post (after) an unwitnessed fall. During a review of the GACH's emergency room (ER) documentation dated 4/12/2024 and timed at 12:03 a.m., the ER documentation indicated Resident 1 had a hematoma (a bruise) above her left eyebrow and pain to her left hip. During a review of Resident 1's X-ray (an imaging test to view the body internal structure) report of the resident's pelvis (the area of the body below the abdomen, between the hip bones that contains the hip bones, bladder, and rectum) area, dated 4/12/2024 and timed at 1:03 a.m., the X-ray report indicated Resident 1 had a probable nondisplaced left intertrochanteric fracture. During an interview on 4/29/2024 at 4:41 p.m., and a subsequent interview on 5/1/2024 at 4:49 p.m., CNA 1 stated, on 4/11/2024 at approximately 10:30 p.m., she was called to Resident 1's room. CNA 1 stated she observed Resident 1 on the floor in a prone position and there was no floor mat on the ground. During an interview on 4/29/2024 at 5:18 p.m., CNA 2 stated, that on 4/11/2024, between 10:15 p.m. and 10:30 p.m., she heard Resident 1 crying in her room. CNA 2 stated she went to check on Resident 1 and found the resident lying on a low air loss mattress (a type of medical mattress designed to reduce pressure on the skin, which helps prevent pressure ulcers or bed sores) on her right side, soiled. CNA 2 stated she went to the bathroom to get supplies to clean and change Resident 1, when she heard a loud thud. CNA 2 stated, she went to check Resident 1 and found her on the floor next to her bed on her stomach. CNA 2 stated Resident 1's mattress and bed were at bedside table height, and she did not recall if a floor mat was in place on the floor. CNA 2 stated the best way to prevent a fall was to have a two persons assistance with Resident 1 care. During an interview on 4/30/2024 at 3:57 p.m., the Licensed Vocational Nurse (LVN 1) stated on 4/11/2024 at approximately 10:40 p.m., she was called to Resident 1's room and when she entered Resident 1's room, she saw Resident 1 on the floor and the Registered Nurse (RN 1) was assessing the resident. LVN 1 stated Resident 1's bed had to be placed in the lowest position in order to transfer Resident 1 back to the bed. During an interview on 4/30/2024 at 4:19 p.m., RN 1 stated she was called to Resident 1's room by CNA 1 and CNA 2 at approximately 10:50 p.m. RN 1 stated when she went to the room, she found Resident 1 on the floor with a bump to her forehead and Resident 1 complained of discomfort. During an interview on 5/2/2024 at 4:26 p.m., the Director of Nursing (DON) stated Resident 1's bed should have been in the lowest position along with floor mats in place on the floor next to Resident 1's at bed along with having two staff members present while providing care. The DON stated floor mats and two staff members are used to lessen the chance of injury if a resident falls out of bed. During a review of the facility's policy and procedure (P/P) title Fall Management System, revised 1/2024, the P/P indicated the facility is to provide an environment that remains as free of accident hazards as possible. The P/P indicated to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on interview, and record review, the facility failed to ensure the residents' ordered medications were available for administration and were administered to residents as prescribed by the physician for four out of five sampled residents (Residents 1, 2, 3, and 4). The facility failed to: 1. Ensure Resident 1 received Seroquel [Quetiapine] a medication used to treat psychotic disorders [a mental disorder characterized by a disconnection from reality]), 150 milligrams [(mg) unit of measurement] twice a day (BID) as ordered for behavioral management. 2. Ensure Resident 2 received Prednisone (a medication used to decrease inflammation [body's response to injury marked by redness, heat, swelling and pain]) 10 mg three-times a day (TID) as ordered for knee inflammation. 3. Ensure Resident 3 received Empagliflozin ([Jardiance] a medication used to improve glucose [blood sugar (BS)] control in people with type 2 diabetes [(DM) a chronic condition which affects the way the body processes BS]), 10 mg daily as ordered for DM. 4. Ensure Resident 4 received injectable Dulaglutide ([Trulicity]) a medication used to improve BS in people with type 2 DM) 0.75 mg/0.5 milliliters ([ml] a unit of measurement) subcutaneously (under the skin) once a week as ordered for DM management. 5. Ensure the licensed nurses did not document the administration of Seroquel, Prednisone, Empagliflozin and Trulicity as given to Residents 1, 2, 3 and 4 when neither of the medications were present in the facility and available for administration. 6. Ensure the licensed nurses verified receipt of ordered medications Seroquel, Prednisone, Empagliflozin and Trulicity and followed-up with the pharmacy when medications were not available for administration to Resident 1, 2, 3 and 4. 7. Ensure the facility had a system in place to determine if the pharmacy received medications orders and to verify medications were dispensed/delivered. 8. Ensure the licensed nurses followed the facility policy and procedure (P/P) titled, Medication Ordering and Receiving from Pharmacy Provider, by contacting the pharmacy and informing of the need for prompt delivery of missing medications for Resident 1, 2, 3 and 4 and requesting delivery within four hours. a. These failures resulted in Residents 1, 2, 3 and 4 not receiving their prescribed medications as ordered placing the residents at risk for ineffective medication management. b. These failures placed Residents 1 at risk for exacerbation of symptoms of uncontrolled behavior compromising Resident 1's safety and safety of other residents and staff. Also, these failures placed Resident 1 and others at risk for injuries. c. These failures placed Resident 2 at risk for unresolved knee inflammation and pain and placed at risk for the potential for deteriorating physical function of a knee. d. These failures placed Resident 3 and Resident 4 at risk for hyperglycemia (high BS) with related adverse effect including coma (state of prolonged unconsciousness, including lack of response from which it is impossible to rouse a person) and possible death. On 8/18/2023 at 3:15 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation caused, or was likely to cause serious injury, harm, impairment, or death to a resident) related to lack of the system to ensure the residents receive ordered medications per physician's order was called in the presence of the Administrator (ADM) and the Director of Nursing (DON). On 8/21/2023 at 3:14 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP] an intervention to immediately correct the deficient practices). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed on 8/21/2023 at 3:42 p.m., in the presence of the ADM and the DON. The IJRP included the following: 1. On 8/3/2023, Resident 1 was transferred to a General Acute Care Hospital (GACH) for hypotension (low blood pressure) and bradycardia (slow heart rate) and did not return to the facility. Resident 1 was discharged from the facility on 8/10/2023. 2. On 7/14/2023, Resident 3 was transferred to the GACH for chest pain and did not return to the facility. Resident 3 was discharged from the facility on 7/21/2023. 3. On 8/18/2023 and 8/19/2023, the primary physicians and the residents Responsible Partys (RP) were notified regarding the residents' not receiving medications as ordered. A licensed nurse assessed Residents 2 and 4 to determine if there were any adverse effects identified related to their missed medications, no adverse effects were found. 4. On 8/14/2023, the facility's pharmacy nurses conducted a cart audit of the two medication carts in the facility to ensure all medications prescribed to residents were present and available for administration. The pharmacy nurses identified 19 medications that were not available in the medication carts and those medications were immediately ordered from the pharmacy. For those residents whose medications were unavailable, they were assessed by the facility's licensed nurses and the resident's physicians and RPs. There were no adverse effects identified. 5. On 8/18/2023, a repeat medication cart audit was conducted on the two medication carts in the facility, by the facility's pharmacy nurses, to ensure all medications prescribed to residents were present and available for administration. The pharmacy nurses identified four medications that were not available in the medication carts and those medications were immediately ordered from the pharmacy. For those residents whose medications were unavailable, they were assessed by the facility's licensed nurses and the resident's physicians and RPs. There were no adverse effects identified. 6. On 8/18/2023, the facility's Clinical Resource Registered Nurse (CRRN 1) observed a 5 p.m. medication administration to ensure residents received all medications prescribed to them. All 70 residents received their medications as ordered. 7. On 8/18/2023, in-services were initiated for all licensed nurses on documenting the correct medication to prevent falsification of medication administration records. 8. On 8/18/2023, in-services were initiated for all licensed nurses on the correct way (how, when, and what time) to document administration of medication on the electronic medical record ([EHR] an electronic version which automates the documentation, storage, and retrieval of patient records). 9. On 8/18/2023 and 8/19/2023, the facility's clinical resource nurses conducted an audit of all active residents (70) medication administration records (MAR) against the pharmacy delivery receipts to determine the extent to which other residents in the facility may not have received prescribed/ordered medications. There were two residents identified who did not receive their medications. A licensed nurse assessed the two resident and notification to the resident's physician and RP was made. There were no adverse effects identified. 10. On 8/18/2023, in-services were initiated for all licensed nurses on when and how to order medications from the pharmacy, how to follow up with the pharmacy to ensure medications were received, and how to follow up with the pharmacy if the medications were not received. 11. On 8/18/2023, in-services were initiated for all licensed nurses on the contents of the facility's emergency kits ([E-Kit] a small quantity of medications which can be dispensed when pharmacy services are not available). On narcotics (a medication which causes insensibility [unconsciousness] or stupor [unresponsiveness from which a person can be aroused only by vigorous, physical stimulation]), E-Kit intravenous ([IV] within a vein), E-Kit, intramuscular ([IM] in the muscle), nonantibiotic E-Kit medications, and on Kayexalate (medication used to treat high levels of potassium [a mineral found in the body which helps the body work properly] in the blood). The in-services also included the process to utilize medications from the E-Kit and the process for ordering a replacement E-Kit. 12. Twenty-five licensed nurses were identified as needing one-to-one in-services. 16 of the licensed nurses were registry staff who will not be returning to the facility and the other 9 licensed nurses received written disciplinary action and one to one ([1:1] one teaching or giving information to the other) in-service by the DON/designee. Findings: A. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and schizoaffective disorder (a mental condition which causes both a loss of contact with reality and mood problems). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/12/2023, indicated Resident 1's cognitive skills for daily decision-making were severely impaired and he was sometimes understood by others. The MDS indicated Resident 1 exhibited physical (which can include hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) and verbal (which can include threatening others, screaming at others, and cursing at others) behaviors that were directed towards others one to three days in a seven-day period. The MDS indicated Resident 1's behavioral symptoms put Resident 1 and others at significant risk for physical injury, significantly interfered with the Resident 1's care, significantly intruded on the privacy or activity of others, and significantly disrupted the care or living environment of others and received antidepressant medication (a class of medications used for the treatment of depression). A review of Resident 1's Care Plan (CP), untitled and dated 7/19/2023, indicated Resident 1 had a potential for mood problems related to depression and schizoaffective disorder. The CP's goal indicated Resident 1 would have an improved mood state through review date of 8/15/2023. The CP's interventions included to administer medications as ordered. A review of Resident 1's CP untitled and dated 7/19/2023, indicated Resident 1 had behavior problems as evidenced by aggressive, combative behaviors, and attempting to hit staff members related to his diagnosis of schizoaffective disorder. The CP's goal indicated Resident 1 would have fewer episodes of aggressive, combative behaviors, decreased episodes of attempting to hit staff members and would have no evidence of behavior problems through the review date of 8/15/2023. The CP's interventions included to administer medications as ordered. A review of Resident 1's Nurses Progress Notes (NPN), dated 7/13/2023 and timed at 3:26 p.m., and a Change of Condition ([COC] a document indicating a deterioration or improvement in a resident's physical or behavioral health which may require a modification in the resident's treatment) dated 7/14/2023 and timed at 6:35 a.m., and a NPN dated 7/20/2023 and timed at 4:30 p.m., indicated Resident 1 exhibited behaviors which included wiping feces on his body, kicking, slapping, making racial remarks to facility staff, irritability and being easily annoyed by staff. A review of Resident 1's Order Summary Report ([OSR] physician's orders), dated 7/20/2023 indicated Resident 1 had a physician's order dated 7/20/23 for Seroquel 150 mg BID for behavior management for administration at 9 a.m. and 5 p.m. daily. A review of Resident 1's Pharmacy Delivery Receipt dated 8/16/2023, indicated 186 tablets of Seroquel 150 mg were delivered to the facility on [DATE], which was 10 days later from the order date (7/20/23). A review of Resident 1's MAR, dated 7/2023, indicated Seroquel 150 mg was signed off as administered to Resident 1 from 7/20/2023 to 7/29/2023 at 9 a.m., and/or 5 p.m. The MAR indicated documentation that Seroquel 150 mg was not available from the pharmacy on 7/21/2023, 7/23/2023, 7/28/2023, and 7/30/2023 for the 9 a.m., and/or 5 p.m., doses. The MAR indicated Resident 1 missed 20 doses of Seroquel from 7/20/2023 to 7/29/2023 due to the medication not being available at the facility. A review of Resident 1's MAR, dated 7/2023, indicated Seroquel 150 mg was documented as given to Resident 1 when the medication was not available at the facility as follows: 1. On 7/20/2023, at 5 p.m. 2. On 7/21/2023, at 5 p.m. 3. On 7/22/2023, at 9 a.m. and 5 p.m. 4. On 7/23/2023, at 9 a.m. 5. On 7/24/2023, at 9 a.m. and 5 p.m. 6. On 7/25/2023, at 9 a.m. and 5 p.m. 7. On 7/26/2023, at 9 a.m. and 5 p.m. 8. On 7/27/2023, at 5 p.m. 9. On 7/28/2023, at 5 p.m. 10. On 7/29/2023, at 5 p.m. A review of Resident 1's MAR comments dated 7/2023, indicated the licensed nurses documented Resident 1's Seroquel 150 mg as not available from the pharmacy as follows: 1. On 7/21/2023, for the 9 a.m. dose. 2. On 7/23/2023, for the 5 p.m. dose. 3. On 7/28/2023, for the 9 a.m. dose. 4. On 7/30/2023, at 9 a.m. and 5 p.m. A review of Resident 1's NPN, dated 7/20/2023 to 7/31/2023, indicated there was no documentation by the licensed nurses indicating the facility's pharmacy was notified Resident 1's Seroquel had not been delivered to the facility. During an interview on 8/17/2023 at 4:35 p.m., Licensed Vocational Nurse 1 (LVN 1) acknowledged he documented that he administered Seroquel to Resident 1 on 7/21/2023, 7/26/2023, 7/27/2023, and 7/28/2023, at 5 p.m. LVN 1 stated he was probably in a hurry and did not verify Seroquel was in the medication cart prior to documenting he administered it to Resident 1. LVN 1 stated, it was hard to stay focused and pay attention during his medication pass because there were so many interruptions during his shift. During an interview on 8/18/2023 at 3:54 p.m., Registered Nurse (RN 2) stated on 7/30/2023 at 9 a.m., she documented on the NPN Seroquel was not available. RN 2 stated she did not call the pharmacy to follow up on the missing Seroquel because she thought someone else had already called the pharmacy and the Seroquel was going to be delivered. RN 2 stated she did not know Seroquel was available in the nonantibiotic Emergency-Kit. B. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including history of falling, difficulty in walking and displaced fracture (bone breaks into two or more parts) of the right femoral neck (region just below the hip joint [where two bones meet]). A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognitive skills for daily decision-making were severely impaired and Resident 2 was usually understood by other and was usually able to understand others. A review of Resident 2's History and Physical (H&P), dated 6/3/2023, indicated Resident 2 was able to make her own medical decisions. A review of Resident 2's OSR, dated 7/6/2023 indicated a physician's order for Prednisone 10 mg TID at 7:30 a.m., 12 noon and 5 p.m.) for knee inflammation. The OSR indicated Prednisone was to be discontinued on 7/9/2023 at 11:59 p.m. A review of Resident 2's Pharmacy Delivery Receipt dated 8/16/2023, indicated there was no documentation to indicate Prednisone 10 mg was delivered to the facility for Resident 2 and was available for administration. A review of Resident 2's MAR, dated 7/2023, indicated Prednisone 10 mg was administered to Resident 1 from 7/7/2023 to 7/9/2023 at 12 p.m., and/or 5 p.m. The MAR indicated the licensed nurses documented Prednisone 10 mg was not available on 7/8/2023 and 7/9/2023 at 7:30 a.m., and/or 12 p.m. The MAR indicated Resident 2 received five doses of Prednisone from 7/7/2023 to 7/9/2023 when the medication was not available at the facility. Resident 2 did not receive a total of seven doses of Prednisone. A review of the facility's nonantibiotic E-Kit Binder dated 7/2023 indicated there was no documentation that Prednisone 10 mg was removed from the E-Kit for administration to Resident 2. A review of Resident 2's NPN, dated 7/20/2023 to 7/29/2023, indicated there was no documentation by the licensed nurses they followed up with the facility's pharmacy regarding Resident 2's Prednisone order. During an interview on 8/16/2023 at 1:23 p.m., Resident 2 stated there were several days when she got a different number of pills when she received her medications, some days I got five pills, and some days six pills. Resident 2 stated, she asked the licensed nurses to explain what medications they were giving her and why the number of pills were inconsistent, and they (the licensed nurses) were not able to explain. During an interview on 8/21/2023 at 2:21 p.m., LVN 2 acknowledged she documented Prednisone as given to Resident 2 at 12 p.m., on 7/7/2023 and 7/12/2023 when she actually did not administer Prednisone to her (Resident 2). LVN 2 stated she thinks she was working too fast and documented the medication as given by accident. C. A review of Resident 3's Admission Record (Face Sheet) indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including type 2 DM and congestive heart failure ([CHF] a chronic condition in which the heart doesn't pump blood as well as it should). A review of Resident 3's MDS, dated [DATE], indicated Resident 3 made independent decisions that were reasonable and consistent. A review of Resident 3's OSR dated 3/28/2023, indicated a physician's order to Resident 3 for Empagliflozin 10 mg once a day for DM. A review of the facility's Pharmacy Consolidated Delivery Sheet dated 6/8/2023, indicated 14 tablets of Empagliflozin 10 mg were delivered to the facility for Resident 3 on 6/8/2023. If Resident 3 was receiving Empagliflozin 10 mg one tablet daily as ordered, 14 tablets received on 6/8/23 would have lasted until 6/22/2023. A review of Resident 3's MAR, dated 6/2023, indicated Empagliflozin 10 mg was administered to Resident 3 daily from 6/23/2023 to 6/30/2023. A review of Resident 3's Pharmacy Delivery Receipt dated 8/16/2023, indicated there was no documentation that Empagliflozin 10 mg was delivered to the facility for Resident 3 after 6/8/2023. A review of Resident 3's MAR, dated 7/2023, indicated Empagliflozin 10 mg was administered to Resident 3 daily from 7/1/2023 to 7/4/2023, and from 7/7/2023 to 7/11/2023. The MAR indicated documentation by the licensed nurses that Empagliflozin 10 mg was not available from the pharmacy on 7/5/2023, 7/6/2023 and 7/12/2023. The MAR indicated the licensed nurses documented Resident 3 received 17 doses of Empagliflozin from 6/23/2023 to 7/12/2023 when the medication was not available in the facility. Resident 3 subsequently missed a total of 19 doses of Empagliflozin 10 mg. A review of Resident 3's NPN, dated 6/23/2023 to 7/12/2023, indicated there was no documentation by the licensed nurses to indicate the licensed nurses notified the pharmacy of missing Empagliflozin 10 mg when the medication ran out. A review of Resident 3's Grievance Resolution Form (GRF) dated 7/4/2023, indicated Resident 3 had concerns with his diabetes medication. The GRF indicated the summary of findings/conclusion and corrective actions sections were left blank. D. A review of Resident 4's Admission Records (Face Sheet) indicated the resident was admitted to the facility on [DATE] with diagnosis including type 2 DM and acute kidney failure (a sudden episode of kidney failure or kidney damage which happens within a few hours or days). A review of Resident 4's MDS, dated [DATE], indicated Resident 4's cognitive skills for daily decision-making were moderately impaired and the resident was usually understood others and was usually understood by others. A review of Resident 4's OSR dated 6/22/2023, indicated a physician's order for Trulicity 0.75 mg/0.5 milliliters ([ml] a unit of measurement) once a week, every Sunday at 9 a.m., for diabetes management. A review of Resident 4's MAR from 6/25/2023 to 7/16/2023 indicated Resident 4 missed three doses of Trulicity. A review of the facility's Pharmacy Delivery Receipt (PDR) dated 6/23/2023, indicated one dose of Trulicity 0.75 mg/0.5 ml was delivered to the facility on [DATE] at 2:02 a.m. There were no additional PDRs for June 2023. A review of the facility's PDR dated 8/16/2023, containing information of medications delivered to the facility in July 2023, indicated there was no documentation to indicate Trulicity 0.75 mg/0.5 ml was delivered to the facility after 6/23/2023. A review of Resident 4's MAR dated 6/2023, indicated Resident 4's Trulicity 0.75 mg/0.5ml was not available from the pharmacy on 6/25/2023. A review of Resident 4's MAR dated 7/2023, indicated Resident 4's Trulicity 0.75 mg/0.5 ml was not available from the pharmacy on 7/2/2023 and 7/16/2023. A review of Resident 4's NPN, dated from 6/25/2023 to 7/16/2023 indicated there was no documentation by the licensed nurses that they notified the pharmacy and followed up on Resident 4's Trulicity order when it was not available for administration as prescribed. During a phone interview on 8/16/2023 at 3:49 p.m. with the Pharmacy Owner (PO 1), the PO 1 stated there was no documentation of Trulicity 0.75 mg/0.5 ml being delivered to the facility after 6/23/23. During a phone interview on 8/17/2023 at 1:38 p.m. with Pharmacy Receptionist (PR 1), PR 1 stated one dose of Trulicity 0.75 mg/0.5 ml was delivered to the facility on [DATE] at 2:02 a.m. The PR 1 stated this was the only dose of Trulicity delivered to the facility for Resident 4. During an interview on 8/17/2023 at 2:28 p.m. with the DON, the DON stated the facility received one dose of Trulicity 0.75 mg/0.5ml on 6/23/2023 at 2:02 a.m. The DON stated he does not have any documentation indicating any additional doses of Resident 4's Trulicity 0.75 mg/0.5 ml was delivered to the facility after 6/23/2023. During an interview on 8/14/2023 at 12:59 p.m., Resident 4 stated the facility previously had issues with the pharmacy not delivering his medications timely. A review of the facility's Resident Council Minutes (RCM), dated 6/22/2023, indicated the residents' concerns included medications not being refilled in a timely manner. The RCM indicated in-services were given to the licensed nurses regarding medications refills. A review of the facility's RCM, dated 7/20/2023, indicated residents were concerned because medications were not being refilled, were not available, and the licensed nurses from the 3 p.m. to 11 p.m., shift were not able to find the resident's medications. During a concurrent interview and RCM review with the DON on 8/17/2023 at 10:06 a.m., the DON confirmed the RCM had no documented resolution to the residents' concerns about medications refill and availability. The DON stated he only looked at timeliness of the medication administration. During a telephone interview on 8/17/2023 at 11:47 a.m., the facility's Pharmacist Consultant (PC) stated accurate documentation of medication administration on the MAR is important because it is reviewed to determine the next time a dose of medication should be administered, to determine if the ordered dosage was effective or needs to be adjusted. The PC stated it is the licensed nurse's responsibility to follow-up with the pharmacy if the medications are not available so the resident can receive their medications as quickly as possible. The PC stated if residents go several days without taking their prescribed medications, it is considered a medication error and poses a risk to that residents to have a negative outcome including uncontrolled pain, behavioral issues, hyperglycemia potentially leading to unnecessary hospitalization s. During an interview on 8/17/2023 at 2:28 p.m., the DON stated the correct way to prepare medications for administration is to take the medication cart to the resident's doorway, verify using the resident's MAR with the medications ordered, prepare the medications, identify the correct resident, administer the medication to the resident, and document the medication as given. The DON stated the licensed nurses should not document medications as given when they (licensed nurses) have not actually administered the medications to the residents. The DON stated if residents do not get their medications as prescribed, the residents are at risk for adverse effects including hyperglycemia, pain, increased inflammation, uncontrolled behaviors which could potentially lead to hospitalization s. During an interview on 8/19/2023 at 10:39 a.m., the Pharmacy Owner (PO) stated the nonantibiotic E-Kit has a list of common medications which are available for the facility's use if there is a delay in receiving medications from the pharmacy or a medication order is not placed. The PO stated the medications in the E-kit can be used until the regular order arrives to the facility. The PO stated the purpose of having the E-Kit is to prevent a delay in medication administration. A review of the facility's undated P/P titled, Medication Ordering and Receiving from Pharmacy Provider, indicated new medications are ordered if needed before the next regular delivery, phone in the pharmacy after faxing the medication order. Inform the pharmacy of the need for prompt delivery and request delivery within four hours. Timely delivery of new orders is required so that medication administration is not delayed. The emergency kit is used when the resident needs a medication prior to the pharmacy delivery. A review of the facility's undated P/P titled, Specific Medication Administration Procedures, indicated after administration, the licensed nurses are to document the administration in the MAR. A review of the facility's LVN Job Description (JD), dated 12/17/2021, indicated duties and responsibilities include the following: 1. Prepares and administers medications as ordered by the physician. 2. Ensure accuracy of documentation. 3. Ensures that adequate stock levels of medications are maintained. A review of the facility's RN JD dated 12/17/2021 indicated duties and responsibilities of the RN include to ensure adequate stock levels of medications are maintained.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1) was free of accidents and hazards. Certified Nursing Assistant (CNA) 1 assisted Resident 1 to the toilet without help of other staff and Resident 1 fell and hit his head on the wall. Resident 1, who was at high risk for fall was not assisted by two or more staff during toilet use as indicated in Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool) and per the Physical Therapy Evaluation and Plan of Treatment. This deficient practice resulted in Resident 1 sustaining a right forehead laceration (deep cut) and was transferred to a general acute care hospital (GACH) via 911 (emergency medical services) and required staples (used to close incisions) to the laceration on the forehead on 6/23/2022. Findings: During a review of Resident 1's Admission Record (Face sheet), dated 6/28/2022, the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] (disease that damages the brain), [CONDITION(S)] ([[CONDITION(S)]] age-associated prostate gland enlargement that can cause urination difficulty), difficulty walking and generalized muscle weakness. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognitive (the ability to understand or to be understood by others) skills for daily decision making was severely impaired, and required extensive assistance with two or more-person physical assist for toilet use and bed mobility. The MDS indicated Resident 1's balance during transitions and walking was not steady, only able to stabilize with staff assistance, and was frequently incontinent with urinary and bladder (7 or more episodes of incontinence, but at least one episode of continent voiding or bowel movement). The MDS also indicated Resident 1 had at least one episode of a fall with injury since admission. During a review of Resident 1's Fall Risk Assessment (a nursing tool that uses a scoring system to evaluate resident's risk of fall), dated 6/18/2022, the fall risk assessment indicated Resident 1 was at high risk for falls due to disoriented mental status, 1 to 2 histories of falls in the past 3 months, required use of assistive device, and balance problems while standing and walking. During a review of Resident 1's Physical Therapy Evaluation and Plan of Treatment, dated 6/20/2022, the record indicated Resident 1's Elderly Mobility Scale, (diagnostic tool used to help assess the mobility of seniors, with score below 10 indicated a high level of dependence and required help with mobility and activities of daily living) indicated the resident had score of 2 out of 20 and needed help from 2 or more people for sitting to standing position. During a review of Interdisciplinary Team [(IDT), a team of professionals from various disciplines who work in collaboration to address the resident's care] incident review note, dated 6/22/2022, the IDT note indicated Resident 1 had a history of witnessed fall on 6/18/22 at 8:55 a.m. The IDT note indicated Resident 1 lost his balance and fell forward with his head up to his waist landing on top of the bed mattress and did not sustain any injury. During an observation on 6/29/2022, at 2:40 p.m., in Resident 1's room, Resident 1 was observed sleeping in the bed. Resident 1 was observed to have two staples on the right top forehead, open to air with no drainage, bruises or swelling noted. During a telephone interview on 6/30/22, at 2:30 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 6/23/2022, she assisted Resident 1 from bed to the toilet by herself, from sitting on the toilet bowl to standing position, and held the resident's left arm to walk out of the bathroom without assistance from another staff. CNA 1 stated Resident 1 verbalized he was not feeling good, his legs gave up and Resident 1 fell and hit his right side of the face against the wall near the bathroom. CNA 1 stated she called the charge nurse for help after Resident 1 had fallen to the floor. During a review of the IDT Incident Review note, dated 6/23/22, the IDT note indicated CNA 1 took Resident 1 to the bathroom and helped cleaned the resident. Resident 1 got up from the toilet and CNA 1 held Resident 1 on his left arm to help steady the resident's gait (manner or style of walking) and while walking back, Resident 1 stated he did not feel good and lost his balance. CNA 1 tried to ease the resident down to the floor, but the resident's legs gave out and the resident fell hitting his head on the wall. CNA 1 noticed the resident bleeding from the right forehead, yelled for help and the charge nurse came to help. The charge nurse applied pressure to the site to stop the bleeding. The note indicated Resident 1's diagnoses of impaired mobility, cognitive impairment and history of falls contributed as risk factors to the fall. The IDT incident review did not address Resident 1's need for assistance by two or more staff during toilet use as indicated in the MDS and PT plan of care. During a telephone interview with Licensed Vocational Nurse (LVN) 1 on 7/13/2022 at 4:56 p.m., LVN 1 stated she was notified by CNA 1 that Resident 1 fell (6/18/2022). LVN 1 stated she immediately assessed Resident 1 and observed a laceration on the right side of the forehead. LVN 1 stated she notified Resident 1's physician and received an order to immediately transfer Resident 1 to the GACH emergency department (ED) on the same day. LVN 1 stated Resident 1 required two people to assist him to the bathroom and CNA 1 should have asked another staff to assist Resident 1 to ensure Resident 1's safety. During a review of Resident 1's Licensed Nurse Progress note, dated 6/23/2022, at 2:17 a.m., the progress note indicated on 6/23/2022 at 2:00 a.m., Resident 1 fell and obtained a laceration on the right side of the forehead. On 6/23/2022 at 2:15 a.m., LVN 1 notified Resident 1's physician of the resident's worsening condition and vitals signs and received an order to transfer Resident 1 to the GACH's Emergency Department at 2:30 a.m., via 911 for further evaluation. During a review of Resident 1's GACH's Computed Tomography (CT, procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) scan of the head report, dated 6/23/2022 at 3:44 a.m., the CT report indicated Resident 1 sustained a right frontal scalp laceration without visible calvarial (top part of the skull) fracture. During a review of Resident 1's Physician's order dated 6/23/2022, the order indicated to cleanse Resident 1's right forehead laceration with Normal Saline ([NS] medical solution used to cleanse wounds), pat dry then apply [MEDICATION(S)] ointment (topical medication used to prevent minor skin infections caused by small cuts, scrapes, or [CONDITION(S)]) everyday for 21 days. During a telephone interview on 7/12/2022 at 3:42 p.m., with Director of Physical Therapy (DPT), the DPT stated a recommendation was made during Resident 1's Physical Therapy Evaluation on 6/20/2022 for Resident 1 to have two people assist him to the restroom and it would be unsafe for Resident 1 to have only one person assisting him. During a telephone interview on 7/12/2022, at 3:27 p.m., with the Director of Nursing (DON), the DON stated CNA 1 should have asked for assistance from other staff if a two-person assistance was required for Resident 1 during toilet use. During a review of the facility's policy and procedure (P/P) titled, Falls-Clinical Protocol, revised March 2018, the P/P indicated the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risk of clinically significant consequences of falling.

Based on observation, interview, and record review, the facility failed to implement its policy and procedures to prevent resident neglect, harm, and mental anguish for one of six sampled residents (Resident 1), who was involved in an intentionally set facility fire next to her bed. The facility's staff failed to adhere to the facility's policy and ensure Residents 1, 3, and 4 were evacuated from the rooms during the two fires that were intentionally set by Certified Nursing Assistant 1 (CNA1), that had the potential for harm to all the residents. This deficient practice resulted in Resident 1, who was documented as being non-verbal, yelling out Fire after being left in the room with the fire resulting in crying, mental anguish, and increased depression and potential harm to the other residents left in the vicinty of the fires. Findings: A review of the facility's Investigation/Incident Report, dated 8/6/17, indicated there was a fire that occurred in two separate locations on 8/6/17, five minutes apart. Initially, there was a fire that occurred in room [ROOM NUMBER] and the second fire occurred in Resident 1's room (room [ROOM NUMBER]). The report indicated the staff did not evacuate the residents in rooms [ROOM NUMBERS], until they were instructed to do so by the Fire Captain, once the Fire Department arrived. A review of Resident 1's Record of Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 5/1/17, indicated Resident 1 was not able to report the correct year, month, and day of the week. The MDS indicated the resident sometimes had the ability to express needs and wants in making concrete requests (verbal and non-verbal expression). The MDS indicated Resident 1 sometimes understood verbal content and only responded adequately to simple, direct communication only. The MDS indicated the resident required extensive assistance (resident involved in activity, with staff providing weight-bearing support) from two or more staff with physical assistance for bed mobility and transferring. The MDS indicated Resident 1 had impairment to one side of the upper and lower extremity and was unsteady in surface-to-surface transferring, and could only stabilize with staff assistance. A review of Resident 1's Physician's Progress Record, written by the Psychiatrist (a physician who specializes in the diagnosis, prevention, study, and treatment of [REDACTED]. A review of an untitled, typed statement from the facility, dated 8/7/17, written by the facility's administrator about the fire incident, indicated the residents in both rooms where the fire was located were either bed bound, or were not in the rooms. A review of Resident 1's Licensed Progress Note, dated 8/5/17 and timed at 4:44 p.m., indicated the resident was alert and responsive to all types of stimuli and able to make simple needs known by use of body gestures. A review of Resident 1's Medication Administration Record [REDACTED] 1. 8/6/17 on the 3 p.m. to 11 p.m. shift (same day after the fire) 2. 8/7/17 on the 7 a.m. to 3 p.m. shift 3. 8/8/17 on the 7 a.m. to 3 p.m. shift According to the MAR for the month of August 2017, Resident 1 had no documentation of sadness and depression two days before the fire on 8/6/17. On 8/8/17 at 7:55 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1), stated Residents 1, 3, and 4 were not evacuated from their rooms during the fires. On 8/8/17 at 8:18 a.m., during an interview, the Medical Record Staff (MRS), stated she saw Residents 1, 3, and 4 in the room during the fire. On 8/8/17 at 8:31 a.m., during an interview, the Maintenance Staff (MS), stated he saw smoke and fire inside Resident 1's room. The MS stated Resident 1 was inside the room in bed during the fire and could not talk or move. On 8/8/17 at 9 a.m., during an observation and interview, Resident 1 was unable to verbalize words, during an interview. The resident turned her head to the left side (looking at the bed next to her), and nodded up and down (meaning yes), when she was asked if she smelled smoke and saw a fire on her roommate's bed pillow on 8/6/17. On 8/8/17 at 9:35 a.m., during an interview, the Administer stated that only Resident 1 was inside the room during the second fire. The Administrator stated Residents 3 and 4 were inside their rooms during the first fire. On 8/8/17, at 9:15 a.m. and 12:20 p.m., during an interview, Certified Nursing Assistant (CNA 1) stated the residents in room [ROOM NUMBER] Beds C and D and room [ROOM NUMBER] Bed D were not removed from their rooms during the fire. CNA 1 stated she did not hear the facility's code word for fire announced for the fire in room [ROOM NUMBER]. CNA 1 stated the resident in room [ROOM NUMBER] Bed D was screaming and looked scared during the fire. CNA 1 stated she observed a lot of white smoke in room [ROOM NUMBER] when she entered during the fire emergency and also smoke in room [ROOM NUMBER] due to the shower blankets that were on fire. On 8/8/17 at 11:23 a.m., during an interview and record review, the Director of Nursing (DON), stated in case of a fire (big or small), residents should be evacuated from their room. The DON stated the residents involved in the fire, and the resident's roommates should have been checked for health and safety issues after the fire. On 8/8/17 at 11:54 a.m., during an interview, the Restorative Nursing Assistant 1 (RNA 1) stated CNA 3 informed her that Resident 1 was yelling fire from her room. RNA 1 stated that Resident 1 only communicated through facial expression and body language, but was able to comprehend what was being said. RNA 1 stated even if the fire was small, the facility's staff should evacuate the residents during a fire. On 8/8/17 at 12:22 p.m., CNA 1 stated Resident 1 does not usually speak, but she heard Resident 1 screaming, and saw a lot of white smoke, when she entered Resident 1's room. CNA 1 stated Resident 1 looked scared as she assisted the resident out of the room after the fire. On 8/8/17 at 12:42 p.m., during an interview, CNA 5 stated Resident 1 cries as a form of communication when she needed something. CNA 5 stated Resident 1 was able to understand, but could not verbally say words. CNA 5 stated Resident 1 appeared scared and was crying when she saw her inside the room after the fire. On 8/8/17 at 2:50 p.m., during an interview, the Director of Staff Development (DSD), stated staff were taught to rescue and evacuate residents if there was a fire in the room. On 8/8/17 at 4 p.m., during an observation and interview two days after the fires, CNA 6 spoke to Resident 1 in Spanish and the resident stated, No, No, No, when CNA 6 asked the resident if she felt safe in her current room. Resident 1 was observed nodding her head up and down twice, while holding unto CNA 6's hand, after CNA 6 asked the resident if she wanted to change rooms. Resident 1 was observed nodding her head up and down and was pointing to the bed on her left side (where the fire was), after CNA 6 asked if she did not feel safe and felt scared due to the fire. A review of a psychiatrist note, dated 8/10/17, four days after the fires, without a time, indicated Resident 1 was more depressed and seemed sleepier and tired and was hard to engage. The psychiatrist documented Resident 1's behavior was different from her usual presentation. The note also indicated the resident was receiving [MEDICATION NAME] XL 300 mg (antidepressant medication) and the psychiatrist documented the plan was to possibly add additional medications if the resident's mood persisted. On 9/13/17 at 8:55 a.m., during a telephone interview and record review, the DON stated staff are expected to assess the resident immediately, turn off the oxygen concentrator or tank, and remove the resident from the area if there is a fire, to prevent combustion. A review of the local Fire Department Arson Investigation note, dated 9/1/17, indicated the investigation concluded, after interviews and video surveillances, that the fires were started intentionally by CNA 1 in the two resident's rooms. The note indicated CNA1 left the facility after she set the fires and never returned. According to the Arson investigation, CNA 1 admitted to the investigator that she started the two fires. A review of the facility's Policy and Procedure titled, Elder/Dependent Adult Abuse, revised on 7/14/17, indicated the facility would protect the rights, safety, and well-being of each resident (regardless of physical and mental condition), for whom the facility provides care and treatment against all forms of mental abuse, neglect, any form of mistreatment, or any other treatment that would result in physical harm, pain, or mental suffering, including the deprivation by a care custodian of goods and services necessary to avoid physical harm, and to attain/maintain physical, mental, and psychosocial well-being of the resident. A review of the facility's Policy and Procedure titled, Staff Response in Case of Fire, with a revision date of 2/8/16, indicated the staff should remove all residents and visitors as quickly and safely as possible. A review of the facility's policy and procedure titled, Staff Response in Case Of Fire, with a revision date of 2/8/16, indicated the following: 1. Call out the code for fire three times and state the location. 2. Remove all residents/visitors as quickly and safely as possible. 3. Close all doors and windows to the involved area(s) or locations. 4. Activate the nearest fire alarm box. 5. Call the Fire Department 9-1-1 6 Bring fire extinguishers. A review of the facility's undated policy titled, Fire Procedures, indicated the following procedures when discovering a fire: 1. Remove Residents/Visitors in immediate danger. 2. Confine the fire by closing all necessary doors and window. 3. Activate the nearest Fire Alarm Box. 4. Call the Fire Department. 5. Announce the code word for fire.

Based on interview and record review, the facility failed to provide the necessary care and services to one of one sampled resident (Resident 1), who was identified as high risk for bleeding and infection. For Resident 1, the facility failed to: 1. Promptly determine the cause of hematuria (presence of blood in the urine) on 2/17/16. 2. Monitor and assess fluid intake and output to prevent fluid deficit (lack of fluid volume in the body) according to the plan of care. 3. Notify Resident 1's primary physician (MD 1) for persistent hematuria on 2/18/16 according to the care plan. 4. Promptly transfer Resident 1 to the hospital when there was a change in condition. 5. Notify the medical director (MD 2) and director of nursing (DON) when MD1 refused to obtain laboratory tests on 2/17/16 and refused to transfer Resident 1 to the hospital on [DATE], at 2 p.m. when Resident 1 continued to have hematuria, with increased weakness and heart rate. As a result of these deficient practices, Resident 1's treatment for [REDACTED]. Resident 1 was then admitted to the hospital in the Intensive Care Unit (ICU) for fluid resuscitation (replacement of fluid loss) and blood transfusion (administration of blood products by IV (given directly into the vein) to replace blood loss). Resident 1 received antibiotic therapy (medication to treat infection) and was closely monitored. Resident 1 stayed in the GACH for 14 days and was diagnosed with [REDACTED]. blood vessel walls and cause severe blood loss). Findings: A review of Resident 1's Record of Admission indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. part of the body) of the buttock. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 2/19/16, indicated Resident 1 was able to make her needs known, was able to understand others, and had no cognitive (ability to think and reason) impairment. The MDS indicated Resident 1required extensive assistance (resident involved in activity, staff provided weight bearing support) with transfer, eating, personal hygiene, and toilet use, and was frequently incontinent (lacking control) of bowel and had an indwelling urinary catheter (a catheter which is inserted into the bladder and allowed to remain in the bladder used to drain urine). A review of Resident 1's plan of care, dated 8/11/15, indicated Resident 1 had the potential for urine infection due to the use of an indwelling urinary catheter and [MEDICAL CONDITION] bladder. The interventions included the facility staff will monitor Resident 1 for signs and symptoms of urinary infection and will observe if there is adequate urine output every shift. A review of Resident 1's plan of care, dated 2/17/16, indicated Resident 1 had the potential for [MEDICAL CONDITION], incomplete bladder emptying and urinary elimination due to hematuria (presence of blood in urine). The intervention indicated the facility staff will notify the physician if severe bleeding and severe pain last for more than one day. A review of Resident 1's physician's orders [REDACTED]. According to <http://www.[MEDICATION NAME].com>, dated 4/2014 indicated, [MEDICATION NAME] alters the blood's ability to clot and can cause excessive bleeding (hemorrhage) and can lead to death. All patients should be carefully monitored while taking [MEDICATION NAME]. The doctor should order blood tests that measure your blood count and check for signs of hidden bleeding while on [MEDICATION NAME]. On 3/17/16 at 1 p.m., Resident 1's closed clinical records were reviewed with Registered Nurse (RN)1. The Advanced SBAR (Situation-Background-Assessment-Recommendation, provides a framework for communication between members of the health care team) Change of Condition Documentation, dated 2/17/16, timed at 10:30 a.m., indicated Resident 1 was observed with large amount of dark red colored urine. A review of the Resident 1's Licensed Progress Notes on 3/17/16 at 1 p.m. indicated the following: 1. On 2/17/16, timed at 4:14 p.m., MD1 ordered to hold [MEDICATION NAME] (medication that thins blood or blood thinner) for two days. 2. On 2/18/16, timed at 11:14 a.m., Resident 1 was observed with moderate amount of dark red colored urine in the indwelling urinary catheter. There was no documentation that MD1 was informed of Resident 1's continued presence of hematuria on 2/18/16. 3. On 2/19/16, timed at 2 p.m., MD1 was informed of Resident 1's increased weakness, continued hematuria (after forty eight hours of continued hematuria) and increased heart rate of 120-124 beats per minute ((bpm) normal range 60-100). RN 1 recommended to MD1 if the labs could be done stat (immediately) or if Resident 1 could be transferred to the hospital, MD 1 refused and stated Resident 1 had [MEDICAL CONDITION] that could cause weakness and still ordered to obtain the following laboratory tests (labs) on Monday, 2/22/15: a. UA (urine analysis, urine test to check for infection in the urinary tract: bladder, ureters and kidney). b. CBC (complete blood count, a blood test to check for infection, blood and fluid loss). c. BMP (basic metabolic panel, a blood test that measures blood sugar level, electrolytes, and fluid balance, and kidney function). d. C&S (culture and sensitivity test, a Culture is a blood or urine test to check for infection, and Sensitivity is a blood test to determine the type of medication to treat the disease causing organism or infection). In an interview on 3/17/16 at 1:30 p.m., RN 1 stated, I saw the patient (Resident 1) with dark reddish brown urine in the Foley (a brand name of an indwelling urinary catheter) bag that was half full (approximately 1000 milliliters) on 2/17/16. RN 1 stated, on 2/17/16, he informed MD1 that Resident 1 had hematuria and MD1 did not order to draw laboratory tests. On Friday (2/19/16) at 2 p.m., RN 1 stated he informed MD1 that Resident 1 continued to have hematuria, with increased weakness and heart rate and asked MD1 if he could do stat (immediately) labs or if Resident 1 could be transferred to the hospital, MD1 refused and he told him that Resident 1 was weak because of MS and ordered, Do not transfer her (Resident 1) at this time. RN 1 stated, MD 1 insisted to have the labs collected on Monday (2/22/16). During the interview on 3/17/16 at 1:30 p.m., about Resident 1, RN 1 stated, At around 3 p.m. on 2/19/16, the patient became confused and her level of consciousness was altered. She could not answer the questions and was not in her usual self. Her heart rate was higher at 140's; her skin was pale and cold. So, at 3:05 p.m., I called 911 and she was transferred to the acute hospital by the paramedics by 3:30 p.m. At 4:21 p.m. that afternoon (2/19/16), I called the doctor again to let him know that I called 911 and transferred the patient to the hospital. During the interview on 3/17/16 at 1:30 p.m., RN 1 was asked if he informed the DON or MD 2 when MD 1 refused to obtain laboratory tests on 2/17/16 or transfer Resident 1 to the hospital at 2 p.m. on 2/19/16, RN 1 replied, I don't recall informing any of them on 2/17/16 and at 2 p.m. on 2/19/16, but maybe I should have called them. On 3/17/16 at 1:30 p.m., in an interview, RN 1 was asked if MD 1 was informed of Resident 1's continued hematuria on 2/18/16, RN 1 replied, No, we did not inform the doctor because she was still on a 72 hours monitoring. During the interview on 3/17/16 at 1:30 p.m., RN 1 was asked if Resident 1's fluid intake and urine output was monitored and documented to determine Resident 1's fluid loss, RN 1 replied, No we did not. There was no MD order to do a strict fluid intake and output monitoring. A review of Resident 1's Licensed Nurse Progress record conducted with RN 1 on 3/17/16 at 1:30 p.m., there was no documented evidence the facility staff informed MD 2 when MD 1 refused to order laboratory test on 2/17/16 and refused to transfer Resident 1 to the GACH on 2/19/16 at 2 p.m. for proper evaluation. During an interview and review of Resident 1's clinical record conducted with RN 1 and the assistant director of nursing (ADON ) on 3/17/16 at 2 p.m., there was no documented evidence that Resident 1's fluid intake and urine output was monitored, recorded, and fluid balance was assessed and analyzed. RN 1 stated, Resident 1's urine remained dark maroon (dark brownish red color) in color and decreased amount with approximately 250 milliliter (ml) in the Foley catheter bag on 2/19/16 at 2 p.m. and did not report the decreased amount of urine to MD 1. On 3/18/16 at 4:30 p.m., the DON was asked if there could have been other interventions provided to Resident 1 for hematuria, the DON answered, Yes we could have collected labs like UA and CBC, but if the doctor did not order the labs or the intake and output monitoring, we cannot go beyond what the doctor ordered. When asked if MD 2 was informed regarding Resident 1's persistent hematuria for three days the DON replied, No, I did not inform him because that could be a conflict of interest. He was not the primary physician of the resident. A review of the facility's policy and procedure, dated December 2010, titled, Catheter Care, indicated the facility will minimize or prevent urinary tract infection for residents with indwelling catheter by: the staff will observe the resident's urine for noticeable increase and decreases. If the level significantly changes, report to the physician; and observed the resident for signs and symptoms of UTI and report findings to the attending physician. According to the National Institute of Health, https://medlineplus.gov/ency/article/ 7.htm, article dated 8/31/15, decreased urine output means that when you produce less urine than normal that may be due to dehydration, blood loss, severe infection that leads to shock (life-threatening condition that occurs when the body does not have enough blood flow). Most adults make at least 500 ml of urine in 24 hours (a little over 2 cups). On 3/21/16 at 9:30 a.m., in a telephone interview, MD1 stated, he was informed by the nurse that Resident 1 had blood in the urine, and he ordered to stop the [MEDICATION NAME] and to observe Resident 1 for further bleeding. MD1 was asked if the facility staff informed him of Resident 1's continued hematuria on 2/18/16, MD 1 replied No I was not. I told the nurses to hold the [MEDICATION NAME] and the hematuria should eventually resolve after two or three days. When asked for the possible causes of hematuria, MD1 replied, If a patient have Foley catheter, the catheter can inadvertently (accidentally) cause bladder trauma when the catheter is pulled during patient care because of tugging and she's on a blood thinner. MD 1 stated, Hematuria can also be due to infection, I do not believe the patient had infection. She had no fever, pain and abdominal tenderness. MD1 was asked what care he provides if a resident had hematuria, MD 1 replied, he would order labs, UA, C&S and CBC to make sure the hemoglobin was not decreasing and then he would transfer the resident to the hospital. MD 1 was asked why Resident 1 was not transferred to the hospital (GACH) for further test and evaluation if she continued to have hematuria for three days and had increased weakness, MD1 answered, I do not remember why. MD1 was asked if he saw and physically assessed Resident 1 on 2/17/16 to 2/19/16 while Resident 1 had hematuria, MD1 replied, No, I did not see her. On 3/21/16 at 9:50 a.m., during an interview with Resident 1's family member (FM1) about Resident 1, FM1 stated, When I tried to speak to her on the phone on 2/19/16, she answered my question with long pauses; that is not how she normally answers. When I spoke to the registered nurse, he told me that he will call 911 to have her transferred to the hospital. When I arrived in the emergency room , I found her urine bag with a large amount of hematuria. I think the nurses in the facility should have been more assertive. On 3/21/16 at 4:20 p.m., during an interview, MD 2 stated, If it was reported to me that the resident (Resident 1) continued to bleed after three days, I would have handled the situation a little different. When asked how soon should the resident be transferred, MD 2 replied, he would order labs right away to rule out infection or cause of bleeding and transfer the resident to the hospital as soon as possible if the hematuria does not resolve. It is always best to transfer the resident to the hospital to be evaluated for the possible cause of infection or bleeding. According to the Emergency Department Clinical Record from the GACH, dated 2/19/16 timed at 4:12 p.m., indicated Resident 1 was admitted emergently to the GACH due to persistent hematuria and progressive weakness, heart rate of 142 (normal range 60-100) and with high temperature of 102.3 Fahrenheit (normal range 98.6-99.6 F). The following were Resident 1's GACH laboratory tests report, dated 2/19/15 at 4:48 p.m.: 1. White blood count 24,000 (normal range 4,000 to 11,000 leukocytes per cubic millimeter) can indicate the presence of infection. 2. Hematocrit 22.1 (test for [MEDICAL CONDITION], indicates percentage of red blood cells in the blood, normal range 36 to 44%) 3. Hemoglobin 7.4 (test for [MEDICAL CONDITION], refers to a protein, found in red blood cells, that is responsible for carrying oxygen from the lungs to all other tissues, normal range 12-15 grams per deciliter) 4. Urinalysis, dated 2/19/15 timed at 4:21 p.m. indicated urine was red, bloody, with bacteria. 5. Culture and sensitivity (C&S), dated 2/21/16 timed at 6:55 p.m. indicated: a. Urine culture had Proteus Mirabilis (bacteria found in putrid meat (rotten), and feces and is the leading cause of urinary tract infections). b. Blood culture had gram negative rods organism (disease causing bacteria). A review of Resident 1's Computed Tomography (CT) scan (an enhanced form of x-ray that evaluates or visualizes the body) result that was completed in the GACH on 2/21/15 at 11:28 a.m., indicated, Resident 1 had a bladder hematoma (leakage of blood from a blood vessel in the bladder). A review of Resident 1's discharge summary record from the GACH, dated 3/4/16, indicated Resident 1 was admitted to the Intensive Care Unit (ICU) for treatment of [REDACTED]. Resident 1 remained in the GACH for 14 days from 2/19/15 to 3/4/15. Resident 1's discharge [DIAGNOSES REDACTED]. According to http://www.merckmanuals.com/home/blood-disorders/[MEDICAL CONDITION]/[MEDICAL CONDITION]-due-to-excessive-bleeding, article dated 2016, [MEDICAL CONDITION] from excessive bleeding results in rapid blood loss, decreased blood pressure, and people may be dizzy, tired, short of breath, pale and reduce the number of oxygen-carrying red blood cells quickly which may lead to a [MEDICAL CONDITION], stroke, or death.