Every finding on record at Foundation Skilled Nursing

Based on observation, interview, and record review, the facility failed to provide services which met professional standards of practice for one of five sampled residents (Resident 1) when Resident 1 refused to shower 16 out of 17 shower days between 6/25/26 and 8/20/26 and the facility did not notify the Responsible Party (RP), hold a care conference or meet as an Intradisciplinary Team (IDT- team from different healthcare disciplines who work together to provide comprehensive patient care) to evaluate and revise care plan interventions to meet Resident 1's needs.This failure had the potential for Resident 1 to experience bacterial (illness caused by a germ that enters the body and makes a person sick) or fungal (a skin, nail or body condition cause by tiny germ-like fungi that thrive in warm, wet places) skin infections, rashes, skin breakdown, odors and to affect her dignity.During a concurrent observation and interview on 8/24/26 at 8:40 a.m. with Resident 1, in Resident 1's room, Resident 1 was standing beside her bed, her hair was unkempt, she had multiple chin hairs, she was dressed, and a urine like odor was noted from approximately a foot away. Resident 1 stated when the staff offered to take her to shower she tells them I am not going to shower until I go home.During a review of Resident 1's admission Record (AR), undated, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis) left side, transient cerebral ischemic attack (temporary blockage of blood flow to the brain that causes stroke-like symptoms), schizoaffective disorder (mental health condition that combines schizophrenia [serious mental health condition that affects how people think, feel and behave] with a major mood disorder [extreme emotional highs or lows]), anxiety disorder (feeling nervous, restless or tense), dementia (loss of memory, language, problem-solving and thinking abilities severe enough to interfere with daily life) and auditory hallucinations (hearing voices or noises that do not exist in reality).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [relating to thinking, learning and memory] and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 09 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 had a moderate cognitive impairment.During an interview on 8/24/26 at 9:34 a.m. with Resident 4, Residents 1's roommate, Resident 4 stated she would frequently hear Resident 1 refuse showers from staff. Resident 4 stated Resident 1 would only take a shower when the family came in to shower her.During an interview on 8/24/26 at 9:48 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 always refused her showers. CNA 1 stated Resident 1 would tell her she would take a shower when she goes home. CNA 1 stated Resident 1 would smell like urine at times because she was mostly independent with toileting and would refuse help with perineal care (hygienic washing and cleaning on a patient's genital and anal area to maintain hygiene, prevent skin breakdown and avoid infections). CNA 1 stated the facility's process for shower refusals was to have a second CNA speak with the resident to offer a shower and then the nurse would be notified. CNA 1 stated after the refusals, both CNAs would sign a shower sheet stating the resident refused and turn the form in to the Licensed Nurse.During a concurrent interview and record review on 8/24/26 at 11:26 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 1 did not like to take showers. LVN 2 stated the facility had tried everything they could but the resident continued to refuse showers. LVN 2 stated the staff could not force Resident 1 into a shower. LVN 2 stated Resident 1 would smell of urine because she did not like staff to help her when she used the bathroom. LVN 2 stated the facility process for shower refusals was for two CNAs to offer a shower to the resident then sign the shower sheet and turn it in to the LVN, the LVN then would offer the resident a shower and if she still refused then the nurse also signed the sheet and turned it into the Director of Staff Development (DSD). Resident 1's ADL care plan dated 6/22/26, was reviewed, the care plan indicated, . Behavioral Care Plan. Noted With Episodes impaired Behavioral Patterns Related To: episodes of refusing showers. Monitor occurrence of targeted behavior. Maintain consistency in timing of ADL's, caregivers and routine as much as possible. Explain all procedures to the resident before starting and allow resident time to adjust to changes. Engage resident in activities for distraction. Approach resident in calm manner. Anticipate and meet resident's needs. LVN 2 stated the staff was monitoring Resident 1's refusal of showers but staff did not document the monitoring in the electronic medical record (EMR-digital version of a patient's chart). LVN 2 was unable to locate any notes indicating the RP was notified that Resident 1 was refusing to shower. Resident 1's progress note dated 8/18/26 at 10:03 a.m., was reviewed. The note indicated, . received call from . son and RP. regarding immunizations. He also stated concerns about his mom showers and how she has been refusing he stated the CNA [name of CNA 3] was able to give her a shower the last time and advise to have her give [Resident 1 showers]. LVN 2 stated there was a CNA who was able to convince Resident 1 to take a shower the previous month but the resident had refused since then.Resident 1's Shower Sheet, dated 7/5/26 was reviewed, the form indicated, . Shower. clean and trim nails [box checked] . Hair/Body washed with shampoo/soap [box checked] . Facial hair shave/trimmed [box checked] . [signed by CNA 3].During an interview on 8/24/26 at 1:13 p.m. with CNA 3, CNA 3 stated Resident 1 refused regularly refused shower. CNA 3 stated Resident 1's son had come in some time in July and they were able to convince Resident 1 to allow the CNA to shower her once. CNA 3 stated she would be cooperative for the family but otherwise would refuse to shower.During a concurrent interview and record review on 8/24/26 at 1:35 p.m. with the DSD, the DSD stated Resident 1 had a known behavior of refusing her showers. Resident 1's shower sheets dated 8/10/26, 8/13/26, 8/17/26 and 8/20/26 were reviewed. The shower sheets indicated Resident 1 repeatedly refused to shower. The DSD reviewed the EMR and stated she was unable to locate any nurse's notes indicating the Responsible Party (RP) had been notified that Resident 1 was refusing to shower. Resident 1's behavior care plan for shower refusals, dated 6/22/26, was reviewed. The DSD stated the care plan interventions had not been updated since it was initiated despite Resident 1's consistent refusals. The DSD reviewed the EMR and stated there was no documentation indicating that the IDT had met, or a care conference had been held to review and revise Resident 1's behavior care plan addressing her continued shower refusals. The DSD stated Resident 1 not showering placed her at risk for infection control issues.During a concurrent interview and record review on 8/24/26 at 2:16 p.m. with the Director of Nursing (DON), the DON stated Resident 1's shower refusals had been brought to the managements attention. The DON stated Resident 1 would usually shower for her family. The DON stated the staff would actively try to convince Resident 1 to shower. The DON reviewed Resident 1's EMR and stated she was unable to find a care conference or IDT note indicating the clinical team had met to discuss alternative interventions. The DON stated Resident 1's care plan dated 6/22/26 had not been reevaluated and revised since it was entered on 6/22/26. The DON stated the IDT should have met and discussed the residents shower refusals because it was important to find a resolution if possible and put new interventions into place. The DON stated showering regularly was important to prevent infections especially if a resident has an underlying condition. The DON reviewed Resident 1's EMR and stated the nurses had not been documenting when they notify the RP of Resident 1's refusals. The DON stated if something was not documented it was not done.During an interview on 8/24/26 at 2:51 p.m. with the Administrator (ADM), the ADM stated Resident 1's shower refusals were addressed during Angel Rounds. The ADM stated, Angel Rounds (staff and administrators check on resident care, health needs, cleanliness and care standards) were done by the Department Head assigned to Resident 1 and any issues would then be discussed at the morning stand up meeting. The ADM stated the Angel Rounds and morning stand up meetings were not documented as a part of the EMR. The ADM stated Resident 1's consistent refusals of showering was not an issue for the IDT to address, but he thought a care conference would be appropriate. The ADM stated a care conference specific to Resident 1's refusal of showers had not been held. The ADM stated there were no interventions that would help Resident 1 agree to showering. The ADM was unaware of potential adverse consequences for not showering regularly.During a review of Resident 1's shower sheets were reviewed and indicated Resident 1 refused to shower on the following dates: 6/25/26,6/29/26, 7/2/26, 7/9/26, 7/13/26, 7/16/26, 7/20/26, 7/23/26, 7/27/26, 7/30/26, 8/3/26, 8/6/26, 8/10/26, 8/13/26, 8/17/26, and 8/20/26. During a telephone interview on 8/25/26 at 2:51 p.m. with Family Member (FM) 1, FM 1 stated the responsible party had not been notified Resident 1 was consistently refusing her showers. FM 1 stated the family and RP would visit Resident 1 and find that she was not clean. FM 1 stated in July she had taken Resident 1 to the shower and found what looked like mold between the resident's toes and that her underwear were dirty and had not been changed for a period of time. FM 1 stated the facility had not contacted the RP to schedule a care conference to discuss possible interventions to help with compliance for showering.During a review of the facility's policy and procedure (P&P) titled Refusal of Treatment, dated 5/2013, the P&P indicated, . Our facility shall honor a resident's request not to receive medical treatment. as well as care routines outlined on the resident's assessment and plan of care. Treatment is denied as care provided for purposes of maintaining/restoring health, improving functional level or relieving symptoms. If a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences. Care Plan Team will assess the resident's needs and offer the resident alternative treatments. Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record. Documentation pertaining to a resident's refusal. residents response and reason(s) for refusal. The resident's condition and any adverse effects due to such refusal. The date and time the physician was notified. During a review of the facility's P&P titled Activities of Daily Living (ADLs), Supporting, dated 3/2018, the P&P indicated, . Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated and revised as appropriate.During a review of the facility's P&P titled Care Plans-Comprehensive, dated 9/2010, the P&P indicated, . Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative . develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain . Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change .During a review of a professional reference from https://canhr.org/making-care-plans-work/ dated 6/23/25, the professional reference indicated, . one of your most important rights as a nursing home resident is to receive the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with a written plan of care. The nursing home must engage you and your representatives in a through and thoughtful care planning process that produces a comprehensive, individualized plan designed specifically for you . Care plans are developed by an interdisciplinary team (IDT) that includes, at a minimum, your attending physician, a registered nurse and nurse aide with responsibility for you. You also have the right to choose or refuse any care or treatment. A nursing home is obligated to identify and present alternative care approaches that address your goals and concerns.During a review of a professional reference from https://canhr.org/nursing-home-care-standards/ titled Nursing Home Care Standards, dated 6/24/25, the reference indicated, . Care, treatment and therapies must be used to maintain and improve health to the extent possible. subject to the resident's right to choose and refuse services. Unless it is medically unavoidable, nursing homes must ensure that a resident's abilities in daily living activities do not decline. federal and California laws set many specific care standards. Nursing homes must establish a comprehensive, individualized care plan for each resident that spells out care needs and how they will be met. the care plan is developed by an interdisciplinary team of facility staff. good care plans address all aspects of a resident's life in the nursing home and are a custom-made strategy for how the staff will help and support the resident each day. residents and their representatives should exercise their rights to participate in care plan meetings, give information, ask questions, offer suggestions, make choices about their care, review care plan documents and accept or refuse offered care. Personal Care. Nursing homes must give residents necessary assistance with personal needs, such as bathing, eating and dressing. Unless it is clinically unavoidable, the nursing home must ensure that a resident's abilities to carry out activities of daily living do not diminish. Residents have the right to choose or refuse any care or treatment offered, at any time and for any reason . they must give residents pertinent information about treatment options and possible benefits and consequences. Residents and their representative have the final say in decisions about accepting or refusing proposed treatment and care. Residents should not be neglected or evicted if they refuse care or treatment. A nursing home is obligated to identify and present alternative care approaches that address resident goals and concerns.

Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance for one of three sampled residents (Resident 1) when Resident 1 who was assessed as needing a staff member to accompany her during medical appointments was transported to a doctor's appointment by herself without a staff member present. This failure resulted in Resident 1 not completing her appointment, delayed care, and placed her at risk for injuries. During a concurrent observation and interview on 6/9/26 at 10:40 a.m. with Resident 1, Resident 1 sat halfway on her bed with her feet on the floor, dressed in a facility gown, with a wheelchair nearby. Resident 1 stated she had a gynecology (GYN) appointment the previous week for evaluation of her cancer. Resident 1 stated she was dropped off at the appointment in her wheelchair, and no one accompanied her. She could not remember further details, including whether she completed the appointment.During an interview on 6/9/26 at 11 am with Certified Nurse Assistant (CNA) 1, CNA 1 stated she knew Resident 1 well. CNA 1 said Resident 1 previously assisted the CNAs with her ADLs but was now completely dependent, required a two person assist for transfers, and was always incontinent. CNA 1 stated Resident 1 went alone only to dialysis appointments and required staff member to escort and assist her to all other medical appointments because she could not walk, use the bathroom independently, or manage her confusion. CNA 1 did not know whether an escort accompanied Resident 1 to the GYN appointment but stated she needed one.During a concurrent interview and record review on 6/9/26 at 11:37 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's ERM was reviewed. LVN 1 stated Resident 1 was a maximum assist, two person transfer and did not walk. LVN 1 stated the facility normally sent someone with her to medical appointments other than dialysis because she needed help with transferring and dressing/undressing. LVN 1 stated Resident 1 required assistance at a GYN appointment and not having an escort would put her at risk for injury.During a concurrent interview and record reviews on 6/9/26 at 11:45 a.m. with the Social Service Director (SSD), Resident 1's social service notes was reviewed. The SSD stated Resident 1's 6/2/26 GYN appointment was not completed because she had soiled herself and the GYN office said they could not complete the appointment without a care giver with Resident 1. SSD stated Resident 1 had a BIMS of 9, was incontinent, a heavy wetter, and he did not know how she went to the appointment without a responsible person. The SSD stated he and the Transportation Scheduler (TS) scheduled appointments and transportation, while nursing ensured residents had what they needed. The SSD said he had never seen and could not find a Policy and Procedure (P&P) for scheduling outside appointments for the residents. He recalled the GYN office reported Resident 1 arrived with a soiled adult diaper and an odor and they could not complete the exam. During an interview on 6/9/26 at 12:10 p.m. with the TS, the TS stated Licensed Nurses forwarded referrals to the SSD, the SSD schedules the appointment, and TS arranged for transportation. The TS stated the Director of Staff Development (DSD) scheduled extra staff when escorts were required. The TS stated Licensed Nurses knew which residents needed escorts and should have ensured Resident 1 had one. The TS reported never seeing a policy for scheduling appointments.During a concurrent interview and record review on 6/9/26 at 12:30 p.m. with Registered Nurse (RN) 1, Resident 1's EMR was reviewed. RN 1 stated to schedule an outside appointment for residents, Licensed Nurses forwarded referrals to the SSD, the SSD schedules the appointment, and the TS arranges the transportation. RN 1 stated the SSD and the TS communicated when a resident needed an escort, or sometimes nursing did. RN 1 stated she based escort need on BIMS scores and would send an escort for residents with scores of 9 or below. RN 1 stated she spoke to GYN office while Resident 1 was there and the Medical Aide stated Resident 1 had soiled herself, could not clean her, and she would need to reschedule the appointment when she could have an escort. RN 1 acknowledged she did not document the incident or the need to reschedule in the EMR and stated she should have. RN 1 stated Resident 1 had a BIMS of 9, was dependent for toileting and dressing, and needed an escort to the GYN appointment. RN 1 stated she saw Resident 1's 6/2/26 appointment on the [NAME] Board but assumed it was a dialysis visit, which Resident 1 attended alone because aides assisted her there. RN 1 stated she had not seen a policy for scheduling appointments for the residents.During an interview on 6/9/26 at 1:00 p.m. with the DSD, the DSD stated she was told Resident 1 went alone to the appointment, was soiled, and the appointment needed to be rescheduled. The DSD stated the TS was responsible for staff scheduling and ensuring escorts for residents. The DSD stated she had not seen a policy for scheduling appointments for the residents.During a concurrent interview and record review on 6/9/26 at 1:30 p.m., with the Director of Nursing (DON), Resident 1's EMR was reviewed. The DON stated Resident 1 had a BIMS of 9 and required an escort for appointments. The DON stated Resident 1 could have fallen or injured without assistance. The DON stated the TS coordinated transportation and staffing for escorts. The DON stated the facility routinely sent escorts with residents who needed them. The DON reported she could not locate a facility policy for scheduling outside appointments for the residents.During a record review of Resident 1's electronic medical record (EMR), Resident 1's Face sheet and Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 4/22/26 was reviewed. Resident 1's Face Sheet showed she was an 84 year old female admitted on [DATE] with a history of encephalopathy (brain not working properly due to disease or injury); muscle weakness; abnormal gait and mobility; Type 2 diabetes; end stage renal disease (ESRD); cancers of the frontal lobe, endometrium, thyroid gland, and right kidney; hypertension; anxiety; and dependence on renal dialysis. Her MDS Section C showed a BIMS score of 9, indicating moderate problems with thinking and memory. Section GG indicated she needed help with functional cognition, previously used a manual wheelchair and walker, required substantial/maximal assistance for toileting and upper body dressing, and was dependent for lower body dressing. ADL documentation for May 2026 showed she was often incontinent and usually required substantial/maximal assistance or was dependent for transfers, dressing, and wheeling her wheelchair.

Based on interview, observation, and record review, the facility failed to maintain accurate documentation for one of three sampled residents (Resident 2) when LVN 1 documented Resident 2's wound care and bandage change was completed on 5/15/26. This failure resulted in inaccurate wound care documentation and had the potential to result in delayed wound healing, infection and sepsis.During a concurrent observation and interview on 5/15/26 at 11:45 am with Certified Nurse Assistant 1 (CNA 1), Resident 2 was observed in her bed. CNA 1 stated the facility was treating Resident 2's foot wounds with blue protective booties. When CNA 1 exposed Resident 2's feet, Resident 2 was wearing the booties on both feet. CNA 1 said they could not see any dressings and did not know whether any should have been present.During a concurrent observation and interview on 5/15/26 at 11:50 am with Licensed Vocational Nurse 1 (LVN 1), Resident 2 was observed in her bed. LVN 1 stated the treatment orders for Resident 2's wounds included hydrocolloid dressings and protective booties. LVN 1 exposed Resident 2's feet and removed the blue protective booties. LVN 1 stated she could not see any wound dressings on Resident 2's wounds. LVN 1 stated she had just finished giving medications to the residents and was about to start on dressing changes. When asked why there was no dressings currently on the wounds, LVN 1 stated it might have come off on the night shift and they forgot to replace it.During a concurrent interview and record review on 5/15/26 at 12:18 pm with the Director of Nursing (DON), Resident 2's medical records were reviewed. Resident 2's Physician's Order for wound care dated 4/24/26 at 6:34 pm, indicated Cleansed with NS (normal saline, a sterile salt solution), pat dry, apply [name of hydrocolloid dressing- a special type of bandage that promotes healing and protects the area from bacteria] to wound and cover with [name of bandage roll- a type of woven absorbent dressing] as needed AND every day shift every Tue, Fri. The DON reviewed the May 2026 TAR (Treatment Administration Record) and stated that LVN 1 had documented the wound care cleansing and dressing as completed that morning [5/15/2026].During a concurrent observation and interview on 5/15/26 at 12:30 pm with the DON, Resident 2's feet were observed. The DON stated she could not find any dressings on Resident 2's foot wounds.During a concurrent interview and record review on 5/15/26 at 12:31 pm with LVN 1, LVN reviewed Resident 2's TAR for 5/15/26 and stated they had mistakenly documented the dressing change as completed. LVN 1 said they had been checking boxes and accidentally checked the wound care box before providing care. LVN 1 acknowledged that documenting care before completing it was poor practice because it could result in wound treatments not being completed timely which could cause infection, wound worsening, sepsis, or amputation.During a concurrent interview and record review on 5/15/26 at 12:40 pm with DON, the facility's Policy & Procedure (P&P) titled Charting and Documentation, dated July 2017, was reviewed. The DON stated that nurses sometimes document orders as completed before performing them, which the DON identified as not being best practice because it could lead to missed care. The DON said the facility had not followed its policy.During a concurrent interview and record review on 5/15/26 at 12:51 pm with the Administrator (ADM), the facility's Policy & Procedure (P&P) titled Charting and Documentation, dated July 2017, was reviewed. the ADM stated Licensed Nurses were expected to follow orders and document only after completing them. The ADM stated documenting before performing care could cause treatments to be missed while appearing completed, leading to negative resident outcomes.During a review of Resident 2's medical records, Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident)(undated), the face sheet indicated Resident 2 was a [AGE] year old female who was admitted to the facility on [DATE] and had a medical history that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and local Infection of the skin and subcutaneous (fat layer under the skin) tissue. Resident 2's BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated 4/21/26, indicated Resident 2 was Severely impaired - never/rarely made decisions.During a review of the facility policy and procedure titled, Charting and Documentation, dated July 2017 indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.5. All documentation shall be accurate, complete, timely, and reflective of the care and services provided.6. When documentation errors are identified, the facility may enter an addendum or correction in accordance with facility policy to clarify the record while preserving the original entry.9. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided.

Based on observation, interview, and record review, the facility failed to maintain a functioning communication system (call light system-an alerting device used by residents to request assistance from nursing staff) for 11 out of 59 resident beds (11A, 11B, 11C, 8A, 8B, 14A, 14B, 17B, 17D, 15A, 15B) when the patient call light system was not activated when the call light was pressed and one resident was missing a call light button. This failure resulted in the affected facility residents being unable to call for help or receive immediate assistance from staff, which placed residents' health and safety at risk.During a concurrent observation and interview on 3/2/26 at 9:57 a.m. with Resident 1, in the resident's room, Resident 1 stated his call light had been working intermittently since his admission on [DATE]. Resident 1 stated his call light stopped working again on 3/1/26 and was still not functioning. Resident 1 pushed on his call light button and there was no light above the door, sound or light at the bed station panel (a wall mounted communication component of the call system that the call light cord plugs into). Resident 1 stated the light on the panel above where the call light cord inserts will usually turn on if the call light was working. The panel had a splitter adapter plugged into the jack and there were two call light cords plugged into the adapter. Resident 1 stated in the past he had gotten out of bed by himself to his wheelchair and went to the door to yell for help. Resident 1 stated he was not steady when transferring and required help to do it safely. Resident 1 stated there was one day a few weeks prior that he had a bowel movement and had to wait for approximately an hour to be cleaned up because his call light was not working. Resident 1 stated the Director of Maintenance (DOM) had come into his room about 3 weeks prior to fix the call light but was unable to fix it. Resident 1 stated the DOM would say he ordered the wrong part or parts were not coming in to fix it. Resident 1 reported when the light first stopped working, he was really upset but now he had gotten used to it. Resident 1 stated he was frustrated that the light continues to not work correctly. During Resident 1's interview, the DOM walked into the room holding a call light cord and stated he received a work order to replace the cord, the DOM received a phone call and stepped out without replacing Resident 1's cord and Resident 1 shook his head and said, he didn't fix it [the call light]. During a review of Resident 1's admission Record (AR), undated, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including mastoiditis (infection of the mastoid bone located just behind the ear), Bell's Palsy (sudden weakness of muscles in one side of the face), muscle weakness, and repeated falls. During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 13 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During an interview on 3/2/26 at 10:29 a.m. with the DOM, the DOM stated there were five call lights not working in the facility. The DOM stated staff completed work order requests on Sunday 3/1/26 regarding the call lights in rooms 8, 11 and 14. The DOM had the paperwork in his hands and stated he had not been told previously that Resident 1's call light was not working intermittently for the past six weeks. The DOM stated, First I have heard of these not working. The DOM stated he walked into Resident 1's room to replace the call light cord because there was a loose contact in the panel, he was going to tighten it and put a new cord in. The DOM stated he was not sure if he had received a previous work order for Resident 1's room.During a concurrent observation and interview on 3/2/26 at 10:35 a.m., in Residents 2 and 3's room. Resident 2 was alert with some confusion and stated I do not have a call light, somebody stole it. Resident 2's bed area was observed and there was no call light near the resident or her bed area. Resident 3's bed area was observed and there was a small silver bell on her overbed table. Resident 3 did not have a call light within her bed area. Resident 3 had partial deformity noted to her hands, making it difficult to use the silver bell.During a review of Resident 2's AR, undated, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including anxiety (feelings of fear, dread, and uneasiness) and dementia (a progressive state of decline in mental abilities).During a review of Residents 2's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 2's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 13 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact.During a concurrent observation and interview on 3/2/26 at 10:42 a.m. with the DOM, room [ROOM NUMBER] beds A and B's call lights were checked. The DOM pressed the button for each bed, and the call light did not turn on. The DOM checked the panel and stated the plug was loose and slightly pulled out of the panel. The DOM pushed the plug back into the panel and the call lights started to work. room [ROOM NUMBER]'s call lights were checked and the resident in 11 A did not have a call light. The DOM looked under the bed and behind the bedside table and stated, I don't know where it is. room [ROOM NUMBER] B was observed and there was no call light, but the resident had a silver bell on her overbed table. The DOM stated the silver bell was there because the call light was not working. The DOM went to 11C and pushed the call light, and there was no light or sound from the call light. The DOM stated he received a work order to check room [ROOM NUMBER]'s call lights that morning.The following call lights were checked and not working:8 A-did not work8 B- did not work- The DOM stated I have a new cord and will be ordering a dual panel for the room.11 A- no call light11 B- no call light11 C- did not work14 A- did not work14 B- did not work17 B- did not work17 D-did not work15 A- did not work15 B- did not workThe DOM stated it was very important for the call lights to work properly because the residents needed a way to call the staff for help if they need attention.During an interview on 3/2/26 at 1:40 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to rooms [ROOM NUMBERS] but was unaware the call lights were not working. CNA 1 stated the previous shift had not reported there was an issue with the call lights in those rooms. CNA 1 stated the residents needed a way to call for help, if they needed water and to prevent falls. CNA 1 stated the call lights were an important way for residents to communicate their needs to the staff.During an interview on 3/2/26 at 2:05 p.m. with CNA 2, CNA 2 stated she did not know there were issues with multiple call lights in the facility. CNA 2 stated the call light to room [ROOM NUMBER] C would not work at times, and the cord would come slightly out of the panel and would have to be pushed back in to start working again. CNA 2 stated call lights were important to call for help, prevent falls and for resident safety.During an interview on 3/2/26 at 2:26 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was not aware the call lights in room [ROOM NUMBER] were not working. LVN 1 stated she was not aware there were other call lights in the facility not working.During a concurrent interview on 3/2/26 at 2:36 p.m. with the Administrator (ADM) and the DOM, the ADM stated he and the DOM checked several call lights and found some of the panels needed the socket tightened on the wall where the call light plugs in. The ADM stated they found there were issues with the call light cords loosening when the beds were hitting them and any small movement caused the lights to not work. The DOM stated he adjusted the panel in room [ROOM NUMBER] because there was not a lot of grip on the end of the call light causing it to slide out and not work.During a concurrent interview and record review on 3/2/26 at 2:42 p.m. with the ADM, the ADM stated the department heads do Angel Rounds (department heads checking on assigned residents in the morning for issues and reporting them during the stand-up meeting) in the mornings and were supposed to check for call light function during rounds. The ADM stated if the department heads found call light issues they would report them during their stand-up meeting otherwise call light issues were reported to the DOM on a maintenance request form by the staff and placed in a binder at the nurses' station. The ADM stated the DOM would review the forms and address the issues. The facility's Maintenance request forms (MRF), dated 1/13/26, was reviewed, the form indicated, . 14D call light not working. Maintenance response. Date completed: 1/20/26. comments: call light working again. The MRF, dated 2/3/26, indicated, . Rm [room] 14 call light system not working for all beds. The MRF, dated 2/3/26, was reviewed and indicated, . call light system not working. Location/room. 8B. date completed: 2/5/26. call light had bad connection in wall. The MRF, dated 2/3/26, indicated, . need call light for both beds. Location/room. 18. completed: 2/9/26. comments: 2/5/26 split connector ordered will replace when arrives. The MRF, dated 2/4/26, indicated, . Call light don't work for room [ROOM NUMBER]. Maintenance response. Date completed: 2/5/26. Call lights working again for all beds in room [ROOM NUMBER]. The facility's MRF, dated 2/20 (2026), indicated, . 11 a doesn't have a call light. Maintenance response . Date completed: 2/23/26. comments call light put in for A bed. The MRF, dated 02/26/26, indicated, . room [ROOM NUMBER]. call light not working. Maintenance response. Date completed: 3/2/26. call lights checked & are good. The ADM stated he was unaware there were several call lights not functioning properly and had not been notified room [ROOM NUMBER] had four maintenance request forms.During an interview on 3/2/26 at 3:00 p.m. with LVN 2, LVN 2 stated room [ROOM NUMBER]'s call lights had not worked for approximately two months. LVN 2 stated there were portable call light buttons given to the residents and there was a receiver plugged in at the nurses' station which would ring when the buttons were pressed. LVN 2 stated she was aware room [ROOM NUMBER] had issues with the call lights at least twice in the previous month. LVN 2 stated if call lights were not working, it was reported to the DOM via a request form. LVN 2 stated it was important to notify the next shift in report if the call lights were not working and to set up frequent checks for resident safety.During an interview on 3/2/26 at 3:23 p.m. with the Scheduler (SCH), the SCH stated she did Angel Rounds for rooms [ROOM NUMBERS]. The SCH stated room [ROOM NUMBER]'s call lights were not working for approximately 2 months, and the residents had been provided with silver bells which were then replaced with the portable call buttons. The SCH stated she thought she checked the call lights earlier in the day but was unaware the resident in 11 A did not have a call light or bell.During a concurrent interview and record review on 3/2/26 at 4:00 p.m. with the DOM, the MRF, forms were reviewed, the DOM stated there were multiple MRFs for room [ROOM NUMBER] because there were issues with different call lights at different times. The DOM stated he did not remember there had been a previous request form for room [ROOM NUMBER] B in February and stated he brought a new call light to the room this morning because of a request he received this morning.The DOM stated he did not do routine maintenance checks on the call lights in the facility, but they were checked by department heads during Angel Rounds. The DOM stated the department heads would report if there were any issues found with the call lights in the morning stand up meeting.During an interview on 3/2/26 at 4:13 p.m. with the Director of Nursing (DON), The DON stated room [ROOM NUMBER] call lights had not been working since January and the facility gave the residents portable call lights to be used until they could be fixed. The DON stated she was told there were connection issues with the call light system in room [ROOM NUMBER]. The DON stated she was unaware the resident in 11 A did not have a call light. The DON stated it was important for the call lights to work properly so the staff could tend to the residents' needs, especially for activities of daily living (bathing, dressing, toileting, transferring, and eating) assistance. The DON stated it could also be a safety issue if the residents tried to get up for help increasing the risk of falls.During a review of the facility's Angel Rounds form untitled, for rooms [ROOM NUMBERS], dated 2/23/26-2/26/26, the form indicated, . Day 2 [2/24/26] . call light button broken. Rm [room] 11.During a review of the facility's policy and procedure (P&P) titled Call Lights: Accessibility and Timely Response, dated 9/2/2022, the P&P indicated, . The purpose of this policy is to assure the facility is adequately equipped with a call light. Staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. staff will ensure the call light is within reach of resident and secured. Staff will report problems with a call light or call system to the supervisor and/or maintenance director.During a review of the facility's job description titled Maintenance Director, dated 8/2025, the job description indicated, . Responsible for the building, the equipment and other materials located in and around the physical property. maintain it in good, clean, and safe order. Maintain a safe and secure environment for all staff, residents and guests.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for one of seven residents (Resident 17) when Resident 17 was assessed with poor safety awareness, did not use safe techniques in self-transfers, had unsteady gait, and suffered multiple falls on 11/18/25, 11/22/25,11/23/25 and 11/24/25. Resident 17 had been determined as high risk for falls on quarterly assessment dated [DATE]. The facility failed to follow its facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, when the facility did not implement effective interventions to prevent falls, including adequate supervision, addressing the cause of frequent self-transferring attempts and reviewing medication for a possible cause consistent with Resident 17's needs, goals and care. The facility failed to follow their policy and procedure titled, Red Sneaker Program (Fall Monitoring/Prevention) when he facility developed a plan to monitor residents every 15 minutes and was not accurately implemented by nursing staff in accordance with Resident 17's comprehensive care plan and the level of monitoring should have been changed to level 3 monitoring with direct supervision. These failures resulted in Resident 17 sustaining four unwitnessed falls on 11/18/25, 11/22/25, 11/23/25, and 11/24/25. During the fall on 11/24/25, Resident 17 was sent out to the acute care hospital due to severe pain in her right hip and inability to bear weight to right leg and was diagnosed with Periprosthetic fracture around internal prosthetic right hip (a broken bone around a hip replacement). During hospitalization, Resident 17 had a surgical procedure ORIF (open reduction internal fixation (is surgery used to stabilize and heal a broken bone) right femur (right thigh bone). Resident 17 experienced a significant change of condition after the fall on 11/24/25, suffered avoidable pain, injury to the right thigh, decreased mobility and decreased quality of life. Findings:During a concurrent observation and interview on 12/2/25 at 9:20 a.m. with Resident 17, in Resident 17's room, Resident 17 was awake, lying in bed with a white sheet covering her body. Resident 17's bed was at standard height position and wheelchair was parked beside Resident 17's left side of the bed. Resident 17 was alert and oriented and able to state her name. Resident 17 was able to recall her recent fall on 11/24/25. Resident 17 stated she fell in her room and went to acute care hospital. Resident 17 stated she fell while walking around the room and stated the fall happened in the morning. After the fall, Resident 17 stated she had no broken bones and showed her right arm with a dried skin tear. Resident 17 stated she is aware of her need to use the bathroom, and she was unable to walk by herself to go to the bathroom. Resident 17 stated, not easy to move my leg. Resident 17 stated she had a bandage on her right leg. Resident 17 stated she had shoulder discomfort and receiving pain medication, and stated, just feel sore here (pointing to right shoulder).During a review of Resident 17's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 12/8/25 , the AR indicated, Resident 17 was initially admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease causing difficulty in breathing), Protein Calorie Malnutrition (is the state of inadequate intake of food (as a source of protein, calories, and other essential nutrients), Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), Sleep Disorder, Anemia (disease that occurs when the body doesn't have enough red blood cells to carry oxygen), Essential Hypertension (abnormally high blood pressure [the amount of force the heart uses to pump blood through the arteries] that is not the result of a medical condition), Osteoarthritis (is a degenerative joint disease that can affect the many tissues of the joint) of Right Shoulder, Chronic Pain syndrome (is pain that persists or recurs for longer than 3 months, and, Scoliosis (is a side-to-side curve of the spine). Resident 17 was readmitted from acute hospital on [DATE] with the following Periprosthetic fracture around internal prosthetic right hip (a broken bone around a hip replacement), Generalized muscle weakness, Abnormalities of gait and mobility (an unusual walking pattern), Spinal Stenosis (a narrowing of the spine that causes pressure on the spinal cord and nerves and can cause pain), and Repeated falls (experiencing two or more falls within a specific timeframe).During a review of Resident 17's progress note, dated 11/27/25, indicated, Received a call from acute care hospital.Resident 17 was admitted on [DATE] for ground level fall, fracture of right femur. ORIF was done on 11/25/25.During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 12/1/25, the MDS section C indicated Resident 17 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 3 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 17 was severely cognitively impaired.During a review of hospital records titled, Case Management Discharge Summary/Orders Report, dated 11/27/25, indicated, .Discharge Diagnosis: (Principal) Periprosthetic fracture around internal prosthetic right hip, Frequent falls.Hospital Course: .with primary history of Alzheimer's.who presented to CRMC (Community Regional Medical Center) from SNF (skilled Nursing Facility).reportedly having increasing falls.sustained an unwitnessed fall yesterday afternoon (11/23/25) and then another unwitnessed fall at 0230, this morning per nursing staff, they attempted to ambulate her after the fall this morning, patient reported pain to her right thigh.transport to CRMC for evaluation. On arrival, patient continued to endorse right thigh pain and radiographs were obtained which demonstrated a right femur periprosthetic fracture.Procedure during this hospitalization: right femur (right thigh bone) open reduction internal fixation (is surgery used to stabilize and heal a broken bone).During a concurrent observation and interview on 12/3/25 at 9:00 a.m. to 9:15 a.m. with Resident 17, in the hallway by the Resident 17's room, Resident 17 was up in a wheelchair with a bandage wrapped around Resident 17's right lower extremity. Resident 17 was propelling her wheelchair slowly and stating she was lost. Resident 17 continuously self-propelled her wheelchair while waiting for staff to assist her.During an interview on 12/4/25 at 9:58 a.m. with Restorative Nurse Assistant (RNA), RNA stated she was familiar with Resident 17. RNA stated Resident 17 was very high risk for falls because she's been falling multiple times and was sent out to the acute care hospital related to a fall. RNA stated Resident 17 had been doing unsafe transfers from bed to wheelchair forgetting to lock the wheelchair. RNA stated Resident 17 can stand and walk in her room with an unsteady gait (a shaky, wobbly, and unstable way of walking). RNA stated she observed a decline in Resident 17's activities of daily living (ADL's - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and cognition when Resident 17 returned from the acute care hospital last week. RNA stated Resident 17 had been on Fall Program Level 2 monitoring (every 15-minute check) and had been falling. RNA stated someone should be with Resident 17 around the clock to prevent additional falls.During an interview on 12/4/25 at 10:00 a.m. with Certified Nurse Assistant (CNA) 3, outside Resident 17's room, CNA 3 stated Resident 17 had a red shoe sneaker picture by her name which indicated Resident 17 was high risk for falls. CNA 3 stated Resident 17 was confused (a state of mental uncertainty where you can't think clearly, feeling disoriented, and having trouble with memory, focus, or decision-making), and she does not use her call light. CNA 3 stated prior to Resident 17's injury related to the fall; Resident 17 always attempted to get up from bed and do self-transfer from bed to wheelchair without assistance from the staff. CNA 3 stated Resident 17 can propel her wheelchair. CNA 3 stated Resident 17 had a decline in function after the fall on 11/24/25, Resident 17 was wearing a brief for incontinence and oral intake was decreased to 25 percent and was provided a bed bath. CNA 3 stated that all residents with level 2 monitoring were documented in a binder. CNA 3 stated level 2 monitoring means every 15-minute check. During a concurrent interview and record review on 12/5/25 at 10:45 a.m. with the Registered Nurse Supervisor (RNS), the RNS stated Resident 17's Medication Regimen Review (MRR) for a fall on 11/18/25 was unable to locate in Resident EMR's and hard copy chart and stated, if not in chart it was not done. The RNS stated Resident 17 was on antianxiety (drug used to treat anxiety [characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities) medication prior to hospitalization and it was discontinued at the acute hospital. The RNS stated Resident 17's MMR after the fall should be completed to address medications that can be contributing to the falls to prevent additional falls.During a review of Resident 17's Electronic Medication Administration Record (EMAR- an electronic daily documentation record used by a licensed nurse to document medications and treatments given to a resident)), dated 11/2025, the EMAR indicated, .Melatonin 3 mg (milligrams- metric unit of measurement, used for medication dosage and/or amount) give 1 tablet by mouth at bedtime for dietary supplement start date: 9/10/24; D/C (discontinue) date: 11/27/25.Clonazepam 0.5 mg give 1 tablet by mouth three times a day related to Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), start date: 8/20/25 D/C date: 11/27/25. During a concurrent interview and record review on 12/4/25 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 3, the facility's fall program monitoring was reviewed. The monitoring form indicated, Level 2 = [equals] Q [every]15 minute dated 11/27/25 name of Resident 17 readmit date started 11/27/25 p.m. DC (Discontinue Date) 11/30/25 p.m. LVN 3 stated Resident 17 Level 2 monitoring was ended on 11/30/25 and she was informed by Interdisciplinary Team (IDT) to start every15 minute check today (12/4/25). LVN 3 stated she was the nurse of Resident 17 and was aware of her repeated falls. LVN 3 stated Resident 17 is high risk for falls due to frequent falls on 11/18/25, 11/22/25 and 11/24/25, unsafe self-transfers and impaired safety awareness (the practice of finding and recognizing risks and hazards). LVN 3 stated level 2 monitoring for Resident 17 was not effective due to increasing number of falls. LVN 3 stated she believed that Resident 17 should be on level 3 monitoring which provides one on one supervision to prevent further falls and to minimize injuries related to falls.During an interview on12/4/25 at 2:41 p.m. with CNA 7, CNA 7 stated Red Shoe Sneaker Program is a Fall Program in which residents with a recent fall are placed on Level 2 monitoring (every 15-minute check) for 72 hours to prevent further falls. CNA 7 stated she was assigned to Resident 17, and she will be responsible for 15-minute check monitoring and responsible in providing care to other residents in their assignment. CNA 7 stated she could not do every 15-minute check monitoring consistently when she was providing care to another resident. CNA 7 stated Resident 17 attempted to stand up and transfer herself from wheelchair to toilet without calling for assistance. CNA 7 stated Resident 17 was a fall risk and requires assistance from staff for transfers. During a concurrent interview and record review on 12/5/25 at 3:27 p.m. with the RNS, Resident 17's oral intake dated 11/28/25-12/5/25, and ADLS care plan, dated 11/27/25 were reviewed. The oral intake indicated multiple refusals and percentage of 0-25. The ADLs care plan indicated, LTCP (long term care plan)I have a physical functioning deficit r/t :Mobility impairment, self-care impairment secondary to dx of Alzheimer's Disease date initiated 11/27/27, Goal: I will maintain current level of physical functioning initiated date 8/7/23, Interventions/Tasks: 'Tasks Assistive device wheelchair, bed mobility; requires supervision assistance with bed mobility; Eating: requires set=up assistance; resident is ambulatory walk 10 feet -supervision; Toileting: resident requires supervision assistance w/toileting; Transfer: resident requires supervision assistance w/transfers initiated date 8/7/23 revision on 8/8/25. The RNS indicated had a decline in oral intake in the past week with multiple refusals and some 0-25 percent of oral intake. The RNS stated Resident 17's ADLs care plan indicated Resident 17 requires supervision with bed mobility, walking, transfers and toileting. The RNS stated Resident 17 had a decline in physical functioning and nutrition when she returned from the acute care hospital on [DATE]. The RNS stated Resident 17's care plan should be revised according to Resident 17's significant change of condition. The RNS stated Resident 17's ADLs care plan should reflect current level of function for staff to follow safely.During an observation on 12/5/25 at 7:45 a.m.-8:00 a.m. with Resident 17, in Resident 17's room, Resident 17 was lying asleep in bed. There were no staff who went to Resident 17's room to check Resident 17. During concurrent interview and record review on 12/5/25 at 10:45 a.m. with the RNS, Resident 17's Electronic Medical Records (EMR- a digital version of a patient's paper chart) titled Risk for Fall Assessment, dated 11/18/25, 11/22/25, and 11/24/25, and Quarterly Fall Assessments dated 11/1/23 and 2/1/24 were reviewed. The Risk for Fall Assessments indicated, .13i. Total score greater than 10 resident is considered at risk for falls: 11 13j. At risk for falls: Yes. The Quarterly Fall Assessments indicated, high fall risk score of 13. The RNS stated Resident 17's fall risk assessment scores were 11 which indicated risk for falls and 13 which indicated Resident 17 was high risk for falls. The RNS stated Resident 17 had an impaired safety awareness and unsteady gait that placed her at increased risk of falling.During concurrent interview and record review on 12/5/25 at 11:00 a.m. with the RNS, Resident 17's SBAR (Situation-Background-Assessment-Recommendation) post Fall, dated 11/18/25, 11/22/25, and 11/24/25 were reviewed. The SBAR post Fall, dated 11/18/25, indicated, .S. Situation 1. Prior to fall resident was a. Ambulating 2. Location in center: c. Hallway 5. Adaptive Equipment at time of fall: d. None 6. Footwear at time of fall b. Bare feet. B. Background 3. Fall Risk Factors: a. History of falls .10. Fall type b. Unwitnessed 10a. Fall Details a. Lost Balance. The SBAR post Fall, dated 11/22/25 indicated, .S. Situation 1. Prior to fall resident was i. Other: putting her slippers on 2. Location in center: a. Resident room [ROOM NUMBER]. Adaptive Equipment at time of fall: d. None 6. Footwear at time of fall b. Slipper s. B. Background 3. Fall Risk Factors: a. History of falls 10. Fall type b. Unwitnessed 10a. Fall Details d. Roll/slid out of bed. The SBAR post Fall, dated 11/24/25 indicated, .S. Situation 1. Prior to fall resident was b. Attempt to self-transfer 2. Location in center: a. Resident room. 5. Adaptive Equipment at time of fall: d. None 6. Footwear at time of fall b. Bare feet. Fall type b. Unwitnessed 10a. Fall Details a. Lost Balance. The RNS stated SBAR was also called a change in condition assessment. The RNS stated Resident 17's SBAR post fall dated 11/18/25, 11/22/25, and 11/24/25 were all unwitnessed falls and had identified risks factors of falling.During concurrent interview and record review on 12/5/25 at 11:20 a.m. with the RNS, Resident 17's Progress Note, dated 11/18/25, 11/22/25, 11/23/25, and 11/24/25 were reviewed. The Progress Note, dated 11/18/25, indicated, at 3:30 a.m. found resident sitting on the floor . The Progress Note, dated 11/22/25, indicated, Approximately 11:00 a.m.patient is sitting on the floor. The Progress Note, dated 11/23/25, indicated, at begin of shift, approximately 1405.was sitting on floor . The Progress Note, dated 11/24/25, indicated, Around 2:30 a.m. the CNA heard a loud thud.found resident on the floor . The RNS stated Resident 17 had been falling on the scheduled 15-minute check on 11/18/25, 11/22/25, and 11/24/25. The RNS stated the level 2 monitoring is an intervention for the facility's fall program. The RNS stated the facility's fall program (Red Sneaker Program) should be reviewed by Interdisciplinary Team (IDT) to prevent falls. The RNS stated Resident 17 level 2 monitoring was not effective, and she should be on level 3 monitoring (one on one) to prevent further falls and minimize fall related injuries. During an interview on 12/5/25 at 1:50 p.m. with CNA 6, CNA 6 stated Resident 17 had an episode of agitation (a feeling of irritability, mental distress or severe restlessness) on 11/23/25. CNA stated on 11/23/25 all p.m. shift CNAs were at the nursing station for a shift-to-shift report. CNA 6 stated they heard a loud scream from the nursing station and found Resident 17 was sitting on the floor in another resident room. CNA 6 stated Resident 17's wheelchair brake on one side was unlocked. CNA 6 stated Resident 17 is high risk for falls and had behaviors of physical aggression (the use of physical force to harm another person) like pushing and scratching other residents and staff. During telephone interview on 12/5/25 at 3:00 p.m. with LVN 2, LVN 2 stated she was the night shift nurse when Resident 17 fell on [DATE] at 2:30 a.m. LVN 2 stated CNA 8 heard a sound while she was performing patient care in room [ROOM NUMBER] or room [ROOM NUMBER]. LVN 2 stated there were six residents in room [ROOM NUMBER] and in room [ROOM NUMBER]. LVN 2 stated CNA 8 went to Resident 17's room and found Resident 17 on the floor. LVN 2 stated CNA reported to her that Resident 17 fell. LVN 2 stated Resident was on the floor facing the hallway and kept trying to get up from the floor. LVN 2 stated Resident 17 was screaming in pain and Resident 17 stated, my hip hurts. LVN 2 stated she suspected of having a hip fracture and Resident 17 was sent out to acute hospital for further evaluation and treatment. LVN 2 stated Resident 17 had been falling and it was a protocol to do level 2 monitoring after the fall and stated there were no other new fall interventions in place. LVN 2 stated level 2 monitoring is a 15-minute check monitoring, CNA assigned to the resident will be responsible in doing every 15-minute check. LVN 2 stated Resident 17 is high risk for fall due to multiple falls. LVN 2 stated Resident 17 was alert with confusion and forgetfulness, with episodes of agitation like screaming and scratching staff, wandering room to room, and she was difficult to be redirected. LVN 2 stated Resident 17 requires one on one supervision to prevent further falls and decrease fall related injuries. LVN 2 stated she had been asking for the IDT for additional staff on night shift due to increasing falls and behaviors. During an interview on 12/9/25 at 9:45 a.m. with the Director of Nursing (DON), the DON stated Resident 17 was high risk for falls due to contributing factors such history of falls, unsteady gait, medications use, diagnosis of Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with impaired safety awareness. The DON stated they had an IDT meeting related to Resident 17's recent fall on 12/5/25 and she suggested a level 3 monitoring (one on one intervention). The DON stated Resident 17 had been on Level 2 monitoring related to repeated falls. The DON stated Resident 17 can benefit from one-on-one intervention to prevent additional falls and to minimize fall related injuries. The DON stated Resident 17's level 2 monitoring was not followed, and Resident 17 was not monitored and supervised in a timely and consistent manner. The DON stated there should be designated staff doing the level of monitoring to effectively manage the prevention of falls. The DON stated she believed all falls are preventable, including the falls experienced by Resident 17. The DON stated the facility's Red Sneaker Program procedures should be reviewed by IDT because each resident had different fall risk factors.During a concurrent interview and record review on 12/9/25 at 10:00 a.m. with the Director of Nursing (DON), Resident 17's EMR and hard copy chart were reviewed. The DON stated there was no MMR done for the fall on 11/18/25. The DON stated the timely completion of Resident 17's MRR for the fall on 11/18/25 was important because there were medications causing the fall for Resident 17. The DON stated Resident 17's falls on 11/22/24, 11/23/25 and 11/24/25 could be prevented if the MRR for the fall on 11/18/25 was completed and carried out. The DON stated there should be new interventions based on root cause of the fall and individualized care plans should be reflected in resident's care plan. The DON stated having individualized care plan was important for nursing staff to know their residents and implement appropriate fall interventions. The DON stated fall care plan interventions should be implemented to prevent falls and fall related injuries.During a concurrent interview and record review on 12/9/25 at 11:25 a.m. with MDS Coordinator (MDSC) 2, Resident 17's EMR titled, Care Plan Report, dated 11/18/25, 11/22/25, and 11/27/25 were reviewed, indicated, STCP(short term care plan) fall unwitnessed date initiated 11/18/25. Goal: minimize falls and fall related injuries revised date:12/4/25 Interventions.; At risk for falls found on the floor 11/22/25 date initiated 11/22/25 Goal: minimize falls and fall related injuries revised date:12/4/25 Interventions.; LTCP (long term care plan) At risk for injury or falls related injury due to resident has impaired safety awareness and does not use or unable to use the call light system secondary to Impaired cognition. Goal - Will have no injury, initiated date: 8/16/24 revision on 12/4/25; LTCP At risk for unavoidable falls and related injury secondary to History of falls, unsteady gait/balance and non-compliant with care. Other Contributory Factors: Meds: Melatonin (supplement to support sleep), Sertraline (antidepressant medication), Tramadol (pain medication). Goal - Minimize falls and fall related injuries-initiated date 11/27/25 revision on 12/4/25 Interventions. MDSC 2 stated Resident 17's fall care plans were not updated and revised with new interventions based on IDT fall reviews for Resident 17's fall on 11/18/25. MDSC 2 stated Resident 17's LTCP fall care plan was initiated on 11/27/25 when Resident 17 was readmitted to the facility from acute care hospital on [DATE].During a concurrent interview and record review on 12/9/25 at 11:45 a.m. with MDSC 2, Resident 17's EMR titled, Progress Notes IDT Fall Review, dated 11/18/25 was reviewed. The Progress Notes IDT Fall Review indicated, Event: unwitnessed fall. Root Cause analysis (Witness/Where/Why): Ambulating without assistance. Intervention: level 2 monitor, red sneaker program, .medication review, . monitor for s/sx (signs and symptoms) of UTI (Urinary Tract Infection- an infection in the bladder/urinary tract) .Refer to therapy. The MDSC 2 stated IDT fall interventions including monitor for signs and symptoms of UTI, medication regimen review, and therapy referral were not in Resident 17's fall care plan and were not implemented. MDSC 2 stated Resident 17's monitoring for UTI was not documented in Resident 17's health record. MDSC 2 stated there was no therapy evaluation done for the fall on 11/18/25, and the therapy evaluation was done on 11/28/25 when Resident 17 was readmitted to the facility from acute care hospital on [DATE]. MDSC 2 stated Resident 17 should be evaluated by the therapy related to the fall on 11/18/25. MDSC 2 stated Resident 17's new fall interventions should be implemented to prevent further falls and minimize major fall related injuries. MDSC 2 stated new fall interventions should be reflected in Resident 17's fall care plan to ensure interventions were in place and nursing staff should know the new fall interventions to be implemented to prevent falls. During an interview on 12/9/25 at 12:24 p.m. with LVN 2, LVN 2 stated Resident 17 was usually wide awake at night, self-propelling her wheelchair in the hallway, and wandering from room to room. LVN 2 stated night shift nursing staff were having a hard time redirecting Resident 17. LVN 2 stated Resident 17 does not use her call light for assistance with ADLs. LVN 2 stated, prior to the fall on 11/24/25 at 2:30 a.m., Resident 17 was up in a wheelchair self-propelling her wheelchair from the nursing station. LVN 2 stated CNA 8 should be checking Resident 17 every 15 minutes. LVN 2 stated CNA 8 documented on level 2 monitoring form that she checked Resident 17 on 11/28/25 at 2:30 a.m. but CNA 8 was performing patient care in another room at the time of the fall (2:30 a.m.). LVN stated it was difficult to provide adequate supervision when CNA 8 assigned for 15 minutes check was also assigned to provide care for another residents. LVN 2 stated Resident 17's fall could be avoided if there is a designated staff doing 15-minute check.During an interview on 12/9/25 at 2:13 p.m. with the Pharmacist Consultant (PC), the PC stated she does monthly medication regimen review and medication regimen review (MRR) for a fall and change in condition. The PC stated she completed Resident17's MRR for a fall on 11/18/25 and was sent to MDSC 2 and clinical consultant on 11/20/25 via electronic mail (email- is a communication method that uses electronic devices to deliver messages across computer networks). The PC stated she made recommendations to address Resident 17's pain medication, sleep medication and anti-anxiety medication that can be contributing factors for the falls. The PC stated when she completed MRR for Resident 17's fall on 11/22/25-11/24/25, Resident 17's 11/18/25's MRR recommendations related to the fall on 11/18/25 were not addressed and carried out. The PC stated MRR was important to address in a timely manner and marked as a clinical priority for Resident 17 due to her multiple falls. The PC stated Resident 17 is high risk for falls. The PC stated she had been working with the clinical consultant regarding the timeliness of the completion of MRR recommendations facility's response. The PC stated she believed all falls are avoidable and there were programs to mitigate the falls.During an interview on 12/9/25 at 2:48 p.m. with CNA 8, CNA 8 stated she was the assigned CNA for Resident 17, and she was responsible in doing 15-minute check when Resident fell on [DATE] at 2:30 a.m. CNA 8 stated on 11/24/25 around 2:30 a.m., she heard a loud sound coming from another room while she was performing care for one of her residents. CNA stated she went to Resident 17's room and found her on the floor. CNA 8 stated Resident 17 was one of the residents in her group assignment. CNA 8 stated she could not do every 15-minute check for Resident 17 while providing care to other residents. CNA 8 stated Resident 17 fall could be prevented if 15-minute check was done timely and consistently. CNA 8 stated Resident 17, being a fall risk with behaviors, unsafe transfers and ambulation without calling for assistance, should be on level 3 monitoring. CNA 8 stated Resident 17 needs one-on-one supervision.During a review of Resident 17's Progress Note, dated 11/18/25 and 11/24/25 were reviewed. The Progress Note dated 11/18/25, indicated, S/P (status post) fall, Screen performed interviewed pt and staff members regarding pt's fall, findings of poor safety awareness and decline in functioning. Therapy to assess. The Progress Note dated 11/24/25, indicated, Attempt for screen made s/p fall however pt is currently at hospital, screen to be complete once pt returns.During a review of facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, undated, the P&P indicated, Based on previous evaluations and concurrent data, the staff will identify the interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall Risk Factors 2. Resident conditions that may contribute to the risk of falls include. c. cognitive impairment, 6. Lower extremity weakness, g. medication side effects, i. functional impairments, .k. incontinence. 3. Medical Factors that contribute to the risk for falls include: a. arthritis; b. heart failure; c. anemia; d. neurological disorders; and e. balance and gait disorders; Resident-Centered Approaches to Managing Falls and Fall Risk 1. The IDT team in collaboration with the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once.) 3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving, footwear, changing the lightning, etc. 4. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even for a trial period. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or correct, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable e. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk - 1. The staff will monitor and document each resident's response to interventions intended to reduce fall or the risk of falling. 2. If the resident continues to fall, the staff will re-evaluate the situation and decide whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.During a review of facility's P&P titled, Red Sneaker Program (Fall Monitoring/Prevention) undated, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance t

Based on observation, interview, and record review, the facility failed to follow policy and procedures to meet professional standards of quality for one of four sampled residents (Resident 64), when Resident 64's admission medications were not available on the next dose as ordered by the physician. Resident was admitted to the facility on [DATE].These failures had the potential to place Resident 64 at an increased risk of health complications and change of condition resulting in hospitalization. Findings:During a concurrent observation and interview on 12/2/25 at 10:02 a.m. with Resident 64, in Resident 64's room, Resident 64 was awake lying in bed. Resident 64 was alert oriented x 4 (refers to someone who is alert and oriented to person, place, time and event). Resident 64 stated she was admitted from acute care hospital to the facility a couple of days. Resident 64 stated she fell at home and broke her pelvis. Resident 64 stated she had not received her medication since she came to the facility because she did not bring her medical card.During a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), MDS section C -Cognition Assessment was not completed. During a concurrent interview and record review on 12/5/25 at 9:27 a.m. with Registered Nurse Supervisor (RNS), Resident 64's progress notes titled, Orders-Administration Note, dated 12/2/25, 12/3/25, and 12/4/25 were reviewed. The Orders-Administration Note, indicated, .12/2/25 Folic Acid (is used prevent anemia, and support cell growth) pending delivery . Bumetanide (is a type of diuretic or water pill. It helps ease fluid buildup (or edema) in adults with heart failure, liver problems like cirrhosis, and kidney problems) pending delivery. Diltiazem Extended Release (treat high blood pressure and chest pain) pending delivery. Sertraline (use to treat depression [persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life]) pending delivery.Rifaximin pending delivery. Lactulose (is the first-line treatment used to prevent and treat hepatic encephalopathy (HE), a serious neurological complication of liver cirrhosis [a condition in which the liver is scarred and permanently damaged]) pending delivery faxed pharmacy. 12/3/25 Rifaximin (used to treat liver cirrhosis) pending delivery not available e-kit (emergency kit for medications). Gabapentin(used to treat nerve pain) pending delivery not available e-kit. 12/4/25 Rifaximin pending authorization. The RNS stated Resident 64's admission medications should be available on the next dose according to physician's orders. The RNS stated Resident 64's medications were ordered by the physician based on Resident 64's medical condition to prevent any complications to Resident 64.During a review Resident 64's admission Record (AR-a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 12/8/25, the AR indicated, Resident 64 was admitted to the facility on [DATE] with diagnosis of End Stage Renal Disease, (a condition where the kidneys can no longer function on their own and dialysis [a process of removing excess water, and waste products from the blood] or kidney transplant is required to survive), chronic kidney disease (a condition when the kidneys suddenly are unable to filter waste products from the blood), multiple fractures (broken bones)of pelvis, Alcoholic Cirrhosis of the Liver (permanent scarring that damages the liver and interferes with its functioning), anemia (disease that occurs when the body doesn't have enough red blood cells to carry oxygen), essential (primary) hypertension (abnormally high blood pressure [the amount of force the heart uses to pump blood through the arteries] that is not the result of a medical condition), type 2 diabetes mellitus (when the blood sugar levels in the body are too high), and major depressive disorder(a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 64's Order Summary Report, dated 12/8/25, indicated, .Pharmacy: Bumetanide 2 mg (milligram- metric unit of measurement, used for medication dosage and/or amount) give 2 tablets one time a day related to chronic kidney disease.Folic Acid 1 mg give 1 tablet one time a day dietary supplement. Diltiazem HCL Extended Release 240 mg give 1 capsule one time a day related to Essential Hypertension. Lactulose 20mg/30ml (milliliter -a standard metric unit of volume used to measure liquid medications) give 30 ml three time a day related to Alcoholic Cirrhosis of the Liver.Rifaximin 550 mg give 550 mg two times a day related to Alcoholic Cirrhosis of the Liver; Sertraline HCL100 mg give 1.5 tablet one time a day related to Major Depressive DisorderDuring an interview on 12/9/25 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated medications should be available as soon as possible, on next dose due for the residents to prevent a change of condition. LVN 3 stated the facility's current pharmacy delivery was taking longer to deliver the medications and stated there was delay in medication delivery. LVN 3 stated a delay in medication delivery can result in late administration of medications.During a telephone interview on12/9/25 at 2:15 p.m. with the Pharmacy General Manager of Operation (PGMO), the PGMO stated it was not acceptable for medication not available for the residents. The PGMO stated the pharmacy had multiple deliveries to provide the medications for the residents. The PGMO stated medications it was her expectation that medications should be available the next dose ordered. The PGMO stated she needed to investigate the cause of delay in delivery of Resident 64's medications.During a concurrent interview and record review on 12/9/25 at 2:39 p.m. with the RNS, Resident 64's Electronic Medication Administration Record (EMAR- an electronic daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 12/2025 was reviewed. The EMAR indicated, . Rifaximin 550 mg give 550 mg two times a day related to Alcoholic Cirrhosis of the Liver on 12/1/25, 12/2/25, 12/3//25, 12/4/25, 12/6/25, and 12/7/25 at 0800 and 1700, indicated 11. The RNS stated the #11 in Resident 64 EMAR indicated medication not available. The RNS stated Resident 64's Rifaximin medication should be available to manage and treat Resident 64's medical condition of cirrhosis of the liver and can potentially result in complications when not received by Resident 64.During a review of Resident 64's care plan report dated 12/2/25, the care plan report indicated, .Hemodialysis Care Plan at risk for complications fluid volume/deficit.Diuretic Med Care Plan Requires the use of diuretic therapy related to cirrhosis of liver, hypertension.Interventions: Administer medication as ordered.Liver Disease Care Plan at risk for abdominal pain and swelling, blood stool related to Cirrhosis. Interventions: Administer medication as ordered.At risk for hypotension(abnormally low blood pressure)/Hypertension related to Hypertension.Interventions: Administer antihypertensive or other medications as ordered.Antidepressant Care plan use for Drug: Sertraline. Interventions: Give antidepressant medications ordered by physician.During an interview on 12/9/25 at 3:40 p.m. with the Director of Nursing (DON), the DON stated Resident 64 was a new admitted resident. The DON stated new admission residents should have their medications available the next day or the next dose for the residents to receive their medications on time especially. The DON stated licensed nurses can access the e-kit for antibiotics and pain medications. The DON stated it was her expectation that all medications must be available to the residents based on physician's orders. The DON stated it was her expectation for the pharmacy to deliver the medications on time for the licensed nurses to administer medications as ordered. The DON stated it was important for residents to receive their medication as ordered by the physician to prevent complications to the residents.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications must be administered in accordance with the orders, including any required time frame.During a review of facility's P&P titled, Medication Services, dated 6/1/24, the P&P indicated, The Community provides medication ordering and medication assistance/administration services. i. Pharmacy identification will be selected as part of the intake process. b. All pharmacies are requested to meet the following minimum quality standards: .ii. Have the ability to provide twenty-four (24) hour emergency service including delivery of medications seven (7) days a week.

Based on observation, interview, and record review, the facility failed to employ sufficient staff with appropriate competencies and skills sets to carry out the functions of food and nutrition services for two of two kitchen staff, Dietary [NAME] (DC)1 and Dietary Manager (DM) when DC1 and DM did not follow the menu at lunch on 12/3/25.This failure had the potential to result in residents nutritional needs not being met.During a concurrent observation and interview on 12/3/25 at 12:30 p.m. with DC1 and DM in the Kitchen, DC1 was preparing a lunch with a croissant sandwich with turkey breast, fresh tomatoes, cheddar cheese, regular bacon, and lettuce. DC1 prepared two garlic bread sticks instead of one. DC1 stated the menu for the lunch sandwich was not followed. DC1 stated, she used what food she had available in the facility and she had informed the DM. DM stated she forgot to order the correct ingredients for the croissant sandwich. DC1 stated, she served two garlic bread sticks instead of one.During a review of the facility's menu titled, TURKEY CROISSANT DELUXE SANDWICH 20Z, dated 12/3/25, the menu indicated, croissant sandwich ingredients included lettuce, oven roasted [NAME] tomatoes, pickled red onions, turkey breast, sliced cheddar cheese, mozzarella, bacon onion marmalade and avocado.During a review of the facility's diet spreadsheet titled, Fall25 Foundation, dated 12/3/25, the diet spreadsheet indicated, . LUNCH. HOMESTYLE BREAD.1. SLICE GARLIC BREAD.During an interview on 12/9/25 at 11:05 a.m. with the Registered Dietician (RD), the RD stated DM forgot to buy the correct ingredients for the croissant sandwich and used whatever available ingredients they had in the kitchen. The RD stated DC1 got nervous, and she gave two bread sticks instead of one. The RD stated the purpose of the menu is to provide nutritionally balanced diet for the residents'. The RD stated if the menu was not followed it would not meet the residents' nutritional needs. The RD stated the kitchen staff did not follow the correct menu. The RD stated kitchen staff should have used a substitute menu instead of omitting the ingredients.During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the P&P indicated, Meals that meet nutritional needs of the resident will be served in an accurate and efficient manner. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's order and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are to be approved by the Facility Registered Dietician prior to the beginning of each quarterly menu cycle.

Based on observation, interview, and record review, the facility failed to employ sufficient staff with appropriate competencies and skills sets to carry out the functions of food and nutrition services for two of two kitchen staff, Dietary [NAME] (DC)1 and Dietary Manager (DM) when DC1 and DM did not follow the menu at lunch on 12/3/25.This failure had the potential to result in residents nutritional needs not being met.During a concurrent observation and interview on 12/3/25 at 12:30 p.m. with DC1 and DM in the Kitchen, DC1 was preparing lunch with croissant sandwich with turkey breast, fresh tomatoes, cheddar cheese, regular bacon, and lettuce. DC1 prepared two garlic bread sticks instead of one. DC1 stated the menu for the lunch sandwich was not followed. DC1 stated she used what food she had available in the facility and she had informed the DM. DM stated she forgot to order the correct ingredients for the croissant sandwich. DC1 stated she served two garlic bread sticks instead of one.During a review of the facility's menu titled, TURKEY CROISSANT DELUXE SANDWICH 20Z, dated 12/3/25, the menu indicated, croissant sandwich ingredients included lettuce, oven roasted [NAME] tomatoes, pickled red onions, turkey breast, sliced cheddar cheese, mozzarella, bacon onion marmalade and avocado.During a review of the facility's diet spreadsheet titled, Fall25 Foundation, dated 12/3/25, the diet spreadsheet indicated, . LUNCH. HOMESTYLE BREAD.1. SLICE GARLIC BREAD.During an interview on 12/9/25 at 11:05 a.m. with the Registered Dietician (RD), the RD stated DM forgot to buy the correct ingredients for the croissant sandwich and used whatever available ingredients they had in the kitchen. The RD stated DC1 got nervous and she gave two bread sticks instead of one. The RD stated the purpose of the menu is to provide nutritionally balanced diet for the residents. The RD stated if the menu was not followed it would not meet the residents' nutritional needs. The RD stated the kitchen staff did not follow the correct menu. The RD stated the kitchen staff should have used a substitute menu instead of omitting the ingredients.During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the P&P indicated, Meals that meet nutritional needs of the resident will be served in an accurate and efficient manner. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's order and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are to be approved by the Facility Registered Dietician prior to the beginning of each quarterly menu cycle.

Based on observation, interview and record review, the facility failed to follow-up with a positive Preadmission screening and Resident Review (PASARR-a federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) level I screening for one of five sampled residents (Resident 7 ) when Resident 7's PASARR level I screening dated 4/8/25 required PASARR Level II mental health evaluation and was not completed.This failure had the potential for Resident 7 to not receive the appropriate services related to her mental disorders.During a concurrent observation and interview on 12/2/25 at 11:06 a.m during initial tour in the doorway of Resident 7's room, Resident 7 was standing outside of room, dressed appropriately and stated she liked to keep her door closed. Resident 7 stated she did not have any issues and staff are good to her. Resident 7 was observed ambulating in the hallway with steady gait. During a review of Resident 7's admission Record [AR-a document containing resident profile information], dated 12/5/25, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder (sometimes called manic-depressive disorder, mood swings that range from the lows of depression to elevated periods of emotional high), schizoaffective disorder (mental disorder that can affect thoughts, mood, and behavior), anxiety (excessive and persistent worry, fear, or panic that is difficult to control and interferes with daily life) and dementia (a progressive decline in mental abilities). During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function), dated 10/2/25, the MDS section C indicated Resident 7 had a Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgment) assessment score of 3 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview), which indicated Resident 7's cognition was severely impaired . During a review of Resident 7's Notice of PASARR Level l Screening Report dated 4/8/25. The Notice of PASARR Screening Result indicated, .A Serious Mental Health Illness (SMI) Level ll Mental Health Evaluation is Required . During a review of Resident 7's Notice of Attempted Evaluation dated 4/12/25, the Notice of Attempted Evaluation indicated, . UNABLE TO COMPLETE LEVEL II EVALUATION FOR SERIOUS MENTAL ILLNESS (SMI) . Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the level I screening . During a concurrent interview and record review on 12/4/25 at 2:05 p.m. with the Infection Preventionist (IP), Resident 7's clinical record was reviewed. The IP stated Resident 7 was admitted with psychotropic medication and are monitored for episodes of mania. The IP stated Resident 7's PASARR level I dated 4/8/25 was positive and needed a PASARR level II assessment. The IP stated PASARR level II was incomplete and should have been followed up and it was not. During a concurrent interview and record review on 12/5/25 with Minimum Data Set Coordinator (MDSC) 1, Resident 7's clinical document titled PASARR was reviewed and stated Level II should have been followed up and completed another Level I assessment. MDSN 1 stated she did not know who received PASARR Level II and filed in Resident 7's record without reviewing. MDSN 1 stated it was important to follow-up on the PASARR in order for facility to know what type of services and needs Resident 7 needed to address her behavior. During an interview on 12/9/25 at 12:30 p.m. with the Director of Nursing (DON), the DON stated her expectation was to make sure PASARR are reviewed for accuracy and complete another assessment if needed. The DON stated the MDSN, business office manager, medical records and admission director are all responsible in making sure there was a PASARR completed and reviewed for accuracy prior to admission of resident to the facility. During a review of facility document titled, Job Description: MDS Coordinator, dated 1/29/25, the Job Description indicated, .Coordinates the development and completion of resident assessment (MDS) in accordance with current federal and state rules, regulations, and guidelines that govern the resident assessment . Facilitates the involvement of appropriate health professionals needed to improve or maintain the resident's functional abilities at the highest practicable level . During a review of facility's policy and procedure (P&P) titled, Resident Assessment - Coordination with PASARR Program, dated 2022, the P&P indicated, .All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related condition in accordance with the State's Medicaid rules for screening . The Social Service Director or designee shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority . Any level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review . During a review of professional reference from the California Department of Health Care Services (DHCS) (a government agency that provides healthcare services to low-income and disabled Californians) titled, Preadmission Screening and Resident Review, undated, (found at https://www.dhcs.ca.gov/services/MH/Pages/PASRR.aspx), the reference indicated .The (DHCS), PASRR Section is responsible for determining if individuals with serious mental illness (SMI) and/or intellectual/developmental disability (ID/DD) or related conditions (RC) require: Nursing facility services, considering the least restrictive setting, Specialized services. This is achieved by completing the PASRR process. The PASRR process consists of a Level I Screening, Level II Evaluation, and a final Determination. Level I Screening-The Screening is submitted online by the facility and is a tool that helps identify possible SMI and/or ID/DD/RC. Level II Evaluation- If the Screening is positive for possible SMI and/or ID/DD/RC, then a Level II Evaluation will be performed. The Level II Evaluation helps determine placement and specialized services. The Department of Health Care Services (DHCS) is responsible for SMI Level II Evaluations, which by law must be performed by a third-party contractor

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services which ensured appropriate administration of medications to meet residents needs when:1.The facility Refrigerator Emergency-kit (E-kit-contains medications provided to residents during emergency situations) containing three vials of insulin (used for high blood sugar level) was opened and no form was found indicating the date and name of person who opened the E-kit and no communication to pharmacy requesting for a replacement. This failure placed residents receiving insulin at potential risk for taking expired or compromised medications which could lead to serious consequences including reduced effectiveness in treating resident's condition in an event of an emergency and potential adverse reaction.2.Marianne1. During a concurrent observation and interview on [DATE] at 8:05 p.m. in the medication room with Infection Preventionist (IP), Refrigerator E=kit was found with red tags. The IP stated Red tag means it was already opened. The IP stated she can not find a form completed when the E-kit was opened. The IP stated whoever opened the E-kit did did not complete the form. The IP stated she was not sure when the E-kit was opened and what medication was taken. The IP stated she was not sure how soon should the pharmacy send a replacement once an E-kit was opened. During an interview on [DATE] at 9:35 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the practice when opening an E-kit was to complete the form that was usually with the E-kit with your name, date and medication taken and fax to pharmacy. LVN 2 stated she was not sure when pharmacy should send a replacement but it should be as soon as possible in case a medication from the E-kit was needed for emergency situations. LVN 2 stated E-kit have green tags when it was not opened and red tag once it was already opened. LVN 2 stated she checked the refrigerator in the morning prior to her morning medication pass but did not check the E-kit if it was opened. LVN 2 stated she did not open the E-kit and did not know who opened it because there was no form found. During an interview on [DATE] at 3:50 p.m. with Registered Nurse Supervisor (RNS), the RNS stated she did not know who opened the refrigerator E-kit because there was no form found. The RNS stated the practice was to complete the form when opening the E-kit then fax the form to pharmacy to let them know it was opened and a replacement was needed. The RNS stated the expectation was to get a replacement the same day in case of emergency situation when a medication was needed and was not available because the pharmacy did not replaced the E-kit. During an interview on [DATE] at 12:30 p.m. with the Director of Nursing (DON), the DON stated her expectation was to have the E-kit replaced the same day it was opened. The DON stated there was a form needed to be completed when opening an E-kit then fax pharmacy. The DON stated she was not sure when the E-kit was opened and how long it has been opened since there was no form completed. The DON stated there was no medicine missing from the E-kit and not sure why it was opened. The DON stated not sure if medication was tampered with or was replaced with another medication which could lead to potential serious health condition. During a review of facility (pharmacy[Omnicare]) policy and procedure (P&P) titled, Emergency Medication Supplies (Emergency Kits), revised date [DATE], the P&P indicated, Facility staff breaking the lock or tamper evident seal on the emergency kit should replace the lock with a tamper-evident lock or seal provided by the pharmacy and located in the emergency kit . record the name of the nurse who accessed the emergency kit, the date and time the e-kit was accessed . To indicate the emergency kit was opened by the facility staff and replacement of the box or replenishment of removed doses is needed, the tamper-evident lock or seals provided by the pharmacy may be a different color than the original one placed by the pharmacy . Fax the eKIT Withdrawal Communication form to the pharmacy. Retain the white copy in the facility files and place the duplicate yellow copy inside the tray from which the medication was removed .

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was eight percent. There were 25 opportunities for errors and two medication errors occurred for one of five sampled residents (Resident 2) when:1. Licensed Vocational Nurse (LVN) 1 prepared an expired medication of five tablets of Folic Acid (is used prevent anemia, and support cell growth)1 mg (milligram- metric unit of measurement, used for medication dosage and/or amount) with an expiration date of 11/5/25 on 12/4/25. LVN 1 did not check the expiration date of the medication prior to medication administration. 2. Resident 2 did not receive the full dosage of inhaler (a small, handheld medical device that delivers medicine as a mist or spray directly to the lungs for treating respiratory conditions like asthma and chronic obstructive pulmonary disease [COPD- a chronic lung disease causing difficulty in breathing]) medication Tiotropium Bromide Monohydrate (is used for the treatment of breathing problems in patients with COPD). It is a specific type of dry powder inhaler (DPI- device designed to deliver tiotropium medication to the lungs in a powder form; a maintenance bronchodilator helps to keep narrowed airways open) when Resident 2 received one inhalation of the inhaler medication on 12/4/25. These failures resulted in a medication error for Resident 2 and the potential for Resident 2 to consume an expired medication and to experience shortness of breath.Findings: 1.During an observation and interview on 12/4/25 at 8:52 a.m. with LVN 1, outside Resident 2's room, LVN 1 was preparing Resident 2's 8:00 a.m. medications on the top of the medication cart. LVN punched five tablets of Folic Acid 1 mg from Resident 2's medication card into the medicine cup. LVN 2 prepared the rest of Resident 2's morning medications and ready to crush each medication. LVN 2 was preparing to crush Resident 2's five tablets of Folic Acid 1 mg, nurse surveyor asked LVN 1 the expiration date of the medication Folic Acid 1 mg. LVN 1 opened the medication cart, took the medication card containing Resident 2's Folic Acid mg, was looking for where she could find the expiration date on the medication label. LVN 1 checked Resident's 2's Folic Acid 1 mg and indicated an expiration date of 11/5/25, stated, it was expired. LVN 1 stated Resident 2's medication card containing Folic Acid 1 mg had been used and had been expired since 11/5/25. LVN 1 showed and given Resident 2's medication card containing the expired Folic Acid 1 mg to the Director of Nursing (DON). During a concurrent interview and record review on12/4/25 at 2:20 p.m. with LVN 1, Resident 2's Electronic Medication Administration Record (EMAR- an electronic daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/2025 was reviewed. The EMAR indicated, .Folic Acid 1 mg give 5 tablets by mouth one time a day related to Anemia order date 10/14/25. LVN 1 stated she was not checking the expiration dates of medications she was preparing during the medication pass on 12/4/25. LVN 1 stated Resident 2's medication card containing Folic Acid 1 mg was not checked on 12/4/25. LVN 1 stated Resident 2's medication card containing Folic Acid 1 mg had been used and had been expired. LVN 1 stated Resident 2's expired Folic Acid 1 mg five tablets had been administered to Resident 2 if not asked by nurse surveyor to check the expiration date. LVN 1 stated Resident 2 had the potential to experience side effects when expired medications were consumed. LVN 1 stated that expired medication will not be effective. During a review of Resident 2's Order Summary Report, dated 12/9/25, indicated, .Folic Acid 1 mg give 5 tablets by mouth one time a day related to Anemia (a condition where the body does not have enough healthy red blood cells) order date 10/14/24 During a record review of Resident 2's admission Record (AR), dated 12/9/25, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of Anemia.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 10/9/25, the MDS section C indicated Resident 2 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 4 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 2 was severely cognitively impaired.During an interview on 12/9/25 at 10:54 a.m. with the DON, Resident 2's medication card containing the expired Folic Acid 1 mg was checked and validated on 12/4/25. The DON stated Resident 2's medication card containing the expired Folic Acid 1 mg had been used with an expiration date of 11/5/25. The DON stated Resident 2's expired medications had the potential to cause side effects to Resident 2. The DON stated expired medication was not as effective and does not work well with the residents. The DON stated it was her expectation for all licensed nurses to check the expiration date of medications prior to administering the medication to prevent medication error. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications must be administered in accordance with the orders, including any required time frame.10. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 12. The expiration/beyond use date on the medication label is checked prior to administering.During a review of the professional reference (PR), found on https://www.ncbi.nlm.nih.gov/books/NBK519065/ an article titled, Medication Dispensing Errors and Prevention, dated 2/12/24, the PR indicated, .Types of Medication Errors: Prescribing, Omission, Wrong time, Unauthorized medication, Improper dose, Wrong dose prescription or wrong dose preparation, Administration errors such as incorrect route of administration, administering the drug to the wrong patient, extra dose, or wrong rate, Monitoring errors such as failing to take into account the patient's liver and renal function, failing to document allergy or potential for drug interaction, Compliance errors such as not following protocol or rules established for dispensing and prescribing medications. 2. During an observation and interview on 12/4/25 at 9:08 a.m. with LVN 1, outside Resident 2's room, LVN 1 was preparing Resident 2's inhaler medications on the top of the medication cart. LVN 2 was trying to figure out how to put the capsule of the inhaler medication Tiotropium Bromide Monohydrate into the inhaler device. LVN 1 asked the DON how to prepare the inhaler medication and stated she did not receive training about the inhaler medication Tiotropium Bromide MonohydrateDuring an observation on 12/4/25 9:10 a.m. with LVN 1, in Resident 2's room, LVN 1 administered 1 inhalation of medication Tiotropium Bromide Monohydrate to Resident 2.During an observation and interview on 12/4/25 at 9:15 a.m., LVN 1signed Resident 2's EMAR. LVN 1stated she signed Resident 2's EMAR indicating she administered all morning medications including the inhaler medication Tiotropium Bromide Monohydrate. LVN 1 checked the label of Resident 2's inhaler medication Tiotropium Bromide Monohydrate and stated she mistakenly administered 1 inhalation of Resident 2's inhaler medication Tiotropium Bromide Monohydrate.During a concurrent interview and record review on12/4/25 at 2:20 p.m. with LVN 1, Resident 2's EMAR, dated 12/2025 was reviewed. The EMAR indicated, .Tiotropium Bromide Monohydrate Inhalation capsule.1 capsule inhale orally one time a day related to COPD one capsule inhaled via two inhalation and rinse mouth after inhalation. start date 5/30/25. LVN 1 stated she administered 1 inhalation of Resident 2's inhaler medication Tiotropium Bromide Monohydrate. LVN 1 stated she did not follow the physician's order of two inhalations and stated it was a medication error. LVN 1 stated Resident 2 should receive two inhalations for the medication to be effective. LVN 1 stated Resident 2 did not receive the full dosage of the inhaler medication and placed Resident 2's at risk for difficulty in his breathing. LVN 1 stated Resident 2 had a diagnosis of COPD.During an interview on 12/9/25 at 10:54 a.m. with the DON, the DON stated it was her expectation for all licensed nurses to follow the physician's order when administering medications to prevent medication error and residents will receive the full effectiveness of the prescribed medications. The DON stated Resident 2 did not receive a full dose of the inhaler medication Tiotropium Bromide Monohydrate and stated it was a medication error. The DON stated Resident 2 had the potential to experience shortness of breath when not receiving the full dosage of the inhaler medication Tiotropium Bromide Monohydrate. During a record review of Resident 2's admission Record (AR), dated 12/9/25, the AR indicated Resident 2 was admitted to the facility on [DATE] with primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing).During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 10/9/25, the MDS section C indicated Resident 2 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 4 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 2 was severely cognitively impaired.During a review of Resident 2's Order Summary Report, dated 12/9/25, indicated, .Tiotropium Bromide Monohydrate Inhalation capsule.1 capsule inhale orally one time a day related to COPD one capsule inhaled via two inhalation and rinse mouth after inhalation. start date 5/30/25.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications must be administered in accordance with the orders, including any required time frame.10. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 12. The expiration/beyond use date on the medication label is checked prior to administering.During a review of the professional reference (PR), found on https://www.ncbi.nlm.nih.gov/books/NBK519065/ an article titled, Medication Dispensing Errors and Prevention, dated 2/12/24, the PR indicated, .Types of Medication Errors: Prescribing, Omission, Wrong time, Unauthorized medication, Improper dose, Wrong dose prescription or wrong dose preparation, Administration errors such as incorrect route of administration, administering the drug to the wrong patient, extra dose, or wrong rate, Monitoring errors such as failing to take into account the patient's liver and renal function, failing to document allergy or potential for drug interaction, Compliance errors such as not following protocol or rules established for dispensing and prescribing medications.

Based on observation, interview and record review the facility failed to ensure proper storage and disposal of medications and biologicals in accordance with facility policy and procedures when in side 1's medication cart, Resident 17 and Resident 45's discontinued bottles of Chlorhexidine Gluconate (antimicrobial mouthwash used to treat gingivitis (gum disease) was observed not separated from medications that were in use for facility residents.This failures had the potential for medications to be administered causing underdosing or overdosing of medications, or to be administered to the wrong residents causing harm to the resident. During a concurrent observation, interview and record review on 12/4/25 at 9:27 a.m. with Licensed Vocational Nurse (LVN) 1 in side 1's medication cart. Two bottles of Chlorhexidine Gluconate was observed with active medications. LVN 1 stated the medication were for Resident 17 and Resident 45. LVN 2 stated she did not know whether Resident 17 and Resident 45 were still given the medication because she did not administer the medication. Resident 17 and Resident 45's electronic medical administration record were reviewed. LVN 2 stated Resident 17's medication was ordered for 14 days only and was administered from 11/14/25 to 11/27/25 and a one time order administered on 11/28/25. LVN 2 stated Resident 45's chlorhexidine medication was ordered for 14 days only and medication was administered from 11/14/25 to 11/27/25. LVN 2 stated Resident 17 and Resident 45's medications should have been pulled out of the medication cart because they were no longer active medications. LVN 2 stated all discontinued and expired medications should be pulled out of the medication cart right away to prevent administering to residents and to prevent medication error.During a review of Resident 17's Physician Order (PO) Resident 17's PO indicated chlorhexidine gluconate start date 11/14/25 and an end date 11/28/25, Give 15 ml (milliliter-unit of measurement) orally every evening shift for gum irritation for 14 days. During a review of Resident 45's electronic medication administration (eMAR-digital system that replaces paper charts to streamline and secure the process of giving medications to patients) dated 11/1/25-11/30/25. The eMAR indicated, .Chlorhexidine Gluconate Mouth/THroat Solution . Give 15 ml orally for 14 days . chlorhexidine was administered daily from 11/14/25-11/27/25.During an interview on 12/5/25 at 2:50p.m. with the Registered Nurse Supervisor (RNS), the RNS stated all discontinued medications should be removed from the medication cart immediately because they are no longer active orders. The RNS stated separating discontinued and expired medications from active medications to prevent using medication which could lead to medication error.During an interview on 12/9/25 at 1:45 p.m. with the Director of Nursing (DON), the DON stated all discontinued medications should be removed from the medication because they are no longer active medication. The DON stated regarding Resident 17 and Resident 45's chlorhexidine medication, licensed nurse could have contacted the medical doctor to continue to give the medication once the order was completed. During a review of facility policy and procedure (P&P) titled Disposal/Destruction of Expired or Discontinued Medications, revision date 7/18/17, the P&P indicated, . Once an order to discontinue a medication is received, Facility staff should remove the medication from the resident's medication supply . Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction .

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment for two of four sampled residents (Residents 33 and 64) when:1.Certified Nursing Assistant (CNA) 5 did not wear appropriate personal protective equipment (PPE- specialized clothing, equipment, and supplies worn by healthcare workers protect residents and themselves from potential infectious hazards) when CNA 5 provided direct care to Resident 33 who was on enhanced barrier precaution (EBP- measures used in healthcare settings to prevent the spread of infections) for a known history of Extended Spectrum Beta-Lactamase (ESBL- are a group of bacteria that commonly cause infections both in healthcare settings and communities) producing bacterial infection/colonization on 12/3/25.2.Housekeeping Staff (HS) 1 used one pair of the same gloves when Resident 64 and Resident 64's roommate's blankets were touched and covered to respective residents on 12/2/25.These failure had the potential for CNA 5 and HS 1 to cause cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) to other residents and staff that CNA 5 came into contact within the facility which could lead to an infection (the invasion and growth of germs in the body), potentially causing health complications, and facility outbreak of infection (a sudden increase or clustering of disease cases beyond what's normally expected in a specific time, place, or population, often involving common exposure). 3.Licensed Vocational Nurse (LVN) 1 did not disinfect the glucometer after use and place the glucometer inside the medication cart.This failure had the potential for other residents to be at increased risk in acquiring blood borne pathogen diseases (is any infectious microorganism, like viruses or bacteria, present in human blood or other potentially infectious materials (OPIM) that can cause disease when transmitted from person to person, primarily through blood-to-blood contact, often via accidental needle sticks, contaminated sharps, or contact with broken skin/mucous membranes; with common examples being HIV, Hepatitis B (HBV), and Hepatitis C (HCV) viruses).4. The facility failed to follow policy and procedures (P&P) for water management and testing.These failures had the potential to place all residents at an increased risk of acquiring Legionella bacteria (is a type of bacteria common found in natural freshwater [lakes, streams] but thrive in man-made water systems like cooling towers, hot tubs, showers, plumbing systems, and decorative fountains, growing best in warm, stagnant water), and infectious diseases including a pneumonia (an infection that affects one or both lungs, causing the air sacs of the lungs to fill with fluid)-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever. Findings:1.During a concurrent observation on 12/3/25 at 9:11 a.m. with CNA 5, in Resident 33's room, CNA 5 came to the room holding one plastic bag containing a diaper and another plastic bag containing clean linen while the nurse surveyor conducting an interview with Resident 33. CNA 5 informed the nurse surveyor that she needed to do a diaper and linen change for Resident 33. CNA 5 went to Resident 33's bedside without wearing appropriate PPE -gown and closed the privacy curtain. CNA 5 was walking towards Resident 33's door with a glove on her hand holding two plastic bags, one for soiled brief and one for used linens. CNA 5 was looking for another CNA to provide her with a container to dispose of the two plastic bags containing the soiled brief and used linens.During an interview on 12/3/25 at 9:20 a.m. with CNA 5, outside Resident 33's room, CNA 5 stated she did not wear appropriate PPE including gown while providing a brief change and linen change to Resident 33. CNA 5 stated she was not aware that she was on EBP. CNA 5 stated she did not check the sign by the door. CNA 5 stated she should check the sign at Resident 33's door and wear appropriate PPE before entering the room and providing direct care. CNA 5 stated not wearing PPE for residents on EBP can result in cross contamination of other residents and risk of getting infection.During an interview on 12/3/25 at 9:34 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated CNAs should be wearing appropriate PPE when providing direct care to the residents on EBP. LVN 3 stated Resident 33 was on EBP for ESBL in urine. LVN 3 stated CNA 5 should wear gowns and gloves when doing brief change and linen change to Resident 33 to prevent cross contamination and infection for our staff and other residents. Staff should change gloves when helping a resident on EBP and another resident to prevent cross contamination.During a concurrent interview and record review on 12/3/25 at 10:34 a.m. with the Infection Preventionist (IP), Resident 33's clinical record was reviewed. The IP stated Resident 33 was on EBP for a known history of ESBL- producing bacterial infection/colonization in her urine. The IP stated it was her expectation for all staff to follow facility's policy and procedure (P&P) for EBP when providing direct care such as activities of daily living (ADLs-, to prevent cross contamination, infection and facility outbreak. The IP stated CNA 5 should wear appropriate PPE when she performed brief and linen change to Resident 33 to prevent cross contamination and transmission of possible infection to other residents and staff.During an interview on 12/9/25 at 9:29 am. with the Director of Nursing (DON), Resident 33 had an EBP sign by her door. The DON stated it was her expectation for nursing staff to follow the P&P for EBP in which the need of wearing appropriate PPE when providing direct patient care was important to prevent cross contamination and possible infection to residents. During a review of facility's P&P titled, Enhanced Barrier Precaution, dated 9/27/24, the P&P indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) .3. Implementation of Enhanced Barrier Precautions - a. Make gowns and gloves available PRIOR TO PERFORMING TASKS. Note: face protection may also be needed if performing activity with risk of splash or spray. 4. High-contact resident care activities include: e. Changing linens; f. Changing briefs or assisting with toileting. 6. Examples of targeted and epidemiologically important MDROs include but are not limited to: g. ESBL-producing Enterobacterales. 7. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility.During a review of the professional reference (PR), found on https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html an article titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 7/12/22, the PR indicated, . [Multi Drug Resistant organisms] (MDROs - germs which have become resistant to medications) may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds . are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply. 2.During an observation on 12/2/25 at 9:42 a.m. outside Resident 64's room, Resident 64's name had an EBP sign and an EBP poster posted on her door. Resident 64's roommate had no EBP sign by her name.During observation on 12/2/25 at 9:48 a.m. with Housekeeper Staff (HS) 1, in Resident 64's room, HS 1 was holding Resident 64's blanket with a glove in her hand and covered Resident 64 with her blanket. HS 1 continued mopping Resident 64's floor area-around and underneath Resident 64's bed using the same pair of gloves. HS 1 went to Resident 64's roommate wearing the same pair of gloves and touched Resident 64's roommate's blanket and covered resident's body. HS 1 went outside Resident 64's room where the housekeeping cart was parked. HS 1 removed her gloves and used an alcohol-based hand rub (ABHR) gel. During an interview on 12/3/25 at 9:26 a.m. with HS 1, in front of Resident 64's room, HS 1 stated the signage indicated Resident 64 was on EBP and her roommate in first bed was not on EBP. HS 1 stated she did not receive training about EBP and was not aware who the IP was. HS 1 stated she did not notice the EBP signage outside Resident 64's room. sign for EBP. HS 1 validated she touched and placed the blankets for Resident 64 and her roommate using the same glove. HS 1 stated she should change her gloves after assisting Resident 4 to prevent cross contamination to Resident 64's roommate. During an interview on 12/3/25 at 9:34 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated CNAs should be wearing appropriate PPE when providing direct care to the residents on EBP. LVN 3 stated Resident 64 was on EBP due to presence of dialysis catheter and her roommate in first bed was not on EBP. LVN 3 stated HS 1 should change her gloves in between resident care to prevent cross contamination and possible infection to residents. During a concurrent interview and record review on 12/3/25 at 10:34 a.m. with the Infection Preventionist (IP), Resident 64's clinical record was reviewed. The IP stated Resident 64 was a dialysis resident and had a dialysis catheter. The IP stated Resident 64 was on EBP due to dialysis catheter. The IP stated HS 1 must change her gloves when providing care from one resident to another resident to prevent cross contamination and transmission of possible infection to residents. During an interview on 12/9/25 at 9:29 am. with the DON it was her expectation for all staff to follow P&P for Standard Precautions. The DON stated gloves must be changed in between resident care to avoid cross contamination and possible infection to residents.During a review of facility's P&P titled, Standard Precautions, dated 10/2018, the P&P indicated, Standard Precautions - Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions are presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. 1. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. 2. Gloves - g. Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. h. After gloves are removed, wash hands immediately to avoid transfer of microorganisms to other residents or environments. 3. During an observation and interview on 12/3/25 at 11:40 a.m. with LVN 1 outside Resident 2's room, wiping the glucometer machine with a white wipe for 2 seconds, placed inside a cup to air dry and secured inside the medication cart. LVN 1 stated she will use the same glucometer machine to another residents. LVN 1 stated residents on blood sugar checked shared the same glucometer machine. During an interview on 12/9/25 at 9:44 a.m. with the DON, the DON stated she needed to check and review the P&P for cleaning and disinfecting of glucometer machine. The DON stated the facility was using a disinfectant wipe with purple top, wet time should be 3-4 minutes based on manufacturer's guidelines. The DON stated it was her expectation for all nurses to follow the P&P for cleaning and disinfecting of glucometer machine. The DON stated glucometer machines should be cleaned and disinfected properly to prevent the transmission of blood-borne pathogens.During an interview on 12/9/25 at 11:25 a.m. with LVN 1, LVN 1 validated she did not disinfect the glucometer machine after using Resident 2. LVN 1 stated she did not follow the wet time of 3 minutes instead she did air dry for more than 3 minutes. LVN 1 stated, glucometer machine should be properly cleaned and disinfected after each use to prevent transmission of infection.During a review of facility's P&P titled, Standard Precautions, dated 10/2018, the P&P indicated, Standard Precautions - Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions are presumed that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. 1. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. 5. Resident-Care Equipment - a. Resident-care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments.During a review of facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 10/2018. Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. d. Reusable items are cleaned and disinfected or sterilized between residents . 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufactures' instructions. 4. During an interview on 12/3/25 at 10:34 a.m. with the IP, the IP stated she was a member of water management committee. The IP stated the facility had a policy and procedures for Legionella. The IP stated the facility's Environmental Services Maintenance (ESM) was responsible in testing and monitoring the water for the detection of Legionella. The IP stated it was important to follow the P&P for Legionella water management to prevent an outbreak of Legionella.During an interview on12/9/25 At 9:13 a.m. with the ESM, the ESM stated an outside service company was facilitating the testing of water for Legionella detection, dated 7/21/25 and 11/17/25. The ESM stated no Legionella detected on 7/21/25 and result was pending for 11/17/25. The ESM stated the outside service company indicated the water testing for Legionella was checked quarterly. During a concurrent interview and record review on 12/9/25 at 1:55 p.m. with ESM, the water management and testing policy was reviewed. The ESM stated she had no chance to implement the water testing P&P for Legionella including the monthly water testing in water pipelines, to ensure there was no standing water, and water was not sitting for a longer period; weekly water flushing, and temperature monitoring to prevent Legionella. The only testing was done was from outside service company which was done quarterly and stated, only relied on their result. The ESM stated the facility's P&P for water management and testing should be followed, implemented and documented to prevent Legionella outbreak. During a review of facility's P&P titled. WATER MANAGEMENT AND TESTING POLICY - Skilled Nursing Facility Water Safety & Risk Management Program - Date: 8/1/2025. 1. PURPOSE - To establish a comprehensive water management and testing program for the Skilled Nursing Facility (SNF) that ensures safe potable water for residents, staff, and visitors. This policy addresses risk associated with waterborne pathogens - particularly Legionella - and defines monitoring, testing, control measures, documentation, and reporting processes. 4. LEGIONELLA TESTING REQUIREMENTS. 4.1 Frequency - Monthly Legionella testing must be performed on: Incoming well water sample - Hot water distribution point(s) - Cold water distribution point(s) - High-risk resident care areas (showers, therapy tubs, etc.) . 5. ROUTINE WATER SYSTEM MONITORING. 5.1 Temperature Monitoring - Hot water storage tanks: 140F minimum - Hot water at point of use: 105-120F (per resident safety requirements) - Cold water: < 77F when possible (reduces Legionella growth). 5.2 Disinfectant Residual Monitoring - Measure at least weekly. 5.3 Fixture Flushing - Flushing must occur: Weekly for rarely used fixtures - After any area is unoccupied for > 7 days - After plumbing disruptions. 9. DOCUMENTATION & RECORDKEEPING. Maintain for minimum of 3-5 years: Monthly Legionella lab reports - Temperature log sheets - Disinfectant residual logs - Fixture flushing logs.

Based on observation, interview, and record review, the facility failed to maintain a resident care equipment in safe operating condition when the facility's mechanical lift (a mechanical device used by caregivers to safely lift and transfer individuals with limited mobility from one surface to another (bed, chair, toilet) using a sling, minimizing physical strain and preventing injury) was not functional to deliver residents' care and activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).This failure resulted in a delay in implementing residents' care including residents' transfers and obtaining weights as ordered and placed residents and staff at an increased risk of accidents.Findings:During an observation on 12/2/25 at 8:39 a.m. with Resident 5, in Resident 5's room, Resident 5 was lying asleep in bed. During an observation on 12/2/25 at 12:39 p.m. with Resident 5, in Resident 5's room, Resident 5 was lying asleep in bed, with food tray at bedside table.During a concurrent observation and interview on 12/3/25 at 10:03 a.m. with Certified Nurse Assistant (CNA) 11, in Resident 5's room, CNA 11 was giving Resident 5 a carton of house supplement via straw. CNA 11 stated Resident 5 should be up in a chair during melas. CNA 11 stated Resident 5 requires a mechanical lift transfer. CNA 11 stated the facility's mechanical lift was not working and stated a new battery for the mechanical lift was ordered. During an interview on 12/4/25 at 9:58 a.m. with the Restorative Nurse Assistant (RNA), the RNA stated the two mechanical lifts were not working due to battery problems. The RNA stated there was no back-up battery for the mechanical lift. The RNA stated the battery for the mechanical lift was ordered and had not been delivered. The RNA stated the facility borrowed another mechanical lift to another facility because their mechanical lift was not functioning well when tested, and stated, it was stacked in the air. The RNA stated the mechanical lift could not move to its normal position which is not safe for residents' use. The RNA stated she was scheduled to weigh all residents for their monthly weights. The RNA stated residents' weight must be obtained by the fifth of every month and stated, due on 12/5/25. The RNA stated the facility should maintain a safe functional mechanical lift to prevent delay in care of the residents. During an interview on 12/9/25 at 9:34 a.m. with the Director of Nursing, the DON stated the two mechanical lifts were not functional because the battery was not charging. The DON stated resident care equipment should be maintained in good working conditions to safely implement the care that resident's needs. The DON stated residents that require a mechanical lift transfer could not get up by the CNAs which resulted in the residents staying in bed that can result in isolation, decrease participation and socialization during activities. The DON stated residents' weights were not done as scheduled every fifth of the month. The DON stated the delay in obtaining weights for residents can cause in a delay of implementation of significant weight changes interventions. The DON stated the facility should maintain operational resident care equipment to continue to provide the care for all residentsDuring an interview on 12/9/25 at 1:55 p.m. with the Environment Services Maintenance (ESM), the ESM stated he was responsible in monitoring all resident care equipment including mechanical lifts were functional. The ESM stated he checked the batteries of mechanical lift weekly and batteries did not arrive as expected. The ESM stated a non-functioning mechanical lift was not safe for residents and staff use. The ESM stated resident care equipment should be maintained in safe operating conditions to prevent accidents. During a review of professional reference retrieved from www.cdc.gov/niosh titled, Safe Lifting and Movement of Nursing Home Residents, dated 2/2006, indicated, .Keep equipment readily available and accessible. The number of lifts required will depend on the level of physical dependency among the residents. As a general rule, one full-body lift should be provided for every eight to ten non-weight bearing residents.Provide back-up battery packs on remote chargers as needed so that lifts can be used 24 hours per day while batteries are being recharged. Implement a routine maintenance program to ensure equipment is kept in good working order (the maintenance program should include tagout and repair procedures for broken equipment).

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when flies were flying around resident's room (room [ROOM NUMBER]) on 12/2/265 and 12/3/25 and transferring from one table to another in resident's dining room during lunch on 12/3/25.This failure had the potential for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effects) and for residents to acquire food borne illnesses (are caused by eating or drinking something that is contaminated with germs).During an observation on 12/2/25 at 8:39 a.m. in room [ROOM NUMBER], multiple flies (three) were going around the round, landing on residents' clothing and privacy curtain.During concurrent observation and interview on 12/2/25 at 9:11 a.m. with Licensed Vocational Nurse (LVN) 3, in room [ROOM NUMBER], LVN 3 validated flies were flying around inside room [ROOM NUMBER]. LVN 3 stated she had seen flies in room [ROOM NUMBER]. LVN 3 stated room [ROOM NUMBER] was close to the exit door where other residents accessed exit door multiple times a day. LVN 3 stated there should be no flies inside the residents' room and inside the facility. LVN 3 stated flies carry bacteria that can cause food boned illnesses to residents.During an observation 12/2/25 at 12:39 p.m. with Resident 5, in Resident 5's room, Resident was asleep. Resident 5 was in room [ROOM NUMBER]. Resident 5's food tray was on top of bedside table with no cover and two flies were flying around Resident 5's food.During a concurrent observation and interview on 12/3/25 at 10:03 a.m. with Certified Nurse Assistant (CNA) 11, in Resident 5's room, CNA 11 was giving Resident 5 a carton of house supplement via straw with two flies flying around Resident 5. CNA 11 was swinging her hand to keep the flies away from the food and Resident 5, and stated, I don't know what to do. CNA 9 stated there should be no be flies inside Resident 5's room. CNA 11 stated flies were not clean and could contaminate the food. During a concurrent observation and interview on 12/3/25 at 10:34 a.m. with the Infection Preventionist Nurse (IP), at the nursing station, a fly swatter (is a household device used to kill the flies) was on the top of the counter. The IP stated the facility was using a fly swatter to eliminate the flies in the facility. The IP stated presence of flies inside the facility can potentially cause cross-contamination and residents could get sick with food-borne illnesses like diarrhea (loose stools).During an observation and interview on 12/3/25 at 11:45 a.m. with the Administrator (ADM), in the residents' dining room, the ADM swung his hand to keep the flies away from the resident's food. The ADM asked the Restorative Nurse Assistant (RNA) to remove the food from the table and replace it with a new one.During an interview on 12/3/25 at 11:55 a.m. with the RNA, in the resident's dining room, the RNA stated the flies in the dining room were transferring from one table to another. The RNA stated, . once in a while, I see flies here (dining room).During an observation on 12/3/25 at 12:22 a.m., in the hallway, the ADM was holding a fly swatter beside the food tray cart.During an interview on 12/4/25 at 8:00 a.m. with CNA 10, CNA 10 stated she was at the dining room yesterday (12/3/25) during lunch when a fly flew around resident's food and water pitcher. CNA 10 stated flies can contaminate the food, and residents can get sick. During an interview on 12/9/25 At 9:13 a.m. with the Environmental Services Maintenance (ESM), the ESM stated he needed to check the pest control services done at the facility. The ESM stated he needed to ensure the facility has an effective pest control service. The ESM stated there should be no flies inside the facility especially in resident's dining room and resident's room. The ESM stated flies can lay eggs and can transfer germs to the resident's food. During an interview on 12/9/25 at 9:34 a.m. with the Director of Nursing (DON), flies can transfer the bacteria into the resident's food and put residents at risk for infection and food borne illnesses.During a review of facility's policy and procedures (P&P) titled, Pest Control, dated 5/2008, the P&P indicated, Our facility shall maintain an effective pest control program. 1. This facility maintains an on-going pet control program to ensure that the building is kept free of insects and rodent. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on interview and record review, the facility failed to ensure their policy on discharge was followed for one of three sampled Residents (Resident 61) when Resident 61 was discharged against medical advice (AMA-patient chooses to leave before the doctor recommends discharge) when Resident 61 was discharged AMA on 9/14/25 and there was no documentation the medical doctor and administrator were notified.This failure had the potential to put Resident 61 at risk for complications like worsening of condition. Findings: During a review of Resident 61's admission Record (AR- a document containing resident profile information) dated 12/9/25, the AR indicated Resident 61 was admitted to the facility on [DATE] with diagnoses which included Spinal Stenosis (narrowing of spinal canal squeezing the nerves and causing pain, numbness, tingling, or weakness), muscle weakness and abnormalities of gait and mobility. During a concurrent interview and record review on 12/9/25 at 8:30a.m. with Minimum Data Set Nurse (MDSN) 2, MDSN Reviewed resident 61's clinical record and stated there was no documentation of Resident 61's discharged . MDSN 2 stated Resident 61 was AMA on 9/14/25. MDSN 2 stated the medical doctor (MD), Administrator (ADM) and Director of Nursing (DON) should have been notified but there was no documentation. MDSN 2 stated the medical record person was responsible in auditing to ensure accurate and complete resident records. During a concurrent interview and record review on 12/9/25 at 9:35 a.m. with Medical Records Person (MRP), the MRP stated she audits resident discharges to ensure all signatures are in place. The MRP stated she remember auditing Resident 61's records and provided a copy to the nurse who was on-duty when Resident 61 was discharged AMA. The MRP stated she did not remember following up with the nurse and just assumed it was completed. The MRP reviewed Resident 61's record and stated, MD was not notified the day of Resident 61's AMA, the MRP stated there should have been a nursing note indicating why Resident 61 wanted to leave AMA and notification to ADM and DON. During an interview on 12/9/25 at 12:11 p.m. with the DON, the DON stated licensed nurses should ensure AMA form was signed when residents wishes to be discharged AMA. The DON stated the MD, ADM and DON should be notified and documented in the progress note. During an interview on 12/9/25 at 3:30 p.m. with the ADM, the ADM stated he was made aware of Resident 61's AMA discharge but was not sure when he was notified. The ADM stated he was not aware there was no documentation of Resident discharged and MD was not notified the day Resident 61 was discharged . The ADM stated the practice was to make sure MD and ADM was notified when residents wanted to leave AMA. During a review of facility's policy and procedure (P&P) titled, AMA (Against Medical Advice) Policy, undated, the P&P indicated, . Any staff member aware that a resident wishes to leave AMA should immediately notify the nursing supervisor, administrator and the attending physician . Document the resident's intent to leave AMA, including their stated reasons and the information provided to them about potential risks . Provide the resident with a written discharge summary, including current treatment, medications, and follow-up care instructions . Arrange follow-up call within 24-48 hours post-discharge to assess the resident's situation and provide additional support if needed .

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 13) was free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when the facility did not attempt or implement behavior monitoring for Resident 13's use of olanzapine (medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thoughts]). This failure placed Resident 13 at risk for experiencing adverse effects from receiving medication without behavior monitoring. During a concurrent observation and interview on 12/2/25 at 2:40 p.m. in Resident 13's room, Resident 13 was ambulating inside the room with steady gait and appropriately dressed. Resident 13 stated he was in the acute care hospital for a week prior to admission in the facility. Resident 13 stated he was in the facility to work with therapy to get stronger and will eventually go home. Resident 13 stated he did not know anybody in the facility but felt safe.During a review of Resident 13's, admission Record [AR- a document containing resident profile information], dated 12/5/25, the AR indicated Resident 13 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), subdural hemorrhage (brain bleed) and muscle weakness. During a review of Resident 13's Physician Order, dated 11/26/25, the Physician Order indicated, OLANZapine Oral Tablet 5 (five) MG (milligram- unit of measurement) . Give 5 mg by mouth at bedtime RELATED TO SCHIZOAFFECTIVE DISORDER . During a concurrent interview and record review on 12/4/25 at 2:03 p.m. with Infection Preventionist (IP), Resident 13's medication orders were reviewed. The IP stated Resident 13 was receiving psychotropic medication and no behavior monitoring in place. The IP stated there should have been a behavior monitoring as soon as psychotropic medication was started. The IP stated it was important to monitor behavior to note if there was an increase or decline in behavior and if gradual dose reduction was required.During a concurrent interview and record review on 12/5/25 at 2:47 p.m. with Registered Nurse SUpervisor (RNS), The RNS reviewed Resident 13's Order Summary and stated she did not find an order to monitor behavior when Resident 13 was started on the psychotropic medication. The RNS stated it was important to monitor behavior of residents taking psychotropic medications in order to make adjustments of their medications if needed to titrate the dose or to discontinue. During an interview on 12/9/25 at 12:25 p.m. with the Director of Nursing (DON) the DON stated her expectation was to ensure a behavior monitoring was started as soon as soon as a psychotropic medication was started. The DON stated behavior monitoring was important to know when a medication was working or not and whether to discontinue or continue medication. The DON stated the licensed nurse receiving the order was responsible in ensuring there was a behavior monitoring started. During a review of facility policy and procedure (P&P) untitled and undated, the P&P indicated, Residents are not given psychotropic drugs unless the medication is necessary to treat specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) . A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior . The indications for use of any psychotropic drug will be documented in the medical record .

Based on interview and record review, the facility failed to complete a level 1 Preadmission Screening and Resident Review (PASARR), (a Federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) screening notifying the state mental health authority or state intellectual disability authority promptly after a significant change for three of five sampled residents (Residents' 1, 3 and 6). This failure had the potential for Residents' 1, 3, and 6 to not receive the appropriate services related to their mental disorders.During a review of Resident 1's admission Record (AR-a document containing resident profile information), dated 12/5/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), psychoactive substance abuse (use of mind-altering drugs in ways that harm health, relationships, or responsibilities causing dependence, tolerance, and negative impacts on mood, cognition, and behavior) and muscle weakness. During a review of Resident 1's PASARR Level I Screening Report dated 11/04/25, the PASARR indicated, . A LEVEL II MENTAL HEALTH EVALUATION IS NOT REQUIRED .During a review of Resident 1's Order Summary Report [OSR], dated 12/5/25, The OSR indicated, .OLANZapine [used to treat psychosis] Oral Tablet 10 MG [milligram-unit of measurement] Give 1 [one] tablet by mouth every 8 [eight] hours for Psychosis . Order Date: 11/11/25, Start Date: 11/11/25 .During a review of Resident 3's AR dated 12/5/25, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia (a mental illness characterized by disturbances in thought), Schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and anxiety (a feeling of worry, nervousness, or uneasiness about an upcoming event or something with uncertain outcome causing physical signs like racing heart, sweating or restlessness).Review of Resident 3's PASARR Level I Screening Report, dated 10/14/25 indicated, . Level I-Negative for SMI [Serious Mental Illness]/Negative for ID [Intellectual Disability]/ DD [Developmental Disability]/RC[Related Condition] Resident 3 did not have diagnosis of serious mental illness and not taking psychotropic medications .During a review of Resident 3's OSR, dated 12/9/25, the OSR indicated, . PARoxetine [medication used to treat depression] HCl Oral Table 10 MG [Paroxetine HCl] Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER . Order Date: 7/11/25 .QUEtiapine Fumarate [medication used to treat schizophrenia) Oral Tablet 50 MG [Quetiapine Fumarate] Give 1 tablet by mouth two times a day . Order Date: 5/5/25 .During a review of Resident 6's AR, dated 12/5/25, the AR indicated Resident 6 was re-admitted to the facility on [DATE] with diagnoses which included schizophrenia, depression (a serious mood disorder causing persistent sadness and loss of interest in activities, affecting how you feel, think, and handle daily life) and psychosis. During a review of Resident 6's PASARR Level I dated 3/14/25 indicated, . Level I Negative for SMI/Negative for ID/DD/RC . No diagnosis of Serious Mental Illness . During a review of Resident 6's OSR, dated 12/5/25, the OSR indicated, . [brand name] Oral tablet 5 [five] MG (Aripiprazole) Give 2 [two] tablet . two times a day for give 2 tabs of 5mg=10mg related to SCHIZOPHRENIA . Order Date: 10/14/25 . trazodone HCl [hydrochloride] Oral Tablet 50 MG [Trazodone HCl] Give 1 tablet . Order Date: 9/3/25 .During a concurrent interview and record review on 12/5/25 at 4:11 p.m. with Minimum Data Set Coordinator (MDSC)1, MDSC 1 stated PASARR screening are completed for new admission, change in condition like a new psychotropic medication was started and re-admission to the facility. MDSC 1 reviewed Resident 1's PASARR Level 1 dated 11/4/25 and stated Resident 1 did not have psychotropic medication when admitted in the facility. Resident 1 was ordered Olanzapine on 11/11/25 and a new PASARR Level 1 screening should have been completed but there was none. During a concurrent interview and record review on 12/5/25 at 4:18 p.m. with MDSC 1, Resident 3's PASARR Level 1 dated 10/14/25 screening completed at the acute hospital was reviewed. MDSC 1 stated Resident 3's PASARR Level 1 was not accurate and it should have been reviewed for accurateness. MDSC 1 stated a new PASARR Level 1 should have been completed and submitted to accurately reflect resident condition. During a concurrent interview and record review on 12/5/25 at 4:30 p.m. with MDSC 1, Resident 6's PASARR Level 1 screening dated 3/14/25 was reviewed. MDSC 1 stated Resident 6's PASARR Level 1 was negative, there should have been another PASARR Level 1 screening completed when Resident 6 was started on psychotropic medications on 9/4/25 and 10/14/25 but there was none. During a concurrent interview and record review on 12/4/25 at 1:55 pm. with Infection Preventionist (IP), the IP reviewed Resident 1's clinical record and stated Resident 1 was admitted to the facility 11/4/25 and one of the diagnoses was unspecified psychosis. The IP stated Resident 1 was started on psychotropic medication after admission to the facility. The IP reviewed Resident 3's clinical record and stated Resident 3 is taking psychotropic medications and has diagnosis of schizophrenia and schizoaffective disorder. The IP stated Resident 6 was readmitted to the facility on [DATE] and was ordered psychotropic medications. The IP stated she was not responsible in the PASARR assessment. The IP stated all residents clinical records should be accurate and reflects current status of residents. During an interview on 2/9/25 at 12:25 p.m. with the Director of Nursing (DON), the DON stated the business office manager, MDS nurse, medical records and admission director are responsible in making sure there was a PASARR completed for each residents in the facility. The DON stated her expectation was to make sure PASARR are reviewed for accuracy and complete a new PASARR assessment if needed. During a review of facility's policy and procedure (P&P) titled, Resident Assessment - Coordination with PASARR Program, dated 2022, the P&P indicated, . All applicants to this facility will be screened for serious mental disorder or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening . Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level ll resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR .

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of four sampled residents (Resident 11) when Resident 11's use of Divalproex (medication used for mood stabilization) was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 11's care needs not met and the potential for adverse reaction to not be monitored.During a concurrent observation and interview on 12/2/25 at 12:15 p.m. during an initial tour in Resident 11's room, Resident 11 was lying in bed covered with blanket and lunch tray was on top of over the bed table. Resident 11 stated he already ate and refused to answer questions stated, Goodbye. During a review of Resident 11's admission Record [AR- a document with personal identification and medical information], dated 12/5/25, the AR indicated Resident 11 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (a diseases characterized by a progressive decline in mental abilities), muscle weakness and dementia (a progressive state of decline in mental abilities). During a concurrent interview and record review on 12/4/25 at 2:05 p.m. with Infection Preventionist (IP), the IP stated Resident 11 was confused and has Alzheimer's disease. The IP stated Resident 11 was ordered Divalproex medication for mood stabilization. During a concurrent interview and record review on 12/9/25 at 8:50 a.m. with Minimum Data Set Nurse (MDSN) 2, MDSN 2 reviewed Resident 11's Admit MDS assessment dated [DATE] Section N (Medications) and Section I (Active Diagnoses). MDSN 2 stated Resident 11 was taking medication for mood stabilization and did not marked in Section I. MDSN 2 stated she did not code Resident 11 as having mood disorder and she should have. MDSN 2 stated it was her responsibility to ensure MDS assessment were accurate. During an interview on 12/9/25 at 12:20 p.m. with the Director of Nursing (DON), the DON stated her expectation was for MDS assessments to be accurate. The DON stated missing or inaccurate MDS assessments are reviewed by the MDS and IDT. During a review of the facility document titled, Job Description: MDS Coordinator, dated 1/29/25, the Job Description indicated, . Coordinates the development and completion of the resident assessment (MDS) in accordance with current federal and state rules, regulations, and guidelines that govern the resident assessment . Ensures the timely electronic submission of of face validity of all Minimum Data Sets to the state database . During a review of facility's policy and procedure (P&P) titled, MDS Error Correction revised 9/2010, the P&P indicated, . Once completed, edited and accepted . MDS data may not be changed just because the resident's status has changed during the course of his or her stay in the facility . Modification requests are used when information in the record contains clinical or demographic errors . During a review of professional reference titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1 10/24, indicated, .Identify Diagnoses: The disease conditions in this section require a physician-documented diagnosis . in the last 60 days . Check the following information sources in the medical record for the last 7 [seven] days to identify active diagnoses: transfer documents, physician progress notes, recent history . medication sheets, doctor's orders .

Based on observation, interview, and record review, the facility failed to provide and maintain a safe, clean, and sanitary environment for one of four sampled residents (Resident 2), when Resident 2's mattress on the floor beside his bed was dirty with brownish dirt built up on the top of the mattress and observed nursing staff walking on the floor mattress.This failure had the potential for Resident 2 acquiring an infection (the invasion and growth of germs in the body).Findings:During an observation and interview on 12/3/25 at 11:40 a.m. with LVN 1, in Resident 2's room, LVN 1 stepped on Resident 2's mattress on the floor beside Resident 2's bed. Resident 2's mattress on the floor was dirty with brownish dirt built up on the top of the mattress. LVN 1 stated, Resident 2's mattress on the floor was dirty and should be cleaned by the housekeeper and covered with a bed sheet. LVN 1 stated Resident 2 had episodes of purposedly rolling over from bed to the mattress on the floor. LVN 1 stated Resident 2's floor mattress should remain clean to prevent infection. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 10/9/25, the MDS section C indicated Resident 2 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 4 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 2 was severely cognitively impaired. During an interview on 12/4/25 at 9:58 a.m. with the Restorative Nurse Assistant (RNA), the RNA stated Resident 2's mattress on the floor was dirty. The RNA stated having a dirty floor mattress is an infection control issue. RNA stated housekeepers should keep Resident 2's mattress cleaned to prevent infection to Resident 2. The RNA stated Resident 2 keeps rolling out of bed to the floor mattress, the floor mattress prevented him from getting hurt. During an interview on 12/9/25 At 9:30 a.m. with HS 2, HS 2 stated Resident 2's mattress on the floor was very dirty. HS 2 we are responsible for cleaning the mattress on the floor. HS 2 stated Resident 2's mattress on the floor should be cleaned and disinfected twice a day and as needed and should have a bed sheet over the bed. HS 2 stated dirty bed can harbor bacteria and can cause infection to Resident 2. During an interview on 12/9/25 At 9:13 a.m. with the Environmental Services Maintenance (ESM), the ESM stated it was her expectation for housekeeping staff to clean and disinfect resident care areas including equipment. The EMS stated Resident 2's mattress on the floor was dirty and should be cleaned to prevent infection. The EMS stated staff walking on Resident 2's floor mattress can harbor germs or bacteria. During an interview on 12/9/24 at 9:44 a.m. with the DON, the DON stated dirty mattress on the floor for resident use was an infection control issue. The DON stated housekeeper should clean and disinfect Resident 2's mattress on the floor to prevent infection to Resident 2.During a review of facility's P&P titled, Standard Precautions, dated 10/2018, the P&P indicated, Standard Precautions - Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions are presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. 1. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. 5. Resident-Care Equipment - a. Resident-care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments.During a review of facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 10/2018. Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. d. Reusable items are cleaned and disinfected or sterilized between residents . 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufactures' instructions .

Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for one of four sampled residents (Resident 1) when Resident 1 was assessed as being at high risk had poor safety awareness (not paying attention to the dangers around you, a history of self-transferring to get to the bathroom, frequent urination (act of releasing liquid waste that your kidneys make to remove excess fluids and waste products from your body) and needed to be supervised by a staff member during transfer and the facility did not implement individualized interventions to prevent falls, including supervision and addressing the cause of frequent self-transferring attempts, consistent with the resident's needs, goals and care according to the resident assessment and plan of care.These failures resulted in Resident 1 sustaining four unwitnessed falls, two falls on 5/19/25, one fall on 6/16/25 and one fall on 7/16/25. During the fall on 7/16/25, Resident 1 sustained an intertrochanteric fracture (a type of hip fracture [broken bone] where the femur [upper thigh bone] meets the pelvis [ring of bones in the hips and lower back that connects the upper body to the legs]) causing her significant pain, decreased mobility and the resident became bedbound (unable to leave the bed). Resident 1 was not transferred to the emergency department because she was on hospice [specialized form of for end-of-life care] and the Responsible Party's request.During a review of Resident 1's admission Record, undated, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of superior rim (upper edge) of right pubis (pubic bone-a bone that makes up the pelvis), displaced intertrochanteric fracture of left femur, dementia (decline in mental ability severe enough to interfere with daily life), retention of urine (inability to completely empty the bladder), and anxiety disorder (feeling of unease, worry or fear).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE] , it indicated Resident 1's Brief Interview of Mental Status assessment (BIMS-assessment of cognitive status for memory and judgement) scored 05 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment score indicated Resident 1 had severe cognitive impairment.During an interview on 8/12/25 at 8:42 a.m. with the Administrator in Training (AIT), the AIT stated Resident 1 was no longer in the facility because she had passed away on hospice on 7/27/25.During an interview on 8/12/25 at 9:26 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated she was not at the facility when Resident 1 fell and fractured her hip on 7/16/25. CNA 1 stated Resident 1 was a high fall risk and had behaviors of frequently getting up and trying to self-transfer while unsupervised. CNA 1 stated Resident 1 was not safe to transfer without assistance. CNA 1 stated Resident 1 had frequent urgency (sudden, compelling need to urinate) to go to the restroom because she felt like she needed to urinate (pass urine from the body). CNA 1 stated the staff would take Resident 1 to the restroom, and she would ask to go again within minutes of urinating.During an interview on 8/12/25 at 10:27 a.m. with CNA 2, CNA 2 stated she took care of Resident 1 while she was in the facility. CNA 2 stated she would want to toilet all the time. We would take her to the bathroom often, then she would want to go again right away. CNA 2 stated even though staff frequently took Resident 1 to the bathroom, she would try to get up unassisted because she felt like she needed to go again, which increased her fall risk. During a concurrent interview and record review on 8/12/25 at 10:51 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was working when Resident 1 fell on 7/16/25. LVN 1 stated on 7/16/25 around 6:55 a.m., she had just arrived at the facility for her shift and saw Resident 1 in bed. LVN 1 stated she had walked to the nurse's station for report from the night shift and a CNA told her Resident 1 was on the floor. LVN 1 stated she assessed Resident 1 for injuries and Resident 1 complained of pain to her right leg from the back of her knee to her hip. LVN 1 stated Resident 1 appeared to be in pain, so she administered her pain medication . LVN 1 stated Resident 1 was able to move but complained of pain. LVN 1 stated Resident 1 was unable to bear weight on her right leg, so she called hospice and notified them Resident 1 had fallen. LVN 1 stated the hospice nurse came in around 7:30 a.m. for a routine visit and she asked the hospice nurse for an order to X-ray (a painless test that captures images of the structures inside the body) Resident 1's hip but was told to just keep the resident comfortable. LVN 1 stated she was informed by the hospice nurse that because hospice was for end-of-life care, they did not routinely perform X-rays on patients. LVN 1 stated Resident 1's pain continued to worsen, and she had facial grimacing [facial expression that show pain], so they requested an X-ray order from hospice a second time and received an order. Resident 1's X-ray report titled Right Hip, Unilateral [one side] W/ [with] Pelvis, dated 7/16/25 was reviewed, it indicated, . Acute intertrochanteric fracture with impaction [broken ends of a bone are driven into each other] and varus angulation [deviation of the bone towards midline of the body] . Soft tissue swelling [abnormal buildup of fluid] around the right hip. LVN 1 stated the Director of Nursing (DON) had contacted Resident 1's responsible party and they did not want the resident sent to the hospital and requested the resident be kept comfortable at the facility. LVN 1 stated Resident 1 had increased pain, and her morphine sulfate (a powerful pain medication) was changed from as needed to routine for pain control. LVN 1 stated Resident 1 had fallen before the 7/16/25 fall, twice on 5/19/25 and once on 6/16/25. Resident 1's care plan dated 7/16/25 indicated, . at risk for fall related to actual fall on 7/16/2025 . 72-hour alert monitoring . X-ray . Communicated X-ray findings to MD [physician]/hospice/IDT [interdisciplinary team-involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident] . Manage resident fall risk through facility red sneaker program . LVN 1 stated the Red Sneaker Program was the facility's fall prevention program and was used for all residents with high fall risk and was not specific to Resident 1. LVN 1 stated Resident 1 needed increased supervision because she had behaviors of getting up to transfer without assistance because she felt like she needed to use the restroom frequently. LVN 1 stated Resident 1 had the urge to urinate frequently causing her to try and transfer herself. LVN was unable to find interventions that addressed urinary frequency and attempts to self-transfer . Resident 1's Fall Risk Assessment, dated 7/3/25, was reviewed. The assessment indicated, . High Risk for Falls . LVN 1 stated Resident 1 fell because she did not have enough supervision and would have required one on one (direct, individualized supervision) to prevent her from falling. During a review of the facility's Red Sneaker Program, the program indicated, . Criteria for Inclusion in the Red Sneaker Program. Resident had had a fall in the last 90 days . has a Fall Risk Assessment Score of above 10 . Care Plan Implementation . Anticipate toileting needs of High Risk for Fall Residents . Focus on residents who are High Risk for Falls that may be attempting to ambulate independently . DON and IDT will make sure appropriate individualized CPs [care plans] and interventions are in place .During a concurrent interview and record review on 8/12/25 at 11:33 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's MDS Section GG [functional status], dated 7/3/25 was reviewed and indicated, . sit to stand [code 02-substantial/maximal assistance- helper does more than half the effort] . Chair/bed-to-chair transfer [code 02] . Toilet transfer [code 02] . The MDSC stated Resident 1's MDS indicated the resident required the assistance of two people to safely transfer between the bed and chair and the chair to toilet. Resident 1's fall risk care plan dated 3/25/25, was reviewed. The care plan indicated, . functioning deficit related to: Mobility impairment, ROM [range of motion] limitations r/t fracture to right superior/inferior pubis ramus . Interventions . Bed mobility assistance . Call bell within reach . Toileting Assistance . Transfer Assistance . Resident 1's fall care plan dated 5/19/25, was reviewed and it indicated, . At risk for delayed trauma r/t actual fall on 5/19/25 at 12:30 PM 1st and 2nd fall at 5:03 PM . 72 hour alert monitoring . Floor mat next to bed . evaluation of the resident's condition . activity programs . low electric bed . Manage resident fall risk through facility Red Sneaker Program . Resident 1's fall care plan dated 6/17/25 was reviewed and it indicated, . At risk for delayed injury r/t actual fall on 6/16/25 . Assist with toileting q [every] 2 hrs [hours], at bed time and as needed . floor mats to side of bed . level 2 [every 15 minute checks] monitoring x 72 hours . Notify hospice . Encourage activities . Resident 1's fall risk care plan dated 7/16/25, indicated, . At risk for unavoidable falls and related injury . Rt. [right] Hip fracture R/T [related to] Osteoporosis/Diffuse Osteopenia . Resident is on Hospice care . Bed in low position . Fall Mat. Turn and reposition Q [every] 2 hours . The MDSC stated the care plan interventions were not personalized to Resident 1's needs. The MDSC stated rounding on residents and offering to toilet the residents every two hours was standard care and did not specifically address Resident 1's frequent urination or attempts to self-transfer.During a concurrent interview and record review on 8/1/25 at 11:55 a.m. with the DON, the DON stated Resident 1 was at high risk for falls and was admitted with fractures from falling prior to admission. The DON stated Resident 1 was not compliant with care and would try to transfer herself because she felt like she needed to use the restroom frequently. The DON stated Resident 1 was anxious, had behaviors of repeatedly requesting to use the restroom and attempting to self-transfer without assistance because she had urinary urgency, increasing her fall risk. The DON stated the CNAs would take Resident 1 to the bathroom and five minutes later she would get restless and want to go again. The DON stated Resident 1 had been seen by a psychologist (a professional who studies mental processes and behavior) to address the behavior of anxiety causing repeated requests to use the toilet. The DON reviewed Resident 1's electronic medical record and stated Resident 1 did not have a urinalysis (U/A-laboratory test that examines a person's urine to detect and assess various health conditions) to rule out a possible infection as a cause for her urinary urgency. The DON stated a U/A was not tested because Resident 1 was on hospice. The DON reviewed Resident 1's fall care plans and stated the resident sustained four falls while at the facility. The DON was unable to find interventions indicating how the plan of care addressed Resident 1's urinary urgency and frequency and her attempts to self-transfer. Resident 1's General Note, dated 6/17/25, was reviewed. The note indicated, . LATE ENTRY . Writer was notified by staff that resident was sitting on the floor . Resident stated I slid from bed and fell. I wanna go to the bathroom, I need to pee . Resident 1's SBAR [situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents] Post Fall, dated 6/16/25 at 11:30 p.m., indicated, . Resident fell in Resident room. Unwitnessed fall . The DON stated the root cause of Resident 1's 6/16/25 fall was the resident's attempt to transfer unassisted because she needed to go to the bathroom. The DON was unable to state if any new, personalized interventions were put into place after the fall on 6/16/25. Resident 1's SBAR Post Fall, dated 7/16/25 at 3:46 p.m. was reviewed and indicated, . Prior to fall resident was Attempt to self transfer . Resident fell in Resident room . Injury . Unwitnessed fall . Fall details: Other Unable to describe . from 7/16/25 was reviewed and indicated, . The DON stated Resident 1's fall was unwitnessed. The DON stated a new intervention was put into place after the fall and Resident 1 was moved into a different room with a CNA assigned in the room for the day and evening shifts. During a review of Resident 1's Psychologist Consultation, dated 6/23/25, . Treatment & compliance . demanding . Affect . Anxious . anxious [with] frequent requests to use restroom .During a review of Resident 1's Post Fall IDT Analysis, Dated 6/19/25, the note indicated, . Fall Date and Time . 6/16/25 . LN was notified by staff that resident was sitting on the floor. LN went to res. room assessed resident, noted this res sitting on the floor leaning her back against the bed .During a review of Resident 1's Psychologist Consultation, dated 7/15/25, . Treatment & compliance . repetitive requests . Affect . Anxious . anxious, forgetful, has frequent requests to use toilet is otherwise cooperative with care & Tx [treatment].During a review of Resident 1's Post Fall IDT Analysis, dated 7/16/25, the IDT note indicated, . Fall Date and Time . 7/16/25 at 06:15 [a.m.] . Immediate interventions post fall . Placed on level 2 monitoring. Hospice Nurse Came New orders for pain meds [medication]. Xray Rt. [right] Leg and Rt. Hip . C/O [complains of] pains Room Change offered for close supervision . At 06:15 AM staff found resident sitting on the floor mat. At 06:05 AM CNA made rounds & res. [resident] was on her bed with her call light within reach. LVN saw res. 10-15 minutes prior to fall. Root cause: Resident was restless and attempted to move from and in her bed and landed on her floor mat .During a review of Resident 1's pain care plan dated 7/16/25, the care plan indicated, . Acute Pain Fracture-Right hip fx [fracture] . Administer Morphine routinely as ordered . Observe for loss of appetite . Utilize non-medication interventions for pain relief . Utilize positioning and relaxation techniques for comfort .During a review of Resident 1's mobility care plan dated 7/16/25, the care plan indicated, . Impaired physical mobility related to acute intertrochanteric fracture of the right hip . Assess for pain regularly . Ensure fracture precautions are communicated . Inspect fracture site for swelling, discoloration or increased tenderness . Maintain toileting schedule .During a review of Resident 1's Order Summary Report [OSR], dated 7/2025, the OSR indicated, . Monitor episode of Anxiety m/b [manifested by] repetitive request to use the restroom despite recently being assisted [Ordered 7/17/25] . Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for Pain [ordered 3/25/25] . Morphine Sulfate 20 mg/ml . Give 0.25 ml by mouth three times a day for Pain [ordered routinely on 7/17/25] . oxybutynin Chloride Oral Tablet [a medication to treat overactive bladder symptoms include frequency, urgency (sudden, compelling need to urinate), and incontinence (involuntary leakage of urine)] . give 1 tablet by mouth two times a day for overactive bladder for 1 Week over active bladder [ordered 7/17/25] . During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, undated, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible . Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents . The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . Implementing interventions to reduce accident risks . Ensuring that interventions are implemented . Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs .During a review of the facility's P&P titled Falls-Clinical Protocol, dated 9/2012, indicated, . As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling . many falls are isolated individual incidents, a significant proportion occur among a few residents . individuals may have a treatable medical disorder or functional disturbances as the underlying cause . After more than one fall, the physician should review the resident's gait, balance, and current medications . staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found. Based on the preceding assessment, the staff and physician will identify pertinent interventions or try to prevent subsequent falls and to address risks of serious consequences of falling . If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment . until falling reduces or stops or until a reason is identified . (for example, if the individual continues to try to get up and walk without waiting for assistance) . The staff . will follow up on any fall with associated injury until the resident is stable . Frail elderly individuals are often at greater risk for serious adverse consequences of falls . If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed . If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling .

Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse for one of four sampled residents (Resident 1) when Resident 1 experienced an incident on 10/26/23 where Resident 2 entered Resident 1 ' s room, unattended and unsupervised, and used a stuffed cat/toy that belonged to Resident 1 to inflict facial and eye injuries. On 2/1/24, Resident 1 was found to have facial and eye injuries of unknown origin. The unwitnessed incident resulting in Resident 1 ' s facial injuries was not reported immediately by CNA 1 in accordance with facility policy and procedure. These failures resulted in Resident 1 to experience avoidable physical, psychosocial, and emotional harm. Resident 1 experienced discomfort and pain that required treatment over several days to heal, and transfer to a higher level of care to the local acute care hospital emergency roiagnom on [DATE] for further evaluation. Findings: During a review of Resident 1's Admission Record (AR - document containing resident demographic information and medical diagnosis), dated 2/2/24, the admission record indicated Resident 1 was admitted to the facility on [DATE] from the acute care hospital with diagnoses which included Alzheimer ' s Disease (loss of memory and ability to carry simple tasks), Protein Calorie Malnutrition (not consuming enough protein and calories), Type 2 Diabetes Mellitus (high blood sugar), Muscle Weakness, Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Dementia with mood disturbance (impaired ability to remember, think, or make decisions), and Psychosis (symptoms that happen when a person is disconnected from reality, it may involve hallucinations or delusions). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident mental and physical function) assessment dated [DATE], Resident 1 ' s MDS assessment indicated Resident 1 ' s cognitive (memory) skills for daily decision-making was severely impaired. The MDS mobility assessment indicated Resident 1 was dependent on staff when repositioning from laying on back to the left and right side and return to laying back in bed. Resident 1 was chairbound and bedbound and could not make needs known to staff. During a review of Resident 1 ' s Progress Note (PN) and Care Plan (CP) dated 10/26/23, the PN indicated, . At around 4:30 a.m., writer heard CNA calling for help in [Resident 1] ' s room, writer immediately ran to [Resident 1] ' s room, staff was bringing out [Resident 2, alleged abuser] out of [Resident 1] ' s room, [Resident 1] was yelling as the staff while holding a cat stuffed toy. [Resident 2] was transferred to activity room. [Resident 1] was screaming and yelling as well. Unable to obtain statement as to resident speak limited English and [Foreign Language]. Per [Resident 2] Resident 1 needs to shut up from screaming. Per CNA report [Resident 2] was standing in front of Resident 1 holding a stuff toy and putting it in resident mouth . CP . RESOLVED: STOP: [Resident 1] was hit by other resident [Resident 2] on face with stuffed toy while lying in bed, noted bruise to right upper lip; at risk for delayed ill effect . Interventions: Notify MD [Physician], RR [Responsible Party], Ombudsman and PD [Police Department] . Monitor for s/s [sign and symptoms] of pain and administered pain medication as ordered . Separate resident from other resident . There was no documented evidence in the PN the incident was reported to the California Department of Public Health. During a review of Resident 2's AR, dated 2/21/24, the admission record indicated Resident 2 was admitted to the facility on [DATE] from a long term care hospital with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD- is a chronic inflammatory lung disease that causes obstructed airflow of the lungs), Dementia, Psychosis, Delusional Disorders (a belief that is firmly maintained despite being contradicted by what is generally accepted as reality), Anxiety (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness) and Hypertension (high blood pressure). During a review of Resident 2's MDS assessment dated [DATE], Resident 2's MDS indicated Resident 2 ' s, Brief Interview for Mental Status (BIMS) Summary Score of 4 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 2 ' s cognitive impairment was severe. The MDS behavior assessment indicated Resident 2 has a behavior of being physically aggressive towards other residents such as hitting, kicking, scratching, grabbing, and abusing others and wandering inside the facility. During a review of Resident 1' s Change of Condition (COC) and PN, dated 2/1/24, the COC and PN indicated, . COC . Noted bruising to left cheek and left eye and jaw. Skin tear to right side of nose . PN . Today around 10 p.m. the resident ' s CNA [Certified Nurse Assistant] let the writer know that the resident had swelling to her left cheek. Upon assessment of the resident ' s skin, it was noted that the resident had bruising to both her cheeks, left eye and left side of her jaw. The resident also had swelling to both her cheeks as well and a horizontal scratch to the right side of her nose . The hospice nurse ordered an ice pack be applied to bilateral cheeks to help reduce the swelling . [Signed LVN 1] . During a concurrent observation and interview on 2/2/24, at 9:41 a.m., with Certified Nurse Assistant (CNA) 2 inside Resident 1 ' s room. Resident 1 was observed sleeping in her bed. CNA 2 stated Resident 1 was started on 1:1 monitoring this morning. CNA 2 stated, [Resident 1] has bruising on her left and right cheeks, below her eyelids. A scratch below her left eye and both of her cheeks are swollen. I was told that the source of her injury was unknown. CNA 2 stated Resident 1 had history of yelling and physical aggression towards staff but no history of hurting herself. During a concurrent observation and interview on 2/2/24, at 9:47 a.m., with CNA 2, inside Resident 1 ' s room, Resident 1 was observed with swollen and purple discoloration around her left and right eyes, left cheek and with a horizontal scratch below her left eye. Resident 1 was observed sleeping in her bed and a brown and white cat stuffed toy was on top of the overbed table and within reach of Resident 1 and to anyone entering the room. The cat stuffed toy was approximately four pounds in weight and made of soft and hard plastic materials. CNA 2 stated the cat stuffed toy was used to keep Resident 1 occupied while in her room. During a concurrent interview and record review on 2/2/24, at 9:54 a.m., with Registered Nurse (RN) 1, Resident 1 ' s PN, dated 2/1/24 was reviewed. The PN indicated, . Today around 10 p.m. the resident ' s CNA [Certified Nurse Assistant] let the writer know that the resident had swelling to her left cheek. Upon assessment of the resident ' s skin, it was noted that the resident had bruising to both her cheeks, left eye and left side of her jaw. The resident also had swelling to both her cheeks as well and a horizontal scratch to the right side of her nose . RN 1 stated Resident 1 was started on 1:1 monitoring at the beginning of her shift, medicated for pain, and staff were applying ice pack to Resident 1 ' s face. RN 1 stated Resident 1 has a history of yelling, screaming, and fighting with staff during personal care but no history of hurting herself. RN 1 stated Resident 1 and her roommates were both bedbound and non-ambulatory. RN 1 stated, I don ' t know how it happened. RN 1 stated all staff are responsible in protecting Resident 1 and other residents from harming themselves or getting hurt by others. During a phone interview on 2/2/24, at 11:05 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she worked on 2/1/24 and was the assigned nurse for Resident 1. LVN 1 stated [CNA 1] reported to her that Resident 1 has bruising, swelling and scratches on her face. LVN 1 stated [CNA 1] discovered the bruising at 7:00 p.m. but did not report to her until 10 p.m. LVN 1 stated she went immediately to Resident 1 ' s room and performed an assessment. LVN 1 stated, [Resident 1] had bruising to both cheeks, left eye and left side of jaw. [Resident 1] also had swelling to both her cheeks as well and a horizontal scratch to the right side of her nose. I called the doctor, hospice agency, Director of Nursing (DON), and the Responsible Party (RP). The hospice nurse came and ordered to apply ice pack to the swollen area. LVN 1 stated prior to the reported incident, she gave Resident 1 ' s 5:00 p.m. [evening] medications and did not observe any facial bruising, swelling or skin discoloration. LVN 1 stated everyone who works in the facility was responsible in protecting residents from harm. LVN 1 stated the facility failed to protect Resident 1 from harming herself or getting hurt by others. During a phone interview on 2/2/24, at 11:13 a.m., with CNA 1, CNA 1 stated she worked on 2/1/24 and was the assigned CNA for Resident 1 from 7:00 p.m. to 10:40 p.m. CNA 1 stated, I saw her at 7:30 p.m. and I noticed the bruising on both of her cheekbones, upper side. She was being aggressive and combative. I left the room and provided care to other residents. I returned to [Resident 1 ' s] room to change her disposable brief around 9:00 pm, [CNA 3] assisted me with changing the brief. I told her about my observation, and she told me to notify the Charge Nurse of the bruising. I reported my observation to [LVN 1] around 10 p.m. I don ' t want to be blamed for it. I forgot to report the bruising right away. I should have reported it as soon as I noticed the bruising and I did not. CNA 1 stated she doesn ' t recall if another resident or staff went to Resident 1 ' s room during her shift. CNA 1 stated she failed to follow the facility ' s policies on reporting alleged abuse and change in condition. During an interview on 2/2/24, at 11:35 a.m., with CNA 4, CNA 4 stated she worked on 2/1/24, from 6:00 a.m. to 6:55 p.m., and was the assigned CNA for Resident 1 from 2:30 p.m. to 6:55 p.m. CNA 4 stated she was the Restorative Nurse Assistant (RNA, assist residents with range of motion exercises) from 6:00 a.m. to 2:30 p.m., then worked for additional four hours to assist the afternoon shift with patient care. CNA 4 stated she delivered Resident 1 ' s dinner around 5:00 p.m. Resident 1 was sleepy and refused her meal. CNA 4 stated she did not notice any bruising on her face and was not in pain. CNA 4 stated, She was just sleepy. Normally, she will be screaming and yelling in her native language. [Resident 1] is total care. Bedbound. She needs assistance during meals. No history of hurting herself. A possibility is someone came to her room and hurt her. We don ' t have a video recording to support my statement. We don ' t have a camera in our hallway.CNA 4 stated Resident 1 was physically abused by Resident 2 several months ago [10/2023] and suffered multiple bruises on her face. CNA 4 stated, This is not the first time that [Resident 1] was hurt by another resident. CNA 4 stated all staff, including her were responsible in preventing resident abuse and the facility failed to protect Resident 1 from abuse. During a phone interview on 2/2/24, at 12:30 p.m., with CNA 3, CNA 3 stated she worked on 2/1/24 and assisted CNA 1 in changing Resident 1 ' s brief around 9:00 p.m. CNA 3 stated she was walking in the hallway, outside Resident 1 ' s room and she heard CNA 1 talking to Resident 1. CNA 3 stated, I knocked and entered the room and found CNA 1 changing Resident 1 ' s disposable brief. I offered to help by holding Resident 1 ' s back while CNA 1 puts on a new brief. CNA 1 told me that she noticed some bruising on Resident 1 ' s face at the beginning of her shift but forgot to report to the Charge Nurse. I advised her to immediately notify the Charge Nurse. CNA 3 stated it is important to report the observed bruising for immediate assessment, treatment interventions, investigation, and to protect the resident from further harm. CNA 3 stated she did not examine Resident 1 ' s face because she was called by another Resident who was asking for help. CNA 3 stated, We have several residents with history of aggression towards other residents who are ambulatory and wander inside the facility and enter other residents ' room. During a concurrent observation and interview on 2/6/23, at 1:22 p.m., with CNA 5, inside Resident 1 ' s room. Resident 1 was observed with purple color skin around her left and right eye, her left cheek was purple in color, a horizontal scratch below her left eye with tinge of dried blood, and a bruising on her right hand. Resident 1 was observed sleeping in her bed and a brown and white cat stuffed toy was on top of the overbed table and within reach of Resident 1 and to anyone entering the room. CNA 5 stated Resident 1 remains on 1:1 monitoring, and the cat stuffed toy was used to keep Resident 1 occupied while in her room. CNA 5 reported Resident 1 sustained bruising on her right hand this morning, around 6:00 a.m. CNA 5 stated Resident 1 was swinging her right arm and hand during patient care and hit the bed side rail. During a concurrent phone interview and record review on 2/16/24, at 11:40 a.m., with Registered Nurse Supervisor (RNS), Resident 1 ' s PN, dated 2/1/24 was reviewed. The PN indicated, . Today around 10 p.m. the resident ' s CNA let the writer know that the resident had swelling to her left cheek. Upon assessment of the resident ' s skin, it was noted that the resident had bruising to both her cheeks, left eye and left side of her jaw. The resident also had swelling to both her cheeks as well and a horizontal scratch to the right side of her nose . RNS stated Resident 1 has a history of hitting, swinging, and grabbing staff during personal care. RNS stated Resident 1 has no documented record of hurting herself. RNS stated CNA 1 failed to report the observed facial bruising in a timely manner. RNS stated the delay in reporting prevented the facility to implement appropriate interventions to protect Resident 1 from potential additional harm and delay in the investigation of the alleged abuse incident. RNS stated Resident 1 was physically abused by [Resident 2, perpetrator] four months [10/26/23] ago that resulted in facial bruising and swelling. RNS stated Resident 2 remains a resident at the facility and continues to wander inside the facility. RNS stated Resident 1 remains to have a circular discoloration around her left and right eyes, purple color in the middle and yellow color on the outer part. RNS stated Resident 1 ' s 1:1 monitoring did not start until the morning shift of 2/2/24. RNS stated the facility failed to protect Resident 1 from harm that resulted in facial bruising and swelling for several days, requiring emergency room visit, treatment and pain medication. During a review of Resident 1 ' s Acute Care After Visit Summary dated 2/4/24, the visit summary indicated, . You were seen for bruising below your eyes. Your CT scan [Computed Tomography, imaging test to detect internal injuries or disease] did not show bleeding or a broken bone . Diagnosis . Periorbital ecchymosis [black eye, often happens form an injury to the area around the eye] . [emergency room Provider] . During a concurrent phone interview and record review on 2/16/24, at 11:52 a.m., with RNS, Resident 1 ' s CP, dated 10/26/23 was reviewed. The CP indicated, . CP . RESOLVED: STOP: Resident was hit by other resident on face with stuffed toy while lying in bed, noted bruise to right upper lip; at risk for delayed ill effect . Interventions: Notify MD, RP, Ombudsman and PD . Monitor for s/s [sign and symptoms] of pain and administered pain medication as ordered . Separate resident from other resident . RNS stated Resident 1 was vulnerable for physical abuse from other residents due to her behavior of continuous yelling and screaming. RNS stated she can ' t find a specific care plan to protect Resident 1 from physical abuse from other residents and there should have been one. RNS stated without a specific care plan to prevent physical abuse, Resident 1 could potentially experience physical abuse from other residents. During a phone interview on 2/16/24, at 12:20 p.m., with the Director of Staff Development (DSD), the DSD stated CNA 1 failed to report Resident 1 ' s bruising on 2/1/24 in a timely manner. The DSD stated she expects CNA 1 to report any observed bruising immediately to the charge nurse and she did not. The DSD stated Resident 1 was abused by Resident 2 on October 26, 2023, which resulted in Resident 1 to have bruising and swelling around her eyes and mouth. The DSD stated Resident 2 remains a resident at the facility and continues to wander inside the facility. The DSD stated everybody is responsible in protecting Resident 1 from physical abuse and failed to do so. During a phone interview on 2/16/24, at 12:20 p.m., with Resident 1 ' s daughter/ Responsible Party (RP), the RP stated [Resident 1] was admitted to the facility on [DATE] from acute hospital. RP stated [Resident 1] was bedbound, dependent on staff for her personal care, and under hospice care. RP stated [Resident 1] was physically abused twice at the facility that resulted to facial bruising, swelling, and affected her quality of life. RP stated [Resident 1] has a history of refusing care by kicking and hitting staff during personal care but no history of harming herself. RP stated she and [Resident 1 ' s] spouse visit the facility on a weekly basis and witnessed on multiple occasions other residents wandering insider Resident 1 ' s room and touching her belongings. RP stated, The facility did not do enough to protect my mom from physical abuse on October 26, 2023, and on February 1, 2024. She ' s under hospice and our goal is to keep her safe. She got hurt twice. It ' s heart-breaking. I hope they do something to protect her from future harm. During a concurrent interview and record review on 2/23/24, at 10:20 a.m., with the Director of Nursing (DON), Resident 1 ' s CP and PN, dated 10/26/23 and 2/1/24 were reviewed. The PN indicated, . 10/26/23 . at around 4:30 a.m., writer heard CNA calling for help in [Resident 1 ' s] room, writer immediately ran to [Resident 1] ' s room, staff was bringing out [Resident 2] out of [Resident 1 ' s] room, [Resident 1] was yelling at the staff while holding a cat stuffed toy . 2/1/24 . Today around 10 p.m. the resident ' s CNA let the writer know that the resident had swelling to her left cheek. The DON stated Resident 1 was bedbound and dependent to staff for all areas of ADLs. The DON stated Resident 1 has no history of hurting herself. The DON stated she was unable to find a specific CP to address Resident 1 ' s vulnerable condition and the potential for physical abuse from other residents. The DON stated the CP should have been initiated on admission and it was not done. The DON stated the physical abuse to Resident 1 on 10/26/23 and 2/1/24 could have been prevented if the proper interventions were in place. The DON stated the facility failed to protect Resident 1 from physical, psychological, and emotional harm. During a review of the facility's document titled, Certified Nurse Aide Job Description, dated 9/25/14, the document indicated, . Perform direct resident care duties under the supervision of licensed nursing personnel. Assist with promoting a compassionate physical and psychosocial environment for resident . During a review of the facility's document titled, Job Description: Charge Nurse Licensed Vocational Nurse (LVN), dated 8/14/15, the document indicated, . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . Must adhere to the Company ' s Code of Conduct and Business Ethics policy including documentation and reporting responsibilities . During a review of the facility document titled, Job Description: Charge Nurse Registered Nurse (RN), dated 8/17/15, the Job Description indicated, . Assure the effective quality nursing care is delivered . Develop individualized plan of care in collaboration with the resident/responsible party and interdisciplinary care team . Demonstrate understanding that state and Federal rules and regulations govern the practices within the facility . During a review of the facility document titled, Job Description: Director of Nursing (DON), dated 10/15/14, the Job Description indicated, . Plans, coordinates, and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to residents. Maintains quality care that is consistent with company and regulatory standards . Oversees and monitors the Resident Assessment process for accuracy, attends care planning conferences periodically to determine compliance with care planning guidelines . During a review of the facility ' s document titled, Your Legal Duty . Reporting Elder and Dependent Adult Abuse, dated 2/23, the document indicated, . Failure to report elder or dependent adult abuse in long-term health care facilities is a crime . This training curriculum has been developed by the Department of Justice, in cooperation with the Department of Health Care Services and the Department of Social Services . During a review of the facility ' s policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated 7/17, the P&P indicated, . All reports of resident abuse, neglect, exploitation . shall be promptly reported to local, state, and federal agencies . Findings of abuse investigations will also be reported . During a review of the facility ' s policy and procedure (P&P) titled, Recognizing Signs and Symptoms of Abuse/Neglect, dated 2/11, the P&P indicated, . Our facility will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately . Signs of Actual Physical Abuse: (1) Welts or bruises; (2) Abrasions or lacerations . (4) Black eyes or broken teeth . During a review of the facility ' s P&P titled Resident-to-Resident Altercations (disputes), dated 2/16, the P&P indicated, .All altercations, including those that may represent resident-to-resident abuse, shall be investigated, and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator . Policy Interpretation and Implementation . 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff . shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator .

Based on observation, interview, and record review, the facility failed to follow their policies and procedures regarding the safe and appropriate prescribing and administering of antipsychotic (medications used to treat [CONDITION(S)]-which is a condition that affects the mind, where there has been some loss of contact with reality) medications and ensure three of three sampled residents (Resident 38, Resident 47, and Resident 150) were free from unnecessary medications when: 1. For Resident 47, staff administered [MEDICATION(S)] (an antipsychotic medication used to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality) without monitoring for side effects. 2. For Residents 38, 47, and 150, the facility did not implement resident specific non-pharmacological (without the use of medications) interventions prior to initiation of antipsychotic medications. These failures had the potential for Residents 38, 47, and 150 to experience the serious negative effects (medication interactions, adverse reactions, dizziness [increasing risk for falls], drowsiness, high cholesterol, high blood sugar [increasing risk for diabetes - high sugar in the blood]), liver dysfunction, weight gain, constipation, heartburn, dry mouth, akathisia (a state of agitation, distress, and restlessness), weakness, [CONDITION(S)] (NMS, a life threatening reaction from use of antipsychotic medication), tardive dyskinesia (uncontrolled body movements), decreased blood pressure, seizures and difficulty swallowing, pseudo parkinsonism (a medical condition causing slowed movements, muscle stiffness, and a shuffling walk), and ingestion of anti-psychotics. For Resident 47, the unnecessary use of [MEDICATION(S)] resulted in the development of [CONDITION(S)] (high blood sugar) from 7/8/22 to 7/11/22 and hospitalization on [DATE] due to [CONDITION(S)]; and constituted harm as a result of administering [MEDICATION(S)]. Findings: 1. During a review of Resident 47's Admission Record (AR), dated 7/13/22, the AR indicated Resident 47 is a [AGE] year old male who was admitted from a general acute care hospital (GACH) on 12/16/21 to the facility, with diagnoses which included type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high), anxiety disorder, chronic kidney disease (gradual loss of kidney function over time), [CONDITION(S)] (too many fats in your blood), unspecified dementia (the loss of memory, language, problem solving and thinking abilities) without behavioral disturbance, hypertensive (high blood pressure) heart disease without heart failure, constipation, and pain. During an observation on 7/11/22, at 11:33 a.m., inside Resident 47's room, Registered Nurse (RN) 1 checked Resident 47's blood sugar and the glucometer (portable device used to measure how much sugar is in the blood) read HI (maximum on glucometer). RN 1 stated she was unable to get a reading on the glucometer because Resident 47's blood sugar was very high and Resident 47's physician (PHY 1), had instructed her to send Resident 47 to the GACH. During a concurrent interview and record review, on 7/12/22, at 2:22 p.m., with RN 1, Resident 47's Order Summary Report (OSR), dated 6/30/22 was reviewed. The OSR indicated on 7/5/22 [MEDICATION(S)] (medication used to treat anxiety) was discontinued, and Resident 47 was prescribed [MEDICATION(S)] 5 milligrams (mg-unit of measure) by mouth once daily on 7/5/22 for diagnosis of brief [CONDITION(S)]. RN 1 stated Resident 47 was on [MEDICATION(S)] 5mg and was still having behaviors, so his dose was increased to 10mg. RN 1 stated, [Resident 47] continued to have behaviors which include talking loudly and if you approach him, he becomes aggressive . RN 1 stated she was aware of the black box warning stating [MEDICATION(S)] could cause an increased mortality for residents with dementia related [CONDITION(S)]. RN 1 stated Resident 47 had dementia, so he would fall in this category. RN 1 stated Resident 47's blood sugars were mainly in the 100-200's but had recently started increasing on 7/8/22 to the 400-500's range (normal blood sugar level is less than 140). During an interview on 7/12/22, at 2:49 p.m., with RN 1, RN 1 stated side effects to monitor for [MEDICATION(S)] included: drowsiness, weight gain, [CONDITION(S)], dry mouth, constipation, and risk for stroke. RN 1 stated licensed nurses (LN) were not monitoring the side effects for [MEDICATION(S)] because she forgot to update the monitoring on Resident 47's electronic medical record (EMR). RN 1 stated it was important to monitor the side effects of [MEDICATION(S)] because of the fatality that could occur which could include death. RN 1 stated if a resident was having bad side effects due to a new medication and LN were not monitoring for side effects, LN would not be able to detect that the resident was experiencing side effects. During an interview on 7/12/22, at 3:07 p.m. with RN 1, RN 1 stated [CONDITION(S)] was a side effect of [MEDICATION(S)] which could cause an increase in blood sugar levels. RN 1 stated, If I notice an increase in blood sugars, I should notify the physician. RN 1 stated she would inform the physician Resident 47's blood sugars were high and the date the [MEDICATION(S)] was started. RN 1 stated if she was monitoring side effects related to [MEDICATION(S)], she would have noticed when Resident 47 was having side effects to [MEDICATION(S)]. RN 1 stated Resident 47 had not been monitored for involuntary movements and had not had any eye exams since he has been admitted to the facility. During a concurrent interview and record review on 7/12/22, at 3:57 p.m., with the Director of Nursing (DON), Resident 47's Psychologist Consultation/Follow up, dated 3/14/21 was reviewed. The DON stated Resident 47's Psychologist Consultation/Follow up indicated, .easily agitated, yells at staff, not combative, no antipsychotic medications recommended . The DON stated psychological evaluations were done every six months. The DON stated the side effects of [MEDICATION(S)] were not being monitored for Resident 47. The DON stated some common side effects of [MEDICATION(S)] included sedation, dry mouth, blurred vision, weight gain, postural [CONDITION(S)], sweating, loss of appetite, [CONDITION(S)], and drowsiness. The DON stated side effects such as abnormal voluntary movements were not being monitored for Resident 47. The DON stated second generation antipsychotics (such as [MEDICATION(S)]) could cause [CONDITION(S)] and was serious enough to warrant monitoring. The DON stated [CONDITION(S)] was not monitored by LN as a possible side effect of [MEDICATION(S)]. The DON stated the blood sugar drawn was previously ordered for Resident 47's diabetes. The DON stated it was important to monitor side effects to evaluate medication cessation (to stop). The DON stated her expectations were for LN to have the knowledge that [CONDITION(S)] was a side effect of [MEDICATION(S)]. The DON stated she was aware of the black box warning for [MEDICATION(S)] used in residents with dementia. During a review of Resident 47's Weights and Vitals Summary (WVS), dated 7/13/22, the WVS indicated Resident 47's blood sugars on 6/4/22 were 104 and 145, on 6/11/22 were 136 and 201, on 6/18/22 were 198 and 216, and on 6/25/22 were 198 and 148. During a concurrent interview and record review on 7/12/22, at 4:30 p.m. with DON, Resident 47's Medical Record (MR), undated was reviewed. The MR indicated on 7/2/22 blood sugars were 144 and 188, on 7/7/22 blood sugars were 162, on 7/8/22 blood sugars were 569, 414, and 275, on 7/9/22 blood sugars were 400, 430, and 415, on 7/10/22 blood sugars were refused, on 7/11/22 blood sugar was HI and Resident 47 was sent to GACH. The DON stated Resident 47's diet was the same and he did not have any previous infections. During a review of Resident 47's hospital After Visit Summary (AVS), dated 7/11/22, the AVS indicated .[Resident 47] was seen today for high blood sugar. He was given IV [Intravenous -in the vein] fluids and insulin and his sugar came down .will need close outpatient follow up with his doctor to better manage his blood sugar . During a review of Resident 47's hospital Summary of Care (SOC), dated 7/11/22, the SOC indicated .Basic Metabolic Panel .glucose 658 . During an interview on 7/14/22, at 1:10 p.m., with PHY 1, PHY 1 stated Resident 47's [MEDICATION(S)] 10mg was not titrated to max dose because Resident 47 was on 5mg BID (twice a day) then 10mg BID and his behaviors got much worst over time and Resident 47 was refusing medications and care, so it was PHY 1's decision to switch from [MEDICATION(S)] to [MEDICATION(S)] 5mg. PHY 1 stated he has ordered [MEDICATION(S)] for other residents for a long time and none of those residents has had a dramatic increase in blood sugar. PHY 1 stated he was aware there were no changes to Resident 47's diet to cause the fluctuation. PHY 1 stated he assumed there was something else going on and Resident 47 was seen and evaluated in the emergency department, but they could not find the cause for the high blood sugar, so he assumed it was because of the [MEDICATION(S)]. PHY 1 stated he had used Ariprazole on his patients for over [AGE] years and agitation had not been an issue for those residents. PHY 1 stated his expectations were for LN to assess residents' baseline scale for abnormal involuntary movements. PHY 1 stated Resident 47 was sent to GACH because the outcome of having a blood sugar over 600 could be a devastating problem. During an interview on 7/14/22, at 3:45 p.m., with the Consultant Pharmacist (CP), the CP stated it was important to assess AIMS (abnormal involuntary movement scale- scale used to measure abnormal movements in a patient taking antipsychotics) which could cause long term effects. The CP stated it was important to monitor visual acuity for residents who were on antipsychotics to see if their vision was getting worse due to the medications. The CP stated it was important to monitor side effects to determine if the medication needed to be discontinued, a dosage increase, or gradually reduce the dose. During a review of a nationally recognized professional reference titled, Lexicomp, the drug manufacturer for [MEDICATION(S)] stated, .WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect .High blood sugar like confusion . Monitoring Parameters . Frequency of Antipsychotic Monitoring . Extrapyramidal symptoms . 4 weeks after initiation and dose change; annually. Use a formalized rating scale at least annually or every 6 months if high risk . Obtain ophthalmic exam (yearly in patients >[AGE] years . 2a. During an interview on 7/12/22, at 3:07 p.m. with RN 1, RN 1 stated nonpharmacological interventions for Resident 47 included leaving him alone when he was having behaviors to allow Resident 47 to calm down. RN 1 stated she did not document all the nonpharmacological interventions implemented for Resident 47. RN 1 stated usually when residents are having behaviors, she does behavior monitoring and would offer food and fluids. During a review of Resident 47's MAR, dated June 2022 and July 2022 was reviewed. The MAR indicated in June 2022, Resident 47 had 13 episodes of behaviors with interventions implemented to include: back rub, change position, give fluids, give good or redirect. The MAR indicated in July 2022, Resident 47 had 20 episodes of behaviors with interventions implemented to include: one on one, activity, or give fluids. During a concurrent interview and record review on 7/12/22 at 3:30 p.m., with RN 1, Resident 47's Care Plan (CP), dated 7/6/22 and the facility document Side Effects Monthly Flow Sheet, undated was reviewed. The CP indicated, on 7/6/22, the focus was: I sometimes have behaviors, such as persistent distress of being territorial over people or items thinking it belongs to me AEB [as evidenced by] verbal & [and] physical aggression when I feel my belongs are threatened .as a diversion, talk to me about my interests. Such as sports and basketball, singing or offer me something I like as a diversion, such as singing, dominoes, and eating all kinds of sweets .elderly patients with dementia-related [CONDITION(S)] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION(S)] is not approved for the treatment of patients with dementia-related [CONDITION(S)] .monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS [extrapyramidal symptoms-serious side effects that can develop after taking certain antipsychotic medications], weight gain, [CONDITION(S)], postural [CONDITION(S)] [low blood pressure that happens when standing after sitting or lying down), sweating, loss of appetite, [CONDITION(S)] (condition in which you cannot empty all the urine in the bladder] .monitor HR [heart rate] & BP [blood pressure], abdominal girth and labs as ordered while on antipsychotic medication .Non-pharmacological interventions: See flow sheet .provide medications as ordered by physician and evaluate for effectiveness through behaviors management program . RN 1 stated the care plan for non-pharmacological interventions should be person centered care plans or resident specific interventions because one intervention does not necessarily work for all residents. RN 1 stated the Side Effects Monthly Flow Sheet was a general list of interventions which were not resident centered care and there were no target end dates. RN 1 stated if she did not document the resident specific interventions implemented then other staff would not know which interventions to implement to help the resident. During a concurrent interview and record review on 7/12/22, at 3:57 p.m., with the DON, Resident 47's Electronic Medical Record (EMR), undated, the DON stated the EMR indicated on 7/3/22 at 7:27 a.m., Resident 47 was yelling, cursing, hard to re-direct and he was offered food and fluids to distract him. The DON stated offering food and fluids was not a resident specific intervention and the DON stated nonpharmacological interventions should be resident specific. The DON stated nonpharmacological interventions should be documented and it was important to document non-pharmacological interventions so LN would know which interventions were effective and they could implement those interventions instead of using pharmacological interventions. 2b. During a review of Resident 38's AR, dated 7/14/22, the AR indicated Resident 38 is an [AGE] year old female who was admitted from an assisted living facility on 5/12/17 to the facility, with diagnoses which included type 2 diabetes, hypertension (high blood pressure), major depressive disorder, [CONDITION(S)], dysphagia (difficulty swallowing), dementia with behavioral disturbance, paranoid personality disorder (condition marked by a pattern of distrust and suspicion of others without adequate reason to be suspicious), and anxiety disorder. During a concurrent interview and record review on 7/14/22, at 1:52 p.m. with RN 1 and DON, Resident 38's Clinical Physician's Orders (CPO), dated 7/14/22 was reviewed. The CPO indicated on 5/17/17, [MEDICATION(S)] 25 mg IM (intramuscular-in the muscle) every 14 days was ordered for paranoid personality disorder and then it was discontinued on 5/25/17. RN 1 stated there were several changes to the [MEDICATION(S)] order and on 12/18/20, [MEDICATION(S)] 0.5 mg BID (two times a day) was ordered and has been the same dose since then. RN 1 stated on 6/28/21, there was a gradual dose reduction (GDR-gradual reduction of medication) review but there was no GDR done. The DON stated a GDR was not done because it was done twice before, and Resident 38 had increased behaviors both times. DON stated PHY 2 signed off for GDR on 7/8/22 but when the LN called family of Resident 38 to inform them of the GDR, Resident 38's family communicated that Resident 38 was in distress and had increased behaviors the last time a GDR was done, and they did not agree to the GDR, so the GDR was not performed. During a review of Resident 38's MAR, dated June 2022 and July 2022, the MAR indicated Resident 38 had 18 episodes of behaviors in June [2022] and 8 episodes of behaviors in July [2022]. During a concurrent interview and record review on 7/14/22, at 2:30 p.m. with DON, Resident 38's Care Plan (CP), dated 7/14/22 and the facility's document titled Side Effects Monthly Flow Sheet, undated was reviewed. The DON stated Resident 38's CP indicated Resident 38 had resident specific nonpharmacological interventions and the facility used food as an intervention to divert Resident 38's behaviors to see if food was a need, that needed to be met. The Resident 38's CP indicated, .I sometimes have behaviors, such as delusion of thinking of others trying to harm me causing persistent distress AEB [as evidenced by] verbal & physical aggression towards others which puts me at risk for harm to self and others .interventions .as a diversion, talk to me about my interests. Such as, working as a teacher's aide, or offer me something I like as a diversion, such as Spanish music, a diet [brand name soda product], ice cream and Mexican food . The DON stated the Side Effects Monthly Flow Sheet is commonly used for all dementia residents and does not display resident specific nonpharmacological interventions. During an interview on 7/14/22 at 3:45 p.m. with the PC, the PC stated it was important for nurses to attempt nonpharmacological interventions and assessing residents for pain and offering as needed medications to see if they were effective because the interventions could reduce the need for antipsychotics and its side effects. During a review of the facility's policy and procedure (P&P) titled, Psychoactive Drug Monitoring, undated, the P&P indicated, .Residents who receive .antipsychotic medications are monitored to evaluate the effectiveness of the medication. Every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects . Residents who are receiving anti-psychotic drug therapy are adequately monitored for significant side effects of such therapy, through the use of the AIMS . 2c. During a record review of Resident 150's AR, dated 7/14/22, the AR indicated Resident 150 is a [AGE] year old female who was admitted from a GACH on 2/1/22 to the facility, with diagnoses which included spondylosis (a [CONDITION(S)] (causing the body part to become weaker) condition of the spine), asthma, hypertension, [CONDITION(S)], [CONDITION(S)], dementia, unspecified [CONDITION(S)] not due to a substance or known physiological condition (a person's thoughts and perceptions are disturbed and the individual may have difficulty understanding what is real and what is not), and low back pain. During a concurrent interview and record review on 7/13/22, at 9:43 a.m. with the DON, Resident 150's MAR, dated 7/14/22 was reviewed. The MAR indicated .[MEDICATION(S)] [medication used to treat [CONDITION(S)], [CONDITION(S)] disorder and major depressive disorder] tablet 50 mg .give 50 mg by mouth in the evening related to unspecified [CONDITION(S)] not due to a substance or known physiological condition M/B verbal aggression as evidenced by screaming at others . The MAR indicated on 4/15/22 Resident 150 had new orders for, .[MEDICATION(S)] 50mg, give 50 mg by mouth two times a day related to unspecified [CONDITION(S)] . The DON stated Resident 150's order for [MEDICATION(S)] was increased from bedtime to two times a day on 4/16/22 due to increased behaviors. The DON stated the MAR indicated Resident 150 had 27 episodes of behaviors in February 2022 and 96 episodes of behaviors in March 2022. During a concurrent interview and record review on 7/13/22, at 10:12 a.m. with RN 1 and the DON, the facility's document titled Side Effects Monthly Flow Sheet, undated was reviewed. RN 1 stated she was aware of the black box warning for the use of [MEDICATION(S)] which could cause an increased mortality in residents with dementia related [CONDITION(S)]. RN 1 stated she did not know all the resident specific interventions for each resident, so she must look in each resident's care plans to see which interventions to implement then she documented the implemented interventions and effectiveness. The DON stated the nonpharmacological interventions implemented for Resident 150 included change position, give fluids, give food, and redirect. RN 1 stated there were no resident specific interventions documented for Resident 150. RN 1 stated it was important to document interventions implemented because they gave resident specific care, and it shows improvement of behaviors which helps reduce the use of antipsychotic medications. The DON stated the Side Effects Monthly Flow Sheet indicated Resident 150 did not have resident specific nonpharmacological interventions. The DON stated it was important to document resident specific nonpharmacological interventions because Resident 150 had increased behaviors which resulted in the physician increasing the frequency of [MEDICATION(S)], when her increased behaviors could have been due to adjusting to her new environment. The DON stated her expectations were for LN to document nonpharmacological interventions when they are implemented. During an interview on 7/14/22, at 1:10 p.m., with PHY 1, PHY 1 stated he was aware of the black box warning related to dementia related [CONDITION(S)] but Resident 47's behaviors warranted antipsychotic medications. PHY 1 stated he based his decisions on the nurses report to him of Resident 47's behaviors. PHY 1 stated his expectations were for nurses to implement nonpharmacological interventions prior to him implementing pharmacological interventions. PHY 1 stated Resident 47 could be re-directed several times, but re-direction was no longer working for Resident 47. During an interview on 7/14/22, at 3:45 p.m. with the CP, the CP stated resident specific nonpharmacological interventions should be implemented and documented to assess the effectiveness of interventions. During a review of the facility's P&P titled, Psychoactive Drug Monitoring, undated, the P&P indicated, Nonpharmacological interventions, such as behavior modification or social services and their effects, are documented as a part of the care planning process, and are utilized by the prescriber in assessing the continued need for psychoactive medication .all of the following conditions are satisfied prior to initiation and/or continuation of therapy: .the need for response to therapy is monitored and documented in the resident's medical record .documentation that the resident is being monitored for adverse consequences or complications of therapy .documentation that a resident's decline or deterioration is evaluated by the interdisciplinary team to determine that the regimen in question is not the cause .the consultant pharmacist compiles, analyzes, and presents data related to psychoactive drug use in the facility .anti-psychotics are given only if the resident has been diagnosed with one of the following indications, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) .the diagnosis is documented in the medical record, or .for a diagnosis .acute psychotic episodes, brief reactive [CONDITION(S)] .dementia, [CONDITION(S)] .and other cognitive disorders with associated psychotic and/or agitated behaviors .Residents receive anti-psychotic medication only for behaviors that are quantitatively and objectively documented through the use of behavioral monitoring charts or a similar mechanism. Residents receive anti-psychotic medication only for behaviors that are persistent, that are not caused by preventable reasons, and are causing the resident to: present a danger to self or others .continuously scream, yell, or pace .experience psychotic symptoms (such as hallucinations, paranoia, and delusions) .