Every finding on record at Four Seasons Healthcare & Wellness Center, LP

Based on interview and record review, the facility failed to follow physician orders for one of six sampled residents (Resident 1) when the general acute care hospital (GACH) physician ordered for Resident 1's suprapubic catheter (a flexible tube placed directly into the bladder through a small cut in the lower abdomen to drain urine) to be changed every three weeks and the facility changed the catheter earlier than what was indicated on the physician's order. This failure had the potential to result in disruption of the suprapubic catheter tract, catheter displacement, trauma, bleeding, and infection. Findings: During a review of Resident 1's admission Record, the admission record indicated the facility initially admitted Resident 1 on 4/14/2004, and readmitted the resident on 2/22/2022 and 6/19/2026 with medical diagnoses including dementia (a progressive state of decline in mental abilities), urinary tract infection (UTI- an infection in the bladder/urinary tract), stage four (4) chronic kidney disease (loss of kidney function), type two (2) diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/26/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was severely impaired. The MDS indicated Resident 1 was dependent on staff for toileting hygiene, dressing, oral hygiene, and personal hygiene. During a review of Resident 1's Urology Consultation Note, dated 2/25/2026, the consultation note indicated Resident 1's last Suprapubic Catheter Tube (SPT) change was on 1/8/2026. The consultation noted indicated under sterile conditions a new 16 french (Fr- scale measures the outer diameter of a foley catheter) Foley (also known as a urinary catheter, a flexible tube placed through the urethra into the bladder to drain urine) was placed to the supra pubic tube orifice (an opening) was performed. The consultation note further indicated a letter for orders to change and flush the SPT every three weeks was sent to the facility today. During a review of a letter addressed to the facility from the GACH, dated 2/25/2026, the letter indicated an order to Please exchange suprapubic catheter every 3 weeks and flush as needed. During a review of Resident 1's Wound Assessment and Plan, dated 3/5/2026, the wound assessment and plan indicated Resident 1's suprapubic catheter was changed. During a concurrent interview and record review with the Treatment Nurse (TN) on 8/20/2026 at 11:15 a.m., the Urology Consultation Note, dated 2/25/2026, was reviewed and indicated under sterile conditions a new 16 Fr Foley was placed to the supra pubic tube orifice. The note further indicated a letter for orders for suprapubic tube change and to flush as needed every three weeks was sent to the facility. The TN stated the suprapubic catheter was changed on 3/5/2026. The TN stated the catheter was changed before the three weeks. The TN stated, they need to follow physician orders to prevent any signs of infection. The TN stated the facility failed to follow physician orders by changing the catheter before the three weeks. During an interview with the Director of Nurses (DON) on 8/20/2026 at 2:15 p.m., the DON stated Resident 1's suprapubic catheter was changed on 3/5/2026. The DON stated the facility failed to follow physician orders by changing the catheter before three weeks. During a review of the facility's policy and procedure (P&P) titled, Physician Orders, dated 12/28/2022 and last revised 11/16/2026, the P&P indicated the licensed nurse will confirm that physician orders are clear, complete and accurate as needed. The P&P further indicated for the facility to have a process to verify that all physician orders are complete and accurate.

Based on interview and record review the facility failed to submit the Payroll Based Journal (PBJ - a mandatory reporting system for healthcare facilities to submit direct care staffing information that is collected and can be audited) for the first quarter (every three months) from 10/1/2025 to 12/31/2025 to the Centers of Medicare and Medicaid (CMS, the federal agency that provides health coverage). This failure compromised the accuracy of the facility's staffing levels and had the potential to affect the facility to not be adequately staffed and/or have the necessary staff to provide care to meet the needs of the residents. Findings: During a review of the CMS PBJ Staffing Data Report, dated 7/22/2026, the PBJ report indicated the facility did not submit staffing data for quarter one (1) from 10/1/2025 to 12/31/2025. During an interview on 7/30/2026 at 10:13 a.m. with the Director of Staff Development (DSD), the DSD stated the corporate office emails the facility if the PBJ report is missing. The DSD stated she takes responsibility for ensuring PBJ submission and the corporate submission error caused the PBJ not to be submitted. The Missing PBJ submissions decrease the facility's star rating, which measures quality of care and staffing levels and a lower star rating gives the impression that the facility does not meet standard care, negatively affecting public perception and discouraging potential residents. During a concurrent interview and record review on 7/30/2026 at 11:22 a.m. with the DSD, the CMS Submission Report PBJ Final File Validation report, dated 2/13/2026, was reviewed and the DSD stated quarter 1 (10/1/2025 to 12/31/2025) was submitted as quarter two (2) (1/1/2026 to 3/31/2026). During a concurrent interview and record review on 7/30/2026 at 11:45 a.m. with the DSD and the [NAME] President for Operations (VPO), CMS Submission Report PBJ Final File Validation report, dated 2/13/2026, was reviewed. The CMS Submission Report PBJ Final File Validation report indicated, submission was for fiscal quarter 2. The VPO stated that there is no validation report for quarter 1 because it was submitted as quarter 2. During a concurrent interview and record review on 7/30/2026 at 11:45 a.m. with the DSD and the VPO, the CMS Submission Report PBJ Final File Validation report, dated 5/5/2026, was reviewed. The CMS Submission Report PBJ Final File Validation report indicated, submission for fiscal quarter 2. The VPO stated quarter 2 was submitted on 5/5/2026 and the VPO stated the team must generate the validation report and ensure its submission. The VPO stated CMS allows only one submission, and the issue was discovered in March 2026. During an interview on 7/31/2026 at 8:36 a.m. with the Administrator (ADM), the ADM stated that the facility did not validate with corporate if the PBJ submission was accurate and complete for quarter 1 of Fiscal Year 2026. The ADM stated that the facility should have followed up with corporate if the submission was accurate and complete to ensure that the public would be aware that the facility has sufficient staff and providing the quality care to the residents in meeting their needs so they can safely go back to the community. During a review of the facility provided reference from CMS.gov titled, Staffing Data Submission Payroll Based Journal (PBJ), last updated 2/24/2026, the Staffing Data Submission Payroll Based Journal (PBJ), indicated that users are strongly encouraged to take additional steps after uploading their data to ensure a successful submission. The Staffing Data Submission Payroll Based Journal (PBJ) further indicated to check the CAPSER for a system generated PBJ Final File Validation Report (FFVR) within 24 hours.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when there were soiled gloves, tissue paper, empty plastic cup container on the floor and there was liquid coming out from one (1) of four (4) black dumpsters (a movable waste container designed to be brought and taken away by special collection vehicles, or to a bin that specially designed garbage truck lifts) outside the facility. These failures had the potential to attract pests such as rats, cockroaches, flies, and ants, which may spread diseases to 185 of 185 residents living in the facility. Findings: During a concurrent observation and interview on 7/29/2026 at 11:10 a.m., with the Dietary Supervisor (DS) of the dumpster floor, observed soiled gloves, cup container and tissue paper on the floor surroundings of the dumpster. One (1) of 4 black dumpster was leaking liquid on the floor was observed. The DS stated the dumpster floor needed to be trash-free to prevent attracting rodents that could spread infection to the residents. The DS further stated the dumpster should not have a leak, but he did not know where the leak was coming from. During an interview on 7/29/2026 at 4:00 p.m. with the Assistant Maintenance Supervisor (AMS), the Maintenance Supervisor (MS), and the Assistant Administrator (AADM) interpreting in Spanish, AMS stated his department is responsible for maintaining the cleanliness of the dumpster surroundings. The AMS stated the dumpster surroundings were a little bit dirty today because the vendor collected trash today. The MS stated they clean the dumpster surroundings but there was a lot of trash that fell off when the vendor collected the trash. The AMS further stated if they see dumpster leak, they replace it but the leak and liquid from the dumpster is from when the truck picks the trash up. The MS stated it is important to keep the dumpster area clean to prevent smell and bacteria from growing and attracting flies and rodents in the facility. During an observation and interview on 7/29/2026 at 4:35 p.m. of the dumpster area with AMS, observed AMS inspecting the dumpsters. The AMS stated they have 1 dumpster leaking and they would need to call the vendor and replace it immediately. During a review of the facility's policy and procedure (P&P) titled, Garbage and Trash Can Use and Cleaning, dated 4/22/2026, the P&P indicated Purpose: To establish guidelines for the use and cleaning of garbage and trash cans. Policy: The dietary staff will use garbage and trash cans according to the manufacturer's guidelines. Garbage and trash cans will be cleaned routinely. During a review of the facility's P&P titled, Waste Management, dated 4/22/2026, the P&P indicated, Food waste will be placed in covered garbage and trash cans. (a) Waste will be disposed of in garbage cans following local city codes. (b) Plastic liners should be used in clean garbage and trash cans to eliminate spillage and reduce garbage and trash can washing time. (c) Sanitation of Equipment (i) Garbage and trash cans are cleaned at least daily, and more often if necessary. (ii) Each time the garbage and trash can is emptied, the containers are to be inspected and cleaned as indicated (a) as necessary, wash with hot detergent solution and rinse. VII. Maintain safe, secure and clean holding area (e.g. soiled utility room) for waste. a. Restrict area for employees only. b. Clean area once daily and whenever spills occur. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

Based on observation, interview, and record review, the facility failed to ensure that the residents' environment was free of accident hazards for four (4) of eight (8) sampled residents (Resident 32, 108, 82, and 129) reviewed for accidents when: 1. Resident 32 was observed with a personal heating pad at the bedside. This failure placed Resident 32 at risk for injury such as accidental burning which may lead to hospitalization. 2. Resident 108 was observed with medication left at the resident's bedside table. On 7/27/2026, observed an Albuterol inhaler (is also known as rescue inhaler that helps open the airways in the lungs so a person can breathe more easily when breathing problems occur and works within minutes) on Resident 108's bedside table. 3. Resident 82's Levalbuterol inhalation (also known as Xopenex, a fast-acting rescue medicine breathed into the lungs to quickly relax tight muscles around the airways) medication was not left at the bedside on 7/27/2026. 4. Resident 129's petrolatum jelly (is a thick, greasy, odorless jelly made from refined crude oil) was not left at the bedside on 7/27/2026. These failures increased the risk of accidents such as drug over dose and adverse effects (an unwanted, uncomfortable, or harmful reaction caused by a medical treatment, surgery, or prescription) of unsupervised medication administration on residents. Findings: a. During a review of Resident 32's Face Sheet (admission Record - front page of the medical record that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 2/19/2026, with diagnoses including kidney transplant status (a procedure to place a healthy kidney from a living or deceased donor into a person whose kidneys no longer work properly), malignant neoplasm of the colon (also known as colon cancer, a growth of abnormal cells in the large intestines), and generalized weakness. During a review of Resident 32's History and Physical (H&P), dated 2/19/2026, the H&P indicated Resident 32 can make her needs known but unable to make medical decisions. During a review of Resident 32's Minimum Data Set (MDS - a resident assessment tool), dated 5/28/2026, the MDS indicated Resident 32 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make her needs known. The MDS further indicated Resident 32 was independent with bed mobility; required setup or clean-up assistance with eating; partial or moderate assistance to total assistance with all other activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 32's Order Summary Report, dated 7/31/2026, the Order Summary Report did not indicate a physician's order for the use of heating pad. During a review of Resident 32's care plans (CP), there were no CPs documented indicating Resident 32's use of personal heating pad. During an observation on 7/27/2026 at 9:30 a.m., inside Resident 32's room, observed Resident 32 lying in bed asleep. Observed a personal heating pad on the floor, plugged into the wall socket. During a concurrent observation and interview on 7/28/2026 at 9:54 a.m., inside Resident 32's room, observed Resident 32 lying in bed awake and responding appropriately and the personal heating pad remained on the floor, plugged into the wall socket. Resident 32 stated that the heating pad was brought by the family and that she uses the heating pad sometimes but was unable to remember the frequency of use. During a concurrent observation, interview, and record review on 7/28/2026 at 10 a.m. inside Resident 32's room, with Registered Nurse (RN) 1, RN 1 observed and stated that the heating pad was on the floor and remain plugged into the wall socket. Resident 32's Order Summary Report and care plan were reviewed and indicated there was no physician's order for the use of personal heating pad and no CP addressing Resident 32's preference to use personal heating pad brought in by the responsible party. RN 1 stated that the physician should have been notified prior to use of the heating pad and there should have been a CP developed and implemented for the use of heating pad. RN 1 stated the presence of personal heating pad for Resident 32's use whenever she needs it placed the resident at risk for accidents or hazards such as accidental burning, skin injury, and electrical hazards. During an interview on 7/29/2026 at 7:45 a.m. with the Director of Nursing (DON), the DON stated that personal heating pads are not allowed in the facility as the facility had hot packs available as needed and was a safer option. The DON stated that she spoke with Resident 32 and that the resident was not aware that they had to notify the staff about the personal heating pad. The DON stated that Resident 32 verbalized understanding that the personal heating pad cannot be used in the facility and that hot packs are available for use as needed. The DON stated that the use of personal heating pad in the facility is not allowed as it was a potential for hazard and injuries. The DON stated that Resident 32's personal heating pad should not have been used as it placed the resident at risk for sustaining injuries such as burn and electrical hazard while using the heating pad without proper supervision by the staff. During a review of the facility's policy and procedure (P&P) titled, Resident Safety, last reviewed on 4/22/2026, the P&P indicated that the residents will be evaluated on admission, quarterly, and whenever there is a change in condition to identify circumstances that pose a risk for the safety and well-being of the resident. The P&P further indicated: - During the comprehensive assessment period the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the residents) members will assess the resident's safety risk as well as any other resident specific safety risks. - After a risk evaluation is completed, a resident-centered care plan will be developed to mitigate safety risk factors identified. - To observe the safety and well-being of the resident, a resident check will be made every 2 hours around the clock by nursing service personnel. The person-centered care plan may require more frequent safety checks. - Any facility staff member who identifies an unsafe situation, practice or environmental risk factors should immediately notify their supervisor or charge nurse. - The Safety Committee will review the occurrence of accidents in the facility at least quarterly to identify patterns and trends, and the committee will make recommendations for changes in facility practices, systems or educational objectives as indicated. b. During a review of Resident 108's Face Sheet, the Face Sheet indicated the facility admitted the resident on 2/4/2025 with diagnoses solitary pulmonary nodule (is a small round spot in one [1] lung); chronic obstructive pulmonary disease, unspecified (COPD- a chronic lung disease causing difficulty in breathing); emphysema, unspecified (is a condition where the lungs are damaged and don't work well making it hard to breathe). During a review of Resident 108's H&P, dated 3/11/2026, the H&P indicated resident has the capacity to understand and make medical decisions. During a review of Resident 108's MDS, dated [DATE], indicated Resident 108 makes self- understood and has the ability to understand others and had intact cognitive function (normal thinking). The MDS indicated the resident is independent with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of Resident 108's Order Summary Report (OSR), dated 3/29/2026, the OSR indicate Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 BASE) MCT/ACT (Albuterol Sulfate) 1 puff inhale orally every 4 hours as needed for SOB unsupervised self-administration Wait 1-2 minutes in between puffs. During an observation on 7/27/2026 at 1:35 p.m. with Certified Nurse Assistant (CNA) 10 in Resident 108's room, observed Albuterol inhaler on bedside table. During a concurrent interview and record review for Resident 108 on 7/27/2026, at 1:51 p.m., with RN 8, Resident 108's Self-Administration of Medication and Care Plans were reviewed. RN 8 stated that there was no Self-Administration of Medication Assessment and Care plan for Albuterol inhaler. RN 8 stated that in order for resident to self-medicate the resident needs to have a physician order, self-administration of medication assessment, and care plan. RN 8 stated that it is important to have all these components because resident can overdose and if Resident 108 does not allow staff to assess, then staff will not know if medication was effective or not and reason why medication was taken. RN 8 stated the resident needs to be educated on medication and the resident needs to inform staff of when medication was taken. During an interview on 7/30/2026 at 3:40 p.m. with the DON, the DON stated Resident 108 can overuse medication and can cause adverse reactions. The DON stated the policy titled, Medication-Self Administration, last reviewed 4/22/2026, was not followed. During a review of the facility's P&P titled, Medication-Self Administration, last reviewed on 4/22/2026, the P&P indicated residents have the right to self-administer medications when it is deemed safe and appropriate. Residents will be assessed and monitored for their ability to self-administer medications. This will be based on an interdisciplinary evaluation and must include physician's approval, which will be documented in the resident's medical record. Self-administration of medication refers to a resident's ability to independently take their own prescribed medications without assistance from licensed nursing staff. This includes preparing, consuming, or applying the medication as directed by physician. PURPOSE To ensure the safe self-administration of medications by residents in compliance with the State and Federal regulations. PROCESS 2. For a final determination of the resident's ability to self-administer medications, the assessment for Self-Administration of Medications will be presented to the resident's Attending Physician and IDT. b. A written physician's order is required before a resident begins self- administration. 3. Storage and Security a. If the IDT team and attending physician approve self-administration of medications, the medications will be placed in a secure drawer or cabinet that is easily accessible to the resident. c. During a review of Resident 82's Face Sheet, the Face Sheet indicated the facility admitted the resident on 4/29/2026, with diagnoses including dysphagia (difficulty swallowing), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and psychoactive substance abuse). During a review of Resident 82's H&P, dated 5/6/2026, the H&P indicated the resident had no memory loss, and the resident had the capacity to make medical decisions. During a review of Resident 82's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. During a review of Resident 82's Order Summary Report (OSR), dated 7/30/2026, the OSR did not indicate an order for Levalbuterol inhalation medication. During a review of Resident 82's Self-Administration of Medication (SAM), dated 5/8/2026, the SAM indicated the resident needs assistance with storing medications in a secure location. During a concurrent observation and interview on 7/27/2026 at 11:16 a.m. with Licensed Vocational Nurse (LVN) 1, inside Resident 82's room, observed Resident 82 had a Levalbuterol inhalation medication on top of the bed side drawer. LVN 1 stated that medications should not be left unsecured at the resident's bedside. LVN 1 stated if the resident had been assessed for medication self-administration and was deemed safe, the medication should be kept in a secure place to prevent other residents from accessing them. LVN 1 stated she had spoken to the resident and stated the medication was from his previous hospitalization and his primary doctor does not want to reorder them. During a concurrent interview and record review on 7/30/2026 at 11:49 a.m. with MDS Assistant (MDSA) 1, Resident 82's Medical Diagnoses, OSR, SAM, and P&P were reviewed. MDSA 1 stated there was no order for Levalbuterol inhalation medication and no order for okay to self-administer medication to the resident. MDSA 1 stated the SAM assessment indicated the resident needed assistance on storing medications in secure location. MDSA 1 stated the staff should have not left the Levalbuterol inhalation medication at the bedside because the resident could over or underdose taking the medication that could cause adverse effects on the resident. MDSA 1 stated the facility did not follow their policy on Medication Self Administration. During a concurrent interview and record review on 7/31/2026 at 10:54 a.m. with the DON, the facility's P&P titled, Medication Self Administration, last reviewed 4/22/2026, was reviewed. The DON stated the licensed staff should have obtained an order from the physician to indicate it is okay for Resident 82 to self-administer medications after performing a SAM on the resident and the resident was deemed competent. The DON stated there should be a care plan on medication self-administration to ensure its safe use. The DON stated the failure of the staff to store the medication on a secure place can lead to resident accidentally getting more dosage as prescribed that can cause a negative effect on the resident. During a review of the facility-provided Highlights of Prescribing Information (HPI), on the use of Xopenex HFA (levalbuterol tartrate) inhalation aerosol, for oral inhalation use, with initial U.S. approval in 1999, the HPI indicated Warnings and Precautions of: -Life-threatening paradoxical bronchospasms (tightening and narrowing the airways instead of relaxing them) may occur. -Need for more doses of XOPENEX HFA than usual may be a sign of deterioration of asthma and requires reevaluation of treatment. -Cardiovascular (relating to the heart and blood vessels) effects may occur. Consider discontinuation of XOPENEX HFA if these effects occur. Use with caution in patients with underlying cardiovascular disorders. -Excessive uses may be fatal. DO not exceed recommended dose. -Immediate hypersensitivity reactions may occur. Discontinue XOPENEX HFA immediately. -Hypokalemia (having too little potassium in the blood) and changes in blood glucose may occur. d. During a review of Resident 129's Face Sheet, dated 7/14/2026, the Face Sheet indicated the facility admitted the resident on 7/14/2026, with diagnoses of dyskinesia of esophagus, diverticulum of esophagus (the muscles in your food pipe do not work together correctly), and dysphagia oropharyngeal phase (the middle part of swallowing). During a review of Resident 129's H&P, dated 7/16/2026, the H&P indicated the resident had the capacity to make decisions for healthcare purposes, and able to identify needs in management of ADLs and to make needs known. During a review of Resident 129's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. During a review of Resident 129's OSR, dated 7/14/2026, the OSR did not indicate an order for petrolatum jelly. During a review of Resident 129's SAM, dated 7/14/2026, the SA indicated the resident needed assistance on storing medications in a secure location and assistance on administering topical (a medicine you put directly on the outside of your body—such as on your skin, eyes, ears, or mouth lining—rather than swallowing or injecting it) medications (including patches). During a review of Resident 129's Care Plan (CP) Report regarding the resident being at risk for aspiration (accidentally breathing food, liquid, saliva, or vomit down the wrong pipe into your windpipe and lungs), choking ., last revised on 7/18/2026, the CP indicated a goal of the resident will have no choking episodes. During a concurrent observation and interview on 7/27/2026 at 11:16 a.m. with LVN 1, inside Resident 129's room, observed Resident 129, had a tube of petrolatum jelly on top of the bed side drawer. LVN 1 stated that medications should not be left unsecured at the bedside of the resident. LVN 1 stated if the resident had been assessed for medication self-administration and was deemed safe, the medication should be kept in a secure place to prevent other residents from accessing them. During a concurrent interview and record review on 7/30/2026 at 11:49 a.m. with MDSA 1, Resident 129's Medical Diagnoses, OSR, SAM, and P&P were reviewed. MDSA 1 stated there was no order for petrolatum jelly and no order for okay to self-administer medication to the resident. MDSA 1 also stated the SAM assessment indicated the resident needed assistance on storing medications on secure location. MDSA 1 stated the staff should not have left the petrolatum jelly at the bedside because the resident could over or underdose taking the medication that could cause adverse effects on the resident. MDSA 1 stated the facility did not follow their policy on Medication Self Administration. During a concurrent interview and record review on 7/31/2026 at 10:54 a.m. with the DON, the facility's P&P titled Medication Self Administration, last reviewed 4/22/2026, was reviewed. The DON stated the licensed staff should have obtained an order from the physician for Resident 129 to self-administer medications after performing a SAM on the resident and the resident was deemed competent. The DON also stated there should be a care plan on medication self-administration to ensure its safe use. The DON stated the failure of the staff to store the medication on a secure place can lead to resident accidentally getting more dosage as prescribed that can cause a negative effect on the resident. During a review of the facility's recent P&P titled, Medication Self Administration, last reviewed on 4/22/2026, the P&P indicated residents have the right to self-administer medications when it is deemed safe and appropriate. Residents will be assessed and monitored for their ability to self-administer medications. This will be based on an interdisciplinary evaluation and must include physician approval, which will be documented in the resident's medical record. PROCESS 2. For a final determination of the resident's ability to self-administer medications, the assessment for Self-Administration of Medications will be presented to the resident's Attending Physician and IDT. b. A written physician's order is required before a resident begins self-administration. 3. Storage and Security a. If the IDT team and Attending Physician approve self-administration of medications will be placed in a secured drawer or cabinet that is easily accessible to the resident.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document outlining a detailed approach to care customized to an individual resident's need) by failing to: 1. Ensure care plan interventions for manipulation of the oxygen setting were specific for one (1) of five (5) sampled residents (Resident 156) reviewed under respiratory care. This failure had the potential for a delay in the delivery of the necessary care and services Resident 156 needed. 2. Ensure the resident's Care Plan (CP) included measurable goals and outcomes for anxiety (a natural response to stress, marked by worry, fear, and an uneasy mind,) and for use of Rexulti (an antipsychotic [a medication used to treat mental illness] medication) for 1 of 5 residents (Resident 15) reviewed for unnecessary medication use. As a result, Residents 15 did not have identified goals and outcomes for anxiety with the use of Rexulti, and did not have monitoring for the effectiveness of Rexulti for anxiety, between 6/13/2026 and 7/29/2026. This failure had the potential to cause Resident 15 to receive suboptimal (less than the highest standard or quality) care, for the facility to not know how to manage and care for anxiety, or to know how effective Rexulti was for the resident's anxiety, possibly leading to medication overdose (giving doses beyond the necessary amount) resulting in excessive sedation or tiredness, inability to function and participate in normal daily activities, impacting on their physical, mental, and psychosocial well-being. Cross-reference F605. 3. Develop and implement a care plan on the use of Amoxicillin-Pot Clavulanate (an antibiotic) Oral Suspension Reconstituted (a liquid medicine made from a dry powder) 250-62.5 milligrams (mg - a unit of measure for weight)/5 milliliters (ml - a unit of measure for volume) on the resident. This failure had the potential for medication errors, treatment failure, and increased microbial resistance. Findings: a. During a review of Resident 156's Face Sheet (admission Record - a document containing demographic and diagnostic information), the Face Sheet indicated the facility admitted Resident 156 on 5/7/2026 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and generalized muscle weakness. During a review of Resident 156's History and Physical (H&P), dated 5/9/2026, the H&P indicated that Resident 156 had the capacity to understand and make decisions. During a review of Resident 156's Minimum Data Set (MDS - a resident assessment tool), dated 5/14/2026, the MDS indicated Resident 156 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make his needs known. The MDS further indicated Resident 156 required supervision or touching assistance with eating and oral hygiene; partial or moderate assistance with toileting hygiene, upper body dressing, personal hygiene and bed mobility; substantial or maximal assistance with all other activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated Resident 156 received continuous oxygen therapy. During a review of Resident 156's Order Summary Report, dated 7/31/2026, the Order Summary Report indicated the following physician's orders: - 5/7/2026 to 7/29/2026: Oxygen at 1 to three (3) liters per minute (L/min – a unit of measurement on the amount of oxygen to be used) via nasal cannula (NC - a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) to keep oxygen saturation (O2 sat – a measurement of how much oxygen the blood is carrying as a percentage) at or above 92 percent (% - a unit of measurement) due to shortness of breath (also known as SOB – difficulty in breathing) every shift. - 7/29/2026: Oxygen at 1 to 5 L/min as needed via NC to keep O2 sat at or above 92% due to SOB every shift. During a review of Resident 156's CP on manipulation of oxygen machine and tubing, initiated on 5/14/2026 and last revised on 7/29/2026, the CP did not indicate specific interventions to address Resident 156's manipulation of the machine and tubing. During an observation on 7/27/2026 at 11:35 a.m. inside Resident 156's room, observed Resident 156 lying in bed asleep with oxygen via NC running at 5 L/min. During a follow up observation and concurrent interview and record review on 7/29/2026 at 9:10 a.m. inside Resident 156's room with Licensed Vocational Nurse (LVN) 4, observed Resident 156 lying in bed asleep with oxygen via NC running at more than 5 L/min. LVN 4 stated that that the oxygen setting was more than 5 L/min and that Resident 156 had a tendency to manipulate the oxygen setting and increase the setting to 5 L/min. Resident 156's physician's order was reviewed with LVN 4. LVN 4 stated that the current oxygen order for the resident is 1 to 3 L/min via NC. LVN 4 stated that the licensed nurses are responsible in making that the oxygen is at the correct setting. LVN 4 stated Resident 156's oxygen setting should have been between 1 to 3 L/min to keep the O2 sat at or above 92%. During a concurrent interview and record on 7/29/2025 at 2:30 p.m. with MDS Assistant (MDSA) 1, Resident 156's physician's orders and CP were reviewed. MDSA 1 stated that Resident 156 had a physician's order for oxygen at 1 to 3 L/min via NC from 5/7/2026 and was changed to 1 to 5 L/min via NC due to resident's manipulation of the oxygen setting. MDSA 1 stated that Resident 156's CP interventions on manipulation of oxygen machine and tubing, initiated on 5/14/2026 and last revised on 5/28/2026, were not specific and resident-centered to address Resident 156's manipulation of the oxygen machine by increasing the amount of oxygen being delivered. MDSA 1 stated that comprehensive care plans are supposed to be person-centered with measurable interventions to meet the residents' specific needs as it serves as a guide for all members of team involved in the resident's care on how to properly care for the resident. MDSA 1 stated that Resident 156 CP interventions should have been person-centered or resident specific, including educating the resident on the risks and consequences of not complying with the physician's orders for all members of the team to be aware on how to properly care and meet Resident 156's needs. During an interview on 7/31/2026 at 11:20 a.m. with the Director of Nursing (DON), the DON stated that nursing staff and members of the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the resident) have access to the care plans and updated quarterly, annually, with any significant change in condition, and/or as needed to ensure that the residents' needs are met timely. The DON stated that CP serves as a guide for all disciplines involved in the residents' care on how to properly care for the resident and prevent delay in providing the care and services the residents' need. The DON stated that Resident 156's CP interventions on manipulation of oxygen machine should have been resident-centered and specific to meet Resident 156's needs including the desired goals and outcomes. The DON stated that if the interventions are not resident-centered and specific, it placed Resident 156 at risk for a delay in providing the care and services Resident 156 needed. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Plan, last reviewed on 4/22/2026, the P&P indicated that the facility would provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. The P&P further indicated that a person-centered care plan is developed for each resident. During a review of the facility's P&P titled, Person-Centered Care Planning, last reviewed on 4/22/2026, the P&P indicated that the facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that are identified in the comprehensive assessment. The comprehensive care plan describes the following: - The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. - Any services that would otherwise be required under, but are not provided due to resident's exercise of rights, including the right to refuse treatment b. During a review of Resident 15's Face Sheet, dated 7/30/2026, the Face Sheet indicated the facility originally admitted Resident 15 on 9/28/2021 with diagnoses including dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and Alzheimer's disease (a common brain disorder that slowly destroys memory, thinking skills, and the ability to do simple daily tasks.) During a review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 15 had Alzheimer's disease and received antipsychotics on a routine basis. During a review of Resident 15's Care Plan, initiated 1/7/2026, the Care Plan did not indicate a measurable goal and outcome for anxiety or for Rexulti use. During a review of Resident 15's Medication Administration Record ([MAR] – a record of mediations administered to residents), for June and July 2026, the MARs indicated Resident 15 was prescribed and administered Rexulti 1 mg, 1 tablet, by mouth once a day at 9 a.m. for Alzheimer's with agitation, starting 6/13/2026. The MARs contained no documentation for monitoring the occurrence/episodes of anxiety with the use of Rexulti. During a concurrent record review and interview on 7/30/2026 at 11 a.m., with the DON in the presence of the Assistant DON (ADON), Resident 15's MDS, dated [DATE], Care Plan, initiated 1/7/2026, and June 2026 and July 2026 MARs were reviewed. The DON acknowledged Resident 15 was prescribed Rexulti for Alzheimer's with agitation and that Rexulti was an antipsychotic medication. The DON stated that she was unable to locate a Care Plan that included measurable goals and outcomes for Alzheimer's with anxiety and for the use of Rexulti. The DON stated not having a Care Plan for anxiety and Rexulti use does not provide person centered care for Resident 15, and the facility to know how to care for Resident 15's needs. The DON also stated that licensed nurses must monitor and document occurrences/episodes of anxiety on the MAR. The DON acknowledged the June and July 2026 MARs did not have occurrences/episodes of anxiety monitored or documented. The DON stated the facility overlooked and failed to initiate and implement a comprehensive Care Plan to accurately reflect the needs of Resident 15 and to ensure to maintain the highest level of functionality and quality of life with measurable goals and outcomes for anxiety with Alzheimer's and use of Rexulti. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, last reviewed 4/22/2026, the P&P indicated: The Facility will provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. To ensure that a comprehensive person-centered care plan is developed for each resident. During a review of the facility's P&P titled Person-Centered Care Planning, last reviewed 4/22/2026, the P&P indicated: 4. Comprehensive Care Plan a. The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. c. Within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. f. Comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. c. During a review of Resident 17's Face Sheet, the Face Sheet indicated the facility admitted the resident on 4/14/2004, and readmitted the resident on 6/19/2026, with diagnoses including urinary tract infection (UTI - an infection in the bladder/urinary tract), enterocolitis (an irritation and swelling of both the small intestine and the large intestine [colon] at the same time) due to clostridium difficile (C. diff, a highly contagious bacteria that causes severe diarrhea), and carrier or suspected carrier of methicillin resistant staphylococcus aureus (MRSA, a bacteria that does not respond to antibiotics). During a review of Resident 17's H&P, dated 6/23/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 17's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognitive skills (a major loss of basic brain functions). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 17's Physician's Order, dated 5/21/2026, the Physician's Order indicated an order for Amoxicillin-Pot Clavulanate Oral Suspension Reconstituted 250-62.5 mg/5 ml. Give 10 ml via gastrostomy tube (g-tube, a flexible feeding tube placed through a small opening in the belly directly into the stomach) three times a day for UTI for 10 days. During a concurrent interview and record review on 7/30/2026, at 9:46 a.m., with the Infection Preventionist (IP), reviewed Resident 17's Medical Diagnoses, PO, CP, and P&P. The IP stated the resident had an order for Amoxicillin-Pot Clavulanate Oral Suspension Reconstituted 250-62.5 mg/5 ml however, there was no care plan developed and implemented on its use until even after the medication was completed. The IP stated it was important to develop and implement a care plan on antibiotics to know the ongoing issues and to know what the plan of care for the resident. The IP also stated the P&P titled, Person-Centered Care Planning was not followed. During a concurrent interview and record review on 7/30/2026 at 11:03 a.m. with MDSA 1, Resident 17's Medical Diagnoses, PO, CP, and P&P were reviewed. MDSA 1 stated there was no care plan on the use of antibiotic Amoxicillin-Pot Clavulanate Oral Suspension Reconstituted 250-62.5 mg/5 ml on the resident's electronic healthcare record. MDSA 1 stated the CP guides the nurses on what to watch out for and what the patient is currently on. MDSA 1 added that the CP is read by all healthcare disciplines to ensure communication to everybody. MDSA 1 stated the P&P titled, Person-Centered Care Planning was not followed when the facility failed to develop and implement a care plan on the use of the antibiotic Amoxicillin-Pot Clavulanate Oral Suspension. During a concurrent interview and record review on 7/31/2026 at 10:54 a.m. with the DON, the P&P titled, Person-Centered Care Planning, last reviewed 4/22/2026, was reviewed. The DON stated the licensed staff were responsible for developing a care plan on the use of antibiotics on residents. The DON stated care plans are important to ensure the right interventions were provided to Resident 17 to address the identified problems. The DON stated the failure of the staff to develop and implement a care plan on the use of antibiotics had the potential for antibiotic resistance (happens when bacteria change and learn to survive the medicines meant to kill them) and unnecessary medications. During a review of the facility's recent P&P titled, Person-Centered Care Planning, last reviewed on 4/22/2026, the P&P indicated under number 4. Comprehensive Care Plan: a. The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident's rights, that includes measurable objectives, and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. c. Within 7 days from the completion of the comprehensive Minimum Data Set (MDS) assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.

Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for two of two sampled residents (Residents 12 and 80) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. These failures had the potential for adverse effects (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat), and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Findings: 1. During a review of Resident 12's Face Sheet (FS - admission Record), the FS indicated the facility admitted the resident on 10/8/2024, with diagnoses including type two (2) diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and long-term use of insulin. During a review of Resident 12's History and Physical (H&P), dated 12/8/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 7/13/2026, the MDS indicated the resident had severely impaired cognitive skills (a major loss of basic mental abilities) and was on a high-risk drug class hypoglycemic (a prescription drug used to lower high blood sugar levels in people with type 2 diabetes). During a review of Resident 12's Order Summary Report (OSR), the OSR indicated an order for: 12/24/2025 Humalog KwikPen (a fast-acting artificial insulin used by people with diabetes) Subcutaneous Solution Pen-injector 100 units per milliliter (unit/ml, tells how strong the liquid insulin is) (Insulin Lispro). Inject as per sliding scale (a personalized chart or guide that tells a person how much fast-acting insulin to inject): if 70 - 149 = 0 unit; 150 - 199 = one (1) unit; 200 - 249 = 2 units; 250 - 299 = three (3) units; 300 - 349 = four (4) units blood sugar (BS) greater than (>) 349 administer five (5)5 units then Notify MD, subcutaneously before meals and at bedtime for type 2 diabetes mellitus. Rotate sites. Call MD if Blood sugar less than (<) 70 or > 350 related to type 2 diabetes mellitus with other specified complication. 1/31/2026 Insulin Glargine (a man-made, long acting insulin injected once a day to help control blood sugar levels in people with diabetes) Solution 100 unit/ml. Inject eight (8) unit subcutaneously one time a day for DM [rotate sites] related to type 2 diabetes mellitus with other specified complication. During a review of Resident 12's Combined Glargine and Humalog LAR, the LAR indicated: 1/31/2026 Insulin Glargine Solution (a long-acting synthetic human insulin used to treat diabetes, working slowly over a 24-hour period to control blood sugar levels) 100 UNIT/ML. Inject 8 unit subcutaneously one time a day for DM [rotate sites] related to type 2 diabetes mellitus with other specified complication. 12/24/2025 Humalog (a rapid-acting prescription insulin used to control high blood sugar in adults and children with type 1 or type 2 diabetes) KwikPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 70 - 149 = 0 unit; 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units BS >349 admin 5 units then Notify MD, subcutaneously before meals and at bedtime for type 2 diabetes mellitus. Rotate sites. Call MD if Blood sugar <70 or >350 related to type 2 diabetes mellitus with other specified complication. 5/7/2026 4 p.m. Arm - right (Humalog) 5/7/2026 21:00 Arm - right (Humalog) 5/21/2026 9 a.m. Abdomen - LLQ (glargine) 5/21/2026 11 a.m. Abdomen - LLQ (Humalog) 5/22/2026 7 a.m. Abdomen - LLQ (Humalog) -The combined Humalog (4x/day) and Glargine (once a day) report indicated repeated sites of administration on 5/7/2026 and 5/21/2026 to 5/22/2026. During a review of Resident 12's Care Plan (CP) Report regarding the resident being at risk for hypoglycemia (low blood sugar)/hyperglycemia (high blood sugar) ., last revised on 4/27/2026, the CP indicated an intervention of diabetes medication (Humalog KwikPen Subcutaneous Solution, Insulin Glargine Solution) as ordered by doctor. Monitor for side effects and effectiveness. During a concurrent interview and record review on 7/30/2026 at 10:49 a.m. with Minimum Data Set Assistant (MDSA) 1, Resident 12's Medical Diagnoses, OSR, CP, and Manufacturer's Specification of Insulins were reviewed. MDSA 1 stated that in their facility when giving insulin subcutaneously they should rotate the sites of administration. MDSA 1 gave an example that if insulin was given at 6 a.m. on the right arm (RA) the next administration should be left arm (LA) or abdomen. MDSA 1 stated their electronic healthcare record had a way of checking for last administration sites of insulin that prevents them from repeating insulin administration sites, although, if bypassed by the licensed staff it could cause repeated sites of administration. MDSA 1 reviewed the LAR for 5/2026 until 7/2026 and stated there were multiple instances of repeated sites of administration in the healthcare records. MDSA 1 stated the reason for rotating sites of administration of insulin was to prevent lipohypertrophy (a lump of fat that builds up under the skin) which can cause the medication absorption (how a medicine moves from the place it was taken, like the mouth, skin, or an injection site, into the bloodstream so it can travel through the body and start working) to be affected on Resident 12. MDSA 1 stated the resident can suffer from hypo/hyperglycemia. MDSA 1 stated the CP regarding the resident being at risk for hypoglycemia/hyperglycemia was not followed because the order indicated to rotate sites. MDSA 1 stated not rotating insulin administration sites was a medication error because the facility did not follow the MD order to rotate sites. MDSA 1 stated the policy and procedure (P&P) titled, Medication- Error, last reviewed 4/22/2026, was not followed. During a concurrent interview and record review on 7/31/2026 at 10:54 a.m. with the Director of Nursing (DON), Resident 12's LAR was reviewed. The DON stated in their facility the staff should rotate insulin administration sites to prevent lipodystrophy on residents. The DON gave an example that when insulin was administered at 6 a.m. on the RA, the next administration should be on the LA, abdomen, or thigh. The DON stated there is nothing in the Manufacturer's Specification on the use of insulin that you can administer the insulin within the same site after 24 hours; the emphasis was on alternating the sites of administration to prevent skin complications. The DON stated she combines the LAR of insulin orders when auditing to ensure the sites of administration were rotated. 2. During a review of Resident 80's FS, the FS indicated the facility admitted the resident on 9/17/2025, and readmitted the resident on 2/27/2026, with diagnoses of type 2 diabetes mellitus with hyperglycemia (high blood sugar) and long-term use of insulin. During a review of Resident 80's H&P, dated 3/2/2026, the H&P indicated the resident did not have memory loss and had the capacity to make medical decisions. During a review of Resident 80's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a person's mental processes-such as thinking, memory, reasoning, and judgment-are working normally with no signs of impairment). The MDS indicated the resident was on a high-risk drug class hypoglycemic. During a review of Resident 80's OSR, the OSR indicated an order for: 2/28/2026 Humalog Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ = 12 units Call MD if BS <70 OR >400, subcutaneously before meals and at bedtime for Type 2 Diabetes Mellitus [rotate sites]. 5/18/2026 Novolog FlexPen (a fast-acting, man-made version of insulin) 100 unit/ml Solution pen-injector. Inject as per sliding scale: if 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 401+ = 12 units Call MD if BS <70 OR >400, subcutaneously at bedtime for DM 2. Rotate sites. 6/24/2026 Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine). Inject 37 units subcutaneously at bedtime for Diabetes Mellitus [rotate sites]. During a review of Resident 80's LAR of Insulin for 5/2026 to 7/2026, the LAR indicated insulin was administered subcutaneously on: Lantus SoloStar 100 unit/ml Solution pen injector 6/12/2026 at 9:54 p.m. on the Arm - left Novolog FlexPen 100 unit/ml Solution pen-injector 6/12/2026 at 9:55 p.m. on the Arm - left Humalog Injection Solution 100 unit/ml 5/1/2026 at 9:36 p.m. on the Thigh - left 5/2/2026 at 10:27 p.m. on the Thigh - left 5/3/2026 at 10:19 p.m. on the Thigh - left 5/4/2026 at 10:44 p.m. on the Arm - left 5/5/2026 at 9:57 p.m. on the Arm - left 5/7/2026 at 9:57 p.m. on the Arm - left 5/8/2026 at 8:24 p.m. on the Arm - left The combined LAR for Lantus SoloStar, Novolog FlexPen, and Humalog Injection Solution indicated repeated sites of administration on 5/1/2026 to 5/3/2026, 5/4/2026 to 5/5/2026, 5/7/2026 to 5/8/2026, and 6/12/2026. During a review of Resident 80's Care Plan (CP) Report regarding the resident being at risk for hypoglycemia/hyperglycemia., last revised on 3/18/2026, the CP indicated an intervention of diabetes medication (Lantus, Novolog)) as ordered by doctor. Monitor for side effects and effectiveness. During a concurrent interview and record review on 7/30/2026 at 10:49 a.m. with MDSA 1, Resident 80's Medical Diagnoses, OSR, CP, and Manufacturer's Specification of Insulins were reviewed. MDSA 1 stated that in their facility when giving insulin subcutaneously they should rotate the sites of administration. MDSA 1 gave an example that if insulin was given at 6 a.m. on the RA the next administration should be LA or abdomen. MDSA 1 reviewed the LAR for 5/2026 until 7/2026 and stated there were multiple instances of repeated sites of administration. MDSA 1 stated the reason for rotating sites of administration of insulin was to prevent lipohypertrophy on Resident 80 and the medication absorption will be affected. MDSA 1 stated the resident can suffer from hypo/hyperglycemia. MDSA 1 stated the CP regarding the resident being at risk for hypoglycemia/hyperglycemia was not followed because the order is to rotate sites. MDSA 1 stated not rotating insulin administration sites was a medication error because they did not follow the MD order to rotate sites. MDSA 1 stated the P&P titled, Medication-Error, last reviewed 4/22/2026, was not followed. During a concurrent interview and record review on 7/31/2026 at 10:54 a.m. with the DON, Resident 80's LAR was reviewed. The DON stated in their facility the staff should rotate insulin administration sites to prevent lipodystrophy on residents. The DON gave an example that when insulin was administered at 6 a.m. on the RA, the next administration should be on the LA, abdomen, or thigh. The DON stated there is nothing in the Manufacturer's Specification on the use of insulin that you can administer the insulin within the same site after 24 hours; the emphasis was on alternating the sites of administration to prevent skin complications. The DON stated she combines the LAR of insulin when auditing to ensure the sites of administration was rotated. During a review of the facility-provided Patient Information on the use of Lantus (insulin glargine injection) for subcutaneous use, 100 units/ml (U-100), last revised on 11/2018, the Patient Information indicated change (rotate) your injection sites within area you choose with each dose. Do not use the exact spot for each injection. During a review of the facility provided Highlights of Prescribing Information (HPI)- Insulin Lispro injection, for subcutaneous or intravenous use, with initial U.S. Approval in 1996, the HPI indicated to rotate infusion sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility's recent P&P titled, Medication-Error, last reviewed on 4/22/2026, the P&P indicated the facility will maintain a medication administration system that minimizes the risk of errors, ensures timely identification and reporting, and incorporates corrective actions to prevent recurrence. All medication errors shall be documented, evaluated, and reported per state and federal regulations, and any necessary care or monitoring shall be provided without delay. Process Medication Error means the administration of medication: a. To the wrong resident; b. At the wrong time; c. At the wrong dose; d. Via the wrong route; e. Which is not currently prescribed; or f. Wrong medication. During a review of the facility's recent P&P titled, Adverse Drug Reactions, last reviewed on 4/22/20276, the P&P indicated the facility will monitor, promptly identify, document, report, and appropriately address adverse drug reactions in accordance with federal and state laws and facility policy and procedures. The goal is to reduce harm, ensure prompt treatment, and support quality medication management. Process Definitions Adverse Drug Reaction (ADR): An unintended and harmful reaction resulting from the use of medication at normal doses for prophylaxis, diagnosis, or therapy. Identification of ADRs a. Nursing staff should observe for any changes in condition that may be associated with medications, including but not limited to: i. Rash ii. Itching iii. Dizziness iv. Confusion v. Bleeding vi. Falls vii. Altered mental status, or viii. Vital sin changes.

Based on interview and record review, the facility failed to implement its antibiotic stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic (ATB, a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) use protocols and a system to monitor antibiotic use for two of two sampled residents (Residents 17 and 80) reviewed for antibiotic use by failing to ensure: 1. Resident 17's Vancomycin+SyrSpend SF Oral Suspension 50 milligrams (mg, a unit of weight)/ milliliters (ml, a unit of volume) (Vancomycin HCl) and Amoxicillin-Pot Clavulanate Oral Suspension Reconstituted 250-62.5 mg/5 ml had monitoring for adverse effects (an unwanted, harmful, or unpleasant reaction that happens when you take a medicine or receive a medical treatment). 2. Resident 17's Vancomycin+SyrSpend SF Oral Suspension 50 mg/ml (Vancomycin HCl). Give 2.5 ml via gastrostomy tube (g-tube, a flexible medical tube placed through a small opening in the belly directly into the stomach) four times a day for clostridium difficile (C. Diff, a bacterium that infects the large intestine (colon)) had an end date. 3. Resident 80's Macrobid Oral Capsule 100 mg (Nitrofurantoin Monohyd Macro) 1 capsule by mouth two times a day for urinary tract infection (UTI, an infection in the bladder/urinary tract) for 5 Days had monitoring for adverse effects. These failures had placed Residents 17 and 80 at risk for adverse effects and multidrug resistant organisms (MDRO, are types of bacteria or germs that have developed the ability to withstand multiple, common antibiotics that used to kill them) resistance to antibiotics. Findings: 1. During a review of Resident 17's Face Sheet (FS), the FS indicated the facility admitted the resident on 4/14/2004, and readmitted the resident on 6/19/2026, with diagnoses including urinary tract infection, enterocolitis (an inflammation of both the small intestine and the large intestine (colon) at the same time) due to C. Diff, and chronic kidney disease stage 4 (the kidneys are severely damaged and only working at a low level (15% to 29% capacity)). During a review of Resident 17's History and Physical (H&P), dated 6/23/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 6/26/2026, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognitive skills (a major loss of brain function). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 17's Physician Orders (PO), the PO indicated orders for: 6/19/2026 Vancomycin+SyrSpend SF Oral Suspension 50 mg/ml (Vancomycin HCl). Give 2.5 ml via g-tube four times a day for C. Diff. 5/22/2026 Amoxicillin-Pot Clavulanate Oral Suspension Reconstituted 250-62.5 mg/5 ml (Amoxicillin & Pot Clavulanate). Give 10 ml via g-tube three times a day for UTI for 10 Days. During a review of Resident 17's Care Plan (CP) Report regarding the resident was on hospice (compassionate care for people who are near the end of life) and was at risk for rehospitalization related to chronic conditions, recurrent UTIs., last revised on 7/9/2026, the CP indicated an intervention to educate the resident about the purpose, side effect, and timing of each medication. During a concurrent interview and record review on 7/30/2026, at 9:46 a.m., with the Infection Preventionist (IP), reviewed Resident 17's Medical Diagnoses, PO, Medication Administration Report (MAR), and CP. The IP stated there was a discontinued order on 5/22/2026 Amoxicillin-Pot Clavulanate Oral Suspension Reconstituted 250-62.5 mg/5 ml (Amoxicillin & Pot Clavulanate). Give 10 ml via g-tube three times a day for UTI for 10 Days and 6/19/2026 Vancomycin+SyrSpend SF Oral Suspension 50 mg/ml (Vancomycin HCl). Give 2.5 ml via G-Tube four times a day for C. Diff. The IP stated the order for Vancomycin+SyrSpend SF Oral Suspension 50 mg/ml (Vancomycin HCl) had missing information which is the end date and for both antibiotics there were no monitoring for adverse effects of its use. The IP stated the missing component which is the end date should have been captured by her during the antibiotic screening process. The IP stated their failure to monitor for adverse effects of the antibiotic and no end date on the use of the vancomycin could lead to adverse effects on the resident and antibiotic resistance (happens when bacteria change and learn to survive the medicines meant to kill them). The IP stated the monitoring for antibiotic side effects should have a physician's order that would later then be transcribed to the MAR to monitor for adverse effects. During a concurrent interview and record review on 7/30/2026, at 11:03 a.m., with the Minimum Data Set Assistant (MDSA) 1, reviewed Resident 17's Medical Diagnoses, PO, CP, MAR, and policy and procedure (P&P). The MDSA 1 stated the nurses' responsibility when giving an antibiotic which is a significant medication was to monitor for adverse effects on its use and it has to have a stop date. The MDSA 1 stated the Vancomycin order did not have a stop date. The MDSA stated the Vancomycin+SyrSpend SF Oral Suspension 50 mg/ml (Vancomycin HCl) and Amoxicillin-Pot Clavulanate Oral Suspension Reconstituted 250-62.5 mg/5 ml (Amoxicillin & Pot Clavulanate) did not have monitoring for adverse effects on its use. The MDSA 1 stated it was important for Resident 17's antibiotic use to have an end date and monitoring for adverse effects so the clinicians can intervene when adverse effects happen and it could also cause antibiotic resistance on Resident 17. The MDSA 1 stated the monitoring for adverse effects should be done every shift. During an interview and record review on 7/31/2026, at 10:54 a.m., with the Director of Nursing (DON), reviewed the facility's P&P regarding Antibiotic. The DON stated the licensed staff documents the monitoring for adverse effects on the use of antibiotics in the progress notes and Change of Condition (COC) follow up. The DON stated that she found some monitoring on Resident 17's electronic healthcare record but was not complete. The DON stated it was important to completely monitor for adverse effects on the use of a significant medication antibiotic every shift for Resident 17 to prevent the unpleasant side effects of the medication and they could intervene timely. During a review of the facility-provided Highlights of Prescribing Information (HPI), on the use of Augmentin (amoxicillin and clavulanate potassium) tablets, for oral use, with initial U.S. approval in 1984, the HPI indicated warnings and precaution of: -Serious hypersensitivity reactions -Severe Cutaneous Adverse Reactions (SCAR): Monitor closely. Discontinue if rash progresses. -Drug-induced enterocolitis syndrome (DIES) has been reported with use of amoxicillin, a component of AUGMENTIN. -Hepatic dysfunction and cholestatic jaundice. -Clostridioides difficile-associated diarrhea (CDAD). During a review of the facility-provided HPI on the use of Firvanq (vancomycin hydrochloride for oral solution), with initial U.S. approval in 1964, the HPI indicated Warnings and Precautions of: -Firvanq must be given orally for treatment of C. difficile-associated diarrhea and staphylococcal enterocolitis. -Nephrotoxicity has occurred following oral vancomycin hydrochloride therapy and can occur either during or after completion of therapy. -Ototoxicity has occurred in patients receiving vancomycin hydrochloride. -Severe Dermatologic Reactions. 2. During a review of Resident 80's FS, the FS indicated the facility admitted the resident on 9/17/2025, and readmitted the resident on 2/27/2026, with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body)/hemiparesis (muscle weakness or reduced control on just one side of the body (left or right), such as an arm, leg, or face). During a review of Resident 80's H&P, dated 3/2/2026, the H&P indicated the resident had no memory loss and had the capacity to make medical decisions. During a review of Resident 80's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a person's mental abilities-such as memory, thinking, reasoning, and problem-solving-are working normally and without noticeable damage or impairment). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 80's OSR, dated 6/5/2026, the OSR indicated an order for Macrobid Oral Capsule 100 mg (Nitrofurantoin Monohyd Macro). Give 1 capsule two times a day for UTI for 5 days. During a review of Resident 80's CP Report titled, Resolved: the resident has a urinary tract infection, last revised on 6/30/2026, the CP indicated an intervention to give antibiotic as ordered. Monitor/document for side effects and effectiveness. During an interview and record review on 7/30/2026, at 11:47 a.m., with the MDSA 1, reviewed Resident 80's Medical Diagnoses, PO, CP, MAR, and P&P. The MDSA 1 stated the nurses' responsibility when giving an antibiotic, which is a significant medication was to monitor for adverse effects on its use, and it has to have a stop date. The MDSA stated the Macrobid Oral Capsule 100 mg (Nitrofurantoin Monohyd Macro) did not have monitoring for adverse effects on its use. The MDSA 1 stated it was important for Resident 80's antibiotic use to have monitoring for adverse effects so the clinicians can intervene when adverse effects happen and it could also cause antibiotic resistance on Resident 80. The MDSA 1 stated the monitoring for adverse effects should be done every shift. During an interview and record review on 7/31/2026, at 10:54 a.m., with the DON, reviewed the facility's P&P regarding Antibiotic. The DON stated the licensed staff documents the monitoring for adverse effects on the use of antibiotics in the progress notes and COC follow up. The DON stated that she found some monitoring but was not complete on the electronic healthcare record of Resident 80. The DON stated it was important to completely monitor for adverse effects on the use of a significant medication antibiotic every shift for Resident 80 to prevent the unpleasant side effects of the medication and they could intervene timely. During a review of the facility-provided Macrobid (nitrofurantoin monohydrate/macrocrystals) capsules Information, revised 2/2008, the Information indicated Warnings: -Acute, Subacute, or Chronic Pulmonary Reactions . -Hepatotoxicity -Neuropathy -Hemolytic Anemia -Clostridium difficile-associated diarrhea 07/30/2026 11:47 AM RN stated no order for monitoring for adverse effects of antibiotics. During a review of the facility's recent P&P titled, Antibiotic Stewardship, last reviewed on 4/22/2026, the P&P indicated the facility will implement an Antibiotic Stewardship Program (ASP) to promote appropriate use of antibiotics optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improve outcomes for Residents. Procedure VII. Education D. the IP will provide results of tracking antibiotic use, outcomes and adverse effects to the clinical staff.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Implement the facility's policy and procedure (P&P) for two randomly observed residents (Resident 126 and 30) when Certified Nursing Assistant (CNA) 5 failed to perform hand hygiene prior to exiting Resident 126's room and proceeded to touch a linen cart then handed towels to Resident 30 in the hallway. 2. Ensure Resident 80's urinal (a portable handheld plastic bottle used by a resident to urinate when they cannot easily walk to the bathroom) was emptied and was not placed in the side table with a food tray on it. 3. Ensure the facility reviewed and revised the water management program (a step-by-step safety blueprint used by a building to keep its water clean, safe, and free from dangerous germs like Legionella [a family of germs found naturally in fresh water and soil]) P&P to reflect current interventions to prevent legionella growth in the water system of the facility. These failures had the potential to spread infection among residents, cause accidents to residents such as skin burns, scalding, and growth of legionella in the facility water system. Findings: A1. During a review of Resident 126's Face Sheet (admission Record), dated 7/31/2026, the Face Sheet indicated the resident was originally admitted on [DATE], and was readmitted [DATE] with diagnoses including paraplegia (loss of movement and feeling in the lower half of the body, usually affecting both legs and sometimes the lower belly), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from lows of depression to elevated periods of emotional highs), and malignant neoplasm of large intestine and rectum (cancerous growth forming in the lining of the large intestine and of the last few inches of digestive tract before anus). During a review of Resident 126's History and Physical (H&P), dated 2/16/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. A2. During a review of Resident 30's Face Sheet, dated 7/31/2026, the Face Sheet indicated the resident was admitted on [DATE] with diagnoses including urinary tract infection (UTI – an infection in the bladder/urinary tract), depression (a serious mental health condition which causes ongoing sadness, low energy, and loss of interest in life), and glaucoma (an eye disease that damages the optic nerve, often caused by a buildup of fluid pressure inside the eye, which can lead to vision loss). During a review of Resident 30's H&P, dated 6/1/2026, the H&P indicated that the resident is not having memory loss and has the capacity to make medical decisions. During a concurrent observation and interview on 7/27/2026 at 9:25 a.m. with CNA 5, observed CNA 5 exit Resident 126's room under enhanced barrier precautions (infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs - microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents] in nursing homes), holding a pitcher and did not perform hand hygiene. CNA 5 filled the pitcher with water by Station 3 and went back inside Resident 126's room, placed the pitcher of water in the resident's bedside table, closed the curtain per resident's request, and exited the room without performing hand hygiene and touched the linen cart. Observed CNA 5 give towels to Resident 30 upon resident's request. CNA 5 stated she did not perform hand hygiene after leaving Resident 126's room because of time constraints. CNA 5 stated that she should have performed hand hygiene after exiting Resident 126's room and before touching any other surfaces or other residents in accordance with standard precautions. CNA 5 further stated that performing proper hand hygiene is essential for preventing cross contamination. During an interview on 7/30/2026 at 12:18 with MDS Assistant (MDSA) 1, MDSA 1 stated that hand hygiene plays a very important role in infection control. MDSA 1 stated that CNA 5 should have observed proper hand hygiene prior to leaving Resident 126's room. MDSA 1 stated that failure to perform hand hygiene may result in cross contamination (the transfer of harmful germs, bacteria, or allergens from one object, surface, or food to another). During an interview on 7/31/2026 at 11:09 a.m. with the Director of Nursing (DON), the DON stated guidelines must be strictly followed when residents are on enhanced barrier precautions such as proper hand hygiene or handwashing and wearing gloves or gowns. The DON stated the importance of hand hygiene is to prevent the spread of infection. The DON stated that the facility P&P regarding hand hygiene was not observed when CNA 5 failed to perform hand hygiene before leaving Resident 126's room. The DON stated CNA 5 should have performed hand hygiene prior to exiting the room to reduce the risk of cross contamination. During a review of the facility's P&P titled, Hand Hygiene, last reviewed on 4/22/2026, the P&P indicated, PURPOSE, to establish the use of appropriate hand hygiene for all Facility staff, healthcare personnel (HCP), Residents, volunteers and visitors while at the Facility. POLICY, the Facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e., alcohol-based hand rub {ABHR} including foam or gel). PROCEDURE (E) The following situations require appropriate hand hygiene: (v) Before and after assisting a Resident with dining if direct contact with food is anticipated or occurs (vii) Immediately upon entering and exiting a resident room. b. During a review of Resident 80's Face Sheet, the Face Sheet indicated the facility admitted the resident on 9/17/2025, and readmitted the resident on 2/27/2026, with diagnoses including difficulty walking, muscle weakness, and reduced mobility. During a review of Resident 80's H&P, dated 3/2/2026, the H&P indicated the resident was not having memory loss and had the capacity to make medical decisions. During a review of Resident 80's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a person's mental abilities—such as memory, thinking, problem-solving, and judgment—are working normally and without any major impairment). The MDS indicated the resident needed supervision assistance on toileting hygiene. During a review of Resident 80's Care Plan (CP) Report regarding the resident preference to have a urinal holder on his wheelchair, last revised on 4/13/2026, the CP indicated an intervention to empty and clean urinal promptly following facility infection control policy. During an interview on 7/27/2026 at 9:30 a.m. with Resident 80, Resident 80 stated he placed the urinal on top of the side table because the staff were not emptying his urinal and mentioned that one time, he had to empty the urinal on the trash because nobody was emptying them for him. During a concurrent observation and interview on 7/27/2026 at 9:35 a.m. with CNA 11, inside Resident 80's room, observed Resident 80's bed side table had a urinal half-filled urine placed beside the breakfast tray. CNA 11 stated it was not okay to leave the urinal with urine on them on top of a table with food for infection purposes. During a concurrent interview and record review on 7/30/2026 at 10:22 a.m. with the Infection Preventionist (IP), the facility's P&P titled, Resident Rooms and Environment, was reviewed. The IP stated it was not appropriate to have a urinal at the bed side with urine in them because the resident can get sick because the food is beside the urinal. The IP stated the staff should have emptied the urinal right away and placed the urinal within a distance from the food tray. The IP stated the facility did not follow their P&P titled, Resident Rooms and Environment. During a concurrent interview and record review on 7/30/2026 at 11:39 a.m. with MDSA 1, Resident 80's Medical Diagnoses, CP, and the facility's P&P were reviewed. MDSA 1 stated the staff should have emptied the urinal in a timely manner and placed the urinal within a distance from the meal tray to prevent infection to the resident. MDSA 1 stated the CP regarding the resident preference to have a urinal holder on his wheelchair, with an intervention to empty and clean urinal promptly following facility infection control policy was not followed and the P&P titled, Resident Rooms and Environment was also not followed by the facility. During an interview on 7/31/2026 at 10:54 a.m. with the DON, the DON stated the staff should have emptied the urinal right away and kept the urinal from a distance to the meal tray to prevent infection to Resident 80. The DON stated their failure to empty the urinal and keep it away from the meal tray had the potential for Resident 80 to suffer from gastrointestinal infection (happens when harmful germs like viruses, bacteria, or parasites enter the digestive system and irritate the stomach and intestines). During a review of the facility's recent P&P titled, Resident Rooms and Environment, last reviewed on 4/22/2026, the P&P indicated to provide residents with a safe, clean, comfortable and homelike environment. Procedure I. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order. c. During a concurrent interview and record review on 7/30/2026 at 8:36 a.m. with the IP, the facility's temperature logs for 5/2026 to 7/2026 were reviewed. The IP stated they adapted the (Centers for Disease Control and Prevention) CDC's Legionella Management Program in the facility. The IP stated they do not provide conditions where legionella grows best in their water systems (77 degrees F – 113 degrees F) and they do domestic water microbiological testing once a year. The IP provided temperature log from 5/2026 to 7/2026, and the form indicated that the water temperature should be between 105 and 120 degrees. The IP stated she cannot explain why the temperature parameter on the form does not match what CDC Legionella Management Program has set which is avoiding temperatures (77 degrees F – 113 degrees F) which legionella grows best. The Log provided was daily monitoring of temperature which was mostly in the shower rooms and resident rooms, most temperatures fall on 77 degrees F – 113 degrees F. The IP came back with a different log and stated that what she gave earlier was the temperature log for water temperature that they use to provide comfortable water for the resident under Title 22 (refers to the state's official rulebook for health, safety, and licensing in community care facilities, childcare centers, and healthcare institutions. In plain English, it is the baseline standard businesses must follow to legally care for children, the elderly, and patients). The IP returned with a log and stated they only monitor for water temperature monthly following the CDC guidance for legionella which is avoiding water temperatures between 77 degrees F – 113 degrees F. The IP reviewed the facility's Domestic Water Heat Exchanger Blowdown and Temperature Monitoring and the monitoring indicated: - On 3/2/2026, the Station 1 & 2 Heater 1 indicated a supply temperature of 120 and a return temperature of 113. - On 3/2/2026, the Station 1 & 2 Heater 2 indicated a supply temperature of 122 and a return temperature of 112. - On 4/6/2026, the Station 1 & 2 Heater 1 indicated a supply temperature of 124 and a return temperature of 112. - On 4/6/2026, the Station 1 & 2 Heater 2 indicated a supply temperature of 122 and a return temperature of 113. - On 5/4/2026, the Station 1 & 2 Heater 2 indicated a supply temperature of 124 and a return temperature of 113. - On 5/4/2026, Basement Heater 2 indicated a supply temperature of 121 and a return temperature of 113. - On 6/1/2026, Basement Heater 1 indicated a supply temperature of 120 and a return temperature of 112. - On 7/7/2026, the Station 1 & 2 Heater 1 indicated a supply temperature of 120 and a return temperature of 112. - On 7/7/2026, the Station 1 & 2 Heater 2 indicated a supply temperature of 124 and a return temperature of 111. - On 7/7/2026, the Basement Heater indicated a supply temperature of 123 and a return temperature of 110. The IP cannot explain why the water temperature on the above log was still within the 77-113 degrees F (the ideal temperature range for legionella growth). During an interview on 7/30/2026 at 10:15 a.m. with the Administrator (ADM), the ADM stated they were only monitoring the temperature for legionella growth in the water every month and they try to avoid the temp below 77 degrees and at or below 113 degrees not to exceed 120 to prevent burns or scalding on the residents. When the ADM was asked why the log still had a temp of 113 and below and what they have done to address the situation, the ADM stated they did not do anything with the temperature at 113 or below degrees F. During a concurrent interview and record review on 7/30/2026 at 10:30 a.m. with the ADM, the facility's recent P&P titled, Water Management Program, last reviewed 4/22/2026, and the Water Safety Plan – 2026 were reviewed. The ADM stated on the Water Safety Plan- 2026, they were following the task listed on the page: Blowdown of Hot Water Heaters monthly Hot Water Heater Temperature Monitoring monthly Activate Point-of-Use Taps in Stagnant areas 4x a month Domestic Water Microbiological Testing once a year. The ADM stated the above-mentioned tasks were not incorporated in their Water Management Program. The Water Management Program P&P indicated under Procedure VI. Water Management team will establish ways to intervene when control limits are not met c. Check disinfectant levels monthly but on their Water Safety Plan- 2026 it indicated Domestic Water Microbiological Testing is only done once a year. During an interview on 7/31/2026 at 10:54 a.m. with the DON, the DON stated the facility should follow the CDC guidelines for Legionella Management and follow its program to ensure their water system does not grow legionella that could harm the residents in the facility. During a review of the facility's recent P&P titled, Water Management Program, last reviewed on 4/22/2026, the P&P indicated the facility will develop and maintain a water management program to reduce Legionella and other waterborne pathogen growth and potential spread in facility. This process will be reviewed at least once per year. Procedure: II. The water management program (WMP) leader will do a building risk assessment (see CDC toolkit for risk assessment form). During a review of the facility provided Developing a Water Management Program to Reduce Legionella Growth & Spread in Building, dated 9/30/2025, the Guide indicated under Factors internal to buildings that can lead to Legionella growth -Water temperature fluctuations: Provide conditions where Legionella grows best (77 degrees F – 113 degrees F).

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Reach-in freezer 2's gasket was torn and ripped. 2. Kitchen and storage areas were not free from dirt and dust debris. a. Two (2) of 2 reach-in refrigerator 3's vent had dust and dirt buildup. b. One (1) of 1 reach-in refrigerator 6's vent had dust and dirt buildup. c. Walk-in refrigerator 4's floor contained food particles such as lettuce, cucumbers, plastic and dirt. Walk-in refrigerator 4's shelves had dirt and dust particles. d. Reach-in freezer 8's and 9's bottom shelves contained dirty debris. e. Dry storage floor had pasta, spaghetti, rice, food and dirt debris. f. Pans storage area contained dust and dirt debris. g. Trayline bottom shelves had crumbs, dust and dirt debris. h. Utensils containers had dirt, dust debris and were stored in different directions or orientation. i. Ice machine internal parts contained hard water buildup and particles. 3. Three (3) of 3 dented cans (a packaged metal food containers that have been physically deformed or crushed) were found with non-dented cans. 4. Three (3) of 3 dietary staff wore earrings with stones during food preparation, cooking and trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving]) service. 5. One (1) of 1 dietary staff did not wash his hands after dropping and picking up kitchenware on the floor, after wiping surfaces and before putting away clean dishes. 6. Eye glass case was in the preparation area. 7. Utensils container had kitchen utensils, cutting gloves, dirty knife sharpener, and dirty brush. 8. Kitchen tools and equipment are not of cleanable surface. a. Two (2) of 2 green chopping boards had knife marks and scratches. b. Twenty (20) of 20 sampled resident's trays had cracks, chips and lost their glaze. 9. Cambro (a brand of heavy-duty, professional grade plastic) containers were not air dried and were stacked wet. 10. Activity staff were not monitoring freezer temperatures for residents' freezers in the activity rooms and using acceptable freezer ranges of 20-30 degrees Fahrenheit ( F, a scale of temperature). These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 171 of 185 medically compromised residents who received food and ice from the kitchen. Findings: 1. a. During an initial kitchen tour observation on 7/27/2026 at 8:14 a.m., of the reach-in freezer 2, observed a torn gasket and formed ice crystals in the freezer roof. During an interview on 7/27/2026 at 8:25 a.m. with the Dietary Supervisor (DS), the DS stated they maintain the freezer gasket and maintenance, or the outside vendor replace the gaskets. The DS stated it was important to have good gaskets so there would not be too much condensation, and the freezer temperature is maintained. The DS stated condensation is when warm air comes in and it creates ice and water causing it to freeze on top and leak to the bottom of the freezer. The DS stated the freezer gasket is torn, worn out and needed to be replaced because there are already ice crystals forming. The DS further stated the ice could melt to water and drip to food causing cross-contamination to food and the freezer temperature could go up and may not keep the food frozen. The DS stated the freshness of food is affected and not maintained and residents could complain if the food is not fresh as a potential outcome. During a review of the facility's policies and procedures (P&P) titled P-DS49 Sanitation of Reach-in Refrigerator, dated 4/22/2026, the P&P indicated, Scrub the interior and exterior of the refrigerator until hot detergent solution or a brush or clean cloth. Pay special attention to shelf guides, gaskets, the door frame and hinge areas. 2. a. During an initial kitchen tour observation on 7/27/2026 at 8:34 a.m., of the reach-in refrigerator 3, observed 2 of 2 vents had dirt buildup. During a concurrent observation and interview on 7/27/2026 at 8:37 a.m., of the reach-in refrigerator 3 with the DS and Assistant Dietary Supervisor (ADS), ADS stated there was dust on the vents and he was not sure as to when the vent was last cleaned by maintenance staff. The DS stated it is important to maintain the cleanliness of the vent so it would not contaminate food by blowing dust in the food. The DS stated if there is dust buildup in the vent, it could affect the refrigerator temperatures and residents could get sick of foodborne illnesses. b. During a concurrent initial kitchen tour observation and interview on 7/27/2026 at 8:56 a.m., of the reach-in refrigerator 6 with the DS, observed the vent had dust buildup. The DS stated there is a little bit of dust and it needed to be cleaned to prevent cross-contamination of food. c. During an observation on 7/27/2026 at 8:42 a.m. of the walk-in refrigerator 4, observed lettuce head, cucumbers, dirt on the floor and dust debris on the bottom shelves. During a concurrent observation and interview on 7/27/2026 at 8:51 a.m., of the walk-in refrigerator 4 with the DS, the DS stated the bottom shelves had dust and the dust comes off when touched. The DS stated the floor had cucumber and lettuce and the dietary staff swept it, but they do not think to bend to see other dirt and food items. The DS stated they needed to maintain the cleanliness of the walk-in refrigerator to prevent cross-contamination. During a review of the facility's P&P titled, D549 Sanitation of Reach-in Refrigerator, dated 4/22/2026, the P&P indicated, The reach-in refrigerator will be maintained in a sanitary condition. Purpose: To establish guidelines for sanitation of the reach-in refrigerator. Daily Task: a. Wipe up spills on shelves, sides, and floor of refrigerator by using clean solution and a clean cloth. d. During an observation on 7/27/2026 at 9:02 a.m., of the reach-in freezer 8, observed dirt debris on the bottom shelves. During an interview on 7/27/2026 at 9:04 a.m., with the DS, the DS stated the freezer was last cleaned last week and both freezers were condensing. The DS stated the freezer had dirt debris on the bottom shelves that could cause cross contamination of food. During a concurrent observation and interview on 7/27/2026 at 9:07 a.m., of the reach-in freezer 9 with the DS, the DS stated the dirt debris on the bottom shelves needed to be cleaned because it could cause cross-contamination. During a review of the facility's P&P titled, Freezer Operation and Cleaning, dated 4/22/2026, the P&P indicated, To establish guidelines for operation and cleaning of the freezer. The dietary staff will use the freezer according to the manufacturer's guidelines. The freezer will be cleaned periodically as necessary. (E). Wash inside racks and fans carefully and thoroughly, using pot and pan washing solution. (F) Rinse and sanitize and allow to air dry. (G) Clean outside of the freezer with detergent solution. e. During a concurrent observation and interview on 7/27/2026 at 9:16 a.m., of the dry storage area by Station 4 with the DS, observed pasta, spaghetti, noodles, rice, plastic debris and dirt on the floor. The DS stated there are pastas and dirt on the floor. The DS stated dietary staff sweep and mop two times (2x) a week, but they have not cleaned under there for a good month, and no one looks under there. The DS stated they needed to maintain the cleanliness of the floor to prevent cross-contamination and dust, and food debris could attract pest. The DS stated pests could spread all kinds of diseases to the residents as a potential outcome. During a review of the facility's P&P titled, DS52 Food Storage and Handling, dated 4/22/2026, the P&P indicated, Food items will be stored, thawed and prepared in accordance with standard sanitary practices. Purpose: To properly store, thaw, and prepare food to avoid foodborne illnesses. 13. Dry storage area (b) the walls, ceiling, and floor should be maintained in good repair and regularly cleaned. During a review of Food Code 2022 dated 1/18/2023 the Food Code 2022 indicated 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (3) at least 15 cm (6 inches) above the floor. f. During a concurrent observation and interview on 7/28/2026 at 11:25 a.m., of the storage area for clean pans with the DS, observed dust and dirt accumulation on the storage area surfaces. The DS stated the storage area is a clean area, however it had dust and dirt debris and could contaminate clean equipment. The DS stated dietary staff needed to clean the area every day to prevent cross-contamination. g. During an observation on 7/28/2026 at 1:59 p.m. of the trayline area where the condiments are stored, observed dust and dirt residue. During an interview on 7/28/2026 at 2:04 p.m. with the DS, the DS stated the dietary staff clean the bottom storage area two times a week and they cleaned it last Sunday. The DS stated the storage area contained dirt, crumbs and debris and it was not okay to clean it just two times a week because there are activities in trayline. The DS stated the storage area needs to be cleaned to prevent cross-contamination. h. During a concurrent observation and interview on 7/28/2026 at 2:09 a.m. of the utensils container by the trayline with the DS, observed dirt and crumbs debris inside it and the utensils handle were stored in different directions. The DS stated the utensils container had crumbs inside and it was not okay due to cross-contamination. The DS further stated the utensils should be stored in one direction so it's more organized and employees would not be touching the lid of the scoops and utensils to prevent cross-contamination. During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 indicated, 4-904.11 Kitchenware and Tableware (A) Single-service and Single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food-and lip-contact surfaces is prevented. i. During a concurrent observation and interview on 7/28/2026 at 2:22 p.m. of the ice machine with the DS, the ice machine contained hard water residue and buildup. The DS stated the internal parts of the ice machine have white particles coming from the hard water and it's not acceptable because it could go to the ice for cross contamination. During a review of the facility's P&P titled, Ice Machine-Operation and Cleaning, dated 4/22/2026, the P&P indicated, Purpose: To establish guidelines for use and cleaning of the ice machine. Policy: the dietary staff will operate the ice machine according to manufacturer's guidelines. The ice machine will be cleaned routinely. During a review of the facility's P&P titled, Cleaning Schedule, dated 4/22/2026, the P&P indicated, To establish guidelines for maintaining a routine cleaning schedule. The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the dietary manager. Procedure: 1. The dietary manager will develop a cleaning schedule that includes the frequency of which equipment areas are to be cleaned. a. The cleaning schedule is posted weekly b. The cleaning schedule includes tasks assigned to specific positions within the dietary department. c. Dietary staff will initial next to the assigned task once it is completed. 2. The dietary manager monitors the cleaning schedule to ensure compliance. During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At anytime when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. During a review of Food Code 2022, dated 1/18/2022 the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 indicated, 4-701.10 Food Contact Surfaces and Utensils shall be sanitized. 4-702.11 Before use After cleaning. Utensils and Food-Contact Surfaces of Equipment shall be sanitized before use after cleaning. 3. During a concurrent observation and interview on 7/27/2026 at 9:20 a.m., of the dry storage area with the DS, observed dented cans separated and labeled dented cans. The DS stated dented cans are damaged, needed to be returned to the vendor and dietary staff are not supposed to use them. The DS stated there were 3 dented cans stored with non-dented cans and dietary staff are not supposed to use dented cans because of holes and leaks in them making the cans swollen resulting in food cross-contamination and botulism (rare but serious illness caused by bacteria leading to difficulty breathing, muscle paralysis and it could be fatal if not treated promptly) During a review of the facility's P&P titled P-DS52 Food Storage and Handling, dated 4/22/2026, the P&P indicated, 8. Canned Fruit Storage: c. Place dented or bulging cans in a separate storage area and return for credit. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 4. During an observation on 7/27/2026 at 12:19 p.m., of the food dietary staff cooking and food preparation, observed [NAME] 1 and [NAME] 2 wearing stud earrings with stones while cooking and during food preparation. During a concurrent observation and interview on 7/27/2026 at 12:20 p.m., of the dietary staff while preparing and cooking food with the DS, the DS stated Dietary Aide 1 (DA 1) is wearing earrings with stones and the dietary staff could only wear one stud earrings with no stones and not dangling because the stones could fall in the food and contaminate it. During a review of the facility's P&P titled, P-DS61 Dietary Department Infection Control for Dietary Employees, dated 4/22/2026, the P&P indicated, Purpose: To ensure that the dietary department is maintained in a sanitary condition in order to prevent food contamination and the growth of disease producing organisms and toxins. I. Personal cleanliness is required in sanitary food preparation. E. Rings, bracelets, and watches are not permitted to be worn while working in the food service area or while preparing food. (1) The only exception is plain band ring (such as wedding band). 5. During an observation on 7/27/2026 at 12:48 a.m. of the dishwashing process, observed Dietary Aide 2 (DA 2) dropped a pitcher on the floor, placed the pitcher in the dishwashing sink, cleaned the surfaces then held a clean brown chopping board. During an interview on 7/28/2026 at 11:35 a.m., with the DS and ADS, the ADS stated DA 2 is still training for dishwashing position and the Director of Staff Development (DSD) did the onboarding orientation. The DS stated he provided training about wearing hairnets, hand washing, sanitation and cleaning to DA 2. The DS stated his in-service included washing of hands at least 20 seconds, rub, rinse, and wipe hands with a paper towel and when to wash hands. The DS stated DA 2 should have washed his hands when he touched the pitcher on the floor. The ADS stated DA 2 should have washed his hands after he cleaned the surfaces and before putting away clean dishes to prevent cross-contamination. During a review of the facility's P&P titled, P-DS61 Dietary Department Infection Control for Dietary Employees, dated 4/22/2026, the P&P indicated, II. Proper Hand Hygiene. (F). After handling soiled equipment or utensils. (K). After engaging in any other activities that contaminate hands. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. 6. During an observation on 7/28/2026 at 9:22 a.m. of the salad preparation area, observed eye glass case by the kitchen equipment on the bottom shelf. During an interview on 7/28/2026 at 9:27 a.m., with the DS, the DS stated dietary staff have their lockers outside the kitchen and personal belongings are not supposed to be in the kitchen or in the janitorial closet. The DS stated the eye glass case should not be in the kitchen to prevent cross-contamination. During an interview on 7/28/2026 at 9:29 a.m., with DA 1 and the DS, DA 1 stated the eyeglasses case is hers and she used her glasses to check the trays. The DS stated the eye case should be in the locker to prevent cross-contamination of food. During a review of the facility's P&P titled, P-DS61 Dietary Department Infection Control for Dietary Employees, dated 4/22/2026, the P&P indicated, IV. Personal items at workstation. A. Personal items are not permitted in dietary preparation, service, storage, or dishwashing areas. B. Personal items must be stored in a designated area. During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 indicated, 6-501.110 Using Dressing Rooms and Lockers. (A) Dressing rooms shall be used by EMPLOYEES if the EMPLOYEES regularly change their clothes in the establishment. (B) Lockers or other suitable facilities shall be used for the orderly storage of EMPLOYEE clothing and other possessions. 7. During an observation on 7/28/2026 at 9:22 a.m. of the salad preparation area, observed a container with kitchen utensils mixed with dirty knife sharpener and dirty brush. During an interview on 7/28/2026 at 9:24 a.m., with the DS, the DS stated the container for the cutting gloves and utensils had dirty brush and stone knife sharpener in it. The DS stated the brush is worn out and the knife sharpener had dark stain. The DS further stated having dirty utensils could contaminate equipment due to the dirt and dust. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. 8. a. During an observation on 7/28/2026 at 9:40 a.m. of the salad preparation area, observed chopping board rack used for storing clean chopping board containing food residue. During a concurrent observation and interview on 7/28/2026 at 9:43 a.m., of the chopping board rack with the DS, the DS stated the chopping board rack had food splatter particularly from the salad or fruit because the dietary staff prepares salad and fruit in the area. The DS stated that the dietary staff needs to clean the rack every day because it holds clean equipment. The DS further stated the dietary staff left the racks not cleaned for a couple of days and it was not okay due to cross contamination of food leading to foodborne illnesses for the residents. During a concurrent observation and interview on 7/28/2026 at 9:46 a.m., of the green chopping board with the DS, observed the green chopping boards had knife marks and visible scratches. The DS stated food contact surfaces should be cleanable, could be washed; clean and sanitize it. The DS stated kitchen equipment and surfaces should be non-porous, smooth, and could not have holes and breakage so they could be sanitized properly. The DS stated they used too much of the green chopping boards as it has knife marks and scratches, and it would be hard to clean and penetrate through the surfaces of the scratches. The DS further stated the more damage to the surface the harder for them to clean it causing mold growth, bacteria and cross-contamination. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-501.12 Cutting Surfaces. Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may be transferred to foods that are prepared on such surfaces. b. During a concurrent observation and interview on 7/29/2026 at 10:16 a.m. of the resident's meal trays with the ADS, observed 20 of 20 sampled clean trays had cracks, scratches and lost their glaze. The ADS stated it would be hard to clean if the trays had cracks and bacteria could grow through the cracks causing cross contamination. During a review of the facility's P&P titled, Discarding of Chipped/Cracked Dishes and Single Service Items, dated 4/22/2026, the P&P indicated, To establish guidelines for service ware and single service items. The dietary staff will maintain a sanitary environment in the dietary department by discarding compromised service ware and single service items. Procedure: 1. The dietary staff will discard chipped or cracked dishes or glass ware. 2. Single service containers such as cottage cheese containers, are discarded after use and are not to be reused as a storage container. 3. Containers used for storage will be purchased for that purpose. a. Store containers will have a tight-fitting lid and are sanitized in the dishwashing machine. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-101 Characteristics. Materials that are used in construction of utensils and food-contact surfaces of equipment may not allow the mitigation of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be (a) safe; (b) durable, corrosion-resistant, and non-absorbent; (c) sufficient in weight and thickness to withstand repeated warewashing; (d) Finished to have a smooth, easily cleanable surface. 9. During an observation on 7/29/2026 at 10:30 a.m., of the Cambro containers by the storage area, observed the Cambro containers were stacked wet and there were still water particles in them. During an interview on 7/29/2026 at 10:38 a.m. with the DS, the DS stated it was important to air dry the Cambro containers to prevent wetness on the trays, chemical contamination for food and making sure the dishes are sanitized well. The DS further stated the Cambro containers should not be stacked wet because of wet nesting (stacking and storing freshly washed dishes, pots and pans while they are still wet causing trap moisture, block air, creating a dark and damp space where germs and mold grow fast) that could cause bacterial growth. During a review of the facility's P&P titled, Pot and Pan Cleaning and Sanitizing, dated 4/22/2026, the P&P indicated, Invert the pots and pans and place them in a drying rack or counter. Allow the items to air dry. Do not sure a towel. When items are dry, store them in the proper storage area. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. 10. During a concurrent observation and interview on 7/30/2026 at 9:45 a.m. of the resident's freezer in Activity room [ROOM NUMBER] with the Activities Assistant 1 (AA1), observed a temperature log for the refrigerator but not for the freezer and there was ice cream in the freezer. AA 1 stated she checks the temperature of the freezer daily and the acceptable range is between 20-30 F. AA1 stated she usually finds 20-30 F temperature of the freezer. During an interview on 7/30/2026 at 9:57 a.m. with the DS, the DS stated freezer temperatures should be 0 F and minus temperatures to keep food frozen and achieve freezing points and 20-30 F is not acceptable freezer temperatures as quality of food would be affected. During an interview on 7/30/2026 at 10:12 a.m. with the Activity Director (AD), AA1 and the DS, AA1 stated they could not store food in the freezer, so they do not monitor the temperature of it for food storage. The AD stated the residents are discouraged to use the freezer, but they can still use it and the acceptable range for freezer is 0 F and below. During an observation on 7/30/2026 at 10:53 a.m., of the resident's freezer in Activity room [ROOM NUMBER], observed no posted temperature log for the freezer. During an interview on 7/30/2026 at 11:00 a.m. with Activities Assistant 2 (AA 2), AA 2 stated they check the freezer temperatures and the acceptable temperature is 20 F but they do not log it because the freezer was empty most times and they do not store in the freezer because they have to toss all the food out after 48 hours of receiving. During an interview on 7/30/2026 at 11:05 a.m. with the DS, the DS stated the acceptable range for the freezer is 0 F and they needed to monitor the freezer to ensure the equipment is working properly to ensure freshness and food safety. During a review of the facility's P&P titled, Refrigerator and Freezer Temperature Record, dated 4/22/2026, the P&P indicated, To establish guidelines to record the temperatures of refrigerated and frozen storage areas. A daily temperature record is to be kept for refrigerated and frozen storage areas. Procedure: 1. The dietary manager or designee is to record daily all refrigerator and freezer temperatures on Form A- Refrigerator/Freezer Temperature Log during AM and PM shifts. 2. The freezer must be 0 F or below. 3. Temperatures above these areas are to be reported to Dietary Manager immediately. 4. Note on the temperature forms the plan of action taken when temperatures are not in acceptable range. 5. Corrective Action should be taken to correct the temperature or the items should be move to another storage area to maintain acceptable temperature. During a review of Food Code 22, dated 1/18/2022, the Food Code 2022 indicated, 3-501.11 Frozen Food. Stored frozen foods shall be maintained frozen.

Based on observations, interviews, and record reviews, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 7/27/2026. This failure had the potential to result in hunger and frustration for 14 to 185 residents, including Resident 12. Findings: During a review of Resident 129's admission Record (AR), the AR indicated the facility admitted Resident 129 on 7/14/2026 with diagnosis including, but not limited to gastrointestinal reflux disease (GERD, stomach acid or contents frequently flow back into the esophagus [the tube connecting the mouth and stomach]) without esophagitis (swelling or irritation of the tissues lining the esophagus), dysphagia, oropharyngeal phase (a condition that makes it difficult to swallow from the mouth, through the throat and into the esophagus), and dyskinesia of esophagus (abnormal, uncontrolled and involuntary movements) During a review of Resident 129's Minimum Data Sheet (MDS- a federally mandated resident assessment tool), dated 7/21/2026, the MDS indicated Resident 129 understood others and make self understood. The MDS indicated Resident 129 needed supervision or touching assistance (helper provides verbal cues and or touching/steadying and/or contract guard assistance as resident completes the activity. Assistance may be provided throughout the activity or intermittently) when eating. During a review of Resident 129's Order Recap Report, dated 7/15/2026, the report indicated Resident 129 was ordered level 6 soft bite sized (diet consisting of tender, moist, and cut into pieces no larger than 1.5 cm x 1.5 cm foods), thin liquid consistency. During an interview on 7/27/2026 at 9:41 a.m., with Resident 129, Resident 129 stated she takes her medication at 6:30 a.m. but the food comes in late at 9 a.m. to 10 a.m. Resident 129 further stated that her doctor said to take her medications with food. During an observation on 7/27/2026 at 7:59 a.m., of the sign posted in the hallway titled Meals, Snacks and Nourishment Schedule, the posted sign indicated meal schedule are as follows: - Breakfast 7 a.m. - Snacks 10 a.m. - Lunch 12 noon - Snacks 2 p.m. - Dinner 5 p.m. - Snacks 8 p.m. During an observation on 7/27/2026 at 11:54 a.m., of the lunch trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving]), observed dietary staff started trayline lunch service. During an observation on 7/27/2026 at 12:57 p.m., of the trayline, observed dietary staff waiting for Swedish meatballs to cook and there were 14 trays for Station three (3) waiting to get dish out. During an observation on 7/27/2026 at 1:13 p.m., of the lunch trayline, observed dietary staff plated the last tray for lunch. During an observation on 7/27/2026 at 1:16 p.m., of the lunch trayline, observed dietary staff pushed the last cart out of the kitchen to Station 3 and it arrived at Station 3. During an observation on 7/27/2026 at 1:22 p.m., of the lunch tray for Station 3, nursing staff observed passing the last meal tray in Station 3. During an interview on 7/27/2026 at 1:40 p.m., with the Dietary Supervisor (DS) and the Assistant Dietary Supervisor (ADS), the DS stated the trayline lunch was late today because they run out of Swedish meatballs and it potentially messes everybody's schedule like nursing schedule and late medication administration. The DS further stated that residents could potentially have inconsistencies with taking their medications. The ADS stated residents could potentially get angry because they are hungry. During a review of the facility's policies and procedures (P&P) titled, Meal Service Times, dated 4/22/2026, the P&P indicated, Purpose: To provide the dietary department with guidelines for meal service. Policy: Meals are served at regular scheduled hours. An HS snack is served at regularly scheduled times and in accordance with prescribed diets. There is no more than 14 hours between dinner and breakfast the following morning. Procedure: - The dietary manager is responsible for monitoring meal service times daily to ensure the facility meets posted mealtimes. - Resident meal hours will be posted in the dining room(s) and are easily visible for the residents and staff. - Mealtimes are typically at 7:00 a.m., 12:00 p.m., and 5:00 p.m.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when the fresh zucchini and carrots are mushy and overcooked. This failure had the potential to result in 120 of 185 facility residents including Resident 18 at risk of unplanned weight loss, a consequence of poor food intake. Findings: During a review of Resident 18's Face Sheet (FS), the FS indicated the facility admitted Resident 18 on 6/17/2026 with diagnoses including but not limited to adult failure to thrive (a disease marked by severe weight loss, poor nutrition, lack of energy and social withdrawal), dysphagia oropharyngeal phase (a condition that makes it difficult to swallow from the mouth, through the throat and into the esophagus), and essential blood pressure (high blood pressure). During a review of Resident 18's Minimum Data Sheet (MDS- a federally mandated resident assessment tool) dated 6/24/2026, the MDS indicated Resident 18 understood others and make self understood. The MDS indicated Resident 18 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) when eating. During a review of Resident 18's Order Recap Report, dated 6/17/2026, the report indicated Resident 18 was ordered no added salt (NAS, no salt packet on the tray), Level 7 regular texture (no texture restrictions), thin consistency, small portions (less servings of food to provide lower calorie and protein food content). During an interview on 7/27/2026 at 11:34 a.m. with Resident 18, Resident 18 stated the food is not appetizing, and she has spoken to the dietitian five times and nothing has changed. During a concurrent observation and interview on 7/27/2026 at 1:11 p.m. of Resident's 18 food tray with Resident 18, observed the food tray was served at Resident 18's bedside. Resident 18 stated she will eat everything except the Swedish meatballs, pasta, zucchini and carrots because it does not look good and the vegetables looked mushy. During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Summer Menus, dated 7/27/2026, the spreadsheet indicated residents on regular texture would include the following foods on the tray: - Swedish meat balls 2 pieces - Gravy 1-2 ounces (oz, a unit of measurement) - Egg noodles 1/2 cup (c, a household measurement) - Fresh zucchini and carrots 1/2 c - Orange slice 1 piece garnish - Wheat roll 1 piece - Margarine 1 teaspoon - Raspberry parfait square 2x2 1/2 inches - Milk oz During an observation on 7/27/2026 at 11:30 a.m. of the start of trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving]) observed a pan of zucchini and carrots looked mushy. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 7/27/2026 at 1:24 p.m. of the regular diet with the Dietary Supervisor (DS) and Assistant Dietary Supervisor (ADS), observed the DS took the temperature of the zucchini and carrots using the facility thermometer. The DS stated the temperature of the zucchini and carrots was 129 degrees Fahrenheit ( F, a degree of temperature). The DS stated the fresh zucchini, and carrots are mushed because they tried to stay in the middle of the residents' requests and food preferences. The DS stated they had complaints in the resident council meeting about the vegetables being hard so they cooked it soft however the resident's food preferences should be individualized. The DS further stated residents who like their vegetables tender-crisp might complain about the mushy vegetables and would not eat their vegetables resulting in them not getting their full nutrition causing malnutrition. The ADS stated residents would be missing nutrients, vitamins and minerals in their diet for not eating vegetables. During a review of the facility's policies and procedures (P&P) titled Menus, dated 4/22/2026, the P&P indicated, To ensure that the facility provides meals to residents that meet the requirements of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. During a review of the facility's P&P titled, Vegetable Cookery, dated 4/22/2026, the P&P indicated, Purpose: To provide the dietary department with guidelines for vegetable cookery. Dietary department employees ensure that food is prepared in a manner that preserves quality, maximizes nutrient retention, and obtains the maximum yield of the product. Procedures: - Vegetables will be prepared as close to time of service as possible to maintain highest quality. - Vegetables will be steamed or cooked in a small amount of water as possible. - Raw, fresh vegetables will be added to boiling water and cooked per recipe directions. - Recipes will be used as a guideline. Additional seasoning maybe added, to taste for seasoning variation. During a review of the facility's standardized recipe titled, Recipe Fresh Zucchini and Carrots, dated 2026, the recipe indicated, Directions: - Wash carrots and zucchini well under cool running water. - Peel carrots and remove the ends of the zucchini. - Make julienne strips about 3 inches long and 1/4 inches wide. This is optional depending on the availability of a food processor and time. If unable, slice carrots and zucchini. - Simmer in boiling water or steam until tender. Suggest cooking the carrots part way, then adding zucchini to avoid the zucchini becoming mush before the carrots are tender. Drain. Add margarine and dill. May add more dill as desired. - Serve on trayline at the recommended temperature of 160 F - 180 F or less.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69% affecting two (2) of three (3) residents observed for medication administration (Resident 101 and 131.) The medication errors were as follows: 1. Resident 101 did not receive a form of aspirin (a medication used for cerebrovascular accident [CVA - an interruption in the flow of blood to cells in the brain, that can be caused by heart disease)] prophylaxis [PPX - prevention]) as ordered by Resident 101's physician. 2. Resident 131 received lidocaine (a medication used to relieve pain) patch (a medication delivery system) applied to the left upper arm instead of back, as ordered by Resident 131's physician. These failures had the potential to result in Resident 101 experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and Resident 131 experiencing unrelieved arm pain, resulting in their health and well-being to be negatively impacted. Findings: During an observation on 7/28/2026 at 8:38 a.m., in Medication Cart 2B, Licensed Vocational Nurse (LVN) 2 was observed applying lidocaine 5% patch to Resident 131's left upper arm. During an interview on 7/28/2026 at 8:40 a.m., with LVN 2, LVN 2 stated during she applied lidocaine 4% patch to Resident 131's left upper arm. LVN 2 acknowledged the physician's order specified to administer lidocaine 4% with menthol 1% patch to the back. LVN 2 stated that LVN 2 failed to follow five (5) rights of medication administration for ensuring the correct medication was prepared and applied to the correct site, and this was considered a medication error. LVN 2 stated applying the wrong medication to the wrong site will not relieve Resident 131's pain. During an observation on 7/28/2026 at 9:12 a.m., in Medication Cart 1, LVN 3 was observed administering aspirin 81 milligram ([mg]-a unit of measure of mass) enteric coated ([EC] - a form of aspirin that is designed to slowly release medication) tablet to Resident 131. Resident 131 was observed swallowing the aspirin tablet with glass of water. During an interview on 7/28/2026 at 11:45 a.m., with LVN 3, LVN 3 stated that LVN 4 administered aspirin 81 mg EC tablet during the morning medication administration at 9:12 a.m. to Resident 101. LVN 3 stated that LVN 3 failed to follow the physician orders to administer aspirin 81 mg chewable (immediate release) tablet. LVN 3 stated EC tablets release slowly over time in the stomach, and chewable tablets release into the blood immediately. LVN 3 stated administering EC tablet was considered a medication error because it was the wrong form of the medications. LVN 3 stated administration of aspirin 81 mg EC tablet could delay the medication action for Resident 101. During an interview on 7/30/2026 at 11 a.m., with the Director of Nursing (DON) and in the presence of the Assistant DON (ADON,) the DON stated that LVN 2 failed to administer aspirin 81 mg chewable tablet to Resident 131 and LVN 3 failed to apply lidocaine with menthol to the back to Resident 101, according to their physician orders. The DON stated that licensed nurses should follow facility medication administration guidelines and five (5) rights of medication administration to ensure physician orders are followed and the right medications are administered to residents. The DON stated Resident 131 may be at risk of delayed medication action from receiving aspirin 81 mg EC tablet and Resident 101 at risk of unrelieved back pain, and that these were considered medication errors. During a review of Resident 101's Face Sheet (a document containing demographic and diagnostic information,) dated 7/28/2026, indicated the resident was originally admitted to the facility on [DATE] with diagnoses including ischemic cardiomyopathy (heart muscle disease.) During a review of Resident 101's Medication Administration Record ([MAR] - a record of mediations administered to residents), for July 2026, the MAR indicated Resident 101 was prescribed aspirin 81 mg chewable one (1) tablet once a day orally for CVA PPX to be given at 9 a.m., starting 7/2/2026. During a review of Resident 131's Face Sheet dated 7/28/2026, indicated Resident 131 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic pain and osteoarthritis (a disease causing bones to rub together leading to pain.) During a review of Resident 131's MAR for July 2026, the MAR indicated Resident 131 was prescribed lidocaine 4%-menthol 1% patch to apply to back once a day for pain to be given at 9 a.m., starting 7/9/2026. During a review of the facility's policy and procedures (P&P) titled Medication Administration - General Guidelines, last reviewed 4/22/2026, the P&P indicated Medications are administered as prescribed. A.4. Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. B.2. Medications are administered in accordance with written orders of the attending physician. During a review of the facility's P&P titled Administration Procedures for All Medications, last reviewed 4/22/2026, the P&P indicated: To administer medications in a safe and effective manner. C. Review five (5) Rights three (3) times: 1) Prior to removing the medication package/container from the cart/drawer; a. Check MAR/TAR for order. 2) Prior to removing the medication from the container a. Check the label against the order on the MAR. 3) After the dose has been prepared and before returning the medication to storage. During a review of the facility's P&P titled Medication -Error, last reviewed 4/22/2026, the P&P indicated: 1. Medication error means the administration of medication: f. Wrong medication.

Based on interview and record review, the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) two (2) medication eKITs containing controlled medications (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) with an inventory count for July 2026, in two (2) of two (2) inspected Medication Rooms (Medication Room Station 3 and 4.) As a result, control and accountability of CM did not follow state and federal regulations and facility policy and procedures. 2. Include the verifying signatures of two (2) licensed nurses on the Multipurpose Drug Disposition Record logs observed in one (1) of two (2) inspected Medication Rooms (Medication Room Station 3.) 3. Not dispose aerosolized (having tiny particles of matter and gas or liquid that turn into a fine mist to be inhaled) inhaler (a device containing a pressurized canister that is inhaled and delivers medication to the lungs) in the pharmaceutical (any medication/drug or dietary supplement for use by humans) waste container in one (1) of two (2) inspected Medication Rooms (Medication Room Station 4.) As a result, control and accountability of discontinued medications and medications awaiting final disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures. These failures had the potential to increase the risk of environmental damage and increase the opportunity for medication diversion (the transfer of medications from a lawful to an unlawful channel of distribution or use,) including CM diversion, and the risk that residents in the facility could have accidental exposure to harmful medications possibly leading to physical and psychosocial harm, hospitalization and death. Findings: During an observation on 7/28/2026 at 12:15 p.m., with Registered Nurse (RN) 7, in Medication Room Station 4 there were: 1. One (1) medication eKIT stored in the refrigerator containing CMs, labeled 212, without an accountability log for the reconciliation of CM inventory at every shift change for July 2026. 2. One (1) pharmaceutical waste container was observed to contain a mixture of loose medication tablets and capsules, medications in manufacturer packs and plastic containers, and an Advair (a medication used for asthma [a condition that makes breathing difficult]) HFA aerosol (pressurized plastic-housed metal canister) inhaler. During an observation on 7/28/2026 at 12:30 p.m., with RN 7, in Medication Room Station 3 there were: 1. One (1) medication eKIT stored in the refrigerator containing CMs, labeled 230, without an accountability log for the reconciliation of CM inventory at every shift change for July 2026. 2. Two (2) pages of Multipurpose Drug Disposition Record logs, dated 7/20/2026 and signed by RN 1, without witness initials for the disposition of 15 medications listed on the logs. During an interview, RN 7 stated that all CMs, including medication eKITs containing CMs, should be reconciled at every shift, like the inventory reconciliation of CMs in medication carts. RN 7 stated that the eKIT labeled 212 in the refrigerator of Medication Room Station 4 and the eKIT labeled 230 in the refrigerator of Medication Room Station 3 contained CMs and were not reconciled with an inventory count at every shift in July 2026. RN 7 stated it was important to account for all CMs by an inventory count to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During the same interview, RN 7 acknowledged the pharmaceutical waste container in Medication Room Station 4 contained Advair HFA aerosol inhaler. RN 7 acknowledged the container was labeled Regulated Medication Waste - UN #3291 for Incineration [process of burning waste materials at very high temperatures] only and indicated to not put flammable (something that can catch fire) waste in the container. During the same interview, RN 7 reviewed two (2) pages of Multipurpose Drug Disposition Record logs dated 7/20/2026 for Medication Room Station 3. RN 7 stated RN 7 was unable to locate the signatures/initials or names of a witness on the two (2) pages for the disposition of 15 medications. RN 7 stated that RN 1 failed to follow facility policy of signing the logs with a licensed nurse as a witness, when RN 1 disposed of the medications on 7/20/2026. During an interview on 7/30/2026 at 11 a.m., with the Director of Nursing (DON) in the presence of the Assistant DON (ADON,) the DON acknowledged pharmaceutical waste container contained Advair HFA aerosol inhaler. The DON acknowledged the container was intended for incineration and that aerosols are pressurized and can explode in the incineration process. The DON stated the facility failed to destroy the medications in Medication Room Station 4 safely and according to federal and state regulations. The DON stated she needed to contact the vendor (an outside company or person that sells goods or services to your business) to obtain the appropriate waste container for aerosol inhalers. During the same interview, the DON reviewed two (2) pages of Multipurpose Drug Disposition Record logs dated 7/20/2026 for Medication Room Station 3. The DON stated she was unable to locate the signatures/initials or names of a witness on the two (2) pages for the disposition of 15 medications. The DON stated that RN 1 failed to follow facility policy of signing the logs with a licensed nurse as a witness, when RN 1 disposed of the medications on 7/20/2026. The DON stated it was important to verify and sign these logs with witnesses to prevent medication diversions and accidental exposure to residents. During the same interview, the DON stated that medication eKITs containing CMs needed to be counted with an inventory count and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated the eKIT containing CMs in Medication Room Station 4 labeled 212 and Medication Room Station 3 labeled 230 were not reconciled with an inventory count at each shift change in July 2026. The DON stated that the facility will immediately implement an accountability log to include the inventory count for the reconciliation of eKITs at each shift change in Medication Rooms. During a review of the facility's Policy and Procedures (P&P,) titled Controlled Substance Storage, last reviewed 4/22/2026, the P&P indicated: D. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including the emergency supply, is conducted by two (2) licensed nurses and is documented. During a review of the facility's P&P, titled Medication Destruction, last reviewed 4/22/2026, the P&P indicated: Discontinued medications and medications left in the facility after resident's discharge are destroyed. Destruction methods comply with federal and state laws and regulations. D. Medication destruction occurs only in the presence of two (2) licensed nurses. E. The licensed nurse(s) and/or pharmacist witnessing the destruction ensures that the following information is entered on the (medication disposition form): 6. signatures of witnesses. During a review of the P&P titled EPA Hazardous Waste Pharmaceuticals Storage and Disposal, last reviewed 4/22/2026, the P&P indicated: This Environmental Protection Agency (EPA) rule governs the removal and destruction of hazardous waste. Subpart P Hazardous pharmaceutical waste is defined as any item that exhibits one of the following four (4) characteristics: ignitability, corrosivity, reactivity, or toxicity. These items are either acutely hazardous (P-listed) or toxic/hazardous (U-listed) and can include prescription drugs, dietary supplements, over-the-counter drugs, homeopathic products, and Drug Enforcement Administration (DEA) controlled substances. Healthcare facilities, defined in this rule as nursing, skilled nursing, and inpatient hospice settings, must now comply with this regulation. During a review of the P&P titled Disposal of Medication and Medication Related Supplies, last reviewed 4/22/2026, the P&P indicated: The facility will dispose of pharmaceutical hazardous and non-hazardous waste using an approved system of disposal that protects employees and the environment according to applicable federal, state and local laws or regulations. 2) Hazardous pharmaceutical waste a. Considered a solid waste that exhibits characteristics of ignitability, corrosivity, reactivity, or toxicity or is -listed b. Can be further defined as acute hazardous waste (P-listed) A complete list of acute and nonacute hazardous waste, as defined by the EPA, can be found here: https://www.epa.gov/hw/defining-hazardous-waste-listed-characteristic-and-mixedradiological-wastes. During a review of Recovery Act regulations at 40 CFR Part 266 (Subpart P) at https://www.ecfr.gov/current/title-40/chapter-I/subchapter-I/part-266/subpart-P, accessed 8/6/2026, the regulation indicated: Long-term care facility means a licensed entity that provides assistance with activities of daily living, including managing and administering pharmaceuticals to one or more individuals at the facility. This definition includes, but is not limited to, hospice facilities, nursing facilities, skilled nursing facilities, and the nursing and skilled nursing care portions of continuing care retirement communities. Non-creditable hazardous waste pharmaceutical means a prescription hazardous waste pharmaceutical that does not have a reasonable expectation to be eligible for manufacturer credit . This includes but is not limited to,., residues of pharmaceuticals remaining in empty containers . During a review of document titled Recovery Act regulations at 40 CFR Part 261 (Subpart C), https://www.ecfr.gov/current/title-40/chapter-I/subchapter-I/part-261/subpart-C, accessed 8/6/2026, the regulation indicated: Characteristic of ignitability: a.3 include an ignitable compressed gas. b. A solid waste that exhibits the characteristic of ignitability has the EPA Hazardous Waste Number of D001.

Based on observation, interviews, and record review, the facility failed to ensure residents with oxygen therapy (a treatment that provides extra oxygen to breathe in) received care in accordance with professional standard of care for two of five sampled residents (Resident 63 and 112) reviewed for respiratory care by failing to ensure: 1. Oxygen was administered to Resident 63 when the resident had the nasal cannula in use. 2. Resident 112's nebulizer tubing (a flexible plastic hose that connects the machine's air pump to the medicine cup) dated 7/12/2026 attached to the bilevel positive airway pressure (BiPAP, a portable medical device that helps you breathe more easily), was discarded and replaced with a new setup. 3. Resident 112's unlabeled nebulizer mask (a soft plastic cup that fits over your nose and mouth) and tubing placed inside a transparent bag on the top of the resident's bedside drawer were discarded and replaced with a new set up with the date it was provided to the resident. These failures had the potential for residents to develop respiratory infections. Findings: a. During a review of Resident 63's Face Sheet, dated 7/31/2026, the Face Sheet indicated that the facility originally admitted the resident on 4/19/2024 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (altered brain function caused by a body-wide chemical imbalance), urinary tract infection (infection in the bladder), and muscle weakness. During a review of Resident 63's History and Physical (H&P), dated 5/25/2026, the H&P indicated that the resident had the capacity to understand and make decisions. During a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool), the MDS indicated that the resident had moderate cognitive impairment (a person has moderate problems with thinking and memory). The MDS indicated that the resident required partial/moderate assistance (helper does less than half the effort) with toileting hygiene and showers, and supervision or touching assistance with eating and other activities of daily living. During a review of Resident 63's physician order, dated 5/24/2026, the physician order indicated an order for oxygen at two (2) liters (L-a unit of measurement) via nasal canula to keep oxygen (O2) saturation above 92% due to shortness of breath (SOB). May titrate up to five L every shift. During a review of Resident 63's Care Plan (CP) titled, Resident 63 is on Oxygen Therapy initiated on 5/27/2026, the CP interventions were including to check oxygen tubing and humidifier as ordered, check O2 saturations every shift, and monitor for signs and symptoms of respiratory distress and report to MD as needed. During a concurrent observation and interview on 7/27/2026 at 10:39 a.m. with Registered Nurse (RN) 6 inside Resident 63's room, observed Resident 63 sitting upright in bed with nasal canula in use with oxygen therapy off. Observed RN 6 turned on the oxygen machine. RN 6 stated that the oxygen machine was off and further stated that he (RN 6) just gave breathing treatment to the resident but was unable to explain why the oxygen machine was off. RN 6 stated that Resident 63 has an order for oxygen at 2 L nasal canula. RN 6 stated that it is her (RN 6) duty to ensure oxygen is administered according to the physician's orders. RN 6 stated that failure to deliver oxygen may result in respiratory distress caused by shortness of breath. During a concurrent interview and record review on 7/30/2026 at 12:13 p.m. with Minimum Data Set Assistant 1 (MDSA) 1, the MDSA 1 stated that Resident 63 has an order for oxygen 2L via nasal canula. The MDSA1 stated that RN is responsible for initiating oxygen therapy and ensuring the administration of oxygen as ordered. The MDSA 1 stated RN 6 should have verified the oxygen delivery following a treatment prior to leaving the resident's room. The MDSA 1 stated failure to administer oxygen to a resident may lead to respiratory distress. During an interview on 7/31/2026 at 12:23 p.m. with the Director of Nursing (DON), the DON stated that Registered Nurses are responsible for administering oxygen. The DON stated that oxygen should be checked to ensure that it is on, as needed according to physician order, or anytime during resident care. The DON stated that the policy and procedures on oxygen therapy was not adhered to when Resident 63's oxygen machine was not continuously operating as ordered. The DON stated that failure to follow orders for oxygen therapy may potentially result in respiratory distress for the resident. During a review of the facility's policy and procedures (P&P), titled Oxygen Therapy, last reviewed on 4/22/2026, the P&P indicated that Administration of Oxygen (A) Administer oxygen and obtain oxygen saturation levels as ordered by the provider. (B) Oxygen titration orders will have parameters specified by the provider (Example: oxygen at 2-4L/min to maintain an oxygen saturation equal to or above 92%) (C) if the oxygen saturation falls below the level identified by the provider, the provider will be notified immediately. b. During a review of Resident 112's Face Sheet, the Face Sheet indicated the facility admitted the resident on 6/27/2026, with diagnoses including acute and chronic respiratory failure (a long-standing, ongoing breathing problem has suddenly gotten much worse) with hypoxia (a medical condition where your body's tissues and organs do not get enough oxygen to work properly), chronic sinusitis (a long-term swelling and inflammation of the air-filled spaces inside your face (sinuses) that lasts for 12 weeks or longer), and emphysema (a long-term lung disease where the tiny air sacs in your lungs are harmed and break open). During a review of Resident 112's H&P, dated 6/29/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 112's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a person's mental abilities—such as thinking, remembering, learning, and reasoning—are working normally without any major [NAME] or damage). The MDS indicated the resident was on oxygen therapy (a medical treatment that gives you extra oxygen when your body cannot get enough on its own through normal breathing) and was on a non-invasive mechanical ventilator (a way to help people breathe using a tight-fitting mask over the nose or mouth instead of putting a breathing tube down the throat). During a review of Resident 112's Order Summary Report (OSR), the OSR indicated an order for: -6/30/2026 BiPAP: 11 centimeters (cm, a small metric unit of length) water (H2O) inhalation and 18 cm H2O for exhalation due to obstructive sleep apnea (a common sleep disorder where throat muscles relax and block the airway). Mask type: Full face mask frequency: on at 9 p.m. and off at 6 a.m. at bedtime for BiPAP use every shift: monitor lung sounds (NC- Normal Clear, W- Wheezing, R- Rhonchi, C- Crackles), side effects (SE) (0-None. NV- Nausea/Vomiting, AD- Abdominal Distension, SI- Skin Impairment under mask/security band), Comfort Y/N, Compliance Y/N, Complications Y/N and vitals. -6/27/2026 Change nebulizer mask/tubing every night shift every Sunday. During a review of Resident 112's Care Plan (CP) Report regarding the resident being at risk for respiratory complications related to chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), acute on chronic hypoxic respiratory failure., last revised on 7/18/2026, the CP indicated an intervention to change nebulizer mask and tubing as ordered. During a concurrent observation and interview on 7/27/2026, at 10:48 a.m., with Registered Nurse (RN) 3, inside Resident 112's room, observed Resident 112 with a BiPAP machine on top of the resident's bed side drawer with a nebulizer tubing attached to it dated 7/12/2026 and a nebulizer mask and tubing placed inside a clear plastic bag without the date it was provided. RN 3 stated the nebulizer tubing attached to the BiPAP should have been discarded and replaced with a new one and the nebulizer mask and tubing inside the clear plastic bag should have been discarded and replaced with a new one to prevent respiratory infections to Resident 112. During a concurrent interview and record review on 7/30/2026, at 11:54 a.m., with Minimum Data Set Assistant (MDSA) 1, Resident 112's Medical Diagnoses, OSR, CP, and policy and procedure (P&P) were reviewed. The MDSA 1 stated the nebulizer mask tubing attached to the BiPAP had an order to change every Sunday, the tubing should have been changed on 7/19/2026 and 7/26/2026. The MDSA 1 stated the failure of the staff to change the setup had the potential for respiratory infection on residents. The MDSA 1 stated with the nebulizer mask and tubing inside a clear plastic bag without a date, it should have been discarded and they should have provided a new setup because they do not know when it was provided to prevent respiratory infection on the resident. The MDSA 1 stated the P&P titled, Oxygen Therapy and Nebulizer (small volume) were not followed. The MDSA 1 stated that the CP regarding the resident being at risk for respiratory complications related to COPD, acute on chronic hypoxic respiratory failure., was also not followed. During a concurrent interview and record review on 7/31/2026, at 10:54 a.m., with the DON, reviewed the facility's P&P regarding oxygen therapy. The DON stated the staff should have discarded the nebulizer tubing attached to the BiPAP dated 7/12/2026 and replaced with a new one and the nebulizer mask and tubing placed in a clear plastic bag undated on top of the resident's drawer should also have been discarded and replaced with a new setup to prevent respiratory infection to Resident 112. The DON stated the policies titled, Oxygen Therapy and Nebulizer (small volume) were no followed. During a review of the facility's recent P&P titled, Oxygen Therapy, last reviewed on 4/22/2026, the P&P indicated on II. Oxygen- Maintenance, and Safety A. Oxygen equipment shall be maintained as follows: The tubing and mask should be changed at least every 7 days and labeled with the date of change. During a review of the facility's recent P&P titled, Noninvasive Ventilation (CPAP/BiPAP), last reviewed on 4/22/2026, the P&P indicated 5. CPAP/BiPAP cleaning and maintenance requirements c. Replace the CPAP/BiPAP unit tubing weekly and as needed for soiling. During a review of the facility's recent P&P titled, Nebulizer (small volume), last reviewed on 4/22/2026, the P&P indicated safely and effectively use aerosol devices to deliver drugs rapidly and directly into the resident's airways. Procedure XV. Place the nebulizer back into the Resident's set-up bag and leave the equipment at the bedside for further treatments. the small volume nebulizer set up and filter will be changed every seven days and as needed.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received services and assistance for two of two sampled residents (Resident 2 and 29) reviewed for urinary catheter (a thin, flexible, hollow tube inserted into the bladder to drain urine (pee) when a person cannot urinate normally) or urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) by failing to ensure Resident 2 and 29's urinary catheter was secured with leg strap (an adjustable fabric band used to secure a urinary catheter and its collection bag directly to the thigh or calf) or stat lock (a specialized, adhesive device used in hospitals to securely hold a catheter tube in place on a patient's skin) and did not have loops on the catheter tubing. These failures had the potential for the urine not to flow freely, and which may lead to the development of UTI. Findings: a. During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted the resident on 3/4/2024 and readmitted in the facility on 7/3/2026 with diagnoses including adult failure to thrive (ongoing decline in health and daily function), dementia (a progressive state of decline in mental abilities), and aphasia (a disorder that makes it difficult to speak), and obstructive (a physical or functional blockage preventing normal urine flow) and reflux uropathy (a condition that involves urine flowing backward from the bladder toward the kidneys). During a review of Resident 2's History and Physical (H&P) dated 7/22/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 7/8/2026, the MDS indicated Resident 2 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) but was able to understand and make her needs known. The MDS further indicated Resident 2 required partial or moderate assistance with eating, substantial or maximal assistance with oral and personal hygiene, and upper body dressing, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive) and had an indwelling catheter in place. During a review of Resident 2's Order Summary Report dated 7/31/2026, the Order Summary Report indicated the following physician's order dated 7/3/2026: - Foley catheter (FC – also known as urinary catheter) care to be provided every shift. - Indwelling catheter size French (Fr – a unit of measurement) 16 per ten (10) milliliters (ml – a unit of measurement) with balloon via gravity drainage for urinary retention every shift. - Assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor and amount of urine output every shift. - Irrigate with 100ml of normal saline (NS - a saltwater solution) if clogged as needed for clogging, obstruction. During a review of Resident 2's care plan (CP) for presence of FC initiated on 5/24/2026 and last revised on 7/27/2026, the CP indicated to maintain catheter tubing free from kinks and secure catheter tubing to thigh as a few of the interventions for Resident 2 to remain free from signs and symptoms of UTI and maintain proper catheter function. During an observation on 7/27/2026 at 10:25 a.m., inside Resident 2's room, observed Resident 2 lying in bed asleep. Observed Resident 2's FC bedside drainage bag hanging on the right side of the bed frame and the FC tubing had a dependent loop with residual urine in the loop. During a concurrent observation and interview on 7/27/2026 at 10:46 a.m., inside Resident 2's room with Registered Nurse (RN) 4, RN 4 stated that Resident 2's FC tubing had a loop with residual urine remaining on the loop and that the catheter tubing did not have a securement device in place on the resident`s right thigh. RN 4 stated that the staff are supposed to ensure the FC tubing had a securement device in place, the drainage bag is below the bladder, and the tubing free from kinks to prevent accidental pulling of the catheter and prevent urine to flow back into the bladder. RN 4 stated that Resident 2's FC tubing should have been repositioned to prevent kinks or loops and that the catheter tubing should have been secured with a securement device. RN 4 stated that if the FC tubing had a loop and did not have a securement device, it placed Resident 2 at risk for UTI due to accidental pulling and urine flowing back into the bladder. During a concurrent interview and record review on 7/30/2026 at 9:48 a.m., Resident 2's physician's orders and CP were reviewed with MDS Assistant (MDSA) 1. The MDSA 1 stated that Resident 2 had a physician's order for FC care every shift and that the CP indicated to maintain catheter tubing free from kinks and secure catheter tubing to thigh as a few of the interventions for Resident 2 to remain free from signs and symptoms of UTI and maintain proper catheter function. The MDSA 1 part of the FC care every shift is that drainage bags should be below the bladder, tubing should be free from kinks or loop and should have a securement device in place at all times to keep residents free from signs and symptoms of UTI. The MDSA 1 stated that Resident 2's FC should have been secured with a securement device to prevent accidental pulling causing trauma and lead to development UTI. The MDSA 1 stated that Resident 2's FC tubing should have no loop or kink to prevent back flow of the urine which can lead to development of UTI. During an interview on 7/31/2026 at 10:56 a.m. with the Director of Nursing (DON), the DON stated that the staff or licensed nurses (LNs) are supposed to secure the catheter tubing to the thigh with a securement device to prevent accidental pulling which can cause UTI, the drainage bag should be below the bladder and that the tubing should not have a loop to prevent the urine from flowing back into the bladder which can lead to development of UTI. The DON stated that Resident 2's FC should have been secured to the thigh with a securement device and there should have been no loop on the tubing as it placed Resident 2 at risk for development of signs and symptoms of UTI. During a review of the facility's policy and procedure (P&P) titled, Catheter – Care of, last reviewed on 4/22/2026, the P&P indicated a purpose to prevent catheter-associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary. The P&P further indicated that the catheter will be anchored to prevent excessive tension on the catheter. During a review of the facility's P&P titled, Indwelling Catheter – Insertion, Maintenance and Discontinuation of, last reviewed on 4/22/2026, the P&P indicated to secure the catheter to the patient's thigh using a securement device or tape and to keep the catheter and drainage tube free from kinking and dependent loops. b. During a review of Resident 29's Face Sheet, the Face Sheet indicated the facility admitted the resident on 7/2/2023, and readmitted the resident on 6/27/2026, with diagnoses including acute pyelonephritis (a sudden, severe bacterial infection of one or both kidneys), UTI, and extended spectrum beta lactamase (ESBL) resistance (enzymes that confer resistance to most beta-lactam antibiotics). During a review of Resident 29's H&P, dated 7/22/2026, the H&P indicated the resident was not awake and alert (a person is completely unresponsive or completely unaware of their basic personal details, surroundings, time, and situation) and aphasic (a disorder that makes it difficult to speak). The H&P indicated the resident did not have the capacity to make decisions at this time. During a review of Resident 29's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition (a major loss of basic mental abilities) and had an indwelling catheter (a flexible tube left inside the bladder to drain urine continuously). During a review of Resident 29's Order Summary Report (OSR), dated 6/27/2026, the OSR indicated an order for: -Indwelling catheter size 16 French (FR, stands for the outer diameter or thickness of the tube) with balloon 10 milliliters (ml, a unit of volume) via gravity drainage for pyelonephritis every day shift. -Foley catheter care (stands for the outer diameter or thickness of the tube) to be provided every shift. During a review of Resident 29's Care Plan (CP) Report regarding the resident being at risk for UTI, recurring UTI, and impaired urinary elimination., last revised on 7/18/2026, the CP indicated a goal of the resident will show no signs/symptoms of infection. During a concurrent observation and interview on 7/27/2026, at 10:10 a.m., with Certified Nursing Assistant (CNA) 8, inside Resident 29's room, observed Resident 29's urinary catheter tubing had a dependent loop with urine on them and there was no securement device to hold the urinary catheter in place. CNA 8 stated the resident was taking the securement device off. During an interview and record review on 7/30/2026, at 10:39 a.m., with Minimum Data Set Assistant (MDSA) 1, Resident 29's Medical Diagnoses, OSR, CP, and the facility P&P regarding urinary catheters were reviewed. The MDSA 1 stated there was an order for urinary catheter insertion and foley catheter care every shift. The The MDSA 1 stated when they are doing foley catheter care the staff is checking for kinks, if it is draining well, if it is below the bladder, they check for drainage if it has sediments, check the bag if it needs changing or leaking, also checking the securement device is in place. The MDSA 1 stated it was not okay to have loops and no securement device on the urinary catheter to ensure proper drainage and the purpose of the securement device was to prevent dislodgement. The MDSA 1 stated if the catheter gets dislodged it can cause trauma to the insertion site; it can cause meatal tear [is a small split, scratch, or sore at the opening where urine leaves the body (the pee hole)] and bleed. The MDSA 1 stated due to opening on the skin caused by the trauma it now has a portal of entry for infection causing UTI. The MDSA 1 stated the CNAs and licensed nurses are responsible for ensuring the resident does not have loops on catheter and had securement device. The MDSA 1 stated the P&Ps Indwelling Catheter- Insertion, Maintenance and Discontinuation of Clinical Staff and Catheter- Care of were not followed. During an interview and record review on 7/31/2026, at 10:54 a.m., with the DON, reviewed the facility's policy regarding urinary catheters. The DON stated the licensed staff should have checked for kinks in the resident's urinary catheter tubing and checked for placement of a securement device every time they provided care for Resident 29. The DON stated they use stat lock, leg bag, and leg strap in the facility to prevent accidental dislodgment of the urinary catheter in the facility that can cause trauma and bleeding of the meatus causing UTI to residents. The DON also stated the nursing staff should check for urinary catheter tubing kinks frequently as the residents changes position frequently. The DON was made aware that after the observation was brought to the staff's attention a care plan for resident removing the stat lock was made. The DON stated the facility did not follow the P&Ps titled Indwelling Catheter- Insertion, Maintenance and Discontinuation of Clinical Staff and Catheter- Care of. During a review of the facility's recent P&P titled, Indwelling Catheter- Insertion, Maintenance and Discontinuation of Clinical Staff, last reviewed on 4/22/2026, the P&P indicated on I. Insertion of an Indwelling Catheter: q. Secure the catheter to the patient's thigh using a securement device or tape. r. Keep the catheter and drainage tube free from kinking and dependent loops. During a review of the facility's recent P&P titled, Catheter- Care of, last reviewed on 4/22/2026, the P&P indicated to prevent catheter-associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary. Procedure VI. Specimen Collection F. The catheter will be anchored to prevent excessive tension on the catheter.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity for one of two sampled residents (Resident 23) reviewed for dignity care area and one of 10 sampled residents (Resident 70) observed during dining observation when: 1. Certified Nursing Assistant (CNA) 3 failed to provide privacy while assisting Resident 23 to the shower chair. This failure had the potential to affect Resident 23's self-esteem, and self-worth. 2. Resident 70 was not offered or provided spoon and fork while eating her breakfast in bed. This failure had the potential for Resident 70 to feel frustrated, annoyed, low self-esteem, and seek alternatives to eat by using their hands. Findings: a. During a review of Resident 23's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted Resident 23 on 3/11/2026 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and generalized muscle weakness. During a review of Resident 23's History and Physical (H&P) dated 3/12/2026, the H&P indicated that Resident 23 had the capacity to understand and make decisions. During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 6/26/2026, the MDS indicated Resident 23 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make his needs known. The MDS further indicated Resident 23 was independent with bed mobility; required set up or clean up assistance with eating, oral hygiene, personal hygiene, upper body dressing, and shower transfers; partial or moderate assistance with toileting, bathing self, and lower body dressing; supervision or touching assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 7/27/2026 at 10:13 a.m. inside Resident 23's room, observed CNA 3 removed Resident 23's clothes exposing the whole body, instructed the resident to stand up, and assisted to the shower chair, and the privacy curtain was more than hallway open. During an interview on 7/27/2026 at 10:55 a.m., CNA 3 stated that when they are providing care to residents, privacy should be maintained by fully closing the curtain. CNA 3 stated that she (CNA 3) did not close the curtain while assisting Resident 23 in removing the clothes and assisted to the shower chair. CNA 3 stated that she (CNA 3) should have fully closed the curtain while assisting Resident 23 to get ready for shower. CNA 3 stated that it was a dignity and privacy issue and Resident 23 could feel embarrassed if other people observed him without any clothes while receiving assistance. During an interview on 7/30/2026 at 10:16 a.m. with the Director of Staff Development (DSD), the DSD stated that when providing care to the residents such as getting ready for shower, providing morning care or incontinence care, the staff are supposed to provide privacy by fully closing the privacy curtain. The DSD stated that CNA 3 should have provided privacy to Resident 23 while assisting to the shower chair by fully closing the privacy curtain. The DSD stated that if the privacy curtain was not fully closed while CNA 3 was assisting Resident 23 getting ready for shower, the resident would feel embarrassed and can affect his self-esteem. During an interview on 7/31/2026 at 11:15 a.m. with the Director of Nursing (DON), the DON stated that when providing ADL care to the residents including providing morning care, incontinence care and assisting to shower chair, the staff supposed to provide privacy by fully closing the curtain. The DON stated that CNA 3 should have fully closed Resident 23's privacy curtain prior to removing the resident's clothes and assisted the shower chair. The DON stated that it was a privacy and dignity issue, Resident 23 can feel embarrassed and can affect his self-esteem. During a review of the facility's policy and procedure (P&P) titled, Resident Rights – Quality of Care, last reviewed on 4/22/2026, the P&P indicated that each resident shall be cared for in a manner that promotes and enhances that quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being. The P&P further indicated that the facility promotes, maintains, and protects resident privacy, including bodily privacy, when assisting with personal care and during treatment procedures. b. During a review of Resident 70's Face Sheet, the Face Sheet indicated the facility admitted the resident on 4/29/2026, with diagnoses including dementia (a progressive state of decline in mental abilities), and muscle weakness. During a review of Resident 70's H&P, dated 4/30/2026, the H&P indicated the resident did not have the capacity to make complex healthcare decisions; however, able to decide for ADLs, and make needs known. During a review of Resident 70's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident had upper extremity impairment and was needing set up assistance during eating. During a review of Resident 70's Care Plan (CP) Report regarding the resident being at risk for malnutrition (the body gets an improper balance, too little, or too much of the energy and nutrients needed to stay healthy) or potential nutritional problems, last revised on 5/26/2026, the CP indicated interventions to ensure resident is in proper positioning for eating, evaluate for signs of impaired swallowing, and monitor resident's ability to feed self. During an observation and interview on 7/27/2026, at 10:03 a.m., with CNA 2, inside Resident 70's room, observed Resident 70 eating cornflakes soaked in tea in a coffee cup using her hands. Resident 70 stated she (Resident 70) was eating with her hands because she (Resident 70) was hungry already and felt frustrated because they did not provide her with utensils to eat her breakfast. CNA 2 stated they should have provided the resident with a spoon and fork for eating. During a concurrent interview and record review on 7/30/2026, at 11:36 a.m., with the Minimum Data Set Assistant (MDSA) 1, Resident 70's Medical Diagnoses, OSR, CP, and P&P were reviewed. The MDSA 1 stated they should have provided Resident 70 spoon and fork to eat. The MDSA 1 stated their failure to offer spoon and fork to eat for the resident can make the resident feel less dignified and not valued by the staff. The MDSA 1 stated the CP and the P&P titled, Resident Rights- Quality of Life and Feeding Assistance were not followed. During an interview and record review on 7/31/2026, at 10:54 a.m., with the DON, the facility's P&P was reviewed. The DON stated that staff should have provided utensils to the residents to eat. The DON stated Resident 70 should have been offered the utensils and assisted during feeding. The DON stated the failure of the staff to provide utensils to the resident while eating had violated the resident's right to dignified existence. During a review of the facility's recent P&P titled, Resident Rights- Quality of Life, last reviewed on 4/22/2026, the P&P indicated that each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being. Procedure IV. Residents are offered meals and snacks in accordance with their individual and/or cultural preferences. During a review of the facility's recent P&P titled, Feeding Assistance, last review on 4/22/2026, the P&P indicated the facility ensures that each resident receives assistance with eating based on resident's need.

Based on interview, and record review, the facility failed to ensure residents were free from unnecessary (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use of psychotherapeutic drugs (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures (P&P) by failing to monitor episodes/occurrences of anxiety with the use of Rexulti (an antipsychotic [type of a psychotropic medication used to treat mental illness] medication) for one (1) of five (5) residents (Resident 15) investigated for unnecessary medications, between 6/13/2026 and 7/29/2026. This failure had the potential to place Resident 15 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotherapeutic drugs, which could result in impairment or decline in the residents' mental, physical condition, mental, functional, and psychosocial status. Findings: During a review of Resident 15's Face Sheet (a document containing demographic and diagnostic information,) dated 7/30/2026, the Face Sheet indicated Resident 15 was originally admitted to the facility on [DATE] with diagnoses including dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and Alzheimer's disease (a common brain disorder that slowly destroys memory, thinking skills, and the ability to do simple daily tasks.) During a review of Resident 15's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 6/26/2026, the MDS indicated Resident 15 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. MDS indicated Resident 15 had Alzheimer's disease and received antipsychotics on a routine basis. During a review of Resident 15's Medication Administration Record ([MAR] - a record of mediations administered to residents) for June and July 2026, the MARs indicated Resident 15 was prescribed and administered Rexulti 1 milligram ([mg] - a unit of measure of mass) one (1) tablet by mouth once a day at 9 a.m. for Alzheimer's with agitation, starting 6/13/2029. The MARs contained no documentation for monitoring the occurrence/episodes of anxiety with the use of Rexulti. During a concurrent record review and interview on 7/30/2026 at 11 a.m., with the Director of Nursing (DON) in the presence of the Assistant DON (ADON,) the DON reviewed Resident 15's MDS dated [DATE] and June 2026 and July 2026 MARs. The DON acknowledged Resident 15 was prescribed Rexulti for Alzheimer's with agitation and that Rexulti was an antipsychotic medication. The DON also stated that licensed nurses must monitor and document occurrences/episodes of anxiety on the MAR. The DON acknowledged the June and July 2026 MARs did not have occurrences/episodes of anxiety monitored or documented. The DON stated without monitoring specific occurrences of anxiety it was unknown if Rexulti was effective in anxiety in treating the anxiety and potentially resulting in the physician making inaccurate assessments of the medication's effectiveness, preventing dose reductions, discontinuation or even making unnecessary dose increases for Resident 15. The DON stated, as a result Rexulti maybe used unnecessarily causing more harm with side effects (such as tremors, dizziness, sedation) than benefit. The DON stated the facility failed to monitor episodes/occurrences of anxiety with the use of Rexulti placing Resident 15 at risk of continuing unnecessary psychotropic medication potentially resulting in adverse consequences and negatively impacting the physical and psychosocial well-being of Resident 15. Review of the facility's Policies and Procedures (P&P,) titled Unnecessary Medications, last reviewed 4/22/2026, the P&P indicated: Each resident must receive and the Facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. ( I ) Unnecessary Drug a. General - Each resident's medication regimen must be free from unnecessary drugs. b. An unnecessary drug is any drug used: iii. Without adequate monitoring.

Based on observation, interview, and record review, the facility failed to ensure a resident was treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for two of three sampled residents (Residents 30 and 77) reviewed for physical restraints by failing to: 1. Ensure that Resident 30's bed placed against the wall had a current physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), restraint assessment, and a care plan (a document outlining a detailed approach to care customized to an individual resident's need). 2. Ensure Resident 108's bed placed against the wall had an informed consent. These failures had the potential to result in restriction of resident's freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from the resident limbs getting entrapped from bed spaces leading to fractures (a broken bone). Findings: a. During a review of Resident 30's Face Sheet (admission Record), the Face Sheet indicated the facility admitted the resident on 5/29/2026 with diagnoses including urinary tract infection (UTI – an infection in the bladder/urinary tract), depression (a serious mental health condition which causes ongoing sadness, low energy, and loss of interest in life), and glaucoma (an eye disease that damages the optic nerve, often caused by a buildup of fluid pressure inside the eye, which can lead to vision loss). During a review of Resident 30's History and Physical (H&P), dated 6/1/2026, the H&P indicated that the resident did not have memory loss and has the capacity to make medical decisions. During a review of Resident 30's Minimum Data Set (MDS – a resident assessment tool), dated 6/5/2026, the MDS indicated that the resident had a moderate cognitive impairment (individual likely struggles significantly with recall or may experience confusion with complex daily tasks while still able to manage basic routines which requires supervision and daily oversight). The MDS indicated the resident needed partial/moderate assistance (helper does less than half the effort) with eating and personal hygiene, substantial/maximal assistance (helper does more than half the effort) with oral hygiene, toileting and shower or bath, and dependent (helper does all of the effort) with sit to stand and chair/bed-to-chair transfers. During an initial concurrent observation and interview on 7/29/2026 at 9:50 a.m. with Certified Nursing Assistant (CNA) 4, inside Resident 4's room, observed Resident 4's bed against the wall. CNA 4 stated that when Resident 30 was admitted in May, the bed was already placed against the wall. During a concurrent observation, interview, and record review on 7/29/2026 at 9:59 a.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 30 does not have an order, an assessment, consent, and care plan for placing the bed against the wall. The ADON stated that prior to positioning a resident's bed against the wall, an assessment should be completed, an order must be obtained from the medical doctor (MD), consent should be secured from the resident or their family representative, and care plan must be developed for appropriate interventions. During an observation inside Resident 30's room with the ADON, the ADON stated that resident prefers transfers to his right side. The ADON stated although there is a small gap between the bed and the wall, there was insufficient space for the resident to facilitate transfers from the left side of the bed. During an interview on 7/29/2029 at 2:38 p.m. with the ADON, the ADON stated placing the bed against the wall was limiting Resident 30's movement despite the resident's preference to his right side. The ADON further stated that bed placed against the wall may increase the risk of entrapment (when a person gets a body part—like their head, neck, or chest—stuck or wedged in the gaps around a bed), potentially leading into injury. During an interview on 7/31/2026 at 11:18 a.m. with the Director of Nursing (DON), the DON stated that prior to placement of any resident's bed against the wall, there should be an MD order, assessment, consent, and care plan. The DON stated the policy and procedure (P&P) regarding restraints was not followed when Resident 30's bed was placed against the wall without assessing the resident, obtaining order from the MD, obtaining a signed consent from the resident or family representative, and creating a care plan. The DON stated that limiting the resident's movement is a form of restraint which could potentially cause injury to the resident. b. During a review of Resident 108's Face Sheet, the Face Sheet indicated the facility admitted the resident on 2/4/2025 with diagnoses solitary pulmonary nodule (a small round spot in one lung); chronic obstructive pulmonary disease, unspecified (COPD - a chronic lung disease causing difficulty in breathing); emphysema, unspecified (a condition where the lungs are damaged and don't work well making it hard to breathe). During a review of Resident 108's H&P, dated 3/11/2026, the H&P indicated resident has the capacity to understand and make decisions. During a review of Resident 108's MDS, dated [DATE], the MDS indicated Resident 108 was able to make herself self understood and had the ability to understand others and had intact cognitive function (normal thinking). The MDS indicated the resident was independent with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of Resident 108's Order Summary Report, dated 4/23/2025, the order summary report indicated an order for may have bed positioned against the wall per resident's preferences. During an observation on 7/27/2026 at 10:40 a.m., observed Resident 108's bed was placed against the wall on the left side of the bed. During a concurrent observation and interview on 7/27/2026 at 1:35 p.m. with CNA 10, inside Resident 108's room, CNA 10 observed and confirmed Resident 108's bed was placed against the wall on the left side of the resident's bed. During a concurrent observation, interview, and record review for Resident 108 on 7/29/2026 at 2 p.m. with Registered Nurse (RN) 2, observed Resident 108's bed was placed against the wall on the left side of the resident's bed. RN 2 stated there needs to be a physician's order, consent, and care plan to place Resident 108's bed against the wall. RN 2 was unable to find a consent for placing Resident 108's bed against the wall. RN 2 stated having bed against the wall can be considered entrapment and staff needs to make sure there are no gaps in between the wall and bed. During a concurrent observation and record review on 7/29/2026 at 2:32 p.m. with the Medical Records Assistant (MRA), Resident 108's electronic and paper records were reviewed. The MRA was unable to find a consent for placing Resident 108's bed against the wall. The MRA stated consent is important because the resident needs to know what is being done and the resident has the right to know. During an interview on 7/30/2026 at 3:40 p.m. with DON, the DON stated that having the bed against the wall is considered a restraint because it limits resident's movement. The DON stated there needs to be an assessment, physician order, and consent. The DON stated it is important to have consent because it is the resident's right and approval. The DON stated the P&P titled Restraints, last reviewed 4/22/2026, was not followed. During a review of facility's P&P titled, Restraints, last reviewed on 4/22/2026, the P&P indicated under POLICY (1) the Facility honors the resident's rights to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the Interdisciplinary Team [IDT - a coordinated group of healthcare professionals from different clinical and support disciplines who work together to plan, deliver, and evaluate resident care], and in accordance with the resident's assessment and Plan of Care, (2) if restraints are used for the least amount of time, and only under carefully monitored circumstances. Every attempt will be made to avoid a decline in the resident's physical functioning, (3) The Facility will document that the resident/resident representative has given informed consent to the procedure when initiating restraints.

Based on observation, interview, and record review, the facility failed to immediately notify the primary care physician of a significant change in condition for one of one sampled resident (Resident 7) reviewed under Urinary Catheters (indwelling catheter, a hallow tube inserted into the bladder to drain or collect urine) care area. The facility failed to ensure the medical doctor was made aware when Resident 7 was complaining of burning sensations. This failure had the potential for Resident 7 to develop catheter associated urinary tract infections (CAUTI, an infection of the urinary tract caused by an indwelling catheter). Findings: During a review of Resident 7's Face Sheet, the Face Sheet indicated the facility admitted the resident on 12/20/2024, with diagnoses including multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), anxiety disorder (body's alarm system reacting to a perceived threat or stressful event) , neuromuscular dysfunction of bladder (when the nerves and muscles cannot send and receive proper signals and lose control over when to urinate), and history of urinary tract infections (infection in the bladder) During a review of Resident's history and physical (H&P), dated 2/26/2026, the H&P indicated the resident had the capacity to make decisions for healthcare purposes and identify needs in management of activities of daily living, and able to make needs known. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool) dated 5/04/2026, the MDS indicated that the resident needs setup or clean up assistance with eating and oral hygiene, substantial/maximal assistance (helper does more than half the effort) with showers/bath and lower body dressing, and dependent (helper does all of the effort) with toileting hygiene. During a review of Resident 7's Care Plan (CP) initiated on 6/24/2025, the CP had a focus indicating that the resident has indwelling Foley Catheter related to neuromuscular dysfunction of bladder, with interventions including monitor/document for signs and symptoms of discomfort on urination and frequency, monitor/document pain/discomfort due to catheter. During an initial interview on 7/28/2026 at 9:08 a.m. with Resident 7 inside the resident's room during an initial interview, Resident 7 stated intermittent burning sensations originating from her urethra upon urination via foley catheter. Resident stated concerns based on her history of multiple UTIs and further stated that she had informed staff regarding her symptoms and did not receive any follow-up or communication from the doctor nor updates from the staff the entire night. During a review of Resident 7's Change of Condition (COC) report, dated 7/28/2026 at 11:30 a.m., signed by Registered Nurse 7 (RN 7), the COC indicated resident reported that she has been experiencing on and off burning sensation when passing urine in her foley catheter for a few days and thinks she has UTI. Offered pain medication but resident refused that there is no burning sensation at this time. (.). Informed MD for urine collection with no response at this time. Will continue to monitor (.) and endorse to next shift. During a subsequent interview on 7/29/2026 at 8:49 a.m. with Resident 7 inside the resident's room, Resident 7 stated that she was having constant burning sensations all night but was still having on and off sensations. Resident 7 stated that she did not receive any updates regarding her complaint. Resident 7 stated she requested for a medical doctor to hear her concerns. During an interview and record review on 7/29/2026 at 9:15 a.m. with Registered Nurse 7 (RN 7), RN 7 stated that upon learning of Resident 7's complaint of burning sensations, he immediately attempted to notify MD, but did not receive any response. RN 7 stated that he endorsed the change of condition to the nurse taking over the next shift. RN 7 stated that there was an attempt made to notify MD by the nurse whom he endorsed the care to, but there was no evidence in the documentation that another attempt was made to reach the MD during the night shift. RN 7 stated that Resident 7's concerns should not have been ignored. RN 7 stated that delay in care could potentially lead to infection, specifically UTI. During an interview and record review on 7/30/2026 at 12:08 p.m. with the Minimum Data Set Assistant 1 (MDSA 1), the MDSA 1 stated when the response from the MD is not received, the Director of Nursing (DON) should have been informed so that the DON can provide specific instructions to the nurse regarding the next step, including guidance on contacting the medical director. The MDSA 1 stated that any delay in providing care could result in adverse outcomes, such as the development of an infection. During an interview on 7/31/2026 at 11:00 a.m. with the Director of Nursing (DON), the DON stated the MD must be informed immediately whenever there is a change in a resident's condition. The DON stated that if multiple follow-up calls has not resulted in a successful response, the medical director must be involved because delay in care may increase the risk of infection. During a review of facility's policy and procedures (P&P), titled Catheter-Care of, last reviewed on 4/22/2026, the P&P indicated Purpose: to prevent catheter-associated urinary tract infections while ensuring that residents are not given in-dwelling catheters unless medically necessary. Nursing staff (II) A Licensed Nurse will notify the Attending Physician of any signs and symptoms of infection for clinical interventions. During a review of facility's P&P, titled Change of Condition Notification, last reviewed on 4/22/2026, the P&P indicated (II) Change in Condition related to Physician/APP notification is defined as when the Physician/APP must be notified when any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require medical assessment, coordination and consultation with the Physician/APP and a change in the treatment plan. Purpose: to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to: 1. Ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one (1) of two (2) sampled residents (Resident 2) reviewed under environment task. 2. Keep the call light within reach for Resident 116. These failures had the potential to result in a delay of care and services and possible injury for Residents 2 and 116 when the residents were unable to call for assistance. Findings: a. During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted the resident on 3/4/2024 and readmitted in the facility on 7/3/2026 with diagnoses including adult failure to thrive (ongoing decline in health and daily function), dementia (a progressive state of decline in mental abilities), and aphasia (a disorder that makes it difficult to speak), and generalized muscle weakness. During a review of Resident 2's History and Physical (H&P) dated 7/22/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 7/8/2026, the MDS indicated Resident 2 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) but was able to understand and make her needs known. The MDS further indicated Resident 2 required partial or moderate assistance with eating, substantial or maximal assistance with oral and personal hygiene, and upper body dressing, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 2's fall risk assessments dated 5/5/2026, 5/22/2026 and 7/3/2026, the fall risk assessments indicated that Resident 2 was at risk for falls. During a review of Resident 2's care plan (CP) for risk for falls initiated on 4/22/2026 and last revised on 7/23/2026, the CP indicated to ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed and anticipate and meet the resident's needs as a few of the interventions for the resident to be free of falls. During a concurrent observation on 7/27/2026 at 10:25 a.m. inside Resident 2's room, observed Resident 2 lying in bed in supine position asleep, with the call light coiled around and tucked in between the right side-rail and the mattress. During a concurrent observation and interview on 7/27/2026 at 10:46 a.m. inside Resident 2's room with Certified Nursing Assistant (CNA) 3, CNA 3 stated that Resident 2's call light was coiled around the right side-rail and tucked in between the mattress and side rail. CNA 3 stated that the staff are supposed to make sure the call light is within reach before leaving the room. CNA 3 stated that Resident 2 was able to make her needs known and that the call light should have been within the resident's reach so Resident 2 can call for assistance. CNA 3 stated that if the call light was not within reach, Resident 2 would be unable to call for assistance, and the staff would not be able to meet her needs. During a concurrent interview and record review on 7/30/2026 at 2:30 p.m., reviewed a photograph of Resident 2's call light with the Director of Staff Development (DSD), the DSD stated that Resident 2's call light was coiled around the right side-rail and tucked in between the mattress and right side-rail. The DSD stated that the staff are supposed to ensure that the call lights are within the resident's reach prior to leaving the room so the residents can call for assistance when needed. The DSD stated that CNA 3 should have ensured Resident 2's call light was within reach so the resident can call for assistance. The DSD stated if the call light was not within Resident 2's reach, it placed Resident 2 at risk for delay in getting the assistance needed and her needs timely. During an interview on 7/31/2026 at 11:15 a.m. with the Director of Nursing (DON), the DON stated staff are supposed to ensure that the call lights are placed within the residents' reach after providing care and prior to leaving the room. The DON stated that CNA 3 should have placed Resident 2's call light within reach so the resident can call for assistance. The DON stated that if the pad call light was not within reach, Resident 2 would not be able to ask for assistance and placed Resident 2 at risk for a delay in staff providing assistance and meeting the resident's needs. b. During a review of Resident 116's Face Sheet, the Face Sheet indicated the facility admitted the resident on 4/21/2022, with diagnoses essential (primary) hypertension (high blood pressure with no known specific cause); other lack of coordination (trouble with balance or movement); muscle weakness (Generalized) (weakness in many muscles throughout the body. During a review of Resident 116's H&P, dated 4/17/2026, the H&P indicated the resident had fluctuating capacity to make medical decisions. During a review of Resident 116's MDS, dated [DATE], the MDS indicated the resident usually makes self-understood and usually understands others. The MDS indicated that Resident 116 had moderate cognitive impairment. The MDS indicated that Resident 116 was dependent to staff on mobility and ADLs. During a review of Resident 116's Fall Risk Evaluation (FRE), dated 7/22/2026, the FRE indicated that the resident was at high risk for falls. During a review of Resident 116's Care Plan (CP) Report, titled The resident at risk for fall, the CP indicated a goal to provide safe environment that minimizes complications associated with falls. The CP intervention was to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an observation on 7/27/2026, at 9:10 a.m., with Restorative Nursing Assistant (RNA) 1, inside Resident's 116 room, observed the resident`s call light on the floor. RNA 1 picked up the call light from the floor and placed call light next to Resident 116. During an interview with RNA 1 on 7/27/2026, at 1:27 p.m., RNA 1 stated Resident 116 would not have been able to call for assistance. RNA 1 stated call light must be within reach of the residents in case of emergency or if they need anything. RNA 1 stated Resident 116 could have potentially fallen trying to reach for the call light. RNA 1 stated everyone is responsible for making sure call light is within reach for residents' safety. During an interview on 7/29/2026, at 2:30 p.m., with Registered Nurse (RN) 2, RN 2 reviewed the FRE and CP. RN 2 stated Resident 116 was at high risk for falls. RN 2 stated call light should be answered right away, and it is everyone's responsibility to answer call lights. RN 2 stated call light should be within reach of resident. RN 2 stated Resident 116 would not have been able to reach the call light and might of overreach trying to get the call light and could have potentially fallen. RN 2 stated care plan and policy titled, Communication-Call System were not followed. During an interview on 7/30/2026 at 3:40 p.m., with the DON, the DON stated the call light is for the resident to request assistance and if call light is not within reach, then resident would not be able to receive assistance when needed. The DON stated resident could have accidentally fallen off the bed. The DON stated policy titled, Communication-Call System was not followed. During a review of the facility's policy and procedure (P&P) titled, Communication –Call System, last reviewed on 4/22/2026, the P&P indicated that the call alert device will be placed within resident's reach, and the facility staff will answer call alerts promptly. The P&P further indicated that an adaptive call alert system will be provided to residents who are unable to utilize the general call alert system.

Based on interview and record review, the facility failed to protect one of five sampled residents (Resident 1) right to be free from sexual abuse (any sexual activity that occurs without consent [permission]), when on 11/23/2024 at approximately 8 p.m., Certified Nursing Assistant 1 (CNA 1) inserted his (CNA 1) fingers inside Resident 1's vagina (female genitalia [reproductive organ of a female involved in producing children]). CNA 1 then grabbed Resident 1's right hand and coerced (to persuade [cause] someone forcefully to do something that they are unwilling to do) Resident 1 to touch CNA 1's penis (male genitalia [reproductive organ of a male]). This deficient practice resulted in Resident 1 being subjected to a nonconsensual (when a resident does not agree or cannot agree to participate in an act) sexual assault (the act in which one intentionally sexually touches another resident without the resident's consent) by CNA 1 while under the care of the facility. On 11/23/2024 at 8 p.m., 11/24/2024 at 10:40 a.m., and 11/24/2024 at 10:55 a.m., Resident 1 was observed agitated (feeling or appearing troubled or bothered), fearful (feeling a strong, immediate reaction to a perceived present danger), anxious (experiencing worry, unease or nervousness), and crying. On 11/24/2024 at 4:38 p.m., Resident 1 was sent to the General Acute Care Hospital (GACH) for further evaluation due to the incident. On 11/27/2024 at 11:17 a.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.12 Freedom from Abuse, Neglect (failed to care for properly), and Exploitation (illegal or improper use of a person's resources) in the presence of the Administrator (ADM), Director of Nursing (DON), and the Regional Director due to the facility's failure to protect Resident 1's right to be free from sexual abuse on 11/23/2024 at around 8 p.m. On 11/28/2024 at 4:18 p.m., the ADM provided the SSA with an acceptable IJ Removal Plan (a detailed plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 11/28/2024 at 5:27 p.m., while onsite at the facility and after verifying and confirming the facility's implementations of the IJ removal plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM and DON. The acceptable IJ Removal Plan included the following summarized actions: 1. On 11/24/2024 at approximately 11:05 a.m., the RN Supervisor notified the local police department of the alleged incident. On 11/24/2024 at approximately 11:15 a.m., the ADM and Director of Staff Development 1 (DSD 1) called CNA 1 to suspend and remove him (CNA 1) from the work schedule. 2. On 11/24/2024 at 12:13 p.m., the Manager on Duty (MOD) reported the alleged violation to the Ombudsman (an advocate for residents of nursing homes) and SSA. 3. On 11/24/2024 at approximately 1:30 p.m., the DON contacted the Psychiatrist (a medical doctor who specializes in diagnosing, treating, and preventing mental health disorders) to arrange a consultation for Resident 1. On 11/24/2024 at 3:42 p.m., the Nurse Practitioner (a nurse who has advanced clinical education and training) working under the Psychiatrist conducted a psychiatric evaluation (a clinical assessment of a person's mental health that can help diagnose and treat emotional, behavioral, or developmental disorders) for Resident 1 via (through) telehealth (using technology like computers or phones to receive healthcare from a distance, allowing you to consult with a doctor or other healthcare provider without physically going to their office, often through video calls or online messaging) at bedside. 4. On 11/24/2024 at 11:30 a.m., the attending physician was notified and gave an order for Resident 1 to be transferred to the GACH for further evaluation. 5. On 11/24/2024 at 3:43 p.m., the Social Worker provided psychosocial support (type of care that helps people meet their mental, emotional, social, and spiritual needs) to Resident 1 by allowing the resident to vent feelings and concerns. The Social Worker encouraged Resident 1 to express feelings as it pertains to mood, behaviors, trauma (when we experience very stressful, frightening, or distressing events) related to the allegation of sexual abuse. 6. On 11/25/2024, the DON, two DSDs (DSD 1 and DSD 2) and Infection Control Nurse immediately conducted an observation on all Certified Nursing Assistants (CNAs) on duty while providing Activities of Daily Living (ADL - basic tasks related to personal care that must be accomplished every day for an individual to stay alive and healthy) care if they (CNAs) are following proper procedures with emphasis on observing resident's rights, dignity, and abuse prohibition. This observation will be completed by 11/27/2024 for all actively employed CNAs and will continue monitoring by conducting observations of 10 CNAs daily for two (2) weeks, weekly for four (4) weeks, then bi-monthly (occurring twice a month) for two months on different shifts. 7. On 11/24/2024, the ADM and Social Services Director (SSD) reviewed grievance reports within the last year to identify any potential concerns that may lead to alleged violations. No other grievances were identified that may be related to this alleged violation. 8. On 11/24/2024, the ADM/designee initiated an interview of actively employed staff members to identify any potential knowledge of residents having been sexually assaulted. None of the staff witnessed or heard any similar allegations by the alleged staff, any male staff, or any other staff. This interview was completed on 11/26/2024. 9. On 11/24/2024, the ADM and Social Worker conducted an interview with current interviewable residents to identify any potential concerns of having been or having witnessed other residents being touched inappropriately (touched in a sexual or improper way). 10. On 11/25/2024, the DON/designees initiated an observation of 22 current non-interviewable residents to identify any residents who may have signs and symptoms of abuse, which may include but not limited to behavioral and physical changes such as emotional distress (negative emotional reactions that can result from a stressful event or situation), unreasonable fear, or pain/discomfort during care. No nonverbal residents were exhibiting any signs and symptoms of having been touched inappropriately. Residents' Representatives for the 22 residents were called by the Social Worker on 11/27/2024 to interview regarding potential abuse allegations, and to provide reassurance related to residents' safety at the facility. 11. The DON and ADM conducted a review of CNA assignments to identify residents who were assigned to CNA 1 within the last 30 days, and residents' representatives were contacted to interview and provide reassurance related to residents' safety. 12. On 11/25/2024, the ADM conducted a Resident Council Meeting with facility leadership, as allowed by the council president to ensure residents' concerns with emphasis on any neglect or mistreatment were heard. Improvement plans and progress were shared with the residents and residents were provided reassurance regarding their safety. 13. On 11/14/2024 and 11/24/2024, the ADM/ designee initiated in-service training to the staff, with post-test regarding Abuse Prohibition, to demonstrate an understanding of the content covered in the training. Staff on leave or unscheduled will receive education from the DON/DSD upon return to work and will be scheduled to receive education. Current active staff completed their education. 14. As part of the New Hire Onboarding and Orientation process, staff will be educated on Abuse Prohibition with post- tests prior to active duty and/or patient care. The DON/designee will continue to educate staff on Abuse Prohibition monthly for the next six (6) months then biannually thereafter, and as needed. 15. The Department Managers will conduct observation and interviews on Mondays to Fridays, regarding any concerns or any possible alleged violations. Findings will be reported to the ADM and DON. The MOD, on Saturdays and Sundays, will conduct observations and interviews regarding any concerns or any possible alleged violations. Findings will be reported to the ADM and DON immediately. 16. The ADM/designee posted signs at the nursing station and other common area for abuse reporting. An Abuse binder can be found at the nurses' station that contained the process, forms and contact information of the ADM, DON, CDPH, LAPD, and Ombudsman. 17. Facility will continue with Resident Council Meeting, monthly, with facility leadership, as allowed by the council president to ensure residents' concerns are heard and improvement plans, and progress are shared with the residents. 18. The facility will obtain services from a reputable and approved third-party educator to provide education to the staff on Abuse Prohibition trainings and education with post-tests and will conduct a monthly inspection for three months and will provide SSA of evidence of completion upon request. The services will be implemented upon securing of the approved third-party educator no later than 12/2/2024. 19. RN Supervisors every shift will conduct rounds to observe care provided to residents by the CNAs and Licensed Nurses to ensure that residents are treated with respect and dignity and be free from any types of abuse. Identified concerns will be immediately addressed to protect the resident, and the ADM and DON will be notified immediately. 20. The ADM and DON will conduct onsite patient care observations rotating on all three shifts throughout the next 30 days and will reduce or increase frequency based on observational findings. 21. The DON/designee will conduct observation on all CNAs while providing ADL care daily for two weeks, weekly for four weeks, and then bi-monthly for two (2) months on different shifts if they (CNAs) are following proper adherence to care. The DON/Designee will do observation of any signs of potential abuse such as a resident exhibiting crying, guarding or refusal of care, retracting and guarding during perineal care. Any findings will be reported to the ADM and DON immediately. The residents identified will be immediately assessed, monitored and the attending physician and resident representatives will be notified to ensure the safety of the residents. 22. The Department Managers will conduct resident interviews and observation for five days in a week for three months, to identify any concerns and possible allegations of abuse. Identified concerns will be immediately reported to the ADM for resolution as warranted. The MOD on Saturdays and Sundays will conduct observations and interviews regarding any concerns, or any possible alleged violations and findings will be reported to the ADM and DON immediately. 23. During the Daily Clinical Meetings on Monday to Friday, the DON and Interdisciplinary Team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the resident) will review Changes of Condition, to ensure that any possible incidence of abuse is/are reported to appropriate agencies, thoroughly investigated and appropriate actions are taken as per Policy and Procedures to ensure the safety of the residents. 24. The ADM will present the results of the above reviews to the Quality Assurance and Performance Improvement (QAPI - is a systematic approach to improving the quality of care and services provided by healthcare facilities) Committee for review and recommendations monthly for three months then quarterly thereafter until substantial compliance is achieved. The plan will be reevaluated monthly by the QAPI Committee and make necessary changes as warranted to ensure that safety of the residents. Findings: During a record review of Resident 1's Admission Record, the Admission Record indicated the facility admitted Resident 1 on 10/24/2024 with diagnoses including neurosyphilis (a bacterial infection of the brain), human immunodeficiency disease (a virus that attacks the body's immune system), suicide attempt (an act in which an individual tries to kill themselves), and muscle weakness. During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/31/2024, the MDS indicated Resident 1 had moderate cognitive (relating to the mental process involved in knowing, learning, and understanding things) impairment. The MDS indicated Resident 1 required maximum assistance from staff with toileting hygiene and was dependent on staff for ADLs including sit to stand (the action of moving from a seated position to a standing position), toilet transferring (the process of safely moving a person to and from a toilet or bedside commode), and showering. During a record review of Resident 2's Admission record, the Admission Record indicated the resident was admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), essential (primary) hypertension (high blood pressure), and muscle weakness. During a record review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment. Resident 2 was dependent on staff for ADLs including toileting hygiene and needed substantial/maximal assistance (helper does more than half the effort) for showering or bathing self and personal hygiene (including combing hair, shaving, applying makeup, washing/drying face and hands). During a review of the Change in Condition (COC - when there is a sudden and significant change from a resident's health) Evaluation Form, dated 11/24/2024, timed at 11 a.m., the COC Evaluation Form indicated that on 11/24/2024, during rounds at 10:55 a.m., Resident 1 reported that her (Resident 1's) CNA (referring to CNA 1) last night (on 11/23/2024) placed a finger inside her (Resident 1) vagina then grabbed her (Resident 1) hand and made her touch the CNA's (CNA 1) penis. The COC form further indicated Resident 1's physician was notified on 11/24/2024 at 12 p.m. and ordered to transfer Resident 1 to GACH 1 for further health evaluation. During an interview with Resident 2 on 11/26/2024 at 10:20 a.m., Resident 2 stated on Saturday, 11/23/2024, at approximately 8 p.m., her roommate (Resident 1) was crying and told Resident 2 that she (Resident 1) did not want CNA 1 in her room again because he (CNA 1) inserted his (CNA 1's) fingers inside her (Resident 1's) private part (vagina). During an interview with Registered Nurse 1 (RN 1) on 11/26/2024 at 11 a.m., RN 1 stated on 11/24/2024 at around 10:55 a.m., Certified Nurse Assistant 2 (CNA 2) notified her (RN 1) that Resident 1 wanted to speak with her. RN 1 stated Resident 1 told her (RN 1) that last night (11/23/2024) CNA 1 placed a finger inside her vagina and stated CNA 1 grabbed her (Resident 1) hand and placed it on his (CNA 1) genitals. RN 1 stated Resident 1 was observed agitated and fearful. RN 1 stated she (RN 1) then called the MD and the MD ordered to transfer Resident 1 to the GACH for further evaluation. During an interview with the MOD on 11/26/2024 at 11:19 a.m., the MOD stated she was working Sunday morning, on 11/24/2024, when RN 1 came to tell her and asked her to assist with Resident 1 because she (Resident 1) had been abused. The MOD went to Resident 1's room and Resident 1 told her (MOD) that last night (11/23/2024) CNA 1 was changing Resident 1's incontinent brief (products that help manage the leakage of urine or stool that occurs with incontinence) wiped her and then placed his fingers inside her (Resident 1) private part. The MOD stated Resident 1 told her that CNA 1 grabbed her (Resident 1) other hand, placed Resident 1's hand on his (CNA 1) genitals, and was rubbing his (CNA 1) genitals with her (Resident 1's) hand. The MOD stated Resident 1 said no, pushed her hand back away from CNA 1's genitals, and CNA 1 stopped. The MOD stated Resident 1 was scared with tears in her eyes. The MOD stated Resident 1 said, I don't want to see CNA 1. The MOD stated she (MOD) told Resident 1 to not worry because she (Resident 1) did nothing wrong and that CNA 1 was not coming back to her room. During an interview with the DSD on 11/26/2024 at 12 p.m., the DSD stated the incident happened on Saturday, 11/23/2024 during the 3 p.m. to 11 p.m. shift. The DSD stated she was notified on Sunday (11/24/2024) at 10: 48 a.m. that CNA 1 had sexually assaulted Resident 1. The DSD stated she called CNA 1 immediately and that he (CNA 1) told her that he was cleaning Resident 1 and that his finger slipped and touched Resident 1's genitalia. The DSD stated she suspended CNA 1. The DSD stated Resident 1 experienced sexual abuse in the facility. During an interview with the SSD on 11/26/2024 at 12:05 pm, the SSD stated the ADM called him (SSD) to come in on Sunday (11/24/2024) to interview Resident 1. The SSD stated he (SSD) entered the room and told Resident 1 that he (SSD) was checking up on her (Resident 1). The SSD stated Resident 1 was visibly upset, fidgety, and stated she (Resident 1) was nervous because she (Resident 1) will be sent to the hospital for further evaluation. During a telephone interview with CNA 2 on 11/26/2024 at 1: 30 p.m., CNA 2 stated that when she was working on Sunday, 11/24/2024, at 10:40 a.m., while she (CNA 2) was changing Resident 1, Resident 1 told her (CNA 2) that she (Resident 1) would like to speak with RN 1. CNA 2 stated Resident 1 appeared agitated and anxious. CNA 2 stated Resident 1 then told her (CNA 2) that last night (11/23/2024) CNA 1 was cleaning her (Resident 1) and he (CNA 1) touched her inappropriately. During an interview with the ADM on 11/26/2024 at 1:35 p.m., the ADMIN stated RN 1 called her (ADMIN) on 11/24/2024 reporting that CNA 1 was changing Resident 1 and that he (CNA 1) inserted his fingers inside Resident 1's private area (vagina). The ADMIN stated she (ADM) called CNA 1 and he (CNA 1) stated he (CNA 1) did slip his fingers inside Resident 1's private area. The ADMIN stated she suspended CNA 1 immediately, pending termination. During an interview with the DON on 11/26/2024 at 3:15 p.m., the DON stated he (DON) was notified on 11/24/2024 at around 12 pm of an allegation of sexual abuse. The DON stated he came to the facility on Sunday (11/24/2024) at 1 p.m. to investigate the allegation. The DON stated Resident 1 told him that the day before (11/23/2024), CNA 1 came in her (Resident 1) room to change her incontinence pad and put his (CNA 1) fingers inside her (Resident 1) genitalia. The DON stated Resident 1 then told him that CNA 1 grabbed her (Resident 1) right hand and placed it on his (CNA 1) private area. The DON stated Resident 1 was upset. The DON stated Resident 1 did not tell any staff right away because she did not want anyone to get in trouble. The DON stated Resident 1 experienced sexual abuse while under the care of the facility. During a record review of Resident 1's GACH Emergency Documentation, dated 11/24/2024, the GACH Emergency Documentation indicated a chief complaint of sexual assault. The GACH Emergency Documentation report indicated Resident 1 complained of sexual assault by an employee of the facility she resides in. Resident 1 stated that CNA 1 was bathing her and changing her when CNA 1 inserted his fingers into her vagina. Resident 1 told CNA 1 to stop, and CNA 1 left the room. The report indicated Resident 1 told her roommate (Resident 2) of what CNA 1 did to her (Resident 1). During a record review of CNA 1's Corrective Action Memo, dated 11/24/2024, the memo indicated CNA 1's type of violation is allegation of sexual abuse. The memo indicated CNA 1 stated he was assigned to Resident 1 and Resident 2 (11/23/2024). The memo indicated CNA 1 stated his fingers slipped Resident 1's private area while cleaning Resident 1. The memo indicated the facility placed CNA 1 on suspension on 11/24/2024. During a record review of CNA 1's Corrective Action Memo, dated 11/25/2024, the memo indicated the type of violation is an allegation of sexual abuse. The memo indicated CNA 1 was interviewed a second time on Monday morning of 11/25/2024 with CNA 1 admitting his fingers slipping into Resident 1's private area and he (CNA 1) also stated Resident 1 touched his private part. The memo indicated the facility terminated CNA 1. During a record review of the facility-provided policy and procedure titled, Abuse-Prevention, Screening & Training Program, dated 6/12/2024, the policy and procedure indicated the facility does not condone any form of resident abuse, neglect, misappropriation (unauthorized, improper, or unlawful use) of resident property, exploitation, and or mistreatment and develops facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Sexual abuse is defined as a non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault.

Based on observation, interview, and record review, the facility failed to evaluate and modify the diet texture to meet the nutritional needs for one of one sampled resident (Resident 103). This deficient practice resulted in a 26.35 percent ([%] a part of every 100) or 39 pounds ([lbs.] unit of measurement) unplanned weight loss, within a six-month period for Resident 103. Findings: A review of Resident 1's Admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2 ([DM] abnormal blood sugar), essential hypertension ([HTN] high blood pressure), anemia (a condition in which the body does not have enough healthy red blood cells), and hemiplegia (weakness of one side of the body that could affect the arms, legs and facial muscles). A review of Resident 103's Minimum Data Set ([MDS] a standard assessment and care screening tool), dated 2/9/2024, indicated Resident 103 was cognitively intact (able to understand and make decisions). The MDS indicated Resident 103 was able to eat with supervision or touching assistance (where the helper provided verbal cues) and or touching or contact guard assistance (a caregiver places one or two hands on the resident's body to help with balance) as the resident completed the activity. A review of Resident 103's Physician's orders indicated the following: a. 11/2/2023- Regular standard portion diet (diet with no restriction), regular texture thin consistency b. 11/19/2023- DM (sugar free oral supplement) 8 oz, high protein nourishment three times a day. c. 1/3/2024-Regular- standard portion diet, mechanical soft chopped texture (a diet consisting of food that are soft and chopped), regular/thin consistency. d. 1/6/2024-Fortified (a process of adding extra nutrients to food by adding margarine, butter, and cream), mechanical soft chopped texture, regular/Thin consistency. Snacks at bedtime for nourishment. e. 3/11/2024- snacks three times a day with meals with soup and vegetables for lunch and dinner. f. 4/15/2024-Fortified puree diet (a type of diet consisting of foods with pudding like consistency) with thin liquids with meals. A review of Resident 103's weight record dated from 11/2/2023 to 4/30/2024 titled Weights and Vitals summary, indicated the following weight trends: 11/02/2023: 148 pounds- admission weight 11/23/2023: 146 lbs. 1.35% (2 lbs.) weight loss since 11/02/2023 (3 weeks) 11/26/2023: 148 lbs. 1.37% (2 lbs.) weight gain in 3 days 12/6/2023: 145 lbs. sitting: 2.03% (3 lbs.) weight loss since 11/26/2023 (10 days) 2.03% (3 lbs.) weight loss since 11/2/2024 (1 month) 1/5/2024: 142 lbs, 2.7% (3 lbs.) weight loss since 12/7/2023 (1 month) 4.05% (6 lbs.) weight loss since 11/2/2023 (2 months) 1/21/2024: 142 lbs. mechanical lift (a device used to move person who is unable to stand on their own): no weight loss since 1/5/2024 (1 month) 2/6/2024 140 lbs. sitting: 1.41% (2 lbs.) weight loss since 1/5/2024 (1 month) 1.41% (2 lbs.) weight loss since 1/21/2024 (2 weeks) 3/5/2024: 136.7 lbs. sitting: 2.36 % (3.3 lbs.) weight loss since 2/6/2024 (1 month) 3.73 % (5.3 lbs.) since 1/5/2024 (2 months) 5.72% (8.3 lbs.) since 12/6/2023 (3 months) 7.64% (11.3 lbs.) since 11/2/2023 (4 months) 3/11/2024: 133.6 lbs. sitting: 2.27% (3.1 lbs.) weight loss since 3/5/2024 (1 week) 4.57% (6.4 lbs.) weight loss since 2/6/2024 (1 month) 5.92% (8.4 lbs.) weight loss since 1/5/2024 (2 months) 7.86% (11.4 lbs.) weight loss since 12/6/2023 (3 months); severe 9.73% (14.4 lbs.) weight loss since 11/2/2023 (4 months); severe 3/19/2024: 132.4 lbs. sitting: 0.9% (1.2 lbs.) weight loss since 3/11/2024 (1 week) 5.43% (7.6 lbs.) weight loss since 2/6/2024 (approximately [~ ]1 month); severe weight loss (a weight loss of more than five (5) lbs. in 1 month, more than 7.5 lbs. in three (3) months and more than ten (10) lbs. in six (6) months.) 6.76% (9.6 lbs.) weight loss since 1/5/2024 (~2 months) 8.69% (12.6 lbs.) weight loss since 12/7/2023 (~3 months); severe 10.54% (15.6 lbs.) weight loss since 11/2/2023 (~4 months); severe 3/26/2024: 130.1 lbs. sitting: 1.74% (2.3 lbs.) weight loss since 3/19/2024 (1 week) 2.62% (3.5 lbs.) weight loss since 3/11/2024 (~2 weeks) 4.83% (6.6 lbs.) weight loss since 3/5/2024 (~3 weeks) 7.07% (10 lbs.) weight loss since 2/6/2024 (~2 months) 8.38% (11.9 lbs.) weight loss since 1/5/2024 (~3 months); severe 8.69% (12.6 lbs.) weight loss since 12/6/2023 (~4 months); severe 10.54% (15.6 lbs.) weight loss since 1/2/2024 (~5 months); severe 4/2/2024: 120.8 lbs. mechanical lift: 7.15% (9.3 lbs.) weight loss since 3/26/2024 (1 week) 8.76% (11.6 lbs.) weight loss since 3/19/2024 (~2 weeks) 9.58% (12.8 lbs.) weight loss since 3/11/2024 (~3 weeks) 11.63% (15.9 lbs.) weight loss since 3/5/2024 (~ 1 month); severe 13.71% (19.2 lbs.) weight loss since 2/6/2024 (~2 months); severe 14.93% (21.2 lbs.) weight loss since 1/5/2024 (~3 months); severe 16.69% (24.2 lbs.) weight loss since 12/6/2023 (~4 months); severe 18.38% (27.2 lbs.) weight loss since 11/2/2023 (~5 months); severe 4/9/2024: 114.8 lbs. mechanical lift: 4.97% (6 lbs.) weight loss since 4/2/2024 (1 week) 11.76% (15.3 lbs.) weight loss since 3/26/2024 (~2 weeks) 13.29% (17.6 lbs.) weight loss since 3/19/2024 (~3 weeks) 14.07% (18.8 lbs.) weight loss since 3/11/2024 (~ 1 month); severe 16.02% (21.9 lbs.) weight loss since 3/5/2024 (~1 month); severe 18% (25.2 lbs.) weight loss since 2/6/2024 (~2 months); severe 19.15% (27.2 lbs.) weight loss since 1/5/2024 (~3 months); severe 20.83% (30.2 lbs.) weight loss since 12/6/2023 (~4 months); severe 22.43% (33.2 lbs.) weight loss since 11/2/2023 (~5 months); severe 4/15/2024: 114.8 lbs. mechanical lift: no weight change since 4/9/2024 4/23/2024: 114.8 lbs. mechanical lift: no weight change since 4/9/2024 11.8% (15.3 lbs.) weight loss since 3/26/2024 (~1 month); severe 19.2 % (27.2 lbs.) weight loss since 2/4/2024 (~2 months); severe 22.4% (33.2 lbs.) weight loss since 11/2/2023 (~5 months); severe 4/30/2024: 109 lbs. mechanical lift: 5.05% (5.8 lbs.) weight loss since 4/23/2024 (1 week) 9.77% (11.8 lbs.) weight loss since 4/2/2024 (~4 weeks); severe 20.26% (27.7 lbs.) weight loss since 3/5/2024 (~2 months); severe 22.14% (31 lbs.) weight loss since 2/6/2024 (~3 months); severe 23.24% (33 lbs.) weight loss since 1/5/2024 (~4 months); severe 24.83% (36 lbs.) weight loss since 12/6/2023 (~5 months); severe 26.35% (39 lbs.) weight loss since 11/2/2023 (~6 months); severe During a concurrent observation and interview with Resident 103, on 4/30/2024, at 11:58 a.m., Resident 103 was lying in bed and unable to use his left hand. Resident 103 stated he had tooth ache and was unable to chew hard vegetables served in the facility and he lost weight. Resident 103 stated he preferred a puree diet (smooth foods with pudding-like consistency) because it was easier for him to eat. Resident 103 stated the staff started offering him a puree diet only three days ago. During a concurrent interview and record review with Registered Dietitian 1 (RD 1) on 5/1/2024 at 10:35 a.m., Resident 103's medical records and nutritional assessment were reviewed. RD 1 stated on 11/17/2023 she completed Resident 103's initial nutritional assessment and Resident 103 reported he had difficulty chewing, and digestion problems after he had a stroke and he preferred liquid- based foods. RD 1 stated Resident 103 wanted a high protein nutrition (HPN, shakes high in protein and calorie) at that time and she recommended HPN sugar free assorted flavor with meals. RD 1 stated the dietary supervisor saw the resident and wrote food preferences after 11/17/2023. RD 1 stated Resident 103 was on a regular diet upon admission and on 3/6/2024, his diet was changed to a mechanical soft diet (soft and chopped foods) with snacks, once a day. RD 1 stated on 3/11/2024 she met with Resident 103 because he was flagged for significant weight loss from 148 lbs, on 1/2/2024, to 136.7 lbs on 3/5/2024 (a total weight loss of 11.3lbs in two months). RD 1 stated Resident 103 had 5.3 lbs weight loss in 1 month. RD 1 stated Resident 103's weight loss was due to variable food intake of 50 to 100% as indicated on his chart. RD 1 stated Resident 103's food intake was not meeting his nutritional needs. RD 1 stated on 3/11/2024 Resident 103's diet was fortified (process of adding extra nutrients to food like margarine, butter, and cream) mechanical soft diet, with snacks once a day and HPN. RD 1 stated Resident 103 requested to update his food preferences so he could get yogurts for all snacks, soups, soft vegetables, and oatmeal with all meals. RD 1 stated she assessed Resident 103 again on 4/3/2024 and his diet was still mechanical soft, fortified diet with three snacks per day plus HPN. RD 1 stated she recommended megace (a medication to improve appetite) to stimulate Resident 103's appetite but did not change the diet's texture. RD 1 stated Resident 103's weight on 3/5/2024 was 136.7 lbs and dropped to 130.1 lbs on 3/26/2024 (6.6 lbs weight loss in 21 days). RD 1 stated her next assessment for Resident 103 was on 4/10/2024 and Resident 103 had lost 15.9 lbs, in one month from 136.7 lbs on 3/5/2024 to 120.8 lbs on 4/2/2024. RD 1 stated Resident 103's diet was a fortified mechanical soft diet. RD 1 stated Resident 103's weight loss was due to his poor food intake of 26 - 76% which was not meeting his nutritional needs. RD 1 stated Resident 103 requested puree foods and ensure (a type of high protein, high calorie shake) with all meals. RD 1 stated she assessed Resident 103 again on 4/30/2024 because the resident was not eating at all. RD 1 stated she could have visited the resident more often and switched the diet to puree diet sooner for a better food intake as Resident 103's main concern was his food intake. RD 1 stated she did not usually attend weight variance meetings but she met with the Director of Nursing (DON) because the meetings were scheduled on the days she was not in the facility. During a concurrent interview and record review with the Dietary Supervisor (DS 1) on 5/1/2024 at 2:35 p.m., of Resident 103's medical records and nutrition notes were reviewed. DS 1 stated Resident 103 had poor food intake and progressive weight loss. DS 1 stated Resident 103 was a picky eater and liked soups and vegetables. DS 1 stated on 2/6/2024 the resident was on a mechanical soft diet with no chewing or swallowing problems. DS 1 stated she assessed Resident 103 on 4/3/2024, and the resident was on a mechanical soft fortified diet with HPN for 3 days. DS 1 stated Resident 103 had a 10 lbs weight loss in one month due to varied food intake of 26 to 100%. DS 1 stated she updated Resident 103's food preferences and added fortified soups, oatmeal, soft vegetables, and yogurts, but did not change the consistency. DS 1 stated her next visit with Resident 103 was on 4/9/2024 and his diet was mechanical soft chopped fortified. DS 1 stated fortification of food varied from every meal like adding margarine, cheese to soup or toppings on the dessert to add extra calories for residents with weight loss. DS 1 stated Resident 103 was eating hot cereals, soups, HPN three times a day, snacks three times a day. DS 1 stated Resident 103 liked soft vegetables, beans, ice cream and disliked meats, chicken, pork, beef, bread and would not even eat fish. DS 1 stated Resident 103 wanted oatmeal so he could pour his health shakes in it. DS 1 stated the facility changed the resident's diet to puree on 4/15/2024 because Resident 103 stated it was easy for him to eat pureed foods. During a concurrent record review of weight variance meeting for Resident 103 and interview with DS 1 on 5/1/2024 at 3:00 p.m., DS 1 stated weight variance meetings were conducted every Thursdays and the DON, DS 1, Activities Director (AD), social services were in attendance. DS 1 stated the first interdisciplinary ([IDT]a group of professionals with a common goal to meet a resident's needs) meeting for weight variance for Resident 103 was on 4/5/2024. DS 1 stated Resident 103 had 9.3 lbs weight loss in one month due to variable food intake. DS 1 stated IDT met for weight variance meeting on 4/11/2024 due to six lbs weight loss in one week because of poor food intake. DS 1 stated Resident 103 was hospitalized on [DATE] due to further weight loss. During an interview with Certified Nursing Assistant 9 (CNA 9) on 5/2/2024 at 10:54 a.m., CNA 9 stated Resident 103 was a picky eater, would complain about his food being hard and difficult to chew. CNA 9 stated Resident 103 only ate soups and oatmeal when he was on soft mechanical diet. CNA 9 stated Resident 103 about four to six months ago, the resident stated that the meals served him were too hard and he preferred soft to chew foods. During an interview with CNA 10 on 5/2/2024 at 11:09 a.m., CNA 10 stated Resident 103 meal intake was 60%, because the resident did not eat the vegetables and complained the vegetables were hard to chew. CNA 10 stated she always notified the charge nurse about the resident's complaints of his food texture, but nothing was done. CNA 10 stated Resident 103 ate better (80%) when he was on puree diet. During a concurrent interview and record review with Utility Manager (UM, a Licensed Vocational Nurse [LVN]), on 5/2/2024 at 5:47 p.m., Resident 103's medical record was reviewed. The UM stated Resident 103 had weight loss concerns from 3/6/2024 and lost 5.3 lbs in a month. The UM stated the facility had a weight variance meeting on 3/7/2024 and discussed Resident 103's diet as fortified mechanical soft, with bedtime snacks. The UM stated Resident 103 complained he had a hard time chewing meat because he had partial dentures, and he did not like wearing them. The UM stated the resident was not educated on a mechanical soft diet during the meeting and his diet was not changed to a puree diet. During a concurrent interview and record review with the UM on 5/2/2024 at 6 p.m., Resident 103's diet order dated 11/2/2023 and 3/6/2024, were reviewed. The UM stated the diet order dated 11/2/2023, indicated the resident was to be served a regular diet. The UM stated the diet order dated 3/6/2024 indicated mechanical soft diet. The UM stated that Resident 103's diet was changed to fortified soft mechanical diet but there was no modification or downgrade in consistency. The UM stated on 3/21/2024 the IDT met again to discuss Resident 103's weight variance but did not talk about changing the resident's diet. The UM stated the staff was to continue serving soups and vegetables to Resident 103. The UM stated on 3/29/2024 the IDT met because Resident 103 had continued to lose weight. The UM stated Resident 103 would get oatmeal for breakfast and monitored for weekly weights. The UM stated there was no discussion on changing the resident's diet. The UM stated on 4/5/2024 the IDT met, and the plan was to serve Resident 103 ice cream with lunch and dinner. The UM stated the resident's diet remained mechanical soft and was not changed to puree. The UM stated next IDT meeting for weight variance was on 4/11/2024 and Resident 103 was to receive megace to stimulate his appetite. The UM stated Resident 103's diet was changed to puree on 4/16/2023. The UM stated Resident 103 was not eating because he was very selective with his meals and did not like the smell of the food. The UM stated the facility should have changed the resident's diet earlier to prevent further weight loss. UM stated there was a care plan for 3/6/2024 for Resident 103 with regards to weight loss, soft mechanical diet, and snacks at bedtime and on 3/11/2024 for soup and vegetables. The UM stated there was a care plan, dated 1/3/2024, for Resident 103's swallowing problems as he could not tolerate regular textures. The UM stated the Resident 103's diet did not change to a different texture and there were no interventions for swallowing problems. The UM stated the facility's failure to change Resident 103's diet could have caused the resident's weight loss. During an interview with the Director of Nursing (DON) on 5/2/2024 at 6:45 p.m., the DON stated Resident 103 lost more than 30 lbs (within a 5-month period) since admission. The DON stated the weight variance committee discussed (DON did not mention the date) Resident 103's meals intake, diet tolerance, food preferences and any infections contributing to Resident 103's weight loss. The DON stated the IDT team collaborated with the physician to address the resident's needs to prevent weight loss. The DON stated Resident 103 was a picky eater, did not like traditional food but liked soft foods, oatmeal, snacks and nourishments such as ice cream, yogurt, and ensure. The DON stated those were not enough to sustain his body's nutritional needs. The DON stated he was not aware Resident 103 had issues with food texture in 1/2024. The DON stated Resident 103 was not tolerating the food texture and that could have contributed to his weight loss. The DON stated the timing of intervention was important to prevent further weight loss for Resident 103. A review of the facility's diet manual titled, Regular Mechanical Soft diet, dated 1/30/2024, indicated Description: The mechanical soft diet is designed for residents who experience chewing or swallowing limitations. The regular diet is modified by mechanically altering, by chopping or gridding, allowable food items and/or cooking raw items to a soft texture. Food items that may need to be modified include proteins, raw vegetables, raw fruit, and all other fibrous fruit. Foods allowed: Mashed or soft whole vegetables, mashed or soft whole cooked beans, creamed corn. Corn may be whole when in mixed vegetables or soups. Soft baked potatoes (skin may be served if soft), white or red. Vegetable juices. Avoided: canned potatoes unless chopped in quarters. Potato chips, tortilla chips or corn chips, popcorn. *Soft = be able to mash with a fork. A review of the facility's diet manual titled, Regular Pureed Diet, dated 1/30/2024, indicated, Description: The pureed diet is a regular diet that has been designed for resident who may have difficulty chewing and/or swallowing. The texture of food should be smooth and moist consistency and able to hold its shape. Portions given will account for the addition of fluids and the specified on the spreadsheet. All foods are prepared in a food processor or blender, except for foods, which are normally in a soft and smooth state such as pudding, ice cream, applesauce, mashed potato. A review of facility's Policy and Procedure (P&P) titled, Nutritional Status Evaluation Committee, dated 1/30/2024, indicated, Purpose: To ensure the physical well-being of residents through the management of weight variance. Policy: The weight of the residents will be monitored for variance and the Nutritional Status Evaluation Committee (made by interdisciplinary team members) will intervene when appropriate. V. Objectives of the Nutritional Status Evaluation Committee may include but are not limited to: (A) Identifying medical or pharmacological (treatment of disease through the application of drugs) conditions, which may be affecting weight changes for the identified residents (B) Evaluating changes in diet, food preferences and increased caloric intake. (C) Ordering a caloric count, if indicated. (D) Identifying residents with signs and symptoms of dysphagia (chewing or swallowing problems) for proper intervention and diet modification. A review of the facility's P&P titled, Evaluation of Weight and Nutritional Status, dated 1/30/2024, indicated, Nutritional Assessment (A) The Dietitian will complete a nutritional assessment initiated by the dietary manager upon admission for residents. Nutritional assessments will also be completed upon readmission, annually, and upon change of condition. (G) The dietitian will complete the nutritional assessment within (14) days of admission. III. Clinical Evaluation (A) In connection with the assessments mentioned above, the registered dietitian and the IDT will further assess nutritional needs and goals of the resident within the context of his/her overall condition, including the following: (iii). Oral intake of foods and fluids. (vi) Nutrition prescription/macronutrients (nutrients we need in larger quantities that provides energy); (x) Chewing and swallowing problems. (D) Insidious weight change refers to gradual, unintended, progressive weight loss or gain over time. The facility will identify those residents who demonstrate insidious weight change over a three (3) to twelve (12) month period. Once insidious weight change has been identified, a representative of the IDT- Nutrition and Weight Variance Committee will: (i) Identify and implement appropriate interventions; (ii). Update and revise the care plan, as appropriate. (iii) notify the family member or responsible party; (iv) Notify attending physician; and (v). Notify the registered dietitian.

Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who did not have the capacity to understand and make decisions, who had a wandering (going about from place to place, walking without purpose) behavior, and was assessed at risk for fall and elopement (a form of unsupervised wandering that leads to the resident leaving the facility without notice or permission and doing so may present an imminent threat to the resident ' s health or safety) received supervision to prevent elopement by: 1. Not ensuring staff provided Resident 1 with supervision and monitoring (a process of observing and tracking activities and progress) to assure that care was provided that met the needs of Resident 1. Per Resident 1 ' s care plan addressing the resident ' s attempt to open facility exit doors, dated 6/30/2022, the goal indicated the resident will remain safe and not have any episodes of trying to open facility exit doors. One of the interventions included the facility will . provide 1 on 1 nurse (when a registered nurse or health care support worker whose role is to provide one to one nursing or observation care to an individual patient for a period of time). 2. Not having a system in place for supervision of residents. The facility did not have a policy and procedure on supervision of residents. 3. Not having a system in place on the use of wander guards (a monitoring bracelet that alarms once the bracelet crosses sensors on an exit door) because the facility had no policy and procedure on the use of wander guards. Facility failed to notice any door alarm triggered by Resident 1, who was wearing a functional wander guard on his left wrist, when he opened the door near the kitchen that opens to the visitor ' s parking lot at the back of the facility. 4. Not having a system in place for the security and surveillance cameras (video cameras that record images in or outside a building or in a public place) to be monitored since per policy, the video surveillance cameras were monitored for the safety and benefit of its residents and video footages were stored. As a result, on 10/4/2023, Resident 1 eloped and was last seen at 6 a.m. inside the facility building in the hallway near Nursing Station 3 by the Director of Staff Development (DSD), who was walking in the hallway going to Nursing Station 4. Resident 1 was at risk for exposure to environmental elements including extreme temperatures (heat during the day and cold during the night) and increased probability of encountering an accident that can lead to serious injury, serious harm, serious impairment, including the possibility of death. Resident 1 was at risk for a negative outcome on his health for not receiving his maintenance medications (are used to treat chronic, long-term conditions) and at risk for infection for not receiving daily dressing changes on his gastrostomy tube (G-tube - a surgical tube inserted from outside of abdomen directly to the stomach to provide nutritional needs) site. Also, based on the Reasonable Person Concept (refers to a tool to assist the survey team ' s assessment of the severity level of a negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Resident 1 ' s impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills and medical condition, an individual lost in the streets and unable to find refuge, food and drinks, may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself). On 10/7/2023 at 1:49 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.25(d) Accidents. The Administrator (ADM), the [NAME] President of Operations (VPO), the Director of Nurses (DON), Nursing Consultant 1, Infection Preventionist (IP) Nurse, and DSD were notified of the IJ from the failure to ensure staff provided supervision to prevent Resident 1 ' s elopement on 10/4/2023. On 10/9/2023 at 4:30 p.m., the IJ was removed in the presence of the ADM, VPO, DON, Nursing Consultant 1, Nursing Consultant 2, IP, and Social Service Consultant while onsite, after verifying through observation, interview, and record review the implementation of the facility ' s submitted and accepted IJ Removal Plan which included the following summarized actions: 1. On 10/4/2023, upon discovery of Resident 1 missing from the facility without notifying any staff member, a Code Yellow, the facility code for elopement, was called to alert staff for further and prompt search of Resident 1 within the facility. 2. On 10/4/2023, the Interdisciplinary Team (IDT - team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions, and share resources and responsibilities) and other staff immediately conducted a thorough search for the resident within the facility, its surrounding areas, nearby establishments, and other areas of the community. The IDT then notified law enforcement agency and filed a missing person report. The IDT also contacted nearby hospitals to inquire about Resident 1. 3. On 10/5/2023, the facility hired a private investigator to locate Resident 1 ' s whereabouts. 4. On 10/5/2023, the DON and designee initiated in-service (training for staff on specific topics) education regarding the facility's policy and procedures related to wandering and elopement, with emphasis on keeping alarms engaged and ensuring that no residents follow a staff member when exiting the facility, unless with proper supervision/authority to leave the premises, and the importance of monitoring placement and functionality of wander guard as ordered. 5. On 10/7/2023, the ADM assigned a designated staff member to provide twenty-four (24) hours a day, and seven (7) days a week (24/7) monitoring of the entrance/exit doors towards the facility ' s back parking lot. The staff member assigned will have a Walkie talkie (portable radio for sending and receiving messages) device on hand for communication purposes. 6. On 10/7/2023, the ADM assigned a dedicated staff member to monitor the camera surveillance 24/7 until the surveillance camera vendor inspects the facility's surveillance system and further plans have been established. 7. On 10/7/2023, the facility staff conducted an audit of current residents with an order for use of wander guard to ensure that functionality is monitored and checked every shift. There were three other residents with an order for use of a wander guard. No other residents were identified to be affected by the same deficient practice(s). 8. On 10/7/2023, the ADM and IDT reviewed the three residents at risk for elopement and completed a room change to ensure that they are away from exit doors, to minimize the risk of elopement. In addition, the ADM assigned a designated staff member to provide 24/7 additional line of sight supervision within the facility. 9. On 10/7/2023, the Maintenance Supervisor (MS) checked the wander guard functionality for the other three residents with a physician ' s order for use of a wander guard. 10. On 10/7/2023, a facility committee meeting was conducted to discuss current concerns regarding supervision and policies related to wander guard system and camera surveillance system. An Elopement Quality Assurance and Performance Improvement (QAPI - process of gathering data for performance improvement to meet quality standards) was updated to reflect current procedures to minimize the recurrence of elopement incidents. 11. On 10/7/2023, the DON initiated an in-service education to the nursing staff regarding the current identification of federal regulations of non-compliance for neglect and supervision, with emphasis on the systemic changes that will be implemented including processes for the use of wander guard. 12. On 10/7/2023, the ADM initiated an in-service to the Maintenance Supervisor (MS) and maintenance staff regarding Elopement and Wandering - monitoring functionality of wander guard system. 13. On 10/7/2023 (in the afternoon), Resident 1 ' s whereabouts was located and was taken to the emergency room by family. 14. On 10/8/2023, Resident 1 returned to the facility at around 9 a.m. from the General Acute Care Hospital (GACH). 15. On 10/8/2023, the facility staff completed the following assessments for Resident 1, but not limited to: Fall Risk Evaluation, Post Fall Evaluation, Elopement Evaluation, Braden Scale Risk Evaluation (evaluation on risk for wound development or skin issues related injury) and Smoking and Safety Evaluation. 16. The Nursing Supervisor(s) will conduct rounds and inspection of all exit doors including sliding doors in residents' rooms every shift to ensure that doors are properly latched/closed, and alarms are always engaged. Any concerns identified will be addressed immediately and reported to the ADM and DON for further actions as warranted. 17. The Governing Body will meet to review the facility's current policies and processes related to surveillance cameras and supervision. 18. In the event of a wander guard malfunction, any accidental or intentional removal of wander guard, the Licensed Nurse will apply a new wander guard to the resident and update the care plan accordingly. 19. The Maintenance Supervisor (MS) will conduct doors and door alarm checks for all exit doors to ensure that all alarms are engaged and functional, two times per week for one month, then weekly for two months. 20. The ADM or designee will conduct elopement drills weekly for one month, then two times a month for two months, to ensure timely staff response to elopement and door alarms. Cross Reference with F600. Findings: A review of Resident 1 ' s Admission Record indicated an admitted [DATE] with diagnoses including traumatic subdural hemorrhage (when a blood vessel near the surface of the brain bursts and blood builds up between the brain and the brain's tough outer lining) without loss of consciousness (traumatic head injury caused by impact or fall), fracture of other specified skull and facial bones/right side (a break in the bone on right side of the head), gastrostomy, and cocaine (a powerful highly addictive drug that affects the brain) abuse. A review of Resident 1 ' s current care plan, dated 5/25/2022 and revised on 4/11/2023, indicated, Resident is at risk for fall secondary to: limited mobility (ability to move), poor balance, lack of awareness, hearing deficit, vision deficit, cognitive deficit, communication deficit, decreased endurance (ability to sustain a prolonged stressful effort or activity, . unsteady gait (manner of walking or moving on foot), . impulsive (doing things suddenly and without careful thought) behavior, . history of falls The care plan indicated the goal to Provide safe environment that minimizes complications associated with falls. A review of Resident 1 ' s Hospitalist Visit Progress Notes, dated 6/2/2022, indicated resident did not have the capacity to understand and make decisions. A review of the Physician ' s orders of Resident 1, dated 6/30/2022 at 7:30 p.m., indicated an order to Apply wander guard as ordered to alert staff secondary to high risk of elopement every shift. A review of Resident 1 ' s current care plan, dated 6/30/2022 and revised on 12/20/2022, indicated, Resident is a risk for wandering or elopement related to: cognitive status, unfamiliarity with new environment, resident is unaware of safety needs, and resident was attempting to open exit doors. Resident 1 ' s care plan goal indicated, Will minimize episodes of wandering and possible injuries. The interventions included to apply wander guard as ordered and to identify if there was a certain part of the day wandering/elopement attempts occur. A review of Resident 1 ' s current care plan, dated 6/30/2022 and revised on 12/20/2022, indicated, The resident had attempted opening facility exit doors. The goal for Resident 1 indicated the resident will remain safe and not have any episodes of trying to open facility exit doors. The care plan interventions indicated, Modify environment as needed to meet current needs: provide 1 on 1 nurse. A record review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 8/3/2023, indicated that Resident 1 was moderately impaired with thought process, remembering names and details, problem solving, and decision-making tasks. The MDS indicated Resident 1 required at least one staff supervision to oversee Resident 1 ' s locomotion (how resident moves from room to other locations of the building). A review of Resident 1 ' s Elopement Evaluation, dated 8/3/2023 at 10:52 a.m., indicated Resident 1 scored four points out of possible 4.2 total points. The elopement evaluation stated, Score value of 1 or higher indicates Risk for Elopement. A review of Resident 1 ' s Change in Condition Evaluation, dated 10/4/2023 at 7 a.m., indicated that facility staff were unable to locate Resident 1 within the facility or the surrounding outdoor areas. On 10/5/2023 at 4:25 p.m., during a concurrent observation, interview, and review of the facility ' s security camera footages with the only active monitor observed inside the administrator ' s office, the ADM stated the facility ' s active camera system only records for 24-hour periods. After 24 hours, the cameras will start recording over the old videos and will not allow staff to review previous days. The ADM was asked to review video surveillance recorded on same date (10/5/2023), starting video around 11:55 a.m. After multiple attempts, the ADM was not able to access the recordings of same day video footages. When ADM was asked if cameras were reviewed on the day of Resident 1 ' s elopement and which door was used by Resident 1 to leave the facility, ADM stated, Sometimes the cameras don ' t work. ADM stated she did not know which specific door Resident 1 used to exit the facility. On 10/6/2023 at 6:32 a.m., during an observation, the facility ' s entrance double doors leading to the back entrance/exit for staff and visitor parking was observed with one door open, no alarm was actively ringing. No staff present in the area. Observed on the inside of the door to be labeled # 8. On 10/6/2023 at 7:03 a.m., during an interview, Certified Nurse Assistant 3 (CNA 3) stated working the 11 p.m. to 7 a.m. shift on the same day Resident 1 was missing from the facility on 10/4/2023 at 7 a.m. CNA 3 stated not hearing any Code yellow for missing persons on the facility overhead page or any door alarms in the morning. CNA 3 indicated not being assigned to Resident 1 but works in the same nursing station where Resident 1 ' s room was located. CNA 3 stated that for Resident 1 to be outside of the facility, Resident 1 can get injured, have a fall, have access to alcohol or drugs that are non-prescription (medicines that you can buy without a prescription), or can get hurt. On 10/6/2023 at 7:30 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated working 11 p.m. to 7 a.m. shift from 10/3/2023 to 10/4/2023 and was assigned to Resident 1. LVN 4 stated that the last time seeing Resident 1 was at the start of the shift on 10/3/2023 at 11 p.m. LVN 4 indicated that the facility ' s double doors (entrance/exit # 8) do not have an alarm. LVN 4 stated that the risks for the missing resident included sleeping in the streets and be subjected to extreme temperatures outside for example during the day it is hot and at nights it is cold. During a concurrent record review, LVN 4 stated there was nowhere in Resident 1 ' s medical record that documentation was completed by LVN 4 on where in the facility Resident 1 was last seen, at what time during the shift LVN 4 confirmed seeing Resident 1, or the description of clothing that Resident 1 was last seen wearing before leaving the facility. On 10/6/2023 at 8:02 a.m., during an interview, Registered Nurse 1 (RN 1) stated working 11 p.m. to 7 a.m. shift from 10/3/2023 to 10/4/2023. RN 1 stated not knowing which door Resident 1 used to exit the facility and eloped. RN 1 stated that the outside temperatures for the day (10/6/2023) was expected to be 96 degrees Fahrenheit (F - unit of measure) which can lead to Resident 1 encountering dehydration (loss of water in the body), or causing the resident to be dry, leading to dizziness and possibly collapsing from the heat, falling, and injuring the head and body. On 10/6/2023 at 8:59 a.m., during an observation, the entrance/exit double doors # 8 leading to the facility ' s visitor parking area was open with one door kept opened by delivery items in boxes designated for the kitchen. No door alarms were actively ringing at this time. There was no staff member monitoring the door for any person coming in and going out. On 10/6/2023 at 11:07 a.m., during a concurrent interview and record review of staff in-service trainings, the Director of Staff Development (DSD) stated not having an in-service training completed for the topic on supervision of residents. On 10/6/2023 at 3:45 p.m., during an interview, the DON stated that the facility had no policy and procedure for the use of wander guard. The DON stated that the purpose of a policy and procedure on the use of a wander guard is to have a baseline guide for the staff on the importance of what needs to be followed in monitoring for the use of wander guard, validation, and functionality. On 10/6/2023 at 5:12 p.m., during an interview, Licensed Vocational Nurse 5 (LVN 5) stated that when Resident 1 left the faciity on [DATE], no staff heard the wander guard and door alarms actively ringing. On 10/7/2023 at 7:07 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated working 11 p.m. to 7 a.m. on 10/3/2023 to 10/4/2023 and was assigned to Resident 1. CNA 1 stated not hearing any door alarms in the morning that Resident 1 went missing. On 10/7/2023 at 10:44 a.m., during an interview, Licensed Vocational Nurse 7 (LVN 7) stated that on 10/4/2023 was informed by the LVN during the 11 p.m. to 7 a.m. shift that Resident 1 was missing from the facility. LVN 7 stated not remembering which wrist Resident 1 ' s wander guard was placed. LVN 7 stated that licensed nursing staff only check that Resident 1 was wearing a wander guard, but it was the maintenance department that checked the functionality of the wander guard. LVN 7 stated that Resident 1 had a history of cocaine abuse and did not know if Resident 1 had access to cocaine while outdoors. On 10/7/2023 at 11:08 am, during a concurrent interview and record review of Resident 1 ' s Medication Administration Record (MAR) for 10/2023, the DON stated Resident 1 who eloped will not be able to take his maintenance medications needed which could compromise resident ' s health. The DON stated Resident 1 ' s maintenance medications and treatment included: 1. Amantadine hydrochloride oral solution 50 milligram (mg - unit of measurement)/5 milliliter (ml - unit of measurement). Give 10 ml by mouth two times a day for dyskinesia (a movement disorder that often appears as uncontrolled shakes, tics, or tremors) due to subdural hematoma (buildup of blood on the surface of the brain). 2. Famotidine oral tablet 20 mg. Give 1 tablet by mouth one time a day for gastroesophageal reflux disease (GERD - occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]). Administer 30 minutes before breakfast. 3. Midodrine hydrochloride oral tablet 5 mg. Give 3 tablets by mouth three times a day for hypotension (low blood pressure). Hold medication if systolic blood pressure (SBP - the top or first number and refers to the amount of pressure experienced by the arteries or blood vessels that bring oxygen-rich blood from your heart to all your body ' s cells while the heart is beating) is greater than 140 millimeters of mercury (mm Hg - a measurement used to record blood pressure). Administer every eight hours (3 tablets = 15 mg). 4. Simvastatin oral tablet 20 mg. Give one tablet by mouth at bedtime for hyperlipidemia (high levels of fats in the blood). 5. G-tube site. Cleanse with normal saline solution (NSS - a mixture of salt and water and is called normal because its salt solution is similar to tears, blood, and other body fluids), pat dry, and cover with dry dressing daily every day shift. On 10/7/2023 at 11:50 a.m., during an interview, the ADM stated she watched the surveillance camera monitor inside her office. The ADM stated no one was monitoring when she was not around. The ADM stated no one was monitoring the camera monitors when Resident 1 left the building. The ADM stated the facility had no policies and procedures on the use of wander guards and on supervision of residents. When asked if there was a system failure on not having policies and procedures on the use of wander guards and on supervision of residents, the ADM stated, Yes, and further stated that there was a system breakdown because there was no direction on what to do and what procedures should be done. The ADM stated there was no concise directive on what is required. A review of Resident 1 ' s Change in Condition Evaluation, dated 10/8/2023 at 9 a.m., indicated Resident 1 was readmitted back to the facility at 9 a.m. accompanied by his Significant Other (SO). The Change of Condition Evaluation indicated Resident 1 had fallen outside the facility two to three days ago and was noted with abrasion on his right knee and multiple abrasions on his right elbow. On 10/8/2023 at 11:26 a.m., during an observation, Resident 1 was sleeping in his bed with his SO sitting in a chair beside Resident 1 ' s bed. Resident 1 was lying slightly on his left side uncovered by a linen. Resident 1 was wearing a maroon jogging pants pulled up to his knees showing a portion of his skin from the knees showing a reddish abrasion on his right knee. On 10/8/2023 at 11:49 a.m., during an observation, Resident 1 was covered with a blanket. In a concurrent interview, SO, who was at the bedside, stated Resident 1 felt cold and was asking for another blanket. SO stated Resident 1 had a disagreement with another resident (name not known) that was why Resident 1 left the facility. SO stated Resident 1 was walking with no food, water, and no medications for a couple of days. SO stated Resident 1 was lost for a few days. SO stated this incident was scary because something bad can happen to Resident 1. SO stated Resident 1 was found with the same clothes he was wearing the last time he was seen in the facility with white dust all over his body. SO stated Resident 1 was seen in the afternoon of 10/7/2023 and was sent to the emergency room of GACH 1. On 10/9/2023 at 11:01 a.m., during an interview, the DSD stated he came early on 10/4/2023 and when he was on his way to Nursing Station 4 at 6 a.m., he saw Resident 1 in the hallway near Nursing Station 3. During a concurrent observation, along the hallway going to Nursing Station 4, the DSD re-enacted (showed) how he saw Resident 1 in the hallway near Nursing Station 3. The DSD stated that was the last time Resident 1 was last seen in the facility. The DSD stated that after making his rounds, he came back to his office and passed by the exit door by the kitchen going out to the visitor parking lot, he did see Resident 1 anymore and he did not hear that exit door alarming. On 10/9/2023 at 11:12 a.m., during a concurrent interview and record review of Resident 1 ' s assessments and MAR for 10/2023, RN 3 stated Resident 1 had low grade fever, had no pain but just sleepy right now tired from all the walking during the elopement. RN 3 stated Resident 1 did not receive his medications for four days starting 10/4/2023 to 10/7/2023 and did not receive any dressing change on Resident 1 ' s G-tube site on these days placing Resident 1 at risk for infection. RN 3 stated Resident 1 had the following skin assessments: 1. Right knee abrasion: three centimeters (cm - unit of measurement) in length by three cm in width and by 0.1 cm in depth (3 cm x 3 cm x 0.1 cm). 2. Right elbow abrasions: 1 cm in length x 0.5 cm in width x 0.1 cm in depth and 1.8 cm in length x 0.5 cm in width x 0.1 cm in depth. On 10/9/2023 at 1:49 p.m., during an interview, Resident 1 stated exiting from the exit door near the kitchen going out to the visitor parking lot. Resident 1 stated nobody was there, he opened the door, left the building, and rode a bus. Resident 1 stated he heard an alarm when he opened the door. Resident 1 stated he had a fall that was why he had some abrasions. Resident 1 stated he saw SO after leaving the bus and was brought back to the facility. On 10/9/2023 at 2:11 p.m., during an interview, The DON stated that when Resident 1 came back to the facility using the front door at the lobby, Resident 1 ' s wander guard bracelet on the left wrist triggered the alarm meaning it was functional. The DON stated that when Resident 1 eloped on 10/4/2023, the wander guard alarm should have triggered and somebody which we have not identified yet have turned the alarm off. A review of the current facility-provided policy and procedure titled, Resident Safety, with last revised date of 4/15/2021, indicated the purpose, To provide a safe and hazard free environment. The policy also stated that the Interdisciplinary Team (IDT) will establish a person-centered observation or monitoring systems for the Resident to address the identified risk factors identified. A review of the current facility-provided policy and procedure titled, Wandering & Elopement, with last revised date of 7/2017, indicated the purpose, To enhance the safety of residents of the facility. The policy ' s procedures include, Facility staff will reinforce proper procedures for leaving the Facility for resident assessed to be at risk of elopement. The procedures also indicated, The Licensed Nurse most familiar with the incident will document in the resident ' s medical record how the elopement occurred. A review of the current facility-provided policy and procedure titled, Security Camera Installation, with last revision date of 9/25/2020, indicated the purpose, To provide guidance for the Facility Security Committee to install, use and monitor video surveillance and security cameras (Security Cameras) in the Facility in a professional, ethical, and lawful manner, and when necessary for the safety and benefit of the Facility, its residents, and its staff. The procedure(s) stated, Retention and Access to Recordings, A.) 24 - hour destruction: any recording should be automatically deleted\overwritten after 24 hours, unless requested by law enforcement approves a longer retention. B.) Retention of security recordings for longer than 24 hours: if there is a reason to maintain recordings for longer than 24 hours, such as a security incident; the recordings should be transferred to secure storage (such as encrypted drive).

Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who did not have the capacity to understand and make decisions, who had wandering (going about from place to place, walking without purpose) behavior, and was assessed at risk for fall and elopement (a form of unsupervised wandering that leads to the resident leaving the facility without notice or permission and doing so may present an imminent threat to the resident ' s health or safety) was free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) by: 1. Not ensuring staff provided Resident 1 with supervision and monitoring (a process of observing and tracking activities and progress) to assure that care was provided that met the needs of Resident 1. Per Resident 1 ' s care plan addressing the resident ' s attempt to open facility exit doors, dated 6/30/2022, the goal indicated the resident will remain safe and not have any episodes of trying to open facility exit doors. One of the interventions included the facility will . provide 1 on 1 nurse (when a registered nurse or health care support worker whose role is to provide one to one nursing or observation care to an individual patient for a period of time). 2. Not having a system in place for supervision of residents. The facility did not have a policy and procedure on supervision of residents. 3. Not having a system in place on the use of wander guards (a monitoring bracelet that alarms once the bracelet crosses sensors on an exit door) because the facility had no policy and procedure on the use of wander guards. Facility failed to notice any door alarm triggered by Resident 1, who was wearing a functional wander guard on his left wrist, when he opened the door near the kitchen that opens to the visitor ' s parking lot at the back of the facility. 4. Not having a system in place for the security and surveillance cameras (video cameras that record images in or outside a building or in a public place) to be monitored since per policy, the video surveillance cameras were monitored for the safety and benefit of its residents and video footages were stored. As a result, on 10/4/2023, Resident 1 eloped and was last seen at 6 a.m. inside the facility building in the hallway near Nursing Station 3 by the Director of Staff Development (DSD), who was walking in the hallway going to Nursing Station 4. Resident 1 was at risk for exposure to environmental elements including extreme temperatures (heat during the day and cold during the night) and increased probability of encountering an accident that can lead to serious injury, serious harm, serious impairment, including the possibility of death. Resident 1 was at risk for a negative outcome on his health for not receiving his maintenance medications (are used to treat chronic, long-term conditions) and at risk for infection for not receiving daily dressing changes on his gastrostomy tube (G-tube - a surgical tube inserted from outside of abdomen directly to the stomach to provide nutritional needs) site. Also, based on the Reasonable Person Concept (refers to a tool to assist the survey team ' s assessment of the severity level of a negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Resident 1 ' s impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills and medical condition, an individual lost in the streets and unable to find refuge, food and drinks, may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself). On 10/7/2023 at 1:49 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation. The Administrator (ADM), the [NAME] President of Operations (VPO), the Director of Nurses (DON), Nursing Consultant 1, Infection Preventionist (IP) Nurse, and DSD were notified of the IJ from the failure to ensure Resident 1 was free from neglect. On 10/9/2023 at 4:30 p.m., the IJ was removed in the presence of the ADM, VPO, DON, Nursing Consultant 1, Nursing Consultant 2, IP, and Social Service Consultant while onsite, after verifying through observation, interview, and record review the implementation of the facility ' s submitted and accepted IJ Removal Plan which included the following summarized actions: 1. On 10/4/2023, upon discovery of Resident 1 missing from the facility without notifying any staff member, a Code Yellow, the facility code for elopement, was called to alert staff for further and prompt search of Resident 1 within the facility. 2. On 10/4/2023, the Interdisciplinary Team (IDT - team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions, and share resources and responsibilities) and other staff immediately conducted a thorough search for the resident within the facility, its surrounding areas, nearby establishments, and other areas of the community. The IDT then notified law enforcement agency and filed a missing person report. The IDT also contacted nearby hospitals to inquire about Resident 1. 3. On 10/5/2023, the facility hired a private investigator to locate Resident 1 ' s whereabouts. 4. On 10/5/2023, the DON and designee initiated in-service (training for staff on specific topics) education regarding the facility's policy and procedures related to wandering and elopement, with emphasis on keeping alarms engaged and ensuring that no residents follow a staff member when exiting the facility, unless with proper supervision/authority to leave the premises, and the importance of monitoring placement and functionality of wander guard as ordered. 5. On 10/7/2023, the ADM assigned a designated staff member to provide twenty-four (24) hours a day, and seven (7) days a week (24/7) monitoring of the entrance/exit doors towards the facility ' s back parking lot. The staff member assigned will have a Walkie talkie (portable radio for sending and receiving messages) device on hand for communication purposes. 6. On 10/7/2023, the ADM assigned a dedicated staff member to monitor the camera surveillance 24/7 until the surveillance camera vendor inspects the facility's surveillance system and further plans have been established. 7. On 10/7/2023, the facility staff conducted an audit of current residents with an order for use of wander guard to ensure that functionality is monitored and checked every shift. There were three other residents with an order for use of a wander guard. No other residents were identified to be affected by the same deficient practice(s). 8. On 10/7/2023, the ADM and IDT reviewed the three residents at risk for elopement and completed a room change to ensure that they are away from exit doors, to minimize the risk of elopement. In addition, the ADM assigned a designated staff member to provide 24/7 additional line of sight supervision within the facility. 9. On 10/7/2023, the Maintenance Supervisor (MS) checked the wander guard functionality for the other three residents with a physician ' s order for use of a wander guard. 10. On 10/7/2023, a facility committee meeting was conducted to discuss current concerns regarding supervision and policies related to wander guard system and camera surveillance system. An Elopement Quality Assurance and Performance Improvement (QAPI - process of gathering data for performance improvement to meet quality standards) was updated to reflect current procedures to minimize the recurrence of elopement incidents. 11. On 10/7/2023, the DON initiated an in-service education to the nursing staff regarding the current identification of federal regulations of non-compliance for neglect and supervision, with emphasis on the systemic changes that will be implemented including processes for the use of wander guard. 12. On 10/7/2023, the ADM initiated an in-service to the Maintenance Supervisor (MS) and maintenance staff regarding Elopement and Wandering - monitoring functionality of wander guard system. 13. On 10/7/2023 (in the afternoon), Resident 1 ' s whereabouts was located and was taken to the emergency room by family. 14. On 10/8/2023, Resident 1 returned to the facility at around 9 a.m. from the General Acute Care Hospital (GACH). 15. On 10/8/2023, the facility staff completed the following assessments for Resident 1, but not limited to: Fall Risk Evaluation, Post Fall Evaluation, Elopement Evaluation, Braden Scale Risk Evaluation (evaluation on risk for wound development or skin issues related injury) and Smoking and Safety Evaluation. 16. The Nursing Supervisor(s) will conduct rounds and inspection of all exit doors including sliding doors in residents' rooms every shift to ensure that doors are properly latched/closed, and alarms are always engaged. Any concerns identified will be addressed immediately and reported to the ADM and DON for further actions as warranted. 17. The Governing Body will meet to review the facility's current policies and processes related to surveillance cameras and supervision. 18. In the event of a wander guard malfunction, any accidental or intentional removal of wander guard, the Licensed Nurse will apply a new wander guard to the resident and update the care plan accordingly. 19. The Maintenance Supervisor (MS) will conduct doors and door alarm checks for all exit doors to ensure that all alarms are engaged and functional, two times per week for one month, then weekly for two months. 20. The ADM or designee will conduct elopement drills weekly for one month, then two times a month for two months, to ensure timely staff response to elopement and door alarms. Cross Reference with F689. Findings: A review of Resident 1 ' s Admission Record indicated an admitted [DATE] with diagnoses including traumatic subdural hemorrhage (when a blood vessel near the surface of the brain bursts and blood builds up between the brain and the brain's tough outer lining) without loss of consciousness (traumatic head injury caused by impact or fall), fracture of other specified skull and facial bones/right side (a break in the bone on right side of the head), gastrostomy, and cocaine (a powerful highly addictive drug that affects the brain) abuse. A review of Resident 1 ' s current care plan, dated 5/25/2022 and revised on 4/11/2023, indicated, Resident is at risk for fall secondary to: limited mobility (ability to move), poor balance, lack of awareness, hearing deficit, vision deficit, cognitive deficit, communication deficit, decreased endurance (ability to sustain a prolonged stressful effort or activity, . unsteady gait (manner of walking or moving on foot), . impulsive (doing things suddenly and without careful thought) behavior, . history of falls The care plan indicated the goal to Provide safe environment that minimizes complications associated with falls. A review of Resident 1 ' s Hospitalist Visit Progress Notes, dated 6/2/2022, indicated resident did not have the capacity to understand and make decisions. A review of the Physician ' s orders of Resident 1, dated 6/30/2022 at 7:30 p.m., indicated an order to Apply wander guard as ordered to alert staff secondary to high risk of elopement every shift. A review of Resident 1 ' s current care plan, dated 6/30/2022 and revised on 12/20/2022, indicated, Resident is a risk for wandering or elopement related to: cognitive status, unfamiliarity with new environment, resident is unaware of safety needs, and resident was attempting to open exit doors. Resident 1 ' s care plan goal indicated, Will minimize episodes of wandering and possible injuries. The interventions included to apply wander guard as ordered and to identify if there was a certain part of the day wandering/elopement attempts occur. A review of Resident 1 ' s current care plan, dated 6/30/2022 and revised on 12/20/2022, indicated, The resident had attempted opening facility exit doors. The goal for Resident 1 indicated the resident will remain safe and not have any episodes of trying to open facility exit doors. The care plan interventions indicated, Modify environment as needed to meet current needs: provide 1 on 1 nurse. A record review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 8/3/2023, indicated that Resident 1 was moderately impaired with thought process, remembering names and details, problem solving, and decision-making tasks. The MDS indicated Resident 1 required at least one staff supervision to oversee Resident 1 ' s locomotion (how resident moves from room to other locations of the building). A review of Resident 1 ' s Elopement Evaluation, dated 8/3/2023 at 10:52 a.m., indicated Resident 1 scored four points out of possible 4.2 total points. The elopement evaluation stated, Score value of 1 or higher indicates Risk for Elopement. A review of Resident 1 ' s Change in Condition Evaluation, dated 10/4/2023 at 7 a.m., indicated that facility staff were unable to locate Resident 1 within the facility or the surrounding outdoor areas. On 10/5/2023 at 4:25 p.m., during a concurrent observation, interview, and review of the facility ' s security camera footages with the only active monitor observed inside the administrator ' s office, the ADM stated the facility ' s active camera system only records for 24-hour periods. After 24 hours, the cameras will start recording over the old videos and will not allow staff to review previous days. The ADM was asked to review video surveillance recorded on same date (10/5/2023), starting video around 11:55 a.m. After multiple attempts, the ADM was not able to access the recordings of same day video footages. When ADM was asked if cameras were reviewed on the day of Resident 1 ' s elopement and which door was used by Resident 1 to leave the facility, ADM stated, Sometimes the cameras don ' t work. ADM stated she did not know which specific door Resident 1 used to exit the facility. On 10/6/2023 at 6:32 a.m., during an observation, the facility's entrance double doors leading to the back entrance/exit for staff and visitor parking was observed with one door open, no alarm was actively ringing. No staff present in the area. Observed on the inside of the door to be labeled # 8. On 10/6/2023 at 7:03 a.m., during an interview, Certified Nurse Assistant 3 (CNA 3) stated working the 11 p.m. to 7 a.m. shift on the same day Resident 1 was missing from the facility on 10/4/2023 at 7 a.m. CNA 3 stated not hearing any Code yellow for missing persons on the facility overhead page or any door alarms in the morning. CNA 3 indicated not being assigned to Resident 1 but works in the same nursing station where Resident 1 ' s room was located. CNA 3 stated that for Resident 1 to be outside of the facility, Resident 1 can get injured, have a fall, have access to alcohol or drugs that are non-prescription (medicines that you can buy without a prescription), or can get hurt. On 10/6/2023 at 7:30 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated working 11 p.m. to 7 a.m. shift from 10/3/2023 to 10/4/2023 and was assigned to Resident 1. LVN 4 stated that the last time seeing Resident 1 was at the start of the shift on 10/3/2023 at 11 p.m. LVN 4 indicated that the facility ' s double doors (entrance/exit # 8) do not have an alarm. LVN 4 stated that the risks for the missing resident included sleeping in the streets and be subjected to extreme temperatures outside for example during the day it is hot and at nights it is cold. During a concurrent record review, LVN 4 stated there was nowhere in Resident 1 ' s medical record that documentation was completed by LVN 4 on where in the facility Resident 1 was last seen, at what time during the shift LVN 4 confirmed seeing Resident 1, or the description of clothing that Resident 1 was last seen wearing before leaving the facility. On 10/6/2023 at 8:02 a.m., during an interview, Registered Nurse 1 (RN 1) stated working 11 p.m. to 7 a.m. shift from 10/3/2023 to 10/4/2023. RN 1 stated not knowing which door Resident 1 used to exit the facility and eloped. RN 1 stated that the outside temperatures for the day (10/6/2023) was expected to be 96 degrees Fahrenheit (F - unit of measure) which can lead to Resident 1 encountering dehydration (loss of water in the body), or causing the resident to be dry, leading to dizziness and possibly collapsing from the heat, falling, and injuring the head and body. On 10/6/2023 at 8:59 a.m., during an observation, the entrance/exit double doors # 8 leading to the facility ' s visitor parking area was open with one door kept opened by delivery items in boxes designated for the kitchen. No door alarms were actively ringing at this time. There was no staff member monitoring the door for any person coming in and going out. On 10/6/2023 at 11:07 a.m., during a concurrent interview and record review of staff in-service trainings, the Director of Staff Development (DSD) stated not having an in-service training completed for the topic on supervision of residents. On 10/6/2023 at 3:45 p.m., during an interview, the DON stated that the facility had no policy and procedure for the use of wander guard. The DON stated that the purpose of a policy and procedure on the use of a wander guard is to have a baseline guide for the staff on the importance of what needs to be followed in monitoring for the use of wander guard, validation, and functionality. On 10/6/2023 at 5:12 p.m., during an interview, License Vocational Nurse 5 (LVN 5) stated that when Resident 1 left the faciity on [DATE], no staff heard the wander guard and door alarms actively ringing. On 10/7/2023 at 7:07 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated working 11 p.m. to 7 a.m. on 10/3/2023 to 10/4/2023 and was assigned to Resident 1. CNA 1 stated not hearing any door alarms in the morning that Resident 1 went missing. On 10/7/2023 at 10:44 a.m., during an interview, Licensed Vocational Nurse 7 (LVN 7) stated that on 10/4/2023 was informed by the LVN during the 11 p.m. to 7 a.m. shift that Resident 1 was missing from the facility. LVN 7 stated not remembering which wrist Resident 1 ' s wander guard was placed. LVN 7 stated that licensed nursing staff only check that Resident 1 was wearing a wander guard, but it was the maintenance department that checked the functionality of the wander guard. LVN 7 stated that Resident 1 had a history of cocaine abuse and did not know if Resident 1 had access to cocaine while outdoors. On 10/7/2023 at 11:08 am, during a concurrent interview and record review of Resident 1 ' s Medication Administration Record (MAR) for 10/2023, the DON stated Resident 1 who eloped will not be able to take his maintenance medications needed which could compromise resident ' s health. The DON stated Resident 1 ' s maintenance medications and treatment included: 1. Amantadine hydrochloride oral solution 50 milligram (mg - unit of measurement)/5 milliliter (ml - unit of measurement). Give 10 ml by mouth two times a day for dyskinesia (a movement disorder that often appears as uncontrolled shakes, tics, or tremors) due to subdural hematoma (buildup of blood on the surface of the brain). 2. Famotidine oral tablet 20 mg. Give 1 tablet by mouth one time a day for gastroesophageal reflux disease (GERD - occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]). Administer 30 minutes before breakfast. 3. Midodrine hydrochloride oral tablet 5 mg. Give 3 tablets by mouth three times a day for hypotension (low blood pressure). Hold medication if systolic blood pressure (SBP - the top or first number and refers to the amount of pressure experienced by the arteries or blood vessels that bring oxygen-rich blood from your heart to all your body ' s cells while the heart is beating) is greater than 140 millimeters of mercury (mm Hg - a measurement used to record blood pressure). Administer every eight hours (3 tablets = 15 mg). 4. Simvastatin oral tablet 20 mg. Give one tablet by mouth at bedtime for hyperlipidemia (high levels of fats in the blood). 5. G-tube site. Cleanse with normal saline solution (NSS - a mixture of salt and water and is called normal because its salt solution is similar to tears, blood, and other body fluids), pat dry, and cover with dry dressing daily every day shift. On 10/7/2023 at 11:50 a.m., during an interview, the ADM stated she watched the surveillance camera monitor inside her office. The ADM stated no one was monitoring when she was not around. The ADM stated no one was monitoring the camera monitors when Resident 1 left the building. The ADM stated the facility had no policies and procedures on the use of wander guards and on supervision of residents. When asked if there was a system failure on not having policies and procedures on the use of wander guards and on supervision of residents, the ADM stated, Yes, and further stated that there was a system breakdown because there was no direction on what to do and what procedures should be done. The ADM stated there was no concise directive on what is required. A review of Resident 1 ' s Change in Condition Evaluation, dated 10/8/2023 at 9 a.m., indicated Resident 1 was readmitted back to the facility at 9 a.m. accompanied by his Significant Other (SO). The Change of Condition Evaluation indicated Resident 1 had fallen outside the facility two to three days ago and was noted with abrasion on his right knee and multiple abrasions on his right elbow. On 10/8/2023 at 11:26 a.m., during an observation, Resident 1 was sleeping in his bed with his SO sitting in a chair beside Resident 1 ' s bed. Resident 1 was lying slightly on his left side uncovered by a linen. Resident 1 was wearing a maroon jogging pants pulled up to his knees showing a portion of his skin from the knees showing a reddish abrasion on his right knee. On 10/8/2023 at 11:49 a.m., during an observation, Resident 1 was covered with a blanket. In a concurrent interview, SO, who was at the bedside, stated Resident 1 felt cold and was asking for another blanket. SO stated Resident 1 had a disagreement with another resident (name not known) that was why Resident 1 left the facility. SO stated Resident 1 was walking with no food, water, and no medications for a couple of days. SO stated Resident 1 was lost for a few days. SO stated this incident was scary because something bad can happen to Resident 1. SO stated Resident 1 was found with the same clothes he was wearing the last time he was seen in the facility with white dust all over his body. SO stated Resident 1 was seen in the afternoon of 10/7/2023 and was sent to the emergency room of GACH 1. On 10/9/2023 at 11:01 a.m., during an interview, the DSD stated he came early on 10/4/2023 and when he was on his way to Nursing Station 4 at 6 a.m., he saw Resident 1 in the hallway near Nursing Station 3. During a concurrent observation, along the hallway going to Nursing Station 4, the DSD re-enacted (showed) how he saw Resident 1 in the hallway near Nursing Station 3. The DSD stated that was the last time Resident 1 was last seen in the facility. The DSD stated that after making his rounds, he came back to his office and passed by the exit door by the kitchen going out to the visitor parking lot, he did not see Resident 1 anymore and he did not hear that exit door alarming. On 10/9/2023 at 11:12 a.m., during a concurrent interview and record review of Resident 1 ' s assessments and MAR for 10/2023, RN 3 stated Resident 1 had low grade fever, had no pain but just sleepy right now tired from all the walking during the elopement. RN 3 stated Resident 1 did not receive his medications for four days starting 10/4/2023 to 10/7/2023 and did not receive any dressing change on Resident 1 ' s G-tube site on these days placing Resident 1 at risk for infection. RN 3 stated Resident 1 had the following skin assessments: 1. Right knee abrasion: three centimeters (cm - unit of measurement) in length by three cm in width and by 0.1 cm in depth (3 cm x 3 cm x 0.1 cm). 2. Right elbow abrasions: 1 cm in length x 0.5 cm in width x 0.1 cm in depth and 1.8 cm in length x 0.5 cm in width x 0.1 cm in depth.[ On 10/9/2023 at 1:49 p.m., during an interview, Resident 1 stated exiting from the exit door near the kitchen going out to the visitor parking lot. Resident 1 stated nobody was there, he opened the door, left the building, and rode a bus. Resident 1 stated he heard an alarm when he opened the door. Resident 1 stated he had a fall that was why he had some abrasions. Resident 1 stated he saw SO after leaving the bus and was brought back to the facility. On 10/9/2023 at 2:11 p.m., during an interview, The DON stated that when Resident 1 came back to the facility using the front door at the lobby, Resident 1 ' s wander guard bracelet on the left wrist triggered the alarm meaning it was functional. The DON stated that when Resident 1 eloped on 10/4/2023, the wander guard alarm should have triggered and somebody which we have not identified yet have turned the alarm off. A review of the current facility-provided policy and procedure titled, Abuse-Prevention, Screening, & Training Program, with last revised date of 7/2018, indicated the purpose, To address the health, safety, welfare, dignity, and respect of residents by preventing abuse, neglect, misappropriation of resident property, exploitation, and mistreatment including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat medical symptoms. The policy also defined neglect as, Failure to provide goods and services necessary to attain or maintain physical, mental, and psychosocial well-being and avoid physical harm, pain, mental anguish, or emotional distress. A review of the current facility-provided policy and procedure titled, Resident Safety, with last revised date of 4/15/2021, indicated the purpose, To provide a safe and hazard free environment. The policy also stated that the Interdisciplinary Team (IDT) will establish a person-centered observation or monitoring systems for the Resident to address the identified risk factors identified. A review of the current facility-provided policy and procedure titled, Wandering & Elopement, with last revised date of 7/2017, indicated the purpose, To enhance the safety of residents of the facility. The policy ' s procedures include, Facility staff will reinforce proper procedures for leaving the Facility for resident assessed to be at risk of elopement. The procedures also indicated, The Licensed Nurse most familiar with the incident will document in the resident ' s medical record how the elopement occurred. A review of the current facility-provided policy and procedure titled, Security Camera Installation, with last revision date of 9/25/2020, indicated the purpose, To provide guidance for the Facility Security Committee to install, use and monitor video surveillance and security cameras (Security Cameras) in the Facility in a professional, ethical, and lawful manner, and when necessary for the safety and benefit of the Facility, its residents, and its staff. The procedure(s) stated, Retention and Access to Recordings, A.) 24 - hour destruction: any recording should be automatically deleted\overwritten after 24 hours, unless requested by law enforcement approves a longer retention. B.) Retention of security recordings for longer than 24 hours: if there is a reason to maintain recordings for longer than 24 hours, such as a security incident; the recordings should be transferred to secure storage (such as encrypted drive).

Based on observation, interview, and record review, the facility failed to administer 17 doses of [MEDICATION NAME] [MED] (an inhaled steroid medication used to treat breathing problems) and failed to monitor oxygen saturations levels (a measure of how much oxygen is in the blood) every shift to maintain the oxygen levels at 92% (percent) as required by the physician's orders [REDACTED]. The facility also failed to administer eight doses of [MEDICATION NAME] (a medication used to treat high blood sugar) between 2/14/2020 and [DATE]20 to one of 12 randomly observed residents (Resident 17. These failures had the potential for Residents 17 and 291 to experience significant harm including respiratory arrest (the inability to breathe) or coma (a prolonged period of unconsciousness brought on by illness or injury) likely resulting in hospitalization or death. On 2/20/2020 at 3:30 PM, the Department of Public called an Immediate Jeopardy situation (IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the administrator (ADM) and director of nursing (DON). On [DATE] at 3:45 PM, the DON and ADM provided an acceptable plan of action (POA) that included the following summarized actions: 1. A licensed nurse notified Resident 291's attending physician (MD 1), and informed her that the resident did not receive the [MEDICATION NAME] [MED] inhaler for approximately nine days. MD 1 gave orders to administer [MEDICATION NAME] [MED] as soon as it was available. MD 1 reassessed Resident 291 and found no signs or symptoms of respiratory distress. 2. A licensed nurse called the pharmacy, on 2/20/2020, to request an expedited order of the [MEDICATION NAME] [MED] for Resident 291. The DON requested that any future requests for medication authorizations be sent to him directly. Upon arrival, on 2/20/2020 at 11:30 AM, a licensed nurse administered [MEDICATION NAME] [MED] to Resident 291. 3. The licensed nurses will monitor Resident 291's oxygen level and titrate (measure and adjust the balance) the according to the physician's orders [REDACTED]. 4. The DON provided one-on-one training and progressive disciplinary action to the licensed nurses involved in signing the Medication Administration Record (MAR) for doses of [MEDICATION NAME] [MED] not administered and failed to monitor Resident 291's oxygen saturation levels as required by the physician's orders [REDACTED].>5. A licensed nurse conducted a facility-wide inspection of all medication orders and availability for all residents in the facility to ensure that medications were on hand to provide for their needs. The DON stated after completing the facility-wide inspection for all residents there were no additional missing medications. On [DATE]20 at 7:47 AM, the Department did a facility-wide random check of medication availability, Resident 17's [MEDICATION NAME] was missing from Station 2's Medication Cart B. On [DATE]20 at 10:05 AM, during an interview, the DON stated the facility's staff must have overlooked Resident 17's missing [MEDICATION NAME] during the facility-wide random check of medication. On [DATE]20 at 4:45 PM, the facility provided an amended POA that included the following additional summarized actions: 1. A licensed nurse assessed Resident 17's condition and there were no signs or symptoms of high or low blood sugar levels. The licensed nurse notified the attending physician (MD 2), that the nurses did not administer Resident 17's [MEDICATION NAME] for eight days. MD 2 gave an order to administer the [MEDICATION NAME] as soon as it was available. MD 2 also ordered additional lab tests to assess Resident 17's condition. 2. A licensed nurse contacted the pharmacy and requested an expedited delivery of [MEDICATION NAME] for Resident 17. 3. The facility's pharmacy consultant provided retraining to licensed nurses on the proper protocols for ordering medications for the residents from the pharmacy. On [DATE]20 at 5:48 PM, while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department removed the Immediate Jeopardy, in the presence of the administrator and DON. Cross-referenced with F7[AGE]. Findings: 1. A review of Resident 291's clinical record indicated an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 291's physician orders, dated 2/10/2020, prescribed [MEDICATION NAME] [MED] 110 micrograms ((mcg) a unit of measure) per inhalation to inhale one puff by mouth into lungs twice daily for shortness of breath. Review of Resident 291's physician's orders [REDACTED]. Further review of the order indicated that facility staff should monitor oxygen saturation on every shift and adjust the oxygen dose as needed to maintain a saturation level of 92%. The order further indicated to monitor the resident's oxygen saturation level every (Q) shift. On 2/20/2020 at 9:53 AM, during a medication administration for Resident 291, the registered nurse (RN 2) prepared the following medications for Resident 291's morning medication administration: 1. One capsule of [MED] (a medication used to treat urinary problems) 0.5 milligrams ((mg) a unit of measure). 2. [MEDICATION NAME] nasal spray (a medication used to treat allergies [REDACTED].>3. One tablet of l[MED] (a medication used to treat [MEDICAL CONDITION] (uncontrolled electrical activity in the brain)) 500 mg. 4. One capsule of [MED] (a medication used to treat urinary problems) 0.4 mg. 5. Thirty milliliters ((ml) a unit of measure for volume) for urinary tract infection to Heal (a supplement.) 6. One tablet of [MEDICATION NAME] (a medication used to treat dizziness) 12.5 mg. 7. One tablet of [MEDICATION NAME] (a medication used to treat mental illness) 1 mg. 8. One tablet of [MEDICATION NAME] [MED] (a medication used to treat [MEDICAL CONDITION]) 500 mg. 9. One tablet of multivitamins with minerals (a supplement.) 10. Thirty ml of [MED] (a supplement.) On 2/20/2020 at 10:15 AM, during an interview, RN 2 stated she has a total of ten medications and supplements to administer to Resident 291. RN 2 stated Resident 291 also needed to have [MEDICATION NAME] [MED] 110 mcg administered but that she was unable to find the inhaler in the medication cart. RN 2 stated she would have her supervisor check on availability of the [MEDICATION NAME]. On 2/20/2020 at 10:16 AM, Resident 291 was observed sleeping in his bed wearing his nasal cannula (a lightweight tube with two prongs at the end inserted into the nostrils to receive a mixture of air and oxygen). On 2/20/2020 at 10:19 AM, RN 2 was observed administering all ten medications listed above to Resident 291. On 2/20/2020 at 10:34 AM, during an interview, the Licensed Vocational Nurse (LVN) 6 stated she was the unit manager for Nursing Station 2 and Resident 291's [MEDICATION NAME] inhaler was not anywhere in the facility. LVN 6 stated the initial order was on 2/10/20 and the facility ordered the [MEDICATION NAME] from the pharmacy that day. LVN 6 stated she would check with the pharmacy, as it usually does not take that long to deliver the medications. LVN 6 added she informed MD 1, on 2/20/20 that the [MEDICATION NAME] was currently unavailable and MD 1's response was to administer the [MEDICATION NAME] to Resident 291 as soon as it was available. LVN 6 stated pharmacy is to deliver the medication later today (2/20/2020.) The licensed nurse was unable to produce a pharmacy delivery receipt for 2/10/20 or any other record of delivery for Resident 291's [MEDICATION NAME] [MED]. A review of Resident 291's MAR for February 2020 indicated that between 2/11/2020 and 2/20/2020, the six licensed nurses (RN 2, Assistant director of staff development (ADSD), LVN's 2, 3, 4, and 5) signed they administered 17 doses of [MEDICATION NAME] on the following dates and times: 1. RN 2 on 2/11 and [DATE]20 at 9 AM, 2/14 and 2/15/2020 at 5 PM 2. LVN 2 on 2/12, 2/15, and [DATE]20 at 9 AM 3. Assistant director of staff development (ADSD) on 2/14/2020 at 9 AM 4. LVN 3 on [DATE] at 9 AM 5. LVN 4 on 2/18/2020 at 9 AM 6. LVN 5 on 2/11, 2/12, 2/13, 2/16, 2/17, 2/18, and 2/19 at 5 PM A review of Resident 291's February 2020 MAR for oxygen administration indicated between 2/12/2020 and 2/20/2020, the licensed nurses documented the oxygen levels a total of six of 25 opportunities on the following shifts and dates: 1. 11 AM-7PM shift on 2/15, 2/16, and [DATE]20. 2. 7 AM-3 PM shift on 2/12, 2/16, and [DATE]20. On 2/20/2020 at 11:21 AM, during an interview, LVN 6 stated after speaking with the pharmacist, they never delivered the [MEDICATION NAME], because it required approval from the DON due to the high cost. LVN 6 stated she was unable to explain why the licensed nurses signed as administering 17 doses of [MEDICATION NAME] when the medication was never available in the facility. On 2/20/2020 at 11:36 AM, during an interview, the DON stated he could not explain why six licensed nurses signed administering Resident 291's [MEDICATION NAME] on the MAR when the medication was not available. The DON agreed it was impossible for Resident 291 to have actually received his [MEDICATION NAME] as documented if the pharmacy never delivered the medication. The DON stated he would provide a list of the names of each licensed nurse who signed, but did not give the [MEDICATION NAME] and provide them with retraining regarding the proper procedures for the documentation of medications. On 2/20/2020 at 12:13 PM, during an interview, RN 2 stated she recognized her initials on Resident 291's MAR as administering the 9 AM [MEDICATION NAME] on 2/11/2020 and [DATE]20. RN 2 stated her initials on those dates and times meant she administered the medication. RN 2 added if, for any reason, she did not give the medication she would initial the dose, circle her initials, and provide a written explanation on the back of the MAR. There was no documentation on the back of the MAR. RN 2 continued she would then follow up with the pharmacy and the physician as required. RN 2 stated she administered [MEDICATION NAME] to Resident 291 on the dates and times she signed but was unable to explain how, since the pharmacy did not deliver the medication. RN 2 stated she may have confused the [MEDICATION NAME] with another inhaler prescribed to Resident 291, but acknowledged it was unlikely since they were scheduled to be given at different times. RN 2 stated it is possible that she signed Resident 291's MAR indicating she gave him the [MEDICATION NAME] without actually giving the medication. On 2/20/2020 at 12:32 PM, during an interview, the ADSD stated sometimes she is responsible for medication administration when other nurses are not available. The ADSD stated she signed Resident 291's MAR for [MEDICATION NAME] at 9 AM on 2/14/2020. Her signature meant she gave the medication to the resident. The ADSD continued if she did not give the medication, for any reason, she would circle her initials on the MAR and explain why on the back of the MAR. There was no documentation on the back of the MAR. The ADSD added she felt rushed having to give medications on the morning of 2/14/2020, due to a nurse calling off duty. The ADSD also stated she most likely signed the MAR indicating she gave the [MEDICATION NAME] to Resident 291 when in fact she had not. On 2/20/2020 at 12:45 PM, during an interview, MD 1 stated she is Resident 291's attending physician and the resident is currently recovering from pneumonia due to an infection caused by drug-resistant bacteria (is the ability of bacteria to resist the power of an antibiotic). MD 1 stated she prescribed [MEDICATION NAME] and other medications on the resident's admission to the facility (2/10/2020) but was not aware he was not receiving the [MEDICATION NAME] until today (2/20/20). MD 1 stated concerns for Resident 291 because the resident also has underlying asthma (a condition in which the tubes that carry air in and out of the lungs narrow and swell causing a reversible obstruction), so she prescribed [MEDICATION NAME]. MD 1 stated without the [MEDICATION NAME] to prevent or treat inflammation (the body's response to harmful stimuli, which may cause swelling) in the airways and lungs, Resident 291 could be at risk for respiratory arrest due to a combination of asthma and diminished lung capacity from pneumonia. MD 1 continued this could cause the resident to need hospitalization or even cause him to die. MD 1 stated she was unaware the licensed nurses signed the resident's MAR as giving the [MEDICATION NAME] when in fact they had not. MD 1 expressed concern that Resident 291's MAR did not reflect the care actually provided to him as she relies on accurate information from the nursing staff in order to make the best treatment decisions. MD 1 added if Resident 291's condition deteriorated she may assume the [MEDICATION NAME], at its current dose is ineffective. This would prompt her to order an increased dose or switch to stronger oral steroid (a synthetic drug used to decrease inflammation), which would put the resident at additional risk for adverse effects associated with higher doses of steroids (such as increased pressure in the eyes, swelling in the lower legs, high blood pressure, mood swings, and weight gain). On 2/20/2020 at 1:49 PM, during a telephone interview, the registered pharmacist (RPH 1) stated they received Resident 291's order for [MEDICATION NAME] on 2/10/2020 along with all of the other medications. RPH 1 stated the [MEDICATION NAME] needed authorization due to high cost based on their agreement with the facility. The pharmacy faxed an authorization request to the DON on the same day (2/10/2020), but did not receive the signed authorization back until 2/20/2020. RPH 1 confirmed they delivered Resident 291's [MEDICATION NAME] [MED] to the facility on [DATE]. A review of the pharmacy's faxed document titled Notification of Non-Covered Items Price Quote & Billing Authorization indicated the pharmacy faxed the request for Resident 291's [MEDICATION NAME] [MED] 110 mcg authorization, to the facility, on 2/10/2020 at 11:42 PM. On 2/20/2020 at 3:30 PM, during an interview, the DON stated he was unaware of ever receiving the pharmacy's request for authorization for the [MEDICATION NAME] before today. The DON stated as soon as he received the fax, he signed it and sent it back. The DON stated he spoke with the pharmacy manager and requested to email all future authorizations directly to him. The DON acknowledged the licensed nurse failed to monitor Resident 291's oxygen saturation levels per the physician's orders [REDACTED]. and did not monitor the resident's oxygen level. The DON stated he would take appropriate steps to remedy the problem. During a concurrent interview, the ADM added, We know we have a problem and we will work to fix it. 2. A review of Resident 17's clinical record indicated an admission to the facility on [DATE] with [DIAGNOSES REDACTED].) A review of Resident 17's physician orders, dated 2/14/2020, indicated to give [MEDICATION NAME] by subcutaneous (under the skin) injection every night at bedtime give ten units (a measurement for the dosage of [MED]). On [DATE]20 at 7:47 AM, during a random inspection of Station 2 Medication Cart B, RN 1 verified the availability of Resident 17's medications listed on the MAR. Upon checking, RN 1 was unable to locate Resident 17's [MEDICATION NAME] in the medication cart. During a concurrent interview, RN 1 stated she searched the medication storage room`s refrigerator, where unopened [MED] vials or pens are kept, to try to locate Resident 17's [MEDICATION NAME] but was still unable to find any [MEDICATION NAME] for Resident 17. On [DATE]20 at 9:31 AM, during an interview, LVN 6 stated the physician`s medication orders are transmitted via fax to the pharmacy and the transmission will generate a transaction report which is then kept on file. LVN 6 further explained the pharmacy provides receipts of delivery for medications, which the facility also files. LVN 6 stated she was unable to produce any transmission record that the pharmacy received Resident 17's [MEDICATION NAME] order or that the pharmacy had delivered it to the facility. LVN 6 stated [MEDICATION NAME] is a diabetic medication and if Resident 17`s diabetes is not appropriately managed, she could become hyperglycemic (high blood sugar), which could lead to diabetic ketoacidosis (a potentially life-threatening complication of diabetes mellitus which may include symptoms such as vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion, and loss of consciousness). A review of Resident 17`s MAR from February 2020 indicated between 2/14/2020 and [DATE], the licensed nurses' signed administering a total of eight doses of [MEDICATION NAME] on the following dates: 1. RN 2 on 2/14 and 2/15/2020. 2. LVN 5 on 2/16, 2/17, 2/18, 2/19, and 2/20/2020 3. RN 3 on [DATE]. On [DATE] at 10:05 AM, during an interview, the DON confirmed that the facility failed to transmit Resident 17's physician order [REDACTED]. The DON agreed it would have been impossible for Resident 17 to receive [MEDICATION NAME], since the licensed nurse' had not ordered it, from 2/14 to [DATE]. On [DATE]20 at 10:15 AM, during a telephone interview, RPH 2 confirmed the pharmacy neither received an order for [REDACTED]. On [DATE]20 at 1:30 PM, during an interview, RN 2 explained on 2/14 and 2/15/2020, it was her first time working the 3-11 PM shift and she was responsible for administering Resident 17's [MEDICATION NAME] on those dates. RN 2 stated she signed as giving Resident 17's [MEDICATION NAME] on the MAR on 2/14 and 2/15/2020. RN 2 stated she administered the [MEDICATION NAME] to Resident 17 on those dates but was unable to explain how when the pharmacy never delivered the medication. RN 2 then stated she needs more training, as she is new to nursing and admitted that it was her mistake. RN 2 stated she may have confused [MEDICATION NAME] with another type of [MED] ordered for Resident 17 but agreed that it was unlikely since the other [MED] is usually given at different times. RN 2 also stated she feels that Station 2 has a high resident load compared to some of the other nursing stations in the facility and feels like she is sometimes overwhelmed with the amount of medication she has to administer. RN 2 stated she could have signed Resident 17's MAR that she gave [MEDICATION NAME] when in fact she did not. On [DATE] at 2:40 PM, Resident 17 was observed lying in bed, alert, awake, but unable to verbalize a response. A review of the facility's policy and procedure document titled Medication - Administration, last revised on 1/1/2012, indicated, Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner and Whenever a medication is held for any reason, the hour it was held must be initialed and circled in the Medication Administration Record (MAR) by the responsible Licensed Nurse. The Licensed Nurse will document on the back on the MAR, noting the time and the reason the medication was held. A review of the facility's policy and procedure document titled Falsification & Omission, last revised on 1/1/2012, indicated, Entries in a medical record at the Facility will be factual and will accurately reflect the services provided to the resident, the condition of the resident, and the resident's response to services provided and Willful material falsifications and omissions are prohibited, a willful material falsification is made with the knowledge that the record falsely reflects the condition of the resident or the care of services provided.

Based on observation, interview, and record review, the facility failed to administer 17 doses of [MEDICATION NAME] [MED] (an inhaled steroid medication used to treat breathing problems) between 2/11/2020 and 2/20/2020 to one of five randomly observed residents (Resident 291) and failed to administer eight doses of [MEDICATION NAME] (a medication used to treat high blood sugar) between 2/14/2020 and [DATE]20 to one of 12 randomly observed residents (Resident 17.) This failure had the potential for Residents 17 and 291 to experience significant harm including respiratory arrest (the inability to breathe) or coma (a prolonged period of unconsciousness brought on by illness or injury) likely resulting in hospitalization or death. On 2/20/2020 at 3:30 PM, the Department of Public called an Immediate Jeopardy situation ((IJ a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the administrator (ADM) and director of nursing (DON). On [DATE] at 3:45 PM, the DON and ADM provided an acceptable plan of action (POA) that included the following summarized actions: 1. A licensed nurse notified Resident 291's attending physician (MD 1), and informed her that the resident did not receive the [MEDICATION NAME] [MED] inhaler for approximately nine days. MD 1 gave orders to administer [MEDICATION NAME] [MED] as soon as it was available. MD 1 reassessed Resident 291 and found no signs or symptoms of respiratory distress. 2. A licensed nurse called the pharmacy, on 2/20/2020, to request an expedited order of the [MEDICATION NAME] [MED] for Resident 291. The DON requested that any future requests for medication authorizations be sent to him directly. Upon arrival, on 2/20/2020 at 11:30 AM, a licensed nurse administered [MEDICATION NAME] [MED] to Resident 291. 3. The DON provided one-on-one training and progressive disciplinary action to the licensed nurses involved in signing the Medication Administration Record (MAR) for doses of [MEDICATION NAME] [MED] not administered to Resident 291. 4. A licensed nurse conducted a facility-wide inspection of all medication orders and availability for all residents in the facility to ensure that medications were on hand to provide for their needs. The DON stated after completing the facility-wide inspection for all residents there were no additional missing medications. On [DATE]20 at 7:47 AM, the Department did a facility-wide random check of medication availability, Resident 17's [MEDICATION NAME] was missing from Station 2's Medication Cart B. On [DATE]20 at 10:05 AM, during an interview, the DON stated the facility's staff must have overlooked Resident 17's missing [MEDICATION NAME] during the facility-wide random check of medication. On [DATE]20 at 4:45 PM, the facility provided an amended POA that included the following additional summarized actions: 1. A licensed nurse assessed Resident 17's condition and there were no signs or symptoms of high or low blood sugar levels. The licensed nurse notified the attending physician (MD 2), that the nurses did not administer Resident 17's [MEDICATION NAME] for eight days. MD 2 gave an order to administer the [MEDICATION NAME] as soon as it was available. MD 2 also ordered additional lab tests to assess Resident 17's condition. 2. A licensed nurse contacted the pharmacy and requested an expedited delivery of [MEDICATION NAME] for Resident 17. 3. The facility's pharmacy consultant provided retraining to licensed nurses on the proper protocols for ordering medications for the residents from the pharmacy. On [DATE]20 at 5:48 PM, while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department removed the Immediate Jeopardy, in the presence of the administrator and DON. Cross-referenced with F6[AGE] Findings: 1. A review of Resident 291's clinical record indicated an admission to the facility on [DATE] with [DIAGNOSES REDACTED].) A review of Resident 291's physician orders, dated 2/10/2020, prescribed [MEDICATION NAME] [MED] 110 micrograms ((mcg) a unit of measure for mass) per inhalation to inhale one puff by mouth into lungs twice daily for shortness of breath. On 2/20/2020 at 9:53 AM, during a medication administration for Resident 291, the registered nurse (RN 2) prepared the following medications for Resident 291's morning medication administration: 1. One capsule of [MED] (a medication used to treat urinary problems) 0.5 milligrams ((mg) a unit of measure for mass). 2. [MEDICATION NAME] nasal spray (a medication used to treat allergies [REDACTED].>3. One tablet of l[MED] (a medication used to treat [MEDICAL CONDITION] (uncontrolled electrical activity in the brain)) 500 mg. 4. One capsule of [MED] (a medication used to treat urinary problems) 0.4 mg. 5. Thirty milliliters ((ml) a unit of measure for volume) of [MED] (a supplement.) 6. One tablet of [MEDICATION NAME] (a medication used to treat dizziness) 12.5 mg. 7. One tablet of [MEDICATION NAME] (a medication used to treat mental illness) 1 mg. 8. One tablet of [MEDICATION NAME] [MED] (a medication used to treat [MEDICAL CONDITION]) 500 mg. 9. One tablet of multivitamins with minerals (a supplement.) 10. Thirty ml of [MED] (a supplement.) On 2/20/2020 at 10:15 AM, during an interview, RN 2 stated she has a total of ten medications and supplements to administer to Resident 291. RN 2 stated Resident 291 also needed to have [MEDICATION NAME] [MED] 110 mcg administered but that she was unable to find the inhaler in the medication cart. RN 2 stated she would have her supervisor check on availability of the [MEDICATION NAME]. On 2/20/2020 at 10:16 AM, Resident 291 was sleeping in his bed wearing his nasal cannula (a lightweight tube with two prongs at the end inserted into the nostrils to receive a mixture of air and oxygen). On 2/20/2020 at 10:19 AM, RN 2 administered all ten medications listed above to Resident 291. On 2/20/2020 at 10:34 AM, during an interview, the Licensed Vocational Nurse (LVN) 6 stated she was the unit manager for Nursing Station 2 and Resident 291's [MEDICATION NAME] inhaler was not anywhere in the facility. LVN 6 stated the initial order was on 2/10/20 and the facility ordered the [MEDICATION NAME] from the pharmacy that day. LVN 6 stated she would check with the pharmacy, as it usually does not take that long to deliver the medications. LVN 6 added she informed MD 1, on 2/20/20 that the [MEDICATION NAME] was currently unavailable and MD 1's response was to administer the [MEDICATION NAME] to Resident 291 as soon as it was available. The pharmacy is to deliver the medication later today (2/20/2020.) The licensed nurse was unable to produce a pharmacy delivery receipt for 2/10/20 or any other record of delivery for Resident 291's [MEDICATION NAME] [MED]. A review of Resident 291's MAR for February 2020 indicated that between 2/11/2020 and 2/20/2020, the six licensed nurses (RN 2, Assistant director of staff development (ADSD) LVN's 2, 3, 4, and 5) signed they administered 17 doses of [MEDICATION NAME] on the following dates and times: 1. RN 2 on 2/11 and [DATE]20 at 9 AM, 2/14 and 2/15/2020 at 5 PM 2. LVN 2 on 2/12, 2/15, and [DATE]20 at 9 AM 3. Assistant director of staff development (ADSD) on 2/14/2020 at 9 AM 4. LVN 3 on [DATE] at 9 AM 5. LVN 4 on 2/18/2020 at 9 AM 6. LVN 5 on 2/11, 2/12, 2/13, 2/16, 2/17, 2/18, and 2/19 at 5 PM On 2/20/2020 at 11:21 AM, during an interview, LVN 6 stated after speaking with the pharmacist, they never delivered the [MEDICATION NAME], because it required approval from the DON due to the high cost. LVN 6 stated she was unable to explain why the licensed nurses signed as administering 17 doses of [MEDICATION NAME] when the medication was never available in the facility. On 2/20/2020 at 11:36 AM, during an interview, the DON stated he could not explain why six licensed nurses signed administering Resident 291's [MEDICATION NAME] on the MAR when the medication was not available. The DON agreed it was impossible for Resident 291 to have actually received his [MEDICATION NAME] as documented if the pharmacy never delivered the medication. The DON stated he would provide a list of the names of each licensed nurse who signed, but did not give the [MEDICATION NAME] and provide them with retraining regarding the proper procedures for the documentation of medications. On 2/20/2020 at 12:13 PM, during an interview, RN 2 stated she recognized her initials on Resident 291's MAR as administering the 9 AM [MEDICATION NAME] on 2/11/2020 and [DATE]20. RN 2 stated her initials on those dates and times meant she administered the medication. RN 2 added if, for any reason, she did not give the medication she would initial the dose, circle her initials, and provide a written explanation on the back of the MAR. There was no documentation on the back of the MAR. RN 2 continued she would then follow up with the pharmacy and the physician as required. RN 2 stated she administered [MEDICATION NAME] to Resident 291 on the dates and times she signed but was unable to explain how, since the pharmacy did not deliver the medication. RN 2 stated she may have confused the [MEDICATION NAME] with another inhaler prescribed to Resident 291, but acknowledged it was unlikely since they were scheduled to be given at different times. RN 2 stated it is possible that she signed Resident 291's MAR indicating she gave him the [MEDICATION NAME] without actually giving the medication. On 2/20/2020 at 12:32 PM, during an interview, the ADSD stated sometimes she is responsible for medication administration when other nurses are not available. The ADSD stated she signed Resident 291's MAR for [MEDICATION NAME] at 9 AM on 2/14/2020. Her signature meant she gave the medication to the resident. The ADSD continued if she did not give the medication, for any reason, she would circle her initials on the MAR and explain why on the back of the MAR. There was no documentation on the back of the MAR. The ADSD added she felt rushed having to give medications on the morning of 2/14/2020, due to a nurse calling off duty. The ADSD also stated she most likely signed the MAR indicating she gave the [MEDICATION NAME] to Resident 291 when in fact she had not. On 2/20/2020 at 12:45 PM, during an interview, MD 1 stated she is Resident 291's attending physician and the resident is currently recovering from pneumonia due to an infection caused by drug-resistant bacteria (is the ability of bacteria to resist the power of an antibiotic). MD 1 stated she prescribed [MEDICATION NAME] and other medications on the resident's admission to the facility (2/10/2020) but was not aware he was not receiving the [MEDICATION NAME] until today (2/20/20). MD 1 stated concerns for Resident 291 because the resident also has underlying asthma (a condition in which the tubes that carry air in and out of the lungs narrow and swell causing a reversible obstruction), so she prescribed [MEDICATION NAME]. MD 1 stated without the [MEDICATION NAME] to prevent or treat inflammation (the body's response to harmful stimuli, which may cause swelling) in the airways and lungs, Resident 291 could be at risk for respiratory arrest due to a combination of asthma and diminished lung capacity from pneumonia. MD 1 continued this could cause the resident to need hospitalized or even cause him to die. MD 1 stated she was unaware the licensed nurses signed the resident's MAR as giving the [MEDICATION NAME] when in fact they had not. MD 1 expressed concern that Resident 291's MAR did not reflect the care actually provided to him as she relies on accurate information from the nursing staff in order to make the best treatment decisions. MD 1 added if Resident 291's condition deteriorated she may assume the [MEDICATION NAME], at its current dose is ineffective. This would prompt her to order an increased dose or switch to stronger oral steroid (a synthetic drug used to decrease inflammation), which would put the resident at additional risk for adverse effects associated with higher doses of steroids (such as increased pressure in the eyes, swelling in the lower legs, high blood pressure, mood swings, and weight gain). On 2/20/2020 at 1:49 PM, during a telephone interview, the registered pharmacist (RPH 1) stated they received Resident 291's order for [MEDICATION NAME] on 2/10/2020 along with all of the other medications. RPH 1 stated the [MEDICATION NAME] needed authorization due to high cost based on their agreement with the facility. The pharmacy faxed an authorization request to the DON on the same day (2/10/2020), but did not receive the signed authorization back until 2/20/2020. RPH 1 confirmed they delivered Resident 291's [MEDICATION NAME] [MED] to the facility on [DATE]. A review of the pharmacy's faxed document titled Notification of Non-Covered Items Price Quote & Billing Authorization indicated the pharmacy faxed the request for Resident 291's [MEDICATION NAME] [MED] 110 mcg authorization, to the facility, on 2/10/2020 at 11:42 PM. On 2/20/2020 at 3:30 PM, during an interview, the DON stated he was unaware of ever receiving the pharmacy's request for authorization for the [MEDICATION NAME] before today. The DON stated as soon as he received the fax, he signed it and sent it back. The DON stated he spoke with the pharmacy manager and requested to email all future authorizations directly to him. The DON stated as the facility's leader, he takes full responsibility and full ownership of the problems identified with resident care, including the fact that six licensed nurses falsified Resident 291's MAR and would take appropriate steps to remedy it. During a concurrent interview, the ADM added, We know we have a problem and we will work to fix it. 2. A review of Resident 17's clinical record indicated an admission to the facility on [DATE] with [DIAGNOSES REDACTED].) A review of Resident 17's physician orders, dated 2/14/2020, indicated to give [MEDICATION NAME] by subcutaneous (under the skin) injection every night at bedtime give ten units (a measurement for the dosage of [MED]). On [DATE]20 at 7:47 AM, during a random inspection of Station 2 Medication Cart B, RN 1 verified the availability of Resident 17's medications listed on the MAR. Upon checking, RN 1 was unable to locate Resident 17's [MEDICATION NAME] in the medication cart. During a concurrent interview, RN 1 stated she searched the medication storage room`s refrigerator, where unopened [MED] vials or pens are kept, to try to locate Resident 17's [MEDICATION NAME] but was still unable to find any [MEDICATION NAME] for Resident 17. On [DATE]20 at 9:31 AM, during an interview, LVN 6 stated the physician`s medication orders are transmitted via fax to the pharmacy and the transmission will generate a transaction report which is then kept on file. LVN 6 further explained the pharmacy provides receipts of delivery for medications, which the facility also files. LVN 6 stated she was unable to produce any transmission record that the pharmacy received Resident 17's [MEDICATION NAME] order or that the pharmacy had delivered it to the facility. LVN 6 stated [MEDICATION NAME] is a diabetic medication and if Resident 17`s diabetes is not appropriately managed, she could become [MEDICAL CONDITION] (high blood sugar), which could lead to diabetic ketoacidosis (a potentially life-threatening complication of diabetes mellitus which may include symptoms such as vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion, and loss of consciousness). A review of Resident 17`s MAR from February 2020 indicated between 2/14/2020 and [DATE], the licensed nurses' signed administering a total of eight doses of [MEDICATION NAME] on the following dates: 1. RN 2 on 2/14 and 2/15/2020. 2. LVN 5 on 2/16, 2/17, 2/18, 2/19, and 2/20/2020 3. RN 3 on [DATE]. On [DATE] at 10:05 AM, during an interview, the DON confirmed that the facility failed to transmit Resident 17's physician order [REDACTED]. The DON agreed it would have been impossible for Resident 17 to receive [MEDICATION NAME], since the licensed nurse' had not ordered it, from 2/14 to [DATE]. On [DATE]20 at 10:15 AM, during a telephone interview, RPH 2 confirmed the pharmacy neither received an order for [REDACTED]. On [DATE]20 at 1:30 PM, during an interview, RN 2 explained on 2/14 and 2/15/2020, it was her first time working the 3-11 PM shift and she was responsible for administering Resident 17's [MEDICATION NAME] on those dates. RN 2 stated she signed as giving Resident 17's [MEDICATION NAME] on the MAR on 2/14 and 2/15/2020. RN 2 stated she administered the [MEDICATION NAME] to Resident 17 on those dates but was unable to explain how when the pharmacy never delivered the medication. RN 2 then stated she needs more training, as she is new to nursing and admitted that it was her mistake. RN 2 stated she may have confused [MEDICATION NAME] with another type of [MED] ordered for Resident 17 but agreed that it was unlikely since the other [MED] is usually given at different times. RN 2 also stated she feels that Station 2 has a high resident load compared to some of the other nursing stations in the facility and feels like she is sometimes overwhelmed with the amount of medication she has to administer. RN 2 stated she could have signed Resident 17's MAR that she gave [MEDICATION NAME] when in fact she did not. On [DATE] at 2:40 PM, Resident 17 was lying in bed, alert, awake, but unable to verbalize a response. A review of the facility's policy and procedure document titled Medication - Administration, last revised on 1/1/2012, indicated, Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner and Whenever a medication is held for any reason, the hour it was held must be initialed and circled in the Medication Administration Record (MAR) by the responsible Licensed Nurse. The Licensed Nurse will document on the back on the MAR, noting the time and the reason the medication was held. A review of the facility's policy and procedure document titled Falsification & Omission, last revised on 1/1/2012, indicated, Entries in a medical record at the Facility will be factual and will accurately reflect the services provided to the resident, the condition of the resident, and the resident's response to services provided and Willful material falsifications and omissions are prohibited, a willful material falsification is made with the knowledge that the record falsely reflects the condition of the resident or the care of services provided.

Based on interview and record review, the facility failed to prevent the elopement (unsupervised wandering and leaving a safe area such as healthcare facility unnoticed) for one of three sampled residents (Resident 1) when Resident 1 was not supervised and monitored. This deficient practice resulted in Resident 1's elopement from the facility and was found by a police officer. Resident 1 was brought to the General Acute Care Hospital (GACH) where the resident was diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Record indicated the resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical dated 5/25/18 indicated the resident had a fluctuating capacity to understand and make decisions and had a [DIAGNOSES REDACTED]. A record review of Resident 1's Elopement Risk assessment dated [DATE] indicated the resident scored six, and the assessment indicated a score of eight or greater is considered a high risk of elopement. Resident 1 was assessed on the following criteria: 1. Level of consciousness and mental status = zero (indicating resident was alert and oriented x3 (person, time and event)). 2. Mobility Status = four (indicating the resident is ambulatory). 3. History of wandering or elopement = two (indicating one to two attempts to leave in the past month). 4. Confounding behavior that increase risk = zero (indicating no behavior) A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 5/31/18, indicated the resident had moderately impaired cognition, was able to make self-understood and understand others. The MDS also indicated Resident 1 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. A review of Resident 1's Care Plan for Activities of Daily Living (ADLs - activities of daily living i.e., toileting, bathing, ambulating, etc.) dated 5/25/18 indicated the resident required assistance from staff with her ADLs due to dementia and poor safety awareness. A review of Resident 1's Dementia/Alzheimer's (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks) Care Plan dated 5/25/18 indicated the resident had dementia, memory loss, and was at risk for fall or injury due to wandering and impaired judgment/impaired motor control/weakness and fatigue. The intervention included maintain consistent routine and environment. The care plan did not address resident wandering behavior. A review of Resident 1's Situation Background Appearance and Review/Notification form (SBAR - used to facilitate prompt and appropriate communication between the health care team about a resident's condition) dated 6/1/18 indicated Resident 1 left the facility without notifying the staff. The note indicated Resident 1 was alert and oriented x 2 (resident was aware of two of four responses to person, place, time and event), which was described to be her normal state. A review of Resident 1's Licensed Nurses Progress Notes dated 6/1/18 indicated at 12:15 p.m., Resident 1's lunch tray was brought to her room but the resident was not present. The note indicated the unit manager and the administrator review the video footage dated (MONTH) 1, (YEAR) indicated the resident leaving the facility at 1:25 p.m. towards passed a nearby restaurant. At around 1:45 p.m., the note indicated the facility received a phone call from the local law enforcement indicating Resident 1 had tripped and fell which resulted in a [MEDICAL CONDITION] (cut) and as a result was taken to the GACH. The facility called Resident 1's family member who stated Resident 1 had a history of [REDACTED]. The family member stated Resident 1 attempted leaving her home, failing to realize she was already at home. A review of Resident 1's GACH Computer Tomography (an imaging procedure that uses special x-ray equipment to create detailed pictures, or scans, of areas inside the body) of the brain dated 6/1/18 the result indicated left frontal (front of the head) scalp swelling, laceration, and hematoma (a solid swelling of clotted blood within the tissues) without underlying skull fracture. A review of Resident 1's GACH X-ray (a quick and simple imaging test that can spot problems in bones, teeth, chest and more) of the ribs dated 6/1/18 the result indicated a displaced lateral right sixth rib fracture and a minimally displaced lateral right seventh rib fracture. During an interview on 3/29/19 at 2:15 p.m., the Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had fluctuating cognitive function and periods of confusion. LVN 1 stated that as a result of Resident 1 having been identified as having some risk for wandering, the resident was placed in a room near the nursing station and frequent monitoring was to be done by staff. LVN 1 was asked how the resident was able to elope with those interventions in place. LVN 1 stated that during the investigation it was discovered that Resident 1 walked out the front door and blended in with the crowd and was not noticed leaving by staff. During an observation on 3/29/19 at 7:02 a.m. of the facility's front door entrance, a receptionist is placed at the doorway. On 3/29/19 at 2:45 p.m., during an interview with the Director of Nursing (DON) the DON stated Resident 1 was not identified as a high risk for elopement. The DON could not answer why the elopement was not prevented even though the resident was identified on 5/25/18 at risk for fall or injury due to wandering and impaired judgment/impaired motor control/weakness and fatigue. A review of the facility policy and procedure titled Wandering and Elopement dated 8/1/12 indicated the facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement.

Based on interview and record review, the facility failed to ensure one of three residents (Resident 306) received a gradual dose reduction (GDR - the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) prior to the discontinuation of an anti-depressant ([MEDICATION NAME] - a psychotherapeutic medication used to treat depression-characterized by persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities). Resident 306 who received [MEDICATION NAME] 200 milligrams at bedtime did not receive a GDR before the [MEDICATION NAME] 200 mg was discontinued on 1/11/19. This deficient practice resulted in Resident 306 experiencing increased aggression and suicidality on 1/22/19 that resulted in a laceration (cut) to her wrist in a self-harm attempt and required a 15-day admission to a psychiatric hospital for mental stabilization. Cross reference F552 and F740 Findings: A review of Resident 306's admission record dated 1/18/19 indicated the resident was admitted to the facility on [DATE] from a General Acute Care Hospital 1 (GACH 1). Resident 306's [DIAGNOSES REDACTED]. Resident 306's responsible party, Family Member 1 (FM 1) with a cell phone contact number, was listed on the admission record in the event the resident required informed consent for discontinuation of medication including, psychotherapeutic medications. A review of Resident 306's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 1/14/19 indicated the resident had adequate hearing, impaired vision, clear speech, and was usually able to understand others, and was usually able to make herself understood. Resident 306's summary score for the Brief Interview for Mental Status (BIMS) was 10. A BIMS score of 10 indicates the resident had moderate cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) impairment. Resident 306 required limited assistance from one person for bed mobility, transfer, walking, dressing, toilet use, and personal hygiene. A review of Resident 306's Verification of Informed Consent, dated 12/31/18, and signed by Licensed Vocational Nurse 7 (LVN 7), indicated Resident 306 allowed the Physician (or designee) to speak to the responsible party regarding [DIAGNOSES REDACTED]. FM 1 had signed under Responsible Party indicating that she had given informed consent for: 1. [MEDICATION NAME] ([MEDICATION NAME] - a medication that is used to treat depression, panic attacks, [MEDICAL CONDITION], a certain eating disorder, and a severe form of premenstrual syndrome) 40 milligrams (mg) capsule by mouth every day; 2. [MEDICATION NAME] two 100 mg tablets (200 mg) by mouth at bedtime. A review of Resident 306's admission orders [REDACTED] 1. [MEDICATION NAME] 40 mg by mouth every day for depression manifested by persistent feelings of hopelessness/helplessness. 2. Monitor with hashmarks every shift for episodes of persistent feelings of hopelessness/helplessness. 3. Monitor for adverse side effects of [MEDICATION NAME] every shift (such as sedation, drowsiness, dry mouth blurred vision, [MEDICAL CONDITIONS] muscle tremor, agitation, headache, skin rash, photosensitivity, excess weight gain). Tally with hashmarks. 4. [MEDICATION NAME] 100 mg/tablets two tablets (200 mg) by mouth every day at bedtime for depression. 5. Monitor with hashmarks every shift for episodes of trouble falling asleep and staying asleep. 6. Monitor for adverse side effects of [MEDICATION NAME] every shift (such as sedation, drowsiness, dry mouth blurred vision, [MEDICAL CONDITIONS] muscle tremor, agitation, headache, skin rash, photosensitivity, excess weight gain). Tally with hashmarks. During an interview and concurrent record review on 2/26/19 at 8:59 AM, LVN 1 confirmed Resident 306's New Admission Medication Regimen Review, dated 12/31/18, indicated a Level 2 interaction - concurrent use of [MEDICATION NAME] and [MEDICATION NAME] may result in an increase in serum levels, toxicities, and/or clinical effects of [MEDICATION NAME]. She also confirmed that she had notified MD 1 of the pharmacy's recommendations and had noted on 1/1/19 at 8:44 AM that follow up was not needed because per MD, continue current medications, no new order. A review of Resident 306's History and Physical, dated 1/2/19 and signed by MD 1, indicated the resident has fluctuating capacity to understand and make decisions. A review of Resident 306's Behavior Management/Psychoactive Quarterly Review, dated 1/3/19, indicated staff reviewed the concurrent use of [MEDICATION NAME] and [MEDICATION NAME] and indicated no adverse side effects were noted for the resident. The review also indicated a trial dose reduction was contraindicated due to the resident had documented history of chronic mental illness depression and recommends continuing medications as ordered it provides benefit and it's effective in managing resident's behavior. There was no documented evidence MD 1 participated in the review. A review of Resident 306's Medication Administration Record [REDACTED]. On 1/10/19, the resident did not receive [MEDICATION NAME] as MD 1 ordered. There was no note indicating why Resident 306, did not receive [MEDICATION NAME]. There was no indication on the MAR from 1/1/19, to 1/11/19, that the resident had trouble falling asleep, staying asleep, or experienced any adverse side effects of [MEDICATION NAME] use. A review of Resident 306's Psychiatric Evaluation, dated 1/11/19, and signed by a nurse practitioner (NP 1), indicated NP 1's decision to discontinue the [MEDICATION NAME] and add [MEDICATION NAME] (a synthetic version of a naturally occurring hormone in the body that regulates sleep-wake cycles) 3 mg at bedtime. The evaluation indicated using [MEDICATION NAME] and [MEDICATION NAME] placed the resident at risk for serotoni[DIAGNOSES REDACTED] (Serotoni[DIAGNOSES REDACTED] - a condition when a resident has excessive nerve activity due to a brain chemical thought to play a role in depression). The evaluation indicated Will continue to monitor behavior, appetite/sleep. During an interview and concurrent record review on 2/26/19 at 8:59 AM, LVN 1 confirmed that Resident 306's clinical record indicated a care plan initiated on 1/1/19 with a concern of the resident having depressive behavior as manifested by depression manifested by trouble of falling asleep and staying asleep and was receiving [MEDICATION NAME] 200 mg at bed time. LVN 1 confirmed this care plan was discontinued on 1/11/19. There was no plan of care developed to address monitoring behavior, appetite/sleep or adverse effects for the reduction of [MEDICATION NAME]. A review of Resident 306's Physician Orders, dated 1/11/19 and signed by MD 1 indicated orders to: 1. Discontinue [MEDICATION NAME] 100 mg 2 tablets at bedtime for depression 2. Discontinue monitoring with hashmarks every shift for episodes of falling asleep. 3. Discontinue monitoring for adverse side effects of [MEDICATION NAME] every shift. A review of the National Library of Medicine (NLM) of the National Institute of Health (NIH) DailyMed website article, titled [MEDICATION NAME] and last updated 10/25/2007, indicated patients should be monitored for withdrawal symptoms when discontinuing treatment with [MEDICATION NAME] tablets. Withdrawal symptoms including anxiety, agitation and sleep disturbances, have been reported with [MEDICATION NAME]. Clinical experience suggests that the dose should be gradually reduced before complete discontinuation of the treatment. A review of Resident 306's laboratory report result dated 1/19/19 indicated the residents urine test had 3 plus leukocyte esterase (a type of urine test that checks for urinary tract infection - UTI - an infection in any part of the urinary system - the kidneys, ureters, bladder and urethra). MD 1 was notified on 1/19/19 at 9:30 AM. A review of Resident 306's Physician Orders, dated 1/19/19 at 9:30 AM, indicated an order to [MEDICATION NAME](a fluoroquinolone antibacterial used to treat infections) 500 mg by mouth twice a day for 7 days for UTI. A review of Resident 306's Situation Background Assessment Recommendation (SBAR) Communication Form indicated on 1/21/19, that the resident had increased confusion and irritability related to UTI. Her blood pressure was 121/68 millimeter of mercury (mmHg-a unit of measure), pulse was 74 beats per minute (bpm), respiratory rate was 19 bpm, and temperature was 97 degrees Fahrenheit. The resident was saying that she wants to kill herself and wanting to be alone and that she was feeling trapped and hopeless about a situation that she cannot go home. The SBAR indicates Resident 306 left the facility via ambulance on 1/21/19, at an unspecified time, to go to GACH 1. A review of Resident 306's clinical record from GACH 1 dated 1/21/19 indicated she was seen in the urgent care. The GACH 1 physician documented under Medical Decision Making that Resident 306's laboratory workup shows no abnormalities of acute significance in the CBC (complete blood count- a blood test used to evaluate your overall health and detect a wide range of disorders) and BMP (Basic Metabolic Panel- a group of blood tests). The ammonia level (a test to determine liver disease or kidney failure) is pending. The urinalysis (a shows brown color, small bilirubin (screening for liver disease) and [MEDICATION NAME] (produced when sugar is not available to the body's cells,) trace of blood and protein, 5-10 white (blood) cells, 5-10 RBC (red blood cells), few bacteria and calcium oxalate crystals (calcium oxalate crystals are considered normal,) and leukocyte esterase negative. The patient (resident) will be discharged if ammonia level is within normal limits. A review of Resident 306's laboratory results indicated on 1/21/19 at 6:20 PM, her ammonia level was 8 (normal value is 11-32). A review of Resident 306's Discharge Instructions of 1/21 19, at 7:34 PM from GACH 1 indicated the resident was discharged and provided education regarding Confusion. A review of Resident 306's Nursing Notes indicated on 1/21/19 at 10:15 PM, the resident was returned to the facility by ambulance from GACH 1. A review of Resident 306's Physician order [REDACTED]. A review of Resident 306's SBAR Communication Form indicated on 1/22/19, the resident was refusing to take medications, attempting to hit staff with her cane, purposely trying to make self-fall on floor. The resident's blood pressure was 142/72 mm/Hg, pulse was 98 bpm, respiratory rate was 24, and temperature was 98.4 degrees Fahrenheit. A review of Resident 306's Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment dated 1/22/19, (at an unspecified time), indicated the resident had been placed on a psychiatric hold (the detainment of a person in a hospital or mental health facility) for danger to self (DTS) and danger to others (DTO). The note indicated the resident cut her left wrist superficially, expressed to facility staff that she wanted to die, attacked facility staff, and attempted to elope from the facility. A review of Resident 306's Physician Order, dated 1/22/19, at 12:01 PM indicated an order to transfer to GACH 2 for further evaluation. A review of Resident 306's Licensed Nurses Progress Notes, dated 1/22/19 at 2:00 PM, indicated Resident 306 was in bed with a 1:1 sitter when the resident grabbed a picture frame and slammed it on her left wrist causing it to bleed slightly. Resident 306 became more combative, refusing assistance. Staff were able to calm resident and provided treatment to the one centimeter (cm) by one cm abrasion to her left wrist. A review of Resident 306's GACH 2 Urgent Care Triage Report dated 1/22/19 at 5:31 PM indicated the resident arrived at GACH 2 by ambulance with a chief complaint of medical clearance screening due to a superficial cut to the left wrist and a psychiatric hold for DTS/DTO. A review of Resident 306's GACH 2 Registration Record indicated the resident was admitted to inpatient behavioral health on 1/22/19 at 9:30 PM with a complaint of [MEDICAL CONDITION]. A review of Resident 306's GACH 2 Psychiatric Evaluation dated 1/22/19 and written by MD 2 indicated the resident decompensated with increasing paranoia (intense anxious or fearful feelings and thoughts often related to persecution, threat, or conspiracy), delusional content, confusion, responding to internal stimuli, aggression (and) striking out at caregivers. A review of Resident 306's GACH 2 Physician order [REDACTED]. A review of Resident 306's GACH 2 Physician order [REDACTED]. A review of Resident 306's GACH 2 Discharge Summary dated 2/7/19 and written by MD 2 indicated the resident was clinically better, not suicidal, not homicidal, not delusional, and could be managed at a lower level of care. During a telephone interview on 02/26/19 at 10:08 AM, the facility's pharmacy consultant (PHC) stated for successful discontinuation of [MEDICATION NAME], the resident's [MEDICATION NAME] should be tapered slowly, and gradually. During a telephone interview on 03/05/19 at 3:42 PM, the resident's attending physician at GACH 2 (MD 2), who provides oversight for NP 1, stated he would consider completely discontinuing a resident's antidepressant medication if the resident was having some sort of medical crisis or was having severe side effects to the medication. But under normal circumstances, I would recommend a gradual dose reduction. The elderly would be more prone to withdrawal symptoms and there are concerns about the behavioral symptoms returning. During the same interview, MD 2 stated he did not recall Resident 306 making any complaints regarding a UTI. MD 2 stated, The UTI could have caused some confusion, there was a lot more psychologically going on for the patient (resident). During a phone interview on 03/01/19 at 8:44 AM, FM 1 stated that Resident 306 was admitted to a different skilled nursing facility and her behavior improved when she was restarted on [MEDICATION NAME] at GACH 2. A review of the facility's behavior /Psychoactive Drug Management dated (MONTH) (YEAR), indicated dosage reduction or re-evaluations are provided according to OBRA regulations. The facility policy did not include specific procedures for discontinuation of psychotherapeutic medications that were used for chronic mental illness or for long term use of psychotherapeutic medications including [MEDICATION NAME].

Based on observation, interview, and record review, the facility failed to fully assess and manage a resident's pain timely and effectively for two of 36 sampled residents (Resident 51 and Resident 109) when the licensed nurses failed to: 1. Assess Resident 51 for pain after the resident reported to Restorative Nursing Assistants (RNAs-a restorative nurse's aide helps patients gain an improved quality of life by increasing their level of strength and mobility) his pain. The RNA documented the resident had pain, but the licensed nurses were unaware. 2. Report Resident 51's fall to physical therapy staff to review for functional change, until 8 days after the fall. 3. Assess Resident 109's pain intensity before and after pain medication administration. As a result, Resident 51 had a delay in assessment of over 4 weeks for left knee pain the resident initially reported during RNA treatment the week of (MONTH) 1, (YEAR). Resident 51 had a fall on (MONTH) 28, (YEAR), and the resident was not fully assessed for possible injuries until (MONTH) 7, (YEAR). Resident 51 was identified with a left knee joint effusion (when excess [DIAGNOSES REDACTED]-joint fluid, accumulates in or around the knee joint after an xray was done on (MONTH) 7, (YEAR). Resident 109's pain was not assessed before and after [MEDICATION NAME] (medication used to treat moderate to severe pain) administration and can lead to unrelieved or ineffective pain control. Findings: a. During an observation and concurrent interview with Resident 51 on (MONTH) 6, (YEAR) at 9:20 a.m., Resident 51 stated he had mucho dolor (or much pain) on his left knee when he moved it. Resident 51 was observed to have a left swollen knee. A review of Resident 51's admission record indicated the resident was originally admitted to the facility on (MONTH) 12, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 51's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool), dated (MONTH) 19, (YEAR), indicated the resident was cognitively intact in skills for daily decision-making. Resident 51 needed one person extensive assistance with transfer, walking, and dressing. There was no indication that Resident 51 complained of pain within the last five days. The MDS indicated a walker and wheelchair are the mobility devices Resident 51 commonly uses. A review of Resident 51's Pain Assessment, initiated (MONTH) 12, (YEAR), indicated there was no indication for complaints of pain by Resident 51. A review of Resident 51's Pain Monitoring Record for (MONTH) (YEAR) and (MONTH) (YEAR), indicated Resident 51 had no pain and no as needed pain medication was administered to the resident. A review of Resident 51's Pain Assessment of (MONTH) (YEAR), indicated Resident 51 made no complaints of pain. A review of the Physical Therapy (PT) Evaluation Assessment, dated (MONTH) 13, (YEAR), indicated there was no pain present from Resident 51. A review of Resident 51's Care Plan for Pain initiated on (MONTH) 13, (YEAR), indicated Resident 51 was at risk for pain. One of the goals indicated the resident will verbalize or show decreased signs and symptoms of pain. The care plan interventions indicated to assess pain medication and treatments for effectiveness and to monitor for vocal complaints of pain. A review of Resident 51's Care Plan for Range of Motion (ROM) Program, initiated (MONTH) 31, (YEAR) indicated the resident is at risk for decline in ROM and decrease in muscle strength. The goals indicated was to maintain/increase ROM and maintain/increase muscle strength. One of the interventions indicated was the RNA to provide PROM on both lower extremities five times a week. Another intervention indicated was the RNA is to ambulate patient when able every day, five times a week, as tolerated. A review of Resident 51's Physician order [REDACTED]. 1. Tylenol 650 milligrams (mg) by mouth every day thirty minutes prior to wound treatment for [REDACTED]. 2. Tylenol 650 mg by mouth every four hours as needed for mild pain severity 1-4/10. (reference range mild pain 1-4, (on a pain rating scale of zero being no pain, and 10 being the worst possible pain, severe pain is rated as 10 on a 1-10 scale), dated (MONTH) 12, (YEAR). 3. RNA to provide AROM (active range of motion- resident performs the exercise to move the joint without any assistance to the muscles surrounding the joint) on both lower extremities every day for five times per week as tolerated, dated (MONTH) 31, (YEAR). 4. RNA to ambulate (walk) patient when able every day for five times per week as tolerated, dated (MONTH) 31, (YEAR). A review of Resident 51's Restorative Nursing Weekly Summary - Ambulation for the week of (MONTH) 25, (YEAR), indicated Resident 51 walked a short distance and had complaints of some discomfort on the legs, charge nurse notified. There is no indication of how many days that week Resident 51 had discomfort. The Restorative Nursing Assistant (RNA) was not available for interview. A review of Resident 51's Restorative Nursing Weekly Summary - Ambulation for the week of (MONTH) 1, (YEAR), indicated Resident 51 complained of pain on left leg, very hard for him to make a step, charge nurse notified. There is no indication of how many days that week Resident 51 had discomfort. A review of Resident 51's Restorative Nursing Weekly Summary - Active Range of Motion (AROM- when patients move their limbs by themselves without assistance) for both lower extremities, for the week of (MONTH) 1, (YEAR), indicated Resident 51 did active assistive range of motion (AAROM-a term commonly used by physical therapists to refer to physical movements through the normal or available range of motion with assistance) motion on left leg due to complaint of pain, charge nurse notified. A review of Resident 51's Restorative Nursing Weekly Summary - Active Range of Motion (AROM) for both lower extremities, for the week of (MONTH) 8, (YEAR), indicated Resident 51 complained of some pain on left leg still, charge nurse notified. A review of Resident 51's Restorative Nursing Weekly Summary - Active Range of Motion (AROM) for both lower extremities, for the week of (MONTH) 22, (YEAR), indicated Resident 51 complained of discomfort on left leg. There were no weekly notes for the week of (MONTH) 1, (YEAR), for Resident 51. A review of Resident 51's Pain Assessment of (MONTH) (YEAR), and (MONTH) (YEAR), indicated Resident 51 made no complaints of pain during that time. A review of Resident 51's Physical Therapy Discharge Summary, dated (MONTH) 7, (YEAR), indicated Resident 51 needed moderate assistance for correct hand/foot placement to prepare for transfers. The document indicated Resident 51 is able to walk 15 feet with maximum assistance with a front wheeled walker. A review of Resident 51's Physician order [REDACTED]. 1. RNA to provide PROM (passive range of motion-therapist moves the joint through the range of motion with no effort from the patient) on both upper extremities and both lower extremities every day for five times per week as tolerated, dated (MONTH) 28, (YEAR). A review of Resident 51's Post Fall assessment dated (MONTH) 1, (YEAR), indicated the resident had a fall in his room on (MONTH) 28, (YEAR). The report indicated the resident had no injury and no complaints of pain. A review of Resident 51's undated Therapy Post-Fall Screen that was in Resident 51's records with the documentation of a fall that occurred (MONTH) 28, (YEAR) indicated physical therapy did not complete the screening as indicated by blank spaces in the therapist's signature and date fields. During an interview with the Director of Rehab (DOR) and concurrent record review, on (MONTH) 8, (YEAR) at 2:29 p.m., she stated the Therapy Post-Fall Screen was not completed because she was unaware of Resident 51 having a fall on (MONTH) 28, (YEAR). The DOR stated nursing staff did not notify her of Resident 51's fall. The DOR stated the screening should be completed sooner than 8 days after a fall. The DOR stated she will complete the form. A review of Resident 51's RNA notes for (MONTH) (YEAR), indicated Resident 15 was provided passive range of motion (PROM-the therapist or equipment moves the joint through the range of motion with no effort from the patient), on both upper and lower extremities, with no pain. The dates RNA worked with Resident 51 was (MONTH) 1, 5, 6, and 7, (YEAR). A review of Resident 51's Pain Assessment of (MONTH) (YEAR), indicated Resident 51 made no complaints of pain during that time except for a complaint of pain on (MONTH) 6, (YEAR), with an illegible time for complaints of left leg pain. No severity was indicated and there was no documentation after pain medication administration to assess if Resident 51 was still in pain. There was no indication that as needed pain medication was administered to Resident 51 at any other time. A review of Resident 51's Physician order [REDACTED]. 1. Left knee with swelling. Monitor for thirty days, dated (MONTH) 7, (YEAR). 2. X-ray to left knee, dated (MONTH) 7, (YEAR). 3. Orthopedic consult (medical field that focuses primarily on the study, diagnosis, and treatment of [REDACTED]. 4. [MEDICATION NAME] (used to treat moderate to moderately severe pain) 50 mg by mouth, one tablet every six hours if needed for pain, (MONTH) 7, (YEAR). 5. [MEDICATION NAME] (a medication used to manage mild to moderate pain) 400 mg by mouth twice a day for knee pain, dated (MONTH) 7, (YEAR). A review of Resident 51's Care Plan for [MEDICAL CONDITION] (swelling), initiated (MONTH) 7, (YEAR), indicated Resident 51 had left knee swelling. The goals indicated the resident will not have [MEDICAL CONDITION]. One of the interventions indicated to give medications and diet as tolerated. The care plan did not specify the medication to give or the specific type of diet to provide. A review of Resident 51's SBAR (Situation Background Assessment Recommendation-a technique that can be used to facilitate prompt and appropriate communication) Communication Form dated (MONTH) 7, (YEAR), indicated Resident 51 had complaints of pain to the left knee with slight swelling. The form indicated the left knee pain started on (MONTH) 7, (YEAR), and indicated there were no changes observed in functional status. The SBAR Communication Form did not include the resident had complained of pain to the RNA on (MONTH) 1, (YEAR), (MONTH) 8, (YEAR), (MONTH) 22, (YEAR), and did not include a history of a fall, that occurred (MONTH) 28, (YEAR). The Communication form option for decreased mobility was not indicated on the form. A review of Resident 51's x-ray report, completed on (MONTH) 7, (YEAR) at 5:33 p.m., indicated there was a left knee x-ray done. The x-ray report indicated the resident had a moderate-sized joint effusion. A review of Resident 51's Physician order [REDACTED]. 1. Hold RNA exercise of AROM on both lower extremities every day for five times a week and hold RNA to ambulate patient every day for five times a week until Monday, for joint effusion dated (MONTH) 8, (YEAR). During an interview with the Director of Rehab (DOR) and concurrent record review, on (MONTH) 8, (YEAR) at 2:29 p.m., she stated there was no indication Resident 51 had any pain upon walking for the month of (MONTH) (YEAR) when the resident was working with physical therapy. The DOR stated Resident 51's prior level of function was walking with no assistive device while living in an assisted living facility. A review of Resident 51's undated Interdisciplinary Team (IDT-a coordinated group of experts from several different fields) Baseline (initial) Care Plan and Summary gave no indication of Resident 51 having pain or had a potential for pain. A review of Resident 51's Pain Re-Assessment, dated (MONTH) 7, (YEAR) indicated Resident 51 had a new onset of pain to the left knee. The severity level was 5-7/10 or moderate pain. The medication indicated to be given was [MEDICATION NAME] 50 mg by mouth every six hours as needed for pain. There was no frequency of pain indicated. The section for no worst pain intensity in last 5 days was blank. There was no documentation indicated for the question: Does the pain make it hard to sleep at night, and limit day to day activities. During an interview on (MONTH) 7, (YEAR) at 11:15 a.m., when Resident 51's pain was brought to attention of the Director of Staff Development (DSD), stated she was unaware of Resident 51's pain. A review of Resident 51's Physician's Progress Record dated (MONTH) 8, (YEAR), indicated Resident 51's left knee was swollen with palpable (able to be felt). The progress record indicated the interventions for the knee effusion was to provide an orthopedic consultation, administer [MEDICATION NAME] twice a day and [MEDICATION NAME]. During an interview with RNA 2 on (MONTH) 8, (YEAR) at 10:35 AM, he stated Resident 51 had left leg pain on (MONTH) 5, 6, and 7, (YEAR), but did not notify licensed staff. RNA 2 stated he should have notified staff of Resident 51's pain. RNA 2 stated he did not complete the previous weeks RNA weekly notes, on (MONTH) 1, (YEAR), because he was behind in documentation. During an interview on (MONTH) 8, (YEAR) at 11:00 a.m., Resident 51 stated he had left knee pain with a severity 6/10 that really hurt. Resident 51's face displayed facial grimacing. Resident 51 stated he was unable to walk because the pain was too unbearable. During an interview with Licensed Vocational Nurse 1 (LVN 1) on (MONTH) 8, (YEAR) at 11:53 a.m., she stated she was not aware of Resident 51's pain as documented in the weekly RNA notes for (MONTH) (YEAR) and (MONTH) (YEAR). During an interview with RNA 1 on (MONTH) 8, (YEAR) at 1:00 p.m., she stated she documented on the RNA Weekly Summary Notes of Resident 51's pain. RNA 1 stated when Resident 51 had pain she notified the charge nurse as she had documented. RNA 1 stated she told Licensed Vocational Nurse 3 (LVN 3). During an interview with LVN 3 on (MONTH) 8, (YEAR) at 3:00 p.m., he stated he was unaware of any RNA notifying him Resident 51 was having any pain when Resident 51 was working with the RNA. A review of the facility's policy and procedure titled Pain Management, revised (MONTH) (YEAR), indicated a licensed nurse will assess each resident for pain when there is a new onset of pain. The nursing staff will implement timely interventions to reduce an increase in the severity of pain. The policy indicates after medication/interventions are implemented, the licensed nurse will re-evaluate the resident's level of pain within one hour. The policy indicates the IDT will document the following: summary of event causing the pain, underlying conditions that contribute or cause pain, root cause analysis, referrals as necessary, and interventions to avoid future pain when possible. A review of the facility's policy and procedure titled, Performing Range of Motion Exercises, revised (MONTH) 1, 2012, does not indicate any instructions for documentation for a resident's pain or with who to notify. A review of the facility's policy and procedure titled Fall Management Program dated (MONTH) 7, (YEAR), indicates fall are not just a nursing issue. In addition to nursing and other staff evaluation, the post fall IDT should include as appropriate consideration of medication regimen by the pharmacist, physical or occupational therapy review for functional change, physician review for medical conditions affecting fall risk. b. A review of the admission record indicated Resident 109 was readmitted to the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated (MONTH) 21, (YEAR), indicated Resident 109 was cognitively intact. Resident 109 experienced occasional pain (five out of 10 on a zero to ten pain rating scale). A review of Resident 109's physician order [REDACTED]. On (MONTH) 9, (YEAR) at 9:47 a.m., during an observation, Resident 109 was sitting at the edge of the bed. During a concurrent interview, Resident 109 stated the licensed nurses were not administering her pain medications timely. Resident 109 stated that when in pain, she would request her pain medication, but would not receive it until 45 minutes after her initial request. Resident 109 stated that she sometimes had to request for pain medication more than once. A review of the Narcotic and Hypnotic Record indicated Resident 109 received [MEDICATION NAME] 10 mg-325 mg two tablets on (MONTH) 11, (YEAR) at 10:30 a.m., 10:30 p.m., and (MONTH) 12, (YEAR) at 5 a.m. A review of the Pain Assessment Flowsheet did not indicate Resident 109 received [MEDICATION NAME] 10 mg-325 mg two tablets on (MONTH) 11, (YEAR) at 10:30 a.m., 10:30 p.m., and (MONTH) 12, (YEAR) at 5 a.m. A review of Resident 109's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. On (MONTH) 12, (YEAR) at 12:46 p.m., during an interview, Licensed Vocational Nurse 9 (LVN 9) stated that the facility's procedure was document a resident's pain management in the Narcotic and Hypnotic record, the Pain Assessment Flow Sheet, and MAR. LVN 9 stated that Resident 109's Pain Assessment Flowsheet did not indicated on (MONTH) 11, (YEAR) at 10:30 a.m., 10:30 p.m., and (MONTH) 12, (YEAR) at 5 a.m. LVN 9 also stated that she could not determine Resident 109's pain level at the time she received [MEDICATION NAME]. LVN 9 stated that there should have been an assessment of Resident 109's pain before and after [MEDICATION NAME] administration. A review of the facility's undated policy titled Pain Management indicated the licensed nurse will administer pain medication as ordered and document medication administered on the MAR. After medications/interventions are implemented, the licensed nurse will re-evaluate the resident's level of pain within an hour. Nurses will complete the Pain Flow Sheet for residents receiving PRN pain medication to evaluate the effectiveness of the medication regimen. The licensed nurse will assess the resident for pain and document results on the MAR indicated [REDACTED]. The Nursing staff will implement timely interventions to reduce an increase in severity of pain. The nursing staff will also utilize non-pharmacological interventions to address possible issues contributing to pain.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement plan of care interventions for one sampled resident (Resident 1). For Resident 1, who had a history of [REDACTED]. These deficient practices resulted in Resident 1 being found in the bathroom slumped on the floor, pale face, cold to touch, and unresponsive, three days after the resident was discharged from the general acute care hospital (GACH) psychiatric unit. Resident 1's lower extremities were cyanotic (blue or purple in color), and he had a shoelace wrapped around his neck where the registered nurse had to cut him free. Paramedics were called and declared Resident 1 expired. Findings: A review of the general acute care hospital records (GACH) Emergency Department Summary Report indicated Resident 1 was taken to the emergency room , on [DATE], on a 5150 hold (involuntary psychiatric hold on one suspected to have a mental disorder that makes them a danger to themselves, a danger to others, and/or gravely disabled). A review of the GACH History and Physical, dated [DATE], indicated Resident 1 was admitted to the geriatric/psychiatric ward for history of depression, danger to self for feeling depressed, and increasingly suicidal over the past several days. The GACH history and physical indicated Resident 1 verbalized wanting to hang himself. A review of the GACH's Involuntary Patient Advisement form, dated [DATE], indicated Resident 1 was placed on a 72 hour hold starting [DATE], due to the resident being increasingly depressed, suicidal over the past several months, and the resident reporting being, suicidal everyday. A review of the GACH Consultation Report, dated [DATE], indicated Resident 1 received Zyprexa 5 milligrams (mg) at bedtime for psychosis, Ativan 1 mg every six hours as needed for anxiety, Wellbutrin SR (slow release) 150 mg every day for depression then increased to 200 mg on [DATE], Cymbalta 20 mg at bedtime for depression, Restoril 7.5 mg at bedtime as needed for insomnia (difficulty falling or staying asleep), and Trazadone 100 mg at bedtime for depression (six different medications). A review of the GACH Nurses' Notes, dated [DATE], indicated Resident 1 was found in the bathroom, standing with a bed sheet around the resident's neck. The resident was alert and found to have redness around the neck area. A 1:1 (one to one) sitter was ordered for safety. According to the GACH Progress Note, dated [DATE], Resident 1 was assessed with [REDACTED]. The progress note indicated the plan, per psychiatry, advised a continued 1:1 sitter and follow up with psychiatry for continued management, with recurrent attempt for suicide. A review of the GACH Psychosocial Assessment, dated [DATE], indicated Resident 1 was depressed, tearful due to the second attempt of suicide on [DATE], and stated he was unable to stop impulses of feeling useless. On [DATE], the Psychosocial Assessment indicated the resident was depressed with negative thoughts, not wanting to get psychologically better. A review of the Psychiatrist Progress Note, dated [DATE], indicated Resident 1 remained on 1:1 supervision. A review of the GACH Psychiatrist's Progress Notes, dated [DATE], indicated Resident 1 was obsessing about attempting to harm himself while on the unit. A review of the resident's Assessment Plan, dated ,[DATE] and [DATE], indicated the resident had severe depression with suicidal ideation and intent, remained with a 1:1 sitter, and the plan was to continue 1:1 sitter and psychiatric management, per psychiatry. A review of the GACH Psychiatrist's discharge order, dated [DATE], indicated Resident 1 was admitted to the acute hospital on 5150 hold for depression and was suicidal. The resident was to be followed-up with the facility internist and psychiatrist. According to the GACH Geri-Psych Discharge Instructions, dated [DATE], at 2:30 p.m., the expected course of recovery was six months and to hold discharge, to follow up with psychiatric and medical doctors. Resident 1's present illness at the time was major depressive disorder, severe recurrent (depression, a mental disorder characterized by at least two weeks of low mood). The discharge instructions indicated Resident 1 was alert, oriented, and ambulatory, and the follow-up care indicated referrals for Medical Therapy, follow-up with internist and Psychiatric Therapy follow-up with psychiatrist. A review of the skilled facility clinical record indicated Resident 1 was admitted , on [DATE], with diagnoses which included acute renal failure (damage to the kidneys), recurrent major depressive disorder, psychosis (characterized by an impaired relationship with reality, a symptom of serious mental disorders) not due to substance or known physiological condition, and anxiety disorder. There was no diagnoses of history of suicide or suicidal ideation. A review of the physician's orders [REDACTED]. depression manifested by episodes of persistent feelings of hopelessness and helplessness, Restoril 7.5 mg at bedtime as needed for insomnia (difficulty falling or staying asleep) manifested by episodes of inability to sleep, and Trazadone 100 mg at bedtime for depression manifested by episodes of persistent fatigue or loss of energy (six different medications). A review of Resident 1's care plan for behavioral and psychotropic medications (any medication capable of affecting the mind, emotions, and behavior), dated [DATE], indicated the nursing interventions were to determine triggers and de-escalation techniques, monitor for antecedal behaviors, minimize environmental stressors, utilize diversion distraction or redirection to limit reoccurrence, and social services to encourage expression of anger, frustration, and guilt. The care plan did not indicate the frequency to monitor the resident. According Resident 1's Medication Administration Record, dated [DATE], at 11:20 p.m., Ativan 1 mg was administered to the resident for anxiety and a review of the resident's licensed progress notes, dated [DATE], indicated no documented evidence the facility staff provided above interventions to relieve the resident's anxiety. During an interview, on [DATE], at 10 a.m., when asked if staff conducted the care plan interventions with Resident 1, the DON stated the resident was fine. According to Nurse's Drug Guide, 2017, the nursing implications (nursing-related consequences of something, the things which may occur which are up to the nurse to resolve) for Ativan indicated to supervise the resident who exhibited depression with anxiety closely, the possibility of suicide exists. The nursing implications for Cymbalta indicated to monitor closely for and report suicide ideation, especially when drug was initiated or dosage changed. A review of Resident 1's care plan for history of suicidal ideation, dated [DATE], indicated the goals included for the resident to discuss to staff and nurse, things that can trigger suicidal thoughts, and the resident would state he believed his life had value. The care plan interventions included being alert of the resident's behaviors especially decreased communication, conversation about death, to be alert for any manipulative attention seeking behavior, assess or identify situations that may trigger suicidal thoughts, and clarifying things that were not under residents control such as other's actions, choices and health status. A review of Resident 1's care plan for history of suicidal attempts, dated [DATE], indicated the goals included for the resident to have no recurring suicidal thoughts and express feelings and concerns to staff. The care plan interventions included orienting the resident to new environment, assess for negative emotions, anger, anxiety and depression, redirect behavior, obtaining a psychiatric and psychology consult. A review of the licensed nurses progress notes dated [DATE], indicated Resident 1 was assessed by occupational therapy with a recommendation made for treatment. There was no documentation regarding Resident 1's psychosis, being alert of the resident's behaviors especially decreased communication, or conversation about death, orienting the resident to new environment, assessing for negative emotions, anger, anxiety or depression, per the care plan. According to the physician's orders [REDACTED]. A review of the clinical record indicated there was no documented evidence Resident 1 was seen by the psychiatrist or psychologist while in the skilled nursing facility from [DATE] - [DATE]. On [DATE], at 9:30 a.m., an interview was conducted with RN 1 who stated, on [DATE] around 9:30 a.m. through 10 a.m., RN 1 was going over medications with Resident 1. During this time, the resident asked to speak with the Psychiatrist and Nurse Practioner (NP) regarding making adjustments to the medications. RN 1 called the Psychiatrist office and spoke with the NP. RN 1 informed the NP of the resident's requests, and the NP informed RN 1 she would come visit the resident on Monday, [DATE] (three days later). A review of the Social Service Notes, dated [DATE] (no time documented), indicated Resident 1 was scheduled to see the psychologist on [DATE] (6 days after resident admitted to the facility). This indicated a psychiatric and psychology consult was not conducted, per the plan of care. A review of the licensed nurses progress notes dated [DATE], indicated laboratory results were received and sent to the physician. There was no documentation regarding Resident 1's psychosis, being alert of the resident's behaviors especially decreased communication, or conversation about death, orienting the resident to new environment, assessing for negative emotions, anger, anxiety or depression, per the care plan. According to the clinical record and licensed nurses progress notes, dated [DATE], the social services department and/or licensed nurse did not interview Resident 1 to determine if the resident had an immediate plan to injure himself, per facility policy. During an interview, on [DATE], at 10 a.m., when asked if staff implemented any of Resident 1's care plan interventions or followed facility policy regarding care, the DON stated the resident was fine. A review of the Change of Condition Assessment Form, dated [DATE], at 4:20 p.m. (three days after admission) indicated Resident 1 was found in the bathroom unresponsive with a shoelace wrapped around the resident's neck. The charge nurse documentation on the change of condition form indicated, at 4:30 p.m., LVN 1 heard CNA 1 calling for help. LVN 1 came to Resident 1's room and found the resident slumped on the floor with the resident's back against the wall and a cord wrapped around the resident's neck. LVN 1 immediately called 911 and asked for assistance. LVN 1 found the resident unresponsive, pale face, cold to touch, lower extremities cyanotic (blue or purple in color), no pulse and not breathing. The change of condition form indicated RN 1 cut the cord from Resident 1's neck with scissors in an attempt to render CPR (cardiopulmonary resuscitation). The paramedics arrived at the facility, rendered CPR for two to three minutes with no success and declared Resident 1 expired. On [DATE], at 10:10 a.m., an interview was conducted with Admissions Coordinator/Marketing who stated, on [DATE], no time specified, the social worker from the GACH contacted him stating Resident 1 was ready to be discharged . The Admissions Coordinator stated he visited Resident 1 at the psychiatric ward of the GACH which was a locked unit. The Admissions Coordinator stated the goal for Resident 1 was to be transferred to the skilled nursing facility for physical therapy and rehabilitation. During an interview, on [DATE], at 11 a.m., Certified Nursing Assistant 2 (CNA 2) stated Resident 1 was alert, oriented, and was independent with walking in and out of the facility. CNA 2 stated she last saw the resident in bed at 2:45 p.m., on the day of the incident ([DATE]). CNA 2 stated the nursing staff never informed her Resident 1 had problems with suicide attempts or hurting himself, and had she known, she would have monitored the resident more often. On [DATE], at 1 p.m., a telephone interview was conducted with CNA 1 who stated on the day of the incident ([DATE]), around 4:20 p.m., CNA 1 went to check on Resident 1's roommate. The roommate asked CNA 1 to check on Resident 1 in the restroom because the resident had been gone for a while. CNA 1 stated she opened the bathroom door in the room and found the resident sitting on the floor with a shoelace wrapped around the resident's neck. CNA 1 yelled out for help and LVN 1 ran in to the room. During a telephone interview, on [DATE], at 1:30 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on the day of the incident ([DATE]), CNA 1 yelled out for help. LVN 1 ran to Resident 1's room and found the resident slumped on the floor with a shoelace or cord tied to the resident's neck on one end and the other end was tied to the grab/towel bar. The resident was not responsive. LVN 1 stated she attempted to loosen the cord, but it was too tight. LVN 1 called 911 paramedics and called for help. RN 1 cut the cord with scissors and attempted to render CPR. On [DATE], at 11:20 a.m., an interview was conducted with Resident 1's roommate (Resident 2), who was alert and oriented. Resident 2 stated he was admitted to the facility on [DATE] and Resident 1 confided in him stating he was, useless, had no purpose in life, and not wanting to live. Resident 2 stated he was unaware Resident 1 attempted suicide in the past and he would have asked the staff to monitor him more closely had he known the resident had a history of [REDACTED]. During an interview, on [DATE], at 10:10 a.m., the DON stated if Resident 1 showed signs or stated he was suicidal, then the facility would take actions to supervise and prevent the resident in attempting suicide, but since he seemingly did not show signs, they expected him to solely receive physical therapy rehabilitation and go home. However, the DON also stated he was aware of Resident 1's psychological medical condition due to a previous denial of Resident 1's admission to the facility on e day prior. According to the facility's in service calendar, dated from [DATE] through [DATE], facility staff were not trained regarding how to handle residents with psychological disorders or handling residents with a history of multiple suicide attempts. A review of Resident 1's Certificate of Death, dated [DATE] at 4:40 p.m., indicated the immediate cause of death was Asphyxia (a lack of oxygen or excess of carbon dioxide in the body that results in unconsciousness and often death and was usually caused by interruption of breathing or inadequate oxygen supply). The Certificate of Death indicated the underlying cause of death was by 'hanging'. The description of how injury occurred was by hanging self with a ligature (a thing used for tying or binding something tightly). A review of the facility's policy and procedure titled, Behavior - Threats to Harm Self, dated [DATE], indicated the facility was to respond appropriately to residents who were verbalizing suicidal thoughts and/or comments about self-harm. The procedures included social services department and/or licensed nurse would interview the resident to determine if the resident had an immediate plan to injure him/her self.

Based on observation, interview, and record review, the facility failed to prevent an accident that resulted in a nasal bone fracture (broken nose) and multiple lacerations to the face that required a surgical repair for one out of 30 sample residents (30) by failing to: 1. Ensure that Resident 30's bed side rail facing the wall was in an upward position to prevent a fall while Certified Nursing Assistant 7 (CNA 7) provided care to the resident on the opposite side. 2. Ensure Resident 30's bed wheels were locked while providing care, to prevent undesired movement of the bed that resulted in the resident's fall from the bed to the floor, face down, when CNA 7 turned the resident to the left side (facing towards the wall) during incontinent care. 3. Ensure that Resident 30 who was assessed at risk for falls, had a body weight of 262 pounds, had severe limitations to all four extremities and who was totally dependent on the facility staff, was provided a two-person assist while providing incontinent care. These violations resulted in Resident 30's fall from the bed to the floor. Resident 30 sustained injuries that included a nasal bone fracture, and a complex laceration (the term usually used by clinicians to describe a wound which may have a number of problems present) of the face measuring approximately 3 by 3 centimeters/cm that caused pain, bleeding, and required surgical repair with six stitches. Findings: On December 9, 2015, the Department received a complaint (CA 246) that alleged resident neglect, admission, transfer, and discharge rights, and quality of care and treatment. Investigation of the complaint was initiated during a recertification survey. According to the admission record, Resident 30 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. Early MS symptoms include weakness, tingling, numbness, blurred vision, muscle stiffness, thinking problems, and urinary problems). The Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated August 4, 2015, indicated Resident 30's cognitive skills for daily decision making were intact, he was totally dependent on staff (two or more persons for assist) for personal hygiene, bathing, and toileting. Resident 30 was 71 inches (6 feet 1 inch) tall and weighed 262 pounds. The MDS indicated the resident was unable to use his upper and lower extremities (arms and legs). Resident 30's plan of care initiated on February 5, 2015, revised August 4, 2015, indicated he was at risk for falls related to limited mobility, poor balance, motor deficit, and totally dependent with care. The goal was to demonstrate preventative measures to minimize injury. The interventions included to assist the resident as needed, keep both half-upper side rails in an upward position, encourage use of assistive devices (side rails), and to keep the bed in a low position. The care plan for personal hygiene and toileting indicated he was totally dependent on staff (two or more persons). A review of the fall risk assessment dated , September 9, 2015, indicated Resident 30 scored 10. According to the assessment tool, the total score of 10 or greater represented a high risk for falls. On December 15, 2015, at 8 p.m., during a room visit, Resident 30 was observed sitting in his motorized electric wheelchair next to his bed. The resident's bed wheels were observed unlocked. Resident 30 during an interview stated, on September 9, 2015, at 12:20 a.m., CNA 7 responded to his call light to provide him incontinent care (to clean and change soiled incontinent briefs) by himself without assistance from another staff member. Resident 30 stated the bed wheels were not locked because he usually senses the movement of the bed when the bed wheels are unlocked. Before CNA 7 started to provide care, he did not pull up the side rails on the opposite side (left side) to prevent a fall. Resident 30 stated when CNA 7 was cleaning him he turned him on his left side facing the wall, on the side the bed side rails were not in upward positions. When the bed moved, he fell on the floor with his face down. According to Resident 30, if the bed side rails had been up, the bed side rails would have guarded him from the fall. He stated his fall would have been prevented if the bed wheels were locked to prevent the bed movement because when the bed moved, without the bed rail in an up position to guard him, a gap was created and he dropped to the floor with his face down. Resident 30 stated, I knew it was going to happen. On December 15, 2015, at 8:10 p.m., during an interview CNA 6 stated the bed wheels should have been locked when providing care to any resident and did not know why the bed wheels were not locked. CNA 7 was not available for interview. On December 15, 2015, at 9:50 p.m., during an interview Licensed Vocational Nurse (LVN 15) stated Resident 30 always required two staff members while providing care. She stated the staff should not have attempted to provide incontinent care for Resident 30 because of his weight, and he could not use his arms or legs (to help). A Review of the facility's investigative report, dated September 9, 2015, indicated on September 9, 2015, at 12:20 a.m., LVN 15 heard the fall and immediately went to the room and applied first aid with dressing. Resident 30 was alert and responsive. The resident fell and sustained a skin tear above the left upper eye brow with bleeding, that measured 3 by 3 cm. A neuro check (used to determine the level of consciousness) was done and the resident reported a pain level of 7 on a pain assessment scale (scale of 0 to 10, 10 being the worst pain). The resident received Oxycodone IR (immediate release narcotic) 30 milligram (mg) for pain control. At 12:45 a.m., the nurse supervisor alerted a physician, who gave orders to transfer the resident to a general acute care hospital (GACH) for further evaluation and care. According to the investigative report, when Resident 30 was asked about the incident, he stated that the side rails were not up. Resident 30 claimed that CNA 7 pushed him towards the wall to clean him up and that was why he fell out of bed. At 4:40 a.m., the resident was transferred to the GACH. A review of the GACH's after visit summary, dated September 9, 2015, indicated Resident 30 was diagnosed with [REDACTED]. Resident 30 required six stitches on the face. Resident 30 was discharged from the GACH emergency department and readmitted to the skilled nursing facility on the same day, September 9, 2015.

Based on observation, interview, and record review, the facility failed to prevent an accident that resulted in a fracture to the right hip from a fall, for one out of 29 sample residents (Resident 25) by failing to: 1.Closely monitor Resident 25 who was assessed as being a high risk for falls, and was receiving Risperdal, a medication with side effects that include lowering or raising the blood pressure, dizziness, and fainting. 2. Provide close supervision with frequent and scheduled nursing rounds to prevent falls as indicated in the plan of care. The above deficient practices resulted in Resident 25's broken hip with associated pain due to a fall that required surgery under general anesthesia, with potential complications associated with surgery under general anesthesia and hospitalization for seven days. The facility also failed to ensure all residents' environment remained as free of accident hazards as possible by failing to: 3. Ensure the refrigerator where specimens were stored was kept locked and inaccessible to confused residents or unauthorized persons to prevent the potential for ingestion of unprescribed medications for one out of four nursing stations. 4. Ensure the trash cans in the resident's smoking patio were enclosed to prevent potential for fire hazards. 5. Ensure that the television set in Room 26-A was securely anchored to prevent potential injuries in case of it falling on a resident. 6. Ensure the medication cart was locked at all times and that medications were not left at a resident's unsecured bedside drawer to prevent the potential accidental access to and ingestion of the medications by confused residents. Findings: a. On August 22, 2014, the Department received an Entity Reported Incident (ERI CA 519) that alleged Resident 25 tried to walk unassisted without asking for help. The resident lost her balance falling on her right side, complained of right hip pain, and was transferred to the general acute care hospital (GACH) on August 21, 2014, for evaluation of a broken hip. On August 26, 2014, the ERI was investigated during the annual survey. According to the admission record Resident 25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS, a standardized assessment and care screening tool) dated August 12, 2014, indicated Resident 25 sometimes makes self-understood and understands others, required total assistance from staff with transferring to her bed, chair, wheelchair, and to a standing position, and was totally dependent on staff for toileting and ambulation in the room. The MDS under Care Area Assessment (CAA) indicated triggers for falls, psychotropic drug use, and urinary incontinence as areas of concern requiring further assessment. The resident had the following physician's orders [REDACTED]. 1. Low bed with bilateral upper half side rails/floor pads for safety because of risk for fall. 2. Risperdal one milligram (mg) by mouth twice a day for a mental disorder. (Risperdal is an antipsychotic medication with adverse drug reactions that included lowering or raising the blood pressure, dizziness, and syncope (fainting) Nursing Drug Handbook 2015, Pages 1243-1244). The Physical Restraint Assessment form dated July 30, 2014, indicated that a body alarm was attempted, but was ineffective because the resident removed the alarm. (A body alarm is a sensor that is attached to the resident and sounds to give an early alert for caregivers when a resident is trying to get out of a chair or bed unassisted). Other less restrictive measures that were documented as "ineffective" were to anticipate the resident's needs and give her safety reminders, because she was unable to use a call light due to her mental impairment. The form also had approaches that included repositioning and visual checks, however, there was no indication as to the frequency of these approaches. There was a plan of care initiated on July 30, 2014, for at risk for fall as a problem related to: limited mobility, poor balance, lack of awareness, cognitive deficit, medication (Risperdal), impulsive behavior, and forgets to call/wait for assistance. The goals on the plan of care included the resident would ask/wait for assistance, and risk for fall/injury will be minimized with staff's interventions. The interventions were: low bed with upper half side rails to both sides of the bed, and floor pads to both sides of the bed for safety, assist resident as necessary, "frequent" visual checks to monitor resident's needs, and anticipate/meet resident's needs. There was no indication as to how the resident was expected to call/wait for help or how staff could anticipate needs since the resident was assessed as lacking awareness with dementia, and these had been listed as "ineffective" on the Physical Restraint Assessment form. There was also no indication as to what time frame was meant by "frequent" visual checks, and there was no specific interventions related to Risperdal. The Interdisciplinary Team (IDT) had a conference meeting on August 1, 2014, to discuss risk for falls, medications, and the care plan for Resident 25. The plan was for the staff to anticipate the resident's needs, however this had been determined as "ineffective" on the Physical Restraint Assessment form dated July 30, 2014. The Certified Nurse Attendant (CNA) was to walk the resident daily, take her to the bathroom, and use a toilet plan. A review of the Fall Risk assessment dated [DATE], indicated that the resident had a score of sixteen that represented a high risk for falls. According to the Nurses' Notes (notes) dated August 21, 2014, at approximately 3 p.m., Resident 25 was noted to be alert, responsive to verbal stimuli but confused/disoriented. The resident was reoriented to place and date only. At 5 p.m., documentation indicated the resident was observed attempting to get out of bed, at which time she was encouraged to "call for assistance" even though this had already been ineffective on July 30, 2014. The next documented note was at 6 p.m. where the resident was assisted to dinner; at 7 p.m. a visual was done, and at 8 p.m. hygiene was provided. Since the notes had indicated that the resident was unable to follow directions, and had just attempted to get out of bed unassisted, there was no indication that a staff person had been assigned to closely monitor the resident in an attempt to prevent falls. According to the Nurse's Notes dated August 21, 2014, at 8:45 p.m., Resident 25 was found on the floor next to her bed. The resident complained of a painful right leg. Norco (pain medication) 5/325 milligram (mg) one tablet was administered by mouth. The physician was notified and an order was obtained to transfer the resident to the GACH, which occurred at 9:30 p.m., according to the documentation. The specific circumstances regarding the incident of fall was not documented, including whether there were landing pads applied to both sides of the bed, and whether the resident landed on the pad if they were present, in accordance with their policy noted below. A post fall plan of care had been initiated, however some of the interventions included were previously found to be ineffective. A review of the Medication Administration Record (MAR) for August 2014 indicated Resident 25 regularly received Risperdal twice a day. On August 21, 2014, the day of the fall incident, Resident 25 had received her prescribed Risperdal at 9 a.m. and 5 p.m., the last dose was administered approximately three hours before her fall. The MAR reflected monitoring for the behavior of anger outbursts. During an interview on August 28, 2014, at 4:50 p.m., regarding Resident 25's fall incident, licensed vocational nurse 4 (LVN 4) stated he found the resident on the floor on the side of her bed. He stated that Resident 25 was probably trying to get out of bed to go to the bathroom, because the resident was always requesting to use the bathroom. He stated the resident gets confused, does not speak English, and that she had not attempted to get out of bed with him, but has tried when other staff were in the room with her. LVN 4 stated an alarm had been attempted previously, but she kept removing it. He said that he checked on the resident frequently but did not document it, and that Resident 25 would have been a good candidate for one-on-one monitoring because of her confusion and unpredictable behavior. LVN 4 did not state whether the landing pads were in place when he found the resident on the floor. During interviews with the DON on August 28, 2014, at approximately 8:30 a.m., and on August 29, at 1:15 p.m., she stated that Resident 25 was placed in a room with an alert roommate to watch her. When asked if the roommate was responsible for monitoring Resident 25, the DON stated that the monitoring was the facility's responsibility and not the responsibility of the roommate. She stated that the roommate had signed a statement regarding what she observed when Resident 25 fell . The DON was not able to provide documented evidence that indicated scheduled nursing rounds in which the nursing staff would perform specific tasks at set intervals and/or monitor the resident, in accordance with the plan of care, in an attempt to prevent a fall incident. The DON stated that the use of a body alarm was attempted but discontinued because the resident kept removing it. She could not provide any documented evidence of structured monitoring done by the staff at "frequent" intervals, as indicated in the current care plan. The DON stated that the facility has a practice of providing one-to-one monitoring, but could not provide documented evidence that this intervention had been considered for Resident 25, especially when it had been documented that the resident had attempted to get up unassisted, shortly before her fall incident. A review of the post fall care plan dated August 22, 2014, to be in place if Resident 25 returned to the facility, now included one-to-one monitoring as an intervention. A review of the facility's Abuse Allegation Investigation form for the August 21, 2014 incident, and dated August 22, 2014, indicated that Resident 25's roommate had witnessed her trying to walk unassisted, loose her balance and fall on the floor. The form did not indicate specific circumstances regarding the incident, such as whether the landing pads were in place at the time that LVN 4 found her, in accordance with their policy below. According to the current standard of nursing practice, falls frequently occur when residents get out of bed to go to the bathroom, walk to or from the bathroom, or experience an episode of incontinence. Frequent "structured" nursing rounds in which the nursing staff would perform specific tasks at set intervals could help reduce the incidence of falls. Studies have demonstrated the benefits of having structured frequent rounds and performing specific nursing actions, such as asking whether the resident needed anything and assisting with toileting at set intervals was associated with statistically significant reductions in the incidence of falls, and with an increase in resident satisfaction (Safe and Reliable Care, American journal of Nursing, July 2009, Volume 109 No. 7, Pages 70-71). A review of the acute emergency room Report dated August 21, 2014, indicated that Resident 25's chief complaint was a painful right leg, and morphine was given for pain. An x-ray was done, and revealed a right femoral neck fracture (where the leg bone attaches to the hip bone) due to a fall. The resident was admitted to the hospital for the repair of the fractured bone. According to the Operation Report dated August 22, 2014, Resident 25's preoperative [DIAGNOSES REDACTED]. The resident had surgery under a general anesthesia to repair the fractured bone that placed the resident at risk for complications associated with surgery under a general anesthesia. She was hospitalized for [REDACTED]. The facility had an undated policy entitled, "Fall Prevention and Management Program " which indicated they would provide an environment free from the hazards over which the facility has control. Following each resident fall, the licensed nurse is to perform a post fall assessment and update, initiate or revise a plan of care. The licensed nurse will document circumstances regarding the incident of fall in the resident's medical record. The IDT will initiate, review and update resident fall risks and plan of care after a fall. A review of the literature indicated the post-operative risk and complications associated with a surgery under general anesthesia included bleeding, infection, heart attack, pneumonia, kidney failure (during or after an operation), deep venous thrombosis (DVT-occurs when blood clots form in the large veins of the leg. If the blood clots in the veins break apart, they travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung, called a pulmonary embolism) and (Save, Richard H., "Postoperative Care." Hospital Medicine, 2nd Edition, Philadelphia: Lippincott, Williams, & Wilkins, 2005, 261-269). b. On August 28, 2014, at 10:15 a.m., it was noted that the specimen refrigerator was located in an unlocked Utility Room on Nursing Station I. The specimen refrigerator was not lockable and provided easy access to the contents. At the time of the observation however, there was no specimens stored in the refrigerator. c. On August 28, 2014 at 11:30 a.m., accompanied by the Maintenance Supervisor, it was noted that there were three open trash cans which were over half full. The trash cans contained flammable materials such paper and disposable cups. There were three enclosed ashtrays located in that area. The open trash can created a fire potential. During the above observations, the Evaluator was accompanied by the Maintenance Supervisor, and the Director of Staff Development confirmed the findings. d. On August 26, 2014 at 9:30 a.m. during a general observation on Station 2, a 24 inch television set was observed at Random Sample Resident 32's (RSR 32) bedside that was not secured. On August 29, 2014 at 10:40 a.m., during an observation and interview with the Lead Maintenance Assistant while securing RSR 32's television he stated it should have been secured, and he was doing it now so it would not tip over. A review of the facility's undated policy and procedure entitled, "Television Sets," indicated all televisions sets used in resident rooms must be approved as safe by the Administrator and the maintenance staff will assist the resident in installing the television set in the resident's room. e. On August 26, 2014, at 4:05 p.m., during the medication pass observation, licensed vocational nurse 4 (LVN 4) left the medication cart open, unlocked and unattended when he left to take Resident 33's blood pressure. On August 26, 2014, at 4:29 p.m., during the medication pass observation, LVN 4 again left the medication cart parked in the hallway unlocked when he went to administer Resident 34's medications. On August 26, 2014, at 4:35 p.m., during an interview with LVN 4, he stated he should have locked the medication cart. The facility's policy and procedure titled "Oral Medication Administration" dated January 2009, indicated the medication cart is to be kept locked at all times when not under the immediate control or direct sight of authorized personnel. f. On August 28, 2014, at 10:55 a.m., during an observation in Resident 4's room in the presence of registered nurse 3 (RN 3), a bottle of Vitamin B complex tablets was found at the resident's unlocked bedside drawer. On August 28, 2014, at 11:10 a.m., during an interview with licensed vocational nurse 5 (LVN 5), she stated the licensed nurses are not supposed to leave the medication at the bedside drawer of the resident. On August 28, 2014, at 11:20 a.m., in the presence of RN 4, the resident was observed sitting in the wheelchair in the room and was able to answer questions with periods of confusion. The facility's undated policy and procedure titled "Medication-Self Administration," indicated the facility will allow a resident to self-administer medications when determined capable to do so by the interdisciplinary team (IDT) and the resident's attending physician.