Every finding on record at Garden City Healthcare Center

Based on interview, and record review, the facility failed to ensure professional standards of care were met for one of three sampled residents (Resident 1) when Resident 1's prescribed medication for shortness of breath was incorrectly transcribed into her orders and was unavailable for use during her stay.This failure had the potential to negatively affect Resident 1's health and well-being. Finding:During a review of Resident 1's clinical document titled, SKILLED NURSING FACILITY admission ORDERS, dated 7/25/26, the document indicated, .You are being discharged from the hospital with a heart failure diagnosis known as Congestive Heart Failure (CHF) or Heart Failure.This means that the heart cannot meet the body's demands. The heart pumps less blood than the body requires, pumps with elevated pressure backing up from the heart, or both. This can cause extra fluid (salt and water) in the body to build up in the lungs, causing difficulty breathing and swelling.During a review of Resident 1's clinical document titled, SNF [skilled nursing facility] Medications, dated 7/25/26, the document indicated, . Atrovent HFA [short acting inhaled medication to help with difficulty breathing] .Inhale 2 puffs by mouth 4 times a day.During a review of Resident 1's Medication Administration Record, (MAR, document used in healthcare facilities to track every medication administered to a patient) dated 7/1/26-7/31/26, the MAR indicated, . Atrovent HFA Inhalation.2 puff inhale orally [ by mouth] two times a day for SOB [shortness of breath]/wheezing. The MAR further indicated that the medication was to be administered at 9 AM and 5 PM daily. The MAR indicated the number 9 where staff initialed to indicate the medication was administered, for the two scheduled administration times on the MAR. The MAR further indicated .9 = Other/See Nurses Notes.During an interview on 8/11/26 at 12:13 PM, with licensed nurse (LN) 2, LN 2 stated medication orders were transcribed into the electronic health record (EHR) on admission and then sent to the pharmacy for processing. LN 2 further stated medications were usually available within 35-45 minutes of the orders being uploaded. LN 2 stated if a medication was not in stock, the physician would be informed, and a new order would be requested.During a concurrent interview and record review on 8/11/26 at 1:23 PM, with the Director of Nurses (DON), the DON confirmed Resident 1's Atrovent order on the MAR did not match the prescribed order. The DON stated Resident 1 should have received 3 doses of Atrovent on 7/26/26 and she did not. The DON confirmed there was no documentation in Resident 1's EHR to indicate why the medication was not administered. The DON stated it was important for Resident 1 to receive her medication as prescribed. The DON further stated when Resident 1 did not receive her prescribed medication she was at risk of worsening shortness of breath and discomfort.During a review of a facility policy & procedure (P&P) titled, Medication Ordering and Receiving From Pharmacy, revised 8/2014, the P&P indicated, . Medications and related products are received from the dispensing pharmacy on a timely basis.Receiving Medications from the Pharmacy.A licensed nurse.Receives medications delivered to the pharmacy and documents the delivery was received.Verifies medications received and directions for use with the medication order form.Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 12 sampled residents (Resident 1 and Resident 2) when insulin (a medicine that helps control blood sugar) orders lacked parameters for licensed nurses regarding when to notify the physician and when to hold insulin administration for abnormal blood glucose levels.This failure had the potential to result in inconsistent clinical decision-making, inappropriate insulin administration, and adverse outcomes, including hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). Findings:1. Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with a diagnosis of, but not limited to type 2 diabetes mellitus with hyperglycemia (the person has diabetes with very high blood sugar).Review of Resident 1's clinical record titled, Order Details, ordered 8/20/24, indicated, Order Summary: NovoLOG Solution 100 UNIT/ML (Insulin Aspart) [a fast-acting insulin medicine used to lower high blood sugar - unit of measurement] Inject 6 unit subcutaneously [given under the skin] before meals for diabetes.Review of Resident 1's clinical record titled, Care Plan Report, dated 12/14/22 and revised 2/25/26, indicated under the section titled, Focus, indicated, .[Resident 1] has Diabetes Mellitus: WITH HYPERGLYCEMIA. Further review under the section titled, Goal, indicated, . Will have no complications.During an interview and concurrent record review on 5/12/26 at 7:45 AM, Resident 1's order for NovoLOG (insulin), dated 8/20/24, was reviewed with Licensed Nurse (LN) 7. LN 7 stated that Resident 1 was diabetic. LN 7 confirmed Resident 1's order for insulin indicated to administer 6 units of insulin and that the 6 units of insulin were administered as ordered. LN 7 confirmed that Resident 1's NovoLOG insulin order did not contain parameters for when to notify the physician and when the insulin should be held. LN 7 stated even though there were no parameters listed on Resident 1's NovoLOG insulin order, that blood sugar levels still needed to be checked because insulin administration could place the resident at risk for adverse outcomes, explaining that low blood sugar could result in a coma and elevated blood sugar could result in adverse effects related to hyperglycemia. LN 7 further reviewed Resident 1's electronic health record (EHR) and stated there were no progress notes or documentation indicating the physician had been notified regarding the need for insulin administration parameters. LN 7 stated it was important to have parameters to guide nurses on when to notify the physician or when to hold insulin administration. LN 7 further stated that without parameters, there was a risk for inconsistent nursing interpretation and management of insulin administration.2. Review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with a diagnosis of type 2 diabetes mellitus (DM) with hyperglycemia (the person has diabetes with very high blood sugar) and diabetic neuropathy (nerve damage caused by diabetes).During an interview with concurrent record review on 5/12/26 at 9:23 AM, Resident 2's insulin orders for Glargine and Lispro, dated 5/7/26 and 5/8/26, and Resident 2' Medication Administration Record (MAR), dated 5/26, were reviewed with LN 3. LN 3 confirmed Resident 2's insulin order indicated the following: Insulin Glargine 36 units at bedtime (HS) and Insulin Lispro 10 units before breakfast, lunch, and dinner. LN 3 further stated that Insulin Glargine was a long-acting insulin and Insulin Lispro was a short-acting insulin. During further record review, LN 3 stated that there were no physician-ordered parameters for either insulin medication indicating when to notify the physician or when to hold insulin administration based on blood sugar levels. LN 3 stated, since there are no parameters, she would use her own critical thinking to hold or administer the insulin. Further review of the EHR revealed that on 5/11/26 before breakfast, Resident 2's blood sugar was 110, and documentation indicated that a licensed nurse administered 10 units of Insulin Lispro. Further review revealed that on 5/11/26 before lunch, the resident's blood sugar was 93, and documentation indicated the insulin was held. Additional review revealed that on 5/11/26 before dinner, the resident's blood sugar was 112, and documentation reflected code 5, indicating that Resident 2 refused the insulin administration. LN 3 stated that it was important to have physician-ordered parameters to guide nursing staff and ensure resident safety during insulin administration. LN 3 further stated that the absence of parameters could place the resident at risk for inconsistent nursing judgment and potential complications related to hypoglycemia or hyperglycemia, including loss of consciousness, change in condition, and possible hospitalization.During an interview on 5/12/26 at 10 AM, with Resident 2 in the resident's room, Resident 2 stated that he had been diabetic for approximately 10 years. Resident 2 stated that licensed nurses routinely checked his blood sugar levels and informed him of the results. Resident 2 confirmed that he refused the insulin administration before dinner on 5/11/26 and stated that he was familiar with how his body reacted when his blood sugar level was becoming too low. Resident 2 stated, I can usually feel when something is not right. When asked whether nursing staff followed specific blood sugar parameters or guidelines indicating when insulin should not be administered, Resident 2 stated that he was unsure whether licensed nurses used a specific lower or upper blood sugar limit for insulin administration. Resident 2 further stated that he could not recall nursing staff explaining any physician-ordered parameters or guidelines regarding when insulin should be held or when the physician should be notified. Resident 2 stated that having such guidelines was important to help prevent possible complications related to blood sugar fluctuations and insulin administration.During an interview on 5/12/26 at 1:29 PM, with the Director of Staff Development (DSD), the DSD stated that all insulin orders should include physician-ordered parameters to provide licensed nurses with clear guidance regarding when insulin should be administered, when insulin administration should be held, and when the physician should be notified based on blood sugar results or changes in the resident's condition. The DSD stated that clearly defined physician parameters were important to promote consistent nursing practice and resident safety, and to help prevent complications associated with hypoglycemia and hyperglycemia. The DSD further stated that it was not considered acceptable or safe nursing practice for licensed nurses to rely solely on personal judgment or individual critical thinking when determining whether insulin should be administered or withheld in the absence of physician-ordered parameters. The DSD stated that without clear physician guidance, residents could be placed at risk for adverse outcomes, including low blood sugar, changes in condition, loss of consciousness, and possible hospitalization. The DSD reiterated that all insulin orders should contain specific physician-ordered parameters and instructions to guide nursing staff in the safe administration and monitoring of insulin therapy.During an interview on 5/12/26 at 3:54 PM, with the Director of Nursing (DON), the DON stated that it was her expectation for licensed nurses to follow insulin orders as written and according to physician instructions. The DON further stated that all insulin orders should include clear physician-ordered parameters indicating when insulin administration should be held and when the physician should be notified based on blood sugar results, changes in condition, or signs and symptoms of hypoglycemia or hyperglycemia. The DON stated that without physician-ordered parameters, licensed nurses would not have clear guidance regarding appropriate interventions, monitoring, or physician notification requirements related to insulin administration and blood sugar management. The DON further stated that the absence of specific parameters could result in inconsistent nursing practices and place residents at risk for complications associated with improper insulin administration, including hypoglycemia, hyperglycemia, changes in condition, and possible hospitalization.Review of facility policy and procedure (P&P) titled, Diabetes - Clinical Protocol, revised date 3/25, the P&P indicated, .The provider will order desired glucose targets and monitoring regimens, as well as parameters for reporting information related to blood sugar management.The staff will incorporate orders and reporting parameters into the Medication Administration Record and care plan.

Based on observation, interview, and record review, the facility failed to ensure 4 of 37 sampled residents (Resident 12, Resident 54, Resident 71, and Resident 79) were provided with reasonable accommodation of needs when;1. Resident 12, Resident 54 and Resident 79's call light (device used to contact staff for assistance) was not within reach; and,2. Resident 71 was not provided with a communication board (Communication boards help people communicate with others by using symbols, pictures, or photos).This deficient practice placed Resident 12, Resident 54, Resident 79 and Resident 71 at increased risk for unmet care needs, delayed staff response, and had the potential to impact their psychosocial well-being.Findings:1. Review of Resident 12's admission Record indicated, Resident 12 was admitted to the facility with diagnoses including Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks), seizures (abnormal electrical brain activity leading to sudden muscle limpness/drop attacks, brief jerks, and/or intense stiffening), abnormalities of gait and mobility (difficulty in walking and mobility), and fracture of the right shoulder blade.Review of Resident 54's admission Record indicated, Resident 54 was admitted to the facility with diagnoses including Epilepsy (recurrent, unprovoked seizures caused by abnormal electrical brain activity), nontraumatic intracranial hemorrhage (a life-threatening ruptured blood vessel bleeding into the brain, causing sudden pressure and potential damage) and dysphagia (difficulty swallowing).Review of Resident 79's admission Record indicated, Resident 79 was admitted to the facility with diagnoses including traumatic subdural hemorrhage (a life-threatening emergency where blood collects between the brain's surface and the outer membrane) dementia, and abnormal posture.1a. During a concurrent observation and interview on 2/9/26 at 11:18 AM with Resident 12 in Resident 12's room, Resident 12 was lying in his bed and Resident 12's call light was observed hanging from Resident 12's left side bed rail. Resident 12 tried to grab the call light and he was unable to grab the call light from the bedside rail.During a concurrent observation and interview on 2/9/26 at 11:18 AM with Licensed Nurse (LN) 4 in Resident 12's room, LN 4 stated Resident 12's call light was not within reach. LN 4 stated that if Resident 12 could not reach or use the call light to ask for help, Resident 12 would be at risk for falls, injury by hitting his head, and unmet needs. LN 4 further stated that Resident 12 had a fall in the past.A record review of Resident 12's Care Plan, in the section titled focus initiated on 6/12/23, indicated, .ADL Self Care Performance Deficit. The section titled Interventions initiated on 6/12/23, indicated . [Resident 12] requires 1-2 staff participation to reposition and turn in bed.A record review of Resident 12's Care Plan, in the section titled focus initiated on 6/12/23, indicated, . [Resident 12] is at risk for falls. The section titled interventions initiated on 3/24/24, indicated, .Advise to call for assistance and use call light.Keep call light within reach.1b. During an observation on 2/9/26 at 9:12 AM with Resident 54 in Resident 54's room, Resident 54 was lying in her bed and Resident 54's call light was observed hanging from the bedside top drawer, out of reach. During a concurrent observation and interview on 2/9/26 at 9:12 AM with CNA 1 in Resident 54's room, CNA 1 confirmed the call light for resident 54 was hanging from Resident 54's bedside top drawer. CNA 1 stated the call light should be within reach of Resident 54 for safety. CNA 1 further stated since Resident 54 was nonverbal and did not have a call light within reach something bad could have happened to Resident 54 in case of an emergency.During a record review of Resident 54's Care Plan, in the section titled focus initiated on 11/4/22, indicated [Resident 149] has ADL self-care performance Deficit r/t cognitive impairment. The section titled interventions initiated on 6/26/23, indicated . [Resident 54] requires extensive assistance. dependent to reposition self and turn in bed .During a record review of Resident 54's Care Plan, in the section titled focus initiated on 11/4/22, indicated [Resident 54] has a potential for falls. The section titled interventions initiated on 11/4/22, indicated Keep call bell in reach and answer promptly.During a record review of Resident 54's Care Plan, in the section titled focus initiated on 4/16/24, indicated [Resident 54] is at risk for impaired communication. The section titled interventions initiated on 4/16/24, indicated Use hand signals and gestures to assist with communication .1c. During an observation on 2/9/26 at 9:15 AM with Resident 79 in Resident 79's room, Resident 79 was lying in her bed and Resident 79's call light was observed to be on the floor next to Resident 79's bed. Resident 79 did not have a call light within her reach.During a concurrent observation and interview on 2/9/26 at 9:15 AM with CNA 1 in Resident 79's room, CNA 1 confirmed the call light for Resident 79 was on the floor next to Resident 79's bed. CNA 1 stated Resident 79's call light should have been within reach. CNA 1 picked up the call light from the floor and placed it within reach of Resident 79.During a record review of Resident 79's Care Plan, in the section titled focus initiated on 12/14/23, indicated, [Resident 79] has an ADL self-care deficit. The section titled Interventions initiated on 12/14/23, indicated . [Resident 79] dependent for assist with transfers.During a record review of Resident 79's Care Plan, in the section titled focus initiated on 12/14/23, indicated, . [Resident 79] is at risk for falls. The section titled Interventions initiated on 12/14/23, indicated .Call light within reach. Continue to remind [Resident 79] to call for assist.During an interview on 2/11/26 at 1:02 PM with the Director of Nursing (DON), the DON stated to anticipate the needs of residents and know residents' needs, the call light should be within reach of residents. The DON stated residents care could be delayed, and residents could fall trying to reach for the call light when the residents call light was not within reach. A review of facility's policy titled, Answering the Call Light, dated October 2010, indicated, .The purpose of this procedure is to respond to the resident's requests and needs .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 2. Review of Resident 71's admission Record indicated, Resident 71 was admitted to the facility with diagnoses including unspecified dementia (severe memory loss, impaired thinking, and reduced social abilities) and history of fall.During a concurrent observation and interview on 2/9/26 at 12:05 PM with Resident 71 in Resident 71's room, by writing on a piece of paper, Resident 71 was asked if he could hear. Resident 71 stated he could not hear, and he did not have a hearing aid (a small, electronic, battery-powered medical device designed to improve hearing and speech comprehension by amplifying sound for individuals with hearing loss worn in or behind the ear). Resident 71 stated it would have been better if he was able to understand staff when staff tried to communicate with him. Resident 71 stated he had an appointment to get a new hearing aid a few weeks ago. Resident 71 stated he had notified the staff at the facility that he could not hear since his old hearing aid did not work. Resident 71 further stated the facility did not provide him with a communication board or any other type of communication device.During a concurrent observation and interview on 2/9/26 at 12:07 PM with CNA 1 in Resident 71's room, CNA 1 stated Resident 71 was deaf (having limited or no hearing; having permanent loss or absence of hearing) and Resident 71 could not hear. CNA 1 stated Resident 71's hearing aid had been ordered. CNA 1 confirmed Resident 71 did not have a communication board or any other type of communication device. CNA 1 stated when communicating with Resident 71, CNA 1 tried his best by speaking loud. CNA 1 further stated during conversation with Resident 71, CNA 1 was not sure if Resident 71 understood CNA 1.During a concurrent observation and interview on 2/9/26 at 12:30 PM with LN 4, in Resident 71's room, LN 4 confirmed Resident 71 did not have a functioning hearing aid or a communication board or any other type of communication device in his room. Resident 71 stated he could not hear LN 4 when LN 4 stood close to Resident 71's ears and notified Resident 71 of the time lunch would be served. LN 4 repeated lunch time three more times to Resident 71 in presence of LN 11. Resident 71 stated he could not hear LN 4. LN 4 confirmed Resident 71 could not hear her when she spoke loud and close to Resident 71' ears. LN 4 stated Resident 71 should have a communication board to feel comfortable and be able to communicate properly with staff. During an interview on 2/9/26 at 2:53 PM with CNA 2, CNA 2 stated he had used verbal cues to communicate with Resident 71 for the past two months. CNA 2 stated it was difficult to communicate with Resident 71 since Resident 71 did not have a hearing aid, communication board, or any other type of communication device. CNA 2 stated Resident 71 should have a communication board when communicating with staff. CNA 2 further stated that without having a communication board Resident 71 could be unable to communicate with staff when Resident 71 was in pain.During an interview on 2/10/26 at 8:30 AM with LN 10, LN 10 stated Resident 71 did not have a communication board or any other type of communication device in his room. LN 10 stated Resident 71 had hearing problems. LN 10 stated Resident 71 should have a communication board for better communication. LN 10 further stated Resident 71 would not be able to understand what staff was telling him if there was no communication board in case of an emergency.During a record review of Resident 71's Care Plan, in the section titled focus initiated on 12/21/24, indicated [Resident 71] is at risk for impaired communication related to highly impaired hearing to bilateral ears. The section titled goal initiated on 12/21/24, indicated . Will be successful using communication board . The section titled interventions initiated on 12/21/24, indicated .Hearing impairment-highly impaired. Requires increased volume. Increase volume of voice and speak distinctly.During an interview on 2/11/26 at 1:02 PM with the Director of Nursing (DON), the DON stated Resident 71 had difficulty hearing and Resident 71 should have a communication board to be able to communicate with staff per his care plan. The DON stated by not having a communication board Resident 71 could have had his treatments delayed.A review of facility's policy titled, Hearing Impaired Resident of, undated, indicated, .Evaluate and address avoidable obstacles to effective communication.Provide pencil and paper or tablet to communicate in writing, if the resident is able.

Based on interview and record review, the facility failed to ensure consistent implementation of its Advance Directive (a legal document that outlines the preferences for medical treatment if the resident become unable to communicate or make decisions for one's self) process for nine of 37 sampled residents (Residents 142, 138, 78, 137, 139, 103, 105, 117, and 3); when Section D of the Physician Orders for Life-Sustaining Treatment (POLST) (POLST, a signed medical order reflecting a resident's life-sustaining treatment preferences) was incomplete and/or the documentation regarding Advance Directive status was inconsistent with other facility records.These failures resulted in the facility being unable to verify who participated in the POLST discussion and was unable to demonstrate that assistance in establishing Advance Directives was offered to the residents and documented in their health records, which could have resulted in the residents' desired life sustaining treatment in the case of an emergency not being honored.Findings:During a review of the sampled residents' Physician Orders for Life-Sustaining Treatment (POLST), the facility's document titled, Resident Services (reflecting the Advance Directive status), and the facility's case management Progress Notes (care coordination documentation), the following were noted:1. For Resident 142, a review of Resident 142's Physician Orders for Life-Sustaining Treatment (POLST), dated 1/29/26, Section D indicated, Discussed with, was left blank and the box that indicated, No Advance Directive, was selected. A review of the facility's document titled, Resident Services, dated 2/1/26, indicated Resident 142 was interested in executing an Advance Directive. A review of an undated case management note titled, Progress Notes, indicated, AHCD (Advance Health Care Directive): Declined.2. A review of Resident 138's Physician Orders for Life-Sustaining Treatment (POLST), dated 2/5/26, Section D indicated, Discussed with, was left blank, and the section that indicated an Advance Directive status was left blank.3. A review of Resident 78's Physician Orders for Life-Sustaining Treatment (POLST), dated 1/20/26, Section D indicated, Discussed with was left blank.4. A review of Resident 137's Physician Orders for Life-Sustaining Treatment (POLST), dated 1/30/26, Section D indicated, Discussed with was left blank and the box that indicated, No Advance Directive, was selected. A review of the facility's document titled, Resident Services, dated 2/1/26, indicated Resident 137 had executed an Advance Directive and was going to bring in a copy of the Advance Directive. A review of a case management note titled, Progress Notes, dated 2/3/26 at 4:26 PM, indicated, AHCD: Declined.5. For Resident 139, a review of Resident 139's Physician Orders for Life-Sustaining Treatment (POLST), dated 2/5/26, Section D indicated, Discussed with, was left blank and the box that indicated, No Advance Directive, was selected. A review of the facility's document titled, Resident Services, dated 2/8/26, indicated Resident 139 had executed an Advance Directive, had provided the facility with a copy, and would bring in a copy of the Advance Directive. A review of case management notes, Progress Notes, dated 2/11/26 at 9:19 PM, indicated, AHCD: Per patient she does have one, states she will provide copy.6. For Resident 103, a review of Resident 103's Physician Orders for Life-Sustaining Treatment (POLST), dated 1/12/26, Section D indicated, Discussed with, was left blank.7. For Resident 105, a review of Resident 105's Physician Orders for Life-Sustaining Treatment (POLST), dated 12/13/25, Section D indicated, No Advance Directive, was selected. A review of the facility's document titled, Resident Services, dated 10/26/25, indicated, Refused, but did not specify who refused to complete the document. A review of an undated case management note titled, Progress Notes, indicated, AHCD: daughter already has a copy.8. For Resident 117, a review of Resident 117's Physician Orders for Life-Sustaining Treatment (POLST), dated 1/11/26, Section D indicated, Discussed with, was left blank and the box that indicated, No Advance Directive, was selected. A review of the facility's document titled, Resident Services, dated 1/14/26, indicated Resident 117 was interested in executing an Advance Directive. A review of an undated case management note titled, Progress Notes, indicated, AHCD: no, declined.9. A review of Resident 3's Physician Orders for Life-Sustaining Treatment (POLST), dated 2/7/26, Section D indicated, Discussed with, was left blank. During a concurrent interview and record review on 2/11/26 at 2:46 PM with the Director of Nursing (DON), the POLST(s) and Advance Directive documentation for Residents 142, 138, 78, 137, 139, 103, 105, 117, and 3, were reviewed. The DON stated the POLST(s) should have been completed in their entirety. During a review of Resident 142's POLST, the DON acknowledged Section D was incomplete, as the area indicated whether the discussion occurred with the resident (if the resident has capacity (person is able to understand medical information and make their own healthcare decisions)) or the legally recognized decision-maker, was not selected. The DON was not able to locate evidence that assistance was offered to Resident 142 to formulate an Advanced Directive. The DON stated the facility could not verify who made the decision reflected on the POLST. The DON stated similar findings may be present in other residents' records. The DON further stated the facility should have ensured the Advance Directive discussions were conducted with the resident or responsible party and documented upon admission. During an interview on 2/11/26 at 4:10 PM with Licensed Nurse (LN) 16, LN 16 stated he admitted new residents during his shift and was familiar with the POLST form. LN 16 stated the POLST form needed to be completed from Sections A through D before the physician signed the document. LN 16 stated the POLST was supposed to be completed with the resident if the resident has the capacity; if the resident did not have capacity, the family was contacted to complete the form. LN 16 stated in the event of an emergency or change in condition, nurses reviewed the POLST and any available Advance Directives and determined the resident's treatment preferences. LN 16 stated if a resident had an Advance Directive, he asked the resident or responsible party to provide a copy. Upon receipt, the copy was given to social services and uploaded into the system. LN 16 stated that if a resident did not have an Advance Directive, he did not offer assistance with establishing one but encouraged the resident to discuss it with their family. LN 16 stated, we don't have any Advance Directive form here in the facility, and stated he was not aware whether the facility had a blank Advance Directive form available to offer to residents. LN 16 stated the admitting nurse was responsible for ensuring the POLST was completed. Following the interview, LN 16 consulted with the DON regarding availability of blank Advance Directive forms. LN 16 stated the DON instructed that if a resident did not have an Advance Directive, the resident or responsible party should have been directed to the social worker for assistance. During a joint concurrent interview and record review on 2/12/26 at 8:30 AM with the Administrator, Director of Marketing, Clinical Resource Nurse, and the Social Services Director regarding completion of the sampled residents' POLST forms, the facility's document titled, Resident Services, and the social work documentation of Advance Health Care directives (AHCD), were reviewed. The facility's team acknowledged inconsistency in documentation related to Advance Directive status between the Physician Orders for Life-Sustaining Treatment (POLST), Resident Services document, and the AHCD documentation. The facility further acknowledged that the process of offering assistance with Advance Directives to residents without one, required improvement. During a review of the facility's policy titled, Advance Directives, revised on 9/22, indicated, .Determining Existence of Advance Directive.Prior to or upon admission of a resident, the social services director or designee inquires of the resident .or.legal representative, about existence of any written Advance Directives.If the Resident Does not have an Advance Directive.the facility staff will offer assistance in establishing Advance Directives.nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.information about whether or not the resident has executed an Advance Directive is displayed prominently in the medical record.

Based on interview and record review, the facility failed to ensure medications were handled, destroyed, and documented in accordance with accepted standards of practice and facility's policy with a census of 101 residents when:1. Destruction and disposition of non-controlled (non-opioid) prescription medications were not co-signed and witnessed by two licensed nurses;2. Medications labeled as hazardous (medications that pose health risks with repeated unsafe handling) were not handled safely during medication administration for Resident 146; and3. Resident 86's narcotic medication, Morphine (a controlled prescription drug) was not accurately documented in the electronic Medication Administration Record (MAR - a legal record of medications administered to a resident) when removed from the Controlled Drug Record (CDR - a paper record sheet for accountability and tracking of narcotic removal with nurses initial, date, and time).These failures compromised medication accountability and created the potential for unsafe medication handling, administration practices, and risk of drug diversion (unlawful drug loss).FINDINGS:1.Review of the facility's non-controlled medication destruction log, titled Medication Disposition Log for July 2025 through January 2026, revealed that medication destructions were documented without a witness signature to verify the destruction process. During a concurrent interview and record review on 02/10/26 at 11:47 a.m. with the Director of Nursing (DON), the facility's non-controlled medication destruction logs for July 2025 through January 2026 were reviewed. The DON confirmed she signed the section indicating the medications were destroyed; however, no witness signature was documented to verify the destruction. The DON agreed that medication destruction should be witnessed to ensure accountability and to reduce the risk of drug diversion. A review of the facility policy titled Discarding and Destroying Medications, revised October 2014, indicated, .10. The medication disposition record will contain the following information: .h. Signature of witnesses.2. Review of Resident 146's admission RECORD indicated Resident 146 was admitted to the facility with multiple diagnoses, including benign prostatic hyperplasia without lower urinary tract symptoms (prostate disease) and mood disorder (mental health condition that primarily affects your emotional state). During an observation and interview on 02/09/26 at 9:05 a.m., the Licensed Nurse (LN 2) was observed in the hallway administering medications to Resident 146. LN 2 handled two medications (Finasteride, drug used for prostate disease, and Divalproex, drug used for mood disorders) labeled as hazardous without wearing gloves and dispensed them into a small container. LN 2 acknowledged that gloves were required when handling hazardous medications and stated she forgot to wear them. During an interview on 02/10/26 at 11:50 a.m., the Director of Nursing (DON) stated staff are expected to wear gloves when handling hazardous medications to protect themselves and ensure safe handling practices. The DON stated it was essential that gloves be used when handling hazardous medications to promote staff and resident safety. A review of the facility policy titled, Hazardous Drugs, revised April 2019, indicated, Hazardous pharmaceutical drugs are handled according to practice standards so as to minimize staff and resident exposure. 9. Staff are trained on and required to wear personal protective equipment (PPE) specific to the risk of exposure and activities performed. During a review of the Center for Disease Control's National Institute for Occupational Safety and Health (CDC, and NIOSH, a federal agency sets standard of safety in health care) document, titled Managing Hazardous Drug Exposures: Information for Healthcare Settings, dated 4/2023, last accessed via https://www.cdc.gov/niosh/docs/2023-130/2023-130.pdf?id=10.26616/NIOSHPUB2023130 and https://www.cdc.gov/niosh/docs/2023-130/default.html , the document indicated Many . drugs intended for individual use can be hazardous to healthcare workers with potential occupational exposure to those who handle, prepare, dispense, administer, or dispose of these drugs. Workplace exposure to hazardous drugs can result in negative acute and chronic health effects in healthcare workers including adverse reproductive outcomes. PPE (or Personal Protective Equipment, items like glove or mask) provides worker protection to reduce exposure to hazardous drugs. Efforts should be made to reduce all worker exposures to hazardous drugs. Occupational exposure to hazardous drugs merits serious consideration, as workers may be exposed daily to multiple hazardous drugs over many years. Further review of the document indicated to use single glove for handling intact tablet form and double glove for handling oral liquid form of the hazardous medications as directed. 3. Review of Resident 86's admission RECORD indicated Resident 86 was admitted to the facility with multiple diagnoses, including muscle weakness, chronic low back pain, depression, and anxiety. Review of Resident 86's Controlled Drug Record (CDR) titled Controlled Substance Accountablilty Sheet, with date range of January 2026 to February 2026, indicated Morphine removal and use for treatment of pain. A comparative review of Resident 86's CDR with Medication Administration Record (MAR) record for the same time period revealed the following discrepancies:1/13/26 - CDR removal documentation present; no MAR documentation. 1/29/26 - No CDR removal documentation; MAR documentation present at 1330 (1:30 p.m.).2/02/26 - No CDR removal documentation; MAR documentation present at 1149 (11:49 a.m.).2/02/26 - No CDR removal documentation; MAR documentation present at 1651 (4:51 p.m.).During a concurrent interview and record review on 02/12/26 at 10:43 a.m. with the Director of Nursing (DON), the CDR and MAR of Resident 86 for January 2026 to February 2026 were reviewed. The DON confirmed nursing staff did not complete the required documentation when removing and administering the resident's-controlled medication. The DON stated accurate documentation was necessary to ensure medication accountability and reconciliation of controlled substances. The DON also stated that incomplete or inaccurate documentation increased the risk of medication discrepancies and potential drug diversion. A review of the facility policy titled, Controlled Substances, revised November 2022, indicated, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications.

Based on observation, Interview and record review the facility failed to ensure safe medication storage practices in the medication carts, Medication refrigerators and medication rooms with resident census of 101 when:1. South hall medication refrigerator stored undated and outdated medications with extensive frost build up and not meeting the temperature range per policy.2. South hall medications cart 3 stored undated and outdated medications.3. North hall medication cart for IV (Into the Vein) stored unlabeled IV solutions.4. North hall medication refrigerator stored discontinued, unlabeled, outdated medications, and co-mingled medication container with different routes of administration, and the storage practices did not follow manufacturer specification for storage temperature.5. South hall medication cart 4 stored undated and outdated medications.These failed practices could contribute to use of medications with lower potency and/or inadvertent use of discontinued drugs.Findings:1.During a concurrent interview with Licensed Nurse 5 (LN 5) and inspection of medication refrigerator in south station, on 2/9/26, at 9:55 a.m., the top section (freezer) had excessive frost and temperature monitoring log posted on the door indicated temperatures outside of the range listed on the log as follow:2/1/26 Temperature recorded 34 degrees Fahrenheit (a temperature scale)2/2/26 Temperature recorded 34 degrees Fahrenheit 2/3/26 Temperature recorded 32 degrees Fahrenheit 2/4/26 Temperature recorded 32 degrees Fahrenheit 2/6/26 Temperature recorded 34 degrees Fahrenheit 2/9/26 Temperature recorded 34 degrees Fahrenheit Further review of the log sheet indicated Refrigerated drugs must be stored at a temperature between 36 and 46 degrees F (or Fahrenheit) in the event of equipment malfunction, all drugs should be removed and taken to another refrigerator . LN 5 stated the refrigerator temperature were recorded twice a day by nursing staff who had key to the refrigerator and was not sure who was responsible for defrosting the refrigerator. During a concurrent interview with LN 5 and inspection of medication refrigerator in the south hall, on 2/9/26, at 9:55 a.m., the refrigerator stored insulin (drug in injection form for diabetes, the blood sugar disease) and eye drop medications as follow:i. Insulin Aspart (short-acting insulin) vial was open with no marking for open date and was dispensed on 12/15/25. The label on the box indicated Store refrigerated (36- 46-degree Fahrenheit) until first use then store either refrigerated or at room temperature . and discard after 28 days. Avoid freezing .ii. Insulin Glargine (long-acting insulin) vials with open date of 12/31/25 and 1/1/26; the label on the box indicated Refrigerate (36- 46-degree Fahrenheit) until first use. Avoid freezing . after first use store at room temperature and discard after 28 daysiii. Eye drop called Latanoprost (glaucoma medication) with open date of 10/7/25. The label on the box indicated unopened bottle under refrigeration at 36 to 46-degree Fahrenheit). Opened bottle may be stored at room temperature up to 77-degree Fahrenheit for 6 weeks.LN 5 stated marking the open date and expiration date was to be done when new drugs were first opened to be used. 2. During a concurrent interview with LN 5 and inspection of medication cart 3, in the south hall, on 2/9/26, at 10:28 a.m., the cart stored multiple open and undated medications as follows:i. Multiple open, undated inhalation medication known as DuoNeb (two medications for treating shortness of breath) were out of the foil wrap. The label on the packet indicated Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within one week.ii. Open and undated Breo Ellipta ( combination of fluticasone and Vilanterol, for treatment of asthma) inhaler. The label on the box indicated Discard the inhaler 6 weeks after opening the moisture-protective foil tray or when the counter reads 0 (after all blisters have been used) whichever comes first.iii. Open and undated Incruse Ellipta (or umeclidinium inhalation powder for chronic breathing issues) inhaler. The label on the box indicated Discard the inhaler 6 weeks after opening the moisture-protective foil tray or when the counter reads 0 (after all blisters have been used) whichever comes first.iv. Three outdated inhaler medication known as Advair (combination of two drugs in one, fluticasone and Salmeterol for treatment of asthma breathing issues) with open date marked as 10/30/25, 11/25/25, and 12/16/25. The label on the container indicated Discard inhaler 1 month after opening the foil pouch or when the counter reads 0, (after all blisters have been used) whichever comes first. LN 5 acknowledged the finding and stated she will remove the products and get replacements. 3. During a concurrent interview with the Assistant Director of Nursing (ADON) and inspection of IV medication cart in North station, on 2/9/26, at 11:25 a.m., the cart stored two unlabeled IV bags marked as emergency kit or Ekit) supply as follows:i. Sodium Chloride (salt) solution one liter IV bag.ii. Dextrose and Sodium chloride solution (D5W/NACL- sterile sugar and salt solution) one liter.The ADON stated the bags were part of emergency supply and should not have been in the IV cart without a resident name. ADON stated once removed from the Ekit, it should be used or returned to Ekit if not used. 4. During a concurrent interview with LN 9 and the inspection of North hall medication room refrigerator, on 2/9/26, at 2:35 p.m., the eye drops and injectable medications were co-mingled in the same crowded areas in addition to the following medications storage irregularities:i. Four vials of a controlled drug (drug with abuse potential) and a hormone called testosterone 200mg/ml ( mg/ml is milligram per milliliter is unit of strength, the shot is a hormone medication) was stored among other non-controlled drugs. The resident was no longer on it, and it was never ordered while at the facility. LN 9 could not explain why the product was stored in the facility's refrigerator.ii. Insulin Degludec (or Tresiba, an ultra-long-acting insulin) in pen form was stored with no resident label.iii. Insulin Glargine (or Lantus, a long-acting insulin) marked with open date of 12/31/25 and expiration of 1/27/26 was stored in active storage areas.iv. Multiple opened eyedrops not following manufacturer requirement for storage as follows: Timolol eye drop ( eye drop for glaucoma); drug box label indicated keep at controlled room temperature of 39-to-77-degree Fahrenheit.Bromfenac eye drop ( anti inflammation eye drop); drug label on the box indicated to store at controlled room temperature between 68-77-degree Fahrenheit.Prednisolone eye drop ( steroid eye drop); drug label on the box indicated to store between 46-to-75-degree Fahrenheit in an UPRIGHT position.Brimonidine/timolol (combination eye drop for glaucoma); the drug label on the box indicated to store at controlled room temperature between 68-77-degree Fahrenheit. v. Six vials of multi-dose lorazepam (or Ativan ,anxiety or seizure medication) injection were stored in the active storage areas. LN 9 stated the resident was no longer using it. The electronic record indicated it was discontinued on 12/9/25.LN 9 acknowledged the findings.5. During a concurrent interview with LN 4 and inspection of the medication cart 4 in south hall, on 2/9/26, at 2:59 p.m., the medication cart stored outdated and undated medications as follows:i. Fluticasone plus Vilanterol inhaler (or Breo Ellipta, an inhalation drug to treat asthma) was dated 11/29/25 when first opened. The label on the box indicated Discard the inhaler 6 weeks after opening the moisture-protective foil tray.ii. Multiple open, undated inhalation drug known as DuoNeb (two medications for treating shortness of breath) were out of the foil wrap. The label on the packet indicated Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within one week.LN 4 acknowledged the findings.In an interview with the Director of Nursing (DON), in her office, on 2/10/26, at 11:47 a.m., the DON stated the multidose medication containers such as insulin should have been dated when first opened along with actual expiration date. The DON stated she needed to consult the pharmacy on keeping the open eye drops in the refrigerator or not. The DON stated that when temperature was not in-range, the nurse needed to notify the management. The DON stated she needed to educate the nurses on how to handle out of range temperatures. The DON also stated the discontinued controlled drugs such as testosterone and Ativan should have been removed from the active storage areas and returned to the DON office for destruction. The DON stated the crowded refrigerator was replaced with a new one and medications were safely organized.Review of the facility's policy, titled Medication Labeling and Storage, dated 4/2019, the policy indicated The facility stores all medications and biologicals in locked compartments under proper temperature . The policy indicated Medications are stored in an orderly manner . Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurse's station or other secured location . Controlled substances . and other drugs subject to abuse are separately locked . The policy further indicated Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Review of the facility's policy, titled Storage of medications, dated 8/2014, the policy indicated Orally administered medications are kept separate from externally used medications . Eye medications are stored separately per facility policy. The policy further indicated Medications and biologicals are stored in their appropriate temperature and humidity according to United States Pharmacopeia guidelines (authoritative, science-based standards for the strength, quality, purity, and packaging of medicines and enforced by Food and Drug Administration) for temperature ranges. Medication requiring storage at room temperature are kept as temperature ranging from 59 to 77 F.

Based on observation, interview, and record review, the facility failed to ensure safe infection prevention practices and provide a clean and sanitary environment with a census of 101 residents when:1. Two water dispensers located at the nurse's stations were found dirty,2. Urinal was not labeled for Resident 9, Resident 98 and Resident 116,3. A pill cutter (a small, handheld device designed to accurately divide pills or tablets into smaller, more manageable doses) was found with unknown powder and dust inside,4. A glucometer (a device for measuring the concentration of glucose in the blood) was cleaned with bare hands using bleach wipes. These failures had the potential to spread disease and illness amongst the residents residing in the facility, negatively impacting their health and well-being.Findings: During a concurrent observation and interview on 2/10/26 at 8:38 a.m., with Licensed Nurse (LN) 6, in the South Nurses Station, a water dispenser was observed having brown, yellow and white residue around the water dispensing nozzle, brown residue in the drip tray and dust around the water dispenser. LN 6 stated the water dispenser was functioning and staff and residents at the facility drank water from the water dispenser. LN 6 confirmed that the water dispenser was dirty and the water dispenser should have been cleaned. LN 6 further stated residents could get sick from water contamination by drinking water from the dirty water dispenser. LN 6 stated she did not know when the water dispenser was cleaned last. During a concurrent observation and interview on 2/10/26 at 8:48 a.m., with LN 8, in the North Nurses Station, a water dispenser was observed having brown and white residue around the water dispensing nozzle, brown residue in the drip tray and dust on the back of the water dispenser. LN 8 stated staff and residents at the facility drank water from the water dispenser. LN 8 confirmed that the water dispenser was dirty and the water dispenser should have been cleaned. LN 8 further stated residents could get sick from food and water contamination by drinking water from the dirty water dispenser. LN 8 stated she had not seen anyone clean the water dispenser in the past. During an interview on 2/10/26 at 4:14 p.m., with LN 2, LN 2 stated Residents and staff drank water from the water dispensers at both North and South Nurses station. LN 8 stated that any staff member who saw the water dispenser was dirty should have cleaned the water dispenser. LN 8 stated housekeeping staff were primarily assigned to clean the water dispenser. LN 8 stated she did not know if there was a cleaning log for the water dispensers. LN8 stated residents could get sick by drinking water from dirty water dispensers. During an interview on 2/11/26 at 8:58 a.m., with the Director of Maintenance (MTD), the MTD stated residents drank water from the North and South Nurses station water dispensers. The MTD stated he was in process of cleaning the water dispensers at the North and South Nurses station. The MTD stated there was no cleaning log to indicate when the water dispensers were last cleaned. The MTD stated the water dispensers had white water stain and calcium build up and there was potential for pathogens (microorganisms including bacteria, viruses, fungi, and parasites that cause diseases by invading a host, evading immune responses, and utilizing host resources to replicate) to grow in the water dispenses. The MTD stated residents could get sick by drinking water from dirty water dispensers. During an interview on 2/11/26 at 9:16 a.m., with LN 7, LN 7 stated residents and staff drank water from the water dispensers located in the North and South Nurses station. LN 7 stated he did not see when the water dispensers were last cleaned. LN 7 stated he did not check the water dispensers, and he did not know how long the water dispensers had calcium residue. LN 7 stated residents could have got sick by drinking water from dirty water dispensers. During an interview on 2/11/26 at 1:05 p.m., with the Director of Nursing (DON), the DON stated residents drank water from the water dispensers located in the North and South Nurses station. The DON stated the maintenance staff was responsible for cleaning the water dispensers. The DON stated residents could have had nausea and vomiting and be at risk for illness by drinking water from the dirty water dispensers. 2.A review of Resident 9's clinical record titled, admission RECORD, indicated, Resident 9 was admitted to the facility with diagnosis of, but not limited to difficulty in walking, abnormal posture, retention of urine (not being able to empty the bladder completely), and generalized muscle weakness. During a concurrent observation and interview, on 2/9/26, at 9:29 AM, in Resident 9's room, a white-colored plastic urinal with a light blue lid hanging on the grab bar on the right side of the bed was observed. The urinal was unlabeled. Resident 9 stated that staff labeled his urinal with his room number or his name. Resident 9 stated further that he preferred it labeled for his own sake and knew the urinal was his. Resident 9 stated, I don't want to use someone's urinal. During an interview on 2/9/26 at 9:53 AM, in Resident 9's room, Certified Nurse Assistant (CNA) 3 confirmed that the white-colored plastic urinal hanging on the grab bar had no label. CNA 3 stated that based on her recent training, the urinal needed to be labeled with Resident 9's name. CNA 3 stated further the importance of proper identification to prevent cross-contamination. CNA 3 stated that the facility did not follow the protocol, which was unacceptable and posed an infection control issue. A review of Resident 98's clinical record titled, admission RECORD, indicated, Resident 98 was admitted to the facility with diagnosis of, but not limited to diabetes mellitus (a condition where the body cannot control blood sugar levels), generalized muscle weakness, abnormalities of gait and mobility, and fall. During an observation on 2/9/26, at 12:46 PM, a white plastic urinal with yellow urine, uncovered by its light blue lid, was observed hanging on the grab bar on the right side of Resident 98's bed. It was not labeled. During an interview on 2/9/26, at 12:50 PM, in Resident 98's room, with Social Service Director (SSD), the SSD confirmed that the urinal was not labeled. The SSD stated that usually, either a Certified Nursing Assistant (CNA) or a licensed nurse (LN) would label it. The SSD stated further that there was a risk of cross-contamination if the urinal was not labeled because without a label, it was unclear who had used it. A review of Resident 116's clinical record titled, admission RECORD, indicated, Resident 116 was admitted to the facility with diagnosis of, but not limited to generalized muscle weakness, abnormalities of gait and mobility, acquired (something that develops later in life) absence of right leg below knee, presence of artificial (made by people, not naturally occurring) left leg and diabetes mellitus (a condition where the body cannot control blood sugar levels). During an observation and interview on 2/9/26, at 10:33 AM, in Resident 116's room, two white plastic urinals were observed. One urinal lay on top of the mattress at the foot of the bed, opening covered with a light blue lid and empty. The other urinal was on the bedside table next to an uncovered water pitcher and a dark blue container for snacks. Resident 116 stated that placing the urinals at the side of bed was better. When asked about labeling the urinals with room numbers, Resident 116 stated that the staff were not consistent in doing so. During an interview on 2/9/26, at 10:35 AM, LN 2 confirmed that one urinal lay on top of the mattress at the foot of the bed, while another urinal was on the bedside table next to an uncovered water pitcher in Resident 116's room. LN 2 stated that urinals were not supposed to be like that and should be placed at the side of the bed inside a urinal holder. LN 2 stated further that the urinal should be labeled with the resident's name. LN 2 stated the importance of following the process due to the risk of infection control concerns. During an interview on 2/10/26 at 11:19 AM, with the Director of Staff Development (DSD), the DSD stated that urinals should not have been placed on top of the bedside table alongside a clean water pitcher. The DSD stated further that urinals should be labeled with the resident's room number, as this is the standard procedure. The DSD confirmed that placing urinals on top of the bedside table alongside clean water pitchers was not a hygienic practice and was unacceptable. During an interview on 2/10/26 at 4:48 PM, with Infection Preventionist (IP), the IP stated that he expected urinals to be labeled with the resident's name. The IP stated further the importance of this practice to ensure that no one else would use it and that staff would know whose urinal it was, even if the resident moved to a different room. The IP stated that not labeling the urinal could mix it with others, potentially allowing an infection from one resident to be transmitted to another. The IP stated further that this practice was unacceptable and not in line with the process. The IP stated that they had already started an in-service training education for all staff, including CNAs and nurses. During an interview on 2/12/26, at 9:10 AM, with the Director of Nursing (DON), the DON stated that she agreed with the staff that labeling urinals with the resident's room number or the initial letter of their name was best practice and should continue. The DON stated further that if a urinal was not labeled, it would be difficult to identify the owner, emphasizing the importance of labeling to prevent cross-contamination. Review of a facility policy and procedure titled, Infection Prevention and Control Program, revised 1/25, indicated, Policy Statement – An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases [illnesses that can spread from one person to another] and infections. The IPCP provides a system for preventing, . and controlling infections and communicable diseases for all residents [Resident 9, Resident 98, Resident 116], staff, volunteers, visitors, and other individuals providing services . Prevention of Infection . instituting measures to avoid complications and disseminations . educating staff and ensuring that they adhere to proper techniques and procedures . following established general . guidelines such as those of the Centers for Disease Control . 3. During a concurrent interview with Licensed Nurse 4 (LN 4) and inspection of the medication cart 4 in south hall, on 2/9/26, at 2:59 p.m., the medication cart stored a pill cutter device that looked unclean with white dust inside and around the blade. LN 4 stated the pill cutter should be cleaned after each use to prevent cross-contamination. 4. During a medication observation and interview with Licensed Nurse 3 (LN 3), on 2/9/26, at 4:30 p.m., LN 3 with gloved hand, used a glucometer to measure Resident 66's blood sugar. When out of the room, she removed her gloves and placed the glucometer on top of the medication cart. LN 3 with no gloves pulled a bleach wipe and cleaned the outer surface of the glucometer. LN 3 then used a second wipe to wrap the glucometer and let it sit on top of the cart. When LN 3 was questioned on need to use gloves to clean and sanitize the glucometer, LN 3 stated she forgot to put gloves on and was not focused. In an interview with facility's infection preventionist (IP), on 2/12/26, at 11:20 a.m., the IP stated he expected the nursing staff to use gloves while cleaning a contaminated glucometer. The IP stated use of bare hands can spread germs to the nurse and spread among residents. The IP stated the facility's policy and staff education, and infection surveillance emphasized the use of gloves when cleaning and sanitizing resident care devices. In an interview with the Director of Nursing (DON), in her office, on 2/10/26, at 12:30 p.m., the DON stated she expected the staff to follow infection control practices they were trained on to prevent spread of infection in the facility. Review of the facility's policy titled Infection Prevention and Control Program, dated 12/2023, the policy indicated An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy on Important facets of infection prevention indicated Instituting measures to avoid complication or dissemination; educating staff and ensuring that they adhere to proper techniques and procedures. Following stablished general and diseases-specific guidelines, such as those at the Center for Disease Control.

Based on interview and record review, the facility failed to obtain and document informed consent (giving permission for medical care after fully understanding it) for psychotropic medications (drugs that affect how a person thinks, feels, or acts) use for 1 of 37 sampled residents (Resident 148) when Resident 148's medical record lacked evidence that Resident 148 was informed of the purpose, risks, benefits, side effects, alternatives, and provided consent for two antidepressant medications (medications that help improve mood) and one sleep aid medication (medication to help induce sleep).This failure had the potential to result in Resident 148 receiving psychotropic medications without understanding avoidable adverse outcomes including adverse drug effects (unwanted or harmful reactions caused by a medication) and a decline in functioning and/or quality of life.Findings:A review of Resident 148's admission RECORD, indicate Resident 148 was admitted to the facility with diagnosis of, but not limited to major depressive disorder (a serious condition that causes long-lasting feelings of sadness and loss of interest) and insomnia (trouble falling asleep or staying asleep).A review of Resident 148's clinical record titled, [Name of Facility] Order Summary Report, dated 1/31/26, in the section titled, Order Summary, indicated, . buPROPion [a medication] . for depression . Rexulti [a medication] for depression . traZODone [a medication that treats depression but can also be used to treat insomnia] for insomnia . A review of Resident 148's clinical record titled, [Name of Company] MEDICATION ADMINISTRATION RECORD, dated 2/1/26 through 2/28/26, in the section titled, Schedule for [DATE], indicated Resident 148 received Bupropion from 2/1/26 through 2/11/26, Rexulti on 2/4/26, 2/5/26, 2/9/26, 2/10/26, 2/11/26, and Trazodone from 2/1/26 through 2/11/26.During a concurrent interview and record review on 2/11/2 at 9:50 AM with the Assistant Director of Nursing (ADON), Resident 148's Electronic Health Record (EHR) was reviewed for Psychotherapeutic Drug Informed Consents. The ADON verified Resident 148's clinical record titled, PSYCHOTHERAPEUTIC DRUG INFORMED CONSENT FORM, dated 2/9/26, and was signed by the Medical Doctor (MD) for the antidepressant medication Rexulti; however, Resident 148 had not signed the consent form. The ADON reviewed the clinical record titled, PSYCHOTHERAPEUTIC DRUG INFORMED CONSENT FORM, which indicated that the MD had signed the form on 2/9/26 for the sleep aid medication Trazodone; however, Resident 148 had not signed the form. The ADON reviewed the clinical record titled, PSYCHOTHERAPEUTIC DRUG INFORMED CONSENT FORM, which indicated that the MD had signed the form on 2/9/26 for the antidepressant medication Bupropion; however, Resident 148 had not signed the form. The ADON stated that the psychotropic informed consent should have been signed immediately by the MD and Resident 148 and verified by the admitting nurse or whoever entered the psychotropic medication orders in the EHR.During an interview on 2/12/26 at 8:55 AM with Director of Nursing (DON), the DON stated that licensed nurses were expected to obtain informed consent for psychotropic medications before treatment was started for Resident 148. The DON further stated that it was important for Resident 148 to be informed about the psychotropic medications, that he acknowledged understanding, and agreed to the treatment.A review of the facility policy and procedure titled, Psychoactive/Psychotropic Medication Use, dated 4/25, indicated, . Informed Consent . The Resident . has the right to be informed in advance, by the physician . of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Prior to administration of a psychotropic medication, the prescribing clinician will obtain informed consent from the resident . and document the consent in the medical record. A licensed nurse must verify informed consent has been obtained from the resident . prior to administering psychotropic medication . The facility must record the signed written consent in the resident's medical record. The facility must verify the presence of written informed consent in the resident's medical record before initiating treatment with psychotropic medication.

Based on observation, interview, and record review, the facility failed to ensure the safety of bedside medication storage and use in one out of seven residents (Resident 63) observed for medication administration based on facility's policy and medical doctor's orders when Resident 63 was self-administering a nasal spray medication that was stored at her bedside without a physician's order or the facility staff being aware of the use.This failed practice and use of medication without a doctor's order could contribute to unsafe medication use in a room shared with another resident and possible drug-drug interaction with prescribed medications.Findings:During a concurrent interview with Resident 63 and a medication administration observation with Licensed Nurse 1 (LN) 1 on 2/9/26 at 8: 45 a.m., LN 1 administered a total of 16 morning medications to Resident 63. The medications included five blood pressure medications among others. Resident 63's bedside table stored two unlabeled bottles of a nasal spray called oxymetazoline (a used to relieve nasal and sinus congestion/pressure caused by colds, hay fever, and allergies). Resident 63 stated she ordered the nasal sprays from an online retailer and did not wait for the facility to call the doctor and order the medication. Resident 63 stated she did not notify the facility, and no one questioned her that she had the medication at her bedside. Resident 63 stated she had been using the nasal spray for about 4 or 5 days.During an interview with LN 1, on 2/9/26 at 2:40 p.m., LN 1 stated she did not realize the nasal spray was at Resident 63's bedside table. LN 1 reviewed Resident 63's electronic medical record and confirmed there was no doctor's order for use of the nasal spray. LN 1 stated the doctor needed to know what other medications the resident was talking as she was on many medications that could interfere with the use or effectiveness of the medication.During an interview with Director of Nursing (DON), in her office, on 2/10/26 at 12:30 p.m., the DON stated she spoke to Resident 63 and explained to her that she needed to notify the facility if she used her own medication. The DON stated the nursing staff should have noticed the bedside use of medications. The DON stated there was a risk of inadvertent use by another resident or possible interaction with other medication when a medication was used but not ordered or assessed by the medical doctor or the care team. A review of facility's policy titled, Self-Administration of Medications, dated 2/2021, the policy indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe for the residents to do so. The policy further indicated Self-administered medications are stored in a safe and secure place which is not accessible by other residents. Any medication found at bedside that are not authorized for self-administration are turned over to the nurse in charge for return to family or responsible party.A review of information on oxymetazoline nasal spray via DailyMed (the official U.S. National Library of Medicine (NLM) database providing comprehensive, up-to-date, and authoritative information on over 1 million marketed s and acts as a trusted, searchable repository for FDA (Food and Administration)-approved medication labels), last accessed on 2/18/26 via https://dailymed.nlm.nih.gov/dailymed/Info.cfm?setid=89c165ba-3ad5-49b5-a5bb-423dc8e15bad, indicated the product is a decongestant (reduce swelling and congestion of nasal vessels) and gave a warning on the use in setting of high blood pressure. The product could further contribute to high blood pressure.

Based on observation, interview, and record review, the facility failed to ensure a home-like environment for two of 37 sampled residents (Resident 116 and Resident 127) when:Resident 116's drawer handle was broken; and,Resident 127's walls were not maintained and painted evenly.These failures had the potential to negatively impact Resident 116 and Resident 127's home-like environment.Findings: 1. A review of Resident 116's clinical record titled, admission RECORD, indicated, Resident 116 was admitted to the facility with diagnoses of, but not limited to generalized muscle weakness, abnormalities of gait and mobility (difficulty walking and moving) absence of right leg above the knee, presence of artificial left leg, and diabetes mellitus (a condition where the body cannot control blood sugar levels). During a concurrent observation and interview on 2/9/26, at 10:33 AM, in Resident 116's room, the bedside cabinet on the left upper side of Resident 116's bed was observed with a broken handle. Resident 116 stated that he reported the broken drawer handle to the staff several times, but they took no action. During an interview on 2/9/26, at 10:35 AM, with Licensed Nurse (LN) 2, LN 2 confirmed that the bedside cabinet had a broken handle and needed to be fixed. During an interview on 2/10/26, at 11:05 AM, with Resident 116, in his room, Resident 116 stated that the broken handle on his bedside cabinet drawer still had not been fixed, despite his previous complaints. Resident 116 stated that his bedside drawer was important because it was where he kept his personal belongings and valuables. Resident 116 stated further, he used a small screw to open and close the drawer until it can be fixed. Resident 116 stated that if he had been at home, he could have fixed it in 5 minutes. During an interview on 2/10/26, at 11:22 AM with Director of Staff Development (DSD), the DSD observed that the bedside cabinet drawer handle was still broken and stated the importance of addressing the issue promptly. The DSD stated further that to create a homelike environment, staff were expected to follow the process for concerns like this and staff needed to write identified issues in the maintenance log to ensure they got fixed. During an interview on 2/10/26 at 11:24 AM, LN 2 stated that she forgot to write the issue about the broken bedside cabinet drawer handle in the maintenance log and instead reported it verbally to the maintenance staff. During an interview on 2/12/26, at 8:38 AM with Director of Nursing (DON), the DON stated that she expected the staff to follow the proper process for reporting Resident 116's broken bedside cabinet drawer handle. The DON stated further the importance of writing such issues in the maintenance log to ensure they were addressed promptly. Review of a facility policy and procedure titled, Homelike Environment, undated, indicated, Policy Statement – Patients [Resident 116] are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Staff shall provide person-centered care that emphasizes the patients' [Resident 116] comfort, independence, and personal needs and preferences.The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.clean, sanitary and orderly environment. 2. Review of Resident 127's clinical record, admission RECORD indicated Resident 127 was admitted to the facility with diagnoses that included insomnia (sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early and being unable to return to sleep) and abnormalities of gait and mobility. During a concurrent observation and interview on 2/10/26, at 2:37 p.m., with Resident 127, Resident 127's wall had a 1 inch ( a unit of measure) length by 1 inch width sized paint chip and a mismatching white paint on the wall that was 17 inches in length by 5 inches in width. Resident 127 pointed at the wall and stated, the walls are chipped and the paint does not match. During a concurrent observation and interview on 2/12/26, with the Director of Maintenance (MTD), the MTD verified the condition of Resident 127's walls included a 1 inch length by 1 inch width sized paint chip and a mismatching white paint on the wall that was 17 inches in length by 5 inches in width, the MTD stated Resident 127's room should have been warm and welcoming. The MTD further stated that Resident 127's room should have been clean, maintained, and ready for him and that he had just changed rooms the day before. During a review of the facility policy and procedure (P&P) titled, Homelike Environment revision date 2/2021, the P&P indicated, .The facility staff and management maximizes, to the extent possible, the characteristics of facility that reflect a personalized, homelike setting. These characteristics include.clean, sanitary and orderly environment.inviting colors and décor.

Based on interview and record review, the facility failed to ensure one of 37 sampled residents (Resident 7) was appropriately discharged when Resident 7 was discharged back to a General Acute Care Hospital (GACH) for insurance purposes.This deficient practice resulted in an inappropriate GACH admission.Findings:A review of Resident 7's clinical record titled, admission RECORD indicated Resident 7 was admitted on [DATE], with diagnoses that included but not limited to type 2 diabetes (the body's inability to control sugar levels), shortness of breath, and muscle weakness.A review of Resident 7's clinical record titled, Progress Notes dated 10/2/25, at 12:25 p.m., documented by Licensed Nurse (LN) 1 indicated, .Writer notified by Admin [administrator] that resident needed to get sent out back to GACH d/t [due to] insurance purposes no clinical [health] changes noted family aware MD aware .A review of Resident 7's untitled GACH document dated 10/2/25, at 12:31 p.m., indicated, .patient presents from rehab without medical complaints. Patient sent back due to what seems to be a medical billing problem after being discharged from our hospital yesterday.During an interview on 2/11/26, at 10:41 a.m., with LN 1, LN 1 stated, Resident 7 was sent back to the GACH due to insurances purposes. LN 1 further stated there was no clinical reason for returning the resident back to the GACH.During a concurrent interview and record review on 2/11/26 at 12:10 p.m., with the Director of Nursing (DON), Resident 7's clinical record titled, Progress Notes was reviewed. The DON stated Resident 7 was stable and had no clinical indication to be sent back to GACH.During an interview on 2/11/26 at 3:18 p.m., with Resident 7, Resident 7 stated if she had to be sent back to the GACH for no clinical reason, that would upset her.During a concurrent interview and record review on 2/12/26 at 11:10 a.m., with the Administrator (ADM) the facility policy and procedure (P&P) titled, Transfer or Discharge with a revision date 3/2025, was reviewed. The ADM verified Resident 7's discharge on [DATE] did not follow the facility's P&P.During a review of the facility's P&P titled, Transfer or Discharge revision date 3/2025, the P&P indicated, .Each resident is permitted to remain in the facility, and not be transferred or discharged unless:. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility.the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility.the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.the health of the individuals in the facility would otherwise be endangered.the facility ceases to operate.the resident has failed, after reasonable and appropriate notice, to pay for a stay at this facility.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - clinical assessment tool used in nursing homes) diagnostic assessments were accurately documented for 2 out of 5 residents reviewed for unnecessary medications, when Resident 2 and Resident 105 received medications for physician-documented conditions that were not coded on the MDS.This failure had the potential to compromise safe and accurate resident assessment and nursing plans of care. Findings:Review of Resident 2's admission RECORD indicated Resident 2 was admitted to the facility with multiple diagnoses, including dementia (cognitive decline where the specific type and severity are not clearly defined or documented) and atrial fibrillation (type of irregular and fast heart rhythm that occurs in sudden and temporary episodes).Review of Resident 2's History and Physical (H&P), dated 6/9/25, indicated the resident was admitted to the facility with diagnoses including hypothyroidism (low thyroid hormone) and osteoporosis (brittle bone disease) for which medications were prescribed. Resident 2's diagnosis section of the MDS, dated [DATE], did not reflect or document the thyroid and bone disease diagnoses while the resident was receiving medications to treat both conditions.Review of Resident 105's admission RECORD indicated Resident 105 was admitted to the facility with multiple diagnoses including dementia and heart disease. Review of Resident 105's admission records from Hospital A, dated 10/20/25, titled Progress Notes, SNF [skilled nursing facility] admission History and Physical, indicated Resident 105 was admitted to the facility with a diagnosis of deep vein thrombosis (DVT - a blood clot that forms in a vein deep inside the body, usually in the lower leg, thigh, or pelvis), for which medication was prescribed. Resident 105's diagnosis section of the MDS, dated [DATE], did not reflect or document the DVT diagnosis while the resident was receiving medication for the condition.During a concurrent interview and record review on 02/11/26 at 4:26 p.m. with the MDS Nurse Coordinator (MDSC), the Active Diagnoses section of the MDS were reviewed for both Resident 2 and Resident 105. The MDSC confirmed there were missing medical diagnoses for both Resident 2 and Resident 105 on their MDS's. The MDSC stated that it was important to be accurate in transcribing the resident's medical history because it can affect the resident's quality measures and any missed diagnosis can have a different plan of care that can potentially affect the resident.During a concurrent interview and record review on 02/12/26 at10:43 a.m. with the Director of Nursing (DON), the Active Diagnoses section of MDS were reviewed for both Resident 2 and Resident 105. The DON confirmed that Resident 2 and Resident 105's diagnoses were not accurately documented in the MDS assessments. The DON stated MDS assessments must be completed accurately. The DON also stated that inaccurate documentation can affect the quality of care provided to residents.A review of the facility policy titled Comprehensive Assessments, revised on March 2022, indicated, . 8. A significant error is an error in an assessment where: . the resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment. 9. A significant error differs from a significant change because it reflects incorrect coding of the MDS and NOT an actual significant change in the resident's health status.

Based on interview and record review the facility failed to ensure residents received pain management interventions in accordance with assessed pain levels for 1 out of 5 residents reviewed for unnecessary medications, when staff administered PRN (as needed) pain medication for Resident 86 despite documented pain assessments indicating a pain level of 0 (a 0-10 pain scale with 0 being no pain, to 10 being the worst pain). This failure had the potential to result in unnecessary medication administration, increased risk for adverse medication effects, and inaccurate pain assessment.Findings:Review of Resident 86's admission RECORD indicated Resident 86 was admitted to the facility with multiple diagnoses, including muscle weakness, chronic low back pain, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).Review of Resident 86's Medication Administration Record (MAR - a legal record of medications administered to a resident) for January 2026 through February 2026 indicated the resident had a physician order for Morphine (opioid pain medication) PRN (as needed) for severe pain. MAR entries documented for Resident 86's pain level were 0 at the time Morphine was administered on the following dates:01/11/26 - Pain level documented as 0; Morphine administered PRN at 0535 (5:35 a.m.).01/24/26 - Pain level documented as 0; Morphine administered PRN at 2350 (11:50 p.m.).01/30/26 - Pain level documented as 0; Morphine administered PRN at 1732 (5:32 p.m.).02/02/26 - Pain level documented as 0; Morphine administered PRN at 1651 (4:51 p.m.).02/08/26 - Pain level documented as 0; Morphine administered PRN at 0241 (2:41 a.m.).02/08/26 - Pain level documented as 0; Morphine administered PRN at 1305 (1:05 p.m.).During a concurrent interview and record review on 02/12/26 at 10:11 a.m. with Licensed Nurse (LN) 6, January 2026 and February 2026 MARs for Resident 86 were reviewed. LN 6 confirmed that staff administered PRN Morphine to Resident 86 when the documented pain level was 0. LN 6 stated staff are expected to assess pain levels prior to administering medication. LN 6 further stated the physician's order specified use for severe pain, which she described as a pain level in the range of 7 to 10. LN 6 stated assessing an accurate pain level of the resident prior to administration of pain medication was important because opioid medication may place the resident at risk for oversedation (extreme tiredness).During a concurrent interview and record review on 02/12/26 at10:43 a.m. with the Director of Nursing (DON), January 2026 and February 2026 MARs for Resident 86 were reviewed. The DON confirmed PRN Morphine was administered to Resident 86 when the documented pain level was 0. The DON stated staff received training on accurate MAR documentation to prevent documentation discrepancies. The DON further stated that assessing pain prior to administering medication was necessary to ensure resident safety.A review of the facility policy titled Pain Assessment and Management, revised October 2022, indicated, .5. During pain assessment gather the following information. (2) Intensity of pain (as measured on a standardized pain scale) .

Based on interview and record review, the facility failed to maintain one of four sampled residents' privacy (Resident 1) when licensed nurse (LN) 3 used her personal phone to take a photograph of Resident 1. This failure resulted in a violation of Resident 1's privacy, potentially negatively affecting his psychosocial well-being. Findings:Findings:A review of Resident 1's clinical document titled, admission RECORD, (contains clinical and demographic data) indicated Resident 1 had been admitted to the facility with diagnoses which included dementia (a general term for a loss of brain function that is not a normal part of aging, causing significant problems with memory, thinking, and social abilities).A review of Resident 1's clinical document titled, Progress Note, dated 9/2/25, by LN 3, indicated LN 3 was informed by a NOC shift (6:30 a.m. through 7 p.m.) nurse that Resident 1's arm was tied to the bed during the Intravenous (IV - plastic tube placed in the vein to deliver medication) line placement. LN 3 informed the NOC nurse that she needed to untie Resident 1's arm from the bed because it was a form of a restraint (devices that limit a resident's movement). LN 3 took a picture with her personal phone before the arm was untied from the bed.During an interview with the Administrator (ADM) on 12/5/25 at 10:34 a.m., the ADM confirmed LN 3 had taken a picture of Resident 1's right arm on LN 3's personal phone. The ADM stated that the importance of not taking pictures on staff's personal phone was that the phone may not be encrypted (coded to protect against unlawful access) and could have been accessed by people who were not employed by the facility. A review of the facility policy titled, Resident Rights, revised 2/2021, indicated, . Employees shall treat all residents with kindness, respect, and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . a dignified existence . privacy and confidentiality .

Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) environment was free of accident hazards when Resident 1's right wrist remained in an arm positioning device (a medical tool that holds a patient's arm in a specific, stable, and extended position during the procedure and does not allow for movement) following a mid-line insertion (medical procedure of placing a thin, flexible tube (catheter) into a large vein in the upper arm, with the tip terminating just below the armpit).This failure had the potential for injury related to the arm positioning device being secured to Resident 1's bedframe, potentially negatively affecting Resident 1's health, safety, and emotional well-being.A review of Resident 1's clinical document titled, admission RECORD, (contains clinical and demographic data) indicated Resident 1 had been admitted to the facility with diagnoses which included a fall, abnormal gait, and impaired mobility (any unusual walking pattern that deviates from a normal, smooth, and coordinated stride).A review of Resident 1's clinical document titled, Order Details, dated 8/31/25, indicated, . May insert midline ., During an interview with certified nursing assistant (CNA) 1 on 11/14/25 at 4:34 p.m., CNA 1 stated she received a shift report from CNA 2 regarding Resident 1's current health condition. CNA 1 explained that when she and CNA 2 went into Resident 1's room, CNA 1 stated she saw the Resident 1's arm in a positioning device. CNA 1 further explained she informed licensed nurse (LN) 1 about the arm positioning device. CNA 1 stated the arm positioning device was still on Resident 1 when she changed his brief (adult diaper) in the morning. CNA 1 explained she removed the arm positioning device to change Resident 1 and when she was done changing him, she put the arm positioning device back on Resident 1.During an interview with LN 1 on 11/14/25 at 4:39 p.m., LN 1 stated she first became aware of the arm positioning device at approximately on 9/1/25 at 6:00 a.m. when she passed medications. LN 1 explained she did not remove the arm positioning device. LN 1 further explained she informed the oncoming day shift nurse (LN 3) of the device.During an interview with CNA 2 on 11/14/25 at 5:26 p.m., CNA 2 confirmed that during shift change (a set of nurses are done working and a new set of nurses start working) he discussed the arm positioning device with CNA 1 and stated he asked CNA 1 if she would inform the nurse. CNA 2 explained CNA 1 told her he would inform the nurse. CNA 2 further stated CNA 1 had informed LN 1 about the arm positioning device.During an interview with LN 2 on 11/18/25 at 10:53 a.m., LN 2 stated she was aware of the arm positioning device when LN 4 (from an outside agency) requested assistance from LN 2. LN 2 explained she saw the arm positioning device on Resident 1's right wrist as she held Resident 1's left arm to assist LN 4. LN 2 further explained LN 4 required assistance due to Resident 1's agitation and aggression. LN 2 stated she had not realized the arm positioning device had still been in place because Resident 1's right wrist was covered.During an interview with LN 3 on 11/21/25 at 11:49 a.m., LN 3 stated that at change of shift on 9/1/25, LN 1 informed her that the arm positioning device on Resident 1's right wrist was still in place. LN 3 explained she informed LN 1 the arm positioning device should not still be on and told LN 1 to remove the device. LN 3 further explained that around 9 a.m., CNA 3 asked her why Resident 1's right arm was secured to the bedframe, LN 3 informed CNA 3 Resident 1's right arm should not be secured to the bedframe. LN 3 stated she went to take a picture of Resident 1's right arm in the arm positioning device so she could inform the administrator. LN 3 stated LN 1 tried to prevent her from taking the picture and managed to unsecure the arm positioning device before she could take the picture. LN 3 further stated she informed the administrator regarding the arm positioning device.During an interview with CNA 3 on 12/2/25 at 1:47 p.m., CNA 3 confirmed she informed LN 3 about the arm positioning device. CNA 3 stated Resident 1's right arm was secured to the bedframe, and he could not move his right arm freely.A record review of Resident 1's clinical document titled, Progress Notes, dated 9/2/25, indicated, . During report on 9/1/25 this write was informed by [night nurse] [Resident 1's] arm was [in an arm positioning device] . Informed [night nurse] [Resident 1] can not be in [arm positioning device] . Informed [night] nurse she needed to [remove arm positioning device] . At 0900 [9 a.m.,] CNA asked this writer why [Resident 1's] arm was [in arm positioning device] . Informed CNA [night] nurse was supposed to [remove arm positioning device] . This writer went to room. [Resident 1's] right arm was in [arm positioning device secured to his bed] .During an interview with an outside Clinical Nurse Officer (CNO) on 12/2/25 at 10:41 a.m., the CNO stated the arm positioning device should not have been left on a Resident 1. The CNO explained an arm positioning device was used for a limited amount of time during mid-line insertion to help keep the arm in place. The CNO further explained that once the mid-line was inserted and secured the arm positioning device should have been removed, its use documented and reported to the LN on duty. The CNO confirmed the arm positioning device was not removed, its use was not documented, and its use was not reported to the LN on duty by LN 4.During an interview with the Administrator (ADM) on 11/21/25 at 12:30 p.m., the ADM stated Resident 1's right arm remaining in the arm positioning device had the potential to cause Resident 1 emotional distress.During a follow-up interview with the ADM on 12/5/25 at 10:34 a.m., the ADM stated when the mid-line insertion procedure was completed the arm positioning device should have been removed and it had not been. The ADM explained Resident 1 would have been unable to move his arm beyond the arm positioning device and could have caused Resident 1 discomfort.A review of the facility policy titled, Hazardous Areas, Devices and Equipment, revised July 2017, indicated, . All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . Identification of Hazards . A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following . Equipment and devices that are left unattended . Assessment and Analysis of Hazards . Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous . Improper or inappropriate use of equipment and devices .

Based on interview and record review, the facility failed to implement appropriate safety interventions including supervision to ensure a safe environment free of accidents and hazards for one of two sampled residents (Resident 1) when:1. Resident 1 was not initially assessed (around the time of admission to the facility) accurately for an elopement risk (the potential for a vulnerable individual to leave a facility without staff awareness, leading to serious dangers like injury or even death) and Resident 1 was not reassessed for an elopement risk after Resident 1 became more confused, began to wander (aimless movement), and attempted to and expressed a desire to leave the facility on several occasions; 2. An elopement risk care plan (a comprehensive resident centered plan which includes interventions such as environmental modifications, supervision, and/or technology integration to prevent a resident from leaving a facility) was not created for Resident 1; and 3. A doctor's order to send Resident 1 to the hospital for a change in condition (any significant physical, cognitive, or mental deviation from a resident's baseline that requires an adjustment to their care plan) was not carried out by facility staff over multiple shifts. These failures resulted in Resident 1 eloping from the facility on the morning of 10/4/25 between 7:30 a.m. and 7:40 a.m. (during rush hour traffic near a busy road) and being found one mile away near a shopping center at 8:30 a.m. by a family friend (FF), looking pale, clammy, sweaty, and shaking. These failures had the potential to result in physical and emotional danger: including injury, exposure to the elements (extreme heat or cold), and/or death and the emotional toll could be severe, leading to feelings of loneliness, depression, and increased anxiety. Findings:Review of Resident 1's admission RECORD, indicated, Resident 1 was admitted to the facility on [DATE] (Monday) with diagnoses which included hepatic encephalopathy (HE, when the liver is unable to properly filter toxins from the blood, leading to their accumulation in the brain which can cause confusion, disorientation, and personality changes among other symptoms) and hyponatremia (low levels of sodium (salt) in the blood which can cause restlessness, irritability, and dizziness when standing up among other symptoms).Review of Resident 1's BRIEF INTERVIEW FOR MENTAL STATUS (BIMS, an assessment tool that healthcare providers use to assess a person's cognitive function), dated 9/29/25, indicated, Resident 1 had a BIMS score of 5, which indicated severe cognitive impairment (Score of 0 to 7: Severe problems with thinking and memory).During a phone interview on 10/6/25, at 4:02 p.m., Emergency Contact (EC) 1 stated Resident 1 was recently admitted to the facility after his family took him to the emergency room (ER) for increased confusion. EC 1 stated Resident 1 experienced a fall on 5/20/25 and broke his neck and required surgery. EC 1 stated Resident 1 had been in and out of the hospital seven times since then due to complications from surgery. EC 1 stated a nurse from the facility called her on 9/29/25 (Monday) because Resident 1 seemed more confused and the family requested blood work be done because he would get confused when he had a low blood sodium level (a mineral needed by the body to keep body fluids in balance). EC 1 stated on 9/30/25 (Tuesday) family were visiting Resident 1 and noticed he was more confused, did not know where he was, and was making up stories. EC 1 stated Resident 1 did not make sense, and she told staff he might be getting an infection, or his blood labs were off. EC 1 stated while at the facility Resident 1 could not get off his bed independently or walk because it was not safe and when she visited him on 10/2/25 (Thursday) she pushed him around in a wheelchair. EC 1 stated someone from the facility called on Thursday night and told them Resident 1 was resisting care and very confused. EC 1 stated Resident 1's responsible party (RP) went to the facility that night and when the RP arrived at the facility Resident 1 was at the entrance door and was trying to leave. EC 1 stated on 10/3/25 (Friday) she met Resident 1 at a medical appointment and when Resident 1 returned to facility after his doctor's appointment he refused to get out of the transport van and would not go inside the facility. EC 1 stated staff called the RP, and the RP was able to get Resident 1 to go back into the facility. EC 1 stated at 5 p.m. on 10/3/25 (Friday), staff called and asked when someone was coming to get him because he was resisting the wander guard (wearable device attached to a bracelet that is integrated with a security system to alert caregivers when residents are near or exit a door leading outside) staff was trying to place on him. EC 1 stated the staff member told her staff would have to send him to the hospital because he was not listening and wanted to leave the facility. EC 1 stated she told the staff member she gave permission to send Resident 1 to the hospital if that was the safest place for him. EC 1 stated she did not hear back from the facility after that, so she thought everything was okay with Resident 1. EC 1 stated the next day, 10/4/25 (Saturday) the neighbor, who lived across the street from Resident 1's previous residence, found him disheveled and dirty, on a bench alone near a shopping center. EC 1 stated, just before 9 a.m., she called the facility to check if they knew Resident 1 was missing because she had not heard from them. EC 1 stated she was placed on hold for 25 minutes, so she used another phone line to call the facility back. EC 1 stated the person who answered the phone told her staff were trying to locate Resident 1. EC 1 stated she told the staff member Resident 1 was already found by the shopping center. EC 1 stated Resident 1 had walked very little since his surgery in May and now he just walked about 2 miles outside of the facility, alone. EC 1 stated Resident 1 could have fallen and reinjured himself, or could have gotten hit by a car, or not been found at all. EC 1 stated they did not take Resident 1 to the doctor after finding him because they were tired of doctors not being able to help him. EC 1 stated nobody from the facility has called her since Resident 1's elopement nor have they spoken to the RP regarding medical updates or the elopement. Review of Resident 1's [Hospital Name] HOSPITALIST DISCHARGE SUMMARY, dated 9/29/25, indicated, .admit date .9/26/25.discharge date .9/29/25.FINAL DISCHARGE DIAGNOSES.Encephalopathy acute [sudden].Hyponatremia.HOSPITAL COURSE.brought in from home for generalized weakness worsening confusion unable to take care of self at home.Patient is currently orientated to his name [and] place could tell me the year but unable to give me history of what happened at home is complaining of back pain. sodium of 131 [normal blood sodium levels are 135-145].ammonia 43 [normal blood ammonia levels are 11-32; high ammonia symptoms include confusion and disorientation].initial labs showed elevated ammonia, which had trended down.mentation improving [less confusion].9/28/25.NA [sodium] 126 (L) [low].HPI [history of present illness].recurrent admissions for hyponatremia.A review of Resident 1's Social Services/Case Management Initial Assessment Note, dated 9/30/25, indicated .Patient had a fall at home prior to admission. Family also emphasized the Importance of monitoring the patient's.hyponatremia and requested close observation of lab values [blood tests]. They asked to be notified of any changes in the patient's condition.Review of Resident 1's Care Plan Report, initiated 9/30/25, indicated, .Skilled PT [Physical Therapy] needed for impaired gait [walking], impaired balance.decreased endurance [strength], and decreased functional level [the loss of ability to perform usual activities due to a decline in physical or cognitive function].Review of Resident 1's Care Plan Report, initiated 9/30/25, indicated, .Falls: Resident is at risk for falls with or without injury related to altered mental status.Goal.Will be compliant with fall interventions.Interventions.Anticipate and meet needs.Education/remind resident to call for assistance with all transfers.Review of Resident 1's Care Plan Report, initiated 10/1/25, indicated, . Not alert to surroundings at eval [evaluation], thinks he is at [name of high school] in the gym.Pt [patient] will be orientated to place/time/circumstances/new deficits and safety precautions.Skilled ST [speech therapy ] 5x wk [times per week] x 4 wks to address Cognitive Communication Deficit.Review of Resident 1's Care Plan Report, initiated 10/3/25, indicated, . Cognitive Impairment.exhibits cognitive loss related to altered cognitive performance with BIMS score of 5.indicating severe impairment.Goal.Will avoid complications.Interventions.Anticipate needs and meet promptly.Monitor for changes in cognitive status. Notify physician if observed.Observe for indicators of clinical changes.behavior changes.Notify physician if occurs.Review of Resident 1's Care Plan Report, initiated 10/3/25, indicated, .[Resident 1] has an alteration in neurological status [mental status] r/t [related to].Encephalopathy. Intervention.Cueing, reorientation as needed.Obtain and monitor lab/diagnostic work as ordered. Report result to MD [Medical Doctor] and follow up as indicated.Review of Resident 1's Physical Therapy Medicare PT Evaluation & Plan of Treatment, dated 9/30/25, indicated, .Patient exhibits new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate and reduced functional activity tolerance. Pt is confused.Fall risk, confusion, poor endurance.Safety Awareness.Poor.the patient is at risk for: falls and further decline in function. Pt unable to take a step on first attempt of gait training [walking]. Pt instructed on side stepping on second attempt but only able to take 2 side steps. On third attempt, pt able to take 3 steps but drags R [right] foot d/t [due to] c/o [complaints of] pain on B [both] ankles and feet.Review of Resident 1's Physical Therapy Medicare PT Evaluation & Plan of Treatment, dated 10/3/25, indicated .Pt educated and instructed on gait training.utilizing FWW [front wheeled walker].Pt completed 200ft.Pt demonstrates increase in confusion requiring frequent redirecting back to therapy tasks. Nursing staff aware.A review of Resident 1's physician order, dated 9/29/25, indicated .CMP [Comprehensive Metabolic Panel - a blood test that includes a sodium level].A review of Resident 1's CMP results, dated 9/30/25, indicated .sodium.127.A review of Resident 1's physician order, dated 10/2/25, indicated .CMP in one week one time only for sodium.Review of Resident 1's PERSONAL HISTORY AND PHYSICAL EXAMINATION, dated 10/2/25, hand-written by Resident 1's Medical Doctor, indicated, .INITIAL EXAM watch mental [observe for mood/behavior changes], Repeat Lab.Na.NH3 [ammonia].A review of Resident 1's physician order, dated 10/3/25, indicated .NH3 one time only for confusion for 1 Day.Review of Resident 1's SBAR [Situation, Background, Assessment, and Recommendation] change in condition form, written by Licensed Nurse (LN) 1, dated 10/3/25 at 12:40 p.m., indicated, .Resident seems very confused.Increased confusion.This started on.10/03/2025.MD notified.if family wants, and condition not better.go back to ER [emergency room].Review of Resident 1's Nurse's Note, written by the director of nursing (DON), dated 10/3/25 at 2:01 p.m., indicated, .Resident noted with aggressive, restlessness behavior concerned about safety/high fall risk.Review of Resident 1's Order Details, created by the DON on 10/3/25 at 2:01 p.m., indicated, .Order Summary.OK to transfer the resident to ER for safety concerns.every shift for 2 days.Review of Resident 1's Nurse's Note, written by the assistant director of nursing (ADON) dated 10/3/25 at 4:30 p.m., indicated .Pt was wandering in building and verbalizing that he wanted to leave and go to various locations. I attempted to place wander guard but pt continued to refuse. DON tried and sat and spoke to him for at least 15 min and pt continued to refuse wander-guard. RN [registered nurse] on shift also attempted to place wander guard without success. I spoke to [RP] and requested that he come and see pt and also try to place wander-guard. He stated that he is busy at this time but will try and come later.Review of Resident 1's Nurse's Note, written by LN 5, dated 10/3/25 at 9 p.m., indicated, .Patient attempted to elope multiple times, not compliant called and notified [EC 1].Review of Resident 1's Nurse's Note, written by LN 5, dated 10/3/25 at 9:58 p.m., indicated, PT REFUSED.LAB DRAWS [blood tests].Review of Resident 1's Behavior Note, written by LN 2, dated 10/4/25 at 7:23 a.m., indicated, .Writer attempted to place wanderguard on pt's ankle. Pt knocked writer's hand away and tried to hit writer. Non-compliant with care, risk for elopement.Review of Resident 1's Nurse's Note, written by LN 3, dated 10/4/25 at 12:57 p.m., indicated, .around 730 [7:30 a.m.], writer redirected resident back to room because breakfast was coming, resident went back to room and around 8:30-8:45 [a.m.] CNA and nurse went looking for resident in all the bathrooms beds and all around the facility. DON notified. Writer called family and family told writer that resident was found at [shopping center] by a [FF]. [FF] took resident to her home and notified family. Family stated to writer that resident will not be returning to facility. DON and MD notified.During an interview on 10/6/25, at 4:52 p.m., LN 5 stated she was Resident 1's evening shift nurse for the two evenings prior to his elopement (10/2/25 Thursday and 10/3/25 Friday). LN 5 stated during her shifts Resident 1 had made multiple attempts to try to elope and was non-compliant of nursing care. LN 5 stated Resident 1 verbalized that he wanted to get out of the facility. LN 5 stated Resident 1 became more confused throughout her two shifts with him, was walking around the facility, and would not listen to instructions to go back to his room. LN 5 stated she and a CNA were watching Resident 1 to prevent him from leaving the facility, but he was not on one-on-one supervision (a single caregiver is continuously and closely monitoring a person who requires constant attention). LN 5 explained she felt Resident 1 needed one-on-one supervision and he was at risk for eloping. LN 5 confirmed she did not send Resident 1 out to the hospital during her shift. LN 5 stated she told the night nurse (LN 2) Resident 1 was wandering and was on visual monitoring. LN 5 stated Resident 1 did not have a wander guard, and she believed he should have one due to him being an elopement risk. LN 5 stated when she returned to the facility for her next shift (10/4/25 Saturday), she learned Resident 1 had eloped. LN 5 indicated that Resident 1's risk of eloping included potential harm, injury, or falls. LN 5 emphasized the importance of providing care to prevent such injuries.During a concurrent interview and record review on 10/6/25, at 3 p.m., LN 1 stated she was Resident 1's day shift nurse (7:30 a.m. to 3:30 p.m.) for the three days prior to his elopement. LN 1 stated Resident 1 seemed more confused on the morning of 10/3/25 and she completed a change of condition and informed Resident 1's doctor. LN 1 stated Resident 1 had a doctor's appointment on 10/3/25 (Friday) and when he returned, he would not listen and began to walk around the facility by himself, would not use his walker, and/or accept staff assistance. LN 1 stated Resident 1 was pacing for a couple of hours in the afternoon after returning from his appointment and the DON was walking with Resident 1 because he would not sit down and was a fall risk. LN 1 stated the DON told her the doctor said it was okay to send Resident 1 out to the ER (emergency room) and the DON had placed the order in Resident 1's clinical record. LN 1 confirmed she did not send Resident 1 out to the ER. LN 1 stated the risk to Resident 1 for not being sent to the ER was risk of symptoms getting worse and elopement. LN 1 stated this morning (10/6/25) she found out from another nurse Resident 1 had eloped over the weekend. LN 1 stated the process when a resident goes missing was to check inside and outside the facility and if the resident was not found then they would call the responsible party, complete a police report, and inform the DON and the Administrator (ADM).During an interview on 10/7/25, at 9:55 a.m. LN 2 stated she worked the night shift from 11 p.m. to 7 a.m. and was Resident 1's nurse on Thursday night (10/2/25) and Friday night (10/3/25) prior to his elopement. LN 2 stated Resident 1 was up and about a lot more, was walking and pacing, was not listening and was non-compliant (not doing what someone asks you to do) with care. LN 2 stated Resident 1 told her he wanted to go home and needed to borrow a phone. LN 2 stated Resident 1 did not know where he was. LN 2 stated he finally settled around 4 a.m. Saturday morning (10/4/25). LN 2 explained Resident 1 was back at it pacing at 6 a.m. LN 2 stated doctor orders were to send Resident 1 out to the hospital if he gets aggressive. LN 2 explained Resident 1 went to the front door around 2:30 a.m. on Saturday morning. LN 2 stated she instructed CNA 1 to keep eyes on him, and she did. LN 2 stated Resident 1 kept his shoes on the whole night and was wearing his clothes from the day before. LN 2 stated she gave shift report to the oncoming nurse (LN 3) at 7:30 a.m., and she saw Resident 1 down the hall, and he was pacing. LN 2 stated she told the incoming nurse who had not worked with Resident 1 that it was her discretion to send Resident 1 out to the hospital. When asked why Resident 1 was not sent out to the hospital, LN 2 stated for her, Resident 1 did not meet the threshold and would have needed to be more aggressive. LN 2 stated Resident 1 should have had a one-on-one staff member supervising him from the beginning. During a concurrent interview and record review on 10/7/25, at 1:18 p.m., Resident 1's Wandering/Elopement Risk Evaluation, dated 9/29/25, and Resident 1's PERSONAL HISTORY AND PHYSICAL EXAMINATION, written by the MD on 10/2/25, was reviewed with the DON. The DON confirmed Resident 1's elopement risk evaluation indicated the following, .If the total score is 10 or greater, the resident would be considered At risk for Wandering or Elopement. Interventions implemented as determined by the facility IDT [Interdisciplinary Team, a collaborative group of healthcare professionals, including nurses, social services, who work together to provide a plan of care for residents] .MOBILITY STATUS.Is the resident able to move or propel themselves in a wheelchair with some assistance from others? [checked].COGNITIVE STATUS.Is the resident disoriented or has periods of confusion and/impaired attention span but does not wander? [checked].DISEASE DIAGNOSIS.Does the resident have a diagnosis that may impact cognition? (i.e., .Dementia [memory loss].or other not listed) .None present. [checked] RESIDENT EVALUATION FACTORS: Does the resident have the ability to walk or self-propel off the premises without assistance .No. The DON stated the questions on the elopement risk evaluation that was completed on 9/29/25 were not correct and staff marked that Resident 1 did not have any cognitive diagnosis, and encephalopathy was a cognitive diagnosis. The DON stated had the section of cognitive diagnosis had been marked correctly, the elopement evaluation tool would have given Resident 1 a positive elopement risk score (10 or greater) and elopement care plan measures would have been put in place at that time. The DON confirmed a new elopement risk assessment should have been completed due to Resident 1's increased confusion and wandering behavior but was not. The DON stated an elopement risk care plan should have been initiated for Resident 1 on 10/3/25 but it was not. The DON confirmed Resident 1's elopement care plan was not initiated until 10/6/25, after he eloped. The DON explained the care plan was important as it offered a guide for staff on how to care for residents and provided interventions for staff to incorporate in their care to keep the residents safe. The DON stated during the afternoon hours of 10/3/25 she called the MD to inform him Resident 1 was more confused and she received new orders to send Resident 1 to the hospital for his safety due to physical therapy stating that Resident 1 was a high fall risk and was walking around unassisted and could not be redirected. The DON stated Resident 1 was trying to go outside and wanted to leave the facility to go to his classroom. The DON explained Resident 1 was pacing, not redirectable, and was an elopement risk. The DON stated she spoke to EC 1 on the afternoon of 10/3/25 regarding sending Resident 1 out to the hospital for safety reasons and EC 1 agreed. The DON stated they were concerned about Resident 1's previous neck surgeries and his risk of falling and injuring himself. The DON stated they tried to place a wander guard on Resident 1, but he refused. The DON stated she sat with him for 40 minutes. The DON stated she did not send Resident 1 to the hospital because he had calmed down while she was sitting with him in the dining room. The DON stated there were no issues with Resident 1 during his first couple of days at the facility and suddenly, he was talking about going to class and teaching. The DON stated she noticed a change in Resident 1's behavior starting on 10/2/25 (Thursday). The DON explained on the evening of 10/2/25 Resident 1's RP was contacted and came in to help Resident 1 since he was more confused. The DON stated the nurses did not follow the protocol and her expectation was the nurse should have sent Resident 1 to the hospital when he became more confused on the evening of 10/3/25 and was walking and pacing in the facility without his walker or assistance. The DON explained that the nurse should have recognized the importance of the need for Resident 1 to be assessed by a medical doctor in emergency room since Resident 1's change of condition and the new symptoms could not be managed safely by facility staff. The DON stated that each nurse interpreted the order to send Resident 1 to the hospital differently. Through review of Resident 1's clinical record, Resident 1's PERSONAL HISTORY AND PHYSICAL EXAMINATION, written by the MD on 10/2/25, the DON stated the MD wanted to repeat labs including ammonia and sodium levels but acknowledged there was no order created for Resident 1 based off the written notes made by the MD. Through review of Resident 1's clinical record, the order for .NH3.one time only for confusion. inputted by LN 5 on 10/3/25 at 12:29 a.m., was reviewed. The DON stated the labs were never drawn for Resident 1. The DON stated she expected the labs to be done immediately (STAT) due to their impact on Resident 1's cognition and medical condition, including his ammonia level. She stated that LN 5 did not understand the urgency of ordering the labs STAT given Resident 1's encephalopathy and increased confusion. During a phone interview on 10/9/25, at 2:49 p.m., the ADM stated he recalled Resident 1, and stated he exhibited off and on wandering behavior. The ADM stated he had reviewed the facility's video cameras located outside the main entrance of the building and Resident 1 was alone when he left through the front doors of the building at 7:45 a.m. on 10/4/25. The ADM stated the night shift staff were responsible for unlocking the front doors each morning at 7 a.m. The ADM explained there was nobody at the front desk at the entrance of the facility at the time Resident 1 eloped and the receptionist, who sits at the main entrance desk, does not start her day until 8 a.m. The ADM stated Resident 1 had refused his wander guard and so there was a preemptive order from the MD to send Resident 1 out to the hospital. The ADM stated staff were watching and trying to redirect Resident 1 and him receiving one-on-one supervision from staff would not be a first-level intervention as it could be restrictive. The ADM recognized the seriousness of Resident 1 leaving the facility and being found about one and half to two miles away, with staff unaware of his absence for roughly an hour and a half.During a concurrent phone interview and record review on 10/7/25, at 4:31 p.m., the MD stated Resident 1 was admitted to the facility for confusion and had a diagnosis of encephalopathy. The MD stated Resident 1's low sodium and/or high ammonia levels could have been related and/or a contributing factor to his increased confusion which was why he was monitoring them by ordering labs. The MD stated he gave staff an order to send Resident 1 to the hospital for confusion and for his own safety, if he was not better and remained confused. The MD explained this was due to the hospital's ability and access to perform faster evaluations including labs and other tests for Resident 1. The MD stated the nurse contacted him regarding Resident 1's confusion and he ordered labs earlier in the week and his expectation was they should be done. The MD stated the next thing he knew he received a phone call from staff stating Resident 1 had eloped from the facility. The MD stated if Resident 1 was confused and combative the staff should have anticipated his risk for elopement; care planned the behavior and notified him. The MD explained had he been aware of Resident 1's increased confusion and refusal of care he might have changed his mind and ordered different interventions. The MD stated his expectation was for the facility to inform the RP and/or family of pending labs, including labs ordered but not followed up on, and inform the family to follow up with Resident 1's primary medical doctor for care. The MD stated the elopement could have put Resident 1 at risk for a negative psychosocial effect and possible injury due to his elopement but that everybody was at risk for this generally. During a phone interview on 10/8/25, at 8:43 p.m., with the RP and EC 1, the RP stated Resident 1 had been more confused and was saying get me out of here and let's make a go and was paranoid. The RP stated at that time Resident 1 was using a wheelchair with assistance and he witnessed Resident 1 get up and walk to his room which was about 100 to 200 feet away. The RP stated on Friday afternoon around 4:30 p.m. (10/3/25), the facility called him to report Resident 1 was not listening and was refusing to get out of the transport van and would not go inside the facility to his room. The RP stated the facility requested he speak to Resident 1 over the phone, and he told Resident 1 he could not leave the facility and needed to go inside. EC 1 stated later in the evening around 5:15 p.m., a nurse called EC 1 and told her she needed to come get Resident 1 because the facility did not have twenty-four-hour care. EC 1 stated staff told her if she did not come to the facility then the nurse would have to call the doctor and get an order to take him to the hospital. The RP stated he told the nurse to do whatever they needed to do to keep Resident 1 safe. The RP explained that was the last phone call they received from the facility regarding Resident 1. The RP stated up until today, the facility never reached out to them regarding Resident 1's elopement or any updates of tests that were pending or ordered from the MD. The RP stated he received a phone call from Resident 1's neighbor (FF) on 10/4/25 around 8:40 a.m., and she told him Resident 1 was in a shopping center sitting on a bench. The RP stated he hung up the phone and drove there. The RP stated by the time he arrived the FF had walked home and returned to Resident 1 with her vehicle, and Resident 1 was in the FF's house when he arrived. The RP stated Resident 1 was wearing shorts and a T-shirt and did not look right. The RP explained Resident 1 appeared scruffy, confused, disoriented, and did not know where he was or how he got there. The RP stated Resident 1 was happy to see her [referring to the FF]. The RP explained Resident 1 was freezing and shaking and was very thirsty. The RP stated he felt Resident 1 was scared and he had not walked that far since he broke his neck in May of 2025. The RP stated Resident 1 looked exhausted and after the elopement slept for three days, barely waking up. The RP stated Resident 1 expressed his body hurt. The RP stated he was not sure how Resident 1 was able to walk almost two miles without falling. The RP explained he was frustrated with the lack of communication from the facility regarding Resident 1's care. The RP stated anything could have happened to him once he left the facility alone. During a phone interview on 10/9/25, at 2:01 p.m., the Family Friend (FF) stated, on 9/4/25, she went on a walk with her son and dog, whom she had adopted from Resident 1 a few months prior. The FF explained they went into the grocery store and when they came out and started the return walk home, she saw Resident 1 sitting on a bench located on the walking trail behind the grocery store. The FF stated Resident 1 looked very fragile and appeared to be dead. The FF further explained Resident 1 looked grey and had lost his color in his face and was shivering. The FF stated she immediately went to him, and Resident 1 appeared super pale, clammy, with sweat on his face, and was shaking and she asked him if he escaped the facility. The FF stated Resident 1 seemed relieved when he saw her. The FF stated Resident 1 was a stubborn guy who does not want help with things but when she found him, he told her he needed help. The FF stated she left Resident 1 with her son and dog while she walked back home to get her car. The FF further explained she returned and loaded Resident 1 into her vehicle. The FF stated Resident 1 was confused and disorientated and was in and out in terms of his ability to recognize her or understand the situation. The FF stated Resident 1 appeared dehydrated and was unbalanced. The FF stated it would have been a long walk and a lot of strenuous physical activity for him to get to the location she found him at. The FF stated she estimated she found Resident 1 around 8:30 a.m. as she had called his son (RP 1) at 8:39 a.m. and he was coming to meet her. The FF stated she didn't know what would have happened to him if she hadn't found him and she was walking a different path home that went behind the building and was very grateful she did because she found Resident 1. The FF stated she felt Resident 1 would have continued to deteriorate while sitting on the bench. The FF explained it could have been much worse as the area was sketchy, and the roads were busy, and Resident 1 could have been hit by a car. A review of a facility policy and procedure (P&P) titled Wandering and Elopements, revised 3/19, the P&P indicated, .The facility will identify residents who are risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.If a resident is missing, initiate the elopement/missing resident emergency procedure.determine if the resident is out on a authorized leave or pass.if the resident was not authorized to leave, initiate a search of the building (s) and premises; and.If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and as necessary v

Based on interview and record review, the facility failed to use safe lifting technique to move one of two sampled residents (Resident 1) from the wheelchair to the bed on 7/5/25, after Resident 1 had an assisted fall (a situation where a resident begins to fall but is supported or guided by another person to minimize the impact of the fall) to the ground.This failure resulted in Resident 1 sustaining a left distal femoral fracture (broken bone in the lower part of the left thigh bone near the knee).Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnosis of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and repeated falls. Review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool), dated 5/9/25, indicated Resident 1 scored three out of fifteen points total. A score of three indicated that Resident 1 had severe cognitive impairment (when a person is likely to experience significant difficulties with mental tasks and may require substantial assistance with daily activities).Review of Resident 1's Progress Notes, dated 7/5/25, indicated, .Resident was not like himself this shift, wasn't talking and looking weak. When CNA [certified nursing assistant] went to get him ready she alerted writer that his left leg was at an weird angle and his knees were stuck together and it was hard hold them apart without resident screaming in pain. Sent out to [name of emergency department] around 1645 [4:45 p.m.].Review of Resident 1's Progress Notes, dated 7/6/25, the document indicated, Licensed Nurse (LN) 2 received a call from the emergency room staff who informed her that Resident 1 .has been admitted [to the hospital] and that he has a shattered knee.A review of Resident 1's hospital record titled, History and Physical/admission Notes, dated 7/6/25, indicated the following: Resident 1 was admitted to the hospital on [DATE], a Computed Tomography (CT) scan (a special x-ray that takes detailed pictures inside your body) of Resident 1's left knee was conducted on 7/6/25, with the following reported findings, .Displaced fracture centered at the distal femoral metaphysis, with intra-articular extension at the level of the anterior medial femoral condyle [a broken bone near the bottom of the thighbone (femur), close to the knee joint. The pieces of bone are out of place (displaced), and the break goes into the knee joint itself].During a concurrent observation and interview on 7/15/25, at 2:04 PM, the Restorative Nursing Aide (RNA) stated that on 7/5/25 between 1 PM to 1:30 PM, she offered Resident 1 to attend the RNA Program and Resident 1 agreed. RNA 1 explained, at that time, she assisted Resident 1 to sit on the edge of the bed, however, Resident 1 was unable to stand like he used to and began sliding off the bed. The RNA stated she then sought assistance from CNA 1, who happened to be inside Resident 1's room. The RNA stated, both herself and CNA 1 were unable to help Resident 1 to stand. The RNA stated they then assisted Resident 1 slowly to the floor. The RNA stated, once Resident 1 was on the floor, CNA 1 and herself transferred Resident 1 to the wheelchair using a gait belt (a safety device used by caregivers to assist patients with mobility and transfers, such as walking or rising from a chair) while supporting Resident 1 under both armpits. The RNA explained, from the wheelchair, they transferred Resident 1 back to the bed using a towel transfer technique. The RNA explained and demonstrated that she placed a towel behind Resident 1's leg, just above the backs of his knees. The RNA stated CNA 1 and herself then positioned themselves on each side of the resident. The RNA further explained, with one arm, each of them supported Resident 1 under his armpits while holding the gait belt; with the other arm, each held one end of the towel. The RNA stated they then lifted and swung Resident 1 back onto the bed. The RNA stated that she taught CNA 1 how to execute the towel transfer on 7/5/25 - at the time of said towel transfer. The RNA stated that she did not document the incident because she had told the nurse in-charge of Resident 1 on that day about what happened. The RNA stated FM 1 went to the facility on 7/6/25 and was able to speak with her regarding what happened.During an interview on 7/15/25 at 4:06 PM, the RNA stated that on 7/5/25, she did not think of using a mechanical lift (a device used to safely transfer individuals who cannot bear weight or have limited mobility, from one place to another) or requesting assistance from a physical therapist (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) to assist Resident 1 off the ground. RNA 1 stated she used the towel transfer technique and manually transferred Resident 1 from the wheelchair to the bed. The RNA stated that she believed a therapy order was required to use the mechanical lift.During an interview with the Director of Nursing (DON) and Administrator (ADM) on 7/15/25 at 4:50 PM, the DON stated when a resident was heavy or considered dead weight or unable to assist during transfers, the expected practice was to use a mechanical lift. When asked about the use of the towel transfer technique, the DON stated that the facility primarily uses gait belts and mechanical lifts but depending on the situation, the facility would use what was appropriate for a safe resident transfer. During the interview, the Administrator contacted the RNA by phone to confirm how the towel transfer had been performed. The RNA explained that Resident 1 had been sliding off the edge of bed. She asked CNA 1 for help repositioning him, but they were unable to move him back up. As a result, they laid him down on the floor. The RNA stated that she and CNA 1 then used a gait belt - holding Resident 1 by the gait belt and under each armpit, to lift him up from the floor into the wheelchair. From the wheelchair they transferred Resident 1 to the bed by lifting him into the air - ensuring he did not touch the floor - using a towel placed under the back of his legs and holding by each arm, swinging him onto the bed.During an interview on 7/15/25, at 12:42 PM, the Director of Nursing (DON) stated Resident 1 was transferred to the emergency room on 7/5/25 due to an Altered baseline and was admitted to the hospital due to a shattered knee. The DON explained that Resident 1 used to be talkative. The DON explained, on 7/5/25, although Resident 1 was not confused, he was notably quiet. The DON stated Resident 1 complained of left leg pain during repositioning by a Certified Nursing Assistant (CNA) and that his knees were together and staff were unable to separate them due to his pain. The DON stated Resident 1 did not fall on 7/5/25; rather, Resident 1 was assisted by both the Restorative Nursing Assistant (RNA) and CNA 1 to the floor sometime between 1 PM and 1:30PM. The DON stated it was unclear what happened because Resident 1 was a one-person assist with transfers (movement from one place to another) according to the therapy department (a group of healthcare professionals who help residents perform physical movements). During an interview on 7/15/25 at 1:26 PM, Family Member (FM) 1 stated he was notified by a facility staff around 5 PM on 7/5/25 that Resident 1 had been sent to the hospital. FM 1 stated he was told that Resident 1's leg appeared crooked. FM 1 stated, the next day, on 7/6/25, he visited the facility because he wanted to find out what happened to Resident 1. FM 1 stated he spoke with the RNA who informed him that Resident 1 began to fall but facility staff were able to assist Resident 1 to the floor, facility staff then used a towel to pick up Resident 1, and Resident 1 said, it hurts, and his leg appeared crooked. FM 1 stated he was also told by the RNA that Resident 1 was put back to bed and refused lunch. FM 1 stated the RNA told him that Resident 1 told her, I think you broke my leg. During an interview on 7/15/25 at 1:54 PM, the Director of Staff Development (DSD) stated that Resident 1's RNA program (a range of treatments and approaches aimed at helping residents regain, maintain, or improve their physical functioning) was ordered three times per week, although the specific days were inconsistent. The DSD also stated that Resident 1 had never refused the RNA program and, although he cannot walk, he can stand up and pivot (to turn or rotate on the foot) with the assistance of one person.During an interview on 7/15/25 at 2:25 PM, with Licensed Nurse (LN) 1, LN 1 stated that she was the nurse assigned to Resident 1 on 7/5/25 for the afternoon shift and was also the one who arranged his transfer to the hospital. LN 1 stated, although Resident 1 was alert, she transferred him out to the hospital because, Resident 1 did not seem like himself and was a bit different from his normal. LN 1 further explained that CNA 2 had alerted her to check on Resident 1's left leg. LN 1 stated, upon assessment, LN 1 observed that Resident 1's left knee was swollen, Resident 1 was complaining of pain, and Resident 1's left leg appeared misaligned or not straight. LN 1 stated that she was not aware of any fall involving Resident 1 but had heard that he had been lowered to the floor. During an interview on 7/15/25 at 3:33PM, CNA 2 stated that she was the CNA in charge of Resident 1 on 7/5/25 and that she was very familiar with him. CNA 2 stated she took Resident 1's vital signs and observed that he was non-verbal and appeared as though he was dying, noting that his eyes looked sleepy. CNA 2 stated after reporting her concerns regarding Resident 1 to LN 1, LN 1 decided to transfer Resident 1 to the hospital. CNA 2 stated before the transfer, CNA 2 intended to change Resident 1's briefs to ensure he was clean and dry. CNA 2 stated when she removed Resident 1's blanket, she noticed that his left leg appeared crooked. CNA 2 stated that when she attempted to reposition Resident 1, he screamed in pain. During an interview on 7/15/25 at 4:02 PM, the DSD stated that the facility's protocol for transferring a heavy or non-weight bearing (one who should not put any weight at all on the injured leg, foot or ankle) resident is to use a mechanical lift. The DSD clarified that they do not require an order to use the mechanical lift. The DSD stated that her expectation was for all resident transfers to be conducted safely and without causing pain.During an interview on 7/17/25 at 9:03AM, the RNA explained that the facility did not provide training on the towel transfer technique. The RNA explained she learned the towel transfer method through years of experience and from working at other facilities. The RNA stated the towel should be placed under the resident's leg - not under the buttocks or hips - According to the RNA, she was holding one side of the towel, which was placed on the resident's leg just above the knee. With her other arm, she was supporting one side of the resident's armpit. She added that placing an arm under the armpit also allows you to hold the gait belt. CNA 1 was positioned on the other side of the resident, using the same technique. When asked whether there are any medical conditions that would make the towel transfer inappropriate, the RNA said she did not know. During an interview on 7/17/25 at 9:15AM, the Physical Therapist (PT) stated that the facility does not offer towel transfer technique (also known as, towel lift transfer or towel lift) training. The PT stated the facility recommended the following lifting transfer methods: Stand and Pivot Transfers (Helping one move from seated position to another by assisting them to stand up, turn and then sit down again), slide board transfers (Way to move a person with limited mobility from one sitting surface to another, use of a Hoyer lift (A special machine to help move someone who cannot get up or move on their own, safely and gently), and use of a Stand-up Hoyer Lift (A special machine that helps a person stand up from sitting position when they cannot do it on their own but still have some strength in legs and can hold on). The PT explained that the towel transfer technique was not typically used at the facility, though it may be considered depending on the specific case. The PT explained that she found it safer not to use a towel transfer technique. The PT explained, with the towel transfer technique, the towel was placed around the buttock/low waist to gain control of the pelvis (hips). The PT stated the towel lift technique was not appropriate for certain residents including residents without lower body strength, residents with general weakness, and residents with neurological conditions (a problem with the brain, spinal cord, or nerves that affect how your body moves, feels, or functions) due to lack of lower extremity control and stability. The PT stated that a resident must be stable before considering a towel lift transfer.During a phone interview with the Director of Nursing (DON) and Licensed Nurse (LN) 3 on 7/17/25 at 10:43 a.m., the DON confirmed that LN 3 was the assigned nurse for Resident 1 during the morning shift on 7/5/25. The DON stated that she was unable to find any documentation of the incident involving Resident 1. LN 3 stated she was caring for Resident 1 during her morning shift on 7/5/25. LN 3 explained that she did not document the incident because she only saw the RNA and CNA 1 transferring Resident 1 to a wheelchair and was not informed that Resident 1 had been lowered to the floor. A review of the facility's policy titled, Safe Lifting and Movements of Residents, dated 7/17, the policy indicated, .Resident safety, dignity, comfort and condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.Manual lifting of residents shall be eliminated when feasible.Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis.assessment shall include.Resident's mobility (degree of dependency).weight-bearing ability. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.Mechanical lifting devices shall be used for heavy lifting, including lifting and moving of residents when necessary.Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents.Staff will be observed from competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.Mechanical lifts shall be made readily available and accessible to staff 24 hours a day.A review of the facility's policy titled, Fall and Fall Risk, Managing, dated 3/18, the policy indicated, .A fall is defined as: Unintentional coming to rest on the ground, floor or other level.An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall.Medical factors that contribute to the risk of falls include.neurological disorder; and balance and gait disorders; etc.Monitoring Subsequent Falls and Fall risk.staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on observation, interview, and record review the facility failed to ensure self-administration of medication was clinically safe and appropriate for one of three residents (Resident 1), when Resident 1 was not assessed for self- administration of his medications prior to being provided his medications to self-administer while out on pass. This failure had the potential to contribute to unsafe medication use by Resident 1 and could have led to Resident 1 experiencing adverse health consequences. Findings: Review of Resident 1 ' s ADMISSION RECORD, indicated Resident 1 was initially admitted to the facility with diagnoses of osteomyelitis (an infection of the bone that causes inflammation and destruction of bone tissue), paraplegia (inability to voluntarily move the lower parts of the body), and chronic pain (persistent pain that lasts for over three months) among other diagnoses. Review of Resident 1 ' s Medication Administration Note, dated 10/17/24, at 3:30 p.m., written by Licensed Nurse (LN) 4, indicated, .Norco [medication used to treat moderate to severe pain, classified as opioid which can slow breathing, cause drowsiness, and be addictive] Oral Tablet .Give 1 tablet by mouth every 4 hours as needed for PAIN .Sent with patient when he went out on pass to school . Review of Resident 1 ' s Medication Administration Note, dated 11/21/24, at 8:00 p.m., written by LN 3, indicated, .Norco Oral Tablet .Give 1 tablet by mouth every 4 hours as needed for PAIN .pt [patient] had taken medication with him while out on pass, pt was given medication by the AM shift [morning shift staff] . Review of Resident 1 ' s Medication Administration Note, dated 2/7/25, at 1:51 p.m., written by LN 1, indicated, .Gabapentin [medication used to treat nerve pain] Oral Capsule .Give 1 capsule by mouth three times a day for neuropathy [nerve pain] .sent with resident out on pass . Review of Resident 1 ' s Medication Administration Note, dated 2/10/25, at 12:55 p.m., written by LN 1, indicated, .Sivextro [antibiotic] Oral Tablet .1 tablet by mouth one time a day for Osteomyelitis of left hip infection Take 1 tablet PO [by mouth] daily sent with resident on pass at 0940am [9:40 a.m.] . During an interview on 2/13/25, at 10:31 a.m., Resident 1 stated he began taking his medications with him to school in the summer of 2024 and the nurses would put his medication in an envelope to take with him. Resident 1 stated he was no longer prescribed Norco and currently the nurses were giving him Sivextro and gabapentin in an envelope to take with him to school. Resident 1 stated he had not received training from facility staff on how to take his medication while at school. During an interview on 2/13/25, at 1:57 p.m. LN 1 stated she gave Resident 1 his scheduled medications of Sivextro and gabapentin in a baggie to take with him when he leaves the facility to go to school. LN 1 stated she has been giving Resident 1 his medications to take with him to school as long as she has been taking care of him at the facility. LN 1 stated she had not asked administration if it was okay to give medications to a resident prior to going on pass and was not sure if there was a policy regarding it. During an interview on 2/13/25, at 2:44 p.m., LN 2 stated she had seen other nurses give Resident 1 his medication to take with him when he leaves on pass, and she followed their process which included placing his scheduled medications in little baggies. LN 2 stated she had not received training regarding giving Resident 1 his medications to self-administer and she had just copied what the other nurses did. During a concurrent interview and record review on 2/13/25, at 4:20 p.m., with the DON and the ADON, the DON stated she was not aware Resident 1 was going out on pass until last week, or that Resident 1 was taking his scheduled medications with him to self-administer. The DON confirmed there was no Inter-Disciplinary Team (IDT, group of health care professions from different fields who work together to care for a patient) meeting held for Resident 1 to discuss the risk and benefit of him self-administering his medications which would include a measure of his ability to safely self-administer his medications while on pass. The ADON stated the purpose of the IDT meeting was to make sure it was safe for Resident 1 to take his medications out on pass and to discuss with the resident expectations, safe handling, when to take the medications including the timing of the medication administration. The ADON explained this would include teaching the importance of taking his antibiotic on time every day and include the indication for the medication regarding his diagnosis. Through record review the DON confirmed there was no note in Resident 1 ' s chart regarding teachings on safe handling of his medication or self-administration. The DON stated this was important due to possible harm to the resident if they did not take their scheduled medication on time. Review of the facility ' s Policy & Procedure (P&P) titled Self-Administration of Medications, dated 2/2021, indicated, .Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so .As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident ' s cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident .The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident .The medication is appropriate for self-administration .The resident is able to read and understand medication labels .The resident can follow directions and tell time to know when to take the medication .The resident comprehends the medication ' s purpose, proper dosage, timing, signs of side effects and when to report these to the staff .If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan .

Based on interview and record review, the facility failed to develop a comprehensive care plan (a plan to address initial goals on admission and physician orders to ensure safety and well-being of a resident) for self-administration of medication for one of three sampled residents (Resident 1) when, Resident 1 was self-administering his multiple medications given to him by facility staff while out on pass from the facility. This failure resulted in a person-centered care plan with individualized interventions not being developed for Resident 1 and had the potential for Resident 1 to not properly self-administer his medications which could have led to subsequent adverse health events. Findings: Review of Resident 1 ' s ADMISSION RECORD, indicated Resident 1 was initially admitted to the facility with diagnoses of osteomyelitis (an infection of the bone that causes inflammation and destruction of bone tissue), paraplegia (inability to voluntarily move the lower parts of the body), and chronic pain (persistent pain that lasts for over three months) among other diagnoses. Review of Resident 1 ' s Medication Administration Note, dated 10/17/24, at 3:30 p.m., written by Licensed Nurse (LN) 4, indicated, .Norco [medication used to treat moderate to severe pain, classified as opioid which can slow breathing, cause drowsiness, and be addictive] Oral Tablet .Give 1 tablet by mouth every 4 hours as needed for PAIN .Sent with patient when he went out on pass to school . Review of Resident 1 ' s Medication Administration Note, dated 11/21/24, at 8:00 p.m., written by LN 3, indicated, .Norco Oral Tablet .Give 1 tablet by mouth every 4 hours as needed for PAIN .pt [patient] had taken medication with him while out on pass, pt was given medication by the AM shift [morning shift staff] . Review of Resident 1 ' s Medication Administration Note, dated 2/7/25, at 1:51p.m., written by LN 1, indicated, .Gabapentin [medication used to treat nerve pain] Oral Capsule .Give 1 capsule by mouth three times a day for neuropathy [nerve pain] .sent with resident out on pass . Review of Resident 1 ' s Medication Administration Note, dated 2/10/25, at 12:55 p.m., written by LN 1, indicated, .Sivextro [antibiotic] Oral Tablet .1 tablet by mouth one time a day for Osteomyelitis of left hip infection Take 1 tablet PO [by mouth] daily sent with resident on pass at 0940am [9:40 a.m.] . During an interview on 2/13/25, at 10:31 a.m., Resident 1 stated he began taking his medications with him to school in the summer of 2024 and the nurses would put his medication in an envelope to take with him. Resident 1 stated he was no longer prescribed Norco and currently the nurses were giving him Sivextro and gabapentin in an envelope to take with him to school. Resident 1 stated he had not received training from facility staff on how to take his medication while at school. During an interview on 2/13/25, at 1:57 p.m. LN 1 stated she gave Resident 1 his scheduled medications of Sivextro and gabapentin in a baggie to take with him when he leaves the facility to go to school. LN 1 stated she has been giving Resident 1 his medications to take with him to school as long as she has been taking care of him at the facility. LN 1 stated she had not asked administration if it was okay to give medications to a resident prior to going on pass and was not sure if there was a policy regarding it. During a concurrent interview and record review on 2/13/25, at 5:07 p.m., the Director of Nursing (DON) stated Resident 1 required a care plan for self-administration of his medications. Through record review of Resident 1 care plans the DON confirmed Resident 1 did not have a care plan for self-administering medications. The DON stated the care plan should have an identified problem, interventions and goals. The DON explained care plans help to teach the patient, and interventions were important for staff and the resident as they provided guidance and would have helped with explaining the risks. The DON further explained the care plan should have been developed prior to Resident 1 self-administering his medications while on pass Review of Policy & Procedure (P & P) titled Self-Administration of Medications, dated 2/2021, indicated, .Residents have the right to self-administer medications if the interdisciplinary team [IDT - a group of health care professions from different fields who work together to care for a patient] has determined that it is clinically appropriate and safe for the resident to do so . Review of P & P titled Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident .The interdisciplinary team (IDT), in conjunction with the resident .develops and implements a comprehensive, person-centered care plan for each resident .The comprehensive, person-centered care plan .includes measurable objectives and timeframes .describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being, including .builds on the resident ' s strengths .reflects currently recognized standards of practice for problem areas and conditions .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change .The interdisciplinary team reviews and updates the care plan .

Based on interview and record review, the facility failed to provide care and services after an unwitnessed fall for one of three sampled residents (Resident 1) when: 1. Resident 1 was found on the floor next to his bed on 12/5/24 at 1:25 a.m., with signs of delirium (a sudden, severe change in mental state which can include confusion, disorientation, and an inability to think clearly) and Licensed Nurse (LN) 1 delayed notifying the physician until 7:00 a.m. on 12/5/24; and, 2. LN 1 documented Resident 1 was experiencing signs of delirium after an unwitnessed fall but did not document a neurological (to evaluate level of alertness, orientation, mood), pain, or skin evaluation (to evaluate for trauma, scratches, bruising) was completed. These failures had the potential for Resident 1 to experience pain, suffering, and an increased length of recovery and rehabilitation. Findings: Review of Resident 1's ADMISSION RECORD, indicated Resident 1 was admitted to the facility with diagnoses including but not limited to dehiscence of an amputation stump (surgical site of an amputated limb reopens), muscle weakness, cirrhosis of the liver (chronic liver disease which can cause a buildup of toxins in the brain), Disseminated Coccidioidomycosis Infection (also known as Valley Fever, a fungal infection that infects the lungs and can affect breathing), and metabolic encephalopathy (disorder of the brain and can cause confusion). A review of Resident 1's NURSING-ADMISSION/READMISSION EVALUATION/ASSESSMENT, dated 12/3/24, indicated, .Level of Consciousness .Alert [marked] .Mood and behavior patterns .Calm/Cooperative [marked] .Admission Summary Note .Resident was admitted from [Hospital A] .Resident is alert and orientated x3 [oriented to person, place, time]. Is here for therapy . A review of Resident 1's Nurse's Note, written by LN 1 and dated 12/5/24 at 2:08 a.m., indicated, at 1325 [1:25 a.m.] found resident sitting up on floor next to bed . assessed for injury .slight confusion . Review of Resident 1's SBAR Communication Form [SBAR, Situation-Background-Assessment-Recommendation, technique which provides a framework for communication between members of the health care team about a patient's condition], dated 12/5/24 and unsigned by a nurse, indicated, .SITUATION .The change in condition, symptoms, or signs observed and evaluated is/are: falls .This started on: 12/05/24 .Mental Status Evaluation . delirium (inability to pay attention disorganized thinking) [marked] .Skin Evaluation .Not clinically applicable to the change in condition being reported [marked] .Pain Evaluation . Not clinically applicable to the change in condition being reported [marked] .Neurological Evaluation . Not clinically applicable to the change in condition being reported [marked] .REVIEW AND NOTIFY .Primary Care Clinician Notified .Yes [marked] Date .12/5/2024 .Time .7:00 AM . A review of Resident 1's Liver Cirrhosis Care Plan, initiated on 12/4/24, indicated, .[Resident 1] has Liver Cirrhosis .Monitor/document/report to MD [medical doctor] s/sx [signs/symptoms] of delirium: Changes in behavior, Altered mental status . A review of Resident 1's Disseminated Coccidioidomycosis Infection (also known as Valley Fever, is a fungal infection that infects the lungs and can affect breathing) Care Plan, initiated on 12/4/24, indicated, .[Resident 1] has DESSEMINATED COCCIDIOIDOMYCOSIS infection .[Resident 1] will be free from complications related to infection through the review date .Monitor/document/report to MD s/sx of delirium: Changes in behavior, Altered mental status . A review of Resident 1's Fall Care Plan, initiated on 12/4/24 and revised on 12/6/24, indicated, .Falls: Resident is at risk for falls with or without injury related to altered balance while standing and/or walking . During a concurrent interview and record review on 1/2/25, at 4:15 p.m., the Assistant Director of Nursing (ADON) stated the Resident 1's SBAR Communication Form was not signed and submitted by LN 1 and was in a draft form. During a review of the document titled SBAR Communication Form , the ADON confirmed the document was dated 12/5/24 and initiated at 1:48 a.m. by LN 1. The ADON confirmed Resident 1's physician was notified of the change in condition on 12/5/24 at 7:00 a.m. The ADON confirmed the document included a Mental Status Evaluation which indicated other symptoms or signs of delirium and Functional Status Evaluation of Falls was marked by LN 1. The ADON confirmed there was no evaluation or assessment performed for Resident 1 indicated on the document for neurological checks, pain, and skin. The ADON stated her expectation was for a resident who has a fall should be immediately assessed for any injuries and for an unwitnessed fall, such as was the case for Resident 1, neurological checks were to be performed. The ADON stated this was especially important for Resident 1 who had a BIMS score of 9 (Brief Interview for Mental Status, a test that measures cognition, a BIMS score of 0-7 indicates severe cognitive impairment, 8-12 indicates moderate cognitive impairment, 13-15 indicates intact cognition) and was sometimes confused. The ADON stated the risk to Resident 1 if the LN did not perform the assessments would be delayed treatment and not catching a potential problem. The ADON stated once a resident was in a safe place the physician should be notified, followed by family and management. The ADON stated it was the facility's protocol to notify the physician within thirty minutes of the event. The ADON stated the importance of notifying the physician was so the physician can decide if there were new orders needed including x-rays and additional monitoring. The ADON stated the risk to the resident if the physician was not notified would be delay of treatment. During a phone interview on 12/31/24, at 10:09 a.m., Family Member 1 stated Resident 1 was currently in the hospital after being transferred to the hospital from the facility on 12/11/24. FM 1 stated this was due to increased confusion and his doctor was concerned his ammonia levels (the amount of ammonia in your blood. High ammonia levels can cause serious brain damage) were too high and/or he had a possible infection. FM 1 stated (Resident 1) had his leg amputated in July of 2024. FM 1 stated after he goes to dialysis (a procedure to remove toxins/waste from the blood when the kidneys do not function well), he gets confused and disoriented and forgets he does not have a leg and will try to get out of bed. FM 1 stated on the evening of 12/4/24 she visited Resident 1 after he returned from dialysis. FM 1 stated she left the facility around 9:20 p.m. and prior to leaving had spoken to the LN regarding (Resident 1's) confused state and told the LN he was more confused than normal. FM 1 stated Resident 1 called her with his cell at 11:27 p.m. on 12/4/24 and told her he was in pain. FM 1 stated the nurse told her (Resident 1) had fallen out of his bed and was found on the floor. FM 1 stated when she went to visit (Resident 1) on 12/5/24 he had a lot of bruises and his side and on his back from the fall. During an interview on 12/31/24 3:18 p.m., Certified Nurse Assistant (CNA) 1 stated on the night of 12/4/24, she was the CNA assigned to Resident 1. CNA 1 stated there was another CNA translating for Resident 1 (CNA 2) and stated they were letting the nurses know he was in super pain and stated the pain was in his stomach, he was upset, and his stomach was bloated. CNA 1 stated Resident 1 was moaning and groaning in pain, and explained he never sounded like this before. CNA 1 stated a staff member went into Resident 1's room at 1:45 a.m. and found him on the ground in his room. CNA 1 stated Resident 1 had a scratch on his back from his bed frame and the bar on his bed. During a phone interview on 1/2/25, at 3:40 p.m., LN 1 stated after a resident falls, the expectation was to follow up with the doctor within thirty minutes to one hour of the fall and inform them of the resident's condition. LN 1 stated it was important to inform the doctor of the residents' condition in case follow-up orders were needed. During a phone interview on 1/2/24, at 1:56 p.m., LN 2 stated she recalled Resident 1 and remembered his fall on 1/5/25. LN 2 explained he was on the floor and she and other staff assisted in getting him back into his bed. LN 2 stated one of the CNA's found him on the floor could not remember if he hit his head. LN 2 stated the protocol for a resident who has a fall was resident safety first, and then to get them back to their bed safely, perform neurological checks, inform the doctor, assess for pain, and to complete a head-to-toe assessment. LN 2 stated the expectation was to contact the doctor immediately and stated if the resident was experiencing confusion or delirium, it would be important to know if this was a new onset and unusual for the resident. LN 2 explained informing the doctor, allows them to decide on treatment and perform interventions for the resident. During a phone interview on 1/7/24, at 12:21 p.m., the Medical Doctor (MD) 1 stated he was familiar with Resident 1 and stated he examined Resident 1 on 12/5/24. MD 1 stated Resident 1 was a complicated patient with a lot of health problems including liver, kidney, and stomach problems, and was admitted with a lot of pain. MD 1 stated for a fall and/or change of condition including a mental status change his expectation was for the nurse to call the doctor. MD 1 stated for a resident who has a fall accompanied with delirium as Resident 1 experienced, his expectation was the LN would have called to inform him after the incident. MD 1 stated this was important due to the possibility of the resident having an infection and he would have wanted to send him to the hospital immediately. MD 1 stated the LN should have conducted a pain, neurological, and skin evaluation for Resident 1 after his fall. MD 1 stated the risk to the resident experiencing a fall with changes such as delirium would be the resident could be experiencing bleeding to the brain. MD 1 stated for something important such as a fall the nurses can call him at any time. Review of a facility policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised 2/21, indicated, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's attending physician or physician on call when there has been a(an): accident or incident involving the resident .significant change in the resident's . physical/emotional/mental condition .need to alter the resident's medical treatment significantly .A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting ); impacts more than one area of the resident's health status; requires interdisciplinary review and/or revision to the care plan .Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . During a review of a facility P&P titled, Falls-Clinical Protocol, revised 3/18, indicated, .Assessment and Recognition .The nurse shall assess and document/report the following: Vital signs .Recent injury .or head injury . Change in cognition or level of consciousness .Neurological status .Pain .Precipitating factors, details on how fall occurred .All current medications, especially those associated with dizziness or lethargy [feeling tired] .All active diagnoses .Falls should also be identified as witnessed or unwitnessed events .Monitoring and Assessment .The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma [brain bleed] have been ruled out or resolved . The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .

Based on observation, interview, and record review, the facility failed to protect resident rights to be free from abuse (verbal, mental, sexual, or physical abuse) and neglect (failure to provide goods and services necessary to avoid physical harm or mental anguish) for two of twenty-one sampled residents (Resident 32 and Resident 38) when the facility was aware that Resident 32 and Resident 38 were continuing to engage in sexual activity which began on or around [DATE] and: 1. The facility did not determine if Resident 32 and Resident 38 had the capacity for sexual consent (physical and psychological actions that involve sexual arousal, desire, and satisfaction); 2. The facility failed to notify the medical doctor and/or psychiatrist regarding the sexual relationship between Resident 32 and Resident 38 to assist in determining if both residents were able to consent to the sexual relationship; and, 3. The facility did not put protective measures in place to prevent potential sexual abuse for Resident 32 and Resident 38 until it was determined if both residents had the ability to give sexual consent. This failure had the potential to result in psychosocial, sexual and/or physical harm to Resident 32 and Resident 38 when it was undetermined if either resident was able to consent to a sexual relationship. This failure also caused Resident 32 and Resident 38 to feel upset and confused due to some staff allowing them to engage in sexual activity and other staff preventing the sexual activity. The failure also placed other vulnerable residents in the facility at risk of sexual abuse due to the facility's lack of a process to evaluate residents' capacity to consent to sexual activity. This created a likelihood of serious physical and/or psychosocial harm (negative impact on physical, emotional, and/or mental wellness) to occur, if not corrected immediately. The Immediate Jeopardy (IJ-a threat to resident health or safety which requires immediate corrective action due to the likelihood of serious injury or harm) began on or around [DATE] when the facility failed to assess Resident 32's and Resident 38's ability to consent to sexual activity and did not identify the sexual contact as potential abuse. The Administrator (ADM) was notified of the IJ on [DATE], at 4:30 PM. On [DATE], at 6:08 PM, a removal plan was provided by the facility. The State Agency verified the facility's implementation of the removal plan while onsite at the facility. On [DATE], at 6:30 PM, the ADM was notified the IJ immediacy was removed. There was no non-compliance identified at a lower level upon removal. Findings: 1. Review of Resident 32's ADMISSION RECORD, indicated Resident 32 was admitted to the facility with a diagnosis including but not limited to cerebral infarction (blood supply to brain is blocked or reduced and can cause brain cell damage), hypertension (heart has to work harder to pump blood), and non-ST elevation myocardial infarction (a type of heart attack when your heart's need for oxygen cannot be met). Resident 32's admission record had a Resident Representative (RP) identified as RP 2. Review of Resident 32's Order Summary Report (document which includes all medication, tests, and non-medication orders), dated [DATE], indicated, .Resident is not capable Of Understanding Right, Responsibilities, And Informed Consent [process of communication between you and your health care provider that often leads to agreement or permission for care, treatment, or services]. Review of Resident 32's BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) (a tool that healthcare providers use to assess a person's cognitive function), dated [DATE], indicated, Resident 32 had a BIMS score of 10, which indicated moderately impaired cognition (when a person has some trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Review of Resident 32's BIMS, dated [DATE], indicated, Resident 32 had a BIMS score of 8, which indicated moderately impaired cognition. Review of Resident's 32's Cognitive Impairment Care Plan (a document that outlines a patient's care needs, diagnosis, treatment goals, and nursing orders), dated [DATE], indicated, . [Resident 32] exhibits cognitive loss related to altered cognitive performance with BIMS Score of ,d+[DATE] indicating moderately impaired and hx [history] of TIA [transient ischemic attack, or TIA, is a temporary blockage of blood flow to the brain] . [Resident 32] will continue to recognize family [Resident 32] will communicate basic needs to the extent possible . Communicate with resident and [RP 2], regarding residents capabilities and needs . Identify yourself at each interaction. Face [Resident 32] when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc .[Resident 32] understands consistent, simple, directive sentences. Provide [Resident 32] with approaches that maximize involvement in daily decision making and activity (limit choices, ask yes or no questions, use cueing, instructions)- stop and return if agitated . Monitor for changes in cognitive status. Observe for indicators of clinical changes . behavior changes. Notify physician if occurs . Review of Resident 32's Activities Note, dated [DATE], indicated, .(Late Entry) on [DATE] at approximately 3pm, [Resident 32] was found in [Resident 38's] bed, when asked what he was doing he explained that she invited him to lie down with her and watch a movie, writer explained to him and her that, that isn't allowed, then writer escorted him out of the room. Writer returned a few minutes later and he was back in her bed . writer again escorted him back to his room and again explained to him the facility rules, he seemed to understand . Review of Resident 32's Nurse's Note, dated [DATE], indicated, .Resident has became [sic; used after a copied or quoted word that appears odd or erroneous to show that the word is quoted exactly as it stands in the original] very affectionate with [Resident 38]. Reported to [staff name redacted] in S.S. [Social Services] . Review of Resident 32's Nurse's Note, dated [DATE], indicated, .resident is being monitored with being affectionate towards [Resident 38] in room [Resident 38's room], but was easily redirected, endorsed behavior to noc [night shift] nurse. will continue to monitor . Review of Resident 32's Social Service Note, dated [DATE], written by the Social Services Director (SSD), indicated, .I had a lengthy meeting with the patient and their peer [Resident 38], during which they referred to each other as boyfriend and girlfriend. They expressed their desire to be discharged from the skilled nursing facility (SNF) and to live in the female resident's apartment .The male party [Resident 32] needed reminders about the purpose of our meeting .overall it was determined and expressed by both, they wish to have private intimateness together. This appears to be the primary motive for wishing to discharge from the SNF . Review of Resident 32's Case Management Note dated [DATE], written by the SSD, indicated, .A female resident [Resident 38] and this patient [Resident 32] have openly expressed their relationship and love for each other .Both residents express their decide to engage in sexual relations and intimate experiences such as holding hands, snuggling, kissing, and fondling .The male resident's responsible party has been informed of this relationship, while the female resident is her own responsible party .The Ombudsman [OMB, representatives who assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences] has been notified and has met with both parties. A care plan will be developed to respect the resident's dignity and autonomy while ensuring safety and minimizing the risk of harm . Review of Resident 32's Behavior Note, dated [DATE], indicated, .resident is being monitored with being affectionate towards a female resident in room [Resident 38's room number], but was easily redirected. endorsed behavior to noc [night] nurse. will continue to monitor . Review of Resident 32's Intimate Behavior Care Plan, dated [DATE], indicated, .Resident displays intimate behavior towards another resident. Both residents consent to these mutual feelings .Goal . Resident will safely act on his feeling with both residents consenting .Interventions/Tasks . Educate/in-service staff regarding mutual feelings as being consented . Encourage residents to act on their intimate desires in privacy and respecting other residents . Encourage safe intimacy practices Invite Psychologist . Provide private space/time . Review of the document did not indicate any communication the facility had with Resident 32's psychologist. Review of Resident 32's Summary for Providers dated [DATE], written by the Director of Nurses (DON), indicated, .the Change in Condition/s reported .Nursing observations, evaluation, and recommendation are: Patient was last seen walking toward the front lobby when this writer asked where he was going he sounded upset prior to that and he wanted to be with his partner .Cna [CNA, Certified Nurse Assistant] stated he was sitting in front of lobby. Then this cna [CNA] went back to front he wasn't to be found immediately made staff aware to look for patient. Housekeeping found him outside by the water shut off .Primary Care Provider responded with the following feedback .apply wander guard frequent visual checks . Review of Resident 32's IDT Note (Interdisciplinary Team, a group of healthcare professionals who work together to assess, coordinate, and manage a resident's care), dated [DATE], written by the SSD, indicated, LATE ENTRY .Elopement Risk On [DATE] around 2030 [8:30 p.m.] [Resident 32] was found outside, within facility grounds and assisted back into the facility. Resident got upset of not spending enough time with another resident. Resident displays intimate behavior towards another resident . New Interventions Implemented .Invite the Psychologist . Note text . [names redacted: SSD, ADM (Administrator), DON, CM (Case Manager) 1] . Review of Resident 32's Nurse's Note, dated [DATE], indicated, .Resident was told to go to his room multiple times he is in room [Resident 38's room number] unable to redirect making roommates uncomfortable . Review of Resident 32's Nurse's Note, dated [DATE], indicated, .resident found with female resident having sex in female resident room. after separating the two residents, both residents refused medication and assessments for am shift; no adverse s/s [signs and symptoms] of missed dose of medications; plan of care ongoing . Review of Resident 32's Physician Progress Note, dated [DATE], written by the Nurse Practitioner (NP), indicated, .Assessment .Dementia [loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life] .Plan .Monitor neuro and mental status . Review of Resident 32's physician progress notes through [DATE] did not indicate or mention Resident 32 engaging in sexual activity with another resident or Resident 32's ability to consent to sexual activity. During a phone interview on [DATE], at 12:14 p.m., RP 2 stated Resident 32 had a girlfriend (Resident 38), and she was dragging him around all over the facility. RP 2 stated Resident 32 will lay down in her [Resident 38's] bed and she was not sure if it was still going on as this was a few months ago. RP 2 stated when visiting, she saw Resident 32 with his pants off, wearing no undergarments, and he was laying in Resident 38's bed. The RP 2 stated she told him to go to his room. RP 2 stated the night Licensed Nurse (LN) told her he was always in Resident 38's room. RP 2 stated the night LN would call her on her phone at 9:00p.m. or 10:00 p.m. and inform her he would not leave Resident 38's room and would ask RP 2 for help in getting him to leave her room. RP 2 stated she was not aware of Resident 32 and Resident 38 engaging in any type of sexual behavior and the SSD had never informed her of this. RP 2 stated Resident 38 was not able to consent to sexual touching due to his dementia. RP 2 stated she would have wanted to be informed by the facility and she stated she would not want him to engage in sexual activity with Resident 38 or other residents. 2. Review of Resident 38's ADMISSION RECORD, indicated, Resident 38 was admitted to the facility with diagnoses including but not limited to dementia, bipolar disorder (mental health condition which causes extreme mood swings), obsessive compulsive disorder (lasting and unwanted thoughts that keeping coming back or urges or images that are intrusive and cause distress or anxiety), anxiety disorder (excessive fear or worry about a specific situation), major depressive disorder (affects how you feel, think and behave and can lead to a variety of emotional and physical problems), attention-deficit hyperactivity disorder (combination of persistent problems, such as difficulty sustaining attention, hyperactivity and impulsive behavior), and herpes viral vesicular dermatitis (a skin infection caused by a virus and spread by skin-to-skin contact). Resident 38's admission record indicated she was her own RP (she made her own medical decisions). Review of Resident 38's Order Summary Report, indicated, physician orders written on [DATE], for the medication Valacyclovir 500 mg [an antiviral medication] to be taken two times a day orally, as follows, .Give 1 tablet by mouth two times a day for HSV [herpes simplex virus] prophylaxis [prevention] If you get an outbreak increase to 4 tablets (BID) [twice a day] ONLY FOR 24 HOURS AFTER THAT RETURN TO 1 TABLET BID . Review of Resident 38's Mood Care Plan, dated [DATE], indicated, .[Resident 38] is a risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social .Being fidgety or restless, moving around a lot more than usual, feeling down, depressed, or hopeless .observe for signs and symptoms of depression/emotional distress and notify physician as needed .Review medications as a possible cause or contributing factor to mood .Social services to visit and evaluate as needed . Review of Resident 38's Antidepressant Medication (prescription medicines to treat depression. Depression is more than feeling a little sad or blue for a few days) Care Plan, dated [DATE], indicated, . [Resident 38] uses antidepressant medication r/t [related to] Depression .Monitor/document/report to MD [medical doctor] prn [as needed] .fear of being alone or with others, attention seeking, concern with body functions, anxiety, constant reassurance . Review of Resident 38's Order Summary Report, indicated physician orders written on [DATE], as follows, .Resident does not have the capacity to make her own decisions related to: DEMENTIA, MAJOR NEUROCOGNITIVE DISORDER DUE TO MULTIPLE ETIOLOGIES [decreased mental function and loss of ability to do daily tasks] . Review of Resident 38's Nurse's Note, dated [DATE], indicated, .Resident noted with unappropriated [sic] sexual behavior. Found performing sexual act with male patient in his room. Staffing intervened and separated both patients. SBAR [Situation, Background, Assessment, and Recommendation-a method used to communicate important information] sent to MD. Social service, administrator, and Ombudsman aware . Review of the clinical record did not indicate communication with Resident's 38's medical physician or psychiatrist. Review of Resident 38's Nurse's Note, dated [DATE], written by the Case Manager (CM) 1, indicated, .This writer met today with the local county ombudsman to address a recent incident involving a resident [Resident 38] and another custodial member [Resident 32]. The resident had contacted the ombudsman expressing concerns about needing her cell phone, purse, clothing from her apartment, and the desire to engage in sexual activity with a companion. During this meeting, the writer and the ombudsman extensively discussed the resident's current major neurocognitive disorders as documented by the doctor. The resident's previous living and functional levels, her ongoing treatment plan, RNA [Restorative Nurse Aide; provides assistance with walking, mobility, dressing, and grooming to prevent decline in activities of daily living] services, and discharge plan was also discussed in length. The most recent recommendation for the resident's transition to custodial care was to provide ,d+[DATE] [24 hours a day, 7 days a week] caregiver support upon discharge due to her functional and progressive cognition conditions. The ombudsman agreed to allow sexual activities within the facility's protocol, ensuring privacy and dignity for others. All parties involved were in agreement with the plan, and the IDT (Interdisciplinary Team) was notified . Review of Resident 38's Behavior Note, dated [DATE], indicated, .Resident was found laying in [Resident 32's] bed next to [Resident 32]. Resident stated that she was sleeping. Resident was convinced by registered dietitian to leave the bed as it was unsafe. Resident agreed and was assisted into wheelchair by LN and CNA and escorted out of room . Review of Resident 38's Social Service Note, dated [DATE], indicated, .RESIDENT REQUESTED TO SPEAK WITH SOCIAL SERVICES ABOUT THE POSSIBILITY OF HER AND ANOTHER RESIDENT MOVING INTO HER APARTMENT; ENDORSED TO SOCIAL SERVICES . Review of Resident 38's Case Management progress note, written by the SSD, dated [DATE], indicated .I had a lengthy meeting with the patient and their peer, during which they referred to each other as boyfriend and girlfriend. They expressed their desire to be discharged from the skilled nursing facility (SNF) and live together in the female resident's apartment. We extensively discussed the necessary coordination that would need to take place for this to realistically happen. This included securing a 24-hour caregiver, addressing financial matters, involving both families, planning for a safe discharge .We also contacted the apartment complex where the female resident resides. However, we were informed that she has been evicted and her whereabouts are unknown. Additionally, her rent has not been paid since [DATE], and her . assistance has expired. The female resident was unaware of these circumstances and believed her rent was being paid automatically. It seems that returning to this apartment, even with a safe discharge plan, is no longer an option .Both parties expressed their love for each other and their desire to leave the SNF together. However, the male party needed reminders about the purpose of our meeting. I emphasized the importance of involving the male resident's responsible party (RP) in this discussion, and both parties agreed to speak with her. I subsequently spoke with the male resident's RP [RP 2] and informed her about everything discussed, including the ongoing relationship between the two. [RP 2] expressed strong disagreement with the male resident's desires to discharge from Garden City. She said she would be speaking with both parties to discuss. Overall it was determined and expressed by both, they wish to have private intimateness together. This appears to be the primary motive for wishing to discharge from SNF. Writer explained to both remaining in the SNF would allow them to be together, as they wish and continue to do safely as they have the care they currently require . Review of Resident 38's Behavior Note, dated [DATE], indicated .resident is being monitored with being affectionate towards a male resident in room [Resident 32's room number], but was easily redirected. endorsed behavior to noc nurse. will continue to monitor . Review of Resident 38's IDT NOTE, dated [DATE], written by the SSD, indicated, .It has been brought to our attention of IDT that this female patient and a male patient are in a romantic relationship and have expressed their desire to engage in sexual intimacy and pursue a relationship Review of the document indicated in attendance at the meeting was the ADM, and the DON amongst others. Review of Resident 38's Nurse's Note, dated [DATE], indicated, Resident kept going in [Resident 32's] room . Tried to redirect but patient won't listen. Finally patient in room [Resident 32's room number] came out she woke him up. She wanted him in her room. Then later she came to nurse station trying to get all her medication she wanted to check out. Will continue to monitor . Review of Resident 38's BRIEF INTERVIEW FOR MENTAL STATUS (BIMS), dated [DATE], indicated, Resident 32 had a BIMS score of 12, which indicated she had moderately impaired cognition. Review of Resident 38's Nurse's Note, dated [DATE], indicated, . Patient's boyfriend came to nurse station saying someone was on floor. When this writer went to evaluate patient she was sitting on floor next to partner's bed. She was able to move upper and lower extremities. No injuries . Review of Resident 38's IDT NOTE, dated [DATE], written by the SSD, indicated, .On [DATE] around 2331 [11:31 p.m.] . [Resident 38] had an unwitnessed fall in her partners room, refused to answer what led to fall. Resident status prior to event: The patient was attempting to visit peer in his room Risk Factors .dementia, muscle weakness .bipolar disorder, OCD, anxiety, depression, ADHD, herpes viral vesicular dermatitis, hx [history] of falls .Cognitive impairment . Review of the document indicated the SSD, Assistant Director of Nursing (ADON), and the Administrator (ADM) were in attendance. Review of Resident 38's Nurse's Note, dated [DATE], indicated, . Resident found with male resident having sex in female resident's room. after separating the two residents, both residents refused medication and assessments for am [morning] shift; no adverse s/s of missed dose of medications; plan of care ongoing . During an interview on [DATE], 3:55 p.m., the Activities Assistant (AA) stated staff had reported to her that Resident 32 and Resident 38 were known to have sex together. The AA stated staff were aware and Resident 38's roommate (Resident 49) had complained about their loud sex and stated she must turn up her television loud. The AA stated Resident 32 and Resident 38 needed their own spot to have sexual activities but stated she did not know what to do about it. the AA stated she had been working at the facility for twelve years and was unsure if there was a policy regarding two residents having a sexual relationship. The AA stated they could not stop their behavior and staff tell the residents to be respectful because they share rooms. The AA stated both families were aware. The AA stated Resident 32 had a responsible party, RP 2 who stated Resident 32 could not consent to the sexual relationship. The AA stated Resident 38 can be persistent and stated she was in charge of the relationship. The AA stated RP 2 was not happy about Resident 32 and Resident 38's relationship. The AA stated their relationship had been going on since January of 2024. During a concurrent observation and interview on [DATE], at 4:02 p.m., Resident 32 and Resident 38 entered Resident 38's room. Resident 32 then sat at the edge of Resident 38's bed. Resident 38 stated she and Resident 32 would like to be together and have privacy. Resident 38 stated it was impossible for them to be alone. Resident 38 stated her roommates did not want them to have sexual partners. Resident 38 stated she spoke to the Administrator (ADM) and asked for their own room to share and was told the facility was not set up to have couples in a room together or cohabitating. Resident 38 stated Resident 32's family was not for it. Resident 38 stated they were going to contact the senior advocacy to get Resident 32's house back and Resident 32 did not remember signing his house away. During a concurrent interview and observation on [DATE], at 8:23 a.m., Resident 32 stated he did not know what day or year it was and stated since his stroke he had become forgetful. Resident 32 stated he cannot remember anything, and RP 2 made all his decisions for him. Resident 32 stated he had a girlfriend but could not remember her name and stated her room was close to his room, but he cannot recall what room she was in. Resident 32 stated he visits with her in the hallway, and he does not visit with her in her room nor was she allowed to visit him in his room. Resident 32 stated he likes to kiss her, but staff do not like them being together. Resident 32 stated he wanted privacy with her, but staff did not give them privacy. Resident 32 stated they just wanted to be together by themselves and stated he was never allowed to be alone with her. It was observed that Resident 32's room was next door to Resident 38's room. As Resident 32 was walking to the dining room, Resident 38 was heard calling Resident 32's name and asking him to come into her room. After leaving the dining room Resident 32 stated he did not remember where his room was. Staff then assisted Resident 32 back to his room. During an interview on [DATE], at 8:51 a.m., Resident 38 stated she wanted to move out of the facility, and she had a boyfriend who lived here, and he owned a home and she wanted to move out of here into his home and get married to him (Resident 32). Resident 38 stated it was hard for them to get together and she could not consistently see him. Resident 38 stated some of the Certified Nursing Assistants (CNA) did not allow her to be with Resident 32 and stated it depended on what staff member was working. Resident 38 stated sometimes her boyfriend (Resident 32) came to her room and sat on or would lay on her bed. Resident 38 stated they talked and hugged and had intimate touching. Resident 38 stated Resident 32 touched her breasts and her vagina. Resident 38 stated she touched Resident 32's private parts. Resident 38 stated the CNAs were aware of what they were doing. Resident 38 stated Resident 32 had a stroke three to four year ago and he was now very forgetful. Resident 38 stated it was very difficult to visit each other, they love each other, and they wanted to be with each other. Resident 38 stated she started seeing a memory doctor recently and she had been seeing a psychiatrist for over [AGE] years, but since being in the facility she could not make an appointment with her psychiatrist. During an interview on [DATE], at 9:05 a.m., CNA 1 stated Resident 38 and Resident 32 were boyfriend and girlfriend and were always together. CNA 1 stated the nurses told her they cannot be together in their rooms alone due to privacy for the other roommates. During an interview on [DATE], at 9:11 a.m., CNA 2 stated Resident 38 had days where she was more confused, and stated she will try to go in Resident 32's room and hold his hand and they kissed each other. CNA 2 stated Resident 38 was not allowed to go in Resident 32's room because they will want to touch each other. CNA 2 stated she had not been instructed by the LN's that Resident 32 and Resident 38 could not be together but had been told by nurses to watch them, so they are not sexually intimate. During an interview on [DATE], at 9:17 a.m., the Rehabilitation Technician (RT) 1 stated she worked with Resident 38 and helped her get dressed in the morning. RT 1 stated last week she observed Resident 32 sitting on Resident 38's bed. RT 1 stated about a month ago she opened Resident 38's bedroom curtain and both Resident 38 and Resident 32 were laying naked in her bed together. RT 1 stated she closed the curtain, spoke to the Director of Rehabilitation (DOR), and was told the residents had a right to privacy and just to close their curtain. RT 1 stated the licensed nurses were aware of the situation and instructed her to respect Resident 32 and Resident 38's privacy and allow them to be intimate together. RT 1 stated she thought staff had an in-service more than a month ago regarding sexual intimacy among residents. During an interview on [DATE], at 9:26 a.m., LN 4 stated Resident 38 and Resident 32 were very close and try to be intimate together. LN 4 stated they were entitled to have intimate relations and they like to be naked. LN 4 stated she had asked questions to administration, and it was up in the air whether it was okay for them to be intimate together. LN 4 stated Resident 32 was confused and had a RP. LN 4 stated Resident 38 was her own RP but did seem confused at times. LN 4 stated she had not heard from management on whether the resident's sexual activity was allowed or not allowed, and she had spoken with social services, and it was up in the air. During a concurrent interview and record review on [DATE], at 1:52 p.m., the Administrator (ADM) stated Resident 38 and Resident 32 were both here for long term care, and they had taken a liking to each other and had established an intimate relationship. The ADM stated his understanding was the relationship included holding hands, kissing, and potentially a sexual relationship. The ADM stated he became aware of their sexual relationships over the last couple of months. The ADM stated he wanted to make sure it was safe and consensual but was not sure if they had met for an IDT regarding their sexual relationship. The ADM stated Resident 32 had a BIMS score of 10 on [DATE], which falls into the category of moderately impaired cognition. The ADM stated Resident 32's RP was not okay with the sexual relationship. The ADM stated if the resident's BIM's score indicates moderately impaired, we should be notifying the RP. The ADM stated so far Resident 32 had not shown distress as far as their relationship. The ADM stated as a facility the IDT approaches residents engaging in sexual activity by asking the family member or RP, and reviewing with their physician was an important step to determine if the moderate impairment was in that area as well, or if they were able to give sexual consent with a BIM's score indicating moderately impaired and lack of medical capacity. The ADM stated he would want to get Resident 38's psychiatrist or psychologist involved in the IDT as well. The ADM stated he was not aware of Resident 38's not having medical capacity. In a record review of Resident 38's clinical record, the ADM confirmed the order dated [DATE] and stated the resident did not have medical capacity to make decisions. The ADM stated the physician order limiting capacity is from a cognition standpoint and stated the RP and the Ombudsman would participate in the IDT meeting to determine what next steps to take and what safeguards should be placed to prevent the residents engaging in sexual activity. In a record review of the Resident 32 and Resident 38's clinical record, the ADM confirmed there were currently no safeguards put in place to prevent Resident 32 and Resident 38 from engaging in sexual contact. The ADM stated the IDT team had not determined if Resident 32 or Resident 38 had capacity to give sexual consent. The ADM stated the risk to residents if safeguards were not in place to prevent sexual activity was for unwanted sexual contact and other behaviors and stated their sexual contact could be considered sexual abuse. The ADM stated he was aware Resident 32 and Resident 38 had sexual intercourse and stated staff have not been instructed to keep the residents apart. The ADM stated he first became aware of Resident 32's and Resident 38's sexual relationship about a month ago and stated since becoming aware he has not put any measures in place to prevent the sexual activity. The ADM stated we were trying to give them privacy, close the curtain, and remove other roommates in their room. During a record review of Resident 32's sexual relations care plan, the ADM stated they ultimately could not keep them separated so they tried to give them a space for pr [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide the necessary supervision to prevent accidents for one of three random sampled residents (Resident 20) when nursing staff were aware Resident 20 had multiple elopement (leaving the facility unsupervised and without permission) attempts and failed to monitor Resident 20's location and personal alarm system (wander guard)(item worn by a resident to alert staff and an audible alarm sounds when they approach an exit door) function as required by facility policy and procedure. These failures resulted in a fall with injuries (right hip fracture, a right arm fracture, and a hand laceration (cut)) during an elopement by Resident 20. Findings: On 12/20/16 at 3:45 p.m., during an interview, the Administrator (Admin) stated Resident 20 had a history of [REDACTED]. The Admin stated the facility had been working for the past year on locating a locked facility placement for Resident 20 due to elopement attempts. The Admin stated Resident 20 eloped from the facility on 12/14/16 and had a fall with injuries. The Admin stated Resident 20 required rehabilitation (physical and occupational therapy to help the resident regain strength and functional abilities) after having sustained a fractured hip during the fall. On 12/20/16 at 4:03 p.m., during an observation and concurrent interview at the nurses station, Resident 20 sat in a wheel chair with a soft cast on her right arm. Resident 20 had difficulty staying awake during the interview and stated she had been given pain medication that made her drowsy. Resident 20 stated she knew she had a fall and broke her hip, but did not remember the incident. On 12/20/16 at 4:29 p.m., during an interview, Certified Nursing Assistant (CNA) 4 stated Resident 20 had a history of [REDACTED]. CNA 4 stated there was a wander guard alarm sensor (electronic device that senses the approach of the resident wearing the alarm) in the middle of the hallway and the exit door was alarmed. CNA 4 stated Resident 20 had to pass those alarms on 12/14/16, the day she eloped from the facility. CNA 4 stated, I don't know how (Resident 20) passed the wander guard sensor and exit door alarm. On 12/20/16 at 4:35 p.m., during an interview, Licensed Nurse (LN) 3 stated on 12/14/16, she observed Resident 20 walking back and forth down the short hall several times pushing her wheelchair. LN 3 stated she heard Resident 20 say repeatedly, I want to see my kids. LN 3 stated Resident 20 had passed the area where there was a wander guard sensor. LN 3 stated she heard the alarm sound and redirected Resident 20 away from the sensor. LN 3 stated she last saw Resident 20 around 4 p.m. walking toward the employee exit door. LN 3 stated, All shifts should check the wander guard alarm (for proper function). Make sure the button (on the alarm sensor) is fully pushed in. LN 3 stated Resident 20 was very independent prior to elopement. LN 3 stated prior to her fall, Resident 20 was steady on her feet and went around the facility pushing her wheelchair. LN 3 stated Resident 20 required minimal assistance with dressing and showering before her fall on 12/14/16. On 12/20/16 at 4:58 p.m., during an interview, Restorative Nurse Aide (RNA) 1 stated on 12/14/16, she observed Resident 20 to continually walk toward the exit door. RNA 1 stated Resident 20 stated repeatedly she wanted to go home and see her family. RNA 1 stated she walked Resident 20 back from the exit door to the activity room several times on 12/14/16. RNA 1 stated Resident 20 had to pass the wander guard sensor and the exit door alarm to elope from the facility. RNA 1 stated, For some strange reason, she (Resident 20) got past those alarms. On 12/20/16 at 5:01 p.m., during an interview, the Facility Maintenance Director (FMD) stated the maintenance department was responsible for testing the wander guard system on a monthly basis. The FMD stated resident wander guards were checked once per week. The FMD produced a written log titled, WANDER GUARDS which indicated a notation of ok written weekly from 9/5/15 to 12/15/16. There was no documentation of Resident 20's wander guard checked every shift by the staff. On 12/20/16 at 6:10 p.m., during an interview, the Admin stated on 12/14/16, the local police department notified the facility Resident 20 was found by a bystander outside the facility. The Admin stated the bystander had called the police department to report the incident. The Admin stated the facility had not investigated the circumstances that allowed Resident 20 to leave the building unnoticed. The Admin stated there was no (staff) timeframe or guideline of frequency to monitor Resident 20's location for prevention of elopement. On 2/14/17 at 5:11 p.m., during an interview, the Director of Nursing (DON) stated the maintenance department was responsible for checking the wander guard system on a monthly and weekly basis. The DON stated the nursing staff checked to ensure the alarm was placed on the resident appropriately, but nursing staff did not check the function of the alarm. The DON stated the facility did not have a policy or procedure to guide nursing staff regarding who should check the alarms, how to check the alarms or how often to check the alarms. The DON stated there was no system in place directing nursing staff in checking wander guard alarms. On 4/6/17 at 3:20 p.m., during a telephone interview, the FMD stated, if working properly, the wander guard alarm in the short hallway would alarm continually until a staff member put the code into the alarm box to turn it off. The FMD stated, if working properly, all exit door alarms would continue to alarm until disarmed by staff. The FMD stated exit door alarms were tested every week. On 4/6/17 at 3:30 p.m., during a telephone interview, the DON stated nursing staff check placement of the wander guard alarms on residents, but do not document the check. The DON stated Resident 20 did not have a detailed monitoring plan for elopement prevention. The DON stated staff were instructed to keep Resident 20 within their line of sight as much as possible, but prior to 12/14/16, there was no regularly scheduled or documented monitoring of her location. On 4/7/17 at 8:55 a.m., during a telephone interview, the Admin stated on 12/14/16, Resident 20 and her wheelchair (W/C) had been found by a bystander and the local police department about a block away from the facility on a side street. The Admin stated facility staff were unaware Resident 20 was missing until notified by the local police department. The Admin stated he was not certain how long Resident 20 was missing, but he had seen her that afternoon in the facility. The Admin stated facility staff were not able to determine how Resident 20 left the building. The Admin stated the door alarms were functioning when tested upon Resident 20's return. The Admin stated, The only thing we can think of is she was very fast that day and by the time the staff silenced the alarms she was already out the door and out of sight. Review of Resident 20's clinical record titled, Face Sheet (document with personal information of the resident), indicated [DIAGNOSES REDACTED]. Review of Resident 20's clinical record titled, Minimum Data Set (MDS) (a resident assessment tool) assessment, dated 11/18/16, indicated a Brief Interview for Mental Status score was 5 of 15 possible points. A score of 5 indicated Resident 20 had severe memory impairment. The MDS dated [DATE], indicated Resident 20 was able to ambulate (walk) in her room and in the facility corridor with staff supervision. Review of Resident 20's clinical record titled, Care Plan dated 9/28/14, indicated Resident 20 was at risk for elopement related to wandering around the facility inside and outside the front door. Resident 20's Care Plan Approach indicated, Equip resident with a device that alarms when resident wanders. Check for proper functioning of device and alarms q (every) shift . Monitor resident's whereabouts frequently. Review of Resident 20's Care Plan dated 5/29/16, indicated Resident 20 Elects to go outside of the facility unescorted potentially related to Advanced Alzheimer's Dementia. Resident 20's Care Plan Goal indicated, Resident (Resident 20) to remain safe within the facility. Review of Resident 20's Care Plan dated 12/8/16, indicated a problem of Recurrent focus on leaving facility to look for family, her car, or because of delusions (false beliefs) or hallucination ( a false perception), and is increasingly more difficult to re-direct. The Care Plan Approach indicated, As possible, keep within line of sight. Review of Resident 20's clinical record titled, Progress Note dated 2/10/15, indicated, She (Resident 20) has often tried to leave the facility . Review of Resident 20's Progress Note dated 10/7/15, indicated, Concern expressed by NHA (Nursing Home Administrator) and IDT (Interdisciplinary Team (a team composed of health care providers who plan resident care)) team members . regarding resident (Resident 20) ambulating outside of facility unattended and high risk for injury. Review of Resident 20's Progress Note dated 5/31/16, indicated, Resident is alert and oriented to family and some staff, otherwise very confused. She went out of facility unescorted. She was promptly brought back to facility. Review of Resident 20's Progress Note dated 8/4/16, indicated, Patient has strong self determination to ambulate throughout the facility and outside grounds with poor insight to risks. Was found wandering outside of facility. Review of Resident 20's Progress Note dated 10/14/16, indicated, (Resident 20) walks independently, daily, throughout the facility either pushing her W/C or without. Often looking for the door. She is noted to become verbally irritable when redirection is attempted to guide her. Review of Resident 20's Progress Note dated 12/8/16, indicated, IDT Discussion regarding multiple elopement attempts by patient (Resident 20). Review of Resident 20's Progress Note dated 12/14/16 at 6:04 p.m., indicated, Call received from (local police department) with information resident was found outside of facility and had sustained a cut on her hand .PD (police department) officer asked what hospital she should be evaluated at .patient will be transported there . Review of Resident 20's hospital (ACH) clinical record titled, Note Report dated 12/16/16, indicated Resident 20 was admitted to the ACH on 12/14/16 following a fall. The Note Report indicated, D/C (discharge) Diagnosis .right Femur (the large bone of the lower extremity) Fracture FX (fracture), Right Humerus (upper arm bone) FX. Hip Fracture Cephalomedullary Nail (a treatment for [REDACTED]. Distal (closer to the hand than to the shoulder) humerus fracture under conservative (non-surgical) management. The facility policy and procedure titled, Wandering, Unsafe Resident dated 12/08, indicated, .6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior.